Kerry Reller 0:28

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Irina Williams. Welcome to the podcast

Irina Williams 0:38

Hi

Kerry Reller 0:38

podcast. So today we're gonna talk about something I think a lot of women experience but may not realize that can be connected to perimenopause and menopause, and that is pain.

Welcome & Meet Dr. Irina Williams

Kerry Reller 0:49

So Dr. Irina Williams is a board-certified pain medicine physician and anesthesiologist, and a menopause specialist who spent years building and leading pain and medical staff programs at Alameda Health System. But today her main focus is the Women's Pain Institute, a telehealth-first practice focused on women's pain and midlife health, helping women connect the dots between chronic pain and the menopause transition. So welcome to Get Healthy Tampa Bay. So why don't we start, from the very beginning, and tell us a little about who you are, what you do, and then let's dive right in.

Irina Williams 1:24

Thank you, Kerry. I'm s- I'm so happy to be here. Thank you for having me. You already introduced me I'm a pain management physician who also specialize in menopause, and I'm also licensed in 50 states and DC, so I can provide care to patients across the nation. And after decades of treating women with complex chronic pain conditions, I kept seeing the same pattern where pain and menopause transition have been historically treated separately, where in fact a lot of it is a part of the same process. And it's frustrating for women to be bouncing around between specialists trying to get answers. So I decided to use all of my previous experiences in healthcare and my knowledge to build the practice that changes this care model, where women have one place for their chronic pain and menopause care, and we can get them the answers and the treatment plan that they deserve. So I'm very excited to be here and talk about it today.

Kerry Reller 2:24

Yeah, definitely that's an amazing, topic as we were discussing. Menopause is very interesting right now, and we're learning even so much more about it, and it's so interesting. I feel when I learned, oh my gosh, menopause can cause that too? And now we're talking about pain, right? So when most people think hot flashes, night sweats, irregular periods, and things like that, so how did

Why Menopause May Be Connected to Chronic Pain

Kerry Reller 2:45

chronic pain become part of the conversation, in this?

Irina Williams 2:49

That's such a good question. And interestingly, statistically, over 80% of women who are going through menopause transition do start experiencing chronic pain, and yet we- we're, I don't feel like we talk enough about it. And it the, the syndrome was defined a few years ago and we gave it a name as musculoskeletal syndrome of menopause. I think Dr. Wright defined that. But and it's a constellation of symptoms that is related to shifts in our estrogen. And part of it is our bone health, part of it is our bone density, but a lot of it is also about tendons, joints, muscles, 'cause all of these tissues have estrogen receptors. And estrogen is also a hormone that gives us anti-inflammatory properties, right? So when it starts going down, we start having these weird aches and pains in random places after doing seemingly normal activities. And also we don't heal as well because, again our anti-inflammatory properties are not as great. And we definitely need more research in that area as well. So we have some studies, but we know women are understudied So we need to close that gap. So yes, and I, and it y- I find it fascinating. A lot of times I talk to patients and it's kind of this pattern that I've been seeing where I would see a woman in her 50s, and she would tell me that her pain started in her late 30s or mid-40s, and you're just starting to connect the dots. She didn't change anything. She didn't do anything different. She didn't change her lifestyle. She didn't change her diet. Why all of a sudden the pain started then? And I see it over and over again with some of the fibromyalgia patients, with some of the patients with back pain, neck pain joint pain, and by the time they come to me, it's already been 10 years. So now we are it's a totally different level of complexity in terms of how to treat their pain. It becomes essentially 10 times harder after they have been in this state for many years. So I'm a huge advocate of intervening early, and that's where I think we need to talk about it now. So when women enter perimenopause and start experiencing these symptoms, we need to help them then so that they don't become these patients with 10-year history of chronic pain, and then nothing seems to work at that point.

Kerry Reller 5:09

Yeah, so you mentioned, musculoskeletal syndrome of menopause, and I think you mentioned Dr. Vonda Wright, who had coined that phrase. And I don't know if it's in the ICD-10 codes or anything yet for us to, actually put it in the chart. But what does it really, what does it really mean? Can you explain a little bit more about that and maybe even go into the biology? You mentioned the estrogen going down and things like that. Can you explain that?

Irina Williams 5:32

Essentially

What Is Musculoskeletal Syndrome of Menopause?

Irina Williams 5:32

a musculoskeletal syndrome of menopause, it's a constellation of musculoskeletal symptoms that arise due to women going into perimenopause and menopause transition, and the change in their estrogen levels. And musculoskeletal tissues are essentially our bones, our joints, our muscles, and our tendons. So all of these tissues get affected by this transition, and it can give this constellation of symptoms where some people can have more pains and aches in their joints or muscles, or can develop specific syndromes that we know are associated with musculoskeletal syndrome of menopause. For example, the infamous frozen shoulder or plantar fasciitis. But it can be other things as well. It can be what we call myofascial pain syndrome, right? Or like the trigger points and muscle aches and tightness that just sits there. Our spine can start hurting all of a sudden, though, again, we didn't do anything differently. Now we can also see symptoms in our bones, right? Where we start losing bone density. We become more prone to developing osteoporosis and osteopenia. We can start seeing symptoms in our tendons, so various types of tendinopathy. We can develop, tennis elbow and stuff like that, even though someone has been playing pickleball forever, but now all of a sudden they're 45 and their elbow finally hurts. That's it. That's essentially some of the examples and the definitions. And so far, we link these symptoms to a shift in levels of estrogen, where all of these tissues have receptors estrogen receptors. And when the estrogen levels go down, these tissues become more prone to inflammation. And like I was mentioning before, the same essentially amount of force or exertion can produce a very different tissue response because it's not as resilient anymore essentially.

Kerry Reller 7:31

Yeah, that's a really good point too. The tissue is actually acting differently as well. I want to share a personal anecdote 'cause I'm in this age window, right? So I was joking in our office that tennis elbow is going around because I was suffering from it, and then one of my... another coworker was also saying that they had it too, and it's funny. So I was, as a bad doctor, I'm trying to self-treat bit, and one of the things I did out of desperation was, go ahead and start estrogen hormone therapy to treat my tennis elbow. So it turns out it was a lot more than that but we don't need to go into my details. But I thought I would at least share that 'cause I always want to ask about the tennis elbow thing. Yeah.

Irina Williams 8:15

Yeah. I'm so glad that you so glad you brought it up because I think ano- another sort of anecdote that I'm seeing is that now that we have so much education and information on social media and women know, "Oh, okay, this is what hurts. It's probably my hormones" and then they get on HRT, and it can be helpful, but it's not always 100% cure, right? And so what I find h- is happening is that women get on HRT with the hope to treat their musculoskeletal symptoms, right? The tennis elbow, the frozen shoulder. A- and they don't get the result they were looking for. And then it's like, "And then what?" "So then what do I do?" And that's where I feel like having a specialist who understands both the body the, the bones, the, the muscles, the joints, the nerves, and menopause transition and really trying to figure out, okay, in... what are the cases where the hormones are the primary culprit versus more classic musculoskeletal conditions versus some sort of combination of both. Like, how do we differentiate that, and how do we really find the right solution for a particular woman? I think that's just very important and sometimes is a missing piece.

Kerry Reller 9:32

Yeah, it's also very individualized, I'm assuming, right? So we're, and not everybody, what, what works for one person may not work for the next, right? So w- being able to do that one-on-one discussions like you are gonna do in your practice is very important. So what kind of symptoms that should make a woman think, maybe this isn't just me getting older, maybe, this isn't just, or could it be hormones or whatever? What kind of symptoms would you think are related to that?

When Should Unexplained Pain Be Evaluated?

Irina Williams 9:56

I don't think there is like a clear answer, okay, this is just hormones and this is, something else. It's we have to look at the whole person, and we have to really evaluate what else is going on. What we need to obtain what we call proper pain history, right? What, what do you do? How do you use your arm? What can make you prone to development of the, for example, tennis elbow? So that we don't just discard the lifestyle or the activity or the sport or injuries and we really find the solution that's tailored to a particular woman. I would say anyone who starts having unexplained pain between the ages 35 to 55, but really sometimes perimenopause can start as early as 30 should see a doctor and to see what's going on. And the sooner the better, because we don't want to sit on it. We don't want it to become more chronic, more inflamed, and we don't want any central nervous system changes to start happening. Because when someone lives in chronic pain really for more than six to 12 months, we start seeing neuroplastic changes in the brain that further down the road make us more sensitive to pain, and then it becomes even harder to treat. So I definitely don't want anyone to go down that road, so I'm advocating just get it checked.

Kerry Reller 11:13

Yeah, definitely, I think like you're saying, treat it earlier. And then what you're also getting is a good, clinical history and everything 'cause I was gonna ask, next is how do you distinguish this pain that can be attributed to menopause transition versus something structural like osteoarthritis or a disc problem or some other injury? And I think you mentioned using some other testing type things. W- what do you typically or how do you distinguish the difference?

Irina Williams 11:38

Yeah. Of course, physical exam is extremely valuable. I feel like in my specialty, physical exam is so important. Looking at imaging doing ultrasound in the office. We can look and see what's going on with the tendon and just using the ultrasound machine in the clinic without really having to send patients anywhere. Looking at blood work and checking the inflammatory markers and see what, what's going on. In terms of hormonal testing, as we know, it's not really that valuable in perimenopause 'cause the results can be normal, but a woman may still have symptoms or depending on what time of the day we draw these labs, it can be different. Sometimes urine like testing the metabolites urine testing for estrogen metabolites can be more helpful 'cause it kinda gives us a slightly better picture in terms of what's chronically going on. But I, I would use that more as an adjunct. I would also look in general at overall metabolic health. I would look at cortisol and what, what's going on in a woman's life as well because that can also contribute to the increased levels of inflammation and potentially predispose a woman to the development of some of these musculoskeletal symptoms

Kerry Reller 12:58

Yeah, those are certainly looking at inflammatory markers, as you mentioned earlier, it's, could be we lose our anti-inflammatory estrogen essentially, right? So

Irina Williams 13:07

Yeah.

Kerry Reller 13:07

Those are good. And then the metabolic system is obviously changing in menopause as well. You mentioned this already, like you said, address the pain earlier because, you don't wanna have just someone kinda dealing with it, and you mentioned neuroplasticity. But is

Why Women Experience Pain Differently

Kerry Reller 13:20

there a difference between men and women? Like, why do you think women maybe experience pain differently, and is there anything that we know about sex hormones and nervous system and pain perception regarding the difference?

Irina Williams 13:32

Yes, definitely. That's a great question. And we need more data on that, but here's what I know. If the woman is still menstruating, a woman still has period and like I've experienced that myself as, as well. So for example the intensity of the pain that we feel changes throughout our cycle. So if we wanna undergo something painful or uncomfortable we should do it probably between the fifth and the 14th day of the cycle because that's when our estrogen and actually testosterone are at the highest, and that gives us some analgesic properties, meaning that during that period of time, we are l- the less sensitive to pain. Now, if we wanna do something like a procedure or waxing towards the end of our cycle in which we do it during that per- maybe like last five days of our cycle or during the first one or two days when we start menstruating, that's gonna be the worst time. That's when we're gonna be the most sensitive to pain. So women... men, they live on a 24-hour cycle Women, we have every day of the month is different for us in terms of our hormonal status, and that does affect how we experience pain. So even within that, 28 ideally cycle period, we experience pain different on different days. So then when our hormones start shifting and fluctuating, it can actually make us more sensitive to pain as well. And again, I don't think we have enough studies on that, but we can, I think, extrapolate that knowledge from the fact... from what we know about how pain sensi- sensitivity changes throughout a period and how it's related to our hormonal changes. Again, women we have times where we are less sensitive to pain, and we have times when we're more or less more sensitive to pain. And as our hormones drop, we enter that Period where we just become potentially more sensitive to pain, in addition to losing anti-inflammatory properties of estrogen. And statistically when we talk about pain in women, like if we Google it, we're gonna see fibromyalgia or migraines or pelvic pain, and those pain syndromes, they are more prevalent in women. However, if we look up the prevalence of back pain it's still more prevalent in women. If we look up the prevalence of complex regional pain syndrome or CRPS, which is an extremely painful condition that if anyone has it, they need to see a pain management physician ASAP. It's like a pain emergency. That's how we treat it. Again, women have higher prevalence of that pain syndrome as well. So women do have higher prevalence of a number of painful conditions, even if they're not considered women's type of pain. And why it's that, I think we need to research that more. I don't think it's 100% related to just the hor- hormones itself. I'm sure there are other factors that play a role. But yeah, that's, that, that's the data

Kerry Reller 16:30

Really interesting. I'm like picturing, the cycle of estrogen and the... I forget w- if it has a name, but the menstrual cycle and everything that we learn in medical school, and like now I can see, like visualize like a pain scale like with it as well. It's really interesting. I know we're gonna talk about exercise, but I think that before we do that, I just have heard some things about exercise of how you should your exercise habits based upon the menstrual cycle, and I don't know, maybe it, maybe that's coming from, maybe it'd be more painful to do this type of exercise or whatever if you are, not having as much estrogen at that time in your cycle. Interesting. I wanted you to comment more on that whole like idea of someone who... What happens basically if they've been in pain for months to years, and can that nervous system really become, better, at pr- producing or amplifying pain? You alluded to that already, but I wanted to discuss more on that.

Irina Williams 17:25

Yes, that's an excellent question. And we

How Chronic Pain Can Change the Nervous System

Irina Williams 17:28

are-- there is a number of evidence around these nervous system changes. They're called neuroplastic changes, and they're, But we still obviously need more studies. But we have enough data, and we know how to treat these types of changes. So yes. It's a twofold process. So our central nervous system can become essentially hyper-hyperactivated, hypervigilant, and go into that fight or flight response due to some sort of stress-related event or trauma or injury or motor vehicle accident. And that-- what happens in that situation is that it can then amplify and propagate the pain experience beyond the per-- the, what it should have been otherwise. And those are the patients who sometimes takes years to recover from injury, trauma, or accident. Now, on the other other end of the spectrum are patients who develop chronic pain or some sort of pain due to a different reason. But then, as they exist in that state of having this pain nearly twenty-four seven and having this pain being intense and disruptive for their life, their central nervous system starts going through those same changes. And it's almost like the dial is turned up, and it-- then our central nervous system gets stuck in that hyperactivated state. And we just can't get out of that pain cycle. Essentially, our body can't get out. And that's when we also start seeing that the pain starts spreading, that some patients become sensitive to touch, that they start having fatigue. They may start having other symptoms like GI disturbances, for example. That's when we're worried about those nociplastic changes and neuro... the, the definition is nociplastic pain. For patients, we usually like to use the term neuroplastic pain and neuroplastic changes in the brain. And those happen inevitably after we live in the pain for more than six to twelve months. And sometimes even earlier, because now the definition of chronic pain is pain beyond twelve weeks, which is really not that long.

Kerry Reller 19:35

Yeah. Wow. Yeah, and even to your point earlier, those are more reasons to, treat them earlier and get them in earlier and hear their story. So I wanted to ask about the exercise stuff. How do do you, approach that with women in midlife? What do you... How do you go through that with I guess the things that you recommend?

Irina Williams 19:53

Yeah.

Exercise, Strength Training & Pain in Midlife

Irina Williams 19:54

I'm a huge fan of exercising, and again my, my personal anecdote is that at some point I was trying to develop a frozen shoulder, and I've had some other sort of pain symptoms where my performance would get tired or I would develop sciatica. And pretty much because I'm I think, aware of what it should feel like, I I approach it very early with specific exercises that I do to get myself out of it, and it typically works. But essentially what I... I think what we see a lot on social media right now, which is the right thing to do, is, a lot of information about strength training, lifting heavy, and really focusing on building the muscle and maintaining the strength of the muscle, and that's, that, that's... I'm a huge fan of that. It's for our bodies, for our brain, it's for our longevity. It's amazing. The caveat in my patient population is that sometimes they're in too much pain to do that. So kinda how do we bridge that gap and get them to the point where we're actually able to exercise and able to lift heavy? That's... I think that's the challenge that I encounter in my patient population. 'Cause I want them to get to the point where they can go to the gym and do deadlifts, but frequently it takes them months, m- months to get there. I think again, depending on the part of the body we're working on I... practically, I like small weights better than bands. I feel like bands can be actually more aggravating, especially if we're trying, let's say, to work the shoulder or to work the glutes or the the, the low back. I prefer, if we wanna add some resistance for the patients, to start with very small weights if they're able to. Body weight at first, and then progress to even a one-pound dumbbell to a three-pound dumbbell if let's say we're talking about the upper body. And just really keep k- I don't want them to stop moving. Now, what I also find works very well for pain in the muscles, so myofascial pain, for example, someone has trigger points or knots in their back, frequently the patients would go get a massage or try to stretch and do yoga, and that can help too. But essentially, we need to, remind this muscle how to properly relax and contract, and just by stretching it or just by massaging it, we're still not teaching it the proper pattern of movement. So what I find helpful, let's say when someone has knots in their back, like trigger points or that tightness in between the shoulder blades that's just sitting there, let's work that muscle. Let's go to the gym and actually do some back exercises. Do some lat pull-downs or, rows so that we bring the blood flow to that muscle and we're reminded, "Okay, this is what you do to relax, and this is what you do to contract." And a- again, that's my anec- anecdotal experience, but I do find it helpful. I would do the same for the piriformis tightness. I like to, again incorporate exercises that allow that muscle to stretch and contract. That would be various types of lunges or deadlifts where we stretch and with load and then we contract. Those are some of the things, but of course, we have to see what the patient can realistically do and build up on that.

Kerry Reller 23:11

Yeah, obviously there's this cycle of pain and then they don't move as much as they should be, then they lose strength and muscle, and then potentially get more pain. So you're working on that with low weights and, reminding the muscle of how it, extrain- expands and contracts so that they can moving, again and get stronger and feel better hopefully overall. How- do you incorporate physical therapy at all? Or is this like your own form of physical therapy?

Irina Williams 23:39

Definitely. I

Physical Therapy & Breaking the Pain Cycle

Irina Williams 23:40

am a big fan of physical therapy and the, a good physical therapist can be so helpful. We just have to really be on the same page in terms of the goals of treatment, what we're trying to achieve. And certain pain syndromes require more sort of specialized approach. For example, that same CRPS, complex regional pain syndrome, that requires very specific interventions. Or patients with fibromyalgia, they may just, they may not able to tolerate a lot at first. And I also wanted to mention that frequently, again, when I see patients, they're typically very uncomfortable, in a lot of pain. In order for me to get them to move and to get them to exercise, because I understand if they're in too much pain, they can't do it. And then if they push themselves too far, they're then recovering for the next three days and they're out of commission. So that's where we really need to work on figuring out, okay what type of medication regimen may they need? What type of supplements? What do I need to do to help them sleep? To really get them to the point of being capable of movement, even with some discomfort. May not be perfect, but at least they'll be better and they'll be in less pain so that I can get them to move, and then they can get out of that cycle of being in pain and not moving and getting worse.

Kerry Reller 24:58

Obviously the exercise physical therapy are su- super big components of, getting better. What about what we've been talking about, right? It, what do you do if you think hormones are contributing to their chronic pain? And do you recommend hormone replacement therapy?

Hormone Therapy, Metabolic Health & Other Treatments

Irina Williams 25:14

I think if a woman based on her symptoms and clinical presentation appears to be in perimenopause or we know that she's in, she has gone through menopause and she's post-menopausal we should consider hormone replacement therapy. And we can do things in parallel. We can try hormone replacement therapy while we're doing all the other interventions and a workup, and just see how a woman responds and how much better we can get her with hormone replacement therapy while, again, looking at the whole picture, imaging, and trying all these other interventions so that we also don't lose too much time and we approach this particular woman and her clinical situation from all angles

Kerry Reller 25:57

Absolutely. So obviously the whole, a whole woman approach and really understanding everything is very important. What about, you mentioned earlier, doing metabolic testing and maybe weight management. Is there any role that you use or would think about, like a GLP-1 medication for either an anti-inflammatory or weight perspective for a patient?

Irina Williams 26:20

I think for the right patient it can be helpful. And again I don't I like to know the baseline to see, if a- and obviously what is their BMI? What is their metabolic status? Do they have insulin resistance? What's going on with their cholesterol? A- and a lot of times it can be helpful from the anti-inflammatory properties, from the weight loss properties. But yeah, it can be part of the tools, one of the tools in the toolbox

Kerry Reller 26:48

Yeah, I was just wondering if you think the metabolic health influences the chronic pain and if that could, treating that is also a way to help treat the chronic pain.

Irina Williams 26:58

Definitely. And there is actually a correlation, again, between the levels of pain and the levels of our blood sugar. So I always tell my diabetic or pre-diabetic patients or patients who are get- getting close to that when our blood sugar spikes, our pain spikes which I find fascinating. So if the patient is on that blood sugar rollercoaster, their pain is gonna be on the rollercoaster as well. There is some connection between the two. So definitely looking into our metabolic health and our blood sugar levels, we can tr- also try and CGM as well just to see where the woman at. It can be helpful data as well. We can also see if they crash in the middle of the night and that's why they're not sleeping well. A CGM can be helpful too with that. So yeah, definitely. Definitely

Kerry Reller 27:46

Are there any other treatment modalities that you may use to, help your patients with chronic pain?

Irina Williams 27:52

Yeah. I think injections is a big part of what I do. I am s- historically in interventional pain management, we do a a number of various steroid injections, so cortisone shots buterol steroid injections, joint injections. I am finding though that the re- the safety and the data behind regenerative medicine and interventions like PRP is growing. And I think that in, in women in m- perimenopause, which is still, relatively young, I would love to offer them more of the regenerative treatments rather than steroid injections because it can actually help rebuild and support those tendons and the joints rather than putting steroids in there, which will be helpful. And again, depending on the s- scenario and the intensity of pain and what we see on imaging, it can still be an option. But I think interventions like PRP injections can be so valuable and more beneficial long-term. I'm a big fan of if there is a right procedure to add that to the mix, because frequently with procedures, we can also potentially see a sort of faster improvement, and some patients would love to fast-track it to then again be able to do all the right things, to exercise eat well and so on. So yeah, injections are a huge part of what I do as well.

Kerry Reller 29:21

Absolutely, yeah. Is there, is there anything else you'd like to share about the treatment and the, the problem of medical, musculoskeletal syndrome and menopause or anything about that overlap before you talk about what you're doing now?

Pelvic Floor Health & The Women’s Pain Institute

Irina Williams 29:35

One more piece that is worth mentioning is the pelvic floor and pelvic health. And really any woman who's been through pregnancy regard- regardless of the mode of delivery needs pelvic floor rehab. And we don't routinely do that after we have children or after we go through pregnancy, and our pelvic floor actually gets weaker as we go through perimenopause as well because it's, again it's a muscle and we can lose the strength there too. And that is frequently a missing piece with someone who has, let's say, a woman has back pain and their MRI looks great, and we've done all the right things, and she's done physical therapy and everything. She's healthy, she's good weight, but her back is still hurting, and sometimes it can be the pelvic floor. So th- that's another area where I think we definitely need to that we need to look at and make sure we address as we evaluate in a woman

Kerry Reller 30:34

Yeah, pelvic floor therapy. One, there... You can't ever find one, so there's still not very many of them, and most every woman, I think even outside of having childbirth is in need of one, and overlaps, like you said. So that, that is a much needed area. And, even there's, chronic pelvic pain that can be, improved with hormones and therapy and many other things, and that's really can decrease quality of life for some people, and it's definitely an area, I don't know about of research, but definitely an area of need, right? So it's an important one. But so you've spent years building and leading, your interdisciplinary chronic pain program. What... When did you realize that traditional pain medicine made you say women in midlife need something extra or something different"?

Irina Williams 31:21

Even my, my recent experience of working in for another health system here in California and helping out with their pain management services, I frequently find myself limited by this by the system when the care is very siloed and fragmented. For example, I see a woman who was referred to that, particular clinic for a procedure. But then as I'm talking to her, I realize that, oh, she needs this, she needs that, and she would also benefit from X, Y, and Z. And I find that I'm not able to provide it to this woman because I have to refer to another clinic because this is how that particular health system is set up, and that specialist may or may not do that. So I've been finding myself giving some sort of unofficial recommendations and suggestions and trying to connect them with the resources I knew of and where if that was my practice, I could be just doing all that myself. Sometimes it's the insurance constraints. Sometimes it's, again, the, just the logistics of a particular health system, how the service is set up. And again, there is a lot of beauty in the way the services can be set up within a particular health system. A- and I think there are still l- limitations and also even limitations in training. I don't think we as pain physicians really get a lot of education about musculoskeletal syndrome of menopause or how ch- differences between pain in women and pain in men. It's sort of a growing area, and we're still learning more. No wonder it becomes challenging to provide that care to when... O- once you know it, once you learn it, you can't unlearn it, and then you find yourself s- stuck within the constraints of a particular organization. So yeah, that's how I started thinking about building a specific,

Kerry Reller 33:14

Mhm

Irina Williams 33:14

practice for women going through the perimenopause and menopausal transition.

Kerry Reller 33:19

Nice. Let me clarify. You didn't or you did get training on musculoskeletal syndrome and menopause during residency and fellowship and things

Irina Williams 33:27

no, we didn't. And granted I did fellowship I, I graduated from fellowship 11 years ago. I think at that time, that was not even a part of the conversation, which I'm actually thinking about considering to r- reconnect with my with where I did fellowship and see if there is interest from current fellows for, for me to educate them, and enrich their training in that way, because I think we need to build a pipeline of physicians who understand differences between pain in men versus women in certain parts of our periods of our life

Kerry Reller 33:59

I think they're probably gonna do a nice little overhaul of the medical education and, include more menopausal type things, which might include something like that as well. So this might be a challenging question, but you're creating a telehealth first pain practice and you mention doing injections and procedures and the physical exam. So how does that look like in a telehealth platform for like a a pain practice?

Irina Williams 34:26

That is such a great question. So the way I envision it is I would like to start with telehealth first because, again, I'm able to have such a large reach with me being licensed nationwide. And really because this is a new care model, I just wanna get a really good understanding of how can I best provide this care, and what is the most val- valuable for women in this space and in this category of patients. And then my phase two will be opening an in-person location here in Northern California where I can really bring all these treatments that I was talking about in terms of the, the ones that require in-person interaction to this location while still being able to help women out of state if they don't have a specialist where they live. But I agree with you. My ideal vision is in person as well, and it's coming. I really see it coming.

Kerry Reller 35:25

Oh, I'm sure it will. And I think you can still do a lot, especially like supporting, somebody who has a pain physician here that maybe doesn't understand the women's perspective or the, the type of pain that they're going through. They maybe they can do the procedure, but there's more to it. So that's definitely a kind of patient. That's what I envision your ideal patient. What do you think your ideal patient is?

Irina Williams 35:43

I think my ideal patient is, it's a woman between the ages of 35 and 55 who is experiencing some changes in her body that can be cause some pain and discomfort and a disruption of their life, and they don't really know who to see or what to do about it. Or they've seen a few doctors and they've gotten some help, but they still feel like it's not... I'm not really where I wanna be and I need to figure this out." So that's that's the woman I would love to help. And you're absolutely correct. If the only thing... Say, if I'm seeing a patient from a different state and the only thing I'm missing in our plan is a specific procedure, maybe we can find a physician who can do that procedure in that particular geography while I can still manage everything else and support her in all the other ways.

Kerry Reller 36:35

Yeah, absolutely. Do you have any patient stories that you'd like to share? I know you haven't really made, started this version of your next practice yet, but what about anybody that you've worked with already that some good stories that might exemplify what we're talking about today?

Irina Williams 36:54

Yeah. Yeah. One one interesting story so I had a I had a patient who's been a regular patient of mine, and the patient was previously seeing different physician, and they have this, o- one of these typical very unpleasant conditions that's called TMJ, where they have this really bad tightness in the jaw, and that i- impacts their sleep and their quality of life. We started working with this patient, did a good workup, and made some adjustments to the treatment plan, the medications. But I noticed that the patient the patient was in the within her 30s, was recently started on metformin, even though the patient has good body composition, normal weight, otherwise seemingly healthy. The, the blood work looked okay except for the hemoglobin A1C. So the primary care doctor started the patient on metformin. So I started digging back and to understand what, what's going on. And the patient barely had any perimenopause symptoms super early on in, in that in that journey. So I wouldn't attribute that to just hormonal shift itself. So then looking back, I discovered that the patient used to come in every three months to get a steroid injection. And I started to connect the dots, and I realized that this shift and the rise in the blood sugar was iatrogenic, which means that was caused by sort of medical interventions. So we changed the plan, and we switched the procedural plan from steroid injections to Botox in that particular patient. And then a eight months later, the numbers came down. The patient was off, off metformin, still getting the same benefits, still getting the the pain control they were looking for, but without the side effects of a treatment. So that's one of, one of the recent patient stories.

Kerry Reller 38:40

Yeah. That's great. I would... Usually you think there's something more multifactorial to develop diabetes from that, or maybe it was pre-diabetes, but

Irina Williams 38:49

so it was free

Kerry Reller 38:49

pre-diabetes. But that's a, a good catch so that they can adjust, those, you know, secondary things. So we have a lot of asthma patients and, think historically before all these new fancy medications were out and the new inhalers and injections and things like that, we used to give lots of steroids, right? We do- weren't doing a great job asking if they had diabetes or high blood pressure or heart failure or osteoporosis and things like that. Now that with all this new stuff, we can certainly do that and definitely steer away from, the steroids so we don't iatrogenically, like you said us causing these problems to happen in the same time. yeah, trying to use less steroids for everybody, I think, which is

Irina Williams 39:28

Yeah. Like I'm sure, and you see it in your practice as well, like steroids have its time and place, and they can be very helpful for the right patient. And we do need to do a better job of monitoring and tracking how much steroids the patient is actually getting. And it becomes even more important in women of perimenopausal, menopausal age because that's when we start losing bone density, and the steroids is like a double whammy. And that's when we start seeing fractures and osteo- osteoporotic fractures that can be devastating and can have consequences and cause pain for the rest of patient's life

Kerry Reller 40:04

Absolutely. Is there anything else you'd like to share on today's, discussion on menopause and musculoskeletal pain or all, I guess all pain, not just musculoskeletal, but

Irina Williams 40:15

I think I just wanted to share that I'm very excited too that my practice, the Women's Pain Institute, is about to launch. We're targeting September the 28th is our soft launch day. I would love patients who want to work with me to check out our website, check out our services, and follow me on social media. And yeah, I would love your feedback and I would love to help, and I'm just super excited to be doing this work and getting started with my practice

Kerry Reller 40:47

So where can they find you? It's, you said the Women's Pain Institute,

Irina Williams 40:50

Ya, setuju.

Kerry Reller 40:51

and your socials and stuff? We'll

Irina Williams 40:53

Yep.

Kerry Reller 40:54

notes too,

Irina Williams 40:54

Okay. So the website is women pain, womenspaininstitute.com, and the social on Instagram is just my name IrinaWilliamsMD on Instagram, Irina Williams on Facebook. And yep, just check it out. Let me know what you think, and yep, I would love to help if I can

Kerry Reller 41:14

Awesome. Everybody please, listen in on that and write those things down, and she is licensed in Florida, so that's awesome. But thank you so much for joining me for today. I think, the big takeaway is that, it's just having joint pain isn't always just getting old or some injury. It could be something else too, so talk to your, doctor about that for sure, 'cause hormonal changes could be part of it. Just maybe one piece of the puzzle, and there's different tools, like you said, that can be used to help diagnose and treat, and, I think following you, you can probably learn a lot of things too. Please do. And yeah, thank you so much for coming on the podcast, and everybody thank you again for listening to Get Healthy Tampa Bay.

Irina Williams 41:54

Thank you so much for having me. It's been a pleasure

Kerry Reller 41:56

Awesome. All right