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The Fullness of Midlife

“We’re all taking care of each other.”

“We’re all taking care of each other.”

by Dr. Barb DePree MD

Nurse Barb Dehn

Barbara Dehn RN, MS, NP is a practicing Nurse Practitioner and a health educator known as Nurse Barb. She is the award-winning author of the Personal Guides to Health used by over five million women in the U.S. and contributes content to HealthyWomen, Huffington Post, NurseBarb, KevinMDm, and The Patch; she has an active and engaged Facebook following and 34,000 Twitter followers. Barb is the author of The Hot Guide to a Cool Sexy Menopause, Nurse Barb's Guide to Breastfeeding and Nurse Barb's Guide to Pregnancy.

Barb earned a masters degree from UCSF and a BS from Boston College. She is certified by the North American Menopause Society and is a Fellow in the American Association of Nurse Practitioners. Over the last several years, she has been an active participant in Global Health Initiatives at FAME Hospital in Karatu, Tanzania. Barb lives in the San Francisco Bay area.

Dr. Barb: My guest today and I have a number of things in common. Nurse Barb Dehn is, like me, committed to women’s health and education, and about healthy lifestyles. We’re both certified by the North American Menopause Society. We’re both actively providing healthcare to women in our practices, as well as writing and speaking on the topic. Welcome, Barb!

Nurse Barb: Oh, Dr. Barb! I’m like thrilled to be here because I think I’m not the president of your fan club, but I’m on the board. [laughs]

Dr. Barb: [laughs] Oh, that’s so sweet of you! And I think it’s important for our listeners to know that we go back a ways. We’ve got mutual colleagues, but over the years we’ve had the opportunity to meet in person and have had reasons to collaborate, so yeah, we have a history of professionalism behind us, and I think that’s where our shared values and interests [show], and that’s why it’s great to catch up with you since we’ve been limited by in-person meetings. You and I haven’t had the typical opportunities to connect. This is our chance today. 

Nurse Barb: I am also thrilled because I love MiddlesexMD. My patients love MiddlesexMD. I just remember the first time I met you thinking, “Gosh, what a phenomenal idea because there are issues that you and I are so passionate about, and that we’re able to talk about around the dinner table. Most women, I think—this is what I hear from patients and friends—they’re not even comfortable talking to girlfriends about. So I’m so appreciative to have this opportunity to talk to your listeners about some of these very personal and private concerns because everyone wants to know a few things, like, “Am I normal?” and “Am I going to be okay?” So thank you for this opportunity. 

Dr. Barb: Yes. So let’s hear a little more about your background, Barb. Share with the listeners some of your interests and your background professionally. 

Nurse Barb: Thanks. I started my career in pediatric intensive care at Stanford University. I was so privileged to be on the team that took care of the first children who had heart transplants. That really was intense, as you can imagine. And I realized why prevention is where it’s at. While I was seeing children I thought, “Well, let me do women’s health.”  So I went back to school and became a women’s health nurse practitioner. I’ve been doing this for over thirty years, which is hard to believe, and I love it. I love seeing women. I love the opportunity, but also the responsibility that comes with having women share. And I think that when the door closes and someone is in the exam room or an office, I like to get to know them fully dressed, and then we can talk about how we can partner in health care. So for me the passion has been about really helping allay fears, answer the questions that need to be answered, and then provide them with lots of options for how to improve their lives. 

Dr. Barb: And I think that’s where we have a lot of shared interests in addressing women in this season of this life, and a lot of important decisions that happen. I think for you, your women’s health practice is probably somewhat more broader than mine; I think you are seeing more women of all ages.

Nurse Barb: I am; I see young girls, as young as eleven. I have a huge adolescent practice, which is so fun. And then I have a lot of patients who are postmenopausal; because of that certification, more and more women find me. I also do a lot of talks in the community, so then patients or women see, “Gosh we can talk about these hot flashes and night sweats and brain fog,” etc., and there’s evidence-based ways to take care of people. And then putting all those fears into context, and really I think a lot of people are afraid. “Oh my gosh this has a side effect!” But when we put it into context that they can understand, then they go, “Gee, maybe I should rethink about some of the options that maybe other providers have scared me away from.” So, I’m very very fortunate. 

I also take care of a lot of women who are post-80, and I see a lot of 90-year-olds, because I like spending time with them, and it's so gratifying to spend time with them! I’m probably very similar to you. You probably have a lot of women in their 50s who bring their moms in to see you. And I know both of us do gynecology, but I’m also often saying, “Look, I have to send you to a specialist.” And they’re saying, “No, no. You take care of it.” And I’m like, “No, no. This isn’t something I know a lot about.” So I think I’ve become a medical home for people, and I’m coordinating so much care, but it is very gratifying because I think in today’s system, not a lot of folks are helping people, helping to coordinate their care, and finding those specialists for those other issues. 

Dr. Barb: Yeah, agreed. One thing I’ve known about you, Barb, over the years is that you’ve had involvement in global health. And you don’t know this, but I’ve thought about you more in the last number of months. I read Melinda Gates’ book, The Moment of Lift, which really, for me, was a somewhat important and pivotal book to really think more deeply about some of the health needs of women globally. And you have been there. You have been providing care; you have been active in care. Can you talk a little bit about your experiences and what you’ve observed as women’s health more globally?

Nurse Barb: Oh, thank you so much for asking! And I love Melinda Gates’ book. I’ve read it twice now and gotten so much out of it. It’s very inspiring. I’ll tell you, I work in sub-Saharan Africa, in Tanzania near the Serengeti. There’s a hospital there called FAME, which stands for Foundation for African Medical Education. It’s this truly sustainable model. It isn’t Westerners jumping in and out. It’s all Tanzanian health care providers—doctors, nurse practitioners, nurses—and what we do as Westerners, we come in to be collegial with Tanzanian counterparts, and we learn from each other. 

There’s so much gap in their education that we’re able to provide. What we see on the ground is that what we take for granted in the United States isn’t available to women globally. There is such a discrepancy: in Tanzania for instance, there are 55 million people. And for those, there’s only 12—only a dozen OBGYNs—for roughly, I’d guess, 27 million women. So there are more OBGYNs down the street from you and from me than there are in the entire country of 27  million people. That means that women don’t have pap smears. They don’t have mammograms. And then, there aren’t many roads, so it’s not like they can jump in their car and go down to CVS and pick up a prenatal vitamin. They have to walk for miles on a dirt road or take a small motorcycle, that’s the taxis. And women just don’t have access. 

So I’ve been out in what we call “the bush” to see traditional birth attendants and teach them how to wash their hands—basic things. Bringing them clean instruments so that they can assist in an emergency or try to bring someone to our facility. It has been eye opening, and I’ve done a World Health Organization program for cervical cancer screening. Barb, we use head lamps and vinegar to detect whether or not there’s changes on the cervix. So for anyone who is interested in global health, you don’t have to fly over to sub-Saharan Africa, but if it is something that you care about in terms of women’s health, I would urge your listeners to get involved in anyway you can, and sometimes the best way to do that is to make a donation to an organization you care about. 

Dr. Barb: What’s available for women there for contraception?

Nurse Barb: Well in Tanzania, there’s so many rules that prohibit women from getting contraception. We have one contraceptive pill that is available and one copper IUD, which typically causes a lot of bleeding. So picture this: you are a Maasai woman. You live in a truly mud hut with sticks for a roof. There are snakes everywhere. You have to carry your firewood for miles, sometimes, to make a cooking fire to boil water so it’s safe. Very few people are able to do that, so there’s tremendous issues with diarrhea, dehydration, and anemia. Severe anemia. It’s not unusual for us to see a lady who has a hemoglobin of six. Now here in the United States, they would get a blood transfusion, because a normal hemoglobin is eleven. But there, the only IUD that’s available is a copper IUD that causes more bleeding. Among women, fertility is valued. It’s still a society where it’s important to have a lot of children to take care of you later on. But unfortunately, many women die in childbirth, for a lot of reasons. So women want contraception. It’s just not available to them, and that’s heartbreaking.

Dr. Barb: Do you have any reason for optimism to think that will change in our lifetime? That in the next 20 years, this next generation of girls in a country such as that might have more access to contraception? I know some of the important—like the Bill and Melinda Gates Foundation—contraception is an important issue to them, recognizing that the size of the family when women start childbearing often determines the trajectory of her life. So I’m just wondering if you have seen any changes that indicate improvement for these women and the choices they have.

Nurse Barb: Yes. I am an optimist, and I didn’t want to paint such a bleak picture, but we still have a long way to go. To your point, Barb, the Bill and Melinda Gates Foundation, they have done so much that I became aware of when I started going to Tanzania. They pretty much eliminated river blindness in East Africa, I’m sorry in West Africa, because there were these flies that caused the farmers to go blind; they would do that. They’ve also helped to eliminate m malaria; malaria used to be endemic everywhere, and they’ve helped eliminate that. I do see improvements in contraception; what the Gates Foundation has done, is they partner with the village elders, and they work with NonGovernmental Organizations or NGOS who are on the ground and who have long established relationships with them. And when the village elders, often men, when they agree that it’s okay for women to start having contraception, then suddenly its okay, so I am encouraged.

Now there’s other issues that come up, which is wonderful. Unfortunately, there are many orphans, many of whom are women who are then not bound by the tribal elders in those cases, when they are going to a girls’ school (and there’s so many girls’ schools), those girls have much more self efficacy, and those girls are much more able to make decisions about their own lives and their own health. That’s where we also see a lot of improvement. There’s several girls’ schools near where I am in Arusha, and those girls are very different from their peers of the same age who live in the villages. These girls are able to go to school; they are able to see that there are more opportunities, because the girls in the villages don’t know what they don’t know. So education, education, education. That’s the key.

Dr. Barb: Thank you for what you are doing there, because I think it is critical work, obviously. In speaking of contraception, one of our headlines in the U.S. recently has been the decrease in birthrates. I don’t know if that is pandemic specific; I think that’s definitely played into it. I’m wondering about your thoughts on contraception here in the U.S., both some of the technologies, availabilities, what does this mean for birthrate? I see it as great, because the number of unplanned pregnancies and the number of teen pregnancies has somewhat diminished, and I think that it is probably somewhat related to availability of contraception. But, you are closer to that population, what are your thoughts on that? 

Nurse Barb: Oh, it is a great question. I think that with contraception and COVID… well, let me say, our birthrates have been declining for years but then covid and the uncertainty, I think—and some researchers have found—that the uncertainty about the future really caused a lot of women to rethink their contraceptive choices and “let me put this off until I know what might happen.” But then I think the availability of the long-acting, reversible contraceptives or what you and I call LARCS, these are game-changers, and most of these are available free of charge through the Affordable Care Act, and so women have been coming in in droves for LARCs. And there’s a new one that’s called Annovera. This is a one-year birth control ring; it was co-developed by the World Health Organization to do what we call #periodsoptional, and it’s wonderful. And hopefully it will be available for some women in sub-Saharan Africa who are terribly anemic and can’t afford to lose blood every month with a period. So that’s been amazing.

Women now are saying to me, I really want that three to five years of contraception through an implant or an IUD, and I need to work on me first. And I see that as such a great opportunity, so they’re having babies when they’re ready, when they’re in a partnered relationship or they’re on their own, and they can afford to take that time to be a mom. I put in between one and four IUDS a day in my practice. 

Dr. Barb: Yeah, I think that’s been a real game changer for most of us. And you know the other thing that came to my attention, which I hadn’t really processed until reading about it within the last year was, in women who are in abusive relationships, whether its physically abusive or emotionally abusive relationships, oftentimes pills—that’s one of the manipulating factors of a partner, is to not make their pills available to them or to disrupt their ability to take their pills, and this idea of an IUD or an arm implant or even Annovera, where women really have truly made the decision and taken full control, I hope that’s not the motivation many women have in making that decision, but I’m glad for those women who do have to make decisions in that area that they do have now, discreet, effective, safe birth control available to to them.

Nurse Barb: Yes, and I will tell you, even in Tanzania, some women who have the access through like a community leader or a woman who is like, a wise women, they will come in and ask for something that their partner will not be able to detect, because they want to be able to control their fertility, so that’s something that we do. But, I agree, we do, too many women are in abusive relationships where they have no power, no control, but you are right, that many woman may have a partner who may limit their access to birth control, and so it is a game changer when a woman can say, gee I don’t know why I’m not getting pregnant. So we want to do whatever we can to empower women. We try to do that in so many ways, even giving them scripts in how to talk to their partners about anything and everything. 

Dr. Barb: Right. Let’s pivot just a little bit and talk a little bit about your practice today, in the midst of a pandemic. What does that look like and how do you see that changing, the way you deliver healthcare, women are asking for healthcare. What’s your perception of that?

Nurse Barb: Well, I feel really privileged that women are able to be vulnerable and talk about the real issues they have. One of the things that’s come up and I want to put this out there to your listeners, that it is normal and natural for women to have more anxiety right now. Really, the rug has been pulled out from all of us. One of the things that comes up for women of all ages—I’m seeing it more in my teens though—is anxiety and panic attacks. There’s a lot of women who are spending one, maybe two hours a day, couple times a week, managing worrisome thoughts; or they’re ruminating so much that they can’t get anything done and they aren’t as productive at work. So that’s the trend that we’re seeing and trying to help women access mental help, counseling, but also making available to them different choices, I call it your mental health toolbox. And we talk about all the different tools in that toolbox, from mindfulness and meditation to exercise.

One of the things I’ve found is it’s important for me to take the time and listen to open-ended questions about what’s happening and what do you think would help? And then having women help decide what they think is going to work best for them. So I’ve seen that. I’ve seen a lot of women become more isolated, and what we are doing is trying to help them get out of their homes in a safe way, sort of baby steps. How could you do this? And I know you and I both use a lot of motivational interviewing, you know “Paint me a picture of what it would be like to be outside, somewhere safe.” So helping people transition back into a society that has opened back up in a safe way, where they feel in control and empowered. That’s really something that I’m working on.

And then probably like a lot of health care providers, we’re the people who are maybe more resilient because we’ve seen so much in our careers, and what I’ve had to do is take a dose of my own medicine, like okay, I have to get out and take a walk every day because I’m not just this unending fountain of help and validation and compassion, I have to take care of myself too. So that’s been a really good learning too, that we’re all taking care of each other; we’re all doing the best we can. 

Dr. Barb: Yeah, I think those are wise words and good advice. I do feel, while I’ve been fortunate to not worry about housing security or food insecurity personally and I do have a job and have had a job that I’ve been able to go to, there’s still a burden of walking through this with others who are more negatively impacted, and I share some of those same thoughts. I think as fellow healthcare providers, we need to encourage one another. You’re on the West Coast, I’m in the Midwest, I don’t think our patients are experiencing this differently regionally, it sounds like. I would nod and affirm all the things that you just said; I’m seeing the same thing.

Nurse Barb: I’m so happy to hear that, because I think that a lot of times there’s shame around, “Am I normal, is this okay? What’s wrong with me that I can’t deal with this?” And one of the things I spend a lot of time on is, “You’re normal!” We’ve never experienced this before, and it is okay to be struggling, and what can we learn from it? This is an opportunity also, instead of running away from these uncomfortable feelings, where can we go now to dig deep. Where is the meaning in this, and does this help me in my life in my own personal journey of fulfillment, whether it’s spiritual, emotional, or relational fulfillment? How does this help me redefine or kind of go back and say, yeah, I am living the way I want or what kind of changes I am going to make post pandemic. 

Dr. Barb: So as we wrap up our time here together, Barb, I do want to hear what you tell your patients. I feel like most of my advice more recently in my practice has been more around encouraging women in their mental health, and maybe a little less about their physical health. But I’m wondering, how do you help encourage women to address their physical health in this unique time? 

Nurse Barb: Barb, I am so excited to hear that you are also working on mental health. This is terrific, because sometimes we, in women’s health, we know that they are very much connected. But in terms of physical health, one of the things I’ve been working on a lot is helping patients, or women, really, identify what can they do to stay healthy right now. And you are in the Midwest; the weather sometimes doesn’t cooperate out there the way it does in the West Coast. It would be interesting to hear what you have been telling your patients. But we’ve been telling especially our postmenopausal patients, “Oh my God, overnight I had twenty pounds at my midsection, I can’t zip up my pants, and I don’t want to sit around in my PJs all day on Skype or Zoom,” on their calls. And so working with them on making better choices, finding great recipes, even making lists of different kinds of food they can buy at their local grocery store.

And then the exercise: Here, let me show you this app that you can get for doing just ten minutes of yoga, because sometimes people get intimidated by doing a whole hour of exercise. Do you think you could do five minutes or ten minutes, that’s really helped a lot of people go, “Oh!” But I’ll tell you the thing that helps a lot of people who are my age, and look, I’m sixty-two and I gotta stretch, because I can’t walk my three miles without knee pain, so I need to stretch, let me show you what I do. And then they say, “Oh, you do it too?” So then they don’t feel like there’s something wrong with them; everyone has to make these adjustments.

And then finally, I also share research with patients from what we know from the North American Menopause Society, what we know about making choices about food. Using a lot of awareness around making choices and helping people kind of look at, oh my gosh, am I just eating unconsciously, am I reaching for something because it is that time of day or I’m watching my favorite show. 

One of the things I’ve been doing is so old school, so old fashioned, but it works, and that’s food diaries. Writing down what’s going on emotionally. I’m helping my patients say, what am I really hungry for right now? Am I hungry for some nurturing? Am I hungry for a way to express some negative emotions, like you just had an argument with your partner and you run to the refrigerator to see if the answer is in there? I do that, right? Do we use food to celebrate? So, I’m working on a lot of food awareness and choices and patients are like, wow, having these aha moments. I’m not hungry, but everyday at four o’clock I have this, people are either salty and crunchy or they are sweets. And so we just try to identify what is that, and what other choice might you make. We also talk a lot about motivation. And still, so many of us are like, I want to be healthy. No, no, no. Tell me the real truth. Okay, I want to look good in that dress. Okay, I know I’m going to see my family at a wedding; I want to look good. That I can buy and that’s a good motivation and that will help you stop, pause, breathe, and say, what am I really hungry for right now, and do I want to make that choice in the moment? 

Dr. Barb: Good. Well thanks for your comprehensive, I would say, very comprehensive way to try to help women seek and achieve a better sense of health and wellness in this really challenging time. So, thanks for your time today Barb. 

Nurse Barb: Oh, thank you Barb. I appreciate being asked. I hope you have a great day. 


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