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The mindbodygreen Podcast
610: Your guide to HRT & lifestyle changes for menopause | Jila Senemar, M.D., FACOG
00:49:09
Jila Senemar, M.D., FACOG, distinguished OB/GYN, medical author, and expert consultant, joins us today to dive deep into women’s hormone health, including hormone replacement therapy (HRT), powerful lifestyle modifications, and smart supplementation.
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A
Welcome to the MyBodyGreen podcast. I'm Jason Wakab, founder and co CEO of MyBodyGreen and your host.
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Joining us today is Dr. Jila Senomar, a board certified OB GYN and menopause specialist. She's on a mission to help women feel seen, supported and empowered through one of the most misunderstood transitions in health, menopause. In our conversation we break down the real story behind hormone therapy, why so many women still fear it, and what the latest research actually says and how to know if it's right for you. And maybe most importantly, we cover all the lifestyle interventions which women can incorporate into their day to day lives that might make hormone therapy unnecessary. Altogether. It is a fascinating conversation and Geela is an instructor in our newly launched Peri Menopause plus class here at mindbodygreen where you can use the code mbgpod. That's mbgpod for $550 off this incredible course. That's code mbgp. And you can find the link to the course in the show notes. Let's get back to the show. An incredible conversation. So I think there's still fear around HRT stemming from the now infamous 2002 WHI study. What do you think is most understood today and what does more recent research tell us here?
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B
I think what is the most misunderstood is the way that study was run. The qualifications to be a part of the study were a big factor. The medications that they used were different than what we're using today. And what I think a lot of people misunderstand is that a lot of the researchers on that study didn't agree with the headlines that were published. Hence they had to go on and publish a book to talk about how everything was kind of twisted a little bit and the wrong data was portrayed and hence women were given the wrong information as well as healthcare providers, to be honest with you, because we were all left in the dark. Okay, don't do it. It's bad. Move on. So a lot of that has been redone, reneged, removed, however you want to call it even by the people of the Women's Health Initiative. But it's done quiet. So they republished the data and say, okay, actually you know, in the estrogen only arm, we actually did notice A decrease in development of breast cancer. So, but where is that there, there are no big headlines saying that component of it. And so those are the things that need to be discussed every time. And you know, Avrim Bleming, if you meet with him and you just have a lecture just by him, he will literally point everything out point by point by point. And it is just so easy to digest and understand where you, you know, it kind of makes you think, why doesn't anyone else talk about this? Why are we still spinning our wheels with the whi? Why is it that women, when they come to us for help and you know, when that discussion does come up, breast cancer is still number one in their mind. You can tell them all of the pluses and all of the pros and everything and at the end of the discussion, they'll still look at me and say, okay, but am I going to get breast cancer?
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So to summarize, in this study essentially drew the wrong conclusion over 20 years ago that linked HRT to breast cancer. And it was wrong. And we didn't really, we drew the wrong conclusions. Media loves, you know, if it, if it bleeds, it leads. So it was a great headline that and scared a lot of women into not looking at this intervention which could save them a lot of pain and suffering through menopause. But it was all, we were all wrong.
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B
And the thing is, everybody is, you know, I mean, most people are accepting that and are understanding and realizing, yes, it was a mistake, okay, you know, we drew the wrong conclusions. Basically, we should have waited. You know, they jumped the gun and that's what happened. I mean, there's a whole generation of women who suffered because of it and not getting those hormones that they may have needed at the time.
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A
So here we are in 2025. HRT has made a roaring return, if you will. I know many women on a personal level who have embarked on that journey and have had incredible results. They say it's life saving. HRT is everywhere. It seems like it's at dinner discussions. All, numerous, numerous dinners discussions here in Miami for sure. And, and it's powerful and it can be incredibly effective. With that said, do you think we maybe went a little too fast and furious here? We went from no hrt, I'm scared of it to let's all get on it. Have we swung the pendulum maybe too far?
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B
Well, isn't that what medicine is all about? We, we're, listen, you know, we, we're trained as healthcare providers. We're black and white pretty much most of the Time with what we do, it's either this way or it's that way. But what we have come to learn and the best way to approach all of this is there's a middle ground, there's a gray zone that you have to really play in safely with patients. And yes, right now we're on a high with hrt. You know, that's like the end all be all in some people's minds. But it, you know, if you really get to the bottom of it, at the end of every discussion that you have with anyone, they'll say, but it's a personalized decision between you and your healthcare provider. It's a discussion. I think there's a little misconception about it. A lot of people you hear HRT this, that and everything else, and the pros and the cons and longevity, you know, correlation and all of that. But what we want people to know is I want patients to walk out of the office with the knowledge of hrt. Now will they go home with it? Different ball game. So most women, as long as they're educated about it, then they can digest the information for themselves and come back with more questions and then decide whether they want to approach it that way or, hey, let me start with the basics. Let me start with lifestyle modifications and see where I get with that and then see if this is something to add on down the road.
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A
Well said. Agreed. It's not black and white. We like to live in the gray, although living in the gray doesn't really do well on social media often and it tends to be black and white and in extremes. But with that said, you mentioned lifestyle modifications and many of our listeners believe in trying lifestyle modifications first and exhausting all options there before they make the decision to turn to a pharmaceutical intervention, myself included. With that said, how do you think about this for women considering hrt? How should they think about lifestyle and all the options there before they decide to turn to a pharmaceutical intervention?
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B
And so this is part of the reason I do what I do is because we need to have these discussions in depth with women. Not everybody is well versed in terms of lifestyle modifications. You can't just give that term to them and say, go do it and come back and see me and let's see how you feel. They need actionable items to take home with them. Okay, this is what I need to start with my nutrition component. I need to know what I'm supposed to be eating, how much of it, how often, and things like that. Where do other things play a role you know, supplementation, Do I need it? Do I not need it? You know, most people will walk in, they've come to me with a bag full of supplements. They don't even know what they're taking. They were just sold on an ad on social media and you know, it sounded good. At three in the morning when they were up from not sleeping and they're like, yeah, that sounds about right. And I, you know, I relate to this, so I'm gonn get it. But they literally have no idea what they're taking. So all of that is what we need to work through on an individual basis with women when they come in. And again, you know, that's not a 15 minute visit, that's over an hour. Sometimes they literally need handholding. So it's what are we eating? How are we eating? Where's my food coming from? Because just because it says organic doesn't mean it's okay. There may still be things they don't even know. Some people don't even know how to read labels. So again, you got to get to the bottom of clean up the diet and nutrition component. And then what about red exercise regimen? What about the pillars of health that we talk about? The, this is where it's at for a lot of women. You can actually alleviate a good chunk of the symptoms if you just modify their diet and add exercise into the regimen. All of a sudden. Okay, okay. But I do feel better. Like those hot flashes have actually improved. My cycle's better. And the weight gain is, you know, not as bad as it was. I'm actually seeing changes happening. These little tweaks can help women address a lot of their symptoms until they're further into the perimenopause menopause stage and then they can decide what's next for them.
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A
So let's start pillar by pillar. I know everyone's an individual, but if you had to generalize, let's start with nutrition. What general advice would you have for someone in terms of their diet who's.
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B
On this journey, Number one, to take out the word diet, right? We, we all use it, but it's in, it's got some negative connotation from back in the 80s and 90s where it was like, you know, we want to be skinny and eat less and do more cardio, because that was the look. That's not the point anymore. The point is strength. We need to be stronger, we need to have muscle mass because that's what's going to help us when we're 70 and 80 years old, not need to use a walker and you know, and not be a burden on our kids at that point. So we need to make sure there is a well balanced nutritional component diet per se. You need protein, you need fruits, you need vegetables. There should not be any one component of the food pyramid that is excluded. We and it needs to be something sustainable because you put people on a low carb, high fat or, you know, and a vegan diet or a vegetarian diet, they're not going to be able to sustain that. They're going to look great and they're going to feel amazing while they're doing it. But as soon as you switch back to regular food, what's going to happen? Everything's going to come back again and they don't feel well and they're like, oh, but it was so much work to get there. Yeah, but if you do it and you make it a part of your life, it actually becomes more second nature. You don't have to think about it too much. And if you know where your food's coming from and how to make your plate, where there's a little bit of everything on there, you're going to be okay. And it, you, it becomes more, it becomes easier to do it.
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A
So it sounds like a well rounded, omnivorous diet. Whole foods, real foods, protein, centric, lots of fruits, veggies, fats, fibers, carbs. So well rounded, omnivorous diet, emphasizing whole foods basically.
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B
And what? Well, you know, what we like to call is like the Mediterranean diet. Imagine, you know, what are they? Fish from the sea, it's fresh right there. They catch it, they eat it. You know, vegetables, you know, carbohydrates, good fats like that, clean, pure olive oil. Put that all over everything. The people, you know, in, like, like in the Greek islands or in Italy, these people live well and, but they eat even better. Better. But why is their food different? I mean, I've traveled over to Europe and when I come back and we eat pasta and bread all day long, but it doesn't do the same thing to our bodies when we're there versus when we're here. Why? It's what's in our food and you know, the cleanliness of it, the lack of preservatives, things like that. Basically they make it, they eat it and that, that's kind of my theory is like, does it come from the ground? Like, is there anything in between that anyone's added to it? No. Okay, then I'm okay to eat it. But other than that, if I don' what's in there. I'm not eating it. I. The label, they should have two, three ingredients on there.
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Well, I think about the carbohydrate discussion. You know, I'll use bread, for example. I think bread has been demonized to some degree. And my question there is, are you eating freshly made sourdough with three ingredients from like my favorite sourdough maker in the world here in Miami, Domicello, or are you eating Wonder Bread? Big difference.
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B
Have you seen Wonder Bread when it sits out like it can, it has no shelf life. It doesn't. It never gets moldy. Why? Because of the preservatives in there. It's insane. There's another one, simply food. It's another brand now in, in Doral, basically. And they make fresh, fresh bread just like that. And if even in the refrigerator, it will become moldy if you don't eat it within a few days.
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Yeah, it's incredible. But, but I, it's. But I think it's also good. We're, we're to your point. I think we went culturally from this idea of being skinny, eating less cleanses, detoxes, depriving ourself fears of carbs, cutting out food groups to being more inclusive. And if, if a well rounded Mediterranean diet is a prior priority and we're going to talk about exercise and muscle mass and, and you need carbohydrates. You really do. Otherwise you're going to suffer.
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B
You need it. It's in part, your body requires it. It's kind of like a part of what we need to. The building blocks of everything. It's in all the foods we eat.
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And so let's segue to exercise. What should we be thinking about in terms of exercise?
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B
Again, back to the 80s and 90s, it was all about cardio. Cardio, cardio. I remember, you know, it was a treadmill. I had a StairMaster. I mean, I would be on that thing like a rat, you know, in a, in a spinning wheel for like hours and just to get the sweat up and going. And luckily, even back then I knew there was something to do with weight. So like I incorporated heavy weightlifting at the time. And lo and behold, I didn't know what I was doing, you know, on a body level. I was just doing it because it felt good and it was my exercise regimen for the moment. But fast forward now we know that that keeps, that builds, that, you know, you build your muscle in your 20s, 30s the most, and your bone strength is its highest in your 30s, so it helps you maintain yourself going Forward in, you know, midlife when with the estrogen levels declining, you need that muscle mass to kind of get you through in terms of metabolism, in terms of strength and bone well being. And we need exercises to promote that. We need. You can do the cardio part, that's okay, but that should not be the core of what you do. The core should be some form of resistance training, whatever that looks like for each individual person. There are people who are weightlifting in the gym and I think that's wonderful as long as they're doing it appropriately with guidance. Because you know, now we're getting the fear of okay, I need to lift weights. They're running to the gym, not ever having done it and then they injure themselves. So we need to make sure it's with appropriate supervision of trainers who are well versed in the midlife. Woman, this is not a 20 year old trying to lift weights. This is somebody 40, 45, maybe 50, who's never really done weights like that before. And it's never done a deadlift or you know, push press or bench press or any. You need to do it with appropriate supervision. That way you get the benefits that you're looking for and you build upon it.
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A
I think that's very sage advice because one of the most effective ways to rapidly decline is become immobile. And when you go a little too hard in the gym or you're not using the right form and I've done this, you end up being injured, then you can't do anything right and just.
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B
Puts you out and then you're kicking yourself like, why did I do that to myself? I was a big, you know, crossfitter all through my 40s and that's when I realized people around me were getting injured. And you know, in CrossFit the mentalities go heavier, heavier, faster, heavier. And, and it was great, I loved it. But I was like, I can't get injured, I have to work. I need to be able to continue working. You know, I have to operate. So it was a no, it was a non negotiable for me. I have to find something else where I can continue maintaining muscle mass but, you know, not get injured. So, you know, so easily. And again, so for me it was a different version. I found something that actually works for me. I do it at home. You know, the Tracy Anderson method. I'm sure you've heard, you know, Tracy. Yes. And so I, I moved over to that and what I've noticed is, you know, it's funny, when I did the method before, I Started, I had gone to my primary care provider who has the DEXA scan in her office, where, you know, it does not only bone mass, but also muscle mass. So you get a whole printout of that. So I did it when I was in my CrossFit era. Fast forward, you know, I did. I've been working out with Tracy for a number of years now, and I decided just for fun, let me go check my level now and compare. Not only did I maintain it actually built more muscle doing her method and her method, you know, what I've done so far, it included really small weights, but a lot of resistance work goes in there. And if you ever watch any of the programming that she does, it is in a heated studio with heat and steam and everything, which is kind of becoming more of a trend now. I've seen my daughter do this, you know, at Fuse House yoga with heat and everything. I was like, wait, or Pilates with heat? I'm like, okay, that's interesting. Everyone's kind of realizing the benefits of that. And so now what she has evolved it into is weight training too. So now there are heavier weights being incorporated into the workout. Her my mode has actually a whole barbell apparatus component to it that actually builds muscle as you go. So in my own and of one, I have noticed differences by going even from heavyweights to this type of weight training, and it works for me. Again, my schedule is nuts. I need to be able to go at 4:30 in the morning and work out in my garage. And that's what I do. I literally get up, get dressed, go work out for an hour in my garage, and then I'm off to go for the rest of the day. And it works. But again, each person, I think, Jason, they need to find what works for them and then just kind of, you know, build their whole thing around it and make sure it's included as part of their daily activity.
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A
Tracy's method's interesting in that it combines a little bit of everything. And if you're crunched for time, it's effective. You kind of get your, your resistance training, a little bit of cardio mobility work all in at one time. That's appealing.
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She's been around a long time and what I love, you know, she's evolved it though. That's the thing. It used to be just the mat, then it was then she developed the my mode. And as you know, things are changing and Tracy's getting older, so she realizes in her own body what she needs. And so she, she changes the programming and even Developing new things and weights and things like that that goes along with it that way, you know, it's not kind of like an outdated thing that doesn't work anymore.
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A
What's also interesting too is Colleen and I discovered this through you and some of our mutual friends in Miami. What's cool is that there's a bit of, like a community you have here within Tracy. And there's real friendships, it's real community. And there's a. And there's joy in that. And that's something I don't think we talk about enough. It just sounds, if one's listening, they're like, oh, great, she's doing this in their garage by herself at 4:30 in the morning. That sounds like. That sounds awful. But that's really not the case. So can you talk about community and joy and how that comes together for you in this group? Because I think it's really, really something we don't spend enough time talking about.
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B
The reason all that came about is actually the pandemic was where we all, you know, the. It's. We call it the Tamily because it's a Tracy Anderson method. So T A M. And so instead of family, it's a tamily. That's like a little, you know, I didn't develop it. It was there when I joined, so I just kind of went with it. The tamily was already in place. It was a community of people. Because, remember, she's global. She's on a online platform that is all across the world. So I have friends that I've never met in person, but I know them globally because we work out together on Zoom. So that's how it started during the pandemic. Everybody was, you know, locked down. And what do we do? We worked out all day long. Tracy moved to, you know, northern Florida to a ranch, built a whole studio and was doing live classes through the whole pandemic. And what we would do is we would all join on Zoom and be working out on a. On a screen next to each other, but, you know, apart. That continued after the fact. And we, we built a lot of, you know, friendships through these workouts. Like, okay, we're jumping on at 8 o', clock, someone send a Zoom link. We would all jump on, share our screen, and we were all, you know, working out together in our respective homes, wherever that may be. Fast forward now. Then we started, you know, the world came back to norm and Tracy started having her vitality weeks in the Hamptons and in Montana and in California. We went the one in the Hamptons. And literally, I bunked up with eight women that we had been zooming with for over two years. And my husband was funny. He's like, so you're going to the Hamptons with a bunch of people that you don't even know for four days? I said, pretty much, I know them, but I don't know them. I only knew one person, Erica, you know, fit mama who's in Miami. So I knew her personally, but the two of us were like, we know everyone else, but we don't know them. Literally, we show up to a house in the Hamptons, and we're all there. We're all there for the same purpose, to work out with Tracy. And, you know, our friendship kind of kept developing from that point because she's, like, the central component of, you know, our interest. But we all have other parts of our lives that can kind of cross over, and the friendships have blossomed since then into, like, you know, even, you know, like, career move and things like that. It's like, okay, well, this one can help me with this, and how can I help this person? And, you know, my friends are need surgery, so they ask me, okay, what do I do? Who do I go to? So it had that. Her method brought us all together, but then our friendship just kind of blossomed out of it, and even the husbands are all friends now, and we kind of travel together sometimes. Abercrombie knows how denim should fit and feel, and this year is about curating.
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A
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B
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A
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B
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A
Abercrombie Denim in the app, online and in stores. It's really incredible because I think many of the zoom communities just disappeared once. Once the world opened up again, but. But this one has really stayed strong, and it's been remarkable to watch. When Colleen started to connect the dots, I was like, oh, that. That's really cool. So, okay, so we talked about nutrition, exercise, sleep. Even though I think this one is kind of straightforward, we should still talk about it.
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B
Sleep kind of runs everything. Like, that's kind of when our bodies are resetting, the cells are developing, they're recharging, you know, kind of doing what they need to do for us to be able to function the next day. Otherwise, if you don't sleep well, you're Tired the next day and you're grumpy and then nothing works. It just sets everything up. I, you know, I tell patients if they're able to, to get a aura ring because that OURA ring really will help guide them to see. Okay, because some people think they get eight hours of sleep, but was it really quality sleep? Did you get that quality that you need? Because you, you know, they wake up and they're, I'm still exhausted. I don't know what's wrong with me. This. But did you. They probably didn't get quality sleep. They probably were tossing and turning all night long. So the OURA ring or other, you know, wearables will help them kind of see. Did I get REM sleep? Did I get what I needed to? And if not, how can I modify what I do at night to be able to get the full amount of sleep? Because without that sleep, your body is still under stress and so it's not going to be, to be able to function well the next day and you can't get anything done. Basic people are grumpy. They don't want to do, they don't want to work out, they don't want to do anything, basically.
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A
And you know, wearables, I think, are just so powerful. And I understand some people will say they bring anxiety. What I would counter that with is just wear it for a couple weeks just to understand how your body responds to whether it's a late meal, an early meal, alcohol, that's huge, tremendous effect. And look, I think no alcohol is better than some alcohol. But if you're something I found, for example, only wearing a wearable, like, I rarely drink, I drink like once every couple months. I have maybe a glass of wine or a Bloody Mary or something, and I still enjoy it. When I do, I make it count. I learn wearing a wearable, if I have a drink at lunchtime on the weekends, brunch, not, you know, not during the day, of course, during the week, out of work. But if I like to enjoy one on the weekends, zero effect if I have it around brunch, but if I have it at dinner and that dinner is after 7pm Whoa. And I'm a big person. I'm 220 pounds. Just one drink. That has a real impact. So just work for a couple weeks. Understand what your triggers are. So diet, exercise, sleep, we kind of touched on relationships and like joy and community. Feels like that's. Those are sort of the big rocks, if you will, as it relates to, to lifestyle. So let's say I'VE dialed in all those things. In your view, does that, does that get some women over the hump and they're, they could be okay and not need hrt. Like, what do you see? Because you're practicing every day. What do you see?
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B
What I see with, with the perimenopausal women who do have a lot of symptoms. And then they come in and we go through all of this and we, you know, guide them and hold their hands and get them through that. A lot of them, this will actually modify their well being and they actually feel better. And they're like, doc, I never knew just by working out, you know, half an hour a day, putting that time aside, or walking 10,000 steps again, these are people who barely, you know, who didn't have that much of a exercise regimen to begin with. So, you know, I had to like kind of prescribe it to them. You need to do this, you need to do this. They come back and they're like, the hot flashes are gone. And you know what? I stopped doing what you said and I ate earlier and I took my magnesium at nighttime and I'm sleeping through the night. They're surprised by it, by these little modifications and they're like, I didn't know this could actually work. And I said, well, this is part of why we need to work together is for you to understand these are things that have been shown to help women. So yes, it will get them through. Then there's that subset who they're like, they're great for two, three years now as they're getting closer to menopause where now we're really losing more and more estrogen at that point they might need more help with, you know, medications and hormone therapy and you know, we'll bring that into the mix. But the majority of it is if I can get that bottom of the, you know, the basics, well handled for them and like kind of ironed out and strong that they're good to go and they don't need anything.
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A
So you mentioned magnesium. What other supplements, again, hard to generalize, but let's do it for the sake of the show can help women during this stage.
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B
I like vitamin D3 and K just because it's good for the bones, it's good for immune system, it's good for the brain health. So that one for sure. Omega 3 fatty acids. We, those are good for you. Even though you can get it through food, it's good to make sure you get the supplementation because, you know, even the best diet, sometimes we're not getting that. And I actually use a little bit of magnesium glycinate at nighttime for sleep. And I use the L3 and 8 for daytime for some patients to help with energy and focus for them. And you know, the brain fog that they get that can affect them at work. So those are my big ones, depending on how the patient feels. Well, creatine, obviously. I mean, that's like, we know it's not just for muscle. It's not for, you know, athletes only. It's for everybody. It helps the body, muscle, brain activity, everything. So that is like one of my easy ones. I'm like, you know what, just put it in your water, okay? Put it in a big bottle and just take it with you and drink it throughout the day. Those are really the ones. I, you know, talk to patients, I have a list. And then it's not that long. It's very short, brief, to the point. And you know, I have them try one at a time, add it to their reg and see how they feel with them.
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A
And so I've done all this and I feel pretty good, but not great, or maybe I'm starting to, you know, feel a little bit of a decline. And now I'm strongly considering hrt. How do you determine if someone's a good candidate for hrt? What are the key factors that should influence the decision to start or not start or avoid it?
- [31:19]
B
It's, it's a lot of history taking Jason, you know, you gotta know their background history, so their medical history. Do they have high blood pressure, do they have diabetes, do they have hypercholesterolemia which can pop up during perimenopause because as soon as that estrogen level starts to decline, your LDL starts to increase where you never had a cholesterol problem before. You have to make sure we know their background history genetic wise of breast cancer, any kind of, you know, uterine cancer, ovarian cancer, anything like that. And most women tend to be candidates for hormone therapy. There aren't, you know, there's only a few major contraindications. And once you make sure you don't have any of those, you can have a better discussion with the patient. And you know, that's just abnormal uterine bleeding or vaginal bleeding of unknown cause. We don't know why it's happening. Somebody obviously with, you know, any kind of cancer going on, like, you know, breast cancer, ovarian cancer, anything, they're not candidates at the time. Somebody who has history of blood clots, pulmonary embolism, that person, it Needs to be evaluated more thoroughly because they can be a candidate for transdermal estrogen but not for oral estrogen. What else? Somebody who has an allergy to any components of it. Obviously we would stay away from that person. But overall, women are candidates. It's a matter of having a very full and blown, you know, full in depth discussion with them about their medical history. Making sure there's nothing major, you know, no red flags that pop out at us. And then we talk about different forms of hormone therapy and the different options and you know, it's, it's all about estrogen, progesterone, testosterone. Those are the top three hormones we talk about all the time because that's what women need. It's not one or the other. It's usually a combination of the three. Because as you are going through midlife changes, estrogen drops off and then progesterone and testosterone is the last one.
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A
These are all great questions that come armed with doctor and if your doctor doesn't want to entertain them, they should probably find a new doctor or go see you.
- [33:33]
B
Well, listen, that's what, what ends up happening. They, they actually have Mary Claire's book and they come in with the questionnaire filled out and they're like, so I read the book and these are my questions and these are my symptoms. And more, more and more women that I'm seeing are educated. They've self educated. Social media has helped them to kind of find their way to the right practitioners who are not just going to dismiss them because I think by the time they get to me, they've already been dismissed two, three, four times and.
- [34:04]
A
They embark on this journey. You just don't throw the lifestyle out the window. Lifestyle still goes hand in hand with it makes the pharmaceutical intervention that much more effective.
- [34:13]
B
100%. They go hand in hand. You can't do one without the other.
- [34:17]
A
And so okay, I made the decision, I'm a candidate. Moving forward, can you talk a little bit about the different, you know, the type bio. Bioidentical versus synthetic hormones, the delivery methods, you know, pill, patch, cre. Let's run through the gamut briefly.
- [34:32]
B
Sure. A lot of what we use these days are the bioidenticals. And by that what we mean is it is what your body naturally recognizes as self. So what the ovaries used to make estradiol and micronized progesterone or something what we call prometrium. These are the two versions that the two types of hormones you want. A lot of times I think what's happened with marketing. You know, people think bioidentical means pellets because the pellets have been marketed as bioidentical. But it's again, it's just a different delivery system. And the pellets are mainly testosterone and estradiol. Your progesterone component still comes from a pill. So the pellets are there as bioidentical, but again they're just another delivery mode on a list of ways to take hormones. There's two groups of thought on pellets. Some are pro, some are against. I think there's somewhere in the middle for them. I think you should be on the list of options for patients. I don't think it should be first line therapy because with a pellet, once it's in your body, you know, takes it and uses it and you know, you have to wait for it to get out of your system within three to six months and God forbid you don't like it or your body doesn't tolerate it, there's no way to get it out. You have to wait for the, you know, the, for it to get out of your bloodstream or God forbid again. But you get a pellet of testosterone and estrogen and you're, you find a mass in your breast and now you need a biopsied and there's cancer there. So again, because of those reasons to not aggravate the situation, I don't use it first line. So my first line is with transdermal topical. So it could be a patch of estradiol, it could be an estradiol cream, we even have a mist version and there's even a vaginal ring that contains estradiol. So those are the ways that I distribute or prescribe the estradiol component. The estrogen and the progesterone is mainly and micronized capsule you take at nighttime. That's it. It's very straightforward, very easy. And I personally depending again, I really listen to my patients and I can read them when I, you know, some are more skittish about it than others. There are those who are like, I don't feel good. I've done everything I can. This is affecting my quality of life. Give me everything. So they get the, they get the estradiol, they get the progesterone and they even want the testosterone which I will start them off with a topical vers of testosterone. Again, as we all know, testosterone is not approved for FDA use in women. So we use men versions but at female dosages, so much lower doses and transdermally they're absorbed. They still get the benefits, but we don't skyrocket their levels to too high above physiologic. So they don't have the side effects associated with, you know, very high testosterone levels. So. So some people get all three. Others get just the estrogen and the progesterone. Then they come back in, you know, six to eight weeks to see how their results are, how they're feeling. And then, you know, either I increase dosage or we stay where we are and we continue. But it's really driven by symptoms. It's not really lab tested. You know, we can have labs done ahead of time just to have a baseline on them. But when I see them in six weeks, I'm not repeating labs. I'm talking to the patient. How are you feeling? Tell me. You know, I have a questionnaire. They fill that out and they. I go through the questionnaire again. Okay, how is this. How is that? How is this improved? What's improved? What hasn't? And then you tweak based on that.
- [38:13]
A
You know, I'm glad you mentioned that. I'm having a similar discussion with my doctor who, you know, Frank Lippman, about hormones for me. And we'll look at the labs, but then Frank will say, well, I don't really care what they say. How did that. Let me rephrase that. He doesn't say, I don't care what they say. He says, well, how do you feel? I said, I feel great. He said, well, that's. That says a lot. You got. You gotta. You gotta talk about feeling and symptoms before we just look at the numbers. As in terms of making decision. I think that's very important. Timing. Can it be ever too early or too late for women to start hrt? How does timing influence.
- [38:52]
B
How does it work in. Yeah, that's a great question. Because women think if they're 41, they're still having periods and they don't have hot flashes, but their quality of life is terrible and they're falling apart and they're fighting with everybody and they're forgetting their kids at school and they can't function. They think they're not a candidate for hormones because I'm technically not there. And if you do blood work on them, it doesn't show anything. It just shows their levels are normal. But that's actually the. The perfect candidate as a perimenopausal woman who could benefit from hormone therapy to bas. Regulate her as she's, you know, navigating this whole seven to ten years of perimenopause. I mean, how many years is she supposed to struggle before it's time that she gets it? And that's kind of where we're at is, okay, well, I've struggled five years now. I think I'm, I'm, I'm valid to start it. No, it shouldn't be like that. It should be how you feel, what is it doing to you and your relationships? And that's when we can start it. So let's say I have a 45 year old woman who's in perimenopause and she's having major, major symptoms and now she wants to try it. She can definitely be on it until she hits menopause. Let's say that's at 51, and then you still have another 10 years that she can take it in terms of getting the benefits out of it. So that's 15 years right there.
- [40:14]
A
So it sounds like there's a pretty large window and you're only too late once you've completely come out the other side.
- [40:22]
B
Even there though, they, they actually there's a new, new published study that shows women over 60, let's say, because, you know, average age of menopause is 51. So we say they take 10 years. Now we're at 60, 61. Even women at 60 who come in with severe enough symptoms where it's affecting them, you need, you just need to do further testing, like cardiac analysis to make sure that they don't have any underlying plaque formation in their vessels that can be dislodged by taking estrogen. So if you do those evaluations and they're clear and there's nothing going on with them, and they don't have any other medical risk factors, they can actually still be a candidate for hormone therapy at that point.
- [41:06]
A
It's interesting because you mentioned the cardiovascular risks and there are benefits to my understanding with hrt, beyond, you know, hot flashes, so to speak. Heart health, brain health, bone, bone, longevity, the whole gamut. So can we talk a moment about the benefits beyond just menopausal symptoms?
- [41:24]
B
That's the big kicker is that, you know, a lot of providers think, okay, well, we're just doing this to, you know, band aid their problems and then later we just take them off. But that isn't the case. We know vasomotor symptoms are actually associated with cardiovascular risk down the road. So the more significant those vasomotor symptoms are, those hot flashes, the more likely that you're at risk for heart disease later on. So we're not just, just band aiding that issue. We're actually protecting your heart. So later you don't have a heart attack or high blood pressure or any other cardiac issues. So it's not just for now, it's for later. Right. So you need to understand because patients will tell me, well, I don't have hot flashes and you know what, I did all the diet modifications and I feel good, so why do I need it? Right, Very good question. And I like that. But we need to, for them to understand. Your heart will still require protection as we go forward. Like right now 45, your HDL, which is your heart, healthy cholesterol and it's protective, is nice and high. But as you get older, that can go down and then you lose that protection of, you know, your vessels getting hard and stiff and not being pliable. So you're high, you get high blood pressure out of that, that, and then that's where the plaque starts to form. So that's just for the heart component. What about your bones? Your bones need that estrogen to keep that turnover and that in the osteoclast and osteoblast activity in check. So as much as you're breaking down bad bone, you're building good, healthy, strong bone, and that's all estrogen mediated. Once you have osteopenia or osteoporosis, then you're going to get on those other medications to try and avoid more breakdown. But it doesn't necessarily mean you're building new bone, but you're just not breaking it down as fast. So it's these things that we want to make sure women understand going forward. You're doing yourself a benefit by being on them. It's not just a matter of let me be on it, you know, just to feel better. It's working for you in the long term.
- [43:40]
A
So we've covered a lot of ground today for women considering hrt. Is there anything we didn't touch on that you'd like to cover?
- [43:48]
B
I think, you know, we talked about community before, but I think what I want women to know is they're not alone in this, this, you know, struggle if they go to lunch with their girlfriend. I can assure you, this discussion now, like you said, it is more and more commonplace. I hear it all the time. Like, you know, it used to be, tell me about babies and how many babies did you deliver? Now I go to lunch and it's like, so I heard about this thing and about hormones and this and that and what do you think about this? So it's becoming more commonplace. But I want women to have a community of talking to one another and sharing what they have learned, sharing what's worked for them and what didn't work for them. Well, I did this and this was good for me, or, you know, I did try the patch and I just wasn't in love with it. It kept falling off. So I had to try the cream or I had to try them. I want women to know they're not alone, that there's a lot of people out there willing to help them. Their online communities talking about all of this, kind of demystifying it, so it's not so taboo to talk about anymore. You know, just because you're in menopause doesn't mean you're old, doesn't mean you're washed up and done with. You're just starting. It's a whole new generation of women that need to understand that.
- [45:00]
A
And we've just launched a course on this, which you're a part of. Could you talk a bit about the course which we're excited to, to, to share with people and, and what you talk about in it?
- [45:11]
B
The course is actually, I think it's, you know, it's going to help a lot of women understand the basics of what's going on with them. It's all about perimenopause, menopause, the sexual health components of things. And it's, it's in a digestible, quick little, you know, video where we kind of go through A to Z of what everything is, how your body is reacting and why it's reacting the way it is and what can you do about it. So, yeah, I'm excited to be a part of that one.
- [45:40]
A
Yeah, it's such a great roster of folks, including Vonda Wright, Jamie Seaman and Michelle Shapiro. The list goes on. Wendy Troxell, I'm so glad you're a part of it. I think it's going to help a lot of people. In closing, how could people find you? Where are you? Let's talk about your new podcast. How can people who are looking for a new doc discover you here in the great city of Miami?
- [46:02]
B
Well, I'm in Miami. I've been in Miami for 23 years. But the new practice is open Coral Gables. And it's just undermined name. Gila, Maryland. And you know what I love is the, the social media component of this. Getting the word out and educating more and more people. I'm, you know, on social, I'm just Dr. Gila senor. I do a lot of like I put educational pieces up there. The podcast is Her Time, her health. It's on Spotify and Apple. And again, all the links are on my Instagram page, so. So I'm there. It's easy to find. And in Miami, I'm taking new patients. So come on over and we'll take good care of you here.
- [46:42]
A
Awesome. Well, we have many friends who come see you who have very high standards with regards to their medical care, and they love you. So I think it speaks volumes. Gila, thank you so much for all that you do. We'll link to everything in the show notes, so thank you.
- [46:56]
B
Thank you for having me.