"I decided to look outside the box."

Lisa Chism is a certified nurse practitioner currently practicing at Karmanos Cancer Institute, Alexander J. Walt Comprehensive Breast Center, Women’s Wellness Clinic. Chism also is the clinical director of the Women’s Wellness Clinic. She has been a registered nurse for more than 22 years and a certified nurse practitioner for 20 years. She is a certified menopause practitioner through the North American Menopause Society (NAMS), and has completed a certificate as a sexual health educator and counselor through the University of Michigan. She's published “The Doctor of Nursing Practice Degree: A Guidebook for Role Development and Professional Issues,” reflecting her interests in the development and promotion of the DNP degree. For her efforts in spiritual care and nursing practice and care for women experiencing menopause and sexual health-related health concerns, she has been inducted as a Fellow of the American Academy of Nurse Practitioners and named a Menopause Practitioner of the Year by NAMS.

Dr. Barb: I’ve known our guest today for a few years, since our paths cross at medical conferences and other women’s health events. Dr Lisa Chism is a certified nurse practitioner, currently at Karmanos Cancer Institute, Alexander J Walt Comprehensive Breast Center. Lisa is also the clinical director of the Women’s Health Clinic. Welcome Lisa!

Lisa: Hi, thank you. Thank you so much for having me!

Dr. Barb: It’s always great to come alongside other colleagues in medicine, and many of them, fortunately, are women, helping to treat other women. Can you give a little insight as to what drew you into the field you are in and how you found yourself in the specialty of women’s health and breast cancer?

Lisa: Sure. I’ve been a nurse practitioner about 26 years, and my background includes probably four different areas. Starting off in geriatrics and gerontological nursing; my certification is actually as a gerontological nurse practitioner. And I did nursing home work, caring for patients in a subacute setting, and I still had a draw towards women’s health. So I went back to school quickly after getting my masters as a gerontological nurse practitioner and I did a women’s health track. So I really started to focused on older women’s health care. I then transitioned to a family practice setting, and in that setting, I was generally the only woman, so I did have a large population of female patients and was able to utilize all of my skills both in adult geriatric medicine and women’s health. I then transferred into an internal medicine practice, and again, was the only woman and cared for a majority of female patients in the practice. And I had just been back to school again and earned my doctorate as a doctorate of nursing practice degree at Oakland University. And interestingly, my position was then eliminated. I worked for Beaumont Health System, and at that time they were going through some transitions and I found myself without a position.

So, I decided to look outside the box. I’d never done oncology or oncology nursing, so I started researching and found this position at the Karmanos Institute downtown in the Breast Center, primarily taking care of what I was told was going to be women with a high risk for breast cancer. This position has evolved into a clinic with a life of its own and we now care for all women with any type of breast concern and breast cancer survivors. We’re kind of a diagnostic clinic, where we see women with any type of a breast complaint and do the initial work-up all the way to diagnosis and give results. And then help women navigate and get the best care with regards to surgery, radiation, oncology, medication, chemotherapy, and so on. And then, fortunately, my patients come back to me as survivors, and we care for them for a very long period of time.

And through this work, I developed an interest in—I noticed women with menopausal symptoms had to come off of their hormone therapy, frequently because of their cancer diagnosis, or their cancer treatment put them into menopause, and they could not take hormone therapy. I then realized we need to do something for these women, and I again began to look outside the box. And so I became certified as a menopause practitioner and really developed a clinic within a clinic, caring for women's menopausal concerns. And then I realized that I wasn’t well-equipped to deal with their sexual health concerns, and there was such an overlap between their menopausal concerns and their sexual health. So I went back to the University of Michigan and earned a certificate in their sexual health program through the School of Social Work department and earned AASECT certification, which is the American Association of Sexual Educators, Counselors and Therapists.

After about three-and-a-half years—it was quite a process between didactic work and supervision—I became a certified sexuality counselor. So the women’s clinic has fully evolved into a menopause and sexual health clinic within a breast clinic. And I think what drew me to this work was all of the years that I spent taking care of women, being drawn to women and especially in midlife to older women’s health. So it’s really been a wonderful journey, I’m really happy to be where I am right now, to be able to do this work. It’s been a valuable, wonderful experience, extremely rewarding.

Dr. Barb: Wow, so you are truly the definition of a life-long learner—

Lisa: [laughs]

Dr. Barb: —and recreating and discovering new areas of expertise. So it’s great that women can have practitioners like you, who have continued to evolve, to fine-tune their practice to meet the needs of some of the women who really, many practitioners don’t seem to have an interest in or any expertise in; and, as you mentioned, a lot of women are being denied some important treatment options. So can you give us an example of a typical patient, post breast cancer treatment and what are the common symptoms she’s going to bring to you, and then maybe talk through what some of those clinical options might be, that listeners may or may not be aware of.

Lisa: Sure. So, when I see a patient for a menopause and/or a sexual health concern it generally tends to be someone who heard of us through our system, or an oncologist or surgeon has referred the patient for care. When someone comes to me at this point, they’ve really either exhausted things they can figure out on their own, or their provider really lacks the expertise.

It begins with assessing what kinds of symptoms the woman’s having when she started—she might not have been menopausal but has become menopausal. Some of the most common symptoms that women will present with are hot flashes, sweats, blushes, inability to sleep—usually due to these types of symptoms—which we call vasomotor symptoms. And then there generally tends to be an overlap with sexual concerns specifically related to menopause, such as vaginal dryness, pain with penetration, decreased desire or lack of interest, which may be partially because of what they are going through with treatment, but it could also be a result of being thrown into menopause, or being menopausal or having their symptoms exacerbated by treatments that they are receiving.

Those are generally some of the most common symptoms that women will present with when it comes to menopausal and/or sexual health concerns, would be the hot flashes, hot flushes, inability to sleep, sexual health concerns, will generally be centered around vaginal dryness or pain with penetration or intercourse, as well as decreased desire. What we do at that point, I believe in shared decision making, so I present to my patient all of the different options that both work in clinical practice and that have good evidence. I really believe in evidence-based practice, so I’ll present women with the literature that I have available with certain modalities.

For example, for hot flashes and sweats, I’ve found that using venlafaxine or Effexor—it’s a specific type of antidepressant—I have found that this works to significantly reduce hot flashes and night sweats. But, it is very important that women understand why they are receiving this particular medication and they also need to understand that it’s off label—in other words, the FDA has approved venlafaxine or Effexor for depression or anxiety, but we know through literature and clinical practice that this medication can significantly reduce hot flashes and help with sleep. And I usually explain to women that this is an antidepressant, because they are going to go to the pharmacy and have their medication filled, and they’re going to have a print out that is going to say, you are on an antidepressant. And if we don’t have that conversation... it’s very important that we have that conversation so that they’re not surprised, because many women may not be depressed. So we talk through what’s going on in the brain with regard to estrogen and melatonin and the dopamine receptors in the brain and the effect on the hypothalamus, to help women understand, that not only have we found that this medication works, but there’s a certain physiology behind what it’s doing in the brain to help control temperature and hot flashes and night sweats. That’s one of my first line medications.

Another is Pristiq or venlafaxine or desvenlafaxine, which is very similar but came along after, almost got FDA approval to control vasomotor symptoms, like hot flashes and night sweats, but didn’t. But also very very effective working on the same pathway in the brain to impact the hypothalamus and control temperature.

Another modality that I have found works very well is actually a supplement that has randomized control trial data, called Relizen. Relizen is a flower pollen extract that was originally developed in Europe. In Europe it is actually a prescription for menopausal symptoms and vasomotor symptoms and in the United States it came over as a supplement, but interestingly, actually has randomized control trial data looking at reduction of hot flashes and night sweats. It does take eight weeks to become effective, but it can be very effective for women and I have found that women get about a 50-percent reduction in hot flashes and night sweats, if it works.

The other thing that women need to understand when they are using modalities that are not hormones, is that we are trying to improve quality of life, and we can frequently reduce their symptoms by about 50 to 75 percent, and I want women to understand that so they have realistic expectations. Nothing is going to be exactly like using hormone therapy, such as estrogen and progesterone, but we usually can’t use those in a presence of a history of breast cancer. So, it’s important that women have realistic expectations and understand that these modalities work, but they may not work to that degree. However, some relief, or half relief, is much better than suffering with these symptoms all together.

For sexual concerns or dyspareunia, pain with penetration, I have several modalities that we talk about. One is intravaginal moisturizers and lubricants. And when I counsel women about moisturizers, I counsel women that moisturizers with hyaluronic acid has been shown in randomized control trials, to actually improve the integrity of the vaginal lining and the epithelial tissue; you can actually get a physiologic response with the hyaluronic acid. Whereas the moisturizers over the counter can offer some symptomatic relief, they aren’t going to have the same effect on the vaginal tissues.

Now, unfortunately I’ve not been able to find a moisturizer over the counter at a drugstore with hyaluronic acid; however you can get hyaluronic moisturizers from certain types of  manufacturers, and usually I advise women on how to obtain those. [MiddlesexMD offers Lubrigyn cream, which contains hyaluronic acid.] Now, they are not going to be covered by insurance, but they can be found quite reasonable. Now, if a woman wants to progress to something beyond a moisturizer, such as a medication, I counsel women about local estrogen therapy, which we have a number of ways to deliver to the vagina, as well as local dehydroepiandrosterone which is DHEA or Intrarosa, now FDA approved, which is a different type of medication—still somewhat hormonal, but has a different pathway.

I counsel women about using this for vaginal dryness. Both have been shown to improve vaginal dryness, irritation, decrease pain discomfort with intercourse. This does require a very long discussion about the literature, what we know, what we don’t know. Because women may need to understand using something with their vagina that is a hormone—they may not be comfortable with that with their history with breast cancer. But usually by the time we get done having our risk/benefit conversation about what we do know, what we don’t know, what the current literature has told us, as well as my experience using either one of these modalities for women, women are usually able through a shared decision-making to come to a decision that they are comfortable with.

As far as desire, I learned about Rosemary Basson's model when I was studying at University of Michigan through their sexual health program. And I found this model to be so helpful, and I actually drew it out for women and I give a copy of it to them; I have it in the pamphlet that I give women. Because when women understand that according to the Basson’s Model, arousal precedes desire—in other words, women don’t often walk into the house, at least somewhere around midlife, and especially after a cancer diagnosis and treatment, don’t necessarily walk into the house wanting to immediately be sexually active or engage in sexual activity. They may need arousal first. They definitely need relationship to be intact and to have a good quality relationship, and this is what Basson's Model has told us. That the very beginning of the cycle starts with a quality relationship with satisfaction and trust and intimacy, followed by arousal and then desire.

And when I explain this to women, this is usually a very “ah-ha” moment, and they want to tell their partner so that they can understand what it is that they are feeling and what they are feeling and what they are going through.

Now, if the woman is having pain with intercourse, that’s what we’re going to address first, or pain with penetration, because once a woman can feel pleasure and arousal and not feel pain, frequently we can work on desire, and desire will follow. So my counsults are generally about 45 minutes long, because, as you can see, there is a lot of information, a lot of shared decision making, a lot of sharing of the literature and what we know, so that women can make a comfortable decision for themselves.

Dr. Barb: And what about the increasing group of women who are finding themselves at higher risk of developing breast cancer because of, now, the awareness of carrying a gene mutation that may put them at risk? So many women, I think, have a fear around our traditional treatment options for instance, for menopausal symptoms or around sexual health symptoms, but for many of them, they can still consider our more traditional, possibly our more effective treatment options. Is that how you advise women?

Lisa: Yeah. The North American Menopause Society Hormone Therapy Guidelines that were published in 2017 actually addressed women with BRCA mutation, and the literature addresses women with an elevated risk for breast cancer. And the way I counsel women is: an elevated risk for breast cancer is not a counter-indication to hormone therapy. And it again becomes a risk/benefit conversation, what we know and what we don’t know. But at this time I don’t discourage women, if they are having symptoms, specifically vasomotor symptoms, with hot flashes, night sweats, that are really interfering with their quality of life, I don’t discourage women from using hormone therapy if they are at risk for breast cancer.

Now, with the BRCA mutation, there are guidelines and literature that address with or without mastectomy, and with or without, obviously women who have had an ovariectomy for risk reduction are definitely going to be possibly be very symptomatic. In other words, if someone has, at age 40, an ovariectomy and becomes menopausal, possibly ten to fifteen years prior to when they would normally have these symptoms and normally not have circulating estrogen, I counsel women that the benefits may outweigh the risks to be on hormone therapy for that period of time, especially if they have elected to have a bilateral mastectomy, and the guidelines actually do address this.

Dr. Barb: So, do you have any optimism that we’re going to have new things to offer women regarding some of these complaints, moving forward? Are you aware of anything new coming through the pipeline? I know we were both at the recent NAMS meeting and there’s some interesting discussion around other approaches to treating hot flashes for instance.

Lisa: Well, I think the discussion about our newer treatment around the KNDy neurons, I believe it was KNDy, I can’t remember what the acronym stood for, but certain neurons in the brain that are actually felt to possibly be related to hot flashes and night sweats and the new medications that are being developed to target these neurons have actually, in early trials, looked very promising. So I am optimistic that there are even more non-hormonal options that will be available.

As far as new options for vaginal dryness and pain with intercourse, I think it is very exciting that Intrarosa or intravaginal DHEA is now FDA approved. Local estrogen now also has new delivery, such as the intravaginal ovule that only has to be inserted twice a week at any time of day, as indicated. I think that’s pretty exciting. I think that it’s a wonderful time in the sexual health world to be practicing, because it is finally getting the attention that it deserves. I think that there is also something coming along for desire for women. Bremelanotide just went through phase-three trials, and they are hoping that sometime this next winter/spring it will be approved, which I think is very exciting. Something that women can use in the moment with a forty five minute onset to increase desire, I think, is going to be very promising and exciting for women. So yes, I do think that there are a lot of new therapies coming. It’s a wonderful time to be in this space to be able to help women and to start to have more and more options.

Dr. Barb: Well, thank you for sharing the depth and breadth of knowledge that you have. And I am, again, thankful that there are women who have a resource that they can improve the quality of their life. Because so many women, with our early detection and successful treatment and now with the genetic changes, just what we’re recognising, so many more women who are coming across these symptoms and needing to deal with them appropriately. So it’s great that you can have a practice that’s meeting those needs specifically. And I know that patients in your area are very appreciative of that.

Lisa: Well, thank you. It’s very rewarding work.

Dr. Barb: And in closing, can you share with listeners, where you find richness at this stage of your life, personally?

Lisa: Wow. Well, I would say really through my family; my daughter just started University of Mercy Detroit in the School of Nursing, and she’s got big aspirations and dreams. She’s actually double majoring in nursing and political science, so she’s planning an internship in DC this summer, so I’m planning how I’m going to spend my summer visiting her [laughs].

strong>Dr. Barb: Well, that sounds like an exciting option—

Lisa: Yeah. Travel, traveling with my family. And professionally, continuing to grow in this specialty. Like I said, it’s a real exciting time to be providing this kind of care, but I’d have to say, really centers around my family. They give me balance.

Dr. Barb: Good. Well, thanks again, Lisa, for your time. I really appreciate it.

Lisa: Thanks so much, Barb. Take care.