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Dr. Sarah Daccarett - What Everyone Needs to Know About Perimenopause
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Welcome to How I Built My Small business. I'm Ann McEntee, your host and today's guest is Dr. Sarah Dacoret, a board certified physician, hormone specialist, and founder and CEO of Inner Balance, a personalized hormone therapy platform that just closed a significant investment round and a is scaling quickly. Dr. Sarah is on a mission to help women take control of their health while also highlighting the serious gaps in women's medical care and research. Today's episode is all about menopause, perimenopause, menopause and postmenopause and the physical, emotional and hormonal shifts that come with it. We talk about common symptoms, how they're often dismissed or misdiagnosed, and what women can do to start feeling better. Now, Dr. Sara's expertise is in hormone replacement therapy, so that's a big part of our discussion. But there are many approaches to menopause care and this episode is meant to inform, not prescribe. My hope is that it helps you feel more seen, ask better questions, and advocate for a path that feels right for you. This conversation is not medical advice. It's for informational purposes only.
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Women shouldn't feel like, oh, I'm 35, I'm too young to be going through this. That is not true. You could be 28 and going through it. It could be your genetics, it could be your environment, it could be your stress, like everything that's combining together to make your ovaries, fatigue or fail. There's no rule book that you should or shouldn't be doing this like your body is just doing it and you need to support it. So if they remember that, then they'll kind of take some of the shame away. Because I also think as we're aging, women feel more shame about this perimenopause, that they, they shouldn't be aging. That's not true. We need to age, but we need to support ourselves. Aging, a lot of the first signs and symptoms are ignored because one, it'll be like slow weight gain and then it'll be attributed to I'm not exercising enough or I'm not eating well enough. A lot of the early signs can be anxiety or stress, even depression or low mood. And then they'll think that it's just something like their job or their kids or their life or their husband or partner or whatever. And they don't attribute it to a drop in hormones. And then they'll even maybe start an antidepressant or an anti anxiety because. Because that's what they're offered. You know, Another early sign is insomnia. And the sleep disruption is fairly hormonal almost all the time. And so a lot of these early signs get missed. They get attributed to something else. They're told that they have leaky gut. Oh, I have all these food insensitivities. I have bloating. They say 90% of the population's bloated. Now, this can be drop in hormones that cause this bloating. Women will have high cortisol. That's an early sign. And then they'll say that all of their problems are from cortisol, you know, so you can kind of see how we will miss perimenopause for a very long time until she's going mad. And then finally her symptoms are so bad that we'll finally recognize and tell her that she's perimenopause in her 40s, but when she's actually been struggling for probably a decade. Autoimmunity women are like four times as likely to get it. And the hormones drop first, and then the autoimmunity comes. So autoimmunity is also an early sign that hormones are not optimal because our hormones are needed in a woman's body to boost and modulate the immune system. When autoimmunity presents, we should automatically be thinking low hormones, but we don't. They're going to their general practitioner, their ob gyn, their primary care physician and endocrinologist. It's like going to your dentist to ask about your back pain. You're going to a doctor that's not specialized. They have no idea what women need. Instead, need to be thinking is, when do I need to see a specialist? So this is like, you get what you pay for. You want to go to somebody who only does that thing. You know, if you're going to go to a surgery, you're only going to go to the surgeon that does that thing right. So women need to start thinking about hormones as an entirely different medical specialty. And they need to be thinking about it early, even in your 20s. Like, should we be getting baseline panels so that women know what their hormones are when they're younger? Probably because you can start to see the decline when they start feeling they lost that kind of vibrancy in life. They should be thinking about it, because hormones literally give us that life force that we need.
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And how do you help women distinguish between normal aging and symptoms they don't have to tolerate? So what's the line?
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We have to age, but we don't have to feel terrible while we're Aging. So we really have the choice of how we want to age now. You have to age, but you don't have to have joint pain, muscle aches, really heavy periods, painful periods, awful skin and hair bloating, weight gain, anxiety, depression, irritability, insomnia, vaginal dryness. I could go on and on. So as the ovaries start to fail and fatigue, what happens first is the ovaries cannot make progesterone, which is our main hormone. So then the brain freaks out, starts making fsh. FSH is a follicle stimulating hormone that will rise and it stimulates a feedback loop. So it'll stimulate the ovaries to try to make more hormone. But the ovaries cannot. They cannot no longer make progesterone in, like, reasonable quantities. And they can make, like, a spike of estrogen. And so women in perimenopause will feel somewhat of a roller coaster because they have no progesterone. And then they're getting these, like, wild spikes of estrogen. And then this goes on for a very long time, 15 years or more. Like, it could be that women will go through this where they don't have a lot of support from progesterone on their body. Their uterus is beginning to atrophy, for example, in the vagina and everything. Like all of the body starts to atrophy. And then you get to menopause. So let's say perimenopause is 15 years worth of your life. It's a long time. And then pause is one day. It's one day, but we spend a lot of time talking about it. Then postmenopause is just where there is essentially the atrophy and aging just continue. And we know that like Alzheimer's and osteoporosis and heart disease and cancer, and a lot of problems start. And aging, diseases of aging, like diabetes happen after menopause. But, you know, heart disease doesn't just happen overnight. Heart disease started in perimenopause when you were 35 years old. Right. And so we want to start to prevent heart disease and Alzheimer's and dementia and osteoporosis when you're 35, not be thinking about it when you're 51 and your period stops. Like, we don't wait until diabetes happens to treat it. We try to prevent it. Like traditional medicine tells women, if you're menstruating and you're perimenopausal, you need birth control. And then once your period has stopped for an entire year, then you can have HRT hormone replacement therapy. Birth control is a lot more risky. And it's not like bioidentical. It's synthetically made. I don't know why we on one would think that it's safer than our own hormones. So this is kind of a little bit twisted. Birth control should not be a hormone replacement therapy. It's not effective for perimenopause. That we should be giving bioidentical hormone replacement therapy. We can give it earlier. The earlier the better, you know. And so this thought is changing, and we're really getting more proactive about our health instead of reactive.
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But there also is a lot of disagreement still about the use of hormone therapy. Why is that?
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You know, I think that it's. People don't like change, especially doctors. Doctors are very dogmatic. They are resistant to that innovation. I think that's a big part of it. I think there's some underlying sexism that happens with women still, that they want to control women's bodies. This is still another opportunity to control what women are doing with their body. A lot of it is defensive medicine and based on fear. It's not based on science. So the resistance is because I am unwilling to look at the literature. I'm unwilling to learn about it myself. I don't want to say that I don't know. Doctors have a hard time saying I don't know. A lot of doctors don't like to admit that they don't know about hormone replacement therapy. And just like nutrition, doctors aren't trained in nutrition. So they'll just be like, nutrition isn't important. And so they'll just kind of undermine it quite a bit. And they're doing the same thing to hormones also. Another reason is because that women's health initiative that was published really did do a lot of damage. It was grossly misinterpreted. Mark Twain said that a lie will travel halfway around the world before the truth can put its shoes on. This is exactly what happened with estrogen and women and hormone replacement therapy. And when they held a press conference, which is unheard of for a study, we spent a billion dollars worth of taxpayer dollars on the Women's Health Initiative and told everybody that it caused breast cancer when that was not what the study showed. And doctors never forgot it. They saw it on the news and then just never bothered to learn about it themselves. And so we have an entire generation of doctors that forgot how to prescribe hormone replacement therapy. Women were told no. Moms told their daughters. And now women like our age are still Very confused, like, does it cause breast cancer? It doesn it. And I think our daughters will be lucky enough that they will not be in the same position that they will know that it's not that. So we're kind of in this transition phase where we're really trying to eliminate this bad press. We're blaming everything on estrogen, weight gain, cancer, like everything, you know, and that's basically telling women that they're the problem, that estrogen is the problem. It's the same thing. A lot of it's sexism too, in my opinion. A lot of the studies too, when you look at the science, they're done on these synthetic hormones, progestin, especially progestin. And it's not progesterone, it's not our natural hormone. And so when you look at mixed studies about it potentially causing, causing Alzheimer's or something, or heart disease or increasing blood pressure or stroke, those are from those fake synthetic hormones too, those studies. And even then, the risk is small. So I don't want to like worry anybody, like on birth control, but it's still like, hey, we have to recognize that bioidentical hormones, they're not patented, they're natural. We don't study them because big pharma doesn't have any interest in making money off of them. So they're not going to, they're not studied the way that we have thousands of studies on birth control. Doctors also need to recognize that it is a natural type of therapy that's not going to be studied at the time. Same, same extent that a pharmaceutical drug is going to be studied. But we, even then we still have hundreds of studies, so there's no excuse. I wish the doctors would say, I don't know, you need to go to a specialist. Instead, they'll tell patients just the wrong thing.
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Well, and these studies that you're referencing, aren't some of them like over 20 years old or so?
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Oh, yes. We have an 18 year follow up from the Women's Health Initiative. 18 years we followed those women. The same cohort, it's like 40,000 women, we followed them. And that study was published in Jamaica, the Journal of American Medical association, which is one of the most prestigious journals. And they showed that not only does estrogen not cause breast cancer, it protects against breast cancer. When I say that, that should be like on every news channel. Everybody should be talking about it. Every 40 year old should be on it to protect against breast cancer. The same people that were saying that it was dangerous are now being very quiet.
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Well, so what about people with a family history of hormone sensitive cancers though? I mean, how should they think about hormone replacement therapy?
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Their decision needs to be based with a provider on risks and benefits. The cancer cell has a receptor for estrogen and progesterone on it. That's a good thing. That means that the cell has not lost its signal like its normal signaling, that the body is able to like, control that cell. So when people say, like, I'm estrogen receptor positive, that's a great thing, actually, that's a really good thing because that means that that cell is not so malignant that it lost its receptors and is completely malignant and rogue in the body now. You know, with prostate cancer, for example, in men, and testosterone, if men have prostate cancer, we know that testosterone has the potential to make it grow. So we. They're not a candidate for hormone therapy at the time that they're being treated for cancer. When they're in remission and they no longer have prostate cancer, they are a candidate and can choose to take testosterone if they want to and they can be followed. Right. So we do this for men. Why? You know, again, it's about control. Like we are putting fear is a very good way to control women. Alcohol causes breast cancer, aging causes breast cancer. Lack of exercises causes it. These things are way bigger contributors. Right? We have a lot of environmental chemicals that are like fragrances and plastics and pesticides that bind to the estrogen receptor and cause cancer. And the idea is that you need to keep your body as healthy as possible and that will prevent disease. But women are going to more likely die from heart disease. One in like three women die of heart disease. But we keep talking about breast cancer when it's actually very rare compared to heart disease. And what protects against heart disease? Estrogen.
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It's an interesting perspective. I see where you're coming from and just how many differing points of view there are. So with hormone replacement therapy though, is there any, any physiological or psychological reliance that develops when you use it? Is there a dependency? So does your, does your body stop producing its own level of hormones once you come in and step in and start giving it?
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So this is an interesting question. The answer is yes. But that's also, you shouldn't be taking HRT if you're making plenty of hormones. If you no longer made a vitamin, you would just take it. You have to supplement something that you can no longer make. So when a perimenopausal woman is like, well, what if I'm going to suppress my own production? It's like what production? If they're making these wild spikes of estrogen, you can stop and suppress these natural spikes, give her, like, a stable level, she's going to feel great. So this is where, yes, I do want to suppress your own production, but does that mean that it's permanent? No. For example, we give women birth control and they get pregnant after that when we've completely suppressed their production. Birth control is not hormones. They're chemicals that bind to the hormone receptors and suppress your own production. And we give men testosterone replacement therapy. Most of the time you can take them off the testosterone, they'll start making sperm again. The same thing is for women. If you suppress their own hormone production and kind of you're suppressing the cycle in the brain, it usually can come back when you stop it if they're at an age where they can still ovulate. But I will say that hormone replacement therapy doesn't necessarily suppress ovulation either. I've had a ton of women get pregnant on hormone replacement therapy. Right. So it's really like how you're doing it. The formulation. This is not a drug. Right. This is not a pharmaceutical. The hormones are made by naturally. They're probably arguably the most natural thing that you can do. We don't make herbs. Like, we don't make black cohosh and dong kuai and ashwagandha. We make estrogen and progesterone. Is that a bad thing, to be dependent on my own natural hormones? No, it's about acceptance, women. It's not shameful that you're aging. Like, it's okay to accept that you're no longer making estrogen or progesterone and that you need to supplement and take it. It's okay. It doesn't mean anything about you. It doesn't mean that you're inferior to, like, your friend who's still making it. Like, it's not something to be ashamed of that you are dependent on having to take this supplement. Does that make sense? It's also a shift with the way of thinking about it.
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I like that perspective and argument because I do rely on ashwagandha and other adaptogens to just help me maintain my level of cortisol. And as you're saying, it's not something that my body naturally produces. And the bioidentical hormone replacement therapy is derived from plants. Is that correct?
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Yeah, typically, like, well, very rarely do you see something sourced from animals anymore. So really, estrogen is sourced from soy and progesterone is sourced from yam. And they're very highly regulated and so you know how much you're getting in a prescription, for example. And women want a natural treatment. And I do too. Like, I get it. Like, I wouldn't want to treat anything non natural naturally. They just need to start thinking about their own hormones as more natural than herbs. And herbs are great. Herbs are medicine. They have a role to play. But on top of the hormones, like, once hormones are your foundation, can I add in ashwagandha or maca or something else to boost my testosterone a little bit more or block a pathway? They're powerful. Like green tea extract is literally toxic to ovarian cancer cells. Women should be drinking green tea every day. So the herbs have their place. It's just not in place of hormones. Like, they don't replace a hormone.
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When it comes to women who either can't for one reason or another or don't want to take hrt, what are some non hormonal interventions that you could recommend that they could use to support their bodies during this time?
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Really hard to do. There's no way to either boost or replace the hormone that's missing. And when, when the receptors are free, you're more susceptible to environmental chemicals. So you would have to completely, like, eliminate every environmental chemical in front of you in order to maintain like some type of stability in the body and prevent cancer. But in the sense that you're eliminating gluten and dairy and a lot of grains, diet matters. And I know there's a lot of different theories out there. Women will do vegan diets and vegetarian diets, but it will actually make their hormones much, much lower. So if you're looking at, like keeping them a little bit higher to help with aging, protein is going to do that for you. Women are like, well, I want to do menopause because it's more natural. Just because it's natural doesn't mean that it's better for you. I have friends that are perimenopausal that don't want to do hrt, and I'm like their friend and could really optimize them. And they're still turning it down. And it's because they one, they just want to try it a little bit longer to do it themselves, but their diet is so restricted, they fall off the wagon one day and they feel it for like three days. Women who want to try to do without hormones really have to have everything so dialed in. It's a lot more challenging.
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Yeah, so it sounds like the hormone replacement therapy is kind of like a shortcut but there are options for people who are willing to do all of the different things for their hair, their skin, their nails, their cortisol, maintaining their level of stress and but it sounds like it's more work, a ton more.
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Work and a lot more money and a lot more everything. Like you're really going to be spending a lot of time doing it for sure.
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So just to go down that avenue a little bit because I know we've spoken a lot about hormones and I know that's your specialty, so you can stop me if you, if you don't feel like answering these. But outside of say multivitamins, what sort of daily supplements do you find to be most helpful for women who are in menopause or post menopause? Specifically for skin cognition and just overall vitality.
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So it is true. Like it not it is, it is like not just a hype. Collagen really does benefit women in a lot of different ways. And obvious, for the obvious skin and hair reasons, but also for the mental reason. So we need, as we age we need dopamine in the brain to be like alert and focused and have as much mental clarity as we can. And so the obvious to raise dopamine is estrogen. But if you don't want to do that, you need something to make dopamine really readily. And collagen is just like drinking straight amino acids that your brain can use and turn into dopamine. So if you do collagen in conjunction with like creatine and something like L tyrazine which is just an amino acid, you can effectively raise dopamine. You know there's other like natural things that raise dopamine like microdosing psilocybin is popular with some practitioners. You will work with you on that turmeric. A thousand milligrams of turmeric like the curcumin or will also help raise dopamine. Turmeric will also support a woman's immune system. So something like reishi and turmeric as she's aging because immunity like if you want to age well, like especially if you want to prevent heart disease and cancer, it's all about the immune system. Immune system is like key. So as I say, like hormones are the fastest and easiest and most effective. But if you're trying to boost your immune system, like turmeric will really help you. Glutathione will help boost your immune system and so will keeping and maintaining gluten free and dairy free diets will help you with your immune system system. So as we are more prone to autoimmunity as we're aging, I would still recommend these for autoimmunity. Even with hormones. I'd be like, turmeric, gluten free, dairy free, and glutathione. So glutathione is, like, so powerful. But NAD is also. So if you inject nad, and there's other ways to, like, raise nad, like these saunas. There's more longitudinal studies on sauna use and women and anti aging and prevention of aging signs with regular sauna use. So you definitely can get there. Like, if you were just look at the immune system, that would be like a collection of things that you could do for your immune system. For example, mushrooms are great. Like, reishi is my favorite. When you want to boost the immune system, it'll raise natural killer cells. Natural killer cells are what really survey the body and kill cancer cells. So if you're really interested in, like, preventing cancer, something like a daily reishi mushroom could potentially raise your natural killer cells and protect you. Look, your immune system is key to, like, really feeling well. And if you protect your immune system, you will feel this, like, lower inflammation in the body. And gluten and dairy are, like, one of the worst things to eat. So I would say anybody aging to avoid these two?
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Yeah, I'm already off of gluten and dairy. I know that it was a hard shift to make, but it's had a tremendous benefit to my health. So what about exercise? Like, what do you do? Or how important is resistance training and sleep and managing symptoms as well? Like, what can you say about this?
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So I tell women, like, I just want you to keep doing what you like doing. And then I'm going to try to support you so that you can keep doing what you like doing. Because I hate it when practitioners are like, okay, you got to stop running. I know you're a runner, but you got to stop. And now you got to, like, lift really heavy weights and, like, completely shift your entire routine now that you're menopausal. And this is, like, kind of devastating for a lot of women because not every woman's into, like, lifting heavy weights and they feel like they have to make a shift when they would like to do Pilates and yoga and running and hiking and, like, some of the other stuff that they naturally have been done doing their whole life. So they've been able to maintain their weight and their health, like, just by doing the cardio. Cardio or whatever they were doing before. I don't really care, like, whatever you liked doing and you're gonna do is what we need to keep you doing. But that being said, like, if you're not going to do hrt, you are going to rapidly lose muscle because this what helps us maintain our muscle, our hormones. So you have to be aware that if you're not going to do hrt, they will decline. And this means more protein and more resistance training. I would say if you're going to do HRT and stay on good HRT regimen, it's less important. Like, you're going to maintain your bones and your muscles without, like the extreme heavy lifting, which although it's still good for you. Like, I would. The more muscle mass we have, obviously, the better off we are going to age. So.
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And what about creatine? I know you mentioned it before, but how do you feel about women taking creatine regularly?
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I think it's more for, like a mental clarity. If you supplement with creatine, you only take a little bit, whereas you have to eat like a ton of meats to get like the same amount of creatine. I wasn't on the bandwagon for a while. I was like, there's no way that works. But I actually started taking it for mental clarity. I'm like, okay, maybe, maybe there. I get it, I get it. Because it's hard to eat that much meat, I think is the problem. So the supplementing really helps you get, like, the core nutrients that are in the meat that you don't really feel like eating all the time. So I do think it helps with mental clarity. And I think anything that you could do to help with recovery is obviously going to help. Like nad. NAD really helps with muscle recovery. NAD is a, like a molecule that is for the powerhouse, then mitochondria of the cell. And you can inject it. It's a peptide that people readily inject. And it helps with, like, mental clarity. It raises dopamine in the brain, helps organize the immune system. It activates SIRT1 pathways, which are longevity genes. Then you can raise NAD by getting in the sauna. So you can still do it. Like, NAD is more expensive to inject, or you can just, I guess, do it in the sauna. But these help you live longer, they lower lipids. Like, there's a lot of research on NAD to show how beneficial it is, and it helps with muscle recovery. Women should be keeping their blood sugar as stable as possible. If you focus on like a fat and a carb and a protein so that you are keeping a stable blood sugar this really helps with perimenopause and menopause in general. Whatever diet you choose, keep your blood sugar really stable. Sugar spikes will cause a change in fluctuation in hormones, enough for you to feel it. And if they eliminate sugar and they just keep their blood sugar really stable, then their mood is also stable. Even if you're on hrt, I would say women, if they can keep your blood sugar stable, our moods and periods and everything are very much connected to blood sugar. Like we need to stabilize it and balance it. And that's another key to like aging and feeling great as you're aging is keeping these stable, unfortunately, because it's like I want to eat all the good stuff too.
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So what about the long term effects of using hrt? Is there any data to say what the long term effects may be?
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There are conflicting studies, but I would say that overall the benefits outweigh any risks. And this is really what women need to think of it because nothing in life is risk free. The most dangerous thing you can do is get in your car, go drive on the highway. That I'm never going to give up driving on highway because it gives me the benefits. And so every time we make a decision about anything, especially medication or something we're going to do forever, it needs to be a risk versus benefit conversation in your head. I think the longest study we have is like 18, 20 years. We don't know what that antidepressant is going to do for 40 years. We don't know what that stimulant that you're taking for ADHD is going to do. Is that going to give you Parkinson's when you're an old person? Right. So we don't actually have those long term studies. And women will take Xanax and birth control. They'll take it for a decade. We're doing a lot of things in medicine that we don't have studies for. We don't need the study to see support the long term abuse. The question is what are the risks of not doing hormone replacement therapy? Because they're big. If you do not do hormone replacement therapy, your risk for osteoporosis, dementia, Alzheimer's, colon cancer, potentially breast cancer, heart disease, urinary tract infections, yeast infections, urinary incontinence. They go up dramatically when hormones drop. People are asking the wrong question. They're asking what's the risk of taking the HRT long term? The question actually is what are the risks of not taking the HRT long term? And they're big.
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B
That's really interesting. So for the men that are listening in, partners, sons, colleagues, what do you wish that they better understood about women that are going through this phase of life and how can they support them?
- [25:33]
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Men can encourage. If their wife wants to do these things that we're talking about, they're not hormones, but like she wants to do the diet, she needs to take care of herself and she wants to set that aside and make it a priority. Spouses can be hugely supportive of women knowing that they might need a little bit of space if she's still cycling a certain time of month. He could be very helpful during that time and just understanding that we do not have stable levels of hormones and they do and they don't get it. And it's okay that they don't get it, but they can be very supportive of whatever she wants to do. I think that's just the key. It's like whatever her decision is, he can be on board with it and then also be a little bit patient knowing that it's not him, you know, because I think they internalize it because they're, you know, sorry guys out there. It's not being self centered, but it's not always about you. And so they, he can just recognize that it's not about him. It's something that she needs to just figure out and it can take some time. Like women will spend one or two years or more trying to feel better. She can do that and spend a lot of money at the same time trying different things and seeing what works for her. And I think a spouse may not understand that and he can just realize that that is true, that she needs to be doing that. We'll treat men with Viagra and testosterone all day long. But we will tell women when she comes into the doctor's office and complains of low libido or vaginal dryness or sex is painful, she's told to like use some lube and read a sexy novel and like go date your husband. You know, this is really unfortunate, so downright criminal that we would give a man Viagra and testosterone and not treat his wife. I think for relationships that men need to be a little bit more like understanding of like and help and supporting their wife that hey, your wife, it's not because she's not into, you know, her hormones are low and she needs some like, if she doesn't want to have sex with you, it's not because of you or your relationship. She needs like help. And this is a health problem. She needs to like get her estrogen up so that she can have sex with you. And so if he stops internalizing so much, I'm thinking it's his fault. Because I've had. I've had male friends tell me this, that they're just like, I just thought she didn't have sex with me. You know what I mean? I just thought that she wasn't into me. And it's like, it's not about you, dude. And they're like, I know it's really hard, right? And so. But if they recognize that it's a hormonal problem, they're going to be a lot more patient. This is so, so such an everyday thing for relationships.
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B
Well, so this also makes me think just about accessibility. Is hormone therapy a luxury or is it essential enough that it should be considered a basic right for women's health?
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A
I think that's a great question. I love how you phrased it. I've never heard it that way, but it's, like, amazing that you say it that way. It should be a right. It should be democratized. Like, it should be accessible. It should be easy with no gatekeeping. It's safe. It's safe for them to try. If it works, it works. If it doesn't, it doesn't. You know, it's kind of one of those things that it's like a supplement. If it doesn't work, then they just stop it. You don't have to keep doing it. It's not like this right now. I would say that it's a luxury. You have to go to these really expensive longevity doctors who know what they're doing, and it's like thousands of dollars. They're going to charge you a lot for labs. They're going to have you do it quarterly. And so when I started my company online, the idea was to make it more accessible. What if you're in a really small town, like, I'm in, you know, a small town in Idaho? Like, what if you're in Montana, North Dakota, and you don't have access to the LA longevity docs? Or even if you're in LA and you don't want to spend 10 grand? And so we're in 44 states and soon to be 50. And the idea is that, can we make it a price point that is more affordable because it's going to be out of pocket no matter what. I think that's also what women want, health insurance to pay for it. And they don't understand that health insurance doesn't see your perimenopause as medically necessary to treat. Like they're just like they have to wait until you're like menopausal. A lot of times insurance sometimes covers it, I should say that. But they're going to be limited in what they do cover and how much they cover. So women just have to get kind of used to the idea that for a while it's going to have to be out of pocket. Doesn't mean it's be forever, but for the next few years probably will be out of pocket. And can we do that? There are a few online companies that are trying to make it more accessible.
- [29:15]
B
For women who are thinking that they're in perimenopause or they're in menopause. They need some help. They want to consider hormone replacement therapy. What is the next step? Do they go and get a test to see what their levels of hormones are?
- [29:30]
A
So the problem with the testing is one, there's a lot of analytical and biological variability. If they come back abnormal, then you have some supporting evidence that you're not going crazy. It's not in your head. But I think what tends to happen is that we only rely on the laboratory testing. And then women are dismissed saying that your labs are normal. And this is the problem. They'll use the lab if it's supports them. But symptoms should always trump a lab test. For example, the best lab test might be to get is actually an fsh because we mentioned that FSH will continue to rise. So even if your estrogen and progesterone are like kind of normal, every time you get your cast and you're going crazy because every time you get a test, everything's normal, but you don't feel normal. But that FSH is like slowly getting higher and higher. That should be like your key that you're perimenopausal. You are better than any lab test, you know, better than any physician. You're the one that has to live with yourself every day. So if you don't feel well, you're the one that needs to take action on it and get help and be proactive. Right? No doctor is going to do that for you. You have to do it. You need to find the doctor that's not going to turn you in. Say no. That's the problem that doctors are like, no, your labs are normal. It's because they're always going to be a little bit normal until you're menopausal. Because we have not developed this comprehensive lab test that's really that good. We have metabolite Testing in the urine. We have an fsh, we have some genetic testing. Like you can test comt and look at metabolism so that you can get like a bigger picture. But very few practitioners will do this for you. Instead they'll just get an estrogen level. Oh, it's normal. You're from your normal. You're too young to be experiencing this. And so women need to just know that. You can get a panel of lab testing and it could be abnormal, but it could also be completely normal. So I think in general, a lot of practitioners are now saying that, look, perimenopause is a clinical diagnosis, it's not a laboratory one. So you have to work with somebody who's willing to just say, hey, the hormones are safe. You can try them. If you, if you just have weight gain but you feel fine, you have a really crappy diet, okay, then change your diet. Try that first. If you're gaining weight and your hair is falling out and your skin looks terrible and you can't sleep and you have anxiety, you have like 10 or 15 symptoms together and you're like food sensitive and you know what I mean? There's just all this stuff that you're like, I just don't feel like it's right. No matter what I do, I just feel terrible. This is hormonal at its core because the hormones basically regulate every pathway in the body. And so you are going to get a lot of symptoms at one time. That's a good rule of thumb. If I just have one thing going on, maybe I could just try to address that one thing. But if you have a lot, sometimes I'll just like, want to look at the lab, you know. But then I'm like, okay, let's put the labs aside and like, tell me what's going on with you, because I can do a much better job just hearing what your symptoms are and what bothering you the most. Because she will tell you exactly what you need to know. The labs are kind of like one snapshot in the day, and they're maybe not even accurate, but like, she will tell you what she's been going through. And this is so much more powerful to listen to than a lab test and providers. And everybody gets so wrapped up in this, like, data driven. But they need to understand how hormones are. There's a wide therapeutic range. They're. They're all over the place in the body. And so labs are not quite as helpful as some of the other. We can get labs like on heart disease and LDLs like that. That's reliable. Like your LDL is what it is, but your estrogen level, take it. An hour later, it'll probably be different. Take it. The end of the day, it's going to be completely different, you know.
- [32:39]
B
Oh, interesting.
- [32:40]
A
Yeah.
- [32:40]
B
And labs are downstream. And then also, as you were saying, it impacts you differently than it will impact me and all of our friends.
- [32:47]
A
Exactly. So even though, even if your hormones, like, are a certain level, you might feel okay because you're also doing a lot of different things, like with your adapt, you know, you have like your stuff dialed in. You're gluten dairy free, you're doing like a lot. So you may not feel as terrible as, like someone else. So it's also, the labs are, you know, you should, I shouldn't force you into some reference range and then say that you should be feeling okay. It's all like, it's an open system and your diet and genetics play a huge role. We just need to be listening to women.
- [33:16]
B
So just as a closing question here, if you could leave women and the people who love them with one message about this phase of life, what would it be?
- [33:24]
A
It would be that, like, it's going to be, it could potentially be like the best time of your life. Like, you could have the most enjoyable time where you're set in your career. You have kids, you have like your partner, you have financial security, most of us. And you can look good and feel good and there are like, things that you can do and sometimes it takes all of them, but it's possible. So like, don't ever let anybody tell you that, like, this is how you have to feel or this is the way it is just being a woman or we have to age a certain way. You get to choose that we have the choice and capacity and control of how our journey looks like. And so just take control of it. Like, it's your responsibility to make sure that you, you take care of your body. And the body is so intelligent and how they can actually heal. So if you're suffering from something and you don't think it's ever going to get better, like, I just, this is just the way it is. And this is how I'm going to feel like this forever. That's not true. The body has the ability to heal. If you give it the foundation and the building blocks that it needs, whatever that is, like, you give it to it, the body will get better. And so it's, it's remarkable. Like, and so it's a positive note, like menopause and perimenopause are not about suffering. We don't need to get together as women and talk about our symptoms and how how much they're suffering. In fact, we should be able to stop all of it. And there's hope. It's like a very hopeful, like instead of this is like a miserable time. It's actually not. It shouldn't be.
- [34:40]
B
Well, Dr. Sarah, thank you so much for coming on and sharing your insights with us. I've never spoken with anybody about perimenopause, menopause or post menopause and so I've learned a lot from listening to you.
- [34:50]
A
Thank you for having me. Really had a good time talking to.
- [34:57]
B
Today's Key Takeaways Perimenopause can start earlier than you think. Hormonal decline might begin in your late 20s or early 30s, not just your 40s. And the symptoms often look like other things. Anxiety, fatigue, mood swings, insomnia, bloating. We blame stress, parenting, food sensitivities, when really it might be your hormones. Even if your labs are normal, your symptoms are real, hormone levels fluctuate and blood tests are just a snapshot downstream from your actual experience. If you feel off, that matters. Perimenopause is often best recognized through your lived experience and not a lab result. Autoimmunity might be a sign of hormonal decline. Women are far more likely to develop autoimmune issues, and hormone shifts can play a role. If you're dealing with autoimmune symptoms, it may be worth exploring your hormonal health. Estrogen and progesterone aren't just about reproduction. They support your brain, bones, heart, mood, metabolism and immune system. When introduced appropriately, HRT may help reduce long term risks of heart disease, osteoporosis, dementia and more. We don't make men wait, so why are women told to? Men don't have to wait for testosterone to fully disappear before getting support. Yet women are often told to wait until a year after their last period to even consider hrt. The fear around estrogen is outdated. The original Women's Health Initiative study was widely misinterpreted and caused decades of fear. But long term follow ups, including one published in jama, found that estrogen may actually reduce the risk of breast cancer. There are other ways to support your health, but they take more effort. Diet, supplements, adaptogens, collagen, creatine, sauna, resistance training. All of these can help, but they require a lot of consistency. HRT for many is a more efficient way to feel well because it restores what your body used to produce naturally to the partners out there. This isn't about you. When the woman you love starts to shift physically, emotionally, sexually, it can feel personal. But it's not rejection. It's not distance. It's biology. And your understanding, your patience, your support is everything. Relationships thrive when women feel seen and backed. Aging is a part of life, but suffering through it is not required. That's it for today. I release episodes once a week, so come back and check it out. Have a great day.