Northern California Center for Well Being: HeartWorks Cardiac Rehabilitation Program (Roosen, 3/25/26)

A recording of this presentation is available HERE.

Thanks so much to Erin Roosen, program manager for our local Center for Well-Being's Cardiac Rehabilitation Program, HeartWorks, located at 500 Doyle Park Drive, Santa Rosa 95405. She gave an inspiring presentation on the value of Cardiac Rehabilitation. She certainly inspired me to give a more robust bedside recommendation for my cardiac patients. 

Cardiac Rehabilitation is an evidence-based intervention that literally saves lives. . .

HeartWorks offers: 

• A 3 month focused exercise program for patients with heart failure, any cardiac procedure (valve replacement or repair, stent, CABG), and recent STEMI/NSTEMI
• Cardiac rehab
• decreases need for hospitalization by 25%
• helps people increase activity level
• improve quality of life (65% improvement on PHQ9)
• improves diet
• decreases mortality (47% decrease in mortality if you complete the program, compared to attending only 1 session)
• Cardiac rehab includes pre and post exercise vitals and 3 lead EKG monitoring
• Phase II is 36 sessions (2-3 days/ per week, depending on availability): goal is to improve aerobic capacity (by increasing the 6 minute walk test and/or improve MET levels). This is generally covered by Medicare insurance
• Phase III is an additional 3 month non-monitored program paid for by participants (24 sessions, 2/week)
• Once participants complete cardiac rehab, they are offered a 3 month voucher for our local YMCA

What was most moving about Erin's presentation was the improvement of patients' quality of life and mental health, as well as a recognition that decreasing loneliness (we are in an epidemic) improves mortality as well. 

We are working with HeartWorks to ensure more of our patients complete cardiac rehab with a special personal focus on our Spanish speaking patients (Erin said they have both a Spanish speaking MA and physiotherapist).

Of note, referrals must be done through a patient's cardiologist!

Update on Hormonal Treatment of Menopause (Mason, 3/18/26)

A recording of this presentation is available HERE.

Many thanks to Dr. Antoinette Mason for an important presentation on Hormonal Treatment of Menopause. Dr. Mason is a graduate of our residency program and is also a graduate of our integrative medicine fellowship.

Her stated goal of the presentation: to empower clinicians to use menopausal hormonal therapy (MHT) 

Before 2002, menopausal patients regularly received MHT. After 2002, when the Women's Health Initiative (WHI) was stopped early due to concerns regarding increased rates of breast cancer, blood clots, dementia, CVD and more. This led to a lot of fear and an abrupt change in practice-- as a result, most clinicians have been trained to avoid hormones in menopause.

Over the past 15 years, there has been lots of re-evaluation of the data. Also formulations of hormones used today are not the same as those used in the WHI. Timing matters, age of start matters. 

We are now reckoning with fear, beliefs, lack of evidence, training. . .many of our leading organizations (Menopause Society, ACOG, Endocrine Society) have guidelines that confirm that MHT is safe and appropriate for many populations. 

bio-identical means "same compounds made by the ovaries" (estradiol  (E2) + micronized progesterone), but there are LOT of different formulations of these as well.

Risks of MHT:

• blood clots: associated with oral estrogen (including OCPs, conjugated equine estrogen, oral estradiol). Oral estradiol safer than OCPs, 3-4x risk OCP vs. oral estradiol. But transdermal (patches, gels, cream) do NOT increase risk of blood clots. 
• gallbladder disease: cholelithiasis, cholecystitis, low but increased
• endometrial hyperplasia/cancer: unopposed estrogen therapy (need to give estrogen therapy)
• breast cancer: WHI showed small increase in rate of breast cancer, but estrogen alone actually reduced breast cancer. Risk for breast cancer seems driven by progestin >5 years (when use mircorinized progesterone NO increased risk of breast cancer but no good RCTs). Safest approach: use MHT<5 years. We may never have RCT with clear data. 

Hormonal Cheat Sheet:

FDA approved indications for MHT:

• vasomotor symptoms: hot flashes, night sweats
• genitourinary syndrome of menopause: urinary/vaginal symptoms, dyspareunia
• prevention of osteoporosis in people who are high risk (e.g. family hx, comorbidities), do NOT treat osteoporosis but does prevent fractures
• treatment of early ovarian failure or surgical menopause

Additional benefits (not FDA approved)

• musculoskeletal syndrome of menopause: changes in joints, connective tissues, muscles (pain, stiffness, new joint pain that is NOT arthritis)
• mood/cognitive changes/sleep
• quality of life
• miscellaneous short and long impacts: fractures, colon cancer, breast cancer (estrogen alone), diabetes, improvement in insulin resistance, better blood glucose control for people with DM, LDL reduction (transdermal estradiol), reduced CVD, dementia (mixed studies, ?vascular)

Timing hypothesis: earlier is better (age <60 years of age or <10 years since menopause onset)

How to rx MHT:

• use bio-identical hormones
• use transdermal estrogen whenever possible
• start early, use lowest effective dose (titrate to symptom control)

Absolute contraindications: current breast cancer or hx of breast/endometrial cancer, current or hx VTE, severe liver disease, pregnancy, uncontrolled severe hypertension (get BP under control first)

Assess risk: If high risk for VTE, do NOT use oral estrogen. If high risk CVD, look at lipids, A1c, recommend yearly mammogram, osteoporosis risk

1. Do they need birth control or do they not want to ovulate? (if yes, consider IUD/OCPs)
2. Do they have a uterus? (if yes, they need some progesterone)
3. Are they having regular cycles? (if yes, luteal dosing of progesterone, if no, can use continuous progesterone)

Progesterone decline

For most people in menopause, progesterone starts to decline and estrogen gets chaotic. Eventually post-menopause, both get low but in the transition it's very unpredictable. A lot of people have symptoms associated with low progesterone state initially. Most common: anxiety, insomnia, shortening cycles, headaches. Can just use micronized progesterone alone in early menopause symptoms: e.g. start with 100mg orally or vaginally (same capsule) just 2 weeks after ovulation (in luteal phase).  . .Can later increase dose or add estradiol. If cycles are irregular and unpredictable, can use continuous progesterone at night. Vaginal progesterone can be less sedating.

LOOP events

LOOP events (luteal out of phase event): ovulatory event, and then in the luteal phase (week or two after ovulation, you get another ovulation>> can cause anemia, other issues for people).

OCP can work, but for those who don't' want OCPs, can use progesterone to stabilize the endometrium and try to reduce bleeding. Start 100mg QHS (lowest dose), can increase to 200-300mg to stabilize bleeding. Adding estradiol can help (oral helps more than transdermal but have to balance safety and benefit). Don't forget birth control!

Common Progesterone side effects: constipation (fiber/magnesium/water), morning grogginess (can try earlier in the evening, switch to vaginal formulation)

Estrogen Decline

estrogen decline symptoms: vaginal symptoms, hot flashes, irregular period

Can start estradiol (start with lowest patch>> twice weekly better than once weekly, smaller, adhesive less sticky). Currently supply chain issue, harder to get right now

Follow up 4-8 weeks because hot flashes should respond quickly>> if they don't get better, need more estrogen

Vaginal Estrogen 

Vaginal estrogen should be used liberally for genito-urinary symptoms of menopause. Vaginal estrogen can be used SAFELY for almost everyone, including post partum. Can decrease UTIs in elders. Cheap, easy, effective tool. Note there are TWO vaginal rings (one rx'd for local therapy, one for systemic therapy. Make sure you know which you are rx'ing)

Testosterone: Low dose topical testosterone VERY low dose for sexual dysfunction of menopause (1/10th male dose). Always optimize estrogen and progesterone first to see if symptoms improve. Do not put testosterone gel on clitoris.

OB and GYN update: highlights and practice changing articles from 2025 (Lund & Bacon, 3/11/2026)

A recording of this presentation is available HERE.

(late entry)

Many thanks to Drs. Allison Bacon and Erin Lund for an excellent review of important practice-changing literature from the fields of OB and Gyn in 2025. It's obviously important for us to keep track of practice-changing advances, but the task can be overwhelming and burdensome, particularly if it's an area you are not using on a daily basis. 

Dr. Bacon started us off with 3 practice-changing OB papers:

1) Quality-Improvement (QI) Strategies for the Safe Prevention of Preterm Birth, ACOG Committee Statement 17, May 2025

Key take homes:

• current US NTSVD (normal term spontaneous vaginal delivery) rate is 25.6% but ranges 18.5-84.6%, and the WHO goal is 23.6%>> the variability represents opportunity for improvement through local QI projects
• in fact the CMQCC initiative in California reduced rates from 26% to 22.8% (from 2014 to 2019)
• suggested strategies to improve vaginal delivery:
• local policies and procedures to support vaginal birth
• labor support huddles
• team trainings for interpretation of fetal heart rate monitoring
• unit based policies for oxytocin and management of labor dystocia

2) FIGO good practice recommendations on preconception care: A strategy to prevent preterm birth, Int'l Journal of Gynecology/Obs 2025

• preterm delivery is responsible for most neonatal and infant deaths
• many risk factors for preterm birth can be targeted outside of pregnancy
• baby-centered assessment as a part of preconception care
• examples risk factors and interventions
• teen pregnancies>> preconception counseling 
• optimize screening/treatment of chronic conditions (e.g. hypertension, DM, thyroid)
• mental health>> screen for mental health and eating disorders
• infectious disease>> HPV vaccination, screen for STIs, preserve oral health
• nurtitional status>> discuss BMI, dx/tx iron-deficiency

 

3) Air Pollution Linked to Risk of Spontaneous Preterm Birth, Celeste Krewson, 2025, Contemporary Ob/gyn

• talk to patients about PM2.5 as mechanism for for social drivers of health, use of air filters?
• solutions driven by housing, community, city planning

Dr. Lund presented the second half on the important gyn literature:

1) ACOG Clinical Consensus #9: Pain Management for in-Office uterine and cervical procedures

• healthcare professionals tend to underestimate the pain people with uterus may feel during a procedure, providers may deem pain management not needed and therefore not offer to patients
• despite discrepancy between level of pain between patients and providers, patients still do report high degree of satisfaction with in-office gyn procedures
• higher pre-procedural anxiety and anticipated pain are 
• associated with higher pain scores
• THEREFORE options for pain management should be offered to all patients for in-office procedures
• IUD: topical anesthetic is more effective over placebo or misoprostol
• lidocaine spray>> lidocaine injection (?2017 RCT)
• no evidence to support pre-procedure NSAID, though may help for post-procedure pain
• use of ultrasound has been shown to decrease pain of IUD insertion

• EMB: 10% lidocaine spray (3 puffs before), naproxen 30 minutes prior reduced pain in one study, performing EMB with full bladder may reduce pain
• Uterine aspiration: paracervical block, NSAIDs pre-procedure (for post-procedure pain), oral benzos do not reduce pain but do reduce anxiety
• Colpo: topical/intracervical lidocaine recommended for biopsies and LEEP

• Trauma-informed care: universal trauma precautions, given patients control over procedure, ask permission to begin/continue procedure, careful with words used (e.g. not bed, table)

2) Management of Recurrent Bacterial Vaginosis, ACOG Clinical Practice Guideline Update 12/2025

• Recurrence is common! 66% of patients experience recurrence of BV within 12 months of initial diagnosis
• Recent RCT comparing partner therapy for recurrent BV (treating partner with oral and topical) showed marked decrease in recurrence (35% vs. 65% at 12 weeks), absolute risk was BIG -2.6 recurrences per person per year
• Increasing evidence that BV should be considered an STI: predominantly occurring in sexually active populations, associated with new/multiple sexual partners, there is microbiological evidence that sexual partners exchange bacteria
• Ideal people to partner treat: monogamous male/female partners (shared decision making for other scenarios)
• Coverage may vary-- CA extended partner therapy applies to STIs (GC/CT), MAY be applied to BV (pharmacy dependent)
• Note clindamycin gel can weaken latex condoms
• Also note, recent evidence based guidelines say it's okay to drink alcohol and take metronidazole!! 

Slow Medicine: finding the balance between knowledge, care and humanity (Paul Nguyen, 3/4/26)

A recording of this presentation is available HERE.

Many thanks to Dr. Paul Nguyen, who gave a moving and important Grand Rounds this week, which he entitled "Slow Medicine: Reflections from a 3rd year resident". What was so compelling about his presentation was how he brought us back to the basics of why most of us came to family medicine in the first place and wove in his reflections on where the rub occurs, and how we might approach it to make it better for patients and for us.

I particularly appreciated his inclusion of two Vietnamese proverbs, which I will leave here for your consideration:

Translation: You only know you're hungry after eating.

Meaning: You may only understand the importance of something once you have experienced it yourself.

Translation: Keep grinding the metal, one day it will turn into a needle.

Meaning: If you keep putting in the hard work, you may wind up with something beautiful and useful

In between these two beautiful proverbs, Dr. Nguyen introduced us to Victoria Sweet's book, Slow Medicine (if you haven't read it, both he and I highly recommend it!) and highlighted some of the core tenets she promotes in her book:

1) Gevuld (Dutch for "stuffed"), in the contest of medicine the idea that wounds can literally fill themselves in, that the body knows how to repair itself, that illness is not always an enemy to defeat. In this model, physicians are stewards of processes, not commanders of outcomes. 

2) Slow ≠ passive: medicine doesn't always require an intervention, time itself may heal. Sometimes the best intervention isn't doing more-- it's doing less. Not ignoring or neglecting but allowing the body's processes to work. 

3) Observation: observation is itself an active clinical skill, paying attention matters, and watching the body heal itself may be our only duty. Tolerating uncertainty is another part of our job. 

I particularly appreciated this slide from Dr. Nguyen, summarizing Sweet's argument and contrasting "fast medicine" (how we do things) to slow medicine (how he wants us to consider doing them):

In this section, he talked about the contrast of metrics vs. meaning, of productivity vs. presence and shared some of the data regarding burnout in the primary care workforce as well as patient perceptions of being held/cared for based on time spent with them. 

And for those of us who have been through residency and/or are witness to our residents going through residents in this era, we can related to these tensions, the feeling of not having enough time to sit with patients BUT wanting nothing more than to have the time to do so. The feeling of data overwhelm without a true understanding of the patient's lived experience.

Dr. Nguyen shared with us two meaningful patient experiences he has had during his residency training-- one that ended with a peaceful death, the other that left a patient without a diagnosis but getting better (who knows why? perhaps it was the time he spent with her?).

And, finally, some wisdom for his juniors and colleagues: