Latest Advances in Women’s Health – Dr. Sara (Gottfried) Szal – HPP 151
Episode 151
Dr. Sara Gottfried Szal
Despite decades of progress, persistent gaps in women’s healthcare continue to leave millions without the care they need. In this episode, Dr. Will Van Derveer and Dr. Sara Gottfried Szal unpack the complex and evolving field of female-related care. Together, they explore opportunities for clinical improvement.
Dr. Szal shares her journey from medical school, where she first encountered the glaring disparities in women’s healthcare. She discusses the evolution of medicine from a physician-centered model to a collaborative and patient-centered approach, emphasizing the importance of personalized care across a woman’s life stages. Through heartfelt anecdotes and professional insights, the conversation addresses common biases and systemic challenges that still hinder optimal care for women.
By equipping practitioners with the tools to address women’s unique health needs—including managing stress, hormones, and cardiometabolic health, it’s the hope that a new era of medicine can be ushered in. With a focus on empowering practitioners to provide proactive, personalized care, Dr. Szal hopes there will be a ripple effect, enabling more women to receive the treatment and respect they deserve.
Show Notes:
Midwifery model advocates collaborative, patient-centered women’s healthcare – 03:04
Midwifery allows for a broader and more generous labor-management model compared to the strictly medicalized approach often followed in traditional hospital settings.
Hormonal complexity reveals broader health treatment gaps – 07:52
Dr. Szal discusses how hormones are transported, their sensitivity at receptor levels, and their detoxification, revealing important systems that are overlooked, contributing to significant gaps in health treatments for women.
Advancing women’s health: Understanding stress, treatment, longevity – 12:17
Understanding the unique stress responses in women can greatly advance women’s health. A holistic approach to treatment will go beyond hormone therapy to include managing muscle mass and cardiometabolic function.
Women’s cardiovascular risks, disparities, and urgent awareness needed – 17:29
Dr. Szal dispels the myth that heart disease predominantly affects men; however, because women often present with atypical heart attack symptoms, they are often misdiagnosed, leading to poorer outcomes. She underscores the importance of educating practitioners about these disparities, which she hopes to accomplish through the IPI Women’s Health Certificate Program.
Full Episode Transcript
Dr. Will Van Derveer [00:00:05]:
Thank you for joining us for the Higher practice podcast. I’m Dr. Will Vandeveer with Keith Kerlander, and this is the podcast where we explore what it takes to achieve optimal mental health. Welcome, Sarah. Great to have you back.
Dr. Sara Szal [00:00:20]:
Well, it’s always good to be with you.
Dr. Will Van Derveer [00:00:23]:
Thanks for your time. I know you’re incredibly busy, so it’s wonderful to have you. And I have so much gratitude and respect for you as such a huge leader in women’s health. And maybe we could start with people who are maybe less familiar with your work around what drove you to take this huge stand for women and the representation of women in healthcare.
Dr. Sara Szal [00:00:56]:
It’s such a good question. It takes me back to medical school, where I just. I really felt like what I heard time and again, and this is back in 1989, that there was this massive women’s health gap. And it felt like, well, if most of the physicians at that time were men, chances are this gap was not going to be filled. Chances are the research is not going to be done. There’s going to be a gap in knowledge and treatment, understanding how prescriptions affect women. And so it felt like a really important opportunity to step in and advance the field of women’s health. So that’s what really got me to do it. I mean, I had a number of influential experiences. Frankly, I loved everything when I went to medical school and rotated through all the different disciplines. But being at a birth and experiencing the transcendence of that moment, seeing that there’s this intersection of mind, body and spirit that comes together in the female body and being able to witness that and also see all the biases and challenges that come into that moment, that’s what got me to say, yes, beautiful.
Dr. Will Van Derveer [00:02:27]:
Thank you. I’m surprised I never asked you that question before, but it’s great to hear the magic of birth. Yeah. It takes me back to my daughter’s birth and the kind of miracle in that case. For me, it was like the first time I’d seen a birth that wasn’t traumatic because I’d been in the hospital for so many births way less than you. But as a medical student, it’s such an crazy environment to have a baby in. I mean, it’s. And thank God we have that for certain kinds of births. But, whoa. The medicalization of birth, it’s a huge.
Dr. Sara Szal [00:03:04]:
Topic on its own. And I was really fortunate to rotate through the Brigham and Women’s Hospital, and they were at the forefront of having, I would say, a broader, more generous labor map that they managed so they had midwives, they had a midwifery model that was integrated with the physician model. And so many of the births that I experienced were part of this midwifery model. And if you look at sort of the labor curve and how many centimeters you’re supposed to dilate per hour, it’s very strict. I think it’s called the Friedman’s curve. Whereas midwives allow for a little more dynamic range. And that really appealed to me. It felt like this is a model that could be applied a lot more broadly than just birth. I mean, yes, we need it in birth, but we need it in perimenopause, we need it in fertility, we need it in menopause and taking care of women as they get older. So, yes, it’s a really good point because we’ve shifted, I would say, from medicine 1.0, which was very doctor centered, like, let me do a C section because I’ve got my golf game, to medicine 2.0, which was disease centered. You’ve got preeclampsia, you need magnesium. End of discussion. To Medicine 3.0, which is collaborative. It’s got streams of data that are owned by the patient. There’s a desire to optimize among some of us. And so we’re really shifting the way that we take care of patients. And I think women’s health can only benefit from that.
Dr. Will Van Derveer [00:04:59]:
Beautiful. Well, that’s a good jumping off point, I think, for this conversation about, you know, speaking of the allopath, how narrow the allopathic can be, or. Or medicine 1.0, let’s say. When I was in med school, it was sort of like women’s health was hormones. You know, it was like there was birth and, you know, there was the, you know, services around gynecology and opinion, obstetric, obstetrics. But as far as women’s health, we really just talked about, okay, well, there’s hormones to manage birth control pills. Right. And then there wasn’t this really nuanced and expanded and personalized, very specific omic, as you would have said before in the past, way of looking at what are the challenges across the lifespan and how do we intervene in a very nuanced and personalized way, which I think is part of what you’re talking about, around the soft touch of midwifery compared to the edge of the scalpel.
Dr. Sara Szal [00:06:20]:
That’s true. And I love roofing on these topics with you, Will, because you’re so thoughtful and. And you’re such a leader in a new way of approaching mental health. And I Feel like with women’s health. You’re right. There was a way that it was overly reductionistic and the focus was basically a simple question. Do you want to get pregnant? Yes or no? And if you want to get pregnant and you’re not getting pregnant, we’ll check every hormone level, we’ll see what’s going on. We think 70% of the time the problem is hormonal. And so that left women who were not trying to get pregnant, women who were 40 plus and were navigating, I would say, the rockiest time in the female life cycle, which is perimenopause. It left them really without information, research, knowledge, treatment. And that gap that I saw back in 1989 persists today. And it’s amazing to me because I talk a lot about medicine 3.0 and menopause 3.0. It’s amazing to me that somewhere around 73 to 75% of women who go through perimenopause menopause don’t get the care that they need.
Dr. Will Van Derveer [00:07:51]:
Wow, that’s shocking.
Dr. Sara Szal [00:07:52]:
So a huge treatment gap. And while hormones start the conversation, it’s really the tip of the iceberg. You know, there’s so much that goes into what happens with your hormones. If we just stay with the topic of hormones, there’s. There’s the production of hormones, which is where we tend to focus. There’s the transportation. What’s going on with your sex hormone binding globulin, what’s going on with cortisol, and how is that affecting the levels of your thyroid and estradiol, progesterone and dhea. There’s the sensitivity at the receptor level. There’s now six different estrogen receptors that we want to be paying attention to, not just er, alpha and er beta that we’ve known about for decades. And then there’s detoxification. So there’s a complexity to hormones that I think most people don’t realize. And then more broadly, a woman is much more than just the sum of her hormones. There’s this gene environment interface that we want to be paying attention to. And I really thought that we would be further along in terms of understanding genomics and how that creates a blueprint and how you can work around some of the issues that you have. We all have about five to seven issues that we have to work on. How the gut interacts with your hormones. I think of the control system for your hormones as not just the hypothalamic pituitary adrenal axis, it’s the hypothalamic pituitary, adrenal, thyroid, gonadal, gut axis. So the control system is pretty complex. And one of the things I’ve been somewhat obsessed about, and this is a big part of our upcoming certification, is mitochondria. And the way that you inherit mitochondria from your mother, there’s epigenetic changes, I think of my own mother and how she handled stress, the foods that she ate. She was born well, she’s now turning 80 and she gave birth to me at the time of Twiggy. She weighed about 120 pounds. She was 5 foot 7. She smoked during pregnancy, she didn’t breastfeed. And yeah, I just think about what kind of mitochondria did we inherit and what kind of signaling is going on. I suspect that the mitochondria I inherited were impaired because there’s so many things that can change that mitochondrial signal. So, yes, hormones are important. And hormones were sort of the thing that the National Institutes of Health blamed as a reason for the research gap. Women are too complicated. Their hormones change too much, such that women weren’t required to be part of research studies until 1993, and sex wasn’t used as a biological variable until 2016. And that was just eight, nine years ago. So, yes, women have so much complexity, and yet we also know a lot about how to help them live a fuller, better life. And we know a lot about the top 10 killers now. They affect women versus men. And yet women still have a higher mortality rate when it comes to cardiovascular disease. They show problems at lower glucoses in the Prediabetes range like 115 to 120. Before diabetes, most of the criteria, like for diabetes were defined in men and assumed to apply to women. And that may not be the case because we show vascular damage at lower glucoses. So, yes, there’s a lot of complexity beyond just hormones.
Dr. Will Van Derveer [00:12:02]:
Wow. Well, tell us about. Why are you excited about teaching about women’s health with IPI right now? Why are we doing this together?
Dr. Sara Szal [00:12:17]:
Well, I’ve devoted my career to women’s health, so I feel like this next exploration with IPI with you and with Keith and all the folks who sign up to work with us is it’s a critical next step in closing that gender health gap. My hope is that people really learn the underpinnings. They understand how to take the scientific evidence and translate that into meaningful practical information. So if I had to just come up with a couple of dreams for how women could be cared for differently for the folks who complete this certificate, I would say, number one, being able to manage cortisol, being able to understand the stress response, being able to have clarity about how women are different than men when it comes to the stress response. And that maps to mental health issues. We know when men and women are exposed to the same trauma, such as wartime trauma, that women have higher rates of post traumatic stress disorder. We know that women have double rates of depression. We know that they’ve got double the rates of insomnia, double the rates of Alzheimer’s disease. And whenever I see that 2x, it always makes me think, okay, there’s something we’re not paying attention to here that we need to be paying attention to, right? So cortisol, I think, is such a critical issue. There’s 24 different areas of the brain that are sexually dimorphic that are different in women versus men. The female brain dramatically changes after 40. I want folks to really understand that and to realize that there’s so many lifestyle things that you can do as well as hormone therapy. So all of those women going through perimenopause, menopause, who aren’t getting the treatment that they need, I want them to get the treatment they need, at least have a discussion about it and whether they’re a good candidate. And I would also say that it’s not as simple as, should this woman have hormone therapy, yes or no? Women need to go beyond hormone therapy, right? They need to be managing their muscle mass because that is the organ of longevity. They need to be managing their cardiometabolic function. So my hope is that the certificate really helps bring a cohort of people into this new age of medicine 3.0.
Dr. Will Van Derveer [00:15:03]:
You know, your enthusiasm is so infectious. I love it. And I so appreciate the way you, you show up and take a stand for this, what, 52% of our population, right? I mean, more than half. And, you know, as you were speaking about heart disease, which is one of the things that’s so under recognized in women, I started thinking about this patient of mine who I treated for many years. Dear beloved psychotherapy patient. I mean, absolute amazing person, terrible trauma, who died of a heart attack out of the blue. I think she was something like 52. And this was so many years ago. I mean, 15, 20 years ago. And I was thinking to myself, when that happened, how did that happen? This is supposed to happen to men. This doesn’t happen to women. It does happen to women. It absolutely does happen to women. And so sort of like this bigger picture conversation is so critical. And I think, you know, for us, it’s, it’s like the time is now to start pushing to help people like you turn the ship around and to really get these advanced tools out into the bigger, bigger impact, bigger circulation amongst practitioners. And, you know, as always, for me, it’s the education as a mental health practitioner is about, um, not that I’m going to become a cardiovascular disease in women expert or practitioner. I’m probably not going to prescribe statins or aspirin or, you know, do treadmill tests on women or sestomibes or whatever they’re called, those things, crazy things. But I need to know ahead of time what these risks are and know how to assess them or make accurate referrals for people so that a wider range of their challenges are addressed in a really proactive way. And I feel like, you know, I really, if I had known then what, more of what I know now, that person might still be alive, you know, Anyway, these are.
Dr. Sara Szal [00:17:29]:
I’d like to speak to your patient because it makes me misty to hear about this experience that you had with her. And I think it might be helpful just to go through some of the myths that exist when it comes to women getting older and their risk of cardiovascular disease, because I was taught that you don’t have to worry about it until after menopause. That’s when women start to catch up to men. And that is not true. So the group, the population that has the greatest increase in admissions for acute coronary syndrome is women aged 35 to 54. Pretty dramatic increase over the past, I would say, five, seven years. That’s mostly because our cardiometabolic health has declined so much in the United States. So you think about the people with polycystic ovary syndrome or the people with pre diabetes who are starting to damage their blood vessels in their 20s and 30s. And so for the patient that you described, the other challenge is that so many people aren’t aware of the way that acute coronary syndrome or a myocardial infarction shows up in a woman compared to men. Women have smaller coronary vessels, we have more microvascular disease, were less likely to have that sudden onset of substernal chest pain, like an elephant is sitting on your chest, more likely to have a feeling of doom or shortness of breath or neck pain or back pain. A lot of non specific symptoms. I have one patient in particular who was really healthy. She was an anesthesiologist and in her 50s. Her presenting symptom was syncope. It was the only symptom she had and her labs were all normal. Nobody knew. And what we know on more of a systems level. And this is from a study that was done in Florida. When men and women present to the emergency room with a heart attack, acute myocardial infarction, the gender of the physician they see matters. So for female patients who see a female physician, their survival is 2, 3x than if they see a male physician. Now, of course, present company accepted. Because you are amazing, Will Vandeveer. But you know, when you look at the female doctors and the male versus female outcomes, they’re the same. So to me, this just shows the gaps that we need to address, the education that we need to be sharing with others so that we can close these gaps and we can all rise together and not have these massive disparities and these gaps that lead to the tragic case of a 52 year old woman dying of a heart attack.
Dr. Will Van Derveer [00:20:49]:
Thank you, Sarah. I’m really excited about this program. It’s overdue, it’s time and we really enjoy collaborating with you and everyone who gets a chance to learn from you raves about you. So the website page for this program, I should mention, is our website, psychiatryinstitute.com so it’s very simple.
Dr. Sara Szal [00:21:21]:
Oh, I like that. We can remember that.
Dr. Will Van Derveer [00:21:25]:
I think so.
Dr. Sara Szal [00:21:25]:
Even after perimenopause, we can remember that.
Dr. Will Van Derveer [00:21:29]:
Psychiatryinstitute.com women. Thank you, Sarah, for joining me today and really excited for this program.
Dr. Sara Szal [00:21:38]:
Me too. And thank you for your leadership, will you and Keith, bringing this forward and offering it to the world. It’s just such a pleasure to be involved with you and to collaborate with you. Thank you.
