A (6:39)

Well, I'm thrilled to be able to join you. And we were talking before starting about all the incredible things that hormones are misunderstood and understood and we need to clarify so many things. So this is a fantastic opportunity.

B (6:53)

Awesome. All right, so let's start with a big bang. Let's talk about estrogens. I think that a lot of people refer to it as estrogen when it's really not just one. It is a family of hormones. And I think that you are such a great educator on this. So let's talk about the different estrogens and the roles that they have in the body and maybe we can divide it up as, you know, a woman who's in her fertile years, a woman who's perimenopausal, what that shift looks like in terms of her estrogens and then in menopause as well.

A (7:23)

Sure. Well, it's such a misunderstood concept about what estrogen is because like you just said, estrogen is not a hormone. It's a family of hormones. And that's so important for people to know there's misunderstandings with other things like fats. You know, people used to say fat is evil or fat this and that. Now it's pretty clear you can't talk about fat. You have to say, what is it? Unsaturated, saturated, omega 3, omega 6 and so on. Well, it's the same with estrogen. So it turns out that there are actually, we always said three, and actually there's technically four. And the only reason I bring up the fourth is because it's actually now used in pharmaceuticals. So they're numbered, just like B vitamins are numbered. There's B1, which is thiamine, and so on. Each one has a letter and a number and a name. So there's E1 and that is known as estrone, E2, which is estradiol. Estradiol is the estrogen made by ovaries during the reproductive years. Then there is E3, which is Estriol. That's the dominant estrogen made by the placenta during pregnancy. And just as a comment, both E1, Estrone and E3, Estriol can be made from estradiol, but they can, like estrone, can also come from precursor androgens that come from the adrenal gland. And we'll touch on how that is seriously important for menopausal women and also metabolically unhealthy women who have a lot of body fat. And then there's E4, which has only recently broken onto the scene. E4, which is Estetrol, that is actually made by the fetal liver. So it's not an adult human female ever. It's only in the fetus, made for a short while by the. By the fetal liver. But because it can be made, you know, and replicated, it's actually now used in some birth control pills and for menopausal hormone use. So it's. We'll just put that on the back burner. But it's kind of strange, you know, because it's never found in an adult human. But I guess if you can make it, they will make it. So and so we'll put that on the back burner. If we, if it's seems relevant, we'll bring it back up again. So in terms of the reproductive aged woman who has functioning ovaries, estradiol is what is made in the ovaries. And I think it's important for people to know that all estradiol is in the ovary made from testosterone, which is also made in the ovaries. And testosterone does not require any eggs to make it. So testosterone is made by the ovaries for the entire life of the woman, even after menopause. And now we know, for example, that removing the ovaries, which I always fought against as a gynecologist, like, why would we take out normal ovaries just because they're in the neighborhood of the uterus, which may have a reason to be removed. We just take out the ovaries in women who are over 40, 45. But that was the standard of care for many, many years, and it never made sense. And now we have had data that show that if you have surgical removal of ovaries prior to the age of 65, you increase mortality for the woman. And that seems to relate to the testosterone that's made, which is 25% of the testosterone circulating in a woman is from the ovaries. So we make our estradiol and we make it in significant quantities. And of course, it's varying in terms of how much is made during the menstrual cycle. It's very variable. And we make the highest amount just prior to ovulation, and the lowest is during the period. And that has a reflection on how the immune system is working, which is really important to come back to if we can, because levels, doses matter, right? And we can learn so much from the menstrual cycle when we have different levels of estrogen and what is happening regarding inflammation and how the immune system is working and so on. And then we have estrone E1, which is made from estradiol. In a normal, healthy reproductive age woman, the body will convert some estradiol into estrone as needed. So the body controls all these things. It's like amazing. We don't think about it, but that's what happens in a healthy woman naturally. And in a woman who is overweight, has a lot of adipose tissue or is postmenopausal, everything changes. And the peripheral tissues, predominantly the adipose tissue, can convert using an enzyme called aromatase. The androgens, like dheas, which is made from the adrenal gland, into estronegary and inflammation, which happens much more after menopause. Systemic levels of inflammation and coming also from the fat tissue. In overweight women who are even younger, inflammation turns on and sort of activates this enzyme, aromatase, that's in fat tissue and converts the androgens, like the male type hormones that come from the fat, the adrenal gland, into predominantly estrone. And when you have inflammation, it down regulates or sort of blocks Partially the enzyme that could allow conversion of estrone back into estradiol. So women who are overweight, metabolically unhealthy, inflamed, postmenopausal, they will have as their dominant estrogen, not estradiol, but estrone. And we can talk about what that means because they have different effects on the tissues. And then in pregnancy, estriol is made in huge quantities from estradiol in the placenta and it too has very different actions on estrogen receptors and it has different effects on the immune system. So these different estrogens are not the same in how they act in the body. It's really important to distinguish when we talk about estrogens, which one we're talking about. And then we have the commercially synthetically made estrogens which they call estrogen. But technically they're endocrine disruptors for estrogen. They're not natural, they're never be found in a human female body ever. Naturally. They're made chemically to have some similar effects as estrogen that is made in the body, but they have different binding effects than say estradiol. They act more like estrone when they go through the liver. So it's not at all the same as the estrogen made by the ovaries when we get in these either man made estrogens that are found often in like birth control pills, that's called ethanol estradiol, which behaves differently, or if you take in menopausal hormone therapy, what's called conjugated equine estrogens that comes from pregnant horse urine and the brand name is Premarin. And that has very different effects. And that has a whole host, like in the dozens of different types of estrogens that are unique to a horse. They call them equal line estrogens. They're never found in a human female either. And so we have to distinguish between all these things because when studies are done and they just say estrogen does the following, what does that mean? Okay, it would be like, remember, if you think of fat, fats have different effects. You can't say fat does this or fat does that or this is, you know, fat is good or fat is bad. It's like, what fat? What are you talking about? And it has to be the same with estrogen because if you don't distinguish which estrogen, then it's meaningless. You have to know what estrogen, where it's coming from and so on. And so, you know, this is like foundational to understanding everything about how the female body works. Both prior and after menopause.

B (16:05)

Well, let's actually talk about the different effects on tissues. I love that we were talking about E1 from, you know, it's made in, with aromatase in the adipose tissue can be converted to E1. And we see this with metabolically unhealthy individuals. We see this with menopausal women in as well. So what are the different effects that estrone has systemically and can we compare and contrast that to estradiol?

A (16:30)

So estradiol is the only estrogen that has a balanced effect on the different estrogen receptors. So we know right now that there are three types of estrogen receptors and they're very complex. So there's alpha and there is beta and there's a G protein coupled receptor. Now both alpha and beta primarily work through the nucleus of the cell. So they're called nuclear receptors that they react with. And then when you react with the receptors in the cell nucleus, they will make some kind of a protein where it's all complicated. And it goes on this little structure called the ribosome and it transcribes it like produces a protein. And that takes a fair amount of time. But they also now we understand have effects on the cell membrane which is really rapid effects like, like super fast. And they can create signaling agents like, but they call them kinases. And the peptides, which are like very trendy now, all these things about peptides, most of the peptides are actually produced in response to, to estrogen. It's like an estradiol of course, as the main one of the reproductive age women. And so you have this complicated relationship as well with the alpha and the beta receptors. For example, if you have high binding to the beta receptor, it actually down regulates or makes less functional the alpha receptor. And when is that a big deal? Well, actually in pregnancy, because the estrogen of pregnancy, estriol predominantly will bind to the beta receptor. And so you have a lot of beta receptor and it downregulates alpha. So what does that have to do with like estrone? Well, estrone predominantly activates alpha and you can think of it as sort of the yin yang kind of thing. And then there is the balance. So the alpha receptor is the dominant one on the innate immune cells. So they would be things like neutrophils, macrophages, mast cells. So they're the first responders of the immune cells of the immune system to invaders like bacteria, viruses. That's what saves your life. So you don't die of sepsis and get an infection that goes, travels through your whole body or to injury, damage and they're, they have signals that respond. They were sensitive to what they call pathogen or damage and they call the pamps and the dam. So if you have invasion of bacteria, viruses, fungi, then they get activated. And if you have trauma from like an accident, you're injured, you're lacerated, then they're also activated. Well, that's predominantly through the alpha receptor. Well estrone, because it only activates the alpha receptor and it predominantly has very little action on the beta receptor, which is sort of like the counter to the alpha, like they balance each other. So think of the beta receptor sort of down toning, you know, like reducing the action. So when you only have the alpha, then you're in a more pro inflammatory state. And it gets even more complicated because we that other system in the body, everything's balanced like between pro and anti inflammation and the natural state when nothing is happening, like you're not being invaded by pathogens, you're not in an accident, you're not injured. Should be the calming effect. Okay. We shouldn't be in a pro inflammatory state, we should be in an anti inflammatory state. That's why it's like the buzzword of the day now, right? Anti inflammatory, anti inflammatory. Well when you are always activating the alpha, it actually is more pro inflammatory. And it turns out that also the renin angiotensin aldosterone system, which regulates the constriction or relaxation of arteries, whether you retain fluid or put out fluid. And like if you're actually pro or anti inflammatory and it's very key for regulating blood pressure and all of these things. It's like, that's why a lot of drugs for high blood pressure actually act on the RAS system or the renin angiotensin aldosterone system, which has two branches, the pro and the anti inflammatory and the alpha activates more the pro inflammatory so it ends up being more pro hypertension, fluid retention that you know, so you have more edema and so on. So we don't want to have all alpha. The other thing that's interesting about alpha is that alpha is what activates the growth factors, what we call proliferation. So we don't want to have uncontrolled growth. That's what actually cancer is, it's uncontrolled growth, uncontrolled proliferation. All breast cancers that have estrogen receptor positivity, it's alpha receptor positive, not beta. It's all alpha. So alpha is really great. Well, we don't want it to Be like just alpha, the only one there. Yeah, Alpha is essential. It's what's in bones and muscles for bone health and muscle growth. You know, we have to have growth. That's how you repair, rejuvenate, replace cells. It's uncontrolled. That's the problem. And in arteries, it's very important for vascular health. So it's not that we don't want alpha, we want it in this beautiful balance with the G protein coupled receptor and the beta receptor. So in an inflamed woman, which is naturally what happens after menopause if you're not on hormones and you know, it's. Even lifestyle makes it, it's not impossible, but it's very hard, even with the most perfect lifestyle, to control all the things that are controlled by estrogen. When you don't have the estradiol produced by the ovaries any longer, and when you get into this pro inflammatory state, then it's like this, like circular, you know, like wheel of badness where you keep making more estrone because you're upregulating the enzyme that produces estrone from the androgens that are circulating from the adrenal. And you suddenly have all this estrone, which creates growth factors and inflammation can cause instability of DNA, DNA breakage, and that can lead to cancer. So then you have the perfect storm where you have chronic inflammation, which can cause DNA breakage, cancer. And then you have the alpha receptor that's being activated, and you have all this estrone that is now being made, which activates the alpha receptor, which creates growth factors. And these alpha receptors are on, for example, breast cancer. So then you can have the estrone that's made in the fat tissue of the breast, which is predominantly fat in menopausal women, creating this situation where you feed the cancer. But it's not estradiol coming from the ovaries or as a supplemental part of menopause hormone therapy at all. It's made by the body and it's made in the breast. And like breast cancer, for example, is extremely inflammatory. It creates inflammation. So breast cancer can create its own estrone supply because it has so much inflammation. And the stroma, the connective tissue and the fat that surrounds the breast cancer in the breast can make estrone when the aromatase enzyme is activated, which inflammation will do, which is created both systemically and also by the breast cancer itself. But this is where people get so confused because they just hear the word estrogen and they don't know where it's coming from they don't know why it's happening. They just then have this image of estrogen causes breast cancer. Estrogen is evil. You know, estrogen causes dementia and heart attacks and hypertension. And it's not estradiol. Estradiol modulates all these things. It maintains the like we'll say the. What should be the default, which is anti inflammatory calmness. I didn't even mention the autonomic nervous system, which is what controls everything in the body that we don't think about all the different organ systems. And estradiol is the modulator of the entire autonomic nervous system that keeps you calm and can sleep. They call it like with the vagus nerve, rest and digest, keeps everything like copacetic. Everything is like calm. But estrone, which is not evil, it's just when you have too much of it, it creates harm. And that is not what's involved in hormone replacement therapy or menopausal hormone therapy is not giving estrone, it's giving estradiol. And when you have estradiol it creates a more anti inflammatory environment which then reduces the inflammation which triggers the production of estrone. So then you won't have this cascade of events that can increase the risk of for example, breast cancer. Breast cancer. The highest risk for breast cancer in menopause is obesity and weight gain. And of course what's underlying that, the inflammation that occurs and then all the estrone produced in the fat tissue that can then create all these growth factors that can help grow and support breast cancer. Or it could be uterine cancer that's caused by inflammation, not by estradiol. So it's like such an important distinction what happens with estrone and what happens with estradiol. It's like they're two different entities.

B (26:41)

Okay, so you said a lot there. Brilliant as usual. If I can recap that for individuals who are like what so estro estrone E1 selectively acts, activates these alpha receptors which is involved in the innate immune system. So we want that, but just it's too much of that. Unilateral activation of the alpha receptor without the balance of estradiol is sort of what I think you're alluding to here. So it's not that estrone in and of itself is, is wrong or is bad or is harmful to the body. I mean we produce it. But it's the lack of balance between alpha receptor activation, beta receptor activation and these G G protein coupled receptors, sort of an aggregate where we have this lopsidedness, if you will, in terms of estrone activation. And this is what's driving some of these. Like this, you know, unchecked unmarked cell proliferation in breast. Or it shuts down bone proliferation, let's say, in. So we have this osteoclastic activity. So in your. In your. Would it be fair to say then that menopause is a default? And of course, I don't want to talk about it like a disease, but when we talk about this loss of estradiol, is it fair to say that is a default pro inflammatory state because we've lost the ability vis a vis the thecal cells to produce the test? You know, we can't produce estradiol anymore.

A (28:09)

Yeah. The only estradiol that we have is what's made. All estradiol is derived from testosterone. There are organs that can make estradiol, but you never make enough. You have very little. Like the skin can make estradiol, the brain can make estradiol, and the gut can make estradiol. So you will have some estradiol, but the amount that's made is insufficient to the needs of the body relative to the estrone, and the estrone becomes dominant. So that's one of the reasons why I talk against this very commonly used expression of estrogen dominance, because what estrogen are you talking about? What's the situation? I just like to, you know, be very clear about what the conversation is about, because when people say estrogen dominance, then it makes women fear estrogen because they don't think, what estrogen are you talking about? They think it's like the same estrogen that the ovaries make estradiol. They're thinking estradiol is bad. No, estradiol is wonderful, but. But it's s. You can call it estrone dominance right then and. Right. Just like you said, it's like too much of a good thing is a bad thing. Everything should be in balance. Right. You can die from water intoxication, but. So that's just another. Too much of a good thing is a bad thing.

B (29:27)

One chocolate square good. The whole chocolate bar bad.

A (29:31)

Yeah, we want it. We want it in balance. And so understanding why inflammation occurs in. In menopausal women, of course, goes even beyond. And. And one of the things that I'm sure you talk is gut dysbiosis. So the microbiome of the GI tract in the whole kit and caboodle of all the GI tract, of course, the greatest numbers are in the colon, but when you don't have enough estradiol, you get dysbiosis. You get the wrong microbial populations and you get a decrease in the diversity. So there's like this change in the diversity and that's, you need to have a lot. So diversity means a lot of different types of microbes and that becomes less common after menopause. And then you don't have the ability to make this protective mucus coating. So you get what's called impaired gut barrier and you get leaky gut, where the contents in the intestinal tract, which includes toxins, they call them lps, lipopolysaccharides or endotoxins, actually can pass between the cells into the body proper, where we have 70 plus percent of our immune system. And the immune cells respond to these toxins coming into the body by exploding with their production of inflammatory cytokines which then circulate. It creates inflammation as a response to this, these toxins coming in. And when it gets very overloaded, they even call it endotoxemia. The toxins can circulate and even get like into the brain and cause a lot of, of neuroinflammation, brain inflammation. And so can the cytokines, these inflammatory little signaling agents. And that underlies a lot of the inflammation, which is total body wide or systemic in menopausal women and also in metabolically unhealthy women. Because that is, you know, gut dysbiosis can occur for a variety of reasons and menopause is just one, but it's always universal. I mean, that's been shown, you have altered gut microbiome and that also when you have the different microbes coming in and the immune system responds, they make antibodies. And over time that can lead to what's called molecular mimicry, where the antibodies produced against the sort of invading bacteria and viruses can cross react with our own tissue. Because RNA and DNA, the building blocks of all cells, has a lot of similars, regardless of whether it's one organism or another. We're similars, right. And so molecular mimicry, the immune system is confused, it's like mistaken identity and it starts making antibodies against ourselves. And that underlies the increase in the incidence of rheumatoid arthritis, an autoimmune disease which becomes more prominent after menopause. And they've even had some identification of different types of pathogenic bacteria from the gut associated with the development of rheumatoid arthritis. And estradiol can help prevent this leaky gut scenario in the first place. If you get on it really early on. And you know, this is a really tragic thing, when so many women get autoimmune diseases. 80% of all autoimmune diseases are in women. And it relates to this leaky gut situation that is almost in. It's like not if it happens, it's how bad it is after menopause.

B (33:14)

Oh, that's a good reframe. It's not if but how bad. Yeah. So is it your position then that every woman, whether she's. I mean, we can make the case. Perimenopausal is a bit more of a complex case. But in menopause, do you think that every woman, if she's eligible for estradiol. I know that there's some contraindications and maybe you can even touch on that. As we age, our ability to digest complex foods like protein declines. This is because our body produces fewer enzymes, which are the proteins responsible for digesting food. Even organic foods won't provide enough enzymes to properly digest them. This is especially true if you cook any of your food because cooking and the heat kills those enzymes that are responsible for digestion. This is where supplementing with a high quality enzyme supplement can be a huge help. I personally recommend Mastzymes by Bioptimizers. It's the best in class supplement loaded with a full spectrum of enzymes for digesting proteins, starches, sugars, fibers and fats. Taking masymes daily helps to top off your enzyme levels and replace the enzymes in your body that your body is no longer producing. This means that you'll be able to eat all sorts of delicious foods and digest them quickly and effortlessly. After you start taking Mazzymes, you may notice that you no longer feel bloated after meals. That's a huge bonus. And that your belly might even feel flatter too. If you have leaky gut, mazymes can reduce that gut irritation and help you absorb more nutrients. Listen, life is too short to suffer from digestive problems. If you want freedom from your food, try Maszymes risk free and experience for yourself the magic of high quality enzymes. For an exclusive offer for my listeners, Please go to buyoptimizers.com better and use code better at checkout to get 10% off your order. That's B I O P T I m I z E-R-S.com better and make sure you use better at checkout. A new year means a new chance to invest in yourself and for most of us that involves the gym. But let me tell you, you cannot out train low energy. It starts deeper than that. The good news is that more energy starts with one simple Daily habit. Metopur gummies are the first ever longevity gummies that support your cellular energy so that you feel strong, clear and vibrant all day, all week, all month and all year long. They're the only clinically proven urolithin, a gummy that helps renew your cell's powerhouses so that you can show up as your best self every single decade. Urolithin A helps with your cellular energy, which means it gives your cells more power to fuel your day. It supports steady, sustained energy, which means that it helps your body turn stress into usable energy, which thank goodness for that because I'm finally putting my stress to good use. And it also helps with strength. Clinical studies show that urolithin A supports muscle strength and function. Think of it as charging your internal batteries every single day. Your body makes less energy with age and this helps bring it back. Don't let another year go by feeling less than your best. Grab 35% off of your one month subscription of Mitopure Gummies at timeline.com forward/better35. That's T I M E L I N E.com B-E-T-T-E-R and the numbers 3 and 5 to grab your 35% off while the offer lasts. Would it be your opinion then that every woman should be on estradiol in order to counteract the growing, let's say, imbalance between estradiol and estrone as we, as we age?

A (36:56)

Well, yes, I really do see, and I know that people talk against what I say sometimes, but I see menopause as a very simple kind of a state. It's a hormone deficiency state. And that actually was what was said back in the 1950s and 60s. It's like the old wisdom is being rediscovered. You know, like people realize that when you lost ovarian function, you lost vital life hormones. You know, if you had your thyroid removed because you had a giant goiter or you had thyroid cancer, nobody would say you shouldn't have thyroid hormone replaced. I mean, whoever says you should treat lack of thyroid gland and lack of thyroid hormone by exercising, meditating or taking Prozac or something? I mean, they may be useful in other situations, but they're not going to replace the missing hormone. It's that simple. Hormones. People may wonder, what do hormones even do? What's the point? So hormones are information. I mentioned that when the receptors are activated in the nucleus, you make proteins. When they're on the membrane, you can make these vital peptides, you can make these kinases, all these signaling Agents. So think of hormones as giving the instructions to the cell so the cell knows what to do, what to make, when to make it. It. If you, if you're missing a hormone, then the cell isn't going to do what it needs to do. It's really very basic. And you need to have the right hormones at the right time, in the right place and so on. And so I do think of loss of ovarian function as creating what seems very simple thinking, a hormone deficiency state. Because essentially your ovaries are no longer making when you're in full blown menopause. The ovaries make take no estradiol and no progesterone. Like I said, they keep making testosterone. So testosterone is a very important hormone, but it's separate from menopause. It's just like, you know, other hormones, like hormones from your pituitary that you need, like growth hormone, although everything interacts with estrogen in some way. But when you don't have enough estradiol and you don't have enough progesterone, the body cannot compensate in a very perfect way. There are compensation, there are some compensatory mechanisms. That's why we keep living. You know, it's not like the only hormone, by the way, that you will die if you don't have it after by 24 hours is actually cortisol. You can live without other hormones. You won't live well, but you know, you're not going to die within 24 hours. But. And we do have estradiol made from circulating testosterone, but we don't make enough. So, yeah, I guess you can call it a deficiency or insufficiency. It's not. We have zero. We just don't have enough to maintain optimal function. So it's a really simple thing when you think about why are these hormones so critical for health and optimization of every organ system functioning. Well, I figured this out very early in my career when I was delivering thousands of babies. Babies. Whether we want to have babies or not have babies is very. An individual, personal decision for total women's rights, okay. Of making choices. But we should understand the female body evolved for the prime directive. And this is every life form, the creation of new life. Okay? And to that end, you need every organ system working optimally in the same time zone. They need to be connecting and talking to one another. They need to be working really in optimal state. So estradiol, I consider it like the master of metabolic homeostasis. It's the master of connectivity, of maintaining optimal health and function of Every organ system for the prime directive of creating new life. Any woman who's been pregnant and or deals with pregnancy knows that pregnancy is a risky time, that there are many complications that can occur. A woman who becomes pregnant, who is unhealthy is going to potentially develop some life threatening medical complications like gestational diabetes and hypertension, preeclampsia. And you can have preterm deliveries, macrosomia like 10 pound, 11 pound babies if you're not metabolically healthy. That's why it's so important, born to be healthy before you conceive, okay? And of course, if you're very unhealthy, typically you can't conceive, right? So that's one of the reasons why there's such a growth of infertility centers, you know, dealing with ivf. Because women are not as optimally healthy for fertility. Fertility is a vital sign of health in the reproductive age woman. So in order to not only conceive, have a healthy pregnancy delivery, women who are humans, to maintain the species, you know, theoretically should have to have multiple pregnancies and raise those children. They have a long timeline before they become adults and become sexually mature themselves. So they need a mom. They need a mom to take care of them, to raise them. So women have to live a pretty long time. They have to be optimally healthy. They, you know, for the species, they should be pregnant and have multiple babies. You know, but remember, I'm like, women's rights do every. Everyone should make their own choices. But if we don't understand that this is what the female body evolved for, we won't understand female health. And so estradiol and reproduction, or they're like this, okay? So hormones from the ovaries and reproduction fertility are completely connected. Like in nature. They go together. You cannot separate them. They're together now. We do that, you know, how do we do that in medical, you know, life? You know, we give women pills that shut down the ovaries, right? Like birth control pills. Literally shut down the ovaries, but they're still there and they can come back another day. But in terms of fertility, what if a woman never went through menopause? What if she made hormones and could ovulate and get pregnant forever for her whole life? Well, she would die. Pregnancy is. She would die from.

B (43:11)

She would die.

A (43:12)

She would die because she would die in pregnant. Every woman knows you call a woman elderly when she's 35 and is pregnant.

B (43:19)

How dare you, by the way?

A (43:20)

Oh, I try. I just say mature or high, higher risk.

B (43:25)

Well lived.

A (43:26)

And women in their 40s who are pregnant are really, really high risk. They have, you know, much higher rates of having complications. And so what if a woman, every woman could be fertile in her 50s and 60s. I'm telling you, they wouldn't survive. The babies wouldn't survive. So nature has to end reproduction for women because reproduction, having babies, being pregnant is too dangerous for older women. Plus, they want them to be around to raise them because they have to be around to get them to their sexual maturity and then they off on their own. Okay, so men, unlike women, they can have sperm that's functional. I mean, hypothetically, some men, you know, could have babies like they say, Picasso in his 90s, right? Because it doesn't harm a man's health. He can survive, doesn't matter where his sperm go. Okay? But women, they won't survive. So here's the thing. These hormones that are vital for life, there are estrogen and we won't even touch for right now on progesterone, but there are estradiol receptors in every organ. Every organ. Name any organ, every organ has estradiol receptors. And they maintain everything working like vascular health, heart health, mitochondria, the creation of energy, self cycles, like when cells should die, when new cells should be born.

B (44:45)

Even satellite cells in the muscle, everything.

A (44:48)

There's nothing that doesn't have estradiol receptors. The bone, the muscle, you know, the connective tissue, everything involving the urological system, you know, the brain, you know, everything. So when, when you lose. But remember, nature made it just how it has to be that reproduction and hormones are like this. You cannot separate them. So women cannot be fertile forever because they could not survive being pregnant forever. And so we, we, nature didn't know how to uncouple so that we could maintain hormones and not be fertile. Because the production of estrodial and progesterone requires eggs. Okay? And we run out of eggs. And that's not an accident. It's to keep us alive so we can keep going. Okay, so menopause is necessary for our long term survival. But there's a lot of unfortunate, you know, sequela that comes from that. So we are so smart, we're so clever that we have figured out how to uncouple fertility from the hormones. So goodbye fertility, reproduction gone. We can't be fertile forever. But hello, hormones, we can keep them. But if we keep those hormones without reproduction, how are we going to use them? To me, that is the big question. Not if we should use hormones, not is every woman going to benefit who doesn't have, have one of those few, you know, contraindications. But we'll say the vast majority of women, will they benefit from maintaining hormones when they lose their fertility? The answer is yes, because those hormones are the hormones of life. And nature just couldn't figure out how we could stay a healthy, functional woman, get rid of our reproductive capability and still maintain those hormones. Since to make those hormones you need eggs and eggs go away when we lose our fertility. That's just how it, how it works. But we figured it out. So that's the really, to me, the key thing is to not figure out should we be on hormones. We have so much science that shows what these hormones do, how they maintain every organ system properly. And we're talking about the hormones estradiol and progesterone from the ovaries, not estrone. I mean estrone is made from estradiol. Estriol is predominantly in pregnancy. We have tiny bits when you're reproductive and estrogen, estriol comes from estradiol. Our bodies will self regulate the production of estrone and estriol as long as we have the right amount of estradiol and we maintain general state of health. So it's not if to me, it's not if. We should stop this debate. We should make it clear these hormones are hormones of life. They are what keep us healthy through all our reproductive years. And it's just what it is that we can't stay fertile. We have to lose our fertility and the hormones just go, go away because it's inevitably linked and critically intertwined with reproductive function. But by being so smart and separating it and giving the hormones, we can optimize health for not, we can't, you know, we can't be 21, we're not giving back a 21 year old set of ovaries, which would be nice. I would take a set right now. But, and that will come, I really believe that's going to come. We're going to have replacement ovaries. But, but they're not available yet. But we can replace the hormones not.

B (48:11)

For the purpose of fertility, not for the purpose of reproduction, but for the purpose of producing the hormones only for.

A (48:17)

The hormones, not for reproduction. Except maybe in women who are, you know, so unfortunate. But to have premature ovarian failure or insufficiency. But, but the thing is, to me, the question should be over, answered, done, sealed. Hormones are great, hormones are wonderful. We have to give the right hormones, you know, estradiol and progesterone, testosterone when you need it, that's a whole different story. But not if we should give it. But here's to me, the really important question, how we should give it. Because more and more women are now realizing, and I'm so thrilled with that. I've been, you know, trying to get people to understand the benefits and the of. Of having hormones replaced or, you know, supplemented, and the harm that happens when we lose them. I mean, we have science upon science upon science about that. And I give lectures on what happens with estradiol in the cardiovascular system, in the neurological system, in the musculoskeletal system. You could know, have hours of lectures on each one of these systems. But in the end, the answer is it keeps everything working right. It's like you can just cut to the chase. Without estradiol, nothing can work optimally. It's that simple. You know, it keeps everything working right and maintains your circadian rhythm. So every organ is in the same time zone. That's, like, really important. It regulates appetite, energy, you know, everything. You know, it's like very finely tuned. When you have estradiol, things are working right. Without it, nothing. You know, it's a fight. It's a battle to keep things optimized. So the real question should be, how are we going to give these hormones to optimize health? How should we dose them? What kind of regimen should we use? And this is where we desperately, desperately need more clinical studies, for sure, you know, so right now, what we can work with, because we have no clinical studies, isn't that sad? You know, like when people say, show me the studies, it's like, you know, we don't have very much. No, because. Because after the Women's Health Initiative, which ended like 23 years ago, it shut down almost all really high quality research. And the little that was done, they were tainted by this, we'll say, the mantra of the Women's Health Initiative, which was based on hormones being evil. Remember, for anyone who hasn't heard it, they didn't use human bioidentical hormones. They used the horse urine, the conjugated equine, estrogen, and a fake type of progesterone, which actually, in certain organs, it's like an endocrine disruptor for progesterone. It actually acts as a progesterone blocker in some organs, and it's super powerful in the uterine lining. But it's not real progesterone. It's what's called medroxyprogesterone acetate, and it's found to be harmful to the cardiovascular system, to the immune system, blood clotting system. It's just not good, okay? It actually has a lot of harm. And that's what they used in the study. So the mantra became if you're going to use hormones, and it was only for suppression of hot flashes and night sweats, okay? And it's still, this is still the case. There's no medical organization or society that is actively promoting in their guidelines the use of hormone therapy for prevention of cardiovascular disease, for prevention of dementia. You know, and there's no neurological society. Like, there's no. I mean, this still hasn't happened yet. I'm fighting for that tooth and nail all the time to get these societies to change their position statements, and they haven't yet. Although individual doctors within those societies are changing how they're behaving in terms of how they, how they care for their patients. But the official societies haven't actually endorsed the use of hormones for anything for optimal health. So the only, the only official recommendation for hormone therapy is for suppression of hot flashes and nice sweats, which is a benefit. I mean, I wouldn't say that that isn't very, very important, but it's just like a little piece of the puzzle. And then it's officially FDA approved for prevention of osteoporosis. So almost nobody, endocrinologists or rheumatologists are using it for that. They don't ever use it for that. And vaginally for, you know, genitourinary syndrome of the menopause, you know, vaginal thinning and pain with sex and infections and bladder issues like incontinence and overactive bladder. And that's where vaginal estrogen has become. And so there's been a lot of attention on genitourinary syndrome of the menopause, but unfortunately not about much else in terms of, you know, strong recommendations for its use.

B (53:00)

So I'll be salacious for a moment and I'll. There's a couple of online. Well, I don't know them personally, I just know them online who will push back and say, well, there's absolutely no evidence for estrogen in helping to prevent cardiovascular disease to improve the outcome. Same goes for bone that there's just no evidence to justify changing their position statements. So is that because, like you had mentioned before, that there's no dosing, no regimen, we don't really understand. And I think that there was like a couple of observational studies around and it might have been in mice. I can't remember if it was mice or humans actually at this point, but it was looking at cardiovascular disease risk with estrogen use. And I don't know if there was a definitive yay or nay. So I don't know. Maybe you can help clarify that for me.

A (53:48)

Well, preceding. Preceding the Women's Health Initiative, there was incredible enthusiasm for hormone therapy. Incredible, in fact, like, very high percentage of women were on hormone therapy. And then some of the medical societies started endorsing hormones for cardiovascular prevention in terms of, like, preventing heart attacks and strokes. And the FDA said, wait a minute. You can't make those claims. Where's your studies? Because all the studies up to that point were observational studies, as you said. Like, there was the Nurses Health Study, and there was like. Like one in Leisure World study that they were observational studies and they were very favorable, and women felt good on hormones, so it was very favorable. But they didn't have the definitive. The gold standard.

B (54:40)

The rct.

A (54:41)

Yeah. The randomized control, placebo blind. Yeah, all that. So they didn't have that. So the FDA said, you can't make these claims without the studies. So that's when they had the Women's Health Initiative study. And which unfortunately, although we knew, I knew because I was there at the time that this was all happening, that medroxyprogestone acetate and premarin were bad choices because that they were not the ideal. And we already had bioidentical transdermal estradiol, micronized progesterone. We already had these. And I was using them before the Women's Health Initiative started, but they used the Prempro because it was what was commonly used previously. And it's just what they did. I mean, that they justify it, but I think it was unjustified because we already knew the outcome was going to not be good. Or I knew it before they started this study because. And if I knew it, they knew it. I mean, come on. Like, how would I know? But that. But after the Women's Health Initiative, this became and is currently a huge problem. The couple of studies that were done that were considered of high quality with the KEEP study, which looked at women who were close to menopause, and in the KEEP study, they used a small dose. They even wrote in the paper that they were influenced by which I started saying the mantra of the Women's Health Initiative based on we hate hormones, which was the lowest dose for the shortest time, the low and always emphasizing lowest dose, lowest dose, lowest dose.

B (56:15)

I hear that all the time. Five years, you get Five years on that came.

A (56:18)

That was happened. That's what was. But they talked lowest dose. So that influenced their choices in the keep study and then also in the subsequent elite study. So in the keep study they used 0.45 milligrams of premarin. That's oral, you know, conjugated equine, horse urine derived estrogen, which orally, which we already knew, increased blood clotting risk and was more pro inflammatory. It works primarily through the alpha receptor, which alpha receptor has benefits. Like I mentioned, it's very good for the bone. They showed reduced bone fractures in that study. And it's good for the arteries, so it's good for muscle, but it's not good for, you know, reducing inflammation. And so, you know, there were some negative things with inflammation related problems. And Premarin itself increases the risk of blood clotting by 400% over not being on it. So that having blood clots is a terrible thing because if you are prone and you're a pro inflammatory person. And the average age in that study was 63, went all the way up at the start to age 79. So these were not like ideally perfectly healthy women. My goodness, where are you going to find that population? So they had hypertension, they, they hadn't been diagnosed with a previous heart attack or stroke. That would have excluded them.

B (57:43)

But some of them were smokers too.

A (57:44)

They were, they, they were, they were typical Americana. They just never had a heart attack or stroke. But they had all the other, you know, metabolic dysfunctions, cardiovascular risk and they were overweight. They were everything. Yeah. So then if you take, take people who are in an inflamed. They're all inflamed. We talked about inflammation. They were all in a pro inflammatory state. And then which pro inflammation is pro clotting. That's part of the inflammatory response. And then you give them something that increases the risk of clotting another 400%. What do you think is going to happen? They had higher rates of stroke and probably vascular dementia because of little blood clots that affect, you know, blood flow to the brain. It's like, duh, who wouldn't have figured this out? Just knowing what these hormones do. These are not human hormones, they're not estradiol, they're not progesterone. But anyway, that influenced. And so for the keep study they used a lower dose of the Premarin than that. What they used in the Women's Health Initiative, which used a 0.625. This one used a 0.45. Okay. Because they wanted less. Because the idea, less is better. Right? And then they used a progesterone gel vaginally, but they used a really tiny dose for only 10 days. It didn't even prevent hyperplasia in a lot of women. So they used the wrong dose of progesterone as well. And for the too few days. And then for the patch, they did use a transdermal patch, but. And it was 0.05. But they measured the levels and the estrogen level in the women in the study who were, you know, the study cases, they never got their estradiol level above menopausal levels, which you have to get over 50. They never got above 40. So even in the highest numbers, they never were left the menopausal hormone range.

B (59:32)

So never really a therapeutic dose.

A (59:33)

Essentially what you're saying, perfect, you said it hit it right on the head. So then if you say, well, see, it didn't reduce buildup of plaque or intimal changes in the carotid artery, which is what they were following, like the carotid artery status, and it didn't show that the women on the hormone regimens did better than the women who were not on the hormone regimens. But then my response is the same. Like I always say with, like, if you do a sub amount, a substandard or beneficial amount of exercise and you find no benefit, that doesn't mean exercise isn't beneficial. It just means maybe the dose of exercise was insufficient. So instead of saying, well, maybe there was a problem with the hormone regimen and the dosing and all that, no, the conclusion was hormones are not beneficial for the cardiovascular system. And getting the cardiologist to budge. I have several cardiologists that are really on board, but the majority are not. They're like, see, that study showed it didn't help. It's like, no, that study showed that if you underdose dose, you're not going to get the benefit. Okay? I mean, like, instead of saying, well, maybe you used the wrong dose. And then in the elite study, which actually did show, weirdly enough, statistical benefit in terms of the cardiovascular system on the carotid, once again, they measured the carotid artery, and it showed very tiny but statistically significant benefits in the women who were close to menopause, you know, they weren't far out. They had to be within, like, six years of menopause. And in that group, they showed statistical benefit for the health of the carotid artery. But a lot of the doctors say it was so little really doesn't count. Even though it met statistical significance, they said clinically it wouldn't even matter.

B (61:25)

And just for the carotid artery, we're talking about the thickness. Are we talking about cac? Are we talking about any type of like calcification? What are we talking about when we're looking at the carotid artery?

A (61:34)

They're looking at the intima and you know, evidence of thyroid thickness. Yeah, the thickness of this. Right, yeah.

B (61:39)

Okay.

A (61:39)

Because this was very short period of time. I mean, you know, in younger women you're not going to see massive buildup of plaque over like five years or six years, you know, typically. But, but it did show benefit in the treated women. But here's the problem. They also used crazy hormones. They used an oral estrogen, an estradiol at 1 milligram, so they gave oral estrogen and then they used a progestin instead of real progesterone. They used a progestin, a fat, you know, mimic. So like, where'd they come up with this hormone regimen? Like, who made that choice? You know, so, you know, but even in that crazy scenario, the women actually statistically did better with their vascular system. But I'll tell you, the cardiologists don't care. I've listened to some of their lectures and they say, as a general statement, nah, it really isn't clinically significant. We don't buy it.

B (62:34)

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A (65:06)

Well, I definitely have thoughts, and there are no guidelines.

B (65:09)

Okay, well, then give me your thoughts.

A (65:11)

So when there are none, I make them up. You know, we have to make up. Like, this is the art.

B (65:17)

This is the art, right? This is the art of clinical practice.

A (65:19)

But it's based on science. It's not random, like, just like a fantasy story. So we now know. I mean, I've known for a long time, but it's been talked about more that the name menopause really does no justice to what's the process here? Because it makes it sound like it's about your periods. The uterus is just one organ that's impacted by these hormones. You know, so it's just one. Like women. I've had women say, well, I had a hysterectomy. Does that mean I don't go into menopause? Well, technically, your period, you Went into, they think, oh, I went into menopause when I had my hysterectomy and I was 32. No, that was, was losing your uterus. You know, they didn't take it, they didn't take out your ovaries. So, you know, they're still chugging away for as long as they're going to keep making hormones. Just, you know, hysterectomy does increase the, on like, it increases the onset of menopause, typically by at least a year. So you'll have an earlier menopause, but, but the ovaries will keep functioning for as long as they'll keep functioning even if you had a hysterectomy. So menopause, the word doesn't really tell the story at all. It's ovarian senescence or ovarian aging, which is a process over years. I mean, you could say you're in, you know, perimenopause from the day you're born. You know, your eggs are declining. You know, the eggs, the eggs are going down. You know, they actually, you lose eggs very quickly, you know, from when you're born. And, and then of course, it really accelerates. And not only do you have, have fewer numbers of eggs, but the egg, what they call egg quality, goes down. So the egg is like old. It doesn't work as well. So think of it as a process. And although this is somewhat arbitrary, we talk about it over like 10 years, okay. But it really, you know, as you could say, it's a process that just evolves over the whole life and it does parallel declining fertility, which, like you mentioned, like, when progesterone goes down, that is going to affect fertility big time. You know, you need progesterone to allow the implantation and support of the embryo in the uterus. So no inadequate progesterone. You're going to have fertility problems big time. That's why a lot of fertility clinics, they support pregnancies with progesterone. Okay? So it is a process over time. And we know that bad things start happening years before the official made up definition of made of menopause. It's made up, okay? So it's officially labeled as 12 consecutive months without any vaginal bleeding. I mean, I always say if you don't have any bleeding for 10 months and then you suddenly start bleeding, the last thing as a gynecologist I would think is, oh, isn't it amazing you ovulated after 10 or 11 months? No, no, that's just, you know, suspicious bleeding until proven Otherwise, So it's arbitrary. Just because we have a rotation of the Earth for 12 months doesn't mean that, you know, that has anything to do with anything with menopause. But you know, it's arbitrary definition. So the reality is that things are happening for years before that official you cross the, the line and you get called menopausal. And so, so ovarian decline varies in terms of its timing and its speed of onset in every woman. So they say the normal menopause, which is then you don't have periods for a year or bleeding for a year, is between age 45 and 55. That's a decade right there. So it's considered normal for a woman to stop having ovarian function at age 45 or at age 55. Late menopause is after age 55 and early is from 40 up to 45 and premature is before age 40. So what if a woman is so called normal and her periods are done at 45? Okay, well it means that her so called perimenopause started 10 years earlier. Oh, that's 35. Okay. And 55, that's your last, last period for a year, you know, then it means 45. So you can see there's huge variation. So what helps predict when your menopause will be? Well, the closest we have is what your mom did. If you, you know, if your mom had a natural menopause, what she did is the best predictor of what you'll do. But it's not precise like that, you know, so we never really know for sure. And there's no absolute predictor. As you get closer and closer, like fsh follicle stimulating hormone will start rising, especially if you test it. Like this is we learn from fertility like we would in fertility. If someone can't get pregnant, she's like 36 or so, we would get a day three. That means the first day of the period is day one of the cycle. And then we get day three. That would be the third day into the period. An FSH follicle stimulating hormone. And if it's 10 or higher, then it bodes poorly for fertility. Okay, and that really is saying what? Like your eggs are old lady, unfortunately, you know, and we better get on.

B (70:28)

Your brain's yelling at them.

A (70:29)

I know. And you better really get going if we're going to conceive, we have a really limited, you know, span of time here to work with. And your eggs are older, you know, so they're going to be more challenged to fertilize you have higher risk of miscarriage and so on. So it's just trying to, you know, be realistic and help women to achieve their goals if it's having a baby. But it also tells us, like, say you don't want to get pregnant. You're done. You know, you're not interested, but it can still do it. And that tells us something about where you are in ovarian aging. It doesn't tell us your last period will be this year or this year or that year. We can't, like, predict it to that degree, but we can say, clearly, your eggs are aging. You know, you're in that process of, you know, ovarian senescence and menopause is definitely on your timeline now. You know, be aware of that. So that is something useful. But it's not precision actual for timeline, but it gives us an idea that your ovaries are getting old, okay? And if you do it and your FSH is 2, then it's, you know, you seem to have more life in those ovaries. You can do an anti mullerian hormone that measures sort of follicle storage. Like, how much do you have still left? In a general sense, it doesn't say you can or can't get pregnant, but it certainly will tell you that, oh, your, your number of eggs is not. Not so good. You know, it's like really getting low. And like, if you want to get pregnant, you better get on it. And if you're not interested, you know, just think, like, menopause is looming, right? We, you know, your eggs are in short quantity here, you know, so we can't give you an exact timeline, but, you know, it's real. You know, your, your ovaries are definitely aging, so we can look at that. But I think that by age, Honestly, by age 35, since we know that it's totally normal to be in menopause at age 45. For myself, I was only. I was early menopause. I was only 43, which actually is really bad for your longevity and mortality. You know, we know that now. Now the earlier you lose your ovarian function, the worse off you are. The longer you keep ovarian function, the better off you are. Because. Why is that? Because we love those hormones. They do good things for your body. So. But for the women that are going to go into menopause early, we better be on top of it. Why would we want them to end up with earlier onset of dementia, heart attacks, strokes, fractures? We don't want that. So we need to start. Start thinking about this whole timeline, Even if they have a family history of anyone having really, like, early menopause, like, like, I had 43. That means you're already potentially like, perimenopausal. You're 33. Like, you know, and it doesn't mean you can't conceive. It just means that you're, you know, less likely to and that maybe you're, you know, you think you're going to have babies in your 40s. That isn't going to happen. Okay. Not unless you use a donor egg or you have eggs. Egg. Frozen. You know, eggs that were frozen. But, you know, I think we should start thinking about perimenopause and all that. It means really early compared to what has been the standard, because we want to help women to optimize their long, healthy longevity. And there are some things that we can do to help ovaries have a little longer life. You know, we can't say we'll add 10 years to ovarian function, but we can add any. Anything we add is good. So, for example, maybe don't have a tubal ligation. There's some question that that can lead to earlier loss of ovarian function, that you'll go into an earlier menopause. And that's what I think happened to me. You know, I had a baby, I had a tubal ligation, and before I knew it, I was in menopause. And I can't prove it, but there is data showing that you affect the function of the ovaries because you affect some of the blood supply to the ovaries when you do a tubal ligation. So I certainly. And I'm a gynecologist, but at that time, nobody was talking about that. You know, live and learn. But so don't have a tubal ligation if you can avoid it and, you know, eat more vegetables, you know, have an anti. Ovaries can get inflamed. Like we talked about, inflammation. Everything is inflamed when you have.

B (74:42)

And just have one vegetable because the low dose is. I'm just kidding.

A (74:46)

I know. I love making a joke.

B (74:48)

Yeah, just have one vegetable because the low dose is the safer dose.

A (74:51)

Yeah, right, right. One. Just one. One type and one dose of one time.

B (74:56)

One squat, one time, and you're good.

A (74:58)

I know. It's like. It's so wild when you say it like that. Of course, everyone says it's crazy, but, yes, that's. People are getting. Women are getting hormone replacement therapy or hormone menopausal, you know, you can pick which words you want to use. Menopausal hormone therapy with absurdly low doses, you know that they're still in the menopausal range, I can tell you. But the weird thing is, is even the tiniest dose of estrogen can help reduce night sweats and hot flashes. Although in some of the studies it takes 12 weeks, three months before they actually see the benefit. And it's statistically significant, but it still may only be 40% of the women, you know, so it's like there is a dose relationship, there's no question. But. And in terms of like keeping women's ovarian function longer, staying anti inflammatory, because when you have systemic inflammation, the ovaries get inflamed too, and the inflammation in the ovaries will prematurely age and damage the eggs. That's not like theoretical, that's fact. Okay. In fact, they've done studies where they've drawn fluid from around the egg and they found it was infiltrated with a lot of inflammatory cells from the immune system. So we don't want inflamed ovaries that will age them. Like everything gets aged. You want neuroinflammation? No, brain inflammation will age your brain. Premature is good when you have inflammation. You mentioned bone. Bone osteoporosis is an inflammatory process going on in the bone, right? It's the inflamed bone that is happening with the osteoclast, the immune cells embedded in the bone that are going crazy, gobbling up bone. That's actually an immune system over response. You know, it's like immune system gone crazy. So in the ovaries you can have inflammation and then the eggs will age prematurely. So the more you have vegetables and exercise, avoid toxicants. You know, anything that avoids the creation of inflammation which creates ovarian inflammation, will help prolong the natural life of your ovaries and, and that it can prolong your life and your health span. So it's really, you know, we, we love those ovaries. And it's like it used to be that women were told, you know, it'll be so nice when you go through menopause, you won't have periods anymore. It's like, like oops. You know, that nobody likes having to have monthly bleeding, but when you look at the cost of not having it, you know, I'll take the bleed and have the health. You know, it's like some people don't like to sweat if they exercise, but they'll take the sweat so they get the benefits of Exercise, you know, so everything good has some little, you know, caveat, you know, that you have to put up with something.

B (77:34)

So I remember my gym teacher, I mean, she was talking about this in the context of fertility, but I think it also applies with menopause. Like, the only thing worse than getting your period is not getting your period.

A (77:46)

Oh my gosh, I love that. You know, I'm going to.

B (77:48)

You can use that with menopause.

A (77:49)

I'm going to use it, you know. Absolutely. Which gets down to, you know, the. What I feel should be the only question of the day we have. We have to have studies because the academics will not change their positions officially without the studies. And science seems irrelevant to them. You know, it's just like I can show you mechanisms galore of. It does this, it does this, it does this, it does this. And when you don't have it, here's all the negatives that happened and we can go on.

B (78:20)

Let's take some time, let's take some time here because even, you know, I've had conversations with medical doctors. They're like, I'm not going to prescribe bioidenticals. That's just a marketing term. So explain to us what a bioidentical hormone is, why that is different from a synthetic hormone. And are there differences in terms of mechanisms and in terms of outcomes and effects on the body?

A (78:43)

Well, the terminology is a problem. Just like the word menopause leads women to think, you know, the wrong thing. It's about periods when it's really about ovarian function and the words really do matter. So we really wish. I wish we had a different vocabulary. And sometimes I make up a new vocabulary. Like in some of the papers I've had published, I say human identical. And I don't use the words bioidentical because it's taken on this aura of negativity in a lot of communities of med. Of doctors because they think it means a free for all of compounded hormones.

B (79:18)

That's it. Yes, that's exactly right. A lot of people like, it's not from a compounding pharmacy. We're gonna get, you know, pharmaceutical grade hormones. Like there's the. There seems to be confusion between the two.

A (79:29)

Yeah, so. So sometimes I do, I just make up my. Like I make up my own protocols because they don't exist, but they're based on science. I have to make up my own new terminology because the terminology is. Is poorly understood. You know, like I get, you know, get rid of estrogen dominance because people don't know what that means, you know, so bioidentical hormones. A lot of people don't know what that means. So to me it just means they're identical molecular compounds to what the human body makes. Okay, Bioidentical is human identical. Like if you did an analysis in a chemistry lab, you could not tell the difference between the human made and the laboratory made of whatever that is because it's identical.

B (80:13)

Like diamonds. There's lab made diamonds and there's diamonds that we mine. And where.

A (80:17)

Yeah, and I don't know.

B (80:18)

Identical.

A (80:19)

Yeah, yeah. And I don't know enough. If you looked at a molecular, you know, level, if you could see the difference, I don't know, know. But with the bio or human identical hormones, they're, they're completely indistinguishable. Completely indistinguishable. And that's what I want to put in the human body. It's like insulin. Nobody questions insulin if. But nobody says human bioidentical insulin. Okay. So, you know, but in the early days, where did they get insulin from before they could make human identical insulin? They got insulin from a rabbit. And it's different, it's molecularly different. It didn't work out that great, but you know, it kept some people alive for a while who had type 1 diabetes. So, you know, we didn't have human identical hormones for a long time. So they did. It's very interesting. The history of hormones is very interesting. The first estrogen they got was from grinding up the ovaries of a cow. I mean, they didn't, they couldn't make it. So you know, and then they got it from horse urine. And so this is, they, you know, they experimented getting it from a ground up placenta, you know, so when you can't make it, then you, you take it from another animal. Right. That's what desiccated thyroid is like, you know, armor NP thyroid. It's like from a pig, they grind up a pig's thyroid gland because they didn't know how to make human identical. Now we have both to choose from another topic for another day. But the thing is that, that when we give hormones now, we should only be giving human identical. That's why I use human identical. Because human identical can come from a, you know, CVS pharmacy, Walgreens, you know, and it's a commercially made product or it can come from a compounding pharmacy because sometimes the other commercial products are not working for someone or they get a reaction, you know, like an allergic reaction to some of the components, you know, so that's what the beauty of compounding pharmacies is for the people who it. When it doesn't work, or like, they get rashes from the patches or they get also, like irritation from the gels or it just doesn't seem to absorb. Because the skin is actually supposed to be a barrier, you know, and we're trying to create a way to get hormones through the skin. I mean, it's supposed to be a barrier. So some women, their skin acts as a barrier, and, you know, these products don't get in. And we have to come up with ways to maybe concentrate it from a compounding pharmacy or put it in a different location that you couldn't put a gel, like maybe around the opening of the vagina, you know, the labia. You can't put a gel there. It'll burn, you know, and you're not going to put a patch, you know, that doesn't work. So, you know, we have to sometimes, you know, work to find ways to get the hormones in, to get the right levels. So compounding is really necessary. But it's the same. It's estradiol. Whether it comes from a compounding pharmacy or from a patch or a gel that you get at CVS Pharmacy or Walgreens, it's still human, identical, molecular identical. Estradiol. And what we should be able to say is just estradiol. We shouldn't have to say, you know, we should just say. If we say estradiol, there is only one estradiol. It's not like. Estradiol is not a generic term like estrogen. It is a molecular substance. That's one substance. It has a molecular, you know, composition. Estradiol. Technically you could say more than that. You know, you can say 17 beta estradiol. But nobody says that. But they could. Okay, but. And then progesterone is progesterone. Then it has a letter and a number, too. It's big P number four. Progesterone. Okay, so progesterone is just progesterone. It's not something else. It's not medroxyprogesterone acetate. It's not levonorgestrel or norithindrone. Those are other progestins. It just is what it is. So we should probably not even say bioidentical or human identical. We should just say, you know, estradiol and progesterone. But, you know, that people. Then you know what you're talking about, because that's the actual substance that we're talking about. Gifts and Whether it's given, like I said, from a bioidentical, from rather from a compounding pharmacy or in a patch or a gel, you know, it's still exactly what it is. Okay, so. But it's really the emotional rawness that gets evoked when you say bioidentical. Hormones in some circles is like, wild, you know, and it's not really the wild West. I mean, you can measure levels. So, you know, whatever you're giving, whichever source you're getting it from, from. You don't know what's getting in the body until you test a level. But testing levels, by the way, is not considered mainstream at all. Well, that's because the goal is not optimizing healthy longevity with giving hormone therapy at all. That's not the goal. The conventional goal is just alleviating night sweats and hot flashes. So you give, once again, the lowest dose to achieve that goal. That's not my goal, but it can be somebody else's goal, you know, in which case, why do you want to know what level you're getting? You just want to give the lowest dose. You start super low. And as soon as you get, you know, reduction of night sweats and hot flashes, that's when you stop, you know, so it's not about optimizing. It's just reducing symptoms. So, you know, we have people in our medical community with very different views about how to give hormones, why we're giving hormones. And I know that although I try to have one foot in both camps, conventional, and we'll say functional, integrative, okay, I'd really try to straddle the two, you know, but if you want to. If I had to be, you know, pigeonholed when it comes to giving hormones, I'm definitely not mainstream.

B (86:07)

Yeah, I mean, I. I really feel that sentiment because I, too, try to straddle both worlds as well. And I find that there's some. There's just some stuff that's really antiqu. Like, and I think the part of it is just cultural. Like, I was at a conference just recently, and one of the presenters was saying that the country of Egypt ran out of vaginal estrogen because the women. The country of Egypt ran out because the women were putting it on their face. Right. So these, you know, it's like, hello, habibtis. Like, the women. The Arab women are like, oh, it's good for your skin. Okay, I'm gonna. We're gonna use a vaginal estrogen. We're gonna put it on our face. And so I feel like like, like you. I think that there's. I, I like to hear what some of the critics are talking about with like hormone therapy. That's why I sort of push back. I'm like, oh, but I've heard people talk about, you know, cardiovascular disease. There's no evidence for that. There's absolutely. This is why the menopause society doesn't talk about it. You have people like that and it's like, okay, I want to hear your justification. And then when I ask someone like you, you're like, and I know all the studies that they're referencing and they actually used to be very open to it prior to, you know, know. And then we get into the Women's Health Initiative, et cetera. But just because we're. I can't let you go without asking you about vaginal estrogen. We love. I mean, I've had so many people on talking about vaginal estrogen. For most women in their 40s, it should be given out like candy and there shouldn't be any for. I mean, I think that there's very few obscure contraindications for it. Vaginal estrogen for gsm. So for painful, whether it's lubrication, painful sex, it feels like sandpaper, maybe even poor or, you know, longer time to orgasm or decreased sensation, clitoral atrophy. Are you a fan of vaginal estrogen for GSM and potentially the off label use of like the country of Egypt. Vaginal estrogen on the face.

A (88:02)

Well, first of all, I do like to think of the genital urinary system as sort of the canary in the coal mine. Okay, so if a woman at whatever age. And by the way, this happens actually unfortunately a lot in women on birth control pills that. Because they actually get atrophy, you know, thinning of the tissues because it's not the right hormones. But so whenever it is, we'll say like perimenopause, they start having any symptoms. That is a real clue. If the, if the genital urinary tissues are showing signs of hormonal deficiency or insufficiency, then what do you think is happening in your arteries, in your bones, in. You know, pick any organ. Well, that.

B (88:44)

Isn't that for men too? Like, isn't ED like an early sign, like a warning sign of cardiovascular disease?

A (88:50)

Absolutely, we have. But we shouldn't like. And when it comes to genital urinary health, we shouldn't just say, well, we'll just give vaginal estrogen and call it a day because you're missing the Significance. So everything has multiple layers of significance, right? So of course we want, if you're having problems, we want to treat it right. We want everyone to have great sex life, great bladder function. What woman wants to start wearing adult diapers when she gets older because she can't control leakage? It's horrible. It changes women's lives. They become recluses. I mean, oh my gosh, like incontinence is like a terrible, terrible fate for any woman to have to deal with, with and, you know, frequency. Like every. You've seen women like that, they have, I call it bathroom mapping. Wherever they go, where's the bathroom? Where's the bathroom? They want to make sure there's a bathroom close by all the time, because when they got to go, they really got to go. They'll have loss of urine. So we want to treat, and we want to treat it early because you can actually prevent a lot of things and vaginal prolapse. There's a whole industry of surgeons doing, you know, picking up bladders and putting back the rectangle. You know, these are giant, like hernias of these organs into the vagina and the uterus can start falling down. This is loss of proper health of your connective tissue, which is all estradiol mediated. Estradiol maintains the connective tissue, the fascia, all of that. You know, that's when things start falling apart and then things start poop, you know, pushing down. And we don't want that. So being early onset of treatment with vaginal estrogen or DHEA is really important, but we shouldn't take it as it only affects those things. If a woman is having signs of hormonal insufficiency that's manifesting through genitourinary tract symptoms, assume that it's affecting every other organ system and maybe even take steps to check on it. Like do ultrasounds of the arteries of the heart looking for energy deficient states in the heart, mild diastolic dysfunction, which you can see on an echocardiography, because that's why I call it the, you know, canary in the coal mine. If that's going south, everything is going south. It's not an isolated thing, which is why I'm against them. When in which. Which is now so common, like at any age, you can treat genital urinary tract symptoms with vaginal estrogen, which is great, except why are you only treating that organ system? What do you think every other organ system is going through if that one is suffering? So, so like take it as a symbol and a Sign that every organ system needs hormones. By the way, if you give women an adequate amount of estradiol and progesterone, she doesn't need extra vaginal estrogen at all. I can tell you that, like, just think about this. Does a 25 year old healthy woman with normal cycles and normal hormones need vaginal estrogen? No. If you have physiologic levels of hormones and you know, then you don't need extra hormones for your vaginal tissues. Okay? But since most women aren't getting that, then yes, they should all be. And there's no harm in giving it anyway. You know, there's no downside, there's no danger, just the costs and little bit the mess, you know, but there's no other, there's no safety danger, there's no health danger from giving vaginal hormones. The dose is really tiny. The estradiol dose for vaginal use, for constant use is twice a week, it's 0.1 milligrams, you know, for people don't know dose, that's really little. Okay, that's really tiny. Now I love, so I love that. Except you know, my goal ultimately is giving physiologic levels. So you don't need extra estrogen vaginally, but, you know, there's no harm in giving it anyway. Okay, what about the face or, you know, in hands? I love hormones, you know, because I always say, well, no matter how much hormones we give to try to be physiologic, what the heck, you can always do a little bit more because that's what you can see. That's why I say, if you really think it's benefiting, you know, maybe your sex drive, because no matter how we give hormones, it's not the same as being 25. So what the heck, you can give vaginal hormones, there's no harm. There's some data that giving vaginal DHEA can improve sex drive and also sexual response. And the same thing for even estradiol. A lot of people don't realize that orgasms really require estradiol. Oxytocin is a peptide that requires estradiol for its production and receptor function. So estradiol is very much about love and bonding and sex and orgasm. So it's not just about testosterone. And plus, estradiol upregulates the function of testosterone receptors. So not enough estrogen. And the test, the testosterone you have isn't going to work optimally either. So it's very important for sex function and sex drive. And for the skin, there's published articles that if you put topical estrogen, and I say estrogen because some of them did use topical premarin, you know, so, so, but I always, of course, would go with estradiol or even estriol, which we really haven't touched on, but estriol, which works primarily on the beta receptor. Well, it turns out that a lot of the skin receptors are beta receptors. Okay. So that's why estriol can be used vaginally with very good results and also on the skin with very good results. But there's also alpha receptors in the connective tissue of the, you know, what we call the stroma of the skin. So the epithelium is, is more, more beta, but a lot of the other structures can be alpha. So I personally, if, if I'm, you know, giving the hormone, like from a compounding pharmacy, I'm giving estradiol cream as a systemic dose, like to try to increase the whole total body levels of estradiol. I tell my women, you know, you want to get more bang for your buck, put it on your face. Okay, but, but if they're using another form of estradiol or they're for some reason not on it, maybe they feel they don't need it yet, but they're perimenopausal, you know, everyone's different. Then in those cases, I would give estriol because estriol doesn't activate the alpha, which is the proliferating, you know, that creates growth factors. So we don't want to accidentally grow our uterine lining by giving estrogen on her face. Okay, so if you're just going to use it for cosmetic aesthetic reasons, then I would use estriol. Okay. And you can have a compounding. This all has to be compounded or, or commercial. But usually I go with compounded because then I know what I'm ordering and I don't know what these commercial over the counter products, their quality or anything. So, you know, I want to use, use products I know I can trust, but then I can get it with progesterone. Progesterone is also very good for the skin. A lot of people don't know that. There's published articles that progesterone on the skin will also reduce wrinkles. So we have data that putting estradiol or estrogen around wrinkles that within two weeks you'll see reduction in visible lines and wrinkles. It's wonderful because it creates collagen, supporting tissues, fat like the good fat, the supporting fat. All of that is controlled by estradiol. So you get wonderful benefits for the skin. It increases things like ceramides, proper sebum, the right microbiome of the skin. All of that is controlled through estradiol. But progesterone is also synergistic and also will help. And then you can add other kinds of interesting products for your skin, like nitric oxide support, which really helps with healing and health of the skin. So there's a lot that can be done. And then you don't maybe need plastic surgery or injections, which I'm not against, by the way. I'm just saying maybe you won't even feel you need it. Right. And also the sooner you get on hormones, the less you'll need. Because one of the earliest signs of aging, of course, is visible when people look in the mirror. Right? Because estradiol maintains means, like we said, you know, all the collagen. You want. Collagen, right, right. You want underneath to support the, the ceramides and all that requires estradiol. So as you, your levels go down, you start seeing the effects on your skin. So once again, if you are seeing significant aging on your face, what do you think's happening to your arteries and your bone and your heart and your brain? So take all these things as clues, like maybe, maybe now's the time to start some systemic hormones because you're seeing hormone deficiency in your face, in your vagina. Like those are like, you know, like, think of it as like, oh, good clue, you know, because they say, how do you know that you need it? Well, sometimes you can just feel it or see it, you know, that's like obvious, you know.

B (97:42)

Yeah. And what about, what about bi? Est, is that, or bi, what is it biased the word? I'm thinking.

A (97:47)

So yes, biased. So biased. I talk against all the time. It was a complete made up creation where you used predominantly Estriol and a little bit of estradiol, also based on fear of estradiol and this sort of irrational love of estriol. Now estriol can have some, we'll say, medicinal uses. There is some data because estriol is the dominant estrogen of pregnancy and it activates predominantly the beta. Now I had mentioned that when you have a lot of beta activation of those receptors, it down regulates alpha. And I mentioned that the alpha receptor is what's on breast cancer. So there were some early use of estriol as a treatment for breast cancer because it can down regulate the alpha receptor, which is the receptor of breast cancer, which is, you know, activated by like estrone and it creates growth and proliferation. So in addition it down regulates the alpha receptor which I mentioned is the dominant one on the innate immune cells. Well, like in pregnancy, the innate immune cells are what make the inflammatory cytokines like tumor necrosis factor alpha. These are inflammatory cytokines that when they're suppressed by drugs, you know, like, you know, humira remicade, there's all these drugs that block cytokines. That's what the treatments, the immune modulator treatments for autoimmune disease. Well, pregnancy can actually help many autoimmune diseases like the big one, multiple sclerosis, to go into remission during pregnancy. So a lot of women who have like multiple sclerosis will actually do better during pregnancy because the estriol is down regulating the alpha receptor and they're making less of the tumor necrosis factor alpha, the less of the inflammatory cytokines. Unfortunately it often explodes after they deliver. You know, so it's, it's a, it's a short lived reprieve from their autoimmune condition because it often will exacerbate also in menopause. Often multiple sclerosis becomes much more aggressive. So you know, we, but they use it. There's been some research, there was years ago using estriol as a treatment for multiple sclerosis. There were studies at ucla. It never seemed to go anywhere. It never really took, you know, anybody. I guess in a way that made them want to pursue it. But I'm not saying that there can't be some like therapeutic uses for estriol. But it's not the hormone of the reproductive age. It's. And we don't want to replicate pregnancy, no way, no how. Pregnancy is a really risky time. You know, there's all kinds of things going on. You're both in a pro and an anti inflammatory state when you're pregnant. That's why you're more likely to have insulin resistance. You gain weight rapidly because you're in an inflamed insulin resistance state. And it's like fine line between when you go over the edge and then you become gestationally diabetic and all that. So the last thing we want to do is try and the gut microbiome changes. So you get leaky gut in pregnancy for the purpose of creating a low level of inflammation to create insulin resistance. So you put on weight and fat. You know, pregnant women can gain fat so fast even when they're not eating that much because they're insulin resistant to a certain degree. But that's not what, what the heck, we don't want that in menopause. Plus, women who are pregnant with all that estriol, they have more trouble dealing with infections because their innate immune system is downregulated. That's why if a pregnant woman catches the flu or gets chickenpox or when we had Covid, they have a higher risk of a worse outcome because their immune system is partially being suppressed. It's a very complicated state, pregnancy, and that's certainly not what we want to replicate for 55 year olds. And we're not going to anyway because there's nothing like giving bios. It's like pregnancy anyway. The hormone levels, the progesterone, it's like ridiculous, has nothing to do with pregnancy. So I'm not against estriol, but you make, and there's published papers showing that if you give adequate normal estradiol, if you give estradiol to a woman in menopause, her body will make estriol appropriately. So she'll have physiologic levels of estriol, not supra physiologic levels. It's like not. I'm a very simple thinker. I want to help women to have optimal hormones. Like she had a 25 so that her cells will work like she was 25. You know, as close as I can. Okay, I'm not going to create a new reality. To me, the biggest failure of trying to create a new reality by thinking we can outsmart nature is ultra processed food. Like how's that worked out for us? You know, trying to create hormone regimens that never exist in any human female that make literally no sense. You're trying to manipulate how hormone receptors are working and the balance of receptor function, function. It's like crazy like this. It just, it shouldn't even be considered as an option. It's not physiologic. It, you know, when you look at the science of how the receptors are working and what you can do if you have all that Estriol, you're going to make women who are in menopause more susceptible to infections. I mean, this makes no sense. And Estriol is not the estrogen that works like in the hypothalamus, that's alpha receptor. You're not going to have enough alpha receptor agonist. And that's what regulates appetite and a lot of mood. I mean, so what are we doing here? Let's just go simple. Give what the body had before back. It's so simple, not biased. And people, I think it got started like 30, 40 years ago, I think goes back 40 or no, even more than 40 years ago. And it was before we even knew the different hormone receptors. We didn't even know anything. So this has to end. We just have to try to. If we're going to give hormones, give it consistent with what the female body is designed to have.

B (103:57)

I think that's the perfect place to finish this conversation. You've been so generous with your time again and it's been such a pleasure. I learned so much. Thank you so much. So if people want to find more about you, you please tell us where they can follow your work, engage with you, tell us all the places.

A (104:14)

Well, I'm still working doc. I have a brick and mortar practice in Southern California in Irvine, where I see patients. This is actually a converted. What I'm in is a converted exam room. There's actually an exam table right over there. You can't see it. So I, I see patients. I'm still a working doc and I have a pretty lively YouTube channel and Instagram live where I try to give out information so that people can have the tools to make the decisions for themselves. Right. So that, and they'll have the right ideas so they'll be able to ask the right questions when they have their healthcare visits. And I have, I have three books and two on PCOS and one on menopause. Menopause. 50 things you need to know. And I hope to get more out, you know, in the near next year because there's so much to say, as we both know.

B (105:06)

Oh my goodness. We didn't even get to testosterone. We did not even get to testosterone.

A (105:11)

I know we need like a two day conference to get through all of this. I know. But at least, you know, hopefully everyone has an idea that estrogen is not a hormone, it's a family. And that it's not simple and that every organ matters and every organ has receptors. So at least they're going to walk away with, you know, the basic six so that they can now start making some good decisions.

B (105:35)

Fantastic. We'll make sure that all those links are on the show. Notes. Doc, you are such a firecracker. I admire you. Thank you so much for your time today.

A (105:43)

My pleasure.

B (105:47)

All right, all right, all right. Welcome to the after party where I tell you what I really feel about this conversation. And man and Dr. Felice, grr. She is a firecracker. She had so much to say. We went for about 90 minutes, like an hour 30, and I think I spoke maybe six times. So for all of those comments, I don't get many of them, but some comments sometimes that pop up that are like, can you let your guest speak? I feel like I think I gave you that gift today because Dr. Felice Gersh has a lot to say and. And, you know, I got a cut in a couple jokes, couple zingers. But she. She was here to educate, like, she had a mission, and she achieved it. So I really feel like this was a masterclass on estrogens. Like, we did not even. Guys, we did not even get. I had a whole thing on progesterone and testosterone and, like, the different types of androgens. Like, we didn't even get there. We spent. Like, I remember I looked at the clock and it was like 14 minutes in, and she was still explaining E1, E, E3, and E4. So estrone, estradiol, estriol, and estrad. So, by the way, Never heard of E4, this fetal liver estrogen before. That's in the birth control pill and some forms of menopausal therapy. That was fascinating to me. So now I have something to go and look up. I think my favorite. I mean, there's lots of favorites in this conversation. But I thought that it was interesting that the way that she described menopause was almost like this default pro inflammatory state. And at one point, she's like, there's only three groups of people that get dom. You know, estrone dominant. You know, it's like overweight people with excess adipose tissue, metabolically unhealthy people, and menopausal women. So it's like all those things don't necessarily overlap. Right. Like, you could be menopausal and not necessarily have excess adipose tissue. But it does seem like being menopausal does seem like it ratchets up your inflammation significantly. And as you know, if you remember, because she went like, guy, she totally went Dark Roast Betty on you. Like, I did not ask her to do that, but she was talking about alpha receptors, beta receptors, G protein, G coupled protein receptors. Like, she went hardcore deep roast. Right? Dark Roast Betty for you guys. I loved the conversation around all the. When we can. When we might think about considering hormone therapy and really in that decade before menopause. So you can start. And she said right at the end of the conversation, if you got that far. Of course you did, because you're listening to this. She was saying, you know, you can see changes in your face. Like, you can see the changes in the. In your body. So maybe, yes, a test but you can also see those changes in real time, and that might be the time where you start having the conversation with your pcp. So I loved that and I loved the. I love the conversation about vaginal estrogen in general. But for the face, I am asked this constantly, should we be putting estrogen, vaginal estrogen on our face? And I thought that she answered that really, really well. Gosh, so much stuff. Like, she was like, everything comes back to estrogen. She's very pro hormone. Probably because her clinical expertise spans, oh, gosh, probably at this point, 30 years, if I had to guess, 40 years. And I loved how she responded to me pushing back on her. So there was a point in the conversation where I said, hey, let me just be salacious for a moment. There's lots of people online that say, hey, the reason why the menopause society, or the reason why these bodies, these governing bodies, let's say, don't have statements around cardiovascular disease or bone disease, anything like that is because they say that there's no evidence. And she's like, oh, yeah, well, here's the evidence for that evidence, you know, so she was really, really well versed on that. And I really appreciated her answer and for her allowing me to really push back, because I see a lot of different sides of the conversation. I follow people online that I don't necessarily agree with, but I follow anyway because there's always going to be parts of what they say that I agree with, and maybe their delivery style, their bedside manner, their dismissive, egregious attitude, I don't agree with, but sometimes what they say is actually the truth. So I try to listen to a lot of different types of opinions and sort of mix and match those opinions and. And sort of land where I land, which is somewhere in the middle, which is often very extreme, doesn't get you a lot of clicks, but it is very nuanced. So. And that's why you listen to this show, Betty, because you are someone who is a true truth seeker. So that is what I really loved. The other thing I really loved was her comment about tubal ligation predicting early menopause. Like, I don't have any evidence to support it, but I think that there is a relationship there. So really appreciated that little clinical pearl. And I think my big takeaway, other than progesterone and estradiol are good for the skin, because y' all know me, I'm a. I'm a skin lover. Love, love, good skin care regimen is that, you know, the lowest dose is not necessarily the ideal dose. Like you don't just get five years to feel good on hormones and it's got to get be taken away from you. And even she had a throwaway comment at one point where she's like, you know, just take a little bit more estrogen and put it on your skin. You know, like it's more is always better, you know. And of course she doesn't mean like to infinity, right? There's obviously a bell curve that she's, she's referencing, but I think that she's a little bit more relaxed around hormone therapy because of her clinical experience around it and the things thousands of patients that she's, that she's cared for over the years. So I want to know what your big aha moment is. What did you think about this conversation? Is that going to change anything in your behavior? Did it change or did it give you a moment to pause and think about your own views on hormone therapy? Are you going to have any different conversation with your doctor next week? I want to know. So leave us a comment. Apple, Spotify, YouTube, read them all. And until next time, I bid you adieu. All right, all right. I hope you enjoyed today's episode and I must give you the obligatory legal and medical disclaimer here. This podcast, Better with Dr. Stephanie, is for general information only and the advice recommendations we discuss do not replace medicine, chiropractic or any other other primary healthcare providers, advice, treatment or care in the consumption of this podcast. There is no doctor patient relationship that has been formed and the use and implementation of the information discussed are at the sole discretion of the listener. The information and opinions shared on this podcast are not intended to be a substitute for primary care diagnosis or treatment. In other words, guys, be smart about this. Take it with a grain of salt. Take this information to your primary healthcare provider and have a discussion with him or her to make the best choice. That is for you. Remember, I am a doctor, but I am not your doctor, and these conversations are meant for educational purposes only.