Dr Louise Newson: Today Kameelah Phillips is my guest. She's a doctor. She's an obstetrician and gynaecologist in New York. She runs Calla Health and she's also the author of The Empowered Hysterectomy. So, we talk a lot about hysterectomy, what it means. How we should prepare ourselves before the operation. And we talk a bit about how hard it can be for women to be listened to and about how medicine is broken in certain ways. It's a really great and very uplifting conversation, which I hope you enjoy.

So great to finally have you here in the podcast studio, even though it's remote. Your I know you're busy working as an ObGyn,I should say over in the UK it's an obstetrician gynaecologist and so your work is really inspiring. And I'm not a gynaecologist and people sometimes find that quite confusing when I'm a hormone specialist because for many decades people have just thought about hormones, progesterone, estradiol a bit about testosterone, thinking they're just ovarian hormones. It's just about our periods. It's about our womb. It's about our fertility. And when I start talking about the role of hormones in our brain and our bones, people get a bit confused. But you, you obviously focus on the pelvic organs, but you think of the woman as an entire person, which is just wonderful.

Dr Kameelah Phillips: I appreciate that. Yes, I appreciate that. And it's so interesting you say that because I wish in our medical training we had more of a holistic approach in that sense, in particular, because, you know, I come across orthopaedists and they are, well should be hormone specialist, right? Because they're dealing with women and broken bones. And that cascade is so dependent on hormones. So there really isn't a field in medicine that you shouldn’t to some degree be a hormone specialist.

Dr Louise: I totally agree. I used to say it was only maybe people who were paediatricians, but then the youngest patient I've met was like 12 because her periods didn't develop. She had streak ovaries. So everybody needs to know about hormones.

Dr Kameelah: Absolutely. I had a 13-year-old here yesterday and that typically is I hear the paediatricians kind of wheelhouse, but no when it comes to puberty. Oh my gosh, the changing brain. Even as brothers, sisters, caregivers, if you have anyone in your life who is going through puberty, you're a hormone specialist now because the changes that the brain experiences are miraculous. So really everyone is a hormone specialist as far as I'm concerned.

Dr Louise: I totally agree, but you know what? I shudder when I look back at my medical training because I did a lot of different hospital specialities because I was a general physician in hospital beforeI changed into being a family physician. And I never thought once abouthormones. And then I became a family physician. I had to do six months obs and gyna eand I saw these women coming in with heavy bleeding, and it was just around the time that Merina coils started to take off. So a lot of women were coming in for hysterectomies because of their bleeding. Now, a lot of these women were in their late 40s, so they would have been perimenopausal. They probably didn't necessarily need a hysterectomy because if if they'd had the right balance of hormones, natural hormones, especially progesterone, they probably would have been fine. But I never even thought to ask them. But the other thing is, they usually had their ovaries taken at the same time. Regardless, it was like, well, we're down there anyway. If we take your ovaries out, then you won't get ovarian cancer. And I sort of look back and I, I don't remember giving them hormones even after their ovaries were removed.

Dr Kameelah: No, I mean, I didn't either, right. That wasn't our training and I think we’re a similar age we grew up in this time where we literally were scared to death of hormones. At least my training and I had very good training, and I think it was all very well-meaning at the time, because that is the information we had to work with. We didn't consider the ramifications of taking out the ovaries, denying women hormones. How it affected their sexual health, their mental health, their bone structures, their cardiovascular health. We had no idea. So I 100% know at the beginning of my career, in doing hysterectomies or seeing these women, you know, you it's a phase. You'll get through it. Like, let's just, treat the symptoms but really not treating the whole person. So I think, you know, we're all kind of guilty of that because that's the information we had at that time. But now we know better, right? Now we know better. When my own mother had a hysterectomy, one without telling me and two, had her ovaries removed. And I could have never been so upset, never been so upset. But this is why we're doing better now. We have to.

Dr Louise: Yeah, we are, and we're not really. So we did an audit, we looked at three teaching hospitals in London. I won't tell you their names, but three big hospitals in London and looked at young women who had had their ovaries removed for benign reasons. So this wasn't cancer related, and looked to see how many of these women had been offered or prescribed HRT following their ovaries being removed. And it was about 5% had been offered or given HRT and it was 0% that had been prescribed testosterone.

Dr Kameelah: I got goosebumps I wish you could touch my arm right now I have goosebumps. But wow, 5%, so the offering of HRT,I think is probably, I wish I had my own studies, is probably a little different in the United States. I can't say it's astronomical by any means. I do not want to pretend that we are having this huge hormone revolution. I think we're experiencing it with everyone else. Testosterone. However, I agree 100%. I cannot tell you like the pushback I get from pharmacists, insurance companies, and even patients themselves when I'm like, okay, so let's add on this next thing. And, well, I don't make testosterone. That's a, that's the male hormone. Only men do that. And so the amount of education that has to go along with the prescription is tremendous, because it is entirely novel to people that, yes, women make and need testosterone.

Dr Louise: And, you know, I was looking at a study recently from the 1980s, so many years ago, showing that when women had their ovaries removed and they had they had estrogen, they felt better. But when they had testosterone added to it, a lot of their symptoms, including wellbeing, improved. And I don't think it's bad is it as a doctor if we improve someone's wellbeing?

Dr Kameelah: Right. And you know it, it's interesting. So I personally do use testosterone. And so part of my education is a, is a bit of that disclosure to humanise, you know. I still look like a woman. I still sound like, like all of those quote unquote ideas of femininity and women are still there. So I use that as part of my disclosure to help them understand this concept of wellbeing. And it's sort of intangible, right. Like what is wellbeing? But when I explain, like, I sleep better, my body moves better, my workouts are better, my mood, you know, really helping them understand what I mean by wellbeing is tremendous.

Dr Louise: Yeah, I totally agree. And you know, I I've been open about it before. I've been taking testosterone for about nine years now and I do not shave every morning. I haven't got a beard, you know. And,I still think I look like a woman, but I often say to people, it's really trivial but lots of women get it. Like when I, when the dishwasher needs emptying, I just go, okay, I'll empty it. Whereas before testosterone, I'm like, I can't. It's another thing to do. You know, it was sort of emptying the washing or like looking at the laundry basket thinking, oh, I'll leave it till tomorrow. And then the next day it's even bigger. And I'm like, I can't sort out the lights and darks because I'm just like, my brain doesn't function. And now it's like, okay, I'll just do it. And, you know, it's those little things and it's very hard. How do you measure that in a study? You're never going todo a study looking at whether women can sort out the washing or not. It's like but actually day to day that makes a massive impact. And, and I think it's very hard as doctors, isn't it, because we, we are used to looking at numbers and figures like someone's haemoglobin level or their iron level or their blood pressure or what their scan shows, but when we're talking about feelings and emotions, and happiness, it's quite difficult, isn't it, to measure?

Dr Kameelah: Right. And I,I do love that, though. There is, a big drive here and maybe not there, but people want to measure their hormones. I want to know where I'm at. You know, they come in all that. I need to check my hormones because I need to know where I'm at. Okay? I don't even argue anymore. Let's do it. Let's do it really as an exercise to help you understand how sometimes these numbers are not reflective of how you feel, how you're functioning, how you're sleeping, how you're thinking all of those things. So I love numbers sometimes from that perspective, because it helps drive home the point that do I not treat you because your numbers says not to treat you. So I do love numbers from that perspective And then it's probably the last time in their treatment we ever, you know, check the numbers again.

Dr Louise: Well, it's interesting, isn't it? I think, you know, any numbers that we do like any blood tests. It's in context. We wouldn't just treat someone in isolation, in isolation. And I think there's always this big debate how useful or not useful are our hormone levels. And they are a guide. But I wouldn't change someone's treatment if I'd never spoken to them. I wouldn't just look at their numbers. You know, I think, I mean, I did have my testosterone level done before I started testosterone, and it was zero point nothing. It was really low. And I was actually quite reassured. It was like, oh, that's a bit of validation. And then I could see it improve. So, but it wouldn't have made any difference. I knew I had like, I was 45, I had like all the symptoms.

Dr Kameelah: The tank was empty.

Dr Louise: Yeah, yeah, yeah, that's exactly right. But talking about personal experience, I think you do learn a lot in medicine. And a few years ago I had a hysterectomy and, and I, I underestimated actually the recovery. I know it's really hard when you're a doctor because people treat you differently. And so I had a great surgeon. I chose my surgeon, of course I was very lucky. I had a good anaesthetist, but no one really gave me any education. And I didn't know whether it was because I should know everything or whether they would just, you know, treat me or that's maybe how they do. So I had this hysterectomy and then I had a few complications. I went into retention. I couldn't empty my bladder. I had to have a catheter. And the nurse put in the catheter, and I knew she wasn't going to do it very well because she was really fumbling fiddle faffing around. And then she inflated the balloon in my urethra, which was incredibly painful and I knew it was, and she walked out to the room and told me to stop making a fuss. And I called the bell. I called to just give me a syringe, I'll deflate the balloon myself and my husband is a urologist so he was pretty annoyed by this stage. And I felt really degraded as a woman because it took them a long time to even put the catheter in. They kept saying, oh, just tickle your back, just relax, go to the toilet, play some music, you’re just a bit…And I was like, no, I can't feel anything. But I'm now a bit uncomfortable and I'm getting some kidney pain and, you know, and then I had an indwelling catheter for about four to five weeks afterwards. So I had to have a leg bag and I had to and every time I tried to have my catheter removed I went into retention. But I felt really like devalued as a person. I don't know whether that's easy to say, but I just I felt like it's really horrible having a catheter in. I, my husband was great because he knew, like how to look after it, but it was like, I was sort of left and lost and didn't really know if my bladder would ever work again. I then had awful urinary tract infections afterwards, once with pyleonephritis, and again, I wasn't really, I was sort of taught a bit about some antibiotics. Never really talked to me about vaginal hormones. And I sort of thought, gosh, like, if I wasn't who I am and have the knowledge that I have it, it would be really different. But, you know, you must hear, I hear stories all the time of women just being sort of left and presume that we can just.. and it's only a hysterectomy to me. We know the womb’s really small. It's a minor operation, but for me it was a really major operation and I was quite like shocked how big an operation it really was for me.

Dr Kameelah: I think we do, absolutely, despite how we approach the hysterectomy, vaginal, laparoscopic open incisions, I think that we often underestimate the impact that in surgery or trauma to your body can potentially have. And I really do find that some physicians, not all, but don't take the time or even I will say in the US system, have the time. We have these 15-minute very crazy intervals to talk about. Hey, these are potential complications. Let's talk about them now in this setting of you being calm, being able to understand and digest and mull over the information in the event that they actually happen. And that was part of the impetus of writing this book, the understanding that I had people come in and they didn't really actually even know what was removed, if you can imagine, not knowing, you know, the difference between their cervix or the actual body of the uterus and where the tubes out, but maybe they left them. Was it the right over to the left? And yes, there's a degree of this recall in memory, but also a degree of information prior to the surgery that is critical prior to the surgery and even post, right? That is critical to feeling empowered about this journey, even if there is a complication.

Dr Louise: Yeah. And I think this is why your book, The Empowered Hysterectomy, you've actually called it your complete handbook. And I like the word handbook to diagnosis decision and treatment. And decision is really important because it's got to be a joint decision. And you know, my knowledge of anatomy is pretty good. But there is still women that think that, wow, if they have their cervix and they womb removed, everything's going to fall out and there's going to be a real problem that also, you know, I had a bit of physio afterwards, but straight afterwards I couldn't feel my pelvic floor at all. So there was no point doing pelvic floor exercises. Everything was numb. Of course, and it took me weeks to get my pelvic floor, my core strength back. But I knew what to do and I knew how to limit myself. But limiting yourself and being very gradual is really important as well. And your book is really detailed. But actually, like I've never read such a detailed book, but that's great because people often don't know where to go to get really detailed advice, do they?

Dr Kameelah: Yeah, and I was hoping to strike a fine chord between very common and, everyday language because I feel like in medicine everything can be explained at a sixth-grade level. And that is not to assume you can't understand or, you know, dumb things down, but it doesn't need to be that technical, right? We can explain things in very simple terms. But then on the flip side, if you want to elevate the conversation and have the advanced understanding of what is happening, that that is there for you too, should you choose to engage in these conversations. So I'm glad that you, you experienced the technicality without sort of being overwhelmed by it because it's already overwhelming. Right? You're going in my body. Something's coming out. I have this recovery. But the anxiety and the, we can decrease with knowledge and managing expectations. And everyone deserves to enter this decision-making process knowledgeable in unison and in concert with their doctor, aligned with their values. And there's a way we can do that. And this helps to revolutionise how we approach the surgery.

Dr Louise: It's so important. And, I think, you know, one of the things that people often are too scared to ask, they've got so much going on, they don't know who to ask. Do they ask the nurse, do they ask the junior doctor who admitting someone. Do they ask the senior doctor? Who may just maybe do the operation. And then like you say, everything's so quick and rushed and you don't always think about the consequences or you might think afterwards. So actually, to be if you can be prepared is really important. Having that list of questions I think is crucially important. But there's a lot of people who have a hysterectomy and have their ovaries from the remaining in, so they don't have their ovaries removed, and then they're told, well, you won't be menopausal because you've still got your ovaries. And that's like just wrong as well, isn't it?

Dr Kameelah: That's just wrong. It's wrong. You know, we spend a lot of time emphasising the period right, as the hallmark of menopause, which is quite helpful until you no longer have a uterus. And so we have to educate and expand the definition of what this transition could look like for you. If you don't have a uterus, and understand that the symptoms may, manifest in your sleep, may manifest in your mood, may manifest in how you feel or experience your body, your joints, your workout, how you experience intercourse. And so, yeah, I do get that a lot because, again, an understanding of the body might be off. And so we have to revisit that. But really making sure women understand that the menopausal transition is still in their future and that there are ways to mitigate those symptoms in a way that will allow them to enjoy the transition. It doesn't have to be. It's not, you know, lost on them just because they've had this procedure.

Dr Louise: So my my mother-in-law, who's now 89, she's very inspirational. When she was about 36, she had her womb removed. And she had, I think one of her ovaries removed. But anyway, she didn't know anything about hormones then. It was a long time ago, and she was talking about it to my husband the day before yesterday, actually, because he was just saying, what was your, what was it like when you, you know, starts to have symptoms? And she got very tearful actually, and started crying because she's a very upbeat, very positive person. And she said, it was just like a black cloud over her. And my husband is now 56. And so he was about two or three. So, it was you know, 50 plus years ago. And she had this black cloud over her. She felt joyless. She felt very sad and she didn't really know what was going on. And then after a few months she read a book, Feminine Forever, which I'm sure you know, the book by Robert Wilson and her husband, who was a GP, came home and she said, I need some estrogen. And he said, what? What are youtalking about? She said, I've read this book and I just know that I need estrogen. So he referred her to a gynaecologist and she had estrogen and within days, literally, she felt better. But yeah. And she's still on HRT now of course. But what's really sad is that she had a sister who was 18 months younger than her and had it was quite a different personality. She was sort of larger than life, quite a party animal, and she had quite a horrible boyfriend at the time, but she had a hysterectomy for I don't know of some reason, and, didn't talk about anything, but no one prepared to know and talk to her about the possibility of any symptoms after her surgery. And she became very dark very quickly, and she took her life and died by suicide one New Year's Eve. And everyone blamed the partner because he was quite argumentative. But my mother in law, like now, like, looks back so much. And just as I wonder whether Barbara would be here if she had had hormones, and of course, we don't know. I can guess what the answer would be. But you know what? Every day in my clinic, I speak to women who have had suicidal thoughts and a lot of them, I'm related to their hormones that it can be quite hard to diagnose if symptoms come on insidiously in somebody who's in their 30s or 40s. But if someone's had surgery, we've got to be thinking more quickly, really, about hormonal changes, haven't we?

Dr Kameelah: Yeah, absolutely. I mean, without a doubt, that story is heartbreaking. And we don't know. However, we do know that she should have been offered hormones. You know, as just the standard of care. I think some of my most rewarding visits and I still do obstetrics. So I love the babies. But really some of my most rewarding visits are the the visits, not the day I start the hormones, right. It's the follow up visit, the follow up visit when she comes in and has lipstick on and her hair is done and the clothes are coordinated and there is a life that was not there just a few weeks ago. And I think the, the, the magical thing, which is just so, I can't think of just mesmerising almost maybe about the human body, specifically the brain, is the impact, how quickly our brains respond to estrogen and again,I, I, it boggles my mind a little bit why it's so weird. But we all went through puberty, right? And that's a little bit of insanity. Why? Our hormones are all over the place. So why is it any different than in pregnancy? Our hormones are all over the place. Then we wouldn't make those same associations with midlife, of course, you know, of course. And so, that story is heartbreaking and it reminds all of us that our brains are so dependent on our hormones. Estrogen is a gift. And it is something that I encourage people to discuss with their physicians.

Now I start talking to my female patients about hormones at their 35-year-old visit. I really do, because, you know, you always have these outliers of women who, yeah, right. Those outliers. You never for me want to miss those people who have that very early, perimenopausal transition. You want to capture them. And so some of them, when I bring it up it, in one ear and out the other. Okay, fine, fine. But I planted the seed for future conversations about how we're going to take care of you during this transition, to make sure your whole person stays intact with the use of hormones. ‍

Dr Louise: Yeah, it's so important because also I feel, you know, we can educate others through our patients as well. So even if some of my patients don't have mental health symptoms, they might have more physical symptoms. If they know those are potential symptoms, they recognise them in their friends as well. So one ofthe things I've earmarked in this book, because I really agree with you, and I feel it's really sad and like my work is full of frustrations. You know, even the story about my mother in law, like it hasn't moved on. This is over 50 years ago. Things are still bad. But you've written here. It's quite early on in the book that medicine is broken. We all know it, you said, and you know, it's really sad. We're both doctors. We're both proud to be both doctors. We love our jobs. But the system is failing people, especially women. Isn't it?

Dr Kameelah: It is. Okay, this is where I show my bias towards women because, especially in the United States, and I touch on it in the book, women's health, women's health care, the phases of our lives truly used to be, quote unquote, women's work. Right? Andno one wanted to do that women's work. So we did it for ourselves, and we did an amazing job, and we took care of our bodies. And we used herbs and we used midwifery and we used these practices that really elevated women's health. And then at least in the United States, the introduction of capitalism, you know, enslaved people needing to breed humans introduced this practice that men got involved. And I really think that the movement to move the women's body away from care directed by and for women to a more male, sort of dominated space and way of thinking and even capitalistic manhandling, has hurt us. It is hurt us. And I see it in a lot of my patients who are transitioning a majority of their care to female doctors, and we have the research to support that, right. Women who have female surgeons have fewer complications. We stay in the hospital longer. We feel listened to. Our outcomes are overall better. And so, yes, I am clearly biased. It teaches us that we have some work to do in the medical training of our male counterparts how to listen, how to communicate, how to care, and in away that innately many women just learn by the fact of being a woman in this world. That that needs to be redone and founded. It teaches us that we have to address how capitalism and that and the need to make money in this system. You can be in medicine and make money. It's possible. And it is also possible to take excellent care of patients. And in, I guess, my final point, and particularly in the United States, our desire for primary care is just.. I mean. I was talking to a patient today, and I don't know if you are familiar with these brand, you know McDonald's. But she was talking about how we have a doughnut brand here called Krispy Kreme. And that's enough. That's all you need to know. Krispy Kreme, right, is now doing a collaboration with McDonald's where they have doughnuts on either side where the bun was, and then you have a sandwich inside. Are we, are you serious? Like, what are we what are we doing? And so in the United States, in particular, our complete disrespect for primary care and prevention, permeates these issues that contribute to medicine is being broken. And so I think we both struggle with that every day. Right. And we just spend our 9 to 5 trying to fix trying to make better the people in the situation in front of us, but certainly on a global well, city, county, state, nationwide level. We need a rehab. We need we need help.

Dr Louise: I totally agree, and I think, you know, a lot of, work as doctors is also educators and actually giving women choices, empowering them and also to listen to them. And that's one of the big thank yous that I get in the clinic is in the first consultation. And people just say thank you because you've listened. That's before giving any treatment, talking about treatment. And that is nice, but it's sad because it's sad because they've not been listened to before and or they've been judged in the wrong way. So we've got a really long way to go. But certainly, you know, your work is amazing and I, this book’s so good. But, I always end with three take home tips. So the women who, are considering having a hysterectomy for whatever reason, or maybe they've had a hysterectomy and they feel that they haven't had the right post, you know, treatment. What are the three things that you think people should be asking their doctors, their team, that looking after them about hysterectomy?

Dr Kameelah: So one thing I do and I encourage people to do, whether it applies I always to them or not I always ask my health care team, have we gone through all the options, whether they apply to me or not? I think it's very important for people to understand that there are many options, and in knowing those options, again, whether they apply to you or not, it helps strengthen the doctor patient relationship in that we are thinking holistically about my care. And I know that given all the options available in the world, I am making the decision that's best for me. So making sure you know all your options. Secondly, I would say, I'm and I'm going to try and do this like beginning, middle, end. What do I need to know about my recovery, this middle space? How what do I do now? My surgery is three months away. How do I optimise my success for recovery, minimising complications? How do I use my family, my friends, my loved ones to support me during this time? So although the component, for example, of urinary retention or potential infection or these things are there, how do I optimise to minimis emy risk should I decide to move forward with hysterectomy?

And then finally, how do I get back to myself? How do I get back to myself? How do I, outside of not having a womb, realise the fabulous person that I am because we've removed something, right? But you are still the same vibrant, amazing, intellectual, interesting, outgoing person that you were before you enter the operating room, I would think about what are my steps to make sure that I regain the life, and that I'm living it even better, because now I've eliminated this issue that was causing me trouble for so long. How do I get my sex back? How do I regain my orgasm? How do I, you know, resolve the anaemia that was plaguing me so much. So my beginning, middle and end would be those three questions, so that at the end of the journey, when you look back, you're like, okay, I handled that. I did that right.‍

Dr Louise: Yeah. That's such great advice. I love the positivity and the the way you think about it. So thank you so much for joining me today.

Dr Kameelah: I've really enjoyed it. Thank you for having me. I will always come back. This has been a pleasure.