Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Why Women are at Greater Risk for Autoimmune Diseases
Unlock the mysteries of why autoimmune diseases disproportionately affect women with insights from the distinguished Dr. Ahmed Elghawy, who brings his wealth of knowledge as a triple board-certified physician. You'll learn about the complex interplay of hormonal, genetic, and environmental factors that could explain this disparity.
Listen for more insights and updates in the ever-evolving field of rheumatology.
To learn more about Dr. Elghawy, follow him on X @AhmedElghawyDO.
Welcome to the Fit, Healthy and Happy Podcast hosted by Josh and Kyle from Colossus...
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Welcome to the Speaking of Women's Health podcast. I'm your host, dr Holly Thacker, the Executive Director of Speaking of Women's Health, and I am glad to be back in the Sunflower House for a new episode. For a new episode. Joining me on today's new podcast episode for Speaking of Women's Health is Dr Ahmed El-Gawi, and I'd like to tell our listeners a little bit about him. Very interesting guy.
Speaker 1:He completed his undergraduate education at Yersinus College, where he graduated cum laude with a Bachelor's of Science in Psychology. And then he went on to medical school and earned his degree at Nova South Eastern University College of Osteopathic Medicine in Fort Lauderdale, florida, fort Lauderdale, florida. And then he went on to complete an internal medicine residency at Mount Sinai Medical Center in Miami Beach, florida. And then he went on to complete postgraduate fellowship training in rheumatology at SUNY Stony Brook University Hospital in Stony Brook, new York. And then he did a fellowship in primary care sports medicine at University Hospitals at Cleveland Medical Center in Cleveland, ohio. So that makes Dr El-Gawi one of the few physicians in the entire nation who is triple board certified in internal medicine, rheumatology and sports medicine.
Speaker 1:And I met Dr Elgawi when he was working at the Cleveland Clinic's Department of Rheumatic and Immunologic Diseases, where he practiced both rheumatology and arthritis, and musculoskeletal health. He's got a special interest in practicing musculoskeletal medicine, treating systemic rheumatic disease, rehabilitating athletes with sports-related injury and performing musculoskeletal guided procedures. He's a girl dad and he got a big promotion and he has left and he is now in sunny Miami Beach, florida, the head of rheumatology. Welcome, dr Elgawi, and tell us where you're at right now and thank you so much for joining us with your move and new baby.
Speaker 2:Oh, what an introduction. Thank you so much. Yeah, it's, yes, I just moved from Cleveland Ohio where we both practiced together at Cleveland Clinic. I moved actually back to where I did my residency at Mount Sinai Medical Center and will be the chief of rheumatology at that department there. So a little bit of a move for us and I'm still in the process of that move and that's why my office is still being built. So that's why I'm kind of in the hallway right now. But yeah, so far it's been really, really nice and I'm really excited to talk with you because we've shared patients before and I think it's really important to talk about rheumatology when we talk about women's health. I mean, I think rheumatology is like a key focus on that. It's kind of missed frequently.
Speaker 1:It is. In fact, when I came to the Cleveland Clinic, I initially came to do my internal medicine training because I was going to be a cardiologist and didn't want to move my husband twice. But my second love was rheumatology and I spent a lot of time in the rheumatology department, had my clinic there A lot of my mentors were rheumatologists, was really close with Dr John Clough who was a chair for a long time, and it always struck me that really rheumatology in a lot of respects is a woman's health field, because so many autoimmune diseases occur in women. And why are women more likely to develop autoimmune diseases compared to men?
Speaker 2:It's really, really strange because probably 20 years ago I probably would not have really had an answer at all. We just we just noticed that in the data there's a clear disparity of leaning towards women, especially premenopausal women, that they are much more prone to developing autoimmune diseases. There's a there's a few theories. One could be that there might be potentially like a hormonal component to it, and then specifically estrogen, and that's why you maybe see women who develop these diseases in their childbearing years and specifically it could be the surge of hormone changes, specifically around puberty or pregnancy, postpartum and then around menopause, which are kind of areas where we see a little bit of an uptick in these diseases, and then, when they're postmenopausal, we start to see that the risk of developing autoimmune diseases gets a little bit closer to a man's. So we do think that there's potentially a hormonal component. There's also the thought that this could be genetic, that women have two X chromosomes men really only have one, and when it comes to X chromosomes, one of them is active and one of them is deactivated, and ZIST is the RNA molecule that deactivates that, and there's a thought that potentially that deactivation could cause an immune surge, and so that's why you may potentially see an autoimmune increase in women. The reality is, we're not 100% sure. We know that there is a genetic component. For sure People who have family members with autoimmune diseases tend to have them themselves.
Speaker 2:We've seen this in identical twins. There's definitely a genetic component, but there's potentially an environmental component as well. Let's think about rheumatoid arthritis, for example. Rheumatoid arthritis we know that smoking is linked to rheumatoid arthritis and that's because we've seen the antibody, the anti-CCP antibody, which is very specific for rheumatoid arthritis, being released in the lung and those who smoke, and we see it also released in the gums and those who have poor dentition or a lot of gingival disease. It's probably a perfect storm, like the right genetics, the right environment, the right family history, being a woman, all those things combined give women a much higher risk, and it's not every disease is like that. If you look at rheumatoid arthritis, probably 70 to 80% of those cases are women, but if you look at lupus, for example, 90 plus percent. There's a clear disparity. But if you gave me one reason, I'm like I can't give you one specific reason. I think I think it's a combination.
Speaker 1:And tell our listeners what's the difference between a rheumatic disease and an autoimmune disease.
Speaker 2:That's a great question. It's, you know, an autoimmune disease is a disease where you have your immune system that's acting inappropriately on itself. Like your immune system is kind of built to fight things that are foreign, like infections. Sometimes it makes a mistake, so then it starts attacking itself. And whether it's autoimmune, where there's an issue of the adaptive immune system, where you make memory B cells and you kind of save it for later, or autoinflammatory disease, which we think of like the periodic fevers, we think of it more like kids developing, like familial Mediterranean fever, but the difference between an autoimmune and a rheumatic condition is it sometimes are synonymous, because we take care of so many autoimmune conditions. But I kind of think of autoimmune as more of an umbrella, and then rheumatic is only one piece under it. Because if you look at other autoimmune conditions like Hashimoto's, like Graves, like inflammatory bowel disease, like Crohn's or ulcerative colitis, you see other specialties manage those diseases. You wouldn't typically think of them as rheumatic conditions.
Speaker 1:Okay, so more musculoskeletal.
Speaker 2:Yeah, by far the most common complaint for our patients is some sort of like joint or musculoskeletal complaint. But the reality is that our diseases, they infiltrate every system in the body, whether it's the heart. You can develop interstitial lung disease, you can develop pericarditis, you can develop nephritis. All these things probably have an autoimmune component as well. Inflammatory bowel disease we know that a lot of those patients develop extra intestinal manifestations like uveitis or even like psoriasis. So autoimmune is like the big overarching umbrella term for these, and then rheumatic is just one part, but it's probably the biggest part. We collaborate with all the other subspecialties when it comes to that, so you could say that they're somewhat synonymous. But when you work at a place like the Cleveland Clinic, for example, we're all so hyper-specialized that you typically will all collaborate together.
Speaker 1:So what are some of the more common autoimmune conditions that might affect women?
Speaker 2:Well, the big one is lupus, for sure. I mean, like I said, there's a huge disparity between men and women when it comes to lupus. Like I said, if I line up 10 people with lupus, nine of them are women, for sure, and specifically premenopausal women. We do see disparities in rheumatoid arthritis as well, like anywhere between 70% and 80% are typically leading towards women. We do have some ones that do affect men more, like things between 70% and 80% are typically leading towards women. We do have some ones that do affect men more, like things like ankylosing spondylitis, which typically affect men in their 20s and 30s, but the ratio is not as strong. It's like a three to two ratio. So it's still like there's a significant portion of women who are affected by ankylosing spondylitis.
Speaker 1:I have several patients.
Speaker 2:Yeah, for sure, and a lot of them. I have several patients way, and that's where that delay gets, that care gets delayed. When you think of like more male, like male men leading diseases you're thinking of, like the crystal arthropodes and gout is by far the most common autoimmune crystal arthropody that we see but interestingly, once men, once women are postmenopausal, the risk is almost one to one.
Speaker 2:Yes, yes, and then in advanced age, one to one, yes, yes, and then in advanced age women overtake them, overtake men, right, yes, like an advanced stage they can, yeah, especially like, like you know, start getting into like the 70s and 80s. You can. We think that potentially, estrogen is protective, uh, against gout and it can help with your gastric excretion, or maybe that just matters, not just much poorer, like you know, part of it is is that we're all very poor at handling uric acid excretion through the kidney. You know, when you think of gout, you think of like king's disease, you think of like drinking alcohol and eating red meat and you think of guys.
Speaker 1:A lot of times, but there's plenty of women who do this moonshine alcohol yeah, exactly.
Speaker 2:And or you think of like the, the Moonshine alcohol yeah, exactly. Or you think of the guy who's going to a wedding eating the serpent herb and has a couple extra drinks than he normally would. But the reality is that's only a very small fraction of patients with gout. Most of it is probably under excretion, and women are just better at it than men are to some degree, but once they're postmenopausal again, their risk goes up significantly.
Speaker 1:And then the other big.
Speaker 2:I'm sorry.
Speaker 1:No, I was just going to say. It's so interesting that estrogen can affect the immune system to make younger women with higher estrogen levels more prone to some of these conditions, whereas testosterone seems to modulate that. On the other hand, then the lack of estrogen brings on its own problems, including osteoporosis, which isn't considered classically. It's not autoimmune or rheumatic, but it is the skeleton, and so that's such a huge hit to women. I see a lot of women, both pre and post-menopausal, with lupus, and a lot of times the previous conventional thinking was well, don't use any hormone therapy or birth control in them. But the Salina trial showed really that we can prescribe in women with lupus as long as it's not active disease with clots and active lupus nephritis, which is pretty serious.
Speaker 2:Yeah, and a lot of these lupus patients are hypercoagulable in general.
Speaker 2:And because lupus is such a heterogeneous disease, you don't know if a patient, even if they don't appear to have a hypercoagulable state, they may develop one in the future. And to me they are similar to someone who is a smoker or someone who is on oral contraceptives or someone who is sedentary. So we have to be extra careful in those patients. Even if their workup looks relatively okay now, it doesn't mean in the future that they're not going to develop more manifestations of lupus later. And that's a really interesting thing about women with autoimmune conditions is a lot of times we get young women who are in their early 20s who have these symptoms and their workup comes back negative. And a lot of times where we tell people like, oh no, this is not autoimmune, but they have a strong family history, they have the right symptoms. And to me you know, most of the time the serologies, the blood work, precedes the symptoms. But that's not always the case. A lot of sometimes the symptoms precede them and those are patients that we have to watch very closely.
Speaker 1:Oh, that is really fascinating. And what are your comments about seronegative rheumatoid arthritis versus seropositive? Is it harder to treat? Is it overlaps with other syndromes?
Speaker 2:Yeah, I mean seropositive is easier because we pick it up earlier. I think that's the biggest thing is that when the workup comes back negative, a lot of people think, well, they don't have the disease. But I like to tell people there's not one rheumatic condition that we can diagnose based on just serologies alone. It has to be a combination of the blood work and the symptoms. A lot of times we use imaging as well, with x-rays or MRI or ultrasound. It's got to be a combination of these things together and the right clinical picture. If your suspicion is high enough, you got to treat. And there are plenty of patients who come in with swollen, like you know, their hands full of synovitis, like polyarticular synovitis.
Speaker 2:In the right distribution, right family history and the workup is negative, I treat it Seronegative rheumatoid arthritis. To me the damage is we still have to treat these patients because if you don't they can go on to develop erosive, damaging, deforming disease in their joints. But also, if you leave these patients with a high inflammatory state, it's very taxing on the body. It puts a lot of stress on the heart and these patients can die earlier of heart disease than they otherwise would have. So it's not it doesn't always have to fit perfectly. Rheumatology does not fit perfectly in any box. I like to say that these diseases, they don't read our textbooks.
Speaker 1:Exactly that's, I think, one of the reasons why I was so attracted to the field of rheumatology, because it really seemed like you had to be an expert diagnostician and you really had to kind of go above and beyond. It's certainly not something that's just cookbook and straightforward and and and simple pathways, and then you layer the whole complexity of the female life cycle on top of it. Is someone pregnant? What's going to happen with pregnancy? And then all the side effects, potentially with steroids. The one thing I'll say over my vast career, I remember early on seeing so much more deforming arthritis, subluxation of the joints, really terrible joint damage, and I have to say that in recent memory I don't seem to see patients with such deformity. Is that because all of your therapeutics has just advanced so much and there's so much change therapies that you have at your fingertips?
Speaker 2:That's exactly why. So, whenever we have a patient with a rheumatic condition, it's the immune system that's acting haywire. And so what we have to do is we have to modulate the immune system and suppress the immune system. And so we use medications called DMARDs or disease-modifying anti-rheumatic drugs, and what they do is, some of them are immunomodulatory, some of them are immunosuppressive, and they prevent the body from basically attacking itself. And so, you know, since the advent of these disease-modifying agents you know, methotrexate, the hallmark one back in the 80s, was actually a chemotherapy medication that was brought over to rheumatology, and then also with the advent of the biologic therapies in the late 90s and early 2000s, I mean it's completely revolutionized the field. It's, you know, these patients that we once would see like with horrible erosive changes or ankylosing changes in the spine. We just don't see those patients like that anymore. We're catching patients earlier, so we're diagnosing these patients earlier, we're starting them on treatment earlier and we're really saving them from, from these these really horrible um things. It's not just the, the joints themselves, but it's like we're also preventing these extra articular manifestations of diseases, like, like the pericardite kid, you know, nephritis and pericarditis and uvitis in the eyes it's, it's all these other manifestations that are late stage diseases that we're just not seeing as much anymore. I think part of that is that we're just catching it and we have much better medications.
Speaker 2:I like this. I like to say that rheumatology is almost like a young he monk. A lot of medications that we use are very much like you know. Here's a good way to explain exactly what rheumatology is. My program director at Stony Brook I says this on my very first day of fellowship. He's like what is rheumatology is? My program director at Stony Brook asked us this on my very first day of fellowship. He's like what is rheumatology? And we didn't know anything back then. We're like you know, we're fellows first day fellows. We're like study of arthritis or autoimmune diseases. He's like no, it's interventional immunology. We are intervening on the immune system to some degree and with these medications, and I love that definition of rheumatology.
Speaker 1:Yeah, that is fabulous. And are you doing any kind of like genetic assessments in terms of trying to? Because I know in the whole cancer field there's a lot of genetic profiling of either the tumor or the person's own germline mutations as to what is the best kind of chemotherapy.
Speaker 2:So we're not quite there yet. So we do some genetic testing for diagnosis for some of our autoinflammatory diseases like the periodic fevers. There's another disease called vexus that we're also checking genetic testing for. Then there's also an overlap with some of the hypermobile diseases like Ehlers-Danlos that we'll do genetic testing for as well, but nothing in terms of treatment modalities yet. I think that part of it will be synovial biopsy. They've talked about doing synovial biopsies that can tell us what is the primary inflammatory cytokine that's really playing a role in this specific patient and then that way we can gear the therapy towards that patient.
Speaker 2:But we're not quite there yet. But that could potentially be the future of rheumatology. They've talked about that being the future of rheumatology for a while. A lot of these new medications come out are essentially different stopping points along that inflammatory pathway to see which works. But some patients you stop at TNF and it works really well, and some patients it works at IL-6 or some patients it works at interferon and we're not sure why some people benefit from one drug over another drug and then they don't all have the same response. But I think that's the future. It's more individualized rheumatology, similar to the way that oncology is where it's much more individualized.
Speaker 1:Than it used to be. Well, you're listening to the Speaking of Women's Health podcast and I'm your host, Dr Holly Thacker and I am interviewing one of the only rheumatology, sports medicine, internal medicine trained physicians in the country who is the chief of rheumatology and at Miami Beach, Florida. He's formerly a colleague of mine at the Cleveland Clinic, Dr El Gawi, and we have been talking about autoimmune conditions. Now we're going to switch gears and talk a little bit more about regenerative medicine. I've had several podcasts on anti-aging. We've certainly focused a lot on nutrition and exercise and nutraceuticals and functional medicine, which I think all potentially have a role in being supportive. So I wanted to ask Dr Al-Ghawi and get your opinion on PRP, platelet-rich plasma. It seems like the dermatologists are using it for hair loss. The sports medicine people are using it in athletes. Can you talk to us about what PRP is and where you see that fitting in in just sports medicine and just rheumatic diseases in general?
Speaker 2:Sure, sure I mean. So PRP is platelet-rich plasma, and so what it is is essentially separating platelets from autologous, like whole blood, and the way to do that is to draw the blood from the patient, spin it in a centrifuge, separate it out and then you inject it to wherever you need to put it. And the idea is that it's not we think of platelets, we think of like clotting and plugging, and that's not the reason why that's not what we're looking at when it comes to PRP. We're actually looking at the growth factors within the platelets, and there's a lot of different growth factors, like ones that will help with revascularization and ones that help with cell regeneration, and so the idea is that all these growth factors work together and help the body try to fix an area that maybe had been forgotten about, and so, like you said, a lot of dermatologists would use it on like alopecia. You know, sports medicine, and that's the context where I use it the most is sports medicine is we use it on osteoarthritis, we use it on chronic tendinopathy. Those are like the two big reasons to do it, but it's interesting because there's not a lot of data on it in rheumatology. And so, actually, about a year and a half ago, myself and a few colleagues put together a review because we were interested Like what's the data on rheumatology using PRP? It's an autologous blood product. There shouldn't be any side effects to it. But one of the big contraindications to using PRP is that in order to let the body kind kind of repair itself, you can't use anything that's going to act as an anti-inflammatory, like things like NSAIDs or steroids or or steroids or our DMARDs, and so historically we've always thought like, hey, we should stay away from PRP and rheumatology. But I wanted to see what the data showed, and so we put together a review and kind of broke it down by different diseases. And again, these are very small randomized control trials, case series, case reports, so these are not the most robust, but there is something to glean over this and to see hey, maybe in the future we can get bigger trials on this. But it seems to work.
Speaker 2:In some of our diseases like rheumatoid arthritis they had done almost like lacrimal gland injections of PRP that really help with dry eyes and Sjogren's. It seemed to work in like discoid lupus, with those with alopecia. It actually seemed to work on like vasculitic ulcers of the skin. It seemed to repair those like vasculitic ulcers of the skin. It seemed to repair those ulcers as well. Um, it actually also seemed to work on on just skin elasticity, you know, and making the skin like a little bit more elastic in terms of like scleroderma, where the skin becomes a bit more fibrotic.
Speaker 2:It could potentially work there too, um, but on the other side of it it actually may make some things worse. It looked like worse. It looked like it triggered pseudo-gout flares in some patients when they got it in their joints. So the verdict is still out to see how useful it is in rheumatic disease, but it seems pretty promising and, like I said before, side effects are minimal because it's your own blood. You're not going to have a reaction to your own blood. So I think it's very promising, especially in those really refractory diseases where, like alopecia is historically very difficult to treat. In lupus, it can be really useful in cases like that.
Speaker 1:Oh, that is so exciting to hear. Since it's considered experimental, I imagine a lot of insurances won't pay for it, so it is self-pay.
Speaker 2:It's self-pay, it's not FDA approved and the reason why it's not is because it's a standardization formula. So every person who uses it, they have their own standardized protocol. And when you look at the studies, the number of platelets are always different, whether it's leukocyte rich or leukocyte poor. There's no standardization protocol that will unify to say, hey, this is consistently working. There's a lot unify to say that, hey, this is consistently working. There's a lot of data to show that, hey, prp is no better than placebo. In some of these cases, the regenerative orthopedic community seems to think that those studies just have the platelets are just too low, the counts are way too low. We should be boosting those counts significantly. And in those in that newer literature it seems to be working a lot more. So I would say, ask me that question in like five years and I think that We'll have you back.
Speaker 2:Yeah, I think that there's going to be a lot of, there's going to be more data coming out that's going to seem to work more consistently, and then, when it works more consistently and there's a standardized protocol, I think it will get FDA approved.
Speaker 1:Now what about patients that have platelet disorders Like I? Have a fair number of women with essential thrombocytosis. Their platelet levels are really high. Would that mean it's better to get their platelets because they have more or because they're diseased and have something, some myeloproliferative problem, that you wouldn't use their own platelets?
Speaker 2:I don't think that there's necessarily. If it's thrombocytosis, for example, I don't think that you would necessarily have an issue with that. I don't know the data behind that, but it's again, it's the growth factors. So you may just need less PRP in general to get the same number of growth factors. I'd probably stay away in those who are thrombocytopenic because you'd have to draw a lot more and maybe the growth factors might not be as robust. But I don't know the data behind using PRP in those with thrombotic disorders. I'm sure that a lot of those patients in those studies are probably excluded.
Speaker 1:Probably as usual, and then you just have to get more experience with widespread use.
Speaker 1:Now in my patient population most of the patients I see have degenerative arthritis. We certainly see a lot of frozen shoulder in women, which we think may in part be related to changes in low estrogen, as well as diabetes or trauma, and that can be very painful, and different tendinopathies who ask me about PRP and different tendinopathies who ask me about PRP and I would imagine if it's bone on bone then you're not going to get into regeneration and then you're talking about orthopedic surgery referrals.
Speaker 2:Yeah, Women definitely have an increased risk of developing osteoarthritis. Men have an increased risk of developing traumatic osteoarthritis than women do. But women have more degenerative primary osteoarthritis than women do. But women have more degenerative like primary osteoarthritis than men do, especially in the weight-bearing joints. And I think part of that is the Q angle you know women tend to. Their hips tend to be a little bit wider, so the vector of their weight doesn't go straight down through their knee and their ankle so there might be more stress on the knee and ankle and hip compared to men. I think a big part of it is muscle mass. I think that women, especially postmenopausal women, they lose bone and muscle mass a little bit quicker than men do, especially bone mass. And so women who, let's say, do not do a lot of resistance training, they develop osteoarthritis for sure faster than the men do, develop osteoarthritis for sure faster than the men do.
Speaker 1:I think women have less cartilage than men too, so that puts them at another risk. And then the whole body shifting and tendon shifting with pregnancy, I imagine is quite a stress yeah.
Speaker 2:Yeah, I mean, I think, especially when it comes to just laxity in general, like women's ligaments and the tendons and the and and and the cartilage tends to be a little bit more lax, and that part of it is to accommodate, uh, the changes in a woman, in a woman's body. Um, men, just we, just our bodies just don't change to the same degree that women's do throughout our lifetime, and so, uh, our, our, our tendons and our ligaments tend to be a bit, a little bit more stable and, like I said, the vector of the weight tends to go a little bit more through the whole joint instead of off to the side a little bit. So I think that that contributes to it as well. I do think that losing that muscle mass, especially as we get older, plays a very big role.
Speaker 1:And of course men have so much more testosterone like 10 times the amount women do which of course affects the immune system and makes them less likely to get autoimmune conditions but maybe more likely to have other problems, because the immune system is not hyperactive. Do you think that the testosterone has a modulatory effect at all at the cartilage level, or do you think it's just muscular?
Speaker 2:I'm not sure. I think that just having more testosterone will lead to more muscle mass in general and will take less stress off the joint. A lot of the movement that we do should be muscle maintained and the joint should really be more for motion. The muscle should be doing the work, not as much as the joint. When the muscle's not there, the joint has to take over and I think that's what leads to early arthritis in a lot of these patients, especially those who do not take care of themselves later in their life.
Speaker 1:So all the more reason listeners, strength training, stretching, aerobics, excellent nutrition, boosting your vitamin D I certainly I have a lot of referrals from the rheumatologist for joint pain that there's no cause and they send them to me for hormones and sometimes there's dramatic improvements in joint pain. And a lot of times I find that so many patients in northern climates maybe not as much at Miami Beach, but certainly low vitamin D seems to propagate a lot of joint and autoimmune and other conditions.
Speaker 2:I agree with you. I totally agree and other conditions.
Speaker 1:I agree with you. I totally agree, and one of my first podcasts in season three was all about vitamin D. Now what other treatments do you like to recommend for joint disease in women?
Speaker 2:So from a lifestyle perspective, I think that the gut is intimately related to the rest of the immune system as well, so eating a lot of natural, healthy, whole foods. Our body's not meant to eat ultra-processed food. You can have it every once in a while, but it's just not very digestible and so it puts a lot of stress on the body and hyper-inflammation in the gut. So I do think that that is a part of it as well, and when it comes to certain diets, I typically tell patients try to eat whole foods, stay on the periphery of the grocery store, try to stay away from the aisles themselves. That's where all the hyper-processed or ultra-processed stuff are. When it comes to certain diets, the autoimmune or auto-inflammatory diet is essentially the Mediterranean diet, and I think the reason why that one's a good one to do is because it's easy to adhere to. I think because it's a lot of leafy greens, it's a lot of lean meats, it's a lot of olive oil, lemon water and it tastes good. It's easy to adhere to, as opposed to going low carb or paleo, which a lot of patients after a few months really hit a wall and they just can't stick to it. After a little while, I think diet is a huge part of it.
Speaker 2:Like you, you touched on vitamin d. I think I, I, I, I very much agree. I've seen patients in the single digits with vitamin d levels and uh who are who are just you, have chronic pain everywhere and you correct that level and they feel so much better. I think it also plays a role in in in terms of uh, their immune system, in terms of just infectious disease. These patients tend to develop less infections in general. So I think that that plays a big role too.
Speaker 2:I think turmeric is a nice mild anti-inflammatory that's also good in your diet. And then I think that resistance training taking care of your body, making sure that your muscles stay really strong I think resistance training is one of the best forms of exercise. I think yoga and flexibility training is really useful in our rheumatic patients, especially ones like with ankylosing spondylitis, where the spine starts to become more rigid. But resistance training is paramount, I think, especially for women, especially as they get close to menopause. I think there's nothing that will help a woman with her bone health more than making her body stronger.
Speaker 1:Yeah, that is excellent and that is our motto be strong, be healthy and be in charge. And so do you ever recommend fish oil or omega-3s, I know, for sometimes people use it for dry eyes. Do you think there's a role in that? I've been increasingly checking omega-3 levels in my patients and I'm hardly finding anyone who's normal. And so getting that omega-3, omega-6 balance, getting the seed oils out of the diet, I think there's probably something to that.
Speaker 2:There could be, and I do recommend omega-3 fish oil, but in terms of the data behind it, in terms of rheumatic disease, it's just not there. We're just not sure. But I think it's good. Even if you don't have a rheumatic condition, I think it's useful.
Speaker 1:And one old, forgotten, cheap treatment that I know they use a lot in veterinary medicine DMSO, which I think officially in allopathic medicine. We just have been using for chronic interstitial cystitis locally, but it's a solvent that I know is used a lot in veterinary medicine and a lot of athletes claim that when they have muscle injury they rub that on. Just wondered if you had any thoughts about that.
Speaker 2:Not for our rheumatic patients Again, maybe for the athletes, but in our rheumatic patients it's very rare with swollen joints, with the immune-related swollen joints, I don't see a role for it.
Speaker 1:And so, for typical injuries, it's the RICE, which is rest, ice compression, elevation, those physical maneuvers and I would even take ice out of it.
Speaker 2:I think even the person who invented that term. Even they say ice is probably not that helpful. It may give you some relief when you have the ice on, but the moment you take it off the relief goes away, and I do think that when it comes to muscular pain, it'll actually tighten your muscles up and make it easier to develop muscle spasm from it.
Speaker 1:So more heat especially after 24 hours.
Speaker 2:Yes, I think heat probably works better, but again, these are in injuries. I would not use it in a rheumatic patient with a warm swollen joint.
Speaker 1:Oh, no, you know what I mean.
Speaker 2:I mean, the heat will probably make it worse. The ice will give you relief while it's on there, but what you really need is you need some. You usually need a DMARD. You usually need a short-term of corticosteroids to bridge with one of our rheumatic medications.
Speaker 1:And DMARD is disease-modifying rheumatic anti-inflammatory drugs.
Speaker 2:Disease-modifying anti-rheumatic drugs, or DMARDs. Yeah, so those are the medications that you see. If you see commercials on TV of people flying kites and dancing on the beach, probably one of our medications in rheumatology. So, yes, and if you see the list, the entire long list of all the side effects, probably one of our medications. They are historically pretty safe, but whenever you're going to get one of these medications, you've got to talk to your doctor about is it right for you or not, if you have a different condition that could make this medication difficult to metabolize we need to know.
Speaker 1:So really, with these kind of serious rheumatic conditions, you really need to see an expert rheumatologist as well as see your primary care physician and kind of get regular and close follow-up because, like you said, it is like chemo chemotherapy.
Speaker 2:So tell us to some degree, yeah we're so grateful um you joining us.
Speaker 1:How can people make an appointment with you, because I know we have people in Florida who listen to our podcast.
Speaker 2:Yeah, so if you want to make an appointment with me, I'm going to be starting off as the chief of rheumatology at Mount Sinai Medical Center in Miami Beach, florida, so you'll be able to find all my credentials online to find that I'm still working on getting an office number and once I do, I can always send that to you to attach to this podcast if you'd like to.
Speaker 1:But yes, they could go ahead. This will air in 2025 in our season three. So, yeah, we will include all of that in the show notes and any personal or professional social media you have that we want to link up to at all.
Speaker 2:Yeah, sure, you can follow me on X, formerly known as Twitter, I think at Ahmed El Gawi DO, or I may have to look exactly and see what I wrote on there, but I can also include that as part of it as well, if you want to connect and follow me. A lot of times I do kind of you know, retweet a lot of the newer data coming out in rheumatology. So, yeah, you can follow me on there.
Speaker 1:Well, that is great, and I would just like to thank our listeners for tuning in to the Speaking of Women's Health podcast. We're so grateful for your support and your listening. Please share our podcast with others, leave a five-star rating and to catch all the latest from us, you can subscribe on Apple Podcasts, spotify, tunein or wherever you listen to podcasts. You can bookmark our website speakingofwomanshealthcom. We have free treatment guidebooks, we're on all the social media and all of this is free. So thanks again for listening and we look forward to seeing you next time in the Sunflower House. Be strong, be healthy and be in charge.
