The Truth About Hormones: Why Every Woman Should Consider Menopause Therapy

Summary

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The Dr. Gabrielle Lyon Show

Episode: The Truth About Hormones: Why Every Woman Should Consider Menopause Therapy

Release Date: September 9, 2025
Host: Dr. Gabrielle Lyon
Guest/Co-Host: Nick (implied, not fully introduced in provided transcript)

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Overview

This episode offers a frank, science-based discussion on women's hormone health, focusing on menopause and perimenopause. Dr. Gabrielle Lyon and her guest break down misconceptions about hormone replacement therapy (HRT), outline the risks of outdated research, explain strategies for hormone management, and urge women to actively participate in their health decisions. The show advocates for informed, empowered conversations with healthcare providers, emphasizing that all women will experience menopause and thus must be equipped with up-to-date knowledge and actionable advice.

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Key Discussion Points and Insights

1. Why Hormone Therapy Matters for Women

• Universal Impact: Every woman will go through menopause, but most receive inadequate treatment due to old studies and persistent myths. This is in direct contrast to men, many of whom are treated for low testosterone even though not all experience it. [00:03]
• Dramatic Drop in HRT Usage: Since the 2002 Women's Health Initiative (WHI) study, hormone therapy in women dropped 30%, from 26.9% to 4.7%. [02:35]/[02:39]
• Quote:
  “The Women's Health Initiative did more damage to women's health and hormones than any other single study in history.”
  — Dr. Lyon’s Guest [00:08]

2. Common Symptoms of Menopause and Hormone Deficiency

• Core symptoms: Hot flashes, joint pain (including frozen shoulder), brain fog, sleep disturbance, mood changes, and changes in blood lipids are commonly linked to low estrogen. [01:28-02:56]
• Underrecognized Symptoms: Musculoskeletal pain and sexual dysfunction often misattributed to aging or overtraining, rather than hormonal shifts. [02:16]

3. Flaws in the Women's Health Initiative (WHI) Study

• Wrong Medications Studied: WHI used Prempro (synthetic estrogen and progestin), not the bioidentical estradiol and micronized progesterone advocated today. [03:48]
• Misinformation Fallout: Mass hysteria and fear of cancer and blood clots led to HRT’s sharp decline, with millions of women suffering needlessly from untreated menopause symptoms of osteoporosis, dementia, and more. [02:56-04:59]
• Quote:
  "The average age of enrollment, by the way, for the Women's Health Initiative was 63. That's 12 years past normal menopause."
  — Dr. Lyon’s Guest [04:41]

4. Testing and Diagnosis

• Proper Assessment: Holistic hormone panels include estradiol, total estrogen, progesterone, FSH, LH, total and free testosterone, sex hormone binding globulin (SHBG), and DHEA. It's essential for providers to test these for accurate understanding and management. [05:38/07:18/27:34]
• Blood Work Frequency: Baseline, then at 4-6 weeks after starting therapy, and again at 3-4 months. Adjustments should prioritize symptom improvement over strict lab values. [40:43]

5. HRT Delivery Methods and Practical Tips

• Estrogen: Transdermal patch preferred for most; oral and injectable routes also discussed. Absorption and compatibility are individual—patches may not stick in hot climates or with excessive swimming. [10:09-10:39]
• Progesterone: Micronized oral progesterone for sleep, especially in perimenopause or with sleep issues. Creams not preferred due to inconsistent absorption. [19:27-20:56]
• Testosterone: Often started as subcutaneous or intramuscular injection at 1/10 male dose (5-10mg/week typical). No FDA-approved products for women; typically used off-label. [15:29/41:54]
• Vaginal therapy: All women should use vaginal estradiol cream, possibly with testosterone or DHEA, to prevent atrophy, UTIs, and improve vaginal flora. Compounded formulations are often necessary. [22:32/23:03]

6. Role and Stigma of Testosterone for Women

• Benefits: Enhances sex drive, muscle mass, and recovery. Indications are broader than just hypoactive sexual desire disorder (main official use).
• Misconceptions: Fear of side effects (acne, hair loss, voice changes) mostly unfounded with proper dosing and monitoring. [14:40-15:15]
• Quote:
  “There is no FDA-approved testosterone for women... I was shocked at how little data is out there.”
  — Dr. Lyon’s Guest [13:13/13:46/13:51]

7. Lifestyle & Non-Hormonal Factors

• Importance of Muscle Mass: Skeletal muscle mass, diet, and physical activity can mitigate some symptoms and are especially important in conditions like PCOS (polycystic ovarian syndrome).
• Supplements: DHEA useful, especially for libido or vaginal atrophy (e.g., Intrarosa, an FDA-approved insert for painful sex in postmenopausal women). No “hormone balancing” foods or supplements are legitimate substitutes for replacement in deficiency. [26:27]

8. Navigating the Medical System and Advocacy

• Finding a Provider: Women are encouraged to find proactive, menopause-literate clinicians, especially if dismissed or told “you’re fine” despite disruptive symptoms. Immediate provider change often recommended. [30:13-30:19/32:14]
• Professional Organizations: NAMS (North American Menopause Society), Endocrine Society, and ACOG provide directories of trained specialists. [33:54]
• Quote:
  “Part of being a physician… it's a team sport. If someone is coming in and saying, ‘Hey, I'm not feeling well,’ you need to listen.”
  — Dr. Lyon’s Guest [30:16]

9. Risks and Monitoring

• Risks: Must weigh risk of breast/uterine cancer, blood clots (mostly oral forms), genetics, and personal factors. Transdermal (patch) estrogen much safer with respect to coagulopathy than oral. [43:51-45:03]
• Routine Screening: Mammograms, uterine ultrasounds, and comprehensive risk assessments are part of best practices, alongside regular hormone labs and symptom tracking. [45:03]

10. Addressing Myths and Future Directions

• No “Cure,” Only Management: Menopause cannot be prevented, but symptoms can be greatly alleviated with timely and appropriate hormone therapy—"waiting" is often unnecessary, as symptoms do not resolve on their own. [08:55/34:40/35:03]
• Preventive Framing: Early intervention supports bone, cardiovascular, cognitive, and sexual health. Waiting for “disease state” can leave women unnecessarily vulnerable. [32:56]
• Quote:
  “If you treat these things early with velocity, then your chances of living a long healthy life...increases.”
  — Dr. Lyon’s Guest [32:56]

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Notable Quotes & Memorable Moments with Timestamps

• “All women should have vaginal estrogen. And when they are entering perimenopause, vaginal estrogen with also testosterone will prevent vaginal atrophy.” — Dr. Lyon’s Guest [00:45]
• “I was shocked at how little data is out there [on testosterone for women]. We’re working on a safety profile study to really help move the needle for people.” — Dr. Lyon’s Guest [13:51-14:00]
• “Not all men will suffer from low testosterone. All women will go through menopause.” — Dr. Lyon’s Guest [06:27]
• “For a woman going on testosterone, I think it’s really important to manage expectations. We typically don’t see a change in body composition if that’s all you’re doing... as opposed to, say, a male.” — Dr. Lyon’s Guest [17:36-18:13]
• "Estrogen therapy is very safe... Menopause hormone therapy considerably lowers risk of hip fractures." — Dr. Lyon’s Guest [37:17]
• “Only 1.8% of women over 40 are using hormone therapy for menopause, even though 100% will go through menopause.” — Dr. Lyon’s Guest [38:16]
• “If a provider immediately shuts you down, go find another provider—immediately.” — Dr. Lyon’s Guest [30:13-30:15]
• “There’s a lot of information that’s taking a long time to get up. Women are not nearly as studied as they should be. It’s embarrassing.” — Dr. Lyon’s Guest [31:07]

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Key Segment Timestamps

• Intro to why men get more treatment than women: [00:00–00:39]
• Symptoms of low estrogen: [01:22–02:56]
• Impact and myth of WHI study: [02:35–05:19]
• Hormone testing and assessment recommendations: [05:29–07:53]
• Birth control’s impact on hormones: [07:18–08:46]
• Natural vs. medical menopause solutions: [08:46–10:24]
• Preferred HRT delivery systems: [10:23–12:38]; revisit [41:53–43:14]
• Testosterone for women; rationale, dosing, stigma: [13:07–16:56]
• Body composition and menopause: [17:15–19:22]
• Progesterone for perimenopause & postpartum depression: [19:27–20:56]
• Vaginal hormones and compounded creams: [22:32–23:03]
• Women’s advocacy and finding the right doctor: [30:13–33:54]
• Addressing risks, screening, and delivery methods: [43:51–45:24]

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Conclusion

The podcast calls for a radical rethinking of menopause treatment—insisting that the vast majority of women are left suffering due to outdated medical beliefs and unnecessary fear. Rather than wait for symptoms to worsen, women should seek proactive care, understand their options, and demand engagement from their providers. Combined with lifestyle changes, the right hormone strategies can dramatically reshape health, vitality, and wellbeing across every phase of womanhood.

Dr. Lyon and her guest make clear: being informed, assertive, and open to change is necessary for every woman facing menopause or perimenopause, and the medical community is (slowly) catching up to these needs.

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For further resources:

• North American Menopause Society (NAMS)
• Endocrine Society
• American College of Obstetricians and Gynecologists (ACOG)
• Dr. Lyon’s practice: Strong Medical

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Note: This summary omits ads, sponsor segments, and non-content material to provide the most direct, actionable insights from this episode.

Transcript

[A]

You're giving your female patients testosterone?

[B]

I am.

[A]

Why are you giving them testosterone?

[B]

There is no wow. Not all men suffer from low testosterone. All women will go through menopause. From 1999 to 2020, menopause hormone therapy dropped almost 30%. So the women's Health Initiative did more damage to women's health and hormones than any other single study in the history. When someone is in perimenopause, should they wait? I hear a lot of people say, well, I want to wait. Wait for things don't get better. I see a lot of providers putting patients on estrogen cream. We don't recommend it.

[A]

Every female listening to this podcast needs to be taking notes and considering this, no matter where they are in their.

[B]

Life cycle, all women should have vaginal estrogen. And when they are entering perimenopause, vaginal estrogen with also testosterone will prevent vaginal atrophy. Women are not nearly as studied as they should be. It's embarrassing. It's actually embarrassing how little we know about women in relation to the science of this stuff. We cannot stop menopause or perimenopause, but we can get ahead of it. Just for the ladies out there listening, we're never going to treat menopause. It's happening.

[A]

Gabrielle, want to talk about estrogen? What are the most common kind of signs and symptoms that a woman is low on estrogen?

[B]

Number one, you won't believe this, and this might be very surprising, but when a woman is going through perimenopause, one of the first signs, she will be getting hot flashes. You've heard about hot flashes? Maybe you've even seen it. Have you ever seen a hot flash?

[A]

I have not.

[B]

You know, we live in Texas, and it's very hot here, but before moving to Texas, I was in New York and nobody was walking around with little. Those handheld fans. Have you ever seen that?

[A]

I know, yeah, the handheld fans, sure.

[B]

Sign and symptom that a woman is going through menopause. Okay, yeah. No, not funny, but true. One of the most common signs or even symptoms that a woman is low in estrogen, hot flashes. Also joint pain, believe it or not, frozen shoulder.

[A]

Frozen shoulder, yes.

[B]

And I learned this from Jocelyn, Dr. Jocelyn. She's an orthopedic surgeon who was recently on the show. And I didn't realize that when women are going through musculoskeletal pain, it's not just over training. Go figure.

[A]

Then why aren't more women on estrogen?

[B]

Well, I've got actually some numbers here for you. Are you ready for this?

[A]

I am.

[B]

Okay. From 1999 to 2020, menopause hormone therapy dropped almost 30%. Why is that from the Women's Health Initiative? So it was 26.9% down to 4.7%.

[A]

Holy smokes.

[B]

Yes. So the Women's Health Initiative did damage to women's health and hormones than probably any other single study in the history. You thought castrating men? Yes, because you thought castrating men was bad. The Women's health initiative left 20 years of women from being treated for menopause. Meaning you asked me what the signs and symptoms are. Hot flashes, brain fog, mood, poor sleep. All of these things can be contributed to low estrogen, not to mention change in the lipid profile. A woman's life who is going through symptoms of menopause is, again, it is so challenging, and I've seen it, and it really affects their lives.

[A]

Can you explain for the audience the Women's Health Initiative that was looking at the relationship between estrogen and cancer?

[B]

If I remember correctly, the Women's Health Initiative did a number of things. And the thing about the Women's Health Initiative is it used Prempro. It didn't use estradiol, which is what we now use, so Prempro, and then it used a synthetic progestin. They found that it increased the risk of cancer. And it was, for example, I'm looking at this here, higher risk of thromboembolism, stroke, and breast cancer. When that happened, they created a mass hysteria, and it really turned people away, everybody.

[A]

So the baby got thrown out with the bathwater.

[B]

Everything got thrown out, which I think is devastating because we're seeing rates of osteoporosis and dementia, Alzheimer's, dementia, in at rates we haven't seen before. And it could have been prevented. The average age of enrollment, by the way, for the Women's health initiative was 63. That's 12 years past normal menopause. A woman typically begins perimenopause, and perimenopause is a big term. It's around menopause. A woman could have these symptoms for 10 years.

[A]

Wow.

[B]

Yeah. Really, really bad. But the thing is, is that the Women's Health Initiative equated this Prempro and synthetic progestin with hormone replacement therapy, and it really turned people away.

[A]

So just to be clear for the audience, they should not use that as a reference point.

[B]

No. It dropped hormone replacement or menopause replacement therapy by 60%. It left millions of women under treated.

[A]

So now that the audience have been educated and we're looking at this. What are some of the options, what are some of the delivery options for a woman who's considering going on estrogen?

[B]

Well, first of all, you don't do estrogen alone. You go to your provider, you get total estrogen, estradiol, progesterone, you get FSH and lh. Typically those numbers will increase, they'll become high when you are in menopause and around perimenopause, they'll be all over the place. Testosterone. Testosterone, yeah, free testosterone and sex hormone binding globulin, all of which are important. These hormones are so important for women, not just for brain and bone and heart health and of course lab values, but also vaginal estrogen. One of the things that I hear all the time in my clinic and strong medical is that sex becomes painful or women are getting more UTIs, and then to top it off, they also can't train and are gaining weight.

[A]

Wow.

[B]

Yeah, it's interesting. Not all men will suffer from low testosterone. All women will go through menopause.

[A]

And yet from based on statistics, a smaller percentage of them is going to get treated than men. Despite the fact that every woman listening to this podcast is either going to experience this or experiencing this now, or it's only a matter of time.

[B]

Yes, you would definitely go. If you are a woman, you will definitely go through menopause. And now we're seeing a resurgence of the conversation around menopause, which is so important in perimenopause because there's a lot of myths out there and especially with the delivery system for fertility and for pregnancy. So if a woman doesn't want to become pregnant when she's young, she's typically put on birth control.

[A]

Yes.

[B]

Birth control will increase sex hormone binding globulin, which, think about it, hormones are like kids. So we have kids, both of us. We do, we do. And they can't go anywhere alone. Same with hormones. Hormones don't go anywhere alone, but when you increase sex hormone binding globulin, you make free hormones less available, which means from a young age, if women go on birth control, then she will likely require, for example, testosterone to have a higher dose of testosterone than she would normally to get the same result.

[A]

Wow. I don't think that's discussed a lot.

[B]

No, what is definitely not discussed is that birth control, while important, that when you are taking an oral agent, it can affect the microbiome. Actually, we worked on a study with the legendary I'll Roll My Eyes, Andy Galpin, Kristen Holmes, we just recently published a study on that.

[A]

But I Saw that.

[B]

Yeah. It affects the microbiome. Also will irreversibly increase sex hormone binding globulin. And again, someone will say, well, isn't preventing pregnancy important? Yes, but there are other ways to do it, like an iud, which is the Mirena, a non hormonal iud. If a woman is entering perimenopause and is starting to get increased bleeding, an IUD can be very helpful if she doesn't want to take the pill, which personally I don't recommend. But again, you have to look at your blood work.

[A]

No, that's, that's great. Hormone replacement therapy isn't an option for somebody. Are there, are there any natural treatments that women for menopause.

[B]

We're never going to treat menopause. It's happening.

[A]

Ah.

[B]

You're never going to stop it. And I was recently at this amazing event. I went to a place called Newtopia, which actually I came over to your house to practice this talk. And it was this talk about conscious consumerism. One of the things that I kept seeing was take this for hormone balancing. This food for hormone balancing. That's the wrong message. Hormones being, quote, balanced. What does that even mean? The outcome that we're looking for probably in younger women is fertility. Polycystic ovarian syndrome is the number one cause of female infertility, which in a large part is related to the health of skeletal muscle. No amount of supplements is going to fix that, but a good diet and training regimen will help, which again, I know that we're talking about menopause and hormone replacement therapy. Estrogen and progesterone and testosterone are not used to treat body composition for menopause, which people will say, I'm going through menopause, my body is changing. Estrogen should never be given alone. It should always be given with progesterone. Progesterone protects the uterus and the endometrium delivery systems for estrogen. Someone listening to this? Our number one delivery system that we like in the clinic is an estrogen patch. Now, we live in Texas.

[A]

Yes.

[B]

Which means it's hot and if you are swimming a lot and going in the sauna, you might find it's not great for you.

[A]

Then, then what do you do? Yeah. So if, if you're using an estradiol patch. What's, what's. You mentioned one mistake. You avoid swimming a lot.

[B]

A great question, actually. I called Dr. Rachel Rubin. I don't know if you know Dr. Rachel Rubin. I do think she listens to this podcast. Rachel, I'm looking forward to seeing you at the North American sexual medicine meeting. But she said she'll use injections and if someone cannot tolerate a patch than potentially an estrogen injection. I think that it's a little volatile for people, but estrogen patch is the number one way to go. People ask me all the time what kind of protein powder I use. And in order for me to feel comfortable recommending a brand, I need to know it is clean and transparent. And that is one reason why I love one of the sponsors of the show, Puri. Because every single batch of PW1 whey protein is is get this third party tested by the Clean Label Project for more than 200 harmful contaminants including lead, heavy metals and pesticides. It also has 21 grams of minimally processed, clean, high quality whey protein powder from grass fed cow's milk. No hormones, no GMOs, no pesticides. They were probably massaged. And Also it has 2.24 grams of leucine. PW1 whey protein is made from a few clean ingredients and comes in two delicious flavors. Bourbon vanilla, which it has real vanilla seeds from Bourbon vanilla from Madagascar. PW1 dark chocolate with dark chocolate from raw organic cacao powder. Sign me up. Go and get 20% off site wide by going to peori.com/doctorlion and use the code Dr. Lion at checkout for 20% off. That is P U O R-I.com DrLion and use the code DrLion for 20% off.

[A]

So for the injections, how do you do that? Is that subcutaneous or intramuscular?

[B]

You can do all hormones subcu and you could even mix it with your testosterone.

[A]

Whoa, whoa, whoa.

[B]

And also guys, we're not giving medical advice, but we get so many questions on hormone replacement therapy or menopause cause replacement therapy. And because of all the myths out there, I thought we could break down a little bit what we do in clinical practice.

[A]

No, but I want to go back to that and you know, pump the brakes. You just said testosterone in terms of hormone replacement therapy when we're talking about the female patient.

[B]

Yeah.

[A]

You're giving your female patients testosterone?

[B]

I am.

[A]

Why are you giving them testosterone?

[B]

I don't want to say it's because it helps their husbands feel happier. I'm just kidding. I'm totally kidding, guys. Testosterone is really important for women and it's important for sex drive. It's important for muscle mass. There is no FDA approved testosterone for women. Even though we can treat hypothyroidism with Thyroid hormone. We can treat menopause with estrogen, estradiol, but there is no FDA approved testosterone for women.

[A]

Do you think there's just such a, like a stigma with testosterone in women or just lack of understanding all of it?

[B]

I was shocked when I started treating women with testosterone. I was shocked at how little data is out there. And actually we're working on a study at Baylor on safety profiles to really help move the needle for people. But in the US it is not prescribed nearly as much as it should be. There is no FDA approved indication. People typically give testosterone off label for hyposexual desire disorder.

[A]

Is that, is that the only reason?

[B]

I mean, not if you're in my clinic, but that is really one of the indications, which is unbelievable to me.

[A]

Yeah, that seems a little sexist, right? In terms of that's the only reason people are prescribing it to a female.

[B]

Well, the off label indication. But when you think about it, testosterone is important not just for men, but also for women. And there are testosterone receptors everywhere. One of the things that I always hear from women is that they're afraid to go on testosterone because they're afraid of losing their hair, getting acne, voice changes, that their clitoris will grow. If you are being treated by a physician who is tracking your blood and you are given appropriate doses, not supraphysiological doses, you should not have a problem.

[A]

And then for their labs, are there any values that hard and fast? Are you just looking at the holistic patient kind of profile every time or their numbers that, you know, kind of like the males have the 300 nanograms per deciliter. What does the female have?

[B]

And that's a really challenging question because we don't have great data. For women, the typical dosing strategy is 1/10amale dose. If a man gets 100 milligrams of testosterone, a woman should get 10, which that would be on the high end for us. The best delivery system for testosterone in my opinion is a sub Q weekly or bi weekly injection, which they could.

[A]

Do also with their estrogen if they don't want to do the estradiol patch. So it's all at once.

[B]

They could. And you're probably thinking, what would you start with?

[A]

Yeah.

[B]

Are you wondering what you would start with?

[A]

I am wondering what you start with.

[B]

I would typically start a woman on testosterone before. If she is younger and she has not gone through menopause and looking at her labs, she has low libido. Why is libido important to treat mental Health.

[A]

There's a lot of other factors. Landmark, Gabrielle.

[B]

I know just setting you up there, that is also hilarious. Think about this. The relationships. Having a good relationship with your spouse is everything. You're not going to be able to live well if you are constantly at odds with your spouse. Now, I've been a doctor for well over a decade. There is two things, or there are two things that people that couples fight about. Money and sex. I can't help someone's financial situation, but I definitely can help their sex life.

[A]

Okay.

[B]

And it is a couple's responsibility. A couple's disease, and I want to say disease, but hyposexual desire disorder would be. It has to last for at least six months. And it's not just a fluctuating libido and it's not just in her head. And oftentimes it has to do with hormonal changes.

[A]

Wow. No, that's great. And I'm sure very helpful for a lot of the listeners. What about. So when the female goes on testosterone, are there any, like, body composition changes? Are there any other things? Because you mentioned some of the masculinizing effects of testosterone. What, what can a female who wasn't on testosterone expect once she goes on testosterone?

[B]

What I have seen is that women's muscle mass can increase if they're training. You'll also see her recovery is better. For a woman going on testosterone, I think it's really important to manage expectations. When women come into our clinic and they say, I'm going through menopause, my body composition has totally changed. When they start estrogen, progesterone and testosterone, we typically don't see a change in body composition. If that's all you're doing, which, and I can't give you an answer as to why, but as opposed to, say, a male. We were talking about that other study you put a man on testosterone goes.

[A]

Up, muscle goes up.

[B]

But also the dose is so much different. The dose is one tenth a male dose. When she is training and her diet is together, we do not necessarily see a negative change of body composition through menopause. And that's probably one of the most common things that women will say, I'm going through menopause. Let's take away hot flashes. Hot flashes, brain fog, those two. Listen, we hear that all the time. But also, women really struggle with body composition changes around this time. And the question is, is it related to hormones? Probably. But once you replace those hormones and her symptoms are better, if she is not training, eating well, and drinking less, we Won't necessarily see changes in body comp.

[A]

Yeah. So you got to do it. But I mean, it makes sense because, right, like, estrogen is going to affect insulin sensitivity. So less estrogen, less insulin sensitive. So I mean, it would make sense that you improve. That you can improve body composition. I know we're talking about menopause, but perimenopause, like, is there, like, fertility? Like, what's. What's that look like if a woman still wants to conceive?

[B]

Are you guys planning on having more kids?

[A]

No, we are not.

[B]

This is a great question. A woman who is going through perimenopause, which perimenopause is that time around menopause can happen. That can last 10 years. The average age of menopause is around 50, which is so disappointing. It's happening. And I do think, just for the ladies out there listening, we have to accept it and kind of sucks because with lower estrogen, our skin changes, our joints change, our hair changes. And how can we stop that from happening? Well, we cannot stop menopause or perimenopause, but we can get ahead of it. What do I mean by getting ahead of it? If a woman is having symptoms but still menstruating, let's say her periods are terrible and she's not sleeping. We would start with progesterone first. For sleep, micronized progesterone, and that is given orally. I see a lot of providers putting patients on estrogen cream. We don't recommend it. We recommend micronized progesterone. The absorption is better. Also functions as a GABA agonist. Helps people sleep. There is also progesterone troches. And I'm going to give you another tip. Postpartum, some women that go through really bad postpartum depression, sometimes providers will give, say, just a shot of progesterone, 200 milligram shot. And that can help with postpartum depression.

[A]

Wow. And the cream, is that just an absorption? Just a. Yeah.

[B]

And also the metabolism cream is interesting. It's really tough for people. Now, the delivery mechanisms for hormones, let's think about what they are. Injectable, topical and oral. Injectable. There's a lot of ebbs and flows because you inject it. There's a peak and a trough. Topically, you have less ability to control the delivery system. Here's why. And I'm saying delivery system. That's not the right word. For example, an estrogen patch. And I've used estrogen patches. I switched from the Vivel dot to generic. And I looked at my numbers and my numbers didn't change. It was because my skin was not compatible with that patch versus a Vivel dot. And again, I have no relationship to these companies. The skin quality and the kind of skin you have makes sense, plays a role.

[A]

Yeah. Thicker skin or you know, for whatever reason. You mentioned those other delivery methods when we were talking a little bit about testosterone. What about the nasal, Is there a nasal estrogen?

[B]

There is. I do not use a nasal estrogen. What a great question.

[A]

Why not?

[B]

I don't know. I don't know. Because the patch works so well. I don't recommend estrogen cream because think about it. The patch exists. Have you ever seen an estrogen patch?

[A]

I don't think I've ever seen one in person. No.

[B]

The patch has the designated amount as opposed to the cream. The cream is. It's totally messy. You might do two pumps and maybe you got. This time you got a bigger pump.

[A]

I can see that.

[B]

But the absorption for estrogen cream, I'm not a fan. What I love estrogen cream for and I think all women should have vaginal estrogen. And when they are entering perimenopause, vaginal estrogen with also testosterone and even DHEA in the cream will prevent vaginal atrophy and prevent protect people from UTIs.

[A]

Wow. Is that compounded that combination or is there a product out there that already does that?

[B]

We typically use compounded. But every woman listening to this who's going through perimenopause or someone who is suffering from UTIs. Number one, do not get constipated. Constipation increases your risk of UTI. Believe it or not, it it affects the anatomy. And number two, estrogen cream is really good for the flora.

[A]

Wow.

[B]

For the vaginal flora. Yeah.

[A]

Didn't know that.

[B]

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[A]

You mentioned DHEA and so kind of as we talked about with with males, are there any supplements or anything like that that are out there for estrogen production or things that you put females on that you'd recommend?

[B]

DHEA is one of the agents that we use. Okay, believe it or not, because I kind of poo pooed any kind of oral hormone balancing. But DHEA definitely can be used and we use anywhere from 5 to 10 milligrams depending. You could even go to 20. Sometimes women will get some acne from it. But there is potential evidence for it to be supportive DHEA use in women. Also we were talking about hyposexual desire disorder and the genitourinary symptoms of menopause. There is an FDA approved vaginal DHA insert which it's 6.5mg and it is called intrarosa and it's indicated for postmenopausal women with painful sex and vulvovaginal atrophy.

[A]

The DHEA versus just the estrogen. Because my understanding, the dhea, it can go to estrogen or testosterone. So is that just kind of given the body, for lack of better word, like the substrate, to produce what it needs to produce in the ratio that's needed.

[B]

But also, keep in mind, if a woman is in menopause, DHEA is separate. And that's one of the blood markers that we measure. I don't know if I mentioned that earlier. We do measure dhea. DHEA can be important for inflammation as well.

[A]

Wow.

[B]

If a woman is on estrogen, progesterone, testosterone, and you measure her DHEA and it's low, definitely supplement it. But I also want to be clear in terms of expectation, a woman who is in menopause isn't going to take DHEA and all of a sudden feel better, as if she is on menopause replacement therapy.

[A]

DHEA is always used in conjunction. It's never like a monotherapy.

[B]

It can be okay. It can be when you're young. But again, define young. That's right. That's such a good, tricky question here. When you are young and you are making hormones, you have a lot of flexibility. As you get into perimenopause, you'll see that sometimes cycles become irregular. You will see sleep gets disturbed. But if you measure your blood work, the blood work, you might go to the doctor and the doctor might say, you're fine. And you go, you know what, Doc, I'm just having brain fog. I'm not feeling well. And you have to be able to treat symptoms. And one of the ways that we. And there's various ways to measure, you know, you can do it very complicated. There are month tests. Can you imagine testing urine or blood levels for a month to see what your markers are?

[A]

That's not fun.

[B]

Not fun. But I think that figuring out how you feel as a woman and understanding that there is a cyclical nature and starting. I think progesterone, which is protective, uterine protective, can be very helpful. And our starting dose for women, again, we use a micronized progesterone. It could be 100-200mg. Women with endometriosis seem to respond really well with micronized progesterone. And it's a. It's a great place to start. Very safe. Again, right now we have a landscape of coming out, of being afraid for the last 20 years.

[A]

Yes. And so in that same vein, I have a female friend who went to their physician and asked about these things and were immediately shut down. Immediately shut. You're fine. Everything's with the normative value. So I want to ask you, you know, how do you recommend that patient who maybe went out and asked their provider about these things we're talking about and they get shut down immediately to tactically push back and then is there a point or cutoff point you would recommend they go find a new provider?

[B]

Probably immediately.

[A]

Okay.

[B]

I mean, because part of being a physician and you know this, you see, you don't see patients, but you have clients. You know, as a ranger and dietitian and you know, taking care of high performance individuals, it's a team sport. If someone is coming in and saying, hey, I'm gonna give you an example, are you ready for this?

[A]

Yes.

[B]

I know a patient, she's postmenopausal and she missed the, quote, window of opportunity for menopause treatment. There is information out there that once you are 10 years past menopause, that you cannot be treated with hormones. Well, think about all the women that.

[A]

Missed that doesn't seem right.

[B]

Right. Part of it was the increase in coagulability with an oral agent. There's concerns about blood clots, strokes, but we have to recognize that, number one, women are not nearly as studied as they should be. It's embarrassing.

[A]

Yes.

[B]

When you go back and you look, it's actually embarrassing how little we know about women in relation to the science of this stuff. And number two, there is a lot of information that's taking a long time to get up. For example, oral, say oral birth control might increase coagulability, which is the clotting in your blood. But there's very little evidence that an estrogen patch because of the delivery method increases coagulability. Or again, people are concerned about dvt. So back to the story. This woman who's postmenopausal said, I chew a lot of nicotine gum. And the provider said, well, we're not going to put you on estrogen because of it. But the reality is we have to re educate and understand that is, I appreciate the safety of that, but we have to recognize that the information out there is not the same. It's not just about estradiol. It's also about the delivery mechanism. From a safety standpoint, estrogen, especially delivered in a patch, is very, very safe.

[A]

So with that, and kind of back to that case, a woman goes into the physician, she's experiencing this, what should she say? I Mean, is there kind of a, for lack of a better word, a script or word she should say? And then you're saying, if that physician immediately like shuts you down and they're like, you know what, you're fine, you're not in a disease state. Yeah, go. You would, you would say immediately go and look and try to find another provider.

[B]

I would. There. I believe that there's two ways to looking at preventative care and medicine. Again, there's probably a lot more than two ways, but there is the physician that is going to treat you for a cold, treat you for things you're coming in, you're sick, I'm treating you.

[A]

Yeah.

[B]

And then there are the physicians that are thinking long term. For example, we know menopause is coming. Hot flashes are real. It's not just hot flashes, it's osteoporosis. If someone falls and breaks a hip, it's not just, I have brain fog now, we're talking about Alzheimer's later. If you treat these things early with velocity, then your chances of living a long healthy life and one that is enjoyable increases. As opposed to, you know what, you're not there yet. Your FSH and LH are not really high. Your estrogen is not zero. Why would you wait?

[A]

No, that makes perfect sense. And so is there a resource or kind of a place for women interested in this, what we're talking about, to find these more forward thinking preventative physicians that are out there?

[B]

Well, we, we treat it in our clinic. Strong medical, but also you can look at, there's various organizations of physicians that are trained in menopause treatment. Again, there's the Endocrine Society, acog, nams N A M S. I don't know who came up with all these acronyms. But yes, and I will say that people will go to non hormonal medications. If someone says, well, you know what, I'm having hot flashes, someone might say, okay, well let's put you on an ssri. Well, or I'm depressed, let's put you on ssri. As opposed to. Just like with men, if a man is depressed, well, we check his testosterone. Or we should be. We should do the same for women for sure.

[A]

Wow, I didn't even think about that. So that, that is really a great point to highlight is some of these psychological issues that we, that we may see that we're going to psychotropics could actually be fixed via hormone therapy.

[B]

Totally. And the other thing is the next question is when someone is in perimenopause, should they wait. I hear a lot of people say, well, I just. I want to wait. Wait for what? And I. And I don't mean to be negative. It's not getting better, but these things don't get better. You are not. I mean, could you suffer and go through hot flashes? Totally could do that. Will your brain fog stabilize? Maybe the next question is, how are we also going to protect your bone? Do you need to train? Yes. Could you just take hormones and be better? No. You have to have these lifestyle factors in place. But the conversation needs to change a bit in the way that certain things are not going to get better. You are going to have less estrogen. You will have typically less progesterone. Your testosterone may go down. These are not things that through a flower or an herbal tincture or psychotherapy is going to change. It's that time again, man. Flu season. Wait, no. Just kidding. All flu season and needed immune support. It's an easy to take, delicious elderberry powder and it's designed to support optimal immune health for the whole family. Man, when I was pregnant, I could not figure out what to take. And most immune support products aren't designed for all ages and all stages. Needed immune support is safe and effective for the whole family. Kids, pregnant, moms, nursing mothers. It has zinc elderberry prebiotics and postbiotics in optimal forms and of course, dosages that are clinically studied, safe and effective. It is formulated by a group of pediatric practitioners and moms, one serving daily for optimal immune support all year round. And let's face it, there's a lot of stuff on the market and it's important to get clean products. Go to thisisneeded.com and use the code doctorline for 20% off your first order. That's thisisneeded.com.

[A]

This is really exciting and eye opening because basically every female listening to this podcast needs to be taking notes and considering this. No matter where they are in their. Their life cycle, Right? Whether it's preemptive or they're already experiencing this and they need to get treatment right away.

[B]

Yes, yes. And estrogen therapy is very safe. It is approved. Mht. So menopause hormone therapy considerably lowers a risk of hip fractures.

[A]

That's huge. Hip fractures, which can be a death sentence. I mean, people don't understand. A hip fracture when you're 70 can be fatal.

[B]

Yes, yes. Cardiovascular protection. Again, it's not the only treatment. We can't say, well, I'm giving you estrogen and it's going to prevent your cardiovascular disease.

[A]

No, but it's going to rage. Hdl, probably lower triglycerides.

[B]

And also transdermal estrogen, micronized progesterone. And then the Mirena. It does not appear to increase the risk of dvt, which again, that has really one of the vein thrombosis, which is one of the reasons why people have really turned away from it. Transdermal estrogen, micronized progesterone. Also, it appears to be favorable in blood pressure.

[A]

Wow.

[B]

Where. That's something that we didn't talk about. Testosterone can increase blood pressure. That is, again, something that we didn't mention. But I also looked up some numbers, and recent reports indicate that only 1.8% of women over 40 are using hormone therapy for menopause. Even though 100 of women go through.

[A]

Menopause, there is like 98.2% of the population out there that needs to be on it who are not getting it.

[B]

And it becomes a really important conversation. Estrogen and progesterone, people are much more open to it now. And that's FDA approved, but testosterone is not. I just want to put that out there. I think that that is fascinating and important to understand.

[A]

Yes. No. Especially given all the benefits that you just highlighted. Why wouldn't it be FDA approved? I wonder if that's coming with enough people using it off label. Right. Or this, the surge.

[B]

And then the other thing is imaging, and we didn't really talk about this. There is also a lot of information out there where people are afraid to get mammograms. At 40. You should. There is no reason why you wouldn't go and get a mammogram. People are afraid of radiation. And I would say, listen, you've got to put these screening pieces in place. But what about the woman that cannot use hormone replacement therapy?

[A]

Yeah. What does she do?

[B]

Well, this is where a real conversation comes in with both the oncologist and the menopause expert, because not all cancers or breast cancers or uterine cancers, whatever kind of cancer necessarily would exclude you from taking hormone replacement therapy. Now, when you take a look at men, there are men that have prostate cancer that are treated with testosterone.

[A]

Yeah, that's. That's fine.

[B]

And they do better. You have to. It's not throwing out the baby with the bathwater.

[A]

Yeah. Separating for taking each of those instances separately and looking at it. No, I mean, this is all great information. And I think for that female looking to, you know, consider hormone replacement therapy or have that conversation, you've laid out a great roadmap into how they should approach that. And then most importantly, if their physician's not willing to have that conversation with them to find a new physician.

[B]

I agree with that. Let's talk about how often individuals should get blood work.

[A]

Yes.

[B]

And listen, depending on where you are in your cycle, you can take it on day 21 day, et cetera. But let's think about how often a woman should be getting her blood work who is going through menopause treatment or even perimenopause at baseline, four to six weeks after she begins a therapy. And then I would do it again another three to four months to make sure that she's regulated. Do we regulate based on blood work numbers? Not necessarily. She should have symptom control vasomotor symptoms. She should be sleeping better, she should be feeling better from a mood perspective. And also, we want to see. Again, this isn't direct treatment, but if her cholesterol numbers really tank during menopause, which is what we see perimenopause menopause, we should see some improvement in that if she's being treated. And then, of course, it's not always hormones. You have to look at thyroid as well, meaning it's not always sex hormones. You have to look at everything.

[A]

So you show a thyroid panel would be part of always. That always is going to go with it.

[B]

Let's talk about how a woman can take testosterone.

[A]

How can a woman.

[B]

A woman can take.

[A]

Besides the mix and the. Okay.

[B]

How a woman can take testosterone. A woman can take intranasal testosterone.

[A]

All right.

[B]

A woman can take testosterone gel or cream. Very messy. She can also take testosterone intermuscular inner shoulder, but she can also take it.

[A]

Sub Q. I imagine the cases are kind of similar like the male and that you're going to see more of the peaks and troughs intramuscular or no?

[B]

Yeah, it depends on if a woman is. And I think that eventually women will be able to take it orally through the lymphatic system, which would be. So Kaiserrex is used for males, but I do think that eventually they will be using it for women. Women do the best clinically that I have seen with sub Q doses of testosterone. And we start anywhere from 5mg a week. It should be typically 110 of the dose of a male. 5mg is often too low for women to feel better with libido. Upwards of 10 milligrams a week seems to be a sweet spot for women.

[A]

When we're talking about this. Just to clarify, would you ever. Would testosterone Just be the only therapy you would do. Or is this always in conjunction with estrogen?

[B]

Actually, sometimes.

[A]

Oh wow.

[B]

Sometimes it depends on the woman. Some women you put on estrogen, they don't feel great. Progesterone is great for sleep and some women do great on progesterone. But nearly all the women that I have treated do very well on a low dose testosterone therapy.

[A]

That's surprising, I think, because what percentage? I don't know if we have that of like women who are, I mean we talked a very low. The low percentage of women taking estrogen. What percentage probably are taking testosterone, even below that. So we talked a lot about estrogen replacement therapy, hormone replacement therapy. These females. What are some of the risks associated or are there any.

[B]

What's that saying? There's no pre launch. I mean there might be, but when it comes to hormone replacement therapy and listen, everything, everything has a risk and we have to balance the risks and benefits. Whether it's Tirzepatide, Ozempic, all of the agents, everything has a risk. Estrogen, progesterone, testosterone. The risk isn't the same for everybody. Would I say that it is of benefit? I would say yes, but it's definitely case by case basis. Can there be an increased risk in breast cancer or uterine cancer, depending on. It depends on your genetics, with your lifestyle, with these agents, a good provider is going to sit down and go through everything with you so that you can make an informed decision. But we can mitigate certain risks that we know. So for example, if we know that an oral agent is going to increase the risk of coagulopathy or some kind of clotting, then we would use transdermal instead of oral.

[A]

Gotcha. So looking at not only the substance but also the administration, the route of.

[B]

Delivery, all like that, and then getting a uterine ultrasound, getting a mammogram, routinely, getting a Primovo or a full body MRI scan, also doing the early detection cancer screenings. There are all things that we can do because ultimately the idea is how do we live as better, stronger humans.

[A]

That is awesome, right? Yes, I love it.

[B]

Again, hopefully this was valuable and helpful for people in understanding what kind of blood to get, how the deliveries are done, why it's important. And again, this is just the beginning of the conversation. Yes, thank you so much, Nick.

[A]

No, thank you.