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Duologue with Leslie Heaney
Redefining Menopause: What Women Need to Know - Dr. Cat Brown, Medical Director at Winona
01:13:34
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- [00:03]
A
Hey, everybody, this is Leslie, and you're listening to duologue with Leslie Heaney. This past Saturday, October 18, was World Menopause Awareness Day. You may not have known. And here to bring us all the latest and greatest in all things menopause is menopause specialist Dr. Kat Brown of Winona Health. Winona Health is a telehealth company that empowers, educates and treats women throughout the entirety of their menopause journey. In this episode, Dr. Brown and I talk about all things menopause symptoms, the latest treatments, the latest research around hormone replacement therapy and what the FDA is also doing around menopause. And in this space, Dr. Brown gives us all the latest hot off the press research information. This is an episode you will not want to miss. Dr. Brown, I'm so excited to be here with you today, just a few days after World menopause awareness day, October 18th. Thank you so much for being here.
- [01:03]
B
Well, thank you so much for having me. It's a pleasure.
- [01:06]
A
So I did an episode about 18 months ago on the subject of menopause. And in the course of that time, I feel like it has just become. And maybe it's because of my algorithm on my Instagram or my age and I'm looking for it, but I feel like awareness has grown so around this issue. Right. We all, as women will eventually go through this process. And, you know, there have been people like Dr. Mary Claire Haver, who's out talking about it. Naomi Watts, the actress, has a whole product line to kind of deal with some of the symptoms around it. And I don't know, there's this amazing woman, if you're on Instagram, Dr. Brown called Melanie, and she has this I Do Not Care club.
- [01:50]
B
Oh, yeah, she's been all over the place.
- [01:53]
A
It's wonderful. Oh, she is so great. I was wearing like pajama bottoms to go get the mail or something, and my kids were like, are you wearing pajama bottoms?
- [02:05]
B
I'm like, oh, yeah.
- [02:05]
A
I'm a member of the Do Not Care club. My husband's like, can we care a little? Can we just care a little? You know, just.
- [02:10]
B
But I.
- [02:11]
A
Anyway, I feel like when you hit a certain age, you know, it is. It just sort of does capture that, you know, the feeling among us ladies that are going through that. That process. Right. Of it sure does.
- [02:24]
B
And I tell you, like, it's liberating to not care. You know, I have to confess, I wore pajama bottoms to drive my son to school this morning. I was like, you know, What? I'm not getting out of the car. It's totally fine.
- [02:37]
A
Yeah, it's so great is when you hit that part of your life where you're like, you know what? I don't necessarily have to brush my teeth just to drive the kid to school or just to. You know, There are certain things that you can definitely get away with, for sure, at the perimenopause and menopause ages. But even despite all of this coverage and awareness, I feel like so many women, or I'm 51, my female friend group, we talk a lot about this subject and what is your doctor saying? And so I think it's great to continue the conversation, and I'm just so delighted that you're here to kind of walk us through some of these things. I thought we would start. I want to get into all the symptoms because, you know, that's sort of how we all realize it or know that we are going through it when the symptoms show up. But could we talk about sort of maybe just at a high level for people who are not as familiar, maybe are some of the men out there who might be listening about what is menopause technically, what is perimenopause, and sort of what are the ages of when those two things generally start?
- [03:48]
B
Sure, sure. So menopause is a natural transition that women go through in midlife that really marks the end of fertility. It's really when our periods stop and we're no longer able to reproduce, just like every other mammal in the world. You know, we have a lifespan as far as when we can actually reproduce and create other mammals like our kind. So when we have that last period, you know. You know, once a last menstrual period happens and 12 months have gone by since that last period, we can say that you're officially menopausal now. Perimenopause is basically that time period leading up to that. It's when our hormones are changing. The ovaries are starting to ramp down their production of hormones. And it's all that time period from when your symptoms start and when that transition starts until that final period happens. So for some women, and for most women, it's. It can be up to 10 years that you can be living in perimenopause. So it's kind of crazy when you think about it, but we could still be fertile and we could still be reproducing during that time, too, but also start to have menopausal symptoms start to creep in. So it's crazy because women, you know, the average age of menopause in the United States is 51. So if 10 years of perimenopause can happen, that means you could start at 41. Some women are earlier and that's the average. Right. So there's always going to be like, when you think about a bell curve, you know, when you were in school and where the grades fall, you know, there's gonna be women that are younger than that, women that are older than that, but that's the average is 51. So.
- [05:16]
A
Well, I remember I had a very close friend. She and her partner did not end up having a child, but they were going through IVF. And she was in her late 30s at the time, and she was not producing very many eggs. The quality of her eggs was not very good. I was really surprised that that would could be happening in your 30s. And I know Naomi Watts, I've heard her story too, is a similar thing. She wanted to start having kids in her late 30s and she was in perimenopause. I mean, her hormones were all over the map and all the. She was having all the symptoms and was ovulating, I think maybe. I don't know if you ovulate less or you just don't have as strong quality of eggs.
- [05:55]
B
So I think not a lot of women realize that we are born with all the eggs we're ever going to have. They don't regenerate during our lifespan. So the most eggs we ever have is when we're actually a female fetus inside of her mothers. And then as soon as we're born, a bunch of them die off. Even before we hit puberty and before we start having menstrual cycles, more die off. And so when we start having our periods, you know, an average age of the first period is around 12, 13 for most women, sometimes younger, sometimes older. But then we start releasing an egg each month and we ovulate each month. And that's why we have that whole cycle. You know, we have menstrual cycles each month, but there's also like, you know, death of the eggs just by attrition and by old age. And so by the time we get to our 30s, you know, it's 30 years of those eggs dying and desiccating. And, you know, so that's. It's crazy, you don't think about it, but that's really the background of why our hormones are changing. Because we have the hormones to support those eggs. And when those eggs are gone, the hormone production really starts to decrease significantly.
- [07:05]
A
So you brought up the big H word of hormone. And I think I want to talk about one of the hottest topics around perimenopause and menopause is hormone replacement therapy. And I think that there are some, at least from what I've learned from doing that episode last year and kind of again, because I am 51, all that comes across my algorithm on Instagram. So I feel like I know about it. But obviously here, I'm here today to talk to you, the expert on it. But it seems like a lot of the controversy and concern or recommendations around the use of hormone replacement therapy has evolved or changed over the past couple of years. So I thought maybe it would be helpful. I know too. This past Summer in July, Dr. Marty Mackerey, I hope I pronounced that correctly, who's the head of the fda, gathered a group of experts to talk about menopause and menopause treatment. But for people, I have friends who either have a history of breast cancer, who've had breast cancer, history of breast cancer in their families, or they themselves are breast cancer survivors who just automatically sort of dismiss hormone replacement as an option for them. And I think that was also based on a study. So I thought maybe we could talk about, if you would give a little more background about how HRT really, hormone replacement therapy got a bad name or bad rap.
- [08:31]
B
Right.
- [08:31]
A
And then what does science say today and what are the recommendations for today?
- [08:36]
B
Yeah, absolutely. So I think, you know, looking into the history of this, women really didn't get many treatments. Medical studies in women just really haven't been done. And even birth control wasn't really available until, you know, the 60s, 70s for most women. And so back in the 80s and 90s, there was a movement where many women were getting HRT and were getting hormone replacement therapy and doing very well. But they realized there weren't many guidelines and there wasn't much information about its safety. And so there was a big study that was done called the Women's Health Initiative Study and that finished in 2002. And basically before it could really be peer reviewed and before it could really be scrutinized by the medical community, they ran with these results and things started be releasing in the news and press and all these headlines started coming out about the dangers of hrt. And they were taking some, and some people say it was a bad study. It was actually a really good study. That was the first time they did a really large scale study looking at this in women. Now we've learned a lot of really good things from that study. But what happened was they took these headlines and little snippets of information from the results of the study and, and went rampant with it in the news. And so suddenly there was this mass fear produced as a result of this study where everyone said, oh God, this is really dangerous. I'm going to pull all my patients off of it. So literally, nationwide, doctors were stopping hrt, women were throwing away their HRT and they weren't really looking at the big picture. So that really swung the pendulum. And then suddenly in the early 2000s and thereafter, no one was getting HRT. It really wasn't made available because of the fear. And it was really the fear of, you know, is HRT going to cause cancer? Is it going to cause somebody to have a blood clot? And what we learned about that study overall is that there is a magic window of time where it's the safest to start hrt. And the women that were at higher risk were the ones were, that were started at a much later age than really would be safe to start somebody, you know, after age 60, you know, after you've been through menopause and you've been menopausal for more than 10 years, it can be more dangerous than good to start you on hormones, you know, you know, at the first point in your life, 10 years after you've completed menopause. So really we're still fighting that stigma and all that negative press that came out of that study. But now more and more information is coming out and now there's more of a call for research and more studies have come out actually showing its safety and the benefits of hrt. So, you know, I think what women have to realize now and the data, like if you, you, anybody can watch that FDA panel that was convened in July, it was excellent. They took some of the world's, you know, experts on HRT and they had basically a short amount of time and they had one slide to be able to present, but they really presented some really great information about the risks and benefits of the medication and really the long term benefits of it and how it can protect our bones as women, how it can really protect our hearts. Because I think there's this widespread panic and fear about getting breast cancer from taking hormones. But what women don't realize is that more women in America die from heart disease and heart attack every year than ever die of breast cancer. So we have this really unfounded fear of breast cancer. And thanks to the Susan G. Komen foundation and all the press that breast cancer research has gotten and all of that, there's this. A lot of knowledge about it, But I don't think women realize they're much more likely to die of a cardiovascular event like a heart attack or a stroke than they ever would be to die from breast cancer.
- [12:06]
A
Yeah. So going back to that Women's Health.
- [12:09]
B
It'S the Women's Health Initiative, whi we call it for sure, the Women's Health Initiative. Yeah.
- [12:13]
A
That test group or that group was generally over 60, getting HRT or starting HRT a little bit later. And that was sort of why it probably isn't a great indicator of how people would be reacting to HRT at younger ages.
- [12:33]
B
Yes. And the other thing, too, what we know too, like, as menopause providers now, the medications they were using in that study were synthetic forms of hormones. So they were using conjugated estrogens, which. One of the oldest medications, like Premarin, which is actually a conglomeration of estrogens, some of which are not even biologically active in human females. So the Premarin word actually comes from pregnant mare's urine. The first time they got that drug, it was actually from extracting it from the urine of pregnant horses. So there were horse estrogens in that drug for a long time. And so what we know now is that if we give women what we consider to be bioidentical, meaning that the hormones we're giving them are the same hormones that their body was producing on its own when it was producing enough, like we have three estrogens in our body as women, as human women, it's estradiol, estriol, and estrone. And anything other than that is a synthetic form. So, like when we take birth control pills, those are synthetic forms of estrogen. Also, the progestin that they were giving, which is a form of progesterone, where synthetic progestins would they. So when they were doing the whi, they were giving a lot of synthetic medications. Where now the really, the push, you know, with medications now, especially with giving hormone therapy, is to give the same exact molecule that our body was making on its own. It seems like, you know, it makes more sense to give your body back what it was making on its own so that it can be more efficient in utilizing those hormones because it's already familiar with their shape and their structure. Like, if you think back to, like, high school chemistry, you know, when you think about a synthetic medication, it's very similar, but it's not the same chemical structure. So your body might not be able to utilize it as much so you end up having to use a higher dose to achieve the same effect as. Whereas if you give the patient back a hormone that they were creating on their own, their body's more efficient in utilizing it and incorporating it into the system.
- [14:28]
A
That is fascinating. I mean, I have a patch. I'm patched and creamed from stem to stone.
- [14:33]
B
Really.
- [14:34]
A
These days I feel like the. And I think I'm on estradiol.
- [14:37]
B
Yeah.
- [14:38]
A
So is that enough or are the drugs being even further refined where they're providing you with all three types? Is that what you're saying? There are three different types?
- [14:48]
B
There's three different types our body has, but estradiol is like the powerhouse. Like, that is the most biologically active estrogen in our body and it does most throughout our body. So being on estradiol patch is perfect. That's exactly what you need with that initial study.
- [15:04]
A
Some of the conclusions that were made were sort of flawed in that it doesn't reflect the sort of the whole population. So that's one issue. And then what about though, is HRT more of a risk factor for people who do have a history of, of breast cancer or are breast cancer survivors?
- [15:27]
B
So it's really. If you're a survivor yourself, right? So if you have, and it's not just breast cancer, but if you have had any kind of female related cancer, whether it be breast cancer, ovarian cancer, uterine cancer, the only one not incorporated into that is cervical cancer because it's typically related to the human papillomavirus, which is sexually transmitted. Okay. But any of the other forms of female cancer, if you have a personal history of those cancers, there's the potential that taking hormones of any kind, whether it be a birth control pill, whether it be hormone therapy and menopause or perimenopause, could feed any residual tumor that could be left in your body. Because especially with breast cancer, you might have heard like a erpr, it's estrogen receptors, progesterone receptors, like some of the tumors actually have receptors for those hormones. And so if you take in exogenous hormone, meaning hormone that's not made by your body, then it could feed tumor tissue that's still lurking in your body. So that's a conversation. It's not that it's completely contraindicated, but you're at higher risk if you've had a personal history of cancer. It's not the same though, as having a family member with cancer. So just because you've had other women in your family that have had breast Cancer does not mean that you're not a candidate to take hrt. Really, we look at many different factors, and now we have genetic studies that we can do to see if you're a carrier of the breast cancer gene, the BRCA gene. So if somebody has a genetic syndrome that increases their risk for breast cancer, they're at much higher risk than the average population. But other than that, if you've had a grandmother or an aunt or someone else with breast cancer, you could still be a great candidate for hrt. Personally, just having a family member does not increase your risk that significantly. But, you know, it's really a personal decision that a lot of women have to make. Right. So, you know, when you're going to see your doctor and you're going through this and you're writing down your symptoms and you're trying to figure out how best to treat yourself and how best to move forward, it has to be an intense conversation and some shared decision making. You know, talking about what your risks are, what the benefits are. You know, anytime you make a big decision, you should think about the pros and cons, and each woman has to make that decision for herself. I think in weighing the good, the bad, and determining, like, what is worth the risk or not.
- [17:42]
A
Right. That's interesting. So just for people who are maybe gene carriers, they also might be in the same boat as someone who was a cancer survivor. Right. But those are things, as you're saying, you really need to get into the weeds with your doctor about and weigh the pros and the cons.
- [18:00]
B
Absolutely.
- [18:01]
A
So with sort of this evolved thinking around it or new science around it, has the FDA changed its recommendations or warnings on some of these drugs or.
- [18:13]
B
Not yet, but that's what the FDA panel was really calling for. That of the biggest things during that FDA panel was that they were talking about vaginal estrogen a lot and systemic estrogens. But the main thing is, even if you've had a breast cancer, you have a higher risk for taking systemic hormone, meaning that hormone that goes throughout your entire body. You can still be a candidate for vaginal estrogen because there's. There's a significant set of symptoms that happen to us in menopause called genitourinary syndrome of menopause. Used to be called atrophic vaginitis or vaginal atrophy, but really it can include, you know, the changes to the vagina. Like, our vagina gets dry, we lose lubrication, but also the tissue around our urethra and our bladder loses support. So we get more risk of, you know, incontinence and urinary tract infections, things like that. And what happened is they took this big black box warning that's on systemic estrogen that talks about, you know, if you take this medication it might increase your risk of having a heart attack or stroke and this and that. It's like a very fear mongering little box that's in the like pharmaceutical paperwork that you get when you get your prescription. And they put that same black box on vaginal estrogen when it absolutely does not apply to vaginal estrogen. Vaginal estrogen we give topically to help support the vaginal tissues. But it's typically only, it's only locally absorbed, not systemically. So it really only gets absorbed in those tissues down there in the vagina, the vulva. And so it doesn't increase your risk of having a blood clot or stroke. It really doesn't increase your risk of those other things. And so they were really pushing for in that panel like let's get rid of the black box warning on vaginal estrogen. And so those things take time. You know, the FDA had that panel and then they had like an open forum where you could go onto the FDA's page and you could either write and support or refute, you know, what they were trying to recommend as far as removing that black box and, and just make commentary on the panel. And what they're going to do is they're going to look at all that information, get more information from the experts and then they'll decide if they're going to make changes. But the menopause community of providers across the country, we're really hoping that they make change. Because the worst thing is when I recommend something for a patient and I order it and then they get the packet and they get home and they read that black box and they're like, Dr. Brown didn't say I was going to do that X, Y or Z. And then they lose trust in me because they see that black box warning and I try to explain to them it really doesn't apply to this product, to vaginal estrogen. But they don't understand. They just see this paperwork they got from their pharmacists. And then we also have the problem with the pharmacists then fear mongering and perpetuating a lot of the fears and a lot of the unfounded warnings about HRT to patients. And so the patients then are confounded. Like, they're like, well, who do I believe? Who do I trust? You Know they want to feel better. They're desperate to feel better. But when you get that paperwork, any paperwork you get with your medication, if any of you have ever read it, it's scary. It's very scary.
- [21:08]
A
How about the commercials when people are like, you'll be bleeding from your eyes. And I'm like, no, I don't need to take that for itchy skin or whatever the thing is. But that is, you're hitting on something, though, with the pharmacist. And not all healthcare is created equal in this country. And some doctors are constantly reading new papers and learning more. Others are perhaps have been practicing for a long time and feel like they don't need to be as sort of on the forefront of the new science. But what's dangerous about that or what's frustrating about it is then you have situations where your patient gets home and says, oh, gosh, I don't want to have a higher risk of cancer because I'm using vaginal estrogen, which, to your point, shouldn't even be, shouldn't even be in the paperwork.
- [21:55]
B
Yeah, exactly.
- [21:56]
A
But I'm glad the FDA is taking the lead on that because I think once the, with that shift, then there will be that trickle down where everybody, everybody seems to follow the fda, you know, recommendations generally.
- [22:10]
B
Right? Generally, yeah. And, you know, we look to, I mean, as a group of people, we look to these bigger organizations to help to reassure us that things are safe. Right. Generally you'd like to know that something you're taking has been vetted by this greater organization that's supposed to be making sure that you're safe. And so a lot of patients, I think, are kind of waiting for that, and I think a lot of doctors are too. But the problem is, is that it takes some time. Sometimes they are not up on the latest science. And so that's, that's the importance of why they had that FDA panel convene because it really was a great venue for them to talk about the latest and the most critical current information of what we know about hormone therapy and it's safety.
- [22:53]
A
Yeah, so, so we talked about the vaginal estrogen. I know because I have some of these things. I have my progesterone and I have my patch. I also went to an endocrinologist for something else, and she was saying that my testosterone level was so low, so she gave me some testosterone cream that I put on the back of my knees three days a week or whatever it is. Should women be getting a full panel to get all their hormones checked? At what age and then what different types of hormone replacement are kind of out there and how is it customarily administered?
- [23:34]
B
Yeah. So the most important thing that I can share too is that when it comes to lab test, if you're considering testosterone treatment, that's the only lab test that typically that we use is when you're replacing testosterone. You have to check levels to make sure it doesn't get too high. But for the average woman going through.
- [23:51]
A
That road rage or beard, I mean, yeah, okay, yeah, you don't want, you.
- [23:55]
B
Don'T want to grow facial hair and your voice change and you know, there's masculinizing side effects that can happen if you get too much testosterone. And that's another thing the FDA panel talked about too, back in July, is that we do not have an FDA approved product or medication to be able to offer to women at all in the United States. So the cream that you're using is actually a male product. It's FDA approved only for men. And so it forces doctors to have to extrapolate and kind of do the guesswork of trying to figure out what an appropriate dose is for a woman because they don't have an FDA approved product of testosterone for women, even though women have testosterone too. I don't think a lot of women realize that, like we have our female hormones, we have estrogen, we have progesterone, but we also have testosterone circulating in our body. It's responsible for a lot of other functions in our body, like our libido, our metabolism. It really has a good effect on our muscle maintenance and our energy level, things like that. And I think a lot of them don't realize they're like, well, I'm a woman, I don't have testosterone. No, you absolutely do. So. But when we're talking about perimenopause and menopause, getting hormone levels really is not helpful. So actually, the guidelines from our menopause society and also the American College of Ob GYN do not recommend getting hormone testing routinely. There's no test that we can order that can tell me when I look at the results, like when I could guess or predict when a woman's going to go through menopause. It doesn't tell me how best to treat her. It doesn't tell me what dose is going to be helpful. So it really is not very helpful information. What's actually more helpful is to start doing symptom tracking. So for women, it's about, you know, learning what are the common symptoms of perimenopause what are the things I should be looking for and tracking those things over time, because as a menopause provider, that's the information that's much more important to me and much more useful for me to know, because I can look at a woman's list of symptoms and I can tell you, okay, these symptoms are happening because her estrogen is dropping. These symptoms are happening because it's more of a testosterone issue. So starting someone on treatment, you really don't need to do any labs. And even after starting hrt, if you're starting estrogen and progesterone, and the reason why you need both is basically whether or not you have a uterus. So for most of us, the treatment we need as we go through this transition is estrogen. But if you still have your uterus in place, meaning you have not had a hysterectomy, the progesterone is added in mainly to protect that uterine lining, because estrogen is so beneficial throughout our entire body. But the one really negative thing that it can do is it makes that uterine lining overgrow or fluff up, kind of like a shy carpet. And that can lead to cancer if not checked and not regulated. So progesterone's main function, and it can help a little bit with some of the other symptoms, but its main purpose is to keep that uterine lining nice and thin while you're taking estrogen.
- [26:43]
A
Interesting.
- [26:44]
B
Yeah.
- [26:45]
A
So you'd want to test your testosterone levels as a female after you start.
- [26:50]
B
Treatment, mainly to make sure you're not getting in a dangerous zone.
- [26:54]
A
Are there zones, you know, like for cholesterol, for example? And I've, you know, learn. I just play a doctor on tv. I learned this from, you know, my kids are like, would you get this from Instagram, too? But maybe. But I know that, you know, there are what doctors will say normal range, and then there's optimal range. Is there such a thing for. I know you just mentioned estrogen and progesterone, rather, you know, don't have. You can't. Getting. Looking at those levels isn't going to really help you. You're really looking for the symptoms. Right, Right. But with testosterone, are there, like, sort of healthy ranges that doctors kind of will know? I mean, my doctor did say, I can't remember what mine is. Mine is like. She almost was surprised I'm standing up because my testosterone was so low. And I do feel, by the way, better, a bit more energized by being on it than I am than I was before. But Are there optimal ranges for testosterone? Is that something we should be?
- [27:51]
B
I mean, there are, and there's different studies that have been done that have come out with, like, a chart for. For where women should be. But again, this is kind of like a call for more research and more information, because most of the charts out there for normal testosterone levels are for men. There are some for women, too. But every lab, anytime you get your levels done, like, if you're going to a hospital or you're going to a separate lab place, they all set their own levels for everything. Whether you're getting a blood count or a chemistry level, getting your liver function tested, Every place that does labs has their own ranges and their own, you know, parameters that they look for. So, and some of that's based on, you know, papers.
- [28:32]
A
They.
- [28:33]
B
They get the information from, you know, some medical. When it comes to medicine textbooks, by the time it gets published in a textbook, it's really old information. So most of the time we look at research studies that are in our medical journals. And, you know, one of the things that we have to do as physicians is to do continuing medical education. And so there's. You have to constantly stay on top of that. And most specialties have that requirement where you have to continue to do, you know, basic education each year to stay up to date. So, I mean, there are levels out there, but it's going to vary. Like, I wouldn't want to say a number, because then if you go to the lab and somebody listening is going to their lab, and their number is somewhat a little bit different because their lab parameters are a little bit different for the. For the assay and the specific test that they're doing at that lab.
- [29:15]
A
But there is a guideline. So it's not totally the wild west.
- [29:18]
B
On the test, what they're looking for, what it is that they're gonna do with the information when they do get the labs. And so there's gonna be some doctors that don't feel comfortable doing levels of anything. If they're not somebody who's prescribing testosterone, they're not gonna be as familiar with looking at testosterone levels. But it's. It's one of those things where if you go to your physician and you're bringing up the fact that you're feeling awful, you're feeling fatigued, your periods are out of whack, you know, you're starting to talk about all the symptoms of periods, perimenopause or menopause, and maybe you're still having cycles, but they're only coming every three to four months or every six months or something like that. And you're going to talk to them about what's happening and they don't want to hear it. Or they tell you, well, this is normal. Or, you know, you're, you're feeling down and you're feeling moody because you're depressed. Here's an antidepressant so, so common that women are just kind of like shushed and kind of told, well, this is a normal part of your life and you get used to it. But when we're going to them or we're telling them like, I don't feel well, I am not functioning like myself. I don't want to feel this way. This is affecting my work, it's affecting my family, my relationships, my interactions with people. And I just don't feel like myself. A lot of us that are going through this transition feel like we're. It's like an out of body thing. It's like we are ourselves. If your doctor is not receptive to that and if you're not seeing a doctor, say you're seeing another provider like a PA or a nurse practitioner. Don't be afraid to just come out and ask them, are you comfortable talking about this? Do you have the experience with dealing with patients with this? And if they get offended, that's your answer right there. They should never get offended. They should be open and say, you know what, I don't really have much experience with this. Then ask them, well, who would you refer me to? You have somebody that you refer patients to for this and if they don't, that's exactly why our platform, Winona exists. We exist for people that do not have access to a doctor in person who's willing to help. Or maybe they live three or four hours from their doctor and it's just a pain in the ass to really drive all that way to go in to get seen. But I think that, you know, as patients, what we have to remember is that we navigate our care. This is our body. We only get one of them. We have to take the best care of it that we can. And if we're not getting the answers that we need, you got to be that squeaky wheel. You got to demand better and you have to push for the care that you need. I think, I think that's. We have to remember that.
- [31:35]
A
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- [33:25]
B
And that's another thing, that's another fallacy that a lot of people out there believe is that if you're still having periods, there's no possible way you could be suffering from menopause symptoms. And that's just not true because until those last few eggs die off and until our period completely ceases, you know, there's symptoms starting to happen as our levels are changing and our hormones are dropping. And that's what a lot of doctors feel that way that they're not safe to prescribe to you. But for some women, by the time your period actually stops, it seems like it's too late because you've already been suffering for years with symptoms.
- [33:58]
A
Yeah. You know, and the suffering is real. I mean, it is real. It's no, I remember my mother being like, I'm having a hot Flash. And I thought she was being dramatic. And I have some newfound patience and respect for some of the things that she went through, having gone through them myself. But just quickly before we move on, because I want to talk about the benefits of HRT and then all the different side effects of menopause and stuff to look for. Is there any alternative? And I had read, I think I could, that there, that the FDA is looking or they're recently approved some drugs to help people who are in a high risk category with some of the symptoms. Can you talk about that?
- [34:37]
B
Yeah. There's a new medication out that's called Vioza, which is a medication that works in the brain, actually on neurotransmitters in the brain to really help with hot flashes.
- [34:46]
A
Okay.
- [34:46]
B
What we consider, we consider hot flashes and night sweats. They're in the category of what we call them vasomotor symptoms. It's basically your body is unable to self regulate its internal thermostat. And so these can be triggered any time. They can be triggered by stress, it can be triggered by alcohol, various things. But also they can just happen haphazard too. So if you're someone who has had a history of breast cancer or ovarian cancer and say you're in that higher risk category where hormones might not be the best option for you, then this is an alternative to help with some of those symptoms. You know, the downside is it doesn't give you all the benefits that taking estrogen can give you. As far as for your bone health. It won't help with brain fog. It won't really help with some of the other mood symptoms. It really only addresses those vasomotor symptoms like the hot flashes and night sweats. But it's the first thing that we have in a while. That's a good alternative. We've had other non hormonal forms of medication that we could offer patients for symptoms over the years. Some of them, you know, we can use antidepressants which can sometimes in low doses can help with hot flashes. There was also an old blood pressure medication that was a really old school medication that would also help with hot flashes when given to patients in this time period too. And there's a seizure medication that we use. It's. It's used for things like chronic pain, for seizure disorders. But that has also been shown to help with hot flashes and night sweats too. So we had those around for years that we would use. But this is like the first, the vioza is the first medication we have that's new in a long time. That's a non hormonal alternative. So it's nice to have another option for sure.
- [36:16]
A
For people that think that they just have to suffer in silence, there is, there may be another non hormone medication that they can take that can help alleviate some of the symptoms. Okay, you mentioned a little few things, you mentioned cardiovascular disease and I think osteoporosis. But let's talk about all the exciting positive effects of hormone replacement therapy.
- [36:39]
B
Absolutely. So really, when you look at estrogen, it's really like the powerhouse hormone for a woman's body. So estrogen really affects our skin and all of our tissues. It helps to maintain their hydration, helps to keep skin and hair and nails healthier. So a woman who has high levels of circulating estrogen, her skin is more supple, it's more moisturized. And so when we lose estrogen, you get this dryness, the skin gets thinner. Actually we lose like the thickness of the skin, the elasticity also. So that's one of the benefits. You know, there's like anti aging benefits. Right. So if you have continuing good levels of estrogen in your body, those negative changes that happen with the loss of estrogen decrease significantly also. It's, you know, for our muscle health and our bone health. You know, keeping the bones healthy, keeping estrogen circulating, helps to keep the bones strong. We also have to do our part as women. It's like going on medications and going on hormones is not like a magic bullet. You still have to do the lifestyle changes that you need to, to take care of yourself. Like I said earlier, like we have this one body, right. We have to take care of it the best we can. So part of doing that too is that we have to maintain our strength. Right. So we have to do as much activity as we can. And finding a way, like I think that so many of us feel like it's an all or none thing. Like if you're not the perfect gym body, going to the gym so many days a week, doing everything perfect in the perfect little gym outfit, that it might not even worth it. But that's not true at all. It's just finding moments of movement, like taking the stairs for a couple flights at work instead of taking the elevator, parking further away from the grocery store and walking a little bit more of a distance rather than parking right up front or getting an instacart delivery or something like that. If we find like these moments of like 10 minutes, 15 minutes of walking or adding things into our life, it has tremendous benefits. For our heart health, but also for our strength and our bone health and our muscles. And I think the other thing too, that women have to realize is they need to do weight bearing or resistance exercises. You know, we don't want to be those little old ladies that are frail with our, like, you know, the little hump on our back, and we don't want to fall and break a hip, and it can be devastating. And really, you know, you want to maintain that health and vitality. And so we have to do that with like, our nutrition and our exercise. But also keeping estrogen circulating in our body helps to keep those tissues healthy as well. So on that FDA panel, they actually had an orthopedic surgeon, Dr. Vonda Wright, who's wonderful. She's another good person to follow on Instagram. Really great information. But she was pushing the FDA to really give more recommendations for estrogen and on the safety of estrogen, because she really, in her case was. She wishes she didn't have to put so much hardware in women who are falling and breaking a hip, who have no bone structure when she goes to try to repair it. Like there's. She tries to repair fractures of women that have fallen in older age. And because of the loss of estrogen, the bone has lost its framework, it doesn't have any strength. And she's putting so much hardware and metal into women unnecessarily when if they had taken estrogen and taken hormone therapy, it could have been preventable. You know, their bones would have been healthier. And that was a big thing to see. Oh, yeah.
- [39:49]
A
And also you mentioned heart health and organs and all those things we've all been told. And the science shows that women live longer than men. But what I wasn't in terms of years, I didn't understand until I've again getting all my information from Instagram, that women don't lead the same quality of life that men do. Meaning we're more likely to be. To fall and break a bone, to. To be in a walker, to just have a limit. And again, I just play a doctor on tv. But I was thinking to myself, gosh, the big differences between us are that women go through this change that men don't. Men, maybe they lose some testosterone as they get older, but it's not this dramatic shift to their body that we all experience. And there has to be some correlation between the frailty and lack of hormones, you know, cardiovascular disease, lack of hormone, you know, cognitive decline. That's another big one.
- [40:49]
B
Yeah, absolutely. Because when you look at cognitive decline and, you know, dementia women are at such higher risk of developing that and developing Alzheimer's disease than men. And it really has been linked to the loss of estrogen in the brain. You know, estrogen is critical for the creation and the function of a lot of neurotransmitters in our brain, which is why when our estrogen falls, we have mood changes, we have cognitive decline, and, you know, issues with memory loss. You know, it's. It's so common in midlife. And I see it and my kids have made fun of me for it because, like, sometimes I go through every single one of their names before I get the right one, you know, or you go into a room to do something and by the time you get there, you're like, what did I come in here for?
- [41:31]
A
Oh, yeah, no. My 16 year old just came home for a long fall weekend from his boarding school. And if I had a dollar for every time he was like, mom, you need to get an mri. I'd come out of the parking lot, the grocery store, I was by there. I'm like, where did we park? I mean, all these things that, you know, he was totally, totally freaked out by my memory gaps. But. But it is a real, it is a real thing. Okay. As we're. One other thing, though, on. I have a question about the estrogen progesterone before I switch to all the symptoms that you want to look for and then how you can treat them. If you were prescribed estradiol or progesterone and it alleviated your symptoms, and then a couple years goes by and you're experiencing some symptoms again, is that the time when you want to go back to your provider and saying, I'm having hot flashes again, I'm having sleep issues.
- [42:18]
B
Again, that's a sign that your estrogen dose needs may have changed. And that can happen because maybe your body, when you first started treatment, maybe your ovaries still had some eggs and you were still producing some of your own estrogen. And then as you age, that continues to decline. And so as you get older, you might need a higher dose to maintain those symptoms. The other thing, the other time it can happen is if women, they gain or lose a lot of weight, that can also change your estrogen metabolism in your body. Because one of the forms of estrogen that we have, our estrone, is stored in fat cells. And so if you lose a significant amount of weight, which a lot of women are doing now with all the GLP1 medications, you know, everyone's getting fit. But if you Lose a lot of weight. It may change your estrogen needs too, because you no longer have that increased level of estrogen circulating when you were heavier set. And so those, those changes can happen. But anytime you have a change in your symptoms and you're on treatment, you definitely want to have a conversation with your doc who's prescribing and just let them know, like, I was feeling great, but over the last month, I'm starting to notice, like, more and more hot flashes, more and more night sweats. The other symptom that a lot of women get a lot that'll come back as their estrogen dose needs change is like body aches, muscle aches, things like that, too.
- [43:29]
A
Yep.
- [43:30]
B
Yeah.
- [43:30]
A
Okay, let's go. This might be like a, like a. I'm mindful of our time here, your time particularly. But some of these symptoms, right, that could, could mean that you might be in perimenopause, something to talk to your doctor about. But in your experience, what is the best way to address them? Because I'll start with the, the most common one that you hear around menopause, which is hot flashes.
- [43:52]
B
Yes. So hot flashes, actually, for most women, happen later in this process than many of the other symptoms in perimenopause. So by the time you're starting to have hot flashes and night sweats, you've already had some other subtle symptoms that maybe you didn't recognize. But when you start to have hot flashes, one of the things you have to look at, you know, even before thinking about medication, is, what's your hydration status? How is your sleep? Sleep is one of the other big symptoms that a lot of women start off with. So starting to have sleep disruptions in perimenopause is one of the first things that a lot of women really start to complain about. Maybe trouble going to sleep, trouble staying asleep, waking up too early, waking up many times in the night, and sometimes it might be that you wake up in the middle of the night and you don't know, is it because I had to get up to pee, Is it because I had a night sweat that woke me up, or am I just not able to stay asleep more soundly? But all those things, like, if you try to do everything you can to optimize your sleep and it's not getting better, your experience of hot flashes and night sweats is going to be worse. Our body, our human body needs a normal sleep wake cycle in order to deal with all the things that are thrown at us. And so if you're not sleeping well, and you're not getting good quality restorative sleep, you're not going to do as well, and you're going to have more symptoms, actually. And I know that from experience, just being an OB GYN doing 24 hour call shifts every time I had been awake throughout my career, even when I was 20, doing overnight shifts and working 36 hours straight. When you are sleep deprived, your internal thermostat, your thermoregulation does not work. Well, I used to have hot flashes back then just from being sleep deprived for a couple days.
- [45:26]
A
Interesting. Okay.
- [45:27]
B
So it's something that though, you really have to focus on. And I think that, you know, we need to focus on quality sleep. I think that many of us would get through much of our health struggles and a lot of the things, and especially midlife and the transition of perimenopause and menopause, we would deal with a lot better. If we could get better sleep and if we really gave ourselves the luxury of getting eight hours a night, that would be wonderful.
- [45:51]
A
But if you're having those sleep disturbances and you're having hot flashes, HRT is probably like, besides working on your hydration and trying to be very intentional about your sleep schedule and those kinds of things, if it's a big shift for you and you're all of a sudden like me, up at 2 in the morning looking at reels from 2 to 4 in the morning now, it doesn't happen to me. I mean, occasionally it does, but not, you know, now that I'm on hrt, it's a new world. Is that those are the two things that you'd recommend?
- [46:20]
B
Absolutely. I think HRT could help tremendously.
- [46:25]
A
Mood swings.
- [46:26]
B
Mood swings too now, you know, and this is so common, mood swings are something that a lot of women experience. But if all of a sudden, like the mood swings are extreme, like suddenly, you know, maybe you've been happily married for 20 years and suddenly you're looking at your partner thinking, why am I married to them? Or you're contemplating like, or, you know, you're just. Your tolerance, your resilience and your tolerance for other people or their behaviors goes really down. We just can't roll with things as well as we used to. But also just large, you know, fluctuations in our mood is very, very common with, with the ups and downs of the hormones as they're occurring, you know, in this perimenopause transition for a lot of women.
- [47:04]
A
So I don't practice anymore, but I was a matrimonial lawyer and I look back at some of my clients that were in their 40s, and it would just be like, I just can't look at him anymore. And now I think to myself, oh, my God.
- [47:16]
B
Right? It's total sense now.
- [47:19]
A
Yeah. Maybe she just needed a patch. Oh, my gosh. So anyway, okay, so mood swings, hrt, or if you aren't a. A candidate, maybe an SSRI or.
- [47:32]
B
Yeah.
- [47:32]
A
Some of these other things that will help with. With mood balance, vaginal dryness, loss of libido.
- [47:39]
B
Yeah, vaginal dryness is a big one. And vaginal estrogen is by far the best treatment for that. To help restore the vaginal tissues to their, you know, prior state and help with the suppleness and the tissue health itself. But there's also. If you're. If you're afraid of doing that, or if you just. Maybe you can't get into the doctor, there's other things you can buy over the counter, like, know, vaginal moisturizers, things like that that you could try when it comes to, like, loss of lubrication. Like, maybe, maybe you have the desire for sex, but when you try to go have sex and you try to be sexually active, like, your body doesn't respond the way it used to. Like, you don't get wet. You don't have that lubrication naturally. So lubrication is really important. There's a lot of different kinds on the market. That's something that can help. But for women that actually start HRT systemically for the other symptoms, they start to notice that their vagina starts responding like it used to when their levels are better. But also vaginal estrogen can help with that too.
- [48:31]
A
Well, I just saw literally yesterday, I wonder if my Instagram heard me talking about the fact I was gonna be talking to you today or I don't know, or it's just what's always on my feed. And it was. Dr. Mary Claire Haver was on some podcasts talking about how you want to have vaginal estrogen just for the suppleness of the tissue.
- [48:50]
B
Yes.
- [48:51]
A
So my question for you was, even if you don't have vaginal dryness because you're on another. A patch or something, do you want to also supplement with that just to sort of. Sort of taking care of the skin.
- [49:03]
B
There, or vaginal estrogen for women that don't need it for symptoms that sometimes the. The reward of it may not be worth the risk because it's messy. You know, you're getting an applicator, you're filling it with cream, and you're inserting the cream into the vagina. And so what goes up must come out, right? So, you know, typically we tell you to put it in at bedtime because then when you're laying horizontal in bed and sleeping at night, the cream maintains the most contact with the vaginal tissues and more of the hormone gets absorbed. But once you're up and vertical in the morning and you're moving about the vehicle, cream, you know, once the hormone's been absorbed, there's still cream left behind. It's not that it doesn't, it's not that the hormone is not getting absorbed. It's. There's a, there's a vehicle that the hormone has to be delivered through, but you'll have a discharge the next morning. So for some women, they might not like that. So if you're not dealing with vaginal dryness directly, sometimes you might not want to deal with the messiness of vaginal estrogen. But, but a lot of my patients do, both systemic and vaginal, and really like the results they're getting. You will get some benefit from being on systemic estrogen for the vaginal tissue. But if you're to the point where you're already noticing a significant amount of symptoms, vaginal estrogen will be by far the heaviest hitter for helping those symptoms faster and helping the dryness get better over time.
- [50:20]
A
And I probably should have asked this of you earlier, but what is the. So you're, let's say you're starting HRT because you're symptomatic, right? You then go through actual menopause. So you've had a year where you don't have a period after that, how long can you be on hormone replacement? Can you stay on it forever? I mean, if you stop taking it, are you going to go back to having those hot flashes, sleep disturb, all those other. Those things that come along with it, or.
- [50:46]
B
Yeah. So this great question, and I get this question from patients pretty much every day. Years ago, we used to tell women that you should be on the lowest dose for the shortest duration possible just because of the risk. And from that WHI study. But now more and more women are deciding to stay on HRT long term because of the health benefits that estrogen affords their body long term, you know, as far as longevity and maintaining their body's vitality and strength and health. But for the average woman, I would say most women that go on HRT are on it maybe four or five years, and then they decide, well, you know, they don't want to be on A bunch of medications and they try to wean off. And some women might get some rebound of symptoms and if that's the case they might choose to go back on. But a lot of women will stop and they do just fine. Really. When we're having the worst of the hot flashes in the night sweats, they're happening because of the wide fluctuations in our hormones. Like one day you might release a lot of estrogen, the next day you have none. And it's that roller coaster of hormones that actually gives us the bulk of those symptoms, especially those vasomotor symptoms. So over time those will fade. And so some women decide they want to go off of it just because they want to reduce the amount of things they're having to take every day. Or maybe they develop a medical issue that then makes the hormones a little bit higher risk, you know, and so then you have to kind of reevaluate their life and reevaluate their medications to determine what's worth keeping versus not. But I'll tell you, when you talk to female OB GYNs in our demographic, which I'm in that group, women that are in this field that are reading the research and that are looking and seeing all the benefits of HRT and we're dealing with patients with this, I'll tell you, you will have to pry my estrogen out of my cold dead hands because I will ever stop it. Like it has made such a difference in my own life and I see what difference it makes in my patients lives that unless there's a real compelling reason for me to have to stop it because of another medical issue, I'm not going to go off of it, I'm going to stay on it forever.
- [52:39]
A
Yeah, 100%. And I have some friends who sort of say oh well I can manage the symptoms and I'm doing all these natural supplements and things which terrific. Not taking that away from them. But then I also say to them you might want to consider it for your bone health and your organ health and your heart health and your cognitive health, all the other pieces of it. Not just mitigating some of these, these perimenopause symptoms. Okay, hair loss is on the list. We're in Winona Telehealth session right now. And I said Dr. Brown, I'm losing my hair. Would you say Rogaine, Oral Minoxidil, HRT combination of all what's sort of in your wheelhouse there?
- [53:23]
B
Typically HRT can help to a certain degree, but there's also a lot of different Things that can affect hair loss. And so minoxidil is something that we know can significantly help. You know, you can take it orally, but there's more risk of doing that, especially because it gets processed by your organs. And so there's more of a risk involved with that. So there's also topical minoxidil, that's prescription strength. And we actually do offer that at Winona now, too. We had so many patients coming to us, you know, with the hair loss issues, that our pharmacists actually developed their own formula. So now we have a prescription strength hair serum for hair loss addition, you know, that women can take in addition to their hrt. So that's something that, you know, they typically recommend for patients.
- [54:02]
A
That's terrific. Okay, the next one, weight gain and Menobelli, which is real. Real.
- [54:12]
B
Absolutely. It is real. A lot of times for women, this comes because our body is in a high stress state. When we're going through these changes, when we're. When we're hitting midlife and we're going through all the symptoms of perimenopause, suddenly our body is in this, like, fight or flight mode. Your cortisol levels are high, you're in a high stress state. And so what happens is your body tends to want to absorb and keep calories. It doesn't want to burn calories. It doesn't matter if you're eating low calorie diet or working out all the time. Sometimes despite all your best efforts, you still will have that weight start to accumulate in the middle. And it's because of that hormonal environment in our body with the cortisol levels being high or estrogen levels dropping. So for some women, you know, getting on HRT and getting their symptoms under control and getting out of that high stress state state goes a long way. And then suddenly all the other efforts they're making with diet and exercise start to do what it did before in the past. And so it helps with, you know, weight management. There's some women that, you know, no matter what we do, we might optimize our hormones by going on HRT and might feel better with all of our symptoms, but we still struggle with the weight. Some women go on medications for weight loss. There's great medications for weight loss now, too. And now the data is telling us for women that are actually in perimenopause or menopause, that are on hrt, that also then decide to go on a weight loss medication like a GLP one, they can be synergistic, meaning that the medications work together and women actually lose more weight being on the combination of the two than even being on a GLP1 by itself.
- [55:41]
A
Wow.
- [55:42]
B
Yeah. So that's something we're learning a lot about. There's more and more coming out in the literature about that. And there's, you know, added health benefits we're seeing from the GLP1 medications.
- [55:51]
A
Oh, my gosh. I, I, you know, I have interviewed an expert on Alzheimer's and then a cardiologist, and they both were so excited about the new research that's coming out around the positive effects of GLP1s.
- [56:07]
B
Yes.
- [56:07]
A
For heart health and for cognitive health. And I don't know if it has to do with reducing inflammation or just keeping your sugar levels. Just sort of that all that science around not having big spikes in your sugar levels throughout, because that's part of what it does. Right. It sort of manages your. Those cravings and those spikes. So sort of helping to mitigate inflammation. I feel like inflammation and gut health are like the new. That's what I want people to talk about.
- [56:38]
B
Just like everyone's talking about menopause, they're talking about those things too.
- [56:41]
A
Yes.
- [56:41]
B
Yeah.
- [56:41]
A
Thank God. Thank goodness. Right. So dry skin, an itchy skin. I make my husband scratch my back every night and he, the other day was like, I'm like, should I get a doormat and nail gun it to the wall of our bedroom and just like scratch my own back at night? Because it's so that, I think is one. And then face dryness. You brought up the estrogen for that? I've also been prescribed an estrogen cream for my face.
- [57:09]
B
Yes. That's just ingredients.
- [57:12]
A
I don't know if Winona carries that, but if you don't, it's something I think to look into because I have friends ask, what are you doing? What did you have? Not that my skin looks particularly great or anything. I'm not trying to say that, but just my skin looks more supple. And I said, I'm on this. I've taken this cream and it seems to sort of plump up the skin a little bit.
- [57:33]
B
It really does. Now, we actually do have a face cream as well. So our pharmacist actually, we made a combination cream that has both estriol and, and tretinoin, which, you know, tretinoin you might know, like from things like Retin A and some other, you know, it's used for acne, but it's also used for its anti aging benefits. A. It really helps with renewal of the skin. And so we have those products combined so that it's. It's really helping with the skin texture, as also in addition to the Estriol, helping with the. Increasing the hydration and the suppleness and the elasticity of the skin of the face. So, yeah, ours is, I think, the only one right now that has both the tretinoin and the Estriol combined in it.
- [58:14]
A
Okay, we're going to. We've got to talk offline about that because I'm very excited about that new development. Okay. I saw some in some reel, and I thought this was hilarious. This woman said my. My joints snap like a glow stick, and I. When I go up and down the stairs, I can hear my hips, you know, cracking. And I also suffered terribly last year from frozen shoulder and was having cortisol shots. It was really, really painful. Those are two other symptoms. And what do we do for those?
- [58:44]
B
And that can be from the loss of estrogen in the joint spaces specifically. So not only when we age are we prone to things like arthritis, and we're more prone to arthritis in joints that we've overused throughout our lifetime. So if you're someone who worked with their hands a lot, you're more likely to get arthritis in your hands. If you were someone on your feet or doing a lot of squatting and whatever job you did or whatever it was that you did with regularity, you might get more arthritis and your knees and your. And your hips. I played softball for a lot of years, and so I was a catcher, and I used to squat, you know, as a catcher, and my hips are awful. But when you notice those joint pains getting dramatically worse in midlife, it's due because of the loss of estrogen from the joint spaces themselves, like our. Our synovial joints and our joint fluid and the joint spaces like the cartilage, it doesn't function its best when our estrogen levels are low. So HRT helps that as well. So that's something that can be treated with HRT in addition to all the other symptoms we talked about.
- [59:43]
A
Okay, and then what about. Would that also be like taking collagen supplements? Is that a joint? I know there's different. I forget who I asked about that, that it's protein and it can't really hurt, but maybe it's not. There isn't necessarily direct scientific proof that the collagen powder does a lot.
- [60:01]
B
Yeah. I mean, and now you'll see all these people kind of pushing more of these liquid collagen supplements. That's what I See, they're given samples of in my coff Costco, and I'm seeing ads all the time for these people drinking this liquid collagen concoction. There's not great data out there in the medical literature yet to really say that something we consume that is being processed by our GI tract is going to get absorbed and cross, you know, the tissues and get into our bloodstream to get to those tissues. But there's some people that swear by it. But I don't know, I haven't seen the data compelling enough for me to start taking it just because, you know, I like to know that it's really going to be worth it for me to add something else that's another supplement. But protein in general, I think is something that we should talk about because women do not get enough protein at all.
- [60:45]
A
Yes, I know you've got like a thousand things to do today, so I want to be quick on the time. Brain fog and loss of muscle mass we talked about, but brain fog also. Is that hrt?
- [60:54]
B
Brain fog can definitely be helped by hrt. Yeah. What I mentioned earlier is that, you know, when we don't have estrogen in adequate levels, our neurotransmitters can't be actually produced or function as well. So you need estrogen in that equation for those to work work better. So the brain fog improves when you go on HRT for sure. And also when you're helping your sleep and you're sleeping better with estrogen on board, that helps with your brain fog as well, because the sleep deprivation makes brain fog worse.
- [61:19]
A
Yes, so true. That is so true. Okay, you brought up protein. My last and final question for you is a little broad, but, you know, so much is coming at us. I know you're getting the same stuff. I feel like I and I screenshot reels about what kind of supplements I should be taking going through this period of life, how much protein I should be eating. Weighted vest. No vest. Weight fiber, Magnesium fiber. Magnesium. I feel like are big creatine is thrown at me. Can we talk about protein fiber supplements and anything else you think or whatever you. I'd love to have. Like, this is what you need to be.
- [61:57]
B
You let me off the hook with.
- [61:59]
A
The collagen powder just then. Yeah. What do we really have to have as part of our, our, our war chest for keeping healthy during this time?
- [62:07]
B
The thing, the, the real bare basics is that if you eat as much of healthy foods and you eat as many different colors of the rainbow as possible, you'll get the nutrients you need from your diet. But we're human, right? And in America, we are, you know, or we're a group of people that are, you know, looking for convenience and ease. And so sometimes we don't always eat the best. Sometimes we get things on the road. And so in that sense, you want to add back in the things that are really critical for you. So for, for us, as we're aging as women, it is so important for us to get enough calcium and vitamin D that helps our bone health, our bone strength, you know, in addition to the weight bearing, exercise and movement and estrogen levels. But that's really important. Magnesium is something that I take regularly because I don't think I get enough of it in my diet. Like, and you could look up and see, like, what foods have enough magnesium and add those into your diet. That's probably a more efficient way for your body to extract those minerals. But for me, I use magnesium at bedtime to kind of help with sleep. It helps with calming, but it also helps with cognition and brain health as well. So, I mean, I personally take a magnesium supplement.
- [63:14]
A
All right, Dr. Man, can I ask you one question? How many. How many milligrams for magnesium and then for calcium do you need to take a calcium supplement if you're not. I know broccoli's got calcium and obviously dairy has calcium.
- [63:25]
B
I mean, if you take a good women's multivitamin, it'll have both things in it.
- [63:30]
A
Okay.
- [63:30]
B
And I don't think there's a great, you know, guideline as far as specific, you know, specific milligrams that you need, but there's several different forms of magnesium. And that's the other thing you have to think about. There's magnesium citrate, there's magnesium gluconate, there's magnesium L Threonate Mag citrate is something we use to prep the bowels before doing a colonoscopy, or we use it for, you know, constipation. So you have to be careful. If you take too much of that, you might give yourself diarrhea.
- [63:55]
A
I have had a cautionary tale. I've had an issue with taking the wrong magnesium. But what is it? It's glycinate you want at night.
- [64:03]
B
Glycinate is good for night, but also for the brain health. Magnesium L Threonate is also good for brain health. It's another isomer of magnesium, but it's supposed to cross the blood brain barrier better as far as for brain health. So that's something that, you know, this is recommended as well.
- [64:20]
A
Okay, so should we take both of those or is there one that maybe has.
- [64:25]
B
I think that you could probably pick one or the other and it's probably just fine. I would steer away from magnesium citrate, basically because of diarrhea issue.
- [64:33]
A
Okay.
- [64:34]
B
Okay. No.
- [64:35]
A
Citran glycine or L3.8L threonate.
- [64:39]
B
It's okay. Yeah. T H R E O N A T E. Yeah. Oh, three.
- [64:45]
A
Oh no.
- [64:46]
B
Yep.
- [64:47]
A
Okay.
- [64:47]
B
And then as far as protein, I'll tell you, like you can google and you can look up. And now with all the AI and search engine stuff information, you could say like at a height of this and you know, a body weight of this, what should my protein intake be to maintain my muscle, and it'll give you a protein goal. When I did this and I looked and found a chart and there's very different sources you can look at. But for me, I'm 58 and I have to get 120 grams of protein a day, fat loss and muscle maintenance. And that's not to bulk up, that's just to maintain the muscle mass that I have. Because I think women don't realize we lose muscle at an alarming rate starting at midlife and after. Part of that's because of the loss of our estrogen. But part of that is with aging too. When you really think about how much protein that is, it's a lot like if you do my fitness Pal or you do a Fitbit tracker or anything like that, where you put in everything that you're eating and it gives you your macros of what you're getting in. As far as fiber, protein, I think if you tracked for one day to see how much you were getting in, see how much you're actually getting. When I was doing that, I was barely getting 50 grams or 60 grams of protein. And so now I've added in protein shakes in the morning and I get, instead of getting granola bars for my kids, I'm buying protein bars now to try to get everybody more protein and everyone's healthier. Just seems like you have more energy, more get up and go when you have enough protein. And the other thing women have to realize is the way that we used to lose weight years ago by like fasting and maybe eating like a bird and trying lower calories. It's not so important. It's not a simple equation of calories in, calories out. Like you have to get quality nutrition. Think about whole foods. Think about your, your bigger macros, like making sure you get enough protein and you're getting enough fiber. Don't worry about the individual calories so much. Make sure that you're focusing on getting healthy lean protein. Eating a lot, a lot of, you know, raw vegetables and fruits, fruits each day because that'll help with your fiber intake too. Because you want to keep, you know, your, your body functioning. It's, it's best. So I mean like I said earlier, eating as many different colors of the rainbow as possible is really good too.
- [66:48]
A
I like you had a number in my mind about where my protein should be and I think it was like around 140, which I think is probably not right. I need to do the, the AI thing but I, that is really hard. It's really, really hard to get there. But certain things I notice like the collagen powder which might not help with maybe my nails and my hair necessarily it does have 15 grams of protein and I put it in my coffee or I'll have cottage cheese as the snack because you're going to get 12 grams in one of those little tiny cottage cheeses. So sort of I'm trying deliberately to kind of get there but it is a, it is not easy. And fiber, is it 30 grams of fiber a day? What is the fiber? There's also fiber powder my sister in law gave me that I will put in stuff too because it's very hard to get the fiber. But getting natural fiber obviously is best. But if you can't.
- [67:44]
B
What I keep at home is benefiber because it's one of the ones that you can sprinkle into anything. It's not like our grandmother's old Metamucil that they used to take. You know, you can sprinkle it on the top of food and it just kind of gets absorbed and you don't even notice it's there. Anytime my kids tell me that they feel constipated or they can't poop easily. Like I'm always sprinkling it into their food without knowing it. And it helps. Yeah. So that's something that I think is good. And then you know, making sure you're getting a lot of, you know, green leafy vegetables. Looking for more whole grains rather than simple carbs. Like going for brown rice rather than white rice, going for the whole grain breads, the things that are, you know, maybe sprouted rather than really highly processed, you know, wheat. And you know, a lot of people are doing gluten free stuff now and when you do that you're getting a lot more quality grains when you're not doing the highly processed things.
- [68:33]
A
Interesting. All right, so protein we're gonna do. Everyone should do an AI assessment, see where they are, hit their goal. Vitamin supplements. A multi is good, but you also probably wanna throw in some vitamin D. You wanna be aware of your calcium and your magnesium citrate. Or you say the other one.
- [68:50]
B
L3 and 8.
- [68:51]
A
L3 and 8, then fiber.
- [68:54]
B
Yeah.
- [68:55]
A
30 grams a day.
- [68:56]
B
I think 30 grams a day is a good goal. If you get above that, that's great too. But I think as a minimum, I think that we should try to shoot for that.
- [69:04]
A
And then we talked about the importance of weight training, weightlifting.
- [69:09]
B
Yeah. And just, I mean, just moving your body and movement. Yeah. And. And that's why the weighted vests are so popular. You mentioned that earlier. But that's why people are getting. Because it's a way to get resistance exercise with normal activity, like walking. Like you could put a weighted vest on and do your housework and you will by far be stronger and your body will be, you know, healthier doing that than just doing the housework itself. Little things like that, like little changes like that. But also just trying to, I mean, walking is a great exercise. I think that too many people underestimate the power of walking because every time you walk you have impact, you know, you have resistance of your body against the ground, you know, and so it really is helpful.
- [69:48]
A
And walking, I know sort of 10,000 steps was the popular goal, but apparently that's not necessarily true for everybody. It could be 7,000 for some people it could be 8, it could be 12 depending on your profile. And there are apps that do that too.
- [70:04]
B
Yeah. At this point it's just like getting any walking in. I think as a society we're too sedentary. We tend to drive to work and then we sit at a desk or, you know, we're not as active as we used to. To be years ago. And just adding in movement and adding in walking is just. Any amount would be better than none.
- [70:22]
A
Okay. Dr. Brown, thank you so much. I'm so, so grateful to you for coming on. I learned a ton. Good. I've got some things I want to follow up with you on about from tons of different creams and other supplements and things. So really grateful to you. Thank you so much.
- [70:39]
B
Well, thank you so much for having me. And if you like the way that I talk or explain things, my, my team at Winona would like me to share that you find me on Instagram. It's drkatobgyn and Also, for anybody that wants to learn more, if you want to read more about perimenopause and menopause, we have a huge section of our website that is free for anybody. You know, when you go to the Winona webpage at W I n o n a dot com, there's a section where if you pull down the menu it just says learn. There are articles that have been curated by me and some of the other doctors. It's really good information. We have free symptom trackers that patients can download. You don't have to be one of our patients to do it. So there's a lot of free resources because we really, really believe that education is important. Yeah. And we hold free webinars twice a month, you know, on our app that patients can dial into ask questions. But I just want women to feel empowered to learn as much as they can about this and share the information with other women in their lives. Like, don't gatekeep the information. You know, there's, there's so much that I think that we can take better care of ourselves if we just learn more about our bodies and demand the care that we need. I think it's so important, 100%.
- [71:47]
A
And that's so great to know that you don't have to be a patient to get access to those resources. But if you aren't getting your questions answered with your local doctor or your gynecologist, knowing that Winona is there, you know, as a resource, you can be a patient anywhere in the country and have access to this wonderful doctors like Dr. Brown who can help you navigate this very, very tricky transition in life that every woman will go through. So, so grateful to Winona for being there.
- [72:13]
B
Thank you. And thank you so much for having me.
- [72:16]
A
Oh, thank you so much. That brings us to the end of this episode of Duologue. A huge thank you to Dr. Kat Brown for joining. If you're suffering from menopausal symptoms or you feel like your healthcare provider just isn't listening, you have questions or, or you just want more information, go check out Winona's website at www.buywinona.com. they have incredible resources and healthcare professionals there that can help you. Also, a huge thank you to our sponsor, Karun. Don't forget to check out their website. They have the most beautiful products. Trust me, you will not be disappointed. Their website again is www.karoon C-O-Double r double o n.com and don't forget to enter the promo code code Duologue at checkout for 20% off.
- [72:59]
B
That's just for our Duologue listeners.
- [73:02]
A
And last but not least, thank you all so much for listening and for all your support of the podcast. It means the world to me. If you enjoyed this episode, please rate or review us on Apple Podcasts or Spotify or wherever you get your podcasts. We release a new one every Wednesday. And don't also forget to check out our new website and subscribe to our substack, where you'll get even more content and more exclusive information and and giveaways. It's a substack you won't want to miss. So until next Wednesday, this is Leslie and thank you for joining us on Duolog.