D (4:21)

Gross.

C (4:22)

Right. But that's what we Use, and that's. Those are highly conjugated estrogens that are very inflammatory, have increased cancer risk and.

D (4:31)

Cause all sorts of problems.

C (4:32)

So we don't want to use that. But we're going to talk more about how to use hormones, when to use hormones, and, and the benefits and the pros and cons in a bit. But first let's discuss what actually happens to a woman's body physiologically during this transition period. Well, first thing is bone density becomes a risk, right? Estrogen. As estrogen levels drop, your risk of bone loss goes up. Right. Estrogen plays a key role in maintaining bone health by helping regulate bone remodeling. And that involves resorption or breakdown of the bone and old bone and the crazy new bone, all that requires estrogen. So how does estrogen do this? Well, it increases the activity of a certain type of cells in your bone called osteoclasts. These are class like breaking down, like an iconoclast. Something breaks icons, right? So it's an osteoclast is a cell that is responsible for breaking down bone, which is normal. You want to recycle old bone and build new bone, and it also decreases the activity of osteoblast cells that are responsible for new bone formation. So that's not a good scene. So you get a double whammy with more breakdown and less buildup. So when you actually in menopause or perimenopause, this combination of bone breakdown and reduced bone growth ultimately leads to a loss in bone density. You see, on average, women lose about 1 to 2% of their bone density per year during perimenopause and menopause. And the rate of bone loss can be even higher in the first five to seven years after menopause. You really got to be on top of this. Get your bone density checked early, check it regularly, and find out what's going on so you don't get into trouble. We'll talk about how to keep your bone density up, too. If you look at what happens, it can. It can lead to up to 20% of loss of your total bone mass if you don't do something about it. And we're going to talk about what to do about it, but it involves taking the right supplements, vitamin D, exercise, strength training, and so forth. And this loss of bone basically increases a woman's risk for osteoporosis and fractures if it's not managed with diet and exercise, particularly strength training. What else goes on? Well, your risk of heart disease goes up, right? Heart Disease and stroke are the leading cause of death in women. But the good news is, in up to 80% of cases, it's preventable with lifestyle and diet. I've seen studies that show over 90% of heart disease disease is preventable. So what's happening in a woman's body to increase her risk during menopause? Well, estrogen plays a role that's protective in the cardiovascular system. It enhances the production of a really important molecule called NO or nitric oxide. It's a vasodilator that helps relax and widen blood vessels and improves blood flow, which we know it works because that's how Viagra works, right? Increases nitric oxide. It also helps reduce inflammation, which is really important because heart disease is an inflammatory disease. And so basically, there's all sorts of things. It also helps your blood vessel health and reduces your risk of high blood pressure. And so all these are great. And the inner lining of your blood vessels is really important. That's what produces nitric oxide. And so that inner lining of your blood vessels is really in part regulated by estrogen. So when it's weak or damaged, that's when cholesterol gets stuck in the arteries and forms plaque that causes hardening of the arteries or atherosclerosis or heart disease. It also increases ldl, the good cholesterol, Although there's really no good and bad, it's a little bit more nuanced than that. And it decreases triglycerides, which is awesome. And it also lowers ldl, which tends to be a problem for people. Now, it decreases LDL cholesterol by enhancing the expression of something called LDL receptors in the liver. And that's good because these receptors basically suck up all the LDL excess, the excess LDL in your blood, and it reduces the risk of plaque buildup in the arteries, which is great. It also has antioxidant properties that help reduce oxidative stress and the oxidation of LDL cholesterol, which is what really causes heart disease. It's not just ldl. It's when it's oxidized or rancid, and then it causes heart disease and blockage in the arteries. So how does estrogen protect against oxidation of ldl? Well, it activates genes that make major antioxidant enzymes, things like SOD or superoxide dismutase and glutathione peroxidase. And these are more powerful than any antioxidants you'll ever take in a vitamin. And. And they. They're produced by your own body. Now these help neutralize free radicals. They protect against oxidative damage or rusting. And that's awesome. And estrogen itself has direct antioxidant properties due to its chemical structure. We call it phenolic structure. Now that the phenolic structure is similar to what we call polyphenols, which are basically these plant compounds are anti inflammatory that help neutralize these free radicals. And there's these phytoestrogens, but I don't like that term because it kind of means that they're stimulating the estrogen receptor, but they're actually modulating it in a beneficial way. And they don't actually cause estrogenic effects, they just help modulate it in a good way. And there's ones from soy for like for example, Genestein and Dazine and that are found in soybeans. Now there's other plant compounds that also help, like lignins. This is a type of plant phenolic with weak estrogen activity in the body. And they're found, guess where? In flaxseeds. So they really help a lot in terms of the overall sort of hormonal balance. So I highly recommend flaxseeds for women in general for lots of things, for constipation and for omega 3s and for particularly for helping with hormonal balance. Estrogen also impacts insulin sensitivity and glucose intolerance, meaning it helps regulate your blood sugar, which is key for preventing heart disease and maintaining your metabolic health. So estrogen plays a huge role in insulin sensitivity and keeping your metabolism healthy. It upregulates the expression of something called glucose transporters in our cells, which is basically our muscle and fat tissue. So essentially, you know, the ability to get glucose out of your blood depends in part on estrogen. It also helps maintain muscle mass, which is key for insulin sensitivity. And it influences secretion of something called adipokines. These are hormones released by fat cells by promoting subcutaneous fat storage rather than visceral fat. Now, the visceral fat's the dangerous fat that's around our belly that's linked to pre diabetes and some resistance. And when you lower estrogen levels during menopause, it increases a woman's susceptibility to insulin resistance and to weight gain, particularly around the belly. Women notice that they get more little pudgy around the middle. That's because of this reduction in estrogen. And eventually it can even contribute to the risk of type 2 diabetes. What about your brain? Well, brain is important and research shows that estrogen has a very important role to play in your brain. It's a neuroprotective compound, meaning it protects your brain, and it's involved in keeping the brain healthy and firing all cylinders. And how does it do that? Well, it helps do it through reducing inflammation in the brain. It modulates the activity of brain immune cells to maintain a healthy brain environment and enhances something called neuroplasticity, which is the ability to grow and strengthen neurons and the connections between neurons. It also influences the production of our neurotransmitters, serotonin, dopamine, which helps support mood and cognition. And so it upregulates beating apples, essentially, like miracle growth for the brain, which promotes the survival, growth, and the differentiation of neurons and increases connections between them. So your brain's more connected and functional. Also, it protects against something called amyloid beta buildup and toxicity. Now, this is the protein, amyloid that accumulates and forms plaque in the brains of people with Alzheimer's, which is why we've seen some data that estrogen is protective against Alzheimer's, which is kind of cool. And that means when estrogen levels decline, the opposite happens, right? Your brain gets more inflamed, you get more brain fog. Maybe serotonin dopamine decrease, which can lead to low motivation, maybe make you anxious, your mood changes. It's not cause you're crazy. It's cause your hormones are changing. Sadly, your risk of dementia goes up and your cognitive decline goes up. So it sounds kind of bummer, right? It's all bummer data. But actually, the reason I'm telling you is because you can do something about it. There's so much you can do about it to prevent all these things and to support your body during this whole time and minimize all these things. So you can't just kind of go through and ignore it and pretend everything's happening fine and not pay attention. You got to pay attention, and you got to take care of yourself, ladies, because here's the deal. Most women in this period of their life, perimenopause or menopause, it's called the sandwich generation. They're sandwiched between their parents and their kids, their teenage kids and their old aging parents. Plus, they're probably in the middle of their career, and there's a lot of stress. So you got to take care of yourself. Like that thing they say on the airplane when you're, you know, you put the oxygen mask on yourself first, then you put on your kid. That's kind of what you got to do. And if you do that, then you can Preserve your brain function, you can preserve your body, you can protect your heart, you can feel good, you can continue to live a happy, healthy, thriving life. But the more proactive you are about it now, the easier the transition is going to be. Here's the problem with traditional medicine. It just doesn't know how to deal with this very well. It's like, okay, take the pill until you're 50 and then we'll switch you to hormone replacement therapy. Well, that ain't the answer, right? Conventional docs don't take a proactive, preventive approach to help protect against bone loss, against muscle loss especially. They don't really focus on preventing high blood pressure, heart disease, or protecting your brain during this time. I mean, basically you might get a platitude, well, just exercise and eat better and, you know, manage your sleep and stress. But that's not very helpful information, and that leads a lot of women to suffer. The truth is, they don't have to.

B (14:10)

Right?

C (14:10)

They don't really have to. So let's first talk about where conventional medicine gets the approach to hormone replacement therapy wrong. Right. Often what they'll do is to wait until symptoms appear to do anything about it, which is often late. And even when they do, their interventions just don't support the transition. They just manage symptoms with SSRIs and hormone replacement therapy. I mean, they now have a drug for pms. It was called Prozac. They changed the name to Seraphim, exactly the same drug, just to make it sound like it was for women. But it's kind of ridiculous. I mean, it's not a Prozac deficiency. Right. There's a change that happens sometimes. Hormones can be helpful and doctors will prescribe them, but they don't usually do it right. They don't do the right kind of hormone therapy, and they use conjugated or equine estrogen. That's horse estrogen. I mentioned the urine, pregnant mares urine estrogen. And that's been linked to a ton of problems. Right. Initially, hormone replacement was seen as highly beneficial based on some observational studies, because they weren't really clinical trials. They just looked at population and shocked them over time. And it was the Nurses Health Study, and they found that, you know, we're 130,000 women, they followed for decades and seemed like the women who took the hormones did better, Right? They had less heart disease, breast cancer, dementia, osteoporosis. Everything seemed great. But it wasn't hormones that were doing that per se. It was really their lifestyle. We call it the health User effect. So there was a large trial, billion dollar study funded by the NIH called the Women's Health Initiative and kind of turned upside down these findings. Now, this is a study of over 160,000 women who are postmenopausal who were either on combined estrogen, progesterone therapy or estrogen only. And they used synthetic forms, they used pregnant marriage urine, and they used synthetic form of progesterone or progestin, which is often very problematic. And now these results were published in a prestigious journal called the Journal of the American Medical Association. Essentially, they showed that hormone replacement therapy actually increased the risk of heart attacks, breast cancer, strokes, dementia and blood clots. And they wound up discontinuing the study early because the results were so shocking and they didn't want to harm women. Further. That study caused a lot of problems because all of a sudden you got 50 million women overnight, boom, stopped hormone therapy and they were miserable, right? And it led to a shift in their recommendations around hormone therapy being very much anti hormone therapy. The problem was that they didn't really get into the nuances and they didn't look at the type of hormone dosage of the hormone. The method of application, Is it a pill, is it topical timing of hormones? It's really subtle and personalized. The truth is that hormone therapy can be used and I would like to call it hormone optimization therapy, because you don't want to overdose, you want to do the right forms, you want to do bioidentical forms. And women who actually begin hormone therapy within six to nine years after menopause can start to benefit from the therapy. But starting it too late after menopause may increase risk. So you gotta be careful about when to start. Now, hormone therapy may also help women in perimenopause and helps to reduce symptoms and provide relief. But you've gotta be very specific and personalized based on the symptoms and the form and the type of hormones used really matter.

A (17:23)

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D (18:22)

What should we actually know from the Women's Health Initiative which is a randomized controlled trial?

C (18:27)

And what do we know now that's.

D (18:29)

Different in the intervening 22 years that has changed our thinking?

B (18:33)

So this was one of the probably the best cases of something going viral before social media and you know, kind of this path of misunderstood information or misinformation. So whi, you know, they started enrolling patients in the late 90s, we knew from observational data that women on HRT tended to have less heart attacks and die from heart attacks less. And so they said, all right, well is it just because women on HRT are healthier and wealthier? Is this an artifact or can we prove this with a randomized control study? First time aging women had ever been studied with that level of and they used prem and prepro which at the time were the two top that wasn't unusual at the time. Those were the two commercially available formulations that they did. So that's one problem. They use one formulation, you know, the Premarin if they had a uterus, if they didn't have a uterus and in Prembra if they didn't versus placebo average age. So the outcome of the study was not safety, it was measured but that was not the primary aim. The primary aim was to see if they would get cardiovascular disease or not. So they started with a much older population. This is key. The average age of the study was 63. They enroll the patients get started in the Premarin and Provera arm. They did notice a very slight relative relative risk increase of breast cancer in that population. Not in the estrogen only arm. They called a press conference. They didn't release the study data at the Watergate Hotel and it was on the COVID of every newspaper, every news story. I remember I was my chief year of training. I was 2002 is when I graduated and it, like you said, it was this massively disrupted. It was the top news medical News story of 2002 and it said estrogen causes breast cancer. Well, turns out the estrogen only arm kept going and they didn't see an increased risk of breast cancer. So now, you know, but that notion just went crazy. No one would prescribe it after everyone was terrified. Those. Those data points have been refuted as, you know, throughout multiple studies, throughout time. But we're just having a hard time, like, getting the world to catch up to this. But in the.

C (20:35)

Was it the forms of hormones that.

D (20:37)

Caused some of the increase?

B (20:38)

Right. And so, you know, Levy and Simon and Levy just published, like, the contemporary view of hormone therapy. You know, formulation matters, type matters, age matters. We have a window of opportunity for protection for cardiovascular disease. And basically it's the time away from estrogen, where the problem starts for females. So the longer my body is away from estrogen, the more likely I am. I had to have a stroke of cardiovascular disease, diabetes, the whole every cardio metabolic disease. Estrogen is protective. Once those diseases start, estrogen is great at prevention, not a cure for some of these things. And so the older women in the study didn't see a cardiovascular benefit because they probably already had heart disease. They missed their window of opportunity because they started older. Their acceleration of their diseases had already occurred. So now we know. If you want the cardiovascular protective benefits, you probably should start within 10 years of your menopause. If you want the neurologically protected benefits for decreased Alzheimer's and dementia, you need to start within the first five to ten years. Lisa Moscone has new data published on this just this week in Nature. Probably it's a bigger window than we thought. If it will always protect your bones, it's always going to protect your general urinary system. It's always going to protect your muscles, you know, but you still have to do the work. So I never want anyone, any of your listeners, to think, oh, I'm just going to take hormones and go about.

D (22:00)

Yeah, you can.

B (22:01)

No, no, you must exercise, you must eat right. You know, this is a tool and the toolkit. So that. Because here's the fact of the matter, women live longer than men. Sure, okay. But we spend 20% of our lives in poorer health than our male counterparts, and that's not okay. And that's the gender health gap. And that's where we have all this is where the work needs to happen.

D (22:24)

Yeah. I think this is so essential. And I think, you know, as I was sort of learning about the Women's Health Initiative, I actually already had kind of gotten a little bit biased because I'd read this book about bioidentical hormones, about using hormones that were the same as your body's own hormones to bind the same receptors that have less Side effects like Premarin, which was used in that original Women's health study, that actually has to be metabolized by the liver and it actually increases inflammation. C reactive protein increases triglycerides, increases your, your risk of breast cancer, I think because of its effect on alcohol metabolism and lots of things. So if you drink a glass of wine, your, your hormone levels would jack up really high. So I think there's a lot of problems with that.

C (23:05)

But now the topical or bioidentical hormones.

D (23:08)

Seem to be better tolerated, more effective.

C (23:10)

Are you worried at all about them?

D (23:12)

Do we be concerned that there is some unknown risks that we haven't determined from the research whether or not these actually may increase breast cancer risk or ovarian cancer risk.

B (23:22)

Not in the estrogen family. Not if you stick to a, you know, not in, not in the estradiol world. Okay. Doesn't look like it's actually protective for breast cancer, especially if you start young. The progestin seem to be where there's a lot of variation. And you know, these studies are being done with lots of data coming out from Europe and other places, but they're all using different progestogens. What I want to see is a head to head of estradiol plus my oral micronized progesterone. And let's follow those women, you know, for 20, 30 years and see who lives longer, what the risk of breast cancer is, et cetera. But, you know, what's happening is bikini medicine in my world where women are little with bikini medicine. So the only thing we need to worry about in women's health is the bikini area, the breasts and everything out of the bikini. And so, you know, the bikini bottom. And it's like you said, we're not testing these drugs, you know, cardiovascular drugs on men. So let's take a statin. You know, my cholesterol went up through the menopause transition. I've been able to get it back down with HRT and diet. Okay. Very successfully. But my doctor recommended a statin. There is no data to suggest that statins decrease the primary risk of a heart attack in women. HRT does. And that was actually Premarin, like not the best of our options out there, so. Oh, I could go on and on about this.

C (24:43)

No, it's good, it's good, it's good.

D (24:45)

I think it's good because I think, you know, we, we, we, we have to sort of empower women with the knowledge that we have now and not be stuck in this old story that we shouldn't do it. Now, the question I have really is, is if. If you're going through, you know, menopause and you have no symptoms and you're good, should you take hormones?

B (25:07)

I would have a balanced conversation with that patient. And that's what I do in my clinic. I'm going to talk to her about. Even though it's not recommended by the societies yet, except for the American Heart Associate. Well, they're a little bit on the fence, but I talk to her about the known protective benefits of hormone therapy. Her bones, her brain, her heart, if she's in the right window of opportunity. And I'll let her make a decision for herself. We'll talk about the risks, her family history, her needs, her wants. What's happening is the old menopause was HRT only for the shortest time, the lowest dose, only if you have severe symptoms and you're going to jump off of it. Okay, but what about the woman who kind of. Luckily the 15% who don't have the cliche symptoms, But I also say, what's your cholesterol? How's your insulin resistance? How's your joint pain? Because those symptoms are just now being recognized as part of the hormone that's going for sure. And maybe we can help those things.

D (26:04)

Yeah.

C (26:05)

And so to flip the question upside.

D (26:07)

Down a little bit, if a woman starts on hormones, is this something they should stay on long term? And is this something that all women should do after menopause? Is this something we should kind of move towards, thinking that all women should be done, or is this more of a personalized approach?

B (26:23)

I definitely think it's personalized. I definitely. Right now in the US 4 to maybe 8% of women who are eligible are on HRT and people are saying that's over medicalized. And I think that's ridiculous. We're just allowing your body to work in the fashion that it used to work before you went through this change and, you know, before you washed your eggs. And so I think every woman deserves that conversation and to be allowed to make a decision for herself. And then if she decides to do it, I review it every year with them. How are you doing? How are you feeling? Have we developed any new medical problems? But it is absolutely possible that a woman can enjoy benefits of hormone therapy until she dies. I might die with an estradiol, so. And let you know. And. But that's my personal choice combined with my knowledge level and my family history.

D (27:15)

So I'm hearing the subtext. Unless someone has significant reasons not to, like breast cancer, Risk or they've had breast cancer and is contraindicated, or ovarian cancer or uterine cancer, which are hormone dependent cancers that do flourish, that would.

B (27:30)

Feed your cancer, would be fed. Yeah, right.

D (27:33)

It seems like what you're a severe.

B (27:34)

Liver disease, a recent blood clot, you know, and you know, recent PT or pe. Yeah. Some really contraindication.

D (27:44)

But for pretty much everybody else, what I'm hearing you say is it's a good idea.

B (27:49)

It's something to consider, and it is something I discuss with every single patient.

D (27:53)

Yeah. The other thing is, you know, women might have a sort of like the frog in cold water that gets turned up slowly and they don't know they're boiling to death. Like, the changes can happen and be.

C (28:03)

Subtle and you think this is just.

D (28:04)

A normal aging, but then you get them on hormones, they go, wow, this is a different me.

C (28:09)

Right?

D (28:10)

This is a whole new, whole new experience.

B (28:12)

That is what I see in my clinic. And that is what the menopause cc, you know, we have this little friend group of clinicians, and we're multidisciplinary, the menopause. And we text all day long. We share patient stories and ask questions and articles. And, you know, it's fun. And so, you know, it's retrospective. It's all these women saying, oh my gosh, I didn't realize that my, my tinnitus sinnitus, my vertigo, my palpitations went away, you know.

D (28:40)

Yeah, yeah, yeah.

B (28:42)

It's pretty exciting. It's exciting stuff.

D (28:44)

So let's talk about testing. Um, you know, you know, what I found is, is hormones fluctuate greatly. And you know, when I was sort of in medical training. Oh, don't worry about testing so much. Cause they're all over the place. And, you know, you, you only want to test after they've stopped having their period to confirm they're in menopause. How do you see testing hormones in women? And, and when should women start testing? What should they be testing? If you're checking hormones as a matter of when in the cycle, you're chest testing, like, should it be day one to three or day 18 to 23 to see what's happening with ovulation. How do you sort of think about this?

B (29:14)

I. Here's my fantasy is that we have a CGM type thing, a continuous chm, continuous hormone monitor. You know, why not? Why not? There's actually I talked to someone who's trying to develop one where you start having symptoms, you pop that bad boy on you, follow yourself for a couple of months. It's tracking all the things, your estrogen, your progesterone, whatever. But, you know, we have these kind of poor panaceas for that right now in the form of, you know, you need to do testing over multiple days. It's, it's hard to read. And so the way I diagnose perimenopause is I talk to the patient. I absolutely believe her. I do a lot of blood work to rule out other things like autoimmune disease, hypothyroidism, inflammatory disorders, nutrition. But like a spot hormone test because of all that crazy chaos is not going to help me that much. Certainly if I can't use her period to help kind of guide me a little bit. I'm doing hormone testing, you know, to see is she really post menopausal and we missed it because we don't have a period to judge. But I, you know, I don't have a great, you know, easy blood, urine, saliva test that I think is 100% reliable. I really just listen to the patient, believe her, go there with her, you know, make sure nothing else is going on or overlapping with all the blood work, and then we just drive into.

D (30:30)

Treatment for, for, you know, premenopausal women, I think, you know, were having a lot of symptoms. I always found that if I checked hormones sort of in the second half of the cycle, like day 18 and 23 of a normal 20 day cycle, that I could see what's going on with their ovulation because their progesterone would.

B (30:48)

Often be low, progesterone would be low.

D (30:49)

And their estrogen would be really high.

C (30:52)

And that would kind of give me.

D (30:53)

A lot of clues about what's going on. And they're like, I might just try progesterone with those women or I might try that and a tiny bit of estrogen and that seem to be a good sort of indicator. Is it, is it, is that a good practice?

B (31:04)

Very reasonable. You know, if you can get it on day 18 just with Modern. We are lucky in the type of clinics we had. But sometimes, you know, the access that patients have to that kind of thing is pretty limited. Yes. But I think, you know, a really high estrogen with a really low progesterone is classic in ovulation. Right. Or oligo ovulation, or that's either peri or PCOS for us. And, you know, giving her progesterone often is miraculous. This patient seems so happy.

D (31:33)

And you can always see the ratio of LH and FSH change where you get high LH and low fsh, which is often correlated with pcos. And we see that too. So it's kind of. What about, you know, early on in the cycle, when is it indicated to do testing? Day one to three.

C (31:47)

You know, typically, most of you or.

B (31:50)

For what I learned that was for fertility. And interestingly, you know, we've fertility does a lot of work with AMH and anti malarian hormone. Anti malarian hormone. They're actually looking at analogs of that or block or. I think they're blockers. These. There's two biotech companies that I know are working on, you know, medications that work with AMH to extend the life of the ovary. Because it seems that rise in AMH is accelerating the loss of the follicles in menopause. And if they can figure out a way to block that process, they think they can extend the life of the ovary so that we have. We can enjoy more of our natural estrogen. But again, that's all in theory, and they're testing it.

D (32:31)

If you measure amh, this, it should be lower in order to indicate better fertility. When it's higher.

B (32:37)

Right. Which means longer. You have a longer time until you're menopausal. So I think there's a lot of work to be done there in the menopause space. So I'm excited to see what's coming in the future that.

D (32:47)

Let's talk about sex. I think, you know, one of the.

B (32:52)

Things that we didn't talk about testosterone yet.

D (32:54)

No, that's what I want to get into. So, you know. You know, you've said before that, and.

C (32:58)

This is sort of well known if.

D (32:59)

You'Re a physician, is that maybe not actually most doctors, is that testosterone, absolute testosterone levels are higher than estrogen progesterone levels in women.

B (33:08)

In women, it's the precursor to estradiol. Down the synth, you know, down the. Down the pathway to create estradiol. Testosterone's the last step before we aromatize it to estradiol. So, yeah, our natural testosterone levels are actually higher in picograms per deciliter than our estradiol levels. But then we lose those, too.

C (33:27)

Yeah. And there's a lot of reasons for.

D (33:29)

Libido issues and sexual dysfunction in women. I once heard a woman, Susan Love, who wrote a book about women's health years ago, she was quite amazing. And she. You said the biggest sex organ for women is between their ears. And I think there's a lot of truth in that.

C (33:45)

But.

D (33:45)

But also, women have vaginal, dryness they have lower testosterone, they have arousal dysfunction, they have all sorts of stuff that.

B (33:51)

Gets kind of orgasmic dysfunction.

C (33:52)

Yeah. And, you know, and men got Viagra.

D (33:55)

And all this stuff, but women kind of don't really seem to get, have this addressed very effectively. And what I found is it can be really effectively addressed by and, you know, addressing overall lifestyle issues and relationship issues, obviously. But sometimes using testosterone can be very effective. And it also is great for bone health and mood and energy and focus and has a lot of benefits. So I'm curious about your perspective about the use of testosterone and how you use it, how you prescribe it.

C (34:22)

You know, I, I, one of the.

D (34:23)

Things I, I, I learned was that you could use it topically on the clitoris and you can get it compounded. And if women use a couple of drops every night, it's over a few weeks, it really increases their arousal orgasm. And I, I think it worked because the women I prescribed it for would always call me back for refills. So I figured that it was working.

B (34:43)

Yeah. So my friend, so in our menopause, we have three or four urologists who are females. You know, they're in Ishwish, the sexual wet medicine wellness conference. And they love topical testosterone in the vulva, especially if they're having it's, there's so many testosterone receptors in that lower in the artist as well. They love it for the clitoris too. So, like doing that, if you look at the vulva, that they call it 12 to 6 when you apply the cream and they have it specially compounded so that they're huge fans of that, especially if they have gsm, generally urinary syndrome of menopause, a combination of estrogen and testosterone, or the dhea, which gets converted down the pathway to birth, is, is helpful. So I love testosterone. I'm a huge fan. Clearly the data for hsdd, hypoactive sexual desire disorder, which is the organ between our head. Oh, my God, it's that, you know, but, you know, does she have a good relationship?

D (35:39)

Doctors like to give these names.

B (35:41)

Yeah. Is she having pain? You know, we're ruling out all the other causes. Making sure she has a stable relationship with a partner who she used to have a good libido with, or, you know, layman's term, libido. Making sure she's not having pain. We gotta fix that. And, um, so all those things are addressed and then testosterone really does seem to be helpful for the hypoactive desire issues. So the brain parts for females also, I use it off label. If my patients come in, I have a monitor in my office for, for muscle mass and visceral fat. I have an in body scanner, electrical impedance scanner. So if she's coming in and she's, she's had a bone density and she's got low bone mass and she's sarcopenic, you know, I am recommending it off label because the data is very promising in combination with. We know that women with higher just natural testosterone levels have less of those diseases. So I'm just trying to help her. But she's got to eat the protein and lift the weights and do all the things as well. And that testosterone can be additive in that.

D (36:40)

And you use it topically or how do you use it?

B (36:43)

I do. So yeah, only on decanoate is and it's. I've been approved in the US is safe, you know, for the liver toxicity part of it. So testosterone therapy should be transmucosal or transdermal for safety reasons. And then in the US there's no FDA approved formulation for women. So in some states than others it's easier to get. Sometimes you can do the male version of like T stem gel and you. But it's hard to dose. You know, it's like a pea size amount or so. Most of my patients, because Texas we really have a hard time getting the T stem from the pharmacist. Um, we'll go around the block and do a compounded cream. So I'll do a transdermal estrogen testosterone cream for the patients and we'll kind of dose adjust, you know, based on her levels and her symptoms.

D (37:30)

And it doesn't cause women to grow mustaches and beards if you stay in.

B (37:34)

A physiologic husky if you don't overdose her, sure if I give her enough she will grow all sorts of things. But I, I try to keep my patients in a healthy physiologic range.

D (37:43)

I think that's so important that is such a key statement and is to use hormones in a way that kind of matches your normal physiologic state for optimal health, not an excess amount. I mean you see these muscle heads and gyms that have huge levels of anabolic hormones that this is our super physiological and there are serious consequences of that. But if you're keeping people in an optimum range, it actually works. And I think again this is one of those areas that has been neglected for women that is so important to be addressed. And again even that there isn't an FDA approved formulation that you have to go hustle around and try to get this prescription covered or go to a compounding pharmacist. Doesn't make any sense, right?

B (38:23)

Exactly. It's so frustrating as a, as a clinician that I can't, it's so complicated sometimes to help my patients get what they need just to feel normal again.

C (38:33)

Yeah, I think, I think we're kind of hopefully coming out of the dark.

D (38:36)

Ages of women's health. I don't know if we are, but it feels like there's a lot of people out there now talking about it. There's you, there's people like Sarah Godfrey, there's others, you know, my friend Gabrielle Line are all kind of advocating for kind of a new way of thinking about women's health. You know, it wasn't something I intended to go into, but it just became something that I was very much immersed in because of the population that I was dealing with. And I just learned so much from my patients. And often the best source of warning is listening and asking what's going on with them. Them telling you and then learning about the condition and how to sort of adjust your, your treatment to match that. And I think, you know, it's been a dark period because, because of the Women's Health Initiative, there's been such a fear and such a resistance to hormone therapy across the medical disciplines and, and now it seems like it's shifting. Is this just on the fringe or do you think this is changing within traditional obstetrics and gynecology?

B (39:33)

I definitely see it changing. I see like in the American Abode, American Board of obj, the Council on Resident Education. I was a program director for like 10 years. So they are pushing to have a menopause curriculum. I see, you know, more and more people contacting me, other clinicians who are like, help me, help me. I want to learn more. You know, the, the rate of people signing up to get certified by the Menopause Society is skyrocketing. Know, I think people are becoming aware mostly due to social media platforms, the news, you know, and patients. This generation of menopausal and perimenopausal woman is not putting up with it. She knows there's a better life for her, that she doesn't have to suffer and she wants more information.

C (40:14)

I'd love you to talk about this.

D (40:15)

Case that you shared a little bit earlier with me about this 52 year old woman who had allergies, migraines, weight gain over eight years, lost her parents, and it was, it's a really great Case and talks about how we think about people going through this phase of life differently.

E (40:28)

Yeah.

D (40:28)

So I want to, by the way, before you do, I just want to say it doesn't matter what phase of life you're in as a woman, whether you're a teenager going through hormonal changes in your 20s, 30s, 40s, 50s, 60s and beyond. We take care of all of it. We're just sort of focusing a little.

C (40:41)

Bit on menopause now.

D (40:42)

But this applies across the board. And we, you know, have different issues at different ages. But looking at the life cycles of women is really a core part of what we do.

E (40:50)

I agree. And I, and I think, as I mentioned before, it's a window of opportunity. It's often the symptoms that bring you into the. To talk to the functional medicine practitioner, but it opens the door for a conversation about everything.

D (41:01)

Yeah.

E (41:02)

Which is really important. I'm going to look back on this. So this is somebody who didn't come to me initially for menopause, but she happened to be in the menopause transition. She was 52. I think her last menstrual period was about six months before she came to see me. And she had this history of allergies and migraines. So just so you know, I'm gonna talk as I go through this. One of the things that comes up for me with allergies and migraines is thinking about the role of histamine in some of her symptomatology the last eight years. So as she's entered the menopause transition, her weight's been going up and she had what's a very common occurrence. She lost both of her parents. Unfortunately, her partner had a serious health issue. So there's been a lot of added stress and face it, mortality was right in front of her. So that can bring up a lot of things about, oh my gosh, what does it mean to be getting older and what's going to happen for me? She had also noticed in the last three years she was starting to have some hot flashes and sleep disruption, brain fog, which she in particular linked to more sugar and carbohydrate intake. And at the same time she was craving more of those foods as she was more stressed. A little bit of a vicious cycle. And we started her really on a nutrition plan while we were gathering some of the data.

D (42:13)

Yeah.

E (42:14)

And our original nutrition plan was kind of what we talked about. Whole food plant based diet, minimizing those processed carbohydrates, even trying a low histamine diet to see if we could sort of clear the decks. And what would happen with her allergies and her migraines? Recommended doing a sleep study. Some breath based practices which we know have shown some evidence for reducing the hot flashes. It's just helping support her.

D (42:37)

Yeah.

E (42:38)

With all the stuff that she's been dealing with. And then when we got her labs back, her estrogen was not measurable. So she's not making any at all. Some women will make a little bit. She had some yeast overgrowth in her gut. We had some elevated markers and it also showed up in her stool test. And she had intestinal methane overgrowth as well, which was probably playing a big role with some of her digestive issues. And this estrobolone that we talked about, um, and she was showing some evidence of increased intestinal permeability. Her LDL particles were higher than we wanted to see it.

D (43:13)

So she had bad bugs growing her gut. Too much yeast, too many bugs in the wrong spot. She got bloating and you know, she had leaky gut and all these things were causing allergies, inflammation and making everything worse.

E (43:25)

Yes. So it wasn't just the hormones.

D (43:27)

Yeah, yeah.

E (43:28)

And I think that's a really important piece of pain.

C (43:30)

I don't ask you this.

D (43:31)

Your experience too zeny? Like what I found is that, that if I start with all these other things, the hormones often get in the line. That actually the hormones are often screwed up as a downstream consequence of other upstream causes.

E (43:44)

Yes.

D (43:44)

It's not usually the hormones themselves are the issue. Right. I mean, think about it like we all have hormones, they all should be working. Why aren't they working? Like, it's like if you have a toxin like mercury, that's a bad thing. If you have a parasite, that's something that's an upstream cause. Right.

C (44:00)

But if you have screwed up hormones, it's usually the consequence of something else.

D (44:04)

That'S screwing them up. It's not a primary thing. It can be.

E (44:07)

It can be. It can be.

C (44:09)

But you can have an insuloma and.

D (44:10)

Producing insulin as a tumor or you could have, you know, I don't know what else you could have a lot of things. You'd have a cortisol producing tumor and have cushing. So there's a lot of things that, you know, obviously aren't what you're doing.

B (44:21)

Right.

D (44:21)

But for the most part, a lot of it I see as downstream. Is that your experience?

E (44:27)

It is. And I will say, with the exception of menopause, because while a lot of women get better, there's Still a subset that the estrogen itself being so low, can be playing a role with some symptoms. Okay, so because there is a, there's a documented change in those hormones.

D (44:41)

Yeah, but like 85 year women are not having hot flashes.

B (44:44)

True.

D (44:44)

And they have low estrogen.

E (44:45)

True.

D (44:45)

Right. So what's going on?

E (44:47)

Oh, that's true, that's true. Actually, about 15% of them will continue to have that. So we don't know what's going on with those women.

B (44:52)

But.

E (44:53)

And oh, and one other thing that showed up for her. She had some common nutrient deficiencies. Her B12 was low, her vitamin D was low. And we mentioned about vitamin D playing a role as actually a hormone as well. So we targeted all those things and she was feeling better, especially the brain fog and fatigue. So that responded really well to the nutrition approaches and addressing her gut.

D (45:14)

So you basically fixed your gut gut elimination diet and healed the microbiome, which is a core part of what we do in functional medicine. And whatever you've got, it's kind of usually plays a role. Whether it's heart disease or diabetes or cancer or allergies or autoimmune disease or autism or ADD or hormonal issues. We really have to look at the gut as a central feature. And so you're saying just by getting rid of the bad bugs, getting rid of the bad foods, put her on foods that healed her gut and things that healed her leaky gut, she improved.

E (45:43)

And supporting her nutritionally. Absolutely. Migraines got better, migraines got better. Migraines got better, allergies got better. Yeah.

D (45:50)

So, Cindy, we did all these things. You did all these incredible things. You diagnosed her with all these imbalances. We corrected them and we do this kind of work at the Ultra Wellness Center. We do deep dives. We find all these things that need to get corrected, we correct them, and people's health just dramatically improves. But sometimes with the hormone issue, you need to use hormones, and it's not that they're bad or good.

C (46:11)

And I think we get into this.

D (46:12)

Binary thinking in medicine. It's good, it's bad, it's good, it's bad.

C (46:15)

And the truth is it's gotta be.

D (46:17)

Personalized, different for everybody. And there are some rules and principles that I think we follow in functional medicine around prescribing hormones, which I want to get into.

C (46:26)

But tell us the rest of the.

D (46:28)

Story with this woman. You got her mostly better, but then she was still having very low estrogen.

C (46:33)

Right.

D (46:34)

What did you do?

E (46:34)

She came back in about three months later. And, and articulated that she was feeling better. The brain fog, that fatigue, her migraines, her allergies, they were all better. But it's interesting, the hot flashes were continuing and her sleep was being more affected. So she now came back saying, you know what? I think I do want to try hormones. We had this conversation back and forth and of course you're gonna do your due diligence before prescribing hormones. You wanna make sure that she's up to date with her mammogram and there's no concern there, that she hasn't had any dysfunctional bleeding, that it raises a red flag and you wanna make sure that there's no hyperplasia or anything going on.

D (47:07)

Heavy bleeding in the perimenopausal area where you get like pre cancerous stuff in the uterus. And you can check that with a vaginal ultrasound.

B (47:13)

Right, right, right.

E (47:15)

And she didn't have any of that.

D (47:17)

So we decided, and now we have something really cool we do is a liquid biopsy, which we didn't have years ago, which is essentially ability to track cancers through a blood test. It looks at fragments of cell free DNA where we can actually see, oh gee, well, maybe we should screen and see not just with a mammogram, which misses a lot, but actually a gallery test which looks at liquid biopsy. And then you say, gee, I'm pretty comfortable this person is not having some latent cancer and I'm going to throw some estrogen on it and give her a problem.

E (47:43)

Right. So we decided to try hormones. And my general thinking about hormones, you know, that term bioidentical like created a lot of confusion back in the day. But my favorite way to do it is to use a patch which has a lot of customizable doses and it's an estradiol that is pharmacologically exactly the same as what your own ovaries would have produced before menopause. I like it because it's convenient. You put it on twice a week, it gives you a steady amount of estrogen. Like I said, there's a range of doses because she's symptomatic. I'm going to start with a mid level dose. We started with a mid level dose for her because she has her uterus. She does need progesterone because progesterone is going to protect overstimulation or over thickening of that lining of the uterus. And we can also take advantage of progesterone because it has some calming sedating effects and give it at Night. So it might also help her sleep.

D (48:36)

Like the body's natural Valium?

E (48:37)

Yeah, yeah, yeah, absolutely. So that's what we did. We started her on a patch.

D (48:41)

And was that an oral progesterone?

E (48:42)

The progesterone is oral for her. It was.

D (48:45)

And it's. And it's not just the progesterone that we used to prescribe. Provera.

B (48:48)

Right.

D (48:49)

My joke with that one, it's. It's called methoxy progesterone. It makes women fat, hairy and depressed.

C (48:56)

And it does.

D (48:57)

It's horrible, in fact. It makes. It makes people eat more. They use it during cancer treatment to get people to eat more. And so when cancer patients are starving because they're losing weight, they give them this to increase their appetite. Right, Yep.

E (49:11)

And we can talk about that because I think the Women's Health Initiative, which prompted everybody to throw their hormones in the garbage, one of the downsides of it or one of the potential flaws of it. Two of them, actually. Most of the women were in their 60s, so they're a decade past the average age of menopause. And physiologically, women are in a different place then. They might not get the same tissue responsiveness to estrogen. And they used Premarin, which is conjugated equine estrogens.

D (49:37)

Horse estrogen. Horse estrogen, but it means pregnant mares urine.

C (49:43)

Premarin. That's actually how they got the name.

D (49:45)

It's get it from pregnant mares and.

C (49:47)

Then they concentrate it and it's horus.

D (49:49)

Estrogen, which is very different than ours. And it's very inflammatory and quite toxic.

E (49:53)

And when it's given by mouth, it goes through the liver and creates higher C reactive protein inflammation markers, higher clotting factors it worse insulin resistance instead of better insulin resistance.

D (50:04)

Higher triglycerides.

E (50:05)

Higher triglycerides. So all of the things that were blamed on estrogen and hormones may have been more a function of the older age group of the women when they started and the formulation and the route of administration.

D (50:16)

So they used basically the wrong kind of estrogen and the wrong kind of.

E (50:19)

Progesterone and the wrong route of administration.

D (50:22)

And the wrong route of administration.

C (50:23)

So, yeah, so the philosophy we use.

D (50:25)

Basically is use as little as possible for as short a time as possible for with the hormone that's same as your body makes and give it bypassing your liver through your skin, hopefully, or under the tongue or. There's a million ways to do it, but basically it's doing it mostly trying to mimic nature and not overdoing it.

A (50:49)

And not underdoing it.

E (50:51)

So that brings up another point. It is not common practice. Once you put somebody on hormones to follow up blood levels.

D (50:58)

Amazing.

E (51:00)

You know what?

D (51:01)

And for me, it's like giving a.

C (51:02)

Person a blood pressure pill and not.

D (51:04)

Checking their blood pressure.

E (51:05)

Exactly.

D (51:05)

Or giving someone a cholesterol pill and not checking their cholesterol.

E (51:08)

So we want to see does it help the symptoms, but we also want to see, well, what is your blood level? Because that can help you gauge. For example, if I start at a given dose of a patch and she comes back and she's still having hot flashes, how well is she absorbing that patch? Is it enough to get a measurable rise in her estrogen or not? Because then that can guide the dosing. I also just from trying to thread the needle of risk and benefit, I don't believe in supplementing somebody's estrogen to the level it was when she was in her 20s or trying to get the benefits, but not really drive too much estrogen. So we mitigate risk.

D (51:42)

Yeah.

C (51:43)

And you know, I don't view this.

D (51:44)

Cindy, but I often will check estrogen metabolites on women who are taking hormones. So I can assess whether or not they're producing toxic estrogens. I will often look at their genetics. You mentioned genetic testing and there's genetics around estrogen metabolism. We can look at like COMT and other hormones, methylation hormones, methylation pathways like mthfr. And basically in English, that means we can check various enzymes that are involved in detoxifying estrogen and whether they're working well or not. And then we can use science to find the right cofactor for that enzyme, which is a nutrient. Right. And so we can start to build a very scientific way of, of personalizing here. And this is where all medicine is going. We're all going to be doing this. And right now, sadly, very few people get this. And it's really why we, we do the work we do at the Ultra Wellness center to give people the chance to get access to the future of medicine now.

C (52:37)

And the good news is people get better.

D (52:39)

Like, it's just amazing to see these.

C (52:41)

Stories that you're telling.

D (52:43)

It's so satisfying because, you know, people have, have all these symptoms, not just menopause, like allergies, migraines, gut issues like this woman had. And, and you were able to get all that sorted and then get her back on track and, you know, people can come back and basically have a resolution. A lot of these really difficult problems that we don't have good solutions for in traditional medicine.

C (53:03)

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C (54:10)

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D (54:18)

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