Senate Standing Committee on Health

This is your 10-second warning for those operating the phones and the Zoom. We will start in 10 seconds. Good morning. The Joint Hearing of the Senate Committee on Health and the Assembly Select Committee on Reproductive Health will convene this morning. Thank you for being here. The subject today is menopause, access to treatment, and coverage.

I don't have to tell you, but this is a very important issue for women around the state, the nation, and, frankly, around the world. And it's a very important issue for men as well, men with wives and men with adult daughters. We are experiencing this as well. So it's appropriate that we have this conversation.

This hearing has been long in planning by my colleague to my left, my former Chair, the much brighter and harder working Chair ever of the Senate Health Committee, and her colleague in the Assembly. And so I'm going to turn the hearing over to them and look forward to the conversation. Senator Eggman, the floor is yours.

Thank you, Senator Roth, it's been a real gentleman to provide the space for us to do this. So, welcome to everybody. Welcome to all of our guests, our distinguished panel, and my colleagues here. I am in my last year in the State Senate, I have started in elected office in 2006.

It is now 2000, and whatever it is. And I went from being under 50 to 63 during my time in elect at office. And as I reflect on that and have served with and also have worked very hard to get more women in the Legislature.

When I got here, there were 23 of us, and I'm very proud to say we're almost gonna hit parity by the time I leave that we've made a concentrated effort to make sure that there's parity so that we can have these kinds of conversations. Right?

Because before women's and women's bodies and women's health wasn't even on the agenda for anybody to be talking about. We weren't sitting here. And so it didn't come up in the same kind of way.

So as I thought about my last year and reflecting on it, we've done a lot of work during my time here on menstrual equity. We've done a lot of work on choice and women's bodies. But the one topic that we have not spent a lot of time on is menopause.

And I have certainly gone through the process as I've, you know, been a Member. Didn't talk much about it, didn't have any conversations about it besides the, you know, is it hot in here? Kinds of conversations that we have.

And I think there's a lot of us that go like that, and we shouldn't have to do it in silence. Right? I remember growing up, my mom never really talked about it. She said it was a white lady thing because we didn't have time as Latinas. Right? And we know that's not true.

We know that especially for women of color, the symptoms are even more pronounced. But oftentimes, there's no space or time to think about those things. They're thought of as more of a privilege for others to think about. So I want to thank everybody today for being here as I wind down.

But as we really start talking about this and prioritizing women's health and menopause, a woman can live long, healthy lives with full sexual activity and joy and all the things that we all want to have as human beings. Right? Freud said he was wrong about a lot of things, but sex, love, and work. Right.

And those things still, I think, maintain very central to all of our lives. So I'm glad to be here with all of you. I want to thank the staff for putting this together and turn it over to my colleague on the Assembly side.

Thank you both, Senators Eggman and Roth. It's a real privilege to be here co-chairing this hearing. Both houses together, bipartisan. This is an issue that crosses every barrier. Every woman who's fortunate to live long enough will go through menopause. And yet, you know, we all grew up with mothers who were told to grin and bear it.

I remember my mother being hospitalized for days because she was turning blue and they couldn't figure out why. And they did every test under the sun, only to say she was perfectly fine. And then telling a girlfriend the story at a luncheon a couple weeks later. And the friend said, oh, it's probably just menopause.

And then she was told, oh, you're fine. Just keep going. And I think that was the lesson that we were each given as we were raised. We weren't taught about menopause. We weren't told we had a right to be treated for menopause.

And as I approached perimenopause, I realized, speaking to my own physicians, many of whom are women, they weren't trained to understand how to treat me, how to care for my body as it transitioned out of the years, the childbearing years, and into the rest of my life.

And, you know, as I've started to have these conversations with my colleagues at women's caucus and other places, we all started to realize that we weren't getting the attention we deserved as more than half of the population and that we as leaders with these platforms, we needed to bring this to bear.

We, as the State of California, the fifth largest economy in the world, some of the best medical institutions in the world, some of the best physicians, so much research funded by this building, it wasn't necessarily going to this. And yet every single woman who lives long enough will experience it.

And so I think it is so critically important that we have these conversations. We learn about the ways that it affects our constituents, our bodies, and what we can do to change the game for women moving forward.

Women go through menopause, just as Senator Eggman highlighted at the height of our career, right when we're about to take off, we know what we're doing and we're ready. And yet we hit this point in our lives where we start to have these symptoms that cause brain fog and sleeplessness and things that really impact our productivity.

And it is no surprise that we aren't breaking more glass ceilings. And so it feels like taking this step and caring for women's bodies at this point in their lives can actually be game-changing, well beyond just our health and well-being.

And so it has really been a privilege to be in these conversations and to learn more and to start to do the work we have, you know, I have a Bill moving this year that will deal with insurance coverage for menopausal care.

Let's start to have the conversations of what it means to cover women and to care for them in all the ways. But there is so much more learning to do. So I want to thank our panelists for being here. I also want to thank our colleagues who are joining us because we should all be engaging in this.

I am eager for some of our male colleagues to show up to learn more. I know they will join us at some point in this conversation. And so I just want to thank you for putting this together and the staff who I know put in incredible work to get this agenda to where it is today.

But I just want women to know that we are paying attention to your health. We care about it and we are going to be fighting for it. And, you know, I think it's critical that we say things like vaginal dryness in hearings because it's real, it affects us, and we need to be addressing it.

And that brain fog, I mean, we give speeches. We're out talking everywhere. I can't tell you the amount of times I say, please God, please let me have my words. Let me find my words because, right, you're getting up to do something big and then.

I just want to give a moment to my other two colleagues here on the dais if they wanted to share anything or. Okay.

I remember my mother sweating. And then she was diagnosed with primary peritoneal cancer, which is very similar to ovarian cancer. And it took a heck of a long time to get to that diagnosis and she lasted five years, but not enough is talked about it. So I'm delighted to be here. Thank you all for putting this on.

Thank you to our witnesses for being here. Take it away.

Fantastic. Okay. And we're going to start with some treatment provider knowledge gaps. We're going to then talk about addressing some disparities and integrating care, what the coverage looks like in California, and then what do we think the next steps should be?

So those of you who will be here longer then can take these ideas and do the next steps. This is the beginning of the conversations, certainly not the end. And I think we'll just have everyone stay up here and then speak, and then we'll ask questions after each speaker goes, if that's okay.

We're going to start off with Doctor Rajita Patil, who's Assistant Clinical Professor, Director of the UCLA Comprehensive Menopause Program, and a lot of places. Please.

Thank you. I'm just going to get my slides up here. All right. So, hi everyone. Thank you for having me here today. I really wanted to talk today about menopause as a critical window of opportunity that needs to be better addressed, and here in California and frankly all over the United States.

So first, we really just need to understand the problem, why it exists, before we really talk about the needs and the solutions to the problem. Menopause as we know, is defined by a cessation of menstrual cycles for 12 months.

And it happens at the average age of 51 in this country, 50%, that is every person with an ovary, goes through menopause in this country. An estimated 6,000 women in the United States reach menopause daily and 1.3 million annually, with an average life expectancy currently being 81 in this country.

That means that there's up to 40% of life to live in menopause. And the menopause transition is marked by a sudden fluctuation of hormones for which there are receptors all over the body. And up to 80% are symptomatic with symptoms like sleep disturbances, hot flashes, vaginal dryness, mood, cognition disturbances.

And these average symptoms really do not last for a short period of time. On average, they last for 7 to 10 years, with 10% having lifelong symptoms. But the problem really is, is that only 50% of people in menopause receive care in the United States today.

And it's even worse for those of lower socioeconomic status and people of color. So why do we care so much? Well, we really want to maximize that quality of life for people that live greater than one third of their life in menopause.

In the short term, these symptoms that are sudden really cause a negative effect on quality of life measures at home and at work.

And just like Rebecca Bauer-Kahan said, was that it really happens at a time when women are juggling enormous responsibility at home and at work, they're often at the peak of their career and requiring high levels of executive function. And at home, they may be taking care of children still, but also elderly.

At work, we know that there's more presenteeism, there's more sick days taken. There's actually a study out of Mayo Clinic in 2019 that estimated a $1.8 billion annual loss to the United States economy based on missed workdays, and this is due to menopause symptoms.

And a $26 billion annual loss due to the economic burden associated with menopause symptoms. From a long-term perspective, it's really important to understand that estrogen is protective to the body, and it is really protective to all the organs.

So when estrogen declines, we see that the chronic disease risk profile drastically changes, increasing the risk of cardiovascular disease, breast cancer, osteoporosis, cognitive impairment and dementia, sleep and mood disorders.

The bottom line is that there is a window of opportunity that exists during early menopause to really optimize a person's quality of life in the short term by treating symptoms, but also their future chronic disease risk profile by using preventative measures. And currently, this window remains unaddressed. So why does this problem exist?

Well, because no one has really been talking about it until recently. Menopause has been stigmatized and framed as if it was a disease instead of a natural part of the women's reproductive life cycle. There's been a negative social stigma around the idea of menopause and this concern for aging and loss of feminism.

People have had nowhere to go, and so instead, what they do is they don't do anything about it at all. Right? And their health suffers for it. Or they try to navigate themselves by going online and trying to make sense of all that information that is contradictory. There's a lot of misinformation.

They may start to take supplements or try to fix it themselves. And these supplements are not FDA approved, and there's really no regulation around the purity, safety, or efficacy, or they may actually try to go find providers.

But there really aren't very many providers currently that are comfortable in caring for menopause, and so they're often prescribed unsafe treatments or their risk factors are dismissed before they're even given those treatments.

So this really brings us to the root of the problem, which is, I have to say, part of it is the WHI, and it's really the knowledge gap that exists with providers because of the WHI, in part.

In 2002, the Women's Health Initiative concluded that the potential benefits of HRT did not outweigh the risks and should not be used for preventative treatment for chronic health conditions.

However, this study did not study younger patients, those that are in early menopause who are very symptomatic, and that did not really study the effect of this hormone replacement therapy on menopause symptoms.

But nevertheless, the results were widely covered in the media and presented in a very skewed fashion, dissuading use and presenting fear with use of HRT for both providers and patients. And this resulted in a chilling effect, causing a dramatic decline in use. Furthermore, the FDA issued a black box warning against use of HRT.

But since this time, further analysis have really shown the benefits for menopause symptoms and that the risk for hormone therapy for using in younger population who's healthy with no high risk conditions is actually, has a quite favorable risk profile and is appropriate based on expert opinion.

But the bigger problem as a result of the WHI was that nearly all education and training in the area halted or slowed. I personally went through residency in 2002 to 2006, and I remember one lecture on menopause and it was related to the WHI. And I am not alone. This was all across the nation happening.

Menopause in general, still is not part of the curriculum in most medical schools or residency programs.

For our listeners, could you talk about WHI?

Sorry?

Hormone replacement therapy?

I'm sorry, hormone replacement therapy. Yeah. And it has not been really addressed or in the curriculums or even taught in training.

In the Mayo, there's a study out of Mayo Clinic in 2019 where they did a survey of all the residents coming out from primary care specialties as well as OB-GYN, and only 8% felt adequately prepared to take care of menopause patients. So providers not being trained means that they don't want to take care of menopause patients.

They don't want to ask questions, they don't know how to answer. And there's a fear around using or prescribing HRT, so they're not given to appropriate patients, or they might use it unsafely. And there's also a lot of knowledge lost in understanding what non-pharmacologic or non-hormonal treatments are available.

The other reason for the knowledge gap is that it's really underfunded. There's a huge scientific knowledge gap, and we know that women's research in general is underfunded, but it's even less for this specific part of the lifespan when you compare it to things like pregnancy. In general, we need more research in this area. But even if you look at what kind of studies are out there, it's on white women and higher socioeconomic statuses.

At the core of the program, we have six certified menopause providers who have specialized training in menopause and provide a place for patients to get trusted information to provide effective treatments, whether whether it's hormonal, non hormonal, pharmacologic, or non pharmacologic, as well as address long term health with our over 30 collaborating specialists in the areas of cognition, heart bones, breast sleep, cancer survivorship, and mental health.

And we've also partnered with our integrative health specialists to provide whole person care. And we've developed a very standardized methodology in terms of how to see a patient using.

What we've created are menopausal care algorithms that have been coded for a decision support tool that can really help guide how to take care of patients and not ignoring their patient specific factors, engage in that shared decision making, and really empower the patient to make the right decision for themselves.

We have a whole arm dedicated to bridging that knowledge gap. We have an in depth lecture series and didactics to our medical students, residency programs, and faculty. We also have a whole patient education piece with a growing library of asynchronous and synchronous materials.

And then all of what we're doing lends very, very well to meaningful research because we have lots of clinical questions that need to be answered. So the result has been, providers are feeling a great deal of satisfaction, but patients have really appreciated the program and showed a great deal of gratitude.

But I will tell you that even though this seems like a great model and we need to replicate this all over California and United States, it has been very challenging. I really. It really happened because of my own strong passion to want to make a difference, my grit, my determination.

But I really did not have any funding externally or internally to help with this process. My chair was very supportive. That's why it happened. She happens to be a woman, but we really had to utilize just the resources within the Ob GYN Department. And I really did this on the outskirts of my entire full time job.

So it really took a lot of passion and grit, and I don't think it should be this difficult. I think that what I've realized is that people don't think menopause is important in the institutions. And also that I will be honest that it's.

There's less incentive to provide such care when you compare it to Ob gyn procedures and obstetrics, which make a lot more money. So I find this mind blowing, because, honestly, there's no reason for this to be so difficult when over 50% of the population goes through this. So what we need.

What we need is to really set aside funding and support to start centers of excellence like ours all over the great State of California, but also to set a gold standard for the entire United States. We need to provide research resource guides as to how to implement this using successful templates like ours.

Create legislation and guidance to public institutions to prioritize this type of care, support and incentivize physicians to provide this care by rewarding their time and effort put into it. We need very much to direct our resources towards increasing awareness and public knowledge in this space.

So we need to challenge that stigma and normalize it more in society and help bridge this transition. And we do need to really address menopause in the workplace and provide protections and policies for those going through this, similar to other countries outside of the United States, like the UK and Australia.

And finally, we do need to work on closing that knowledge gap by increasing funding and support to medical schools, residency programs to existing providers who are taking care of midlife women, and to really address that knowledge gap by prioritizing funding and really invest in the menopausal research at all levels, at the state and the national level.

I thank you for your time, and I look forward to questions.

Are you fully funded? Still not at all. Still just scratching by. Shame on UCLA, huh?

Well. You know, one thing that I think it's really important for us to say is that we are obviously in tough budget times. That is no secret to anybody who's paying attention. And I don't think this is an issue of more money to these institutions. I personally think it is an issue prioritization.

And I think that we have for a long time deprioritized women and women's health. When men went through erectile dysfunction, that was not ignored, but yet our transition is ignored. And so I think that, you know. We need to look at how we.

Are spending money and ensure that, just like everything else, it is equitable for women's health. And I think one of the points you made that I'm sure we'll hear from others is that when we fail to care for women through this transition, the lasting impacts on women's health are incredible. And this is especially true.

And you touched this briefly for women of color, which I learned through this research, go through surgically induced menopause at much greater numbers, much earlier, and have much longer health impacts.

And so we're taking women of color who we know have never gotten the attention of our funding and our resources, and we are under resourcing that research, that training and all that goes with it.

And so I think it is incumbent upon us to look at the way our state dollars are being spent by these institutions and ensure equity.

And so, you know, I, I do think that the next step in our work together is the Senator and I joint authoring and audit request to look deeply into these institutions and how this money is being spent, because it is appalling to me that you are caring for women in a way that will ensure brain health and heart health for the rest of their lives.

And by the way, especially for our medi Cal patients, save us incredible dollars if we actually prevent those impacts and yet we're not resourcing it and taking care of them. And so I think that is one of the things that we must do.

I see Doctor Tammy Shereen Rowan from UCSF getting ready to go. So I will turn it over to you now, and we'll see if your institution is any more supportive.

Let me. Hold on. Where's the presentation? Thank you so much for the opportunity to speak. So, I'm Tammy Serene Rowan. I'm an associate Professor at UCSF, and I wear many hats at UCSF, including the Director of our sexual medicine program.

I'm the lead gynecologist in our newly developing menopause clinic, which I'm taking lots of hints of how to make successful. And then I'm also a Member of our gender affirming healthcare program.

And I always mention that because when we talk about women, I also want to address the fact that there are people who don't identify as women who also go through menopause, and they deserve our attention and just acknowledgement as well. So I really appreciated Rebecca Barakhan's mention of talking about the vulva and vagina.

And that is, I'm putting that on large screen here, because what I'm going to talk today about is sex and the vulva and vagina.

In menopause, we talk a lot about hot flashes, cognitive changes, brain fog, and the way that affects our ability to work, but we don't talk about what are actual, some physical aspects of what menopause does to our bodies and how that affects our relationships. And I think that those are really key.

So how many symptoms are we talking about when it comes to what happens to the vulva and vagina? This is just like a smattering, right? So there are signs and symptoms of something called genitourinary syndrome of menopause. So these are the vaginal and vulvar changes that are a result of decreasing estrogens and androgens.

Androgens include testosterone as well. Those are not just about sex and vaginal dryness. One of the main symptoms is actually urinary symptoms. And people get recurrent utis, they get infections. These infections cost lots of health dollars, and they can actually be treated very simply, not with antibiotics, but actually with local hormones.

Obviously, there's more genital changes that happen. The tissue gets fragile, painful. It looks different and it feels different. And so people have very changing experiences of sexual function and, in fact, sexuality. Sexual dysfunction really peaks as people age.

All right, so the vaginal symptoms, it used to be called vulvovaginal atrophy, and it ranges in upwards of up to 90% of people in various studies. Women in the United States have much higher rates of discomfort discussing this with a provider.

But one thing that I think is important is that the symptoms of GSM actually can occur at many stages of the reproductive cycle. It can happen in premenopausal, perimenopausal, and it actually happens in lactation women especially. So these are premenopausal women who are breastfeeding because the breastfeeding suppresses their ovaries, and they don't have androgens and estrogens.

And this is important when we talk about medical coverage, because the drugs that are approved for genital atrophy would. Then the question would be, how can we give this to a premenopausal woman who actually is suffering from those same symptoms? Fewer than 10% of women with GSM, and we're talking about probably about half to the majority.

And I see GSM at all stages. It happens to women in their forties, fifties, sixties, seventies, eighties. I see them present at different ages, but almost everyone's going to get it at some point, fewer than 10% are actually treated.

And it's a huge underutilization, and it's probably related to a lack of both the patient and provider knowing how to ask and also what medications are available. So patients are uncomfortable discussing this, right? We're told it's dirty. It's down there. I'm talking in front of the Legislature about the vagina and Vulva.

And I'm excited because this is California providers are uncomfortable asking about symptoms. There's limited knowledge about treatment options, and there's big concerns regarding the safety of treatment. And this is really a result of the women's health initiative when the black box warning got put on systemic estrogen products.

There is also a black box warning on local estrogen products as well, saying that they also cause heart disease and breast cancer and blood clots, even though no study has ever shown it. And there is no physiologic explanation for how that could happen, given the systemic absorption. Right.

It's not getting into the bloodstream, but those products have a black box warning that patients, when they go to the pharmacy to pick them up, these medications are also considered lifestyle medications. And so when they are going up for approval or coverage, this is for lifestyle. This is quality of life.

And I will argue that recurrent utis sepsis from those is not a lifestyle. But also, sex is not about lifestyles, it is about relationships. And if you look at research, 75% of women will say that sex is incredibly important to maintaining a healthy relationship. And healthy relationships are huge drivers and quality of life.

And people's sexual health relates very much to their overall physical health. And then additionally, there are huge cost barriers to treatment. And so while we say that there is approval. Right. So even for public insurance, they will say that a drug in this category is approved. That doesn't mean the right drug is approved for our patient.

So this is just showing a study that I think is really important, not just about GSM, but about sexual desire. So this was a research done from someone at UCSF, and it was published. It was the largest study looking at sexual dysfunction.

And I show this because I want you to look at this is all types of sexual dysfunction. It's desire, orgasm, arousal, and then any sexual dysfunction. And you can see where does it peak in the fifties.

And what I always explain to my patients is, it's not because as people get older, necessarily having better sex and their sexual function goes down. It's because the significant changes that happen in the menopause transition affect every aspect of sexuality, and that really affects people's lives.

And I have patients crying in my office every week about the sexual changes that are happening because of menopause. So what are the limitations? So, for sexual desire in menopause, the FDA approved medications are only for premenopausal women, so they are not approved for postmenopausal women who have the highest rates of sexual dysfunction.

And the reason for that is that in order to get a drug approved by the FDA for sexual problems, it has to go through the same committees that would approve hormone therapy. Right. Even though these are psychotropic medications, they actually work on serotonin receptors.

Prozac didn't, you didn't have to prove that Prozac doesn't cause breast cancer, but you have to prove that these drugs do. Because sex is considered part of the hormone therapy arm. Many women are seeking off label medications, especially testosterone, which is not approved for women, but there is significant evidence for use.

It was actually, it went to the FDA in the mid to late two thousands, and they said, we acknowledge that it works, but we don't have safety data because no hormone therapy was going to get approved in the wake of the WHI.

The lack of approved products leaves many to seek care with people who do not follow any guidelines on prescriptions and expose our patients to harm. And we can tell you lots of stories of the harmful treatments people are getting for sexual dysfunction in menopause.

So recommendations, I think it's really important to consider the different types of medications that are out there for GSM. There's local vaginal hormones, and they come in different forms. So there's estradiol, and then there's also prosterone, which is a pre hormone, basically, or pro hormone dhea, that's local.

There's also medications that can be taken orally to help GSM. And these are great for my radiation patients. I do a lot of survivorship for patients with cancer, and they need oral meds.

So, as I said, the right medication for the right patient and many of the laws that we have in the coverage is really one medication from this clinic class, creams. Well, we can't give creams to women with hormone sensitive breast cancer because those are more likely to get absorbed.

I want to give them a lower dose vaginal estrogen. They can't access it. Their insurance won't cover it. And so we need to have more coverage for a variety of medications. We need coverage for perimenopausal women to get access to the FDA approved medications for Low desire. They are FDA approved in premenopause, so perimenopause does qualify.

But there's very limited coverage for these medications. And this is, and this is, you know, different. Well, people always ask me, is this different than what's approved for men? I'm actually married to a sexual medicine expert, urologist, and I spend a lot of time talking about the research and the data and the coverage for men versus women.

He'd be happy to testify, too, because he'll, he argues with me that it's the same for men. It's not true. We need regulation and oversight for off label use of hormones, focusing on the role of professional guidelines for off label use. Testosterone is not going away. There will never be an FDA approved product.

So if people are going to be using it, we need education and we need regulation for how people are using it. And with that, I thank you for your attention. I look forward to questions later in the. Thank you very much.

I just have one question, which is you mentioned, and maybe I misheard you, are these medications you're talking about psychotropic.

They work on neurotransmitters, so we call them psychotropic medications, basically. So the largest sex organ is the brain, and so the locus of desire is in the brain. And the neurotransmitters specifically are, dopamine is the main neurotransmitter. And so drugs that affect dopamine are going to be the ones that are going to increase desire.

And so the first FDA approved medication is called flobanserin. It was approved in 2015 under lots of controversy. I can tell that story all day long. It's got data in post menopausal women, but it is not approved for them again because the standards of getting approval are so much higher, even though it's a serotonin drug. Right.

It works kind of the opposite, but in some ways to the serotonergic drugs that we're familiar with. The second drug was approved in 2019 called bremelanotide, which works on melanocortin four receptors. It is an autoinjector, and it also is only approved for premenopausal women, again, because it's much easier to get approval for them than postmenopausal women.

That is fascinating. And I think we know. You know, and there has been, and Senator Eggman has done work on the health of people as they age. And as you mentioned, we know that our seniors age with better brain health and other things when they are in relationship. Right. When they are not.

You know, loneliness is a real indicator. Yes. So I think it's really critical that we look out for that.

I want to acknowledge that we've been joined by the chair of health on the Assembly side. Assembly member Mia Bonta.

Good morning. Thank you so much for both of those presentations. I was just wondering for either one of you who previously spoke, what is it that you think that we could do better at the state level? Because a lot of what you're referring to is either we need more studies.

The FDA needs to move quicker as far as, you know, med school training and curriculum, that's really under the purview of ACGME and ACOG guidelines as to what our residents should be trained in.

But as far as from a state's perspective, given the fact that this is a field that is so, I mean, it's completely evolving so quickly. I mean, when I was a resident, we didn't have half the things that we have today.

And we want to ensure that we're doing all that we possibly can from the state in a safe manner because, like you said, patients are seeking these things out and oftentimes going to people who are untrained and getting all of these, you know, non FDA approved, bio identical hormones and putting themselves at increased risk for other things like, you know, uterine cancer.

So what is it that you think that we could take away today that we could do from a state perspective?

Well, I think that one of the big things is really, number one, raising awareness, because I do think that we need to spend effort and time and money on just awareness of that. Menopause. What is menopause, first of all, what are the symptoms that are associated? How does it impact short term, long term health, just education.

But also, I do think that there has to be effort placed and priority placed on the institutions. They get the money, but then what do they do with the money? And, you know, I don't think, like you said, it's not necessarily that they're not getting money, but they're not prioritizing this.

And I'm not sure from the state level how that can be sort of incentivized to the institutions or mandated or, you know, because I don't think that this is going to work where we just leave it to the institutions to figure it out. It depends who's running the place.

And I would also add that my understanding is that the state does have the power in some ways to mandate coverage for certain types of treatments. And so one of the focuses that I really wanted to emphasize is that we need to expand coverage for the right medication for the right patient.

And there's different medications that target different aspects of the menopause transition.

Yeah. And I want to highlight these two ladies over here because they do have a Bill that does expand coverage. But I think even with that 11 of the concerns was originally was, like, bio identical hormones, which is very broad. And it's like, okay, we need to bring it back to FDA approved bio identical hormones.

So, you know, we are, I think.

It's a great Bill. And so I think that. And there are other categories of medications also that I think fit into the menopause transition that could be considered. And I definitely agree that this kind of explaining what bio identical hormones means from the layperson's mind versus the physician or clinician's understanding is a little bit different.

Thank you. And I'll just add on that one of the things that was challenging about drafting that Bill is there's not consensus right now. So when you draft a Bill and say menopausal care, we knew we were leaving that in the hands of the plans. And so you have to.

That is part of our, you know, challenge in all of this, because when we don't have consensus around what should be covered, at what stage in life, it is harder to ensure that the right things are protected. But that's the work that we have ahead of us.

And I know Doctor Weber has been a huge help in that.

Yeah. And I think, and that's, again, one reason why I'm asking, because a lot of this has to be flushed out from studies and what, you know, FDA approved, even though this is, you know, very variable, this is one of the areas in medicine where it is very individualized. Right.

It's not like a one size fits all, but we do need more information about this. And unfortunately, what has happened with the Whi study that really just kind of halted things. So. But just wondering what your thoughts were, what we could do more from the state level. Thank you.

And that's what Assembly Member and I were just saying that hopefully doing an audit on what percentage of the funding is going for everything, at least we can get a baseline look and then we can start ordering if we need to. All right, we're going to move on now with Doctor Katrina Mitchell, breast surgeon at Sutter. Thank you.

Thank you for the opportunity to be here today. My name is Katrina Mitchell. I'm a breast surgeon and lactation consultant and perinatal mental health provider in Santa Barbara. And I'm going to be speaking briefly here on the unique needs of breast cancer patients in relation to the hormonal changes they experience in their breast cancer care. Let's see. Okay, so this is just kind of the age span of the patients that I took care of in 2023. And you'll see that the over 50 age group, that's largely my breast cancer patients. So I will say I have a handful of lactating patients in their early fifties.

Under fifty, this is largely my perinatal mental health, health and lactation population. But unfortunately, with the increasing prevalence of young women's breast cancer, unfortunately, there is a decent proportion of these patients that are also my breast cancer patients, and in fact, patients that overlap with lactation and breast cancer. So this image here is actually one of my patients from England who was breastfeeding her toddler at the time of her right breast cancer diagnosis, and she had a right mastectomy and continued to breastfeed her baby during that time.

So this is important because with very few exceptions, breast cancer patients will receive chemotherapy and or endocrine therapy, which is hormone blocking medication that results in premature menopause or worsening of their existing symptoms. So every day I hear patients talk about vaginal dryness, urinary complaints, joint pain is a huge one.

Hair, skin and nail changes, libido, sexuality concerns, energy, cognition, the brain fog we're talking about. This happens to women even in their thirties and twenties when they're undergoing breast cancer care. And this patient here is Miriam Dance. She's one of my patients who became the face of the Breast Cancer Research Foundation ad campaign in 2021. And I have this framed in one of my exam rooms, and I look at it every day and think about what can we do better for Miriam and for patients like her? So these are our non operative requirements for our breast surgical oncology fellowship.

And as you can see, none of these relate to helping patients with the main side effect of our therapy, which is the hormonal changes. Fortunately, there is increasing research and awareness of the fact that vaginal estrogen therapy is safe for breast cancer survivors. But I think, as Doctor Rowen had mentioned, that coverage can be variable. So the lower doses of vaginal estrogen that we want to use in some of these patients is prohibitively expensive in terms of patients actually utilizing this care.

And I'm also so glad that she mentioned the genitourinary syndrome of lactation, because this is, I think, probably even more under recognized compared to the genital urinary syndrome of menopause, though the symptoms are the same. And fortunately, this is starting to be more talked about in the breastfeeding lactation medicine world. But we still have a long way to go. So when I think about what legislation can do to improve these barriers to care and education, I really think about diversifying the physician and provider workforce.

This is my OR scrub Nicora and my medical assistant, Maria, and they both want to further their medical education, but have different challenges to do so. And I just think about where we would be today if people like Nicora and Maria had a seat at the table to begin with. And I really, actually can't be here today without just mentioning one slide on this topic, that beyond the hormonal changes with breast cancer care, there's a huge psychosocial impact of care related to breast cancer reconstruction.

So this is my colleague, Mark Soares, who was the last plastic surgeon between Los Angeles and San Francisco to offer insurance coverage for breast cancer reconstructive surgery. He recently had to drop this coverage because the provider reimbursements are so low that he couldn't afford to keep his practice open. So now if a patient needs a mastectomy in the central coast region, they either have no reconstruction, they have to pay cash, or they have to go to Los Angeles or San Francisco. So if anyone wants to talk separately about this after, I'm happy to do that as well.

So just in conclusion, many specialties interact with patients at times of hormonal change and often have no education on the topic. So I think when we're talking about just expanding access and expanding understanding, it's beyond OBGYNs and really just should be accessible to all provider education. And we do need increased awareness regarding safety information for vaginal estrogen, even among people like pharmacists that may warn patients that they should.

We're talking about creams and such, right?

Right. Vaginal estrogen. Yeah, but they, like Doctor Rowen said, there's black box warnings.

So. Doctor Rowen mentioned estradiol when she was talking about vaginal estrogen. So are the patches also considered vaginal estrogen?

Patches are, yeah.

Okay. Sorry. I just want to make sure we all are talking about the same thing.

Yeah. So there's a difference between systemic hormones and local hormones, but the hormones we're mainly talking about are estradiol. So when you have a patch that's going into your bloodstream to help with hot flashes, cognitive changes, sleep disturbances. When you have vaginal symptoms, we recommend placing the estradiol directly into the vagina, and that it's not going to absorb as much. And so that is the creams that we're talking about. But the main thing to understand is there's actually several different estradiol products.

The creams are the ones that absorb the most and the ones we don't recommend for breast cancer patients. So there are tablets and there, there is a ring, and there also is a tablet of prosterone. Sorry, I know you know this as well, but there's different products. And unfortunately, coverage usually only is for one of the creams. And those actually are not safe for breast cancer patients. And then it's too expensive to get any of the alternatives. Okay.

And can you get a patch and cream.

Not in breast cancer survivorship. Because the patch will be systemic estrogen, and we're talking about relieving the symptoms in the genital, urinary tract.

Okay but for traditional menopause.

Absolutely.

Insurance coverage.

Insurance coverage, you can, because they are treating two different symptoms. Now, sometimes pharmacists don't understand that, and so they'll be giving patients warnings. But the symptoms of, like I said, the systemic symptoms, that's where the systemic treatment goes. Hot flashes, brain fog, but the genitourinary symptoms, that's local and both are safe to combine together if you don't have a hormone sensitive cancer.

Thank you. Sorry to stop you, but we were just.

No, I'm glad you asked, because this is part of breaking the silence about everything I actually have.

I'll forget my question.

I have a framed in both of my exam rooms, in my lactation room, and my breast cancer room that says, ask me about vaginal estrogen. And I think it's really helpful for breaking the silence and just having patients say, oh, okay, this is up there, we need to ask about it. And people do every single day.

We will have you finish. I have more of my colleagues wanna ask questions, but we'll have you finish and then we'll get into the questions for this.

So we just talked about the cost of vaginal estrogen being prohibitive for many, many, many patients. And just the impact of care is not hormonal only. We need to address access to care issues in breast reconstruction in rural communities. So if anyone has any additional questions, this is my website, and it is dedicated to breastfeeding and perinatal mental health and the intersection of breast cancer and lactation. So please reach out.

Thank you so much. Thank you to all three physicians. Senator Rubio.

Thank you. And I know we're here to break the cycle of silence here, but earlier you said, I'm not sure who made a statement. Like, there's so many stories I can tell you about women going, you know, off the counter, and these effects that are having on women can give us an example.

I know I heard something like, it's been terrible stories, but this is why we're here. I want to hear examples of when women go outside a doctor to get these products that are not approved. Give us an example. Like, maybe top two horrific stories that you've heard of women having to go outside a doctor and then the effects.

Well, I mean. The biggest one that comes to mind, and it's still going to a provider, but not necessarily someone who's trained to provide evidence based medicine, but it's really pellet use. I think all of us here.

Testosterone pellets.

Yeah, testosterone pellets, but even estrogen and progesterone pellets. And sometimes they're all combined in one. And the problem with pellets is that they are unregulated once they get into the body system. And so the serum levels, the levels in the bloodstream just go unchecked. And I oftentimes will see patients with testosterone levels that are, like three to four times what they should be, which is extremely dangerous.

And so that's an example of, like, a patient trying to, they're trying to just go find someone who's going to help them. But it doesn't necessarily mean they're finding the right providers that really know how to kind of manage a safe, like, really help them safely.

I would say the other thing is supplements, because they really are on multiple, multiple supplements, and a lot of them do have estrogen in them or forms of estrogen and all sorts of other ingredients that really have not been studied. But also, we don't really know what's in them. And so they're not really regulated.

So can I just add, I'm sorry to interject on this, because I know someone who was taking the pellets many years ago saying, I'm taking them for years. You know, that was her suggestion in the future for me. And, you know, currently she's going through cancer. I'm not suggesting, but is there any correlation that you've seen.

So I think that depending on what type of cancer. So the thing about the pellets to understand is that this is probably more medical, but testosterone has been shown to improve libido. There's lots of guidelines that show that. And it can help people with energy, muscle mass and various other symptoms. And so when we give transdermal testosterone and we monitor it safely, it actually is quite safe to use. The issue with the pellets is that they come in specified doses. The testosterone level of a woman is one 10th of that of a man. And so men get 10 pellets.

And so in theory, it makes sense to give a woman one pellet. But the difference is that different women are going to absorb it differently and they're going to have different symptoms. And so some of them get very high levels. And there are some cancers that are sensitive to testosterone. Most breast cancer, as far as I know, is not currently being tested for testosterone receptors, but that there are definitely hormone sensitive androgen receptors, which testosterone is an androgen. And then there is some concern about androgens and other types of cancers as well. But in general, the data is actually quite reassuring in terms of testosterone not causing cancer. So I would actually say, as an expert in this, that I don't think testosterone has a high risk of causing cancer. I can defer to, in the breast cancer world, a little different.

I think it's more the issue of the lack of regulation. And it's one thing if you're able to actually study the medications and have large patient cohorts and make clear determinations about risk benefit. But when you have people that are providers, that are not trained and existing because of the void of medical education on the topic, that that's when you get into trouble. And I can say that exists with lactation also, even though we are mammals, because we have mammary glands, there is no education in medical school or any other health professional on lactation.

And I want to add also that we have good long term data on patients on gender affirming hormone therapy, especially high doses of testosterone. Those high doses, much higher levels than what we're giving to anybody for menopausal symptoms or libido. Those studies are quite reassuring in terms of health side effects, cardiovascular disease, breast cancer. There's actually lower rates of breast cancer in one study that for people that hadn't had mastectomies on high dose testosterone therapy. But again, if someone gets a cancer that is hormone sensitive and they have a pellet in them, you cannot take that pellet out and it can last for months.

The other kind of not horror story, but one thing I do want to bring to attention is that hormone therapy, the big cancer that hormone therapy does cause is endometrial cancer. Specifically estrogen unopposed. And what that means is when we give estrogen, it stimulates the lining of the uterus. And if you don't do something to oppose that, you will develop endometrial cancer. What we give to oppose it is progestins or progesterone. Many people who are not trained and are not familiar with these cancers are giving people high doses of estrogen, and they are not properly giving them progesterone. They are giving them bio identical compounded products.

They put that on the skin, it does not get absorbed through the skin. They're giving them sub therapeutic, maybe oral. However they're doing it, they are not giving them proper progesterone. So I had diagnosed several women with cancer because they were being given estrogen and not counseled or understood appropriately how to use and how much progestins or progesterone they needed.

Again, why this is so frightening and why we need to do so much work on it. And I see Doctor Gunter is itching to get in. So you haven't gone yet but.

Doctor Gibson, I just want to note another thing that I see that people are doing kind of on their own for self medicating, especially for menopause symptoms, sleep difficulty, the joint aches and pains and mood is self medicating with cannabis. And we just don't know about how helpful or harmful that may be. Of course, if somebody is smoking anything on a daily basis, which you may do if you're having sleep difficulty and pain and anxiety on a daily basis, some likely health concerns there, as well as potential for dependence and cannabis use disorder. So that's an area of active research, but definitely something that we're starting to see a lot of hints around.

Chair, may I ask just this last comment, and I think I'm so thankful that you're having this, because just like I explained to you that I'm getting advice, that's what. Because there's not enough.

Everybody gives advice.

You rely on your friends telling you what to take and when to take, and you know how it helps. And yet we're all relying on, you know, just word of mouth, which is really scary. And so thank you for putting, just highlighting this issue, and we need to bring it to the forefront. So thank you too, all of you, for putting this together. Appreciate it.

Thank you. And thank you for this presentation. Very familiar with Doctor Mitchell's work. I'm a big fan of hers. You know, one of the things I think that came up was just these deserts we have. And so I'm wondering if in the audit report, in addition to looking to finance, we can think more broadly also about where the deserts are. You know, rural California certainly is going to see. We know this in every specialty area. There's no question about it. We see it on a regular basis.

But to only say that or to only have providers in Los Angeles and San Francisco really leaves out maybe 40% of the people that live on the coast. That's a lot. And there's a lot of different reasons why that happens. But I do want to acknowledge that point that was made and how serious that is in terms of getting care. People can't always go to Los Angeles or San Francisco. They can't make that trip. And that means that they will be, you know, we will have limits to the access to care. And certainly this is not the only space we see on a regular basis, particularly in rural California. So I just want to acknowledge that and thank you all for your work and really helping us think through this issue. And San Diego, like the big cities, right? Like the big cities.

Yeah, but I represent the Central Valley. Right. You have a high degree of immigration, you have a high degree of poverty, and you have a very low degree of healthcare and access. And, you know, again, 50% of us are women.

And I'll point out our Medi-Cal deserts and our urban environments as well. So we have our own version of these healthcare deserts for people who can't afford it. I'll turn it over to.

Yeah, I just wanted to speak specifically to the reimbursement rates that you mentioned. Are you finding that there's a differential in reimbursement rates for different regions of the state that are causing.

Are you asking about the breast cancer reinstruction? Yes. So the way it's designed is that the insurance companies want people to go to centralized areas like Los Angeles or San Francisco, in big centers. So in the rural areas, the compensation to hospitals that don't have competition is higher, and the physician reimbursement is incredibly low to the point that they literally can't afford to keep their practice open. They. Most of them, like Doctor Soares, he was supporting his breast reconstruction practice with cosmetic practice on the side. But then there's just a point where when you get paid $500 to do a 12 hour flap reconstruction for breast cancer, you just can't do that.

And what's the rationale that the insurance providers give for trying to centralize?

That's probably a more complicated question for insurance companies, but I think it really does have to do with the ability to lobby. Bigger hospital groups can lobby the insurance companies better than individual physician practices in rural communities, but it's, it's absolutely devastating. And he just dropped insurance this month, and it's awful to talk to a woman. And I feel like the message is that we as a culture and a medical profession don't care about you.

You know, there's, there's just no other message for a woman to be sitting there with an, you know, a really life changing breast cancer diagnosis and then to be told that she's going to have to pay cash or get no reconstruction or if you're from San Luis Obispo, drive all the way to LA or drive all the way to San Francisco if you want reconstruction, which is obviously an incredible financial hardship and delays care.

And is there a scarcity? I mean, the idea that you'd have to go to LA or San Francisco or San Diego, is it because there's a scarcity of providers?

No, the scarcity is in the fact that there's enough plastic surgeons, but they're reimbursed so poorly for breast cancer reconstruction that they don't accept insurance. It's not that it's a law, obviously, that insurance companies have to cover breast cancer reconstruction, but their physician reimbursement rates are so low that they can't afford to do that.

But in the larger areas they can because there is a larger volume.

There's bigger lobby, there's, the hospital system can absorb the cost of, for example, flap reconstruction, where you use your own tissue to reconstruct the breast, is the best and most durable reconstruction, but it is labor intensive for the hospital and for the surgeon.

Commercial insurance, not just Medi-Cal rises.

Commercial insurance, yes.

Yeah. Does Medi-Cal pay?

Medi-Cal reimbursements are way horrible, too.

It's not great. Medicare, really, which, you know, the commercial insurances follow Medicare, so the dropping physician reimbursements for that. And it's not that people think that plastic surgeons are just trying to make a bunch of money on patients, and really this is providing service to women at incredibly vulnerable times in their life, and it's just devastating.

Well, I want to thank you. I have a friend who had to have a complete hysterectomy, and she was in perimenopause, said to her surgeon, does this mean I should go on hormones? The surgeon said, I don't know about that. I just do the surgeries. And so she didn't.

And now she's seeing injuries from the joint impacts of such rapid menopause and the like. And so it's just so critical that people who see these patients that have these medically induced menopausal symptoms are treating them, their whole body, and not just, you know, the specific thing they're in there to do.

So I really appreciate your research and talking about it and the push for education and care, because it is really, really important. So. And one of the things you guys mentioned that I just wanted to touch on was sort of this way in which the insurance only covers people at certain phases. Right. So you mentioned women, I think, who are lactating and their need for care. So does the insurance company actually dictate when in someone's life they can have coverage for this specific drug.

Or is that because of approval? FDA approval.

Oh, okay.

Yeah, it's FDA approval. And so you have to be very specific. So, again, for drugs that are considered for menopause. Right. So these are like the vaginal hormones, for example. These are menopausal drugs considered for vaginal dryness and menopause. If you're premenopausal, it's going to be harder to get them.

Some people can get average, but they're going to dictate exactly which ones you can get. And some of them are a little more effective and also more tolerated by patients than others. And then the sexual desire drugs that I mentioned, that's FDA approval completely. FDA does not approve postmenopause, but very few insurances even cover for premenopausal women. These medications.

Thank you.

Okay. Thank you to the three of you very much. I'm sure we'll have more questions as we move on. But moving on, talk about addressing disparities, and we're going to hear from Kimberly Robinson, Community Liaison for Black Women for Wellness Northern California, and Carolyn Gibson, PhD, MPH, Assistant Professor, Department of Psychiatry and Behavioral Sciences, UCSF. Miss Gibson.

Hello, everyone, and thank you. I am honored to be a part of this discussion, and I have learned a lot just in the time being here, so I appreciate this. I am Kim Robinson, the Community Liaison for Black Women for Wellness, and I work out of our Northern California office in Stockton. And Black Women for Wellness, we are a statewide reproductive justice organization committed to improving the overall health status and well being of black women and girls. And we work to achieve this by building the political and electoral power of black women throughout California.

And so we believe in a just and equitable future for black women, and as such, engages in policy and legislation that advances equity as to affect systemic change. And so this conversation is important to myself. Being a woman of color over the age of 50. I can't believe I'm saying that, and also my organization and the community that we serve because we bear the disproportionate burden of the institutional and systematic inequities that lead to poor health outcomes, we also have devastating and lasting impacts on the black community, and a core tenet of the reproductive justice framework which guides our work is a recognition of basic human dignity.

With mounting research that establishes the role of implicit bias in health outcomes, rigorous trainings that's grounded in reproductive justice values that stand to improve the quality of care we're seeking is a simple step and a minimal ask for the harms that are inflicted due to not addressing one's bias. Unconscious racism and implicit bias is also a determinant of health disparities. Discrimination due to implicit bias must be addressed because it is unnecessarily decreases the quality and length of life of people in our country who are not white.

Unfortunately, implicit bias is a key determinant of healthy that current civil rights and other legal frameworks are ill equipped to address effectively. Black California has experienced disparities in care and outcomes. Due to OBGYN department closures across California, which have been mentioned here today. There's a lack of reproductive health services and expertise in medically underserved communities, which have also been discussed as well. Implicit bias this significantly affects interactions between patients and providers providing treatment decisions, adherence to treatment, and actual health outcomes.

Studies have shown an Association between implicit racist bias and diagnostic uncertainty, and for black patients, negative ratings of this clinical interactions causes less patient centeredness, poor provider communication, under treatment, under treatment of pain, and providers views of black patients as less compliant with treatment recommendations.

In some testing, implicit attitudes were found to be significantly related to patient and provider interactions and health outcomes, or more often than treatment processes. Evidence suggests that implicit bias can hinders the provider's ability to accurately assess patients views on treatments, curtail productive discussions, and undermine trust and engagement in care, leading to less follow up and worsened adherence to treatment plans.

Changing the way the healthcare provider recognizes and overcome their own implicit bias when treating black women is a critical step in addressing the racial disparities. I have personal experience with the healthcare system where my concerns about my health was not addressed. After three years of having irregular menstrual cycles, I thought I was premenopausal and then I began having really heavy menstrual flows, oftentimes having to call out sick from work because of fear of bleeding through my clothes. I contacted my provider monthly because I was concerned that I would bleed to death.

I'm also anemic, and so I was concerned about the amount of bleeding that I was that was happening monthly. I was told over and over that I was probably entering menopause, and I had to just wait it out. I changed my medical provider three times because my concerns were not addressed. I finally found a provider that listened to me. After several series of tests, it was determined that I was nowhere near premenopausal. It was finally determined that I had three fibroids that had various sizes, and I was also severely anemic. At that time, my hemoglobin was an eight. The doctor advised me that if my hemoglobin went any lower, I would need to be hospitalized and receive a blood transfusion. So this happened to me. Someone who knows how to navigate the system, someone who knows how to uplift my voice.

And so this is concerning to me because what is happening to those who can't advocate for themselves or don't know how to navigate the systems? So I cringe to think of what is going to happen moving forward. In addition to my situation last year, I had five friends who was experiencing similar symptoms, and the recommendation that was given to them was to have a complete hysterectomy as treatment. I also had a friend who tragically died because her concerns were ignored and she hemorrhaged to death in her home alone.

So I thank you all for being champions on this issue. Black women across California deserve better treatment by healthcare systems. We deserve healthcare that's grounded in comprehensive, evidence based approach. We deserve providers that will listen to our concerns because we know our bodies best, and we deserve policies that will hold these systems accountable. So please continue to uplift the voices of our black patients. Thank you.

Thank you so much for sharing that story. And I could see the physicians over here just being horrified as you were describing what was going on. Cringing right. Because it's in hindsight now, but as you're living it. Right. And again, you are not alone in that experience. I think that is the point that you're trying to make. This happens every single day in a world of abundance.

Yeah. I want to thank you. We had a chance to hear in different hearing from a researcher at Stanford who's researching these exact issues about fibroids, hysterectomies that are resulting when full in women going into early menopause, and the way black women are being cured for their heart health and all the other ways that it impacts women. And that research is so important, and then it's also important for our physicians to be trained on that research so that it can get to the patients who need it, but.

It's just so upsetting to hear again and again about, you know, people who are seeking care and aren't getting the care they need in our great state. Right. We are supposed to provide some of the best care in the world, and yet this is happening to women of color. So I just want to thank you for giving voice to that and reminding us sort of who we need to pay attention to.

It happening to all women, but especially to women of color. Thank you.

Thank you so much.

Thank you. Moving on now to Doctor Carolyn Gibson, Assistant Professor, Department of Psychiatry and Behavioral Health, UCSF, and you also have affiliation with the VA.

I also want to lift up something that Doctor Mitchell said that relates to the testimony we just heard, which is if we diversified our healthcare provider workforce, I think it would also make a huge difference in what we're talking about.

Remember when all doctors were men.

Sometimes it's like an intergenerational trauma that some female physicians have not had good care themselves. And then, unfortunately, that translates into their personal experiences translate into the care that they provide other patients. Like, we see that in surgery, certainly with the intergenerational trauma of surgery training.

Yeah. I think I had two women physicians who both said to me what I was told my whole life, like, we just suffer through it. I think that we, as women, are taught and that our women providers heard that their whole life.

And I finally found a male provider who had trained himself, he said, because his female colleagues were saying this, and he thought, why do they all think they need to suffer through this? Because he had not been given that message as a man. And it was fascinating to me to sort of, he put that together for me.

He said, I kept saying to my women colleagues, why aren't you, you know, why are we doing more? And they're like, well, it's just what we do. And that does not have to be what we do.

I also do think, and I was thinking this during lots of the speaking, that there's this interesting element about menopause, that people only pay attention to it when they go through it. And we don't talk about that with, like, cardiology, right? It's not like someone's interested in a heart attack because they know someone that went through it.

Why is this thing that's affecting half the population only becomes relevant when you actually experience it and it has so many medical side effects?

And I think it's also, I mean, the risk of that is exactly what we just heard, which is we need to know. And the age span in which women go through it, which you all know better than me, is actually incredibly broad.

And so we need to know enough to be able to seek the treatment, ask the right questions, know if this is what it is or not. And you have to learn that before, or else there's no way.

Yeah. Echoing that is just that, you know, it's better to be aware. We need to start younger because it's not just about the short term effects and the smooth transition. It's actually the long term impacts that-- I mean, really, all the organ systems are truly affected, and so we should be doing better from an earlier age. So I would even say that just like everybody goes to the pediatrician during puberty, they have a place to go. For pregnancy, they have a place.

But there is not that feeling that you should really get that understanding of what you're going to go through before you even go through it in menopause.

I just wanted to thank Ms. Robinson for your testimony. As a black Latina, this is particularly important for me, and I just wanted to highlight some of the things that you talked about in the research, in background materials that we get.

Black women are half as likely to use hormone therapy to treat menopausal symptoms as white women, despite having greater symptom burden. There are the kind of secondary issues of higher incidence of dementia, more likelihood of suffering from Alzheimer's and other related issues, more likely to suffer from cardiovascular issues.

So there are all these kind of secondary, untreated issues because the menopausal transition is completely ignored for the majority of the black community in particular, and Latino community as well. So, you know, I think incredibly important that we have culturally concordant care providers for sure.

I also think that there's an incredible dearth of research that is centered around black and Latino women and their experience through menopausal transition. And what we can do as a state is making sure to focus our research dollars from the brightest minds on making sure that we're centering that experience in a way that we're not doing right now.

Thank you for uplifting that. And I want to add, my mother, at age 60, started with early signs of dementia, and now at age 70, is in the other side of that, declining. And so thank you so much for uplifting that.

And when talking with providers about, you know, symptoms and what she's experiencing, and even when me going through what I was experiencing, I asked my provider, I said, do you ever think outside the box? Because what is right for one person is not right for everyone? And she looked at me and she was like, no, not really. I said, well, that might be a part of the problem. So, yes, thank you so much for uplifting that.

I was just going to say that. Exactly, it's not one size fits all. Everybody's coming into menopause with different health history, different ethnicities, different genetic predispositions, different lifestyle practices. All of that matters. And actually what even matters most is really what do the patients want. What do they value? All of that has to be taken into account when we see a patient and they're coming to us during that menopausal transition.

And let's talk about the impact on our mental health. Yes, that's what I want to hear.

All right, thanks. I'm Carrie Gibson. I'm a Psychologist and Health Services researcher. So I must this talk briefly about mental and behavioral health in the menopause transition.

So when we think about those most commonly reported and most commonly reported as negatively impactful during this period in the lifespan symptoms, mood symptoms are kind of at the top of the list right there, with hot flashes and night sweats, sleep difficulty, and genitourinary symptoms. And those mood symptoms can be depressive symptoms, anxiety, irritability, complaints of just not feeling like myself, and different aspects of mood and well-being that affect our health and day-to-day functioning.

And mood symptoms often coincide with, influence, and are influenced by these other common menopause symptoms. We spoke already about potentially the impact of genitourinary symptoms on sexual function, on relationships, how that can affect our mood and well-being on a regular basis.

Can make the same case for the co-occurrence and bidirectional relationships between mood symptoms and all of these common menopause symptoms. The menopause transition has also been examined as a window of vulnerability, not just for mood symptoms, but for clinically significant mental health diagnoses. Just like we think about other periods of reproductive change across the lifespan like postpartum or puberty.

This has been most well examined with depression, which is still a bit controversial, but generally evidence shows that women may be two to four times more likely to have a depressive episode in the menopause transition than other periods in the lifespan. That may be particularly for or limited to those women with a history of depression prior to menopause.

Over half of women report problematic sleep difficulty during this period that may be raised to a level of clinical insomnia for up to one in four women in the menopause transition. We know insomnia is a risk factor for a number of mental health concerns as well as coincides.

And then more research is needed but there is suggestive evidence that the menopause transition or a higher level of menopause symptom burden is related to increased risk for or worsening of a range of other mental health concerns, including substance use disorders, eating disorders, PTSD, anxiety disorders, serious mental illness, and suicide risk. And so where is this vulnerability coming from?

At every point in the lifespan, we think about the biopsychosocial model to explain mental health and well-being. Basically that there are biological, psychological, and social factors that contribute to risk. And when we think about the menopause transition, there's a lot of extra biological and social factors that are at play.

So things like hormones, aging, physical health, and other these medical conditions, pain, those other menopause symptoms and social factors, aspects of upbringing, of background trauma stressors, things that affect health across the lifespan are important social connection.

And then also think about the number of life events, role transitions, as previously mentioned, peak career, complicated caregiving responsibilities, the amount of things that women are juggling, particularly in their forties, fifties, and sixties, when they're most likely to be also managing these symptoms and risks.

And then also psychological factors like engagement in protective or adaptive or less adaptive coping skills, health behaviors, cognitive appraisal, or the way we're perceiving symptoms and experiences. And again, that's psychiatric history. And so what do we do about it?

We have a number of evidence-based treatment options that have been shown to be effective for depression, for insomnia, for other mental and behavioral health concerns in the menopause transition. I'm a psychologist, so I focus on the non-pharmacological treatment options that are kind of part of our gold standard.

Foremost among these are cognitive behavioral therapy, which has been shown to be effective for depression, for insomnia, and even for reducing the negative impact of hot flashes and night sweats for women specifically in the menopause transition.

But ideally, I'm not working alone, right, that I'm working as part of an interdisciplinary, integrated care team that is using all of the evidence-based approaches in our arsenal in a coordinated fashion with kind of knowledge and information about all of the unique concerns that come up during this period in the lifespan to effectively treat all of these menopause symptoms and to address mental health and behavioral health concerns during this period to address the whole health of women. So thank you for your time. Some references and my contact information.

And how often does that happen? That we treat the whole person.

That's the goal, right? I'm excited to learn more about the UCLA Center. I'm part of the workgroup trying to establish this at UCSF. I think we're increasingly seeing these types of centers across the US. I'm excited about them, and I think it's important that mental health has a place at the table in these types of centers. And I don't think we know yet. It's pretty new.

And I was going to say all three of the physicians, when you're treating, are you also addressing and referring for mental health issues?

Yes, we are. I will say the major limitation is insurance coverage. So even at UCSF, where we're relatively insurance agnostic, I see everybody, and it's one of the things I love about working at a public institution like that.

So we have, you know, public/private insurance, but when I refer for psychiatric services, they will not take any public insurance and they won't take a lot of private insurance as well. And no one in the community will take any insurance.

Yeah, we have a similar problem. We do have some--we are able to see some of those patients, but there's such limited access and there's so few, honestly, psychologists and psychiatrists that actually want to take menopause seriously.

So we are looking and really trying to kind of find those reproductive psychiatrists, honestly, because they take a lot of interest in wanting to take care of our patients, but we have not been able to really get buy in.

It's really hard to get psychiatrists and psychologists that really want to focus on this, you know, and I will tell you that out of the 500 patients we've seen so far, one in three patients needs to see someone. Either it's because they're the first time having symptoms, or it's that they're having a relapse of prior, you know, clinical depression or anxiety.

Or relationship transitions.

It's a huge need.

I would say that's why I did the perinatal mental health training, because I was seeing so much need in my lactation and my breast cancer patients. And our group that offers insurance coverage has a two year wait for psychiatry. And psychiatrists that are in private practice in our community start at $700 or $800 a visit.

I said, I'm in the wrong specialty. But the, you know, so just being able to provide what I call basic primary care of mental health, what I'm doing is not complicated. And I do refer to UCLA's Reproductive Health Center for truly complicated mental health conditions. But a lot of it is just things that other providers can do alongside their daily practice with just a little bit of education.

And I think that is such a critical point. I mean, we all know as people who head into the doctor, I am almost never asked about my mental health at my checkup, whether it's my OB or my primary care physician.

And I think we've done a really good job in the postnatal period of integrating that into care, but we have not done the same thing as it relates to menopausal care. And so I think it is something we should work on. And again, I think we're doing it more at the pediatric phase now. So we're thinking about whole health care in certain phases, but this is not one of them.

One point I think that's really interesting is I've seen several patients who were treated for psychiatric symptoms of menopause with psychiatric medications that cause significant side effects. I saw a patient get diabetes. I've seen patients get suicidal when what they needed was some hormone therapy.

And it's really fascinating how the downstream effects of the WHI, that most of the people in practice right now are so unfamiliar and uncomfortable with even the idea of medications that they can't recognize that these psychiatric symptoms may actually be cured with some hormones. Not all, and we definitely need, we need more therapies and more access.

And additionally, at UCSF, we've had an incredibly challenging time holding on or retaining any mental health provider because they are very interested in it. They will start for a few years. They will get burnt out real fast and realize they can make $800 an hour in the community seeing the same patients who actually have more resources, it's so unfortunate and very frustrating.

We've been working on our pipeline, but we have to do more. And I will say that I had a colleague comment to me recently, out of the blue, to say, God, you seem so much happier. And I said, well, it's my hormones.

Senator Roth and then Assembly Member Aguiar-Curry and then Senator Rubio.

Well, I'm a little reluctant to ask a question in this forum, but I have to ask this. Is there a way to introduce this subject if it's not introduced effectively at medical school at the beginning of the medical education process, where we perhaps could interest medical students in moving into some of these areas, whether it's the mental health area or provide more information to the extent we aren't in some of the areas that you were talking about, doctors? Is that a fair question for somebody who's out of place here?

You're not out of place. We need more men.

No, I think that it's a great question. Yeah. I think stemming from why there's not--there's a need for more psychiatrists, more psychologists. But I think, and I'm not sure what, like, what is the supply need? What's that balance like?

We don't have very many psychiatrists.

Well, I agree that they're just hard to also just retain because they just leave. They do leave for practices because they're making more money. And I don't know if that's the problem versus, there's just not enough going into that specialty. I don't know. Do you know the answer to that?

I think it does begin with the residency education and the medical school education. I learned from the reproductive psychiatrist that they have one lecture in their general psychiatry residency on reproductive mental health, that is mental health at times of hormonal transition, and that includes cancer care, menopause, perinatal care. It's one lecture in their whole residency.

I mean, women have more mental health disturbance than men by two fold or more, and yet we have to have something called a reproductive psychiatrist. Like, why does that even exist?

I also think it's fascinating how regional it is. You know, I mean, so I give the medical-- I'm in charge of the menopause curriculum at UCSF, and one of the things that's happening in medical schools is that people are moving out of the pre-clinical or kind of basic education years and moving into the hospital space a lot sooner.

So there's much smaller window to teach them some kind of really key, what we call outpatient quality of life issues. And so there's a big gap. And so they're trying to fit a lot into a small period of time.

And then once in the hospital, the way our medical training works is it's very inpatient-focused and that people both in medical school and in residency don't spend time in clinics. It's pretty rare. I have seen psychiatric inpatients related to menopause or peri-menopause, but that's not where you're seeing them. We're seeing them in the clinic, and that's not where our education dollars are really being spent.

And my understanding anecdotally in talking to medical students and talking to--a lot of the direction that medical students ultimately move in is the result of conversations and interactions that they have early on in medical school with their professors and other clinicians that they come in contact with.

And if they don't have a lot of contact with people who are talking about the very issues that you're talking about here now, this afternoon, this morning, then they move in another direction is what I guess happens. And that's unfortunate, based on what I've been hearing today. Thank you for letting me ask a question.

Aguiar-Curry and then Rubio. And we have two more speakers, and we're going to try to finish by noon,.

I'll make it quick. First of all, thank you very much for being here. I only wish I had this information 35 years ago because I went through menopause younger and it was miserable and no one would ever have a conversation with me because I knew something was off.

And I tried to figure it out because I was very young and I had three quarters of my one ovary taken out and over my half the other. And no one told me what the ramifications could be from all that and how my body was going to have a difficult fight. And so after one of these we had a couple months ago, maybe a month ago, there was a list given to us of signs of menopause.

And ironically, I went to a really nice dinner with five of my girlfriends, and I pulled it out of my purse and I started reading some of them and they go, are you kidding me? Why don't we know this? And so I think it's, a lot of it just has to do with education, who to go to and ask the right questions if you're a provider, not all of them are going to have that answer.

But to struggle as many years that I did for sleepless nights and being crabby, and they diagnosed with fibromyalgia, you name it, I got it, anxiety, heart palpitations. It was miserable. I weathered the storm because my mother had breast cancer. And they said you couldn't take any hormones and you couldn't take anything.

Now, times have changed, but I just want to say that we need to get more education out there so that women aren't afraid to have these questions. But I want to just commend Senator Roth for being here today, because how important it is is that our men friends know what's going on as well and have some compassion and empathy and understanding while we go through this time. And it'll save them a lot of headaches as well.

But I just want to commend you for being here today. I would love to stay longer, but I've been called elsewhere. But thank you very much. And thank you for putting this on, Senators and Assembly Members. It makes a big difference to me. And I'm going to take this tape from all three of those and give it to my kids.

All right. Senator Rubio.

Thank you. Yeah, it's a lot of aha moments for me, just in terms of never having heard, not there yet, but never having heard that from my parents. Because we're taught to, even sex, right--we come from a Latino family that you just don't talk about these things.

But now I'm going to transition in my role as a teacher because, you know, as a administrator, assistant principal, I've had to chaperone a lot of the sex education courses that we give our kids, like in fifth grade. And it just occurred to me that, I mean, I know we separate the boys and the girls, and then we teach them, but it's also about sex and puberty. But I don't recall ever hearing anything about menopause.

And I think it's, I think critically important that if we're going to teach girls about sex and, you know, their periods and everything that they're going to experience--I think we catch them about, I think it's 10 years old.

I think that we should include the other end, not just, you know, you're going to get your period and this is what's going to happen to you. But look out for when you're 50. You know, this is menopause, even just saying the word and making sure they know what it is.

And because it's interesting that we teach at the beginning and, but we don't do it. And I was just thinking, you know, possible bill idea is making sure that that sex education includes the other end, which is menopause.

But as I was hearing you talk about how we have a hard time retaining people in that profession, same thing. My experience as a teacher, we're offered these grants that if we put in 10 years of our teaching lifecycle into a lower income community, they pay some of your education off.

And I was thinking also possibly a grant program that would incentivize medical students. I know that it's very expensive based on what I hear from friends and other people, it's so expensive. But maybe having a program where we reimburse someone for staying five years or 10 years. That's how the teacher grant program worked.

I think you had to after five years, you'd get a certain amount of money. After 10, then they would pay the rest. And so that's so important because instead of wanting to take off and go make $800 an hour, they would be committed to staying because that's going to pay off their loans, right?

So anyways, just some thoughts to put out there. And we have to say it out loud because, you know, the budget is having a hard time these days, right? But these are important conversations and it's so important that we put funding into the research, into grants, whatever we need to do to educate and make sure that there's access, especially in the black and brown community. So thank you for that. Just want to put that out there.

Thank you. Another area I work on is end of life. No one likes to talk about that either in the healthcare field. We all go through menopause and we all die. John Lewis, MPA, and you're going to talk about California health benefits.

So thank you. My name is John Lewis. I work with the California Health Benefits Review Program, and I want to focus on benefit coverage for the pharmaceutical drugs that are generally discussed around treatment for symptoms of menopause. And what is that benefit coverage look like among people enrolled in commercial health insurance?

In general, when we're talking about these drugs, they kind of fall into two big categories. The hormonal is the first set, and for those that are manufactured, there are about five therapeutic categories and about 24 drugs. Many are available under multiple brand names. They can be oral, topical, transdermal, or vaginal.

And by the way, this set includes the manufactured bioidentical hormones. And I want to underline that because then there's this separate group, the compounded bioidentical hormones. Those are produced on demand by a compounding pharmacy, and their production is not regulated by the FDA. They also, though, can vary, so they can be oral or vaginal or topical.

In terms of commercial health insurance enrollees with on-formulary coverage, we looked recently and we think about 100% of these enrollees have coverage for one or more of the drugs, for almost all the therapeutic groups. But there are exceptions, and some of them notable.

Only about 8% of enrollees had coverage for the vaginal estrogen high-dose ring, or Femring is its commercial name. And about 91%, even though that's still a fair number, had coverage for the compounded bioidentical hormones. In terms of the other big set, the non-hormonal drugs, these are generally oral, and they include about five therapeutic categories.

For the antidepressants, about eight drugs. Anticonvulsants, about two drugs. Drugs to prevent or treat bone loss, about nine drugs. There are two outliers, though. They're essentially sort of categories unto themselves at this point. The neurokinin receptor antagonist, the Fezolinetant, and also the selective estrogen receptor modulator, Ospemifene.

And in terms of coverage for folks, for enrollees in the commercial world on-formulary coverage is, you know, pretty close to 100% for one or more of the drugs for almost all the therapeutic groups. But the exceptions here, only about 7% for Fezolinetant and only about 13% for Ospemifene.

I would note that these very low numbers we see, they're generally newer drugs, and that's fairly common. As drugs come out, coverage is often fairly limited, and as they are around longer, they may become more commonly covered. It's somewhat of how the constantly evolving science behind medicine is reflected in the constantly evolving ways in which health insurance addresses various things.

Then do we judge efficacy by use?

It varies. That's a long and complicated question. And it's back to not only the insurance companies themselves, but as was brought up earlier, what is the FDA willing to actually make statements about?

And this is also somewhat all over the board, as the suggestion was made, there's some real hesitancy around getting things approved, particularly for menopausal women. This is beyond my program scope. We're aware that federal issue is large. I did want to just really underscore again, there are medically effective prescription drugs that can reduce or abate menopause symptoms.

And the on-formulary benefit coverage is pretty broadly present, though likely any one could be only for one. If there's a set of competing brand names, it may take a while for newer drugs to be on-formulary from most enrollees. Any questions?

So I saw the doctors seem to have some thoughts about this presentation, so I would be curious their thoughts.

Well, I think, first of all, just talking a little bit about compounding, and I think that there's this notion of compounding bioidentical. Like, a lot of our patients don't understand it.

I'm curious if you all understand, because I feel that when people talk about, they feel that it's better, patients really feel that compounding is better when in fact it's not regulated necessarily. And we have bioidentical, FDA-approved medications. So we were just talking about the fact that, why are we calling them compounding bioidentical?

Everything comes from a plant. Even bioidenticals that are FDA-approved or compounded, they're all coming from a plant. Bioidentical just means that it's identical to chemical structure of the hormones that are endogenous in the body. Compounding is just, it's formulated. We don't know what's going in there, honestly.

So we do use it, but it's definitely not the mainstay. I would say that we try to stick with the FDA formulations if possible, just because we know what's going in there.

I think that we were just talking about the fact that some of the, some of the times when we get, you know, denials for medications, the alternatives that are brought back to us don't make any sense, right. So they'll be like, oh, we won't approve a vaginal estrogen. And they'll say to use, because you need to try a systemic estrogen first, which doesn't make any sense because totally different purpose. So we were just talking about that.

We were also talking about, there's lots of different types of medications that are out there, and so the coverages vary. And what's interesting about hormonal medications is they can be used not just for menopausal purposes, but I was just talking about, you know, there's many reproductive-related mental health conditions, right?

So I see a lot of patients with premenstrual dysphoric disorder, for example. And those that can be, that is a hormone sensitivity. It is a psychiatric diagnosis, but it actually is a progesterone sensitivity. And so I oftentimes use menopausal management and kind of my knowledge and understanding of that physiology.

And it is extremely hard to get these medications covered for that indication. And these are really severe mental health issues that can be cured, really, with some hormone therapy. So we were just talking about the different drugs that we use and how hard it is to get some of them covered.

And you feel like the public thinks compounding is better?

Yeah, yeah. A lot of our education when we see our patients for the first time is that we really have to talk about what is compounding. Somewhat of a marketing gimmick in some ways. Right. I mean, people feel that it's better, it's formulated for them, it's extremely expensive. We were surprised that there was even coverage.

I didn't even know there was coverage. But really they feel that it's better, and that's just not so. And so we really do spend a lot of time educating.

Sorry. Yeah. And I think it's because we say compounded, bio identical. And really what we need to say is compounded hormones and FDA approved hormones. That is the terminology. Because the compounded ones, yes. Are they in general are identical to what our ovaries make. But the FDA approved therapies, the majority of them are bio identical as well.

And that's the confusion. So when we reeducate our patients and our providers that the majority of the medications, especially when it comes to estrogens, are bio identical, then they will come around. The role of compounding pharmacies is actually important, and I don't think they should be taken away.

Many of the ingredients and the additives to the FDA approved products cause allergies or cause problems for our patients, and then we can compound them with different additives that they're not allergic to, for example.

And we'll do that certainly for vaginal products and some systemic, though I'm very cautious with systemic products, again, because estradiol can cause endometrial cancer. I wanna know exactly what's going into my patient. Additionally, progesterone is where we get really, there's a lot of nuance.

And progesterone, there's only one bio identical FDA approved progesterone product, and it's poorly absorbed. It's a great medication, but you have to know how to use it. And there are synthetic progestins that are FDA approved that are stronger and can be more effective. But there is concern about their safety profile when it comes to breast cancer.

So there's a lot of nuance to hormone therapy. But bioidentically or compounded progesterone is where I am most concerned because this is where I see patients coming in with creams, they're coming in with sub therapeutic dosages.

And remember, progesterone has many functions, but the primary one is to prevent endometrial cancer, which they will get if they use unopposed estrogen for long enough.

I mean, part of what I'm hearing today throughout these conversations is that women and anyone going through menopause, they don't know what to ask and they don't know what works. And I know that we've felt that way. I guess part of it is they shouldn't have the answers.

They should be able to go to their physician and get the answers. But I think that women need. Is there somewhere they can go to know what to ask? Like, is there some resource out there you would point women to?

I mean, definitely a certified menopause provider is going to be a good one. There's a whole list of certified menopause providers all over the country.

And so that's like a, those are definitely people that are physicians and all types of physicians, not just OBGYNs, but they all have, you know, they are really interested in this field. They're trained. They want to provide evidence based medicine. Not that you don't, you don't have to have good providers be, you know, certified, but this is just one source.

How do you find? Where?

There's a whole list if you just go to the Menopause Society. Yeah. And they have a whole.

Start posting on social media.

Yeah, yeah, that's one. But honestly, a lot of the centers will also have good, just like our center, we have a really good website for resources for FAQs. Like trusted information is placed on there. So I think going to academic centers, looking at their websites, that's another good place to get good information.

I refer my patients to menopause.org. So the North American Menopause Society, now called the Menopause Society is where the certification comes from. And again, it takes extra steps and resources. Not everybody that does menopause has to be certified by them.

But I actually send most of my patients to their website where it has a for patient section. I also refer everybody to, you know, it was to the New York Times article, women have been misled about menopause.

It is the best article that has ever been written ever about menopause that takes complex medical understandings and puts it into something that is palatable for patients to read. So that I started sending everybody there. And then there also are, you may be familiar with different types of telehealth companies that are popping up.

Unfortunately, the majority of those companies are cash based. They don't take insurance. I actually am a medical director liaison with UCSF for one that really does take insurance. And their goal is to take all insurances.

And I do think, you know, there's questions about telehealth companies, and people should just be going to their providers. But as we've established here, most people's providers know nothing about menopause.

And so there are these kind of special companies that are popping up that are going to be able to provide access to those that don't have local access. The big issue is going to be coverage for them.

We have one more speaker on Zoom, Dr. Jan Gunter, who's going to close us out with and the author of the Vagina Bible, the Menopause Manifesto, and Blood, the Science and Medicine and Mythology of Menstruation.

Hi. Thank you. Yeah, thank you so much for having me in allowing me to come remotely. My son is having open heart surgery next week, and I don't want to risk catching anything by being out of the house in public.

We don't want you to.

Yeah. So first of all, I'm going to try to bring all this home. So there's a big sort of theme about lack of education. And I think that we could be doing things at a state level by bringing education into the schools. We center sex education around sex, as opposed to around the biology of the reproductive tract and how that has widespread scoping influences. So people are graduating school knowing more about frog biology than human biology.

But when we just spoke just now about where can people go to get information about menopause, why could we not design a module that lives on the California Department of Health website where people can go to. And this is an evidence based place to get information, so the state can certainly take some interest there, and we could have that type of thing that could be available.

Now, one thing that's been touched on, and this is a super important theme, is when the women's health initiative came out, and that sort of was misinterpreted by many people. I've been doing this for 30 years, so I practiced long before the WHI as well. When that study came out and was misinterpreted, I believe it was really a golden opportunity for many people to stop getting involved with menopause because it is so poorly reimbursed.

And you've heard this thread over and over again, primary care, meaning sitting in the office or talking to your doctor about the symptoms that you're having, something that doesn't need surgery, doesn't need expensive cardiac stuff, doesn't need a lot of tests, pays so poorly.

And so the reason why we heard it's so difficult to get it set up at a university is they had to use funding from the dean, funding from the chair. They can't pay to sort of make that clinic run by itself with what they make from seeing patients. So that's a really important part of sort of this desert of menopause care is that people are simply not reimbursed.

Another important thing that we really need to talk about, which isn't happening, I think, right now as much in California, but I understand there's a bill around that could have an impact in it, is the influence of private equity. So in other states, we are seeing private equity firms come in and basically shuttering the GYN component of obstetrics practices that they buy, because you can make money doing a high volume obstetrics. Medicaid's in different states pay quite well for OB, but you can't make money seeing GYN patients in the office.

So that's an important thing to keep on the radar for our state. I also want to talk a little about the online care that was brought up. So all of these VC funded online care platforms are coming out for menopause. And on one hand, it's great because if you live in the Central Valley and there isn't a menopause practitioner close by, you can find one online. But VC funding exists to make money for the VCs. And I just told you how you can't make money seeing menopause patients in the clinic.

So many of these platforms make money by selling untested supplements, by selling compounded hormones, compounded estrogen face cream, compounded estrogen body cream. And so there's absolutely no regulation for that.

And so that's just an important thing when you keep in mind about these online platforms is they have good, they, many of them have North American menopause certified practitioners, menopause society practitioners, but they also have this other arm that is what makes money. So you have to keep that in mind.

I want to talk a little bit more. This has been emphasized or talked by several people about compounded bio-identical hormones, which is of course a bit of a misnomer, if you will, because the worst thing you can do is to have something that's not regulated and not made in a way that people know what they're getting.

Only 14% of the population knows that compounded hormones are not FDA approved. I don't understand why we couldn't have legislation in California that requires that if you're getting a compounded hormone, that people are given a document that says you must know that this is not FDA approved. We can have those kinds of regulations.

When people go and they try things like pellets, which you've heard talked about, which cause so much harm. 94% of people who choose pellets didn't know about the standard of menopausal hormone therapy that we're talking about. When you talk about how much harm these pellets have, they carry no warning label.

So if I prescribe an estrogen patch for somebody, they get the warning label from the FDA. We can argue about whether the warning label should have what it says, but my patient is going to get a warning label. If I send someone to a compounding pharmacy or give them a pellet, they get no warning labels.

They think it's safer when in fact it's not. We know these pellets aren't recommended by any hormone society. And there is one of the largest companies that makes these pellets, BioTE, had over 4,000 adverse events that went unreported to the FDA. And many of these pellets are made here by pharmacies in California.

So is there some way that we can have legislation that affects, you know, whether pharmacies in California at least aren't contributing to the pellet problem? And then we have other non-physician providers stepping in. So if you don't get your care from a physician, you've unfortunately fallen into one of the many gaps we've heard about.

You could end up getting ozone therapy from a naturopath. You could get a gas that is toxic that has no known health benefits at all, according to the CDC. But yep, you can still get it in California, and the websites look really cool. So there are so many gaps that have been created, and I'm not sure why there couldn't be some type of legislation to not only focus on funding and focus on how we can improve labeling, but also tighten these gaps because people are making money hand over fist in these gaps.

So that's why we're seeing kind of that whole shift. I think it's really important, so I kind of want to bring it home that mandating training, whether it's, you know, at the school level, in medical school level, residency level.

I train in Canada, which is an additional year program, and we spent almost six months doing in office sort of hormone management, complex birth control pill, management, complex hormone management, those types of things. So it's kind of a different level of training. We can talk about mandating appropriate reimbursement. We can talk about mandating affordable therapies.

And that would include not just the important vaginal hormone therapies we heard about, but the compounded, but not the compounded hormones, the CBT, and also the newer therapies like the neurokinin three inhibitors, that are just not affordable for so many people.

And we can talk also about making online modules that have been approved by the state so people can go to a place and learn that maybe what they've heard from their provider is incorrect and really focus on consumer protection at multiple different levels.

Thank you so much. That was a lot. You've clearly been listening the whole time, and we're ready to close it out with a lot of good, concrete ideas. And we are out of time. But I really, really, really want to thank all the presenters today for being here, for sharing with us.

Again, I wish I had done this hearing when I was 40 and not 63, but here we are now. Yeah, you're welcome. With a lot more work to go. And while we didn't have a lot here, I know there were a lot of people watching and listening because people keep texting me about different things they've heard.

So thank you all for your work. It's very valuable. Thank you for bringing it to the Legislature. And I think get ready to make this trip, because hopefully we're going to do a lot more work in this space and make sure women can age as well as we can.

Yeah, I want to thank you. I. You know, before I was perimenopausal, the first conversation I think I ever had with my girlfriends about this was two of my girlfriends who were fighting about whether pellets were a good idea or not.

One who had a certified menopause practitioner who had warned her against pellets and the other who was using pellets. And you know, this is how we're getting our advice, right? Sitting around a kitchen table. And so I think it is so critical that you guys be here to help educate us.

I really want to thank our last witness, Dr. Gunter, for some really concrete suggestions, but all of you for really coming here and telling us how we can help move the ball forward for women as they transition through menopause.

I guess I'm the lucky one because I'm only 45 and I'm getting to have this conversation and I'm sure I will benefit from everything I'm learning, but so will everyone who's listening and those who come after us. I have a 12 year old daughter and she thinks it's hilarious that we're on opposite ends of this journey, but that's where we are. Thank you.

Thank you all very much. Thank you. And thank you to Senator Roth for letting us hijack his hearing.

You know, I have to say that this was very, very informative. I am disappointed that more of my male colleagues, Members of the Health Committee, were not here. We do have a role in this process and I think it's very important that we learn all that we can. Knowledge is power.

It's our responsibility to be both supportive and sensitive to those that we love as they go through this. And hopefully next time we'll have more of my male colleagues here. Thank you very much for what you presented.

This hearing is now closed.