← The Neuro Experience
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- [00:00]
Dr. Alicia Robbins
So many women are kind of made to feel like they're going crazy.
- [00:03]
Louisa Nicola
My guest today is Dr. Alicia Robbins.
- [00:05]
Dr. Alicia Robbins
They're not being told there's a biological process that explains what you're feeling.
- [00:10]
Louisa Nicola
A board certified OB GYN who specializes in guiding women through midlife and menopause.
- [00:16]
Dr. Alicia Robbins
It was a patient who really changed the course of my career and why I feel like this is my life's calling.
- [00:22]
Louisa Nicola
Every physician has that one patient that changes the trajectory of their career.
- [00:26]
Dr. Alicia Robbins
There was this aha moment of like, what? I need to focus on this because this is crazy.
- [00:31]
Louisa Nicola
In this episode, you'll learn how to recognize and define perimenopause, what hormone replacement therapy really means.
- [00:38]
Dr. Alicia Robbins
In this perimenopausal phase, estrogen's fluctuating up and down a lot. Progesterone's going lower at a faster rate. And so you can get these months where you have high estrogen and low progesterone and then you're feeling breast tenderness, bloating, more irritability, you feel pregnant.
- [00:53]
Louisa Nicola
That could cause a marriage breakdown.
- [00:55]
Dr. Alicia Robbins
Thousand percent. And there are some studies on this.
- [00:57]
Louisa Nicola
Oh my God. What is it saying?
- [00:58]
Dr. Alicia Robbins
There is a much higher correlation of divorce in women in our 40s and 50s.
- [01:02]
Louisa Nicola
And they the key questions to ask your doctor to make confident choices. Perimenopause is so misunderstood by providers as well.
- [01:10]
Dr. Alicia Robbins
We haven't educated women and because really, because we haven't educated providers. Because your labs can be normal on paper, because you still have enough estrogen, progesterone to have a cycle.
- [01:20]
Louisa Nicola
Strokes in women triple at the onset of menopause.
- [01:23]
Dr. Alicia Robbins
Yes, the solutions are there and they're quite simple.
- [01:27]
Louisa Nicola
Two out of three cases of Alzheimer's disease is female.
- [01:29]
Dr. Alicia Robbins
Let's talk about what estrogen does in the brain.
- [01:33]
Louisa Nicola
Menopause is in the spotlight right now, which I, I love.
- [01:37]
Dr. Alicia Robbins
Yes, same.
- [01:37]
Louisa Nicola
But I'm still not understanding what exactly is happening to women and their hormones from 35 and above. So why don't we open the stage by just discussing the life cycle of what's happening to females in that age group.
- [01:52]
Dr. Alicia Robbins
I think that even medical providers haven't thought about it correctly in the sense that we kind of treated it like it happened overnight. You know, even when I was, I got probably more than average training in menopause when I was in medical school and residency. And it was sort of like, okay, you're in. Once you're in menopause, it's like there was never the discussion that it's a transition, it takes time, it's not like the night before your 50th birthday, you're in menopause. Right. Just like any other hormone, a neuroendocrine disorder. These levels basically take time. You know. Well, let's define menopause. Menopause. The medical definition is it's the normal period, the cessation of menses for one full year. But it's. That's really not that important, honestly, the period and that one year is not that important. What's really important is to understand that the perimenopause period can last two to 10 years. And basically what's happening is your ovaries, which are the primary source of estrogen, progesterone and testosterone, have been, prior to this, secreted at normal reproductive levels. But what happens in perimenopause, and that is different for every woman, but it can start as early in your really early to mid-30s, especially if you're someone who's going to be going into menopause earlier, is that estrogen is going up and down, but overall trending down. You're getting these big fluctuations. So some months you're having a lot of estrogen, some months a little bit low. But overall in the big picture, it's going down. Progesterone is going down at a faster rate, a slightly more linear rate, not as many fluctuations, but faster and also trending downward. Same thing. While testosterone sort of peaks in our late twenties and in our thirties starts to decline. It makes sense, if you think about it, that if you understand that these hormones are doing so much more than regulating a period. They're involved in our brain, our skin, our heart, our gut, our bones. It makes sense that if you have fluctuating and declining levels of these hormones, you might have symptoms to reflect that.
- [03:44]
Louisa Nicola
It's interesting because we really only always hear about estrogen, but I know that there's progesterone, I know there's estrogen, there's fsh, and then there's testosterone. But when we think about perimenopause, which, by the way, is so misunderstood, it's so misunderstood by providers as well.
- [04:02]
Dr. Alicia Robbins
Totally.
- [04:03]
Louisa Nicola
And that's my whole issue with this, this space, because you can get somebody, a female who's 42 and she's having so many issues, sleeping, dysregulated sleep, mood, gaining weight, she'll go to her primary care. Her primary care may take a snapshot of her hormones and say, your hormones are fine, you're not in perimenopause, but she's got all the symptoms. So can you tell Me why perimenopause is so misunderstood and how is it actually diagnosed?
- [04:31]
Dr. Alicia Robbins
So it's misunderstood because we haven't educated women and because, really, because we haven't educated providers. Most providers are not educated in menopause, and they're definitely not educated in perimenopause. Because, Mary, perimenopause is a little bit more nuanced. Because your labs can be normal on paper, because you still have enough estrogen progesterone to have a cycle, but that doesn't mean that your levels are not different or declining compared to what they were several years before. And because our lab reference ranges are very wide and not very sophisticated, really, your. Your labs will appear normal on paper because it's a snapshot in time and not in. In, let's say, assuming there aren't any sort of obvious diagnoses like premature ovarian failure or early menopause. But let's just say, like the, you know, most women who are in early menopause perimenopause, their labs can be normal. And so it's confusing. And so a lot of doctors, especially if they don't understand perimenopause, it's kind of easier to just say, oh, your labs are normal. You know, try to work out more and focus on sleep and prioritize sleep. You're like, I would love to prioritize sleep.
- [05:36]
Louisa Nicola
Calorie restricted.
- [05:37]
Dr. Alicia Robbins
Calorie restricted. I just can't prioritize sleep because I can't seem to sleep, you know, so. And one of the reasons why women don't know because providers don't know, and the reason providers don't know is because it really hasn't been prioritized in medical school. Like, there is, I think, a societal focus more on pregnancy and fertility, which are, of course, so important. But our lives don't end at all once we're done with that phase. You know, our lives are just as valuable evolutionarily.
- [06:02]
Louisa Nicola
Yes, speaking.
- [06:03]
Dr. Alicia Robbins
Yes. And so, unfortunately, a lot of providers just don't pick up on it. And to be honest, Louisa, I was one of those providers. I was one of those providers who I didn't identify perimenopause until a patient basically showed me. And that was when I really changed the course of my career. And what sort of changed my calling, I would say to focus on this.
- [06:24]
Louisa Nicola
I have a friend, okay, I won't name her name. She listens to my podcast. She's midway through 40. She'll be 41 soon. She's starting to experience these symptoms. Can you Tell me what you think, by the way. Labs came back completely normal for hormones. All of a sudden, just cannot sleep at night. She's getting really hot at night in bed. She's. And she's waking up and she's sweating, but then she's getting cold. So she's going through temperature fluctuations. Irritable, extremely irritable. Has always been so fit and she's got a very, you know, tiny figure. And now she's starting to gain weight. That's her observation. Gaining weight around the mid region. She can't explain it. And she's also, from what I see, she's also her, her mood is starting to change and it's going up, it's going down. And she's like, I don't know. She goes, my brain just doesn't seem to work. Actually fun fact. She locked herself out of her apartment yesterday because she said my brain's just for some reason not working. As somebody who is trained in perimenopause and menopause and you're a board certified OB gyn, how would you approach this?
- [07:32]
Dr. Alicia Robbins
So, and you had asked me earlier, which I should answer now is how do you diagnose it? It's a clinical diagnosis. So labs are helpful to rule out, but we don't need labs to diagnose it. So just listening to this story, it checks all the boxes. And so what providers have to realize, and women too, because I really think that change is happening because women are becoming educated and they're forcing the health care healthcare providers to get up to date and educated. But when you understand that estrogen, progesterone, testosterone do so much more than regulating a period. They work in the brain, they're involved in sleep, they're involved in mood. Estrogen is important for where we deposit visceral. Our visceral fat. It makes. When we lose estrogen, we become more insulin resistant. Once you start to realize that and you understand what those that the hormones are not just. I think Dr. Moscone refers to it as bikini medicine. We tend to just focus on period, period, you know, or just hot flashes. It's like that's the only symptom we think of when it comes to menopause. I'm not sure why. Sometimes it's not hot flashes, sometimes it's just feeling hot like your friend. But this is a classic to me, a classic case of perimenopause. And it's really straightforward, like simple. If you think about it, it's just like any other hormone deficiency. I, you know, people get Weird about it because it's women's health and because there was, you know, a lot of bad press about hormones with the whi. But in reality, I don't see why it should be treated any differently than any other hormone deficiency like thyroid hormone.
- [08:58]
Louisa Nicola
I think it's because traditionally when we hear about menopause and, and by the way, I, I still hear many women who don't understand, who don't know the word perimenopause, they just hear menopause.
- [09:09]
Dr. Alicia Robbins
Right.
- [09:10]
Louisa Nicola
So a lot of people relate perimenopause to that is the end of fertility. I think it becomes scary.
- [09:16]
Dr. Alicia Robbins
Right, right.
- [09:17]
Louisa Nicola
Which maybe they don't want, they're not willing to accept.
- [09:20]
Dr. Alicia Robbins
Right.
- [09:21]
Louisa Nicola
They're in that stage. Can you clarify that? Because I also see I've got another friend who's. She's 44 and she, she fell pregnant.
- [09:29]
Dr. Alicia Robbins
Right? Yes. It is true that it somewhat reflects declining fertility because part of the reason why we're losing estroge egg follicles are declining and they start to decline pretty rapidly in our late 30s and early 40s and fertility. So women in perimenopause can still get pregnant. They are still fertile, just less. They're not ovulating as regularly. And so. And the quality of their eggs decline because of the aging process of the ovaries. But they're still able to get pregnant. It's just not. Their fertility has decreased compared to decades prior. And I think there is that sort of stigma. Yes. Part of it is like it has the word menopause in it. And so you think maybe. Does that mean I'm close to menopause? Perimenopause doesn't mean that you're close to menopause necessarily. It doesn't mean that you're going into menopause earlier necessarily. It just reflects that there. It just means that there are hormonal shifts happening that are leading to. That are sort of the beginning of what ends up being menopause. But again, if menopause is the average age of 51 and perimenopause can last almost a decade, a lot of women start feeling these symptoms in their mid-30s.
- [10:39]
Louisa Nicola
So it's like a 10 year hormonal storm.
- [10:41]
Dr. Alicia Robbins
It can be. It's different for everyone. And that really comes down to genetics, lifestyle. Yeah.
- [10:46]
Louisa Nicola
My mother, they say that you follow your mother. My mother never felt a thing. She never had a hot flash.
- [10:51]
Dr. Alicia Robbins
Never.
- [10:52]
Louisa Nicola
I mean, as her daughter, her only daughter, I saw some of the changes that took place. But in terms of like the hard symptoms she never experienced it. And when I asked her what age were you? 51. She goes, I'm not sure.
- [11:05]
Dr. Alicia Robbins
It's really variable from woman to woman. Very variable. It's like what, it's almost like labor and delivery or having a baby where women have such different experiences. So it's hard to compare. You know, I'll have someone say, yeah, but I went through, I didn't, I'm fine, I feel great. And that's great. But some women really, really struggle and can just feel a complete shell. They just don't recognize themselves in so many ways.
- [11:29]
Louisa Nicola
That's a really good segue into the next part, which is estrogen's role in the brain.
- [11:34]
Dr. Alicia Robbins
Yes.
- [11:35]
Louisa Nicola
So two out of three cases of Alzheimer's disease is female. Now there is some, you know, it's a controversial topic because it is. Is it because we live longer? Is it because of menopause? Look, I'm in a, I'm in the middle there. I'm a bit Switzerland. I do veer more towards the side of menopause. So evidently we know that the decline in estrogen affects the brain. We see you're getting brain fog, you're getting irritability. I'm actually just reading up right now on the latest 2024, 2025 reviews on Brain starvation from estrogen and what it does. So why don't we talk about estrogen's role in the brain?
- [12:13]
Dr. Alicia Robbins
Yeah, so let's talk about what estrogen does in the brain. It is overall a very neuroprotective hormone. So just in general it's anti inflammatory and it's anti inflammatory in the neurons. It's also anti inflammatory in the vascular system. So it protects, it's neuroprotective, but it also helps protect against cerebral ischemia. So let's focus on the neurons. In terms of the neurons, estrogen helps with glucose uptake, it helps against oxidative stress and damage, it helps with neuroplasticity. It actually augments levels of bdnf. So as we lose estrogen, we lose levels of bdnf, which is some brain derived neurotropic factor, which is why we start to have some women who are genetically predisposed can start having issues with memory and cognition. In terms of the vasculature, it helps promote blood flow because it helps with vasodilation, it helps with nitrous oxide production in the cerebral vasculature. So it is overall very protective. And so when you start to lose these levels of estrogen in the brain, you actually start having chronic low grade inflammation with accumulation of inflammatory inflammatory cells like T cells and microglia cells and more cytokines. Estrogen also affects neurotransmitters, so its net effect in the brain is to increase serotonin levels as many women might recognize. Serotonin. Just like selective serotonin reuptake inhibitors to antidepressants, it acts as a natural antidepressant in the brain.
- [13:43]
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- [16:26]
Louisa Nicola
I'm wrong, but after the WHI, wasn't there a rise of women being prescribed SSRIs?
- [16:32]
Dr. Alicia Robbins
Oh, yes. So prior to the WHI, almost half of women were on hormone therapy. It kind of started off as this sort of treatment for women to stay, you know, youthful and feminine. And it was a little bit of like a 1950 retro kind of popular trend. But leading up to the early 2000s, the NIH was like, we should study actually and see if the, see if it's actually safe. And when they did the whi, their findings, which were later just basically a lot of them, you know, who were debunked and discredited. But when their initial findings came out, it scared a lot of women. And physicians and physicians were basically told stop prescribing it. So it went somewhere from 50% of women to single digits. And by the way, even now only about 4 to 6% of women on hormone therapy.
- [17:24]
Louisa Nicola
Is everyone still scared of getting breast cancer? Increasing their risk of breast cancer? Is that, is that what's happening? Is that why they're fearing it's getting better?
- [17:32]
Dr. Alicia Robbins
But it's still a big fear. And for some reason, breast cancer tends to scare women more than almost anything else, which I always try to remind women. Like, that's not usually what women die of, though. We're dying from cardiovascular disease, frailty, dementia, you know, neurocognitive disorders. But when the big, huge drop in HRT came after the whi, if you look at trends in prescribing practices, what you see, that kind of replaced HRT was a big increase in sleep aids, big increase in antidepressants, big increase in Xanax and benzodiazepines to help with sleep. That's. I don't think that's a coincidence. They had to do something for these women who are no longer sleeping and having terrible mood disorders.
- [18:18]
Louisa Nicola
I mean, even now, perimenopause is replaced with Some sort of neuropsychiatric disorder. Confused.
- [18:24]
Dr. Alicia Robbins
So many women feel. Are kind of made to feel like they're going crazy and that they're not normal. They're not being told there's a biological process that explains what you're feeling.
- [18:33]
Louisa Nicola
I mentioned two out of three cases of Alzheimer's is female. It's also 2/3 of caretakers are female.
- [18:41]
Dr. Alicia Robbins
Oh, right, yes.
- [18:42]
Louisa Nicola
So there's definitely a problem here. Now you mentioned we, you know, estrogen receptors in the brain that are responsible for. It's also a bioenergetic. So we've got all these neurons in the brain, around 100 billion of them. And if they're starved at the endothelial level. Now the brain is the most vascular, rich organ in the entire body. And the first things to really go are the little capillaries.
- [19:04]
Dr. Alicia Robbins
Right.
- [19:04]
Louisa Nicola
And if they start to go, the next things to go then are the bigger blood vessels in the brain. And once they start to deteriorate, you don't get any blood flow to the brain. This means you are starving the brain of nutrients and oxygens, which ends up leading to programmed cell death.
- [19:20]
Dr. Alicia Robbins
Exactly.
- [19:21]
Louisa Nicola
Or as you said, ischemia, which. Which is a stroke. And by the way, strokes in women triple at the onset of menopause.
- [19:29]
Dr. Alicia Robbins
Yes.
- [19:30]
Louisa Nicola
Could this explain why?
- [19:32]
Dr. Alicia Robbins
Yes, I think so. I think that there is. We definitely know that once a woman goes through menopause. Yes. Her rate of stroke increases, her rate of a heart attack increase. Her. She is much more at risk to cerebral vascular disease and damage than a man. Than a man at that same controlled for age. So there is something hormonally that is happening, you know, during perimenopause and menopause. And also what I think will shock a lot of people is that some of the findings, you know, in terms of inflammation and looking at the effects of loss of estrogen in the brain are happening earlier than we thought. We always kind of thought these changes were happening in menopause. But again, sort of consistent with realizing that the hormones are declining before menopause for years. Those changes are subtly happening in our 40s, you know, for a lot of women. So it is something to know about sooner. I think a lot of women don't realize that this is Alzheimer's is really the pathology is starting earlier than we really thought.
- [20:32]
Louisa Nicola
So what can a woman expect who is going through all of these changes? And you prescribe her, is it oral estrogen or is it an estrogen gel? Whatever you prescribe her, what can she start to feel? Symptoms wise over the course of a.
- [20:49]
Dr. Alicia Robbins
Week or a month, I generally start things in a very stepwise manner and layer things in and I actually start. So it depends on where she is in her perimenopausal or menopausal journey. So if she's early perimenopause, let's say late 30s, early 40s, remember I said one of the first hormones that starts to decline is progesterone. I actually start with progesterone first, which is unusual. A lot of people think give her estrogen, estrogen. But a lot of times one of the two most common symptoms that women come to see me for in their 40s is sleep issues and mood, specifically more anxiety, depression or irritability. And often that can is really a reflection of loss of progesterone. So I start with progesterone and honestly within a few days, if the cause, if the etiology of what she's feeling is from progesterone loss her within a few days, in a few weeks, she'll start feeling better and sleeping better and the mood will be better. Estrogen takes a little bit longer to feel the effects from.
- [21:48]
Louisa Nicola
Is that a patch that you put on?
- [21:49]
Dr. Alicia Robbins
Progesterone is an oral pill that you take at bedtime and it's dose, it's a, you take it at bedtime, it's dosed, you know, anywhere from 100 to 400 milligrams or even more. And, and for most women tolerate it very well. There's a very small percentage of women have progesterone tolerance. But if she's earlier in her perimenopausal stage, then generally it's more of a progesterone loss. And this explains why you had mentioned your friend sometimes feels pregnant. Because what can happen is in this perimenopausal phase, remember I said estrogen's fluctuating up and down a lot, progesterone's going lower at a faster rate. And so you can get these months where you have high estrogen and low progesterone and then you're feeling breast tenderness, bloating, more irritability, you feel pregnant. And usually what they need is progesterone. Because it's what I focus on. I can pretty much immediately tell from listening to a woman if she's more progesterone deficient or more estrogen deficient or both. So then if she also has a lot of estrogen deficient signs, which would be more brain fog, feeling hot, temperature regulation right from the hypothalamus or Joint pain. Then I start introducing estrogen. Estrogen takes a couple of weeks. But I would say I tell women with. If this is from a hormone deficiency, within a couple weeks you should be feeling better. Definitely by three to six months, I can get someone feeling better.
- [23:06]
Louisa Nicola
And I have had an endocrinologist on here before and she mentioned that whenever she's prescribing anything and she's, she's actually just really prescribing GLP1s and she's in that. But she, she makes sure that she monitors every four weeks. I'm guessing you do something similar to that.
- [23:23]
Dr. Alicia Robbins
Yes. So it depends. Now, with perimenopause, the labs are not as helpful. In menopause, they are a little bit more helpful because their blood levels are going to reflect whatever hormones they're being given. Right. That they're taking externally. In perimenopause, you can't account. Your body can't tell the difference between the hormones I'm giving her and the hormones her ovaries are secreting.
- [23:46]
Louisa Nicola
Because it's bioidentical.
- [23:48]
Dr. Alicia Robbins
Right? Right. So bio. Exactly. So we're prescribing. Modern practices of hormone therapy are really prescribing bioidentical hormones, which means they are structurally, chemically the same as your own natural hormones. Your body can't tell a differ, which is great. And it's an amazing, you know, I mean, it's amazing that we have access. Well, that some women, we want more women to have access and have this conversation. But, but it, they're very safe because they're bioidentical.
- [24:12]
Louisa Nicola
Can I ask a really low level, probably dumb question? No, not at all. I mean, if they are bioidentical hormones.
- [24:20]
Dr. Alicia Robbins
Yes.
- [24:21]
Louisa Nicola
Then why can't we reproduce for the rest of our lives?
- [24:23]
Dr. Alicia Robbins
So when we give women these hormones, they're all. Are actually really small levels. And so women, when we talk about hormone therapy, everyone thinks we're like flooding women with these crazy amounts of hormone. When we do hormone therapy, it's about one third the dose of a birth control pill, one third to a quarter. It's. They're very small doses. And just to put into perspective, in menopause, someone in menopausal and hormone therapy, her estradiol levels will be anywhere from 20 to maybe 120. In pregnancy, they're in the thousands. So we're just not repleting these hormones to a degree where they're able to cycle again.
- [24:59]
Louisa Nicola
Why is that?
- [25:00]
Dr. Alicia Robbins
I think that's because those are the guidelines. And most women clinically Feel better. They can feel better on these levels. But I have, I do prescribe higher levels than guidelines sometimes in the right person because some women need higher levels and that's where they feel best.
- [25:17]
Louisa Nicola
Let me tell you the guidelines.
- [25:19]
Dr. Alicia Robbins
I don't know the guidelines are, you know, I, you know, the menopause space gets really, people get, get really opinionated about things and there's a lot of, there's a lot of territory. People get really territorial who have, you know, been doing this for a long time and are very, you know, dogmatic about the guidelines. But the thing is the guidelines are meant as a guide. Right. And I'm never going to do anything that is going to veer too much from the guidelines or be dangerous. Guidelines are helpful, but they, I don't think that they are the end all be all in terms of because. And also given that women were include, weren't included in clinical trials until like the early 90s. We just don't have that many randomized control trials. We have to use a lot of the observational data that we have, but we do have a good amount of observational data.
- [26:04]
Louisa Nicola
What I feel like you're saying is that you want women to start listening to themselves.
- [26:09]
Dr. Alicia Robbins
Yes.
- [26:09]
Louisa Nicola
And stop thinking and overriding some of the symptoms that they have and just talking about like, oh, maybe it's just work stress.
- [26:18]
Dr. Alicia Robbins
Well, one thing that I think the physicians have been wrong about for a long time is that we have to wait till menopause to treat women with hormone therapy. That was always the assumption it's not beneficial. They already have estrogen, progesterone, they're still having a period. Why would we give them hormone therapy? And honestly, the reason I learned about when I discovered this was a story. It was a patient who really changed the course of my career and why I feel like this is my life's calling. I remember it so vividly. I was sitting with this patient, a Lovely, I think 42, 43 year old woman attorney from the city, high functioning. We had been, I had been her doctor for a couple of years. She's, you know, lovely. And she came and she started having sleep issues, difficulty falling asleep, difficulty staying asleep. And the sort of traditional, you know, first line guidelines were, you know, sleep hygiene counseling, of course. You know, then we started doing Ambien, you know, then Xanax as needed. We had her ruled out for sleep apnea. The whole thing that most providers are gonna do for a woman who's 42 coming with sleep issues and you know, she was still having a Period. And she was getting more and more frustrated, aggravated. She was affecting her way functioning at work. It was affecting her relationships. She was, and, and I was, you know, feeling her frustration. I was also frustrated myself for not being able to help her, give her answers. And I did know because I've actually always loved brain science. I did neuroscience research in undergrad and I've, I read a lot about sort of brain health. It's just something I think is so fascinating. So I knew more than most OB GYNs that progesterone and estrogen play roles in the brain with sleep. And sort of my last ditch effort, I thought, why don't, I said to her, why don't we try some progesterone and some hormone therapy? And she kind of looked at me almost offended because she was like, but I'm not even menopausal. And I said, I know, I know, but you know, estrogen and progesterone are involved in the brain and help with sleep potentially for menopausal. It's not going to harm, it's not going to be, it's not dangerous. Look, I literally, I think I told her it probably won't even work, but let's try it. I gave her a prescription for this time. I did give estrogen and progesterone together. And then she came back in a couple of weeks. She was a different person. She said, I can't thank you enough. Like I'm sleeping. I feel like my life is, I have hope now. I, and I can't even, I can't even thank you. I'm a different person. I at that moment obviously was so thrilled and happy for her, but I had, there was this aha moment of like, what it works and how come I, as someone who went to an academic trained center, did get menopause training, had great training in New York City. Somehow I got this far in my career as an OB gyn and I didn't know that this could help women. What other women was I not helping because of this, that I was inadvertently gatekeeping. So I was a terrible perimenopausal provider. But it was that moment where I was like, okay, I, I've got stop everything. I need to focus on this because this is crazy that we are withholding this from women in their 40s and just patting them on the back and expecting them to just knuckle through.
- [29:21]
Louisa Nicola
Every physician has that one patient that changes the trajectory of their career.
- [29:25]
Dr. Alicia Robbins
Yeah.
- [29:26]
Louisa Nicola
So I love that.
- [29:28]
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- [31:49]
Louisa Nicola
All right, so we've mentioned estrogen receptors in the brain and there's estrogen receptors really all over the body. And so basically if we can try and understand like the pathophysiology of it, the key unlock when we talk about hormones and estrogen, if we are, if there's no estrogen circulating in the body and these receptors become somewhat starved, then whatever they're attached to Whether it's a bone or an organ, they're on organs. Right. Then that organ probably comes slightly dysfunctional at a very small stage. But that's why diseases occur over a long period of time. Alzheimer's takes around 20 years for your first symptom to appear.
- [32:28]
Dr. Alicia Robbins
Exactly.
- [32:29]
Louisa Nicola
Yeah. So. So where else are these estrogen receptors?
- [32:32]
Dr. Alicia Robbins
The FDA approved indications for starting hormone therapy are vasomotor symptoms. So hot flashes, genital urinary syndrome of menopause, so vaginal dryness and pain with intercourse and prevention of osteopenia because we get bone loss as we lose estrogen receptors. Bone loss is affected by loss of estrogen. Metabolic health is affected by loss of estrogen. We, we deposit more visceral fat in our midsection. That's why a lot of women, the average menopausal woman gains 10 to 15 pounds during menopause, even if they're calorie restricting and exercising. And, and it's not just that they're gaining weight, they're specifically gaining visceral fat, which as you know, is more of a risk factor for pre, pre diabetes, insulin resistance, cardiovascular disease. It's more of a, it's sort of a high risk fat, so to speak. Speak.
- [33:22]
Louisa Nicola
Yeah.
- [33:24]
Dr. Alicia Robbins
There are changes in skin. So skin thinness, decreasing elasticity, dryness. So those are just a number of symptoms to reflect. Yeah.
- [33:37]
Louisa Nicola
It's funny because I just hear all these marketers now, like booming. They're like, okay, I know, you know, like, what products can we sell to these vulnerable women? Yes, regarding, like. And by the way, that's another symptom that my friend is having skin issues.
- [33:50]
Dr. Alicia Robbins
Yes.
- [33:51]
Louisa Nicola
That she didn't have in her 30s, more body odor.
- [33:54]
Dr. Alicia Robbins
Because the ratio of estrogen to testosterone switches in your like axilla, in your underarms. You get more testosterone, more sort of androgens and stronger body odor for some women.
- [34:04]
Louisa Nicola
Have you heard of androgel?
- [34:06]
Dr. Alicia Robbins
Yes.
- [34:07]
Louisa Nicola
Yes. Of course. You have?
- [34:08]
Dr. Alicia Robbins
Yes.
- [34:09]
Louisa Nicola
What's the indications of taking that? Because I was actually prescribed it because I had, I had low testosterone. And then I realized that testosterone is a receptor hormone. So just, I don't have any, I didn't have any symptoms of it. I mean, I live in New York City. I got tested in, I think it was like January, so the peak of like how cold it is. I wasn't getting any sunlight. I mean, why, why do women get low testosterone? A, you know, if I had taken that, what would the effects have been?
- [34:37]
Dr. Alicia Robbins
So women get low testosterone one, because the ovaries, again, are not secreting as much we also. It's impacted by stress, poor sleep.
- [34:46]
Louisa Nicola
It's not just about ovaries. Like, what if you're really stressed, sleep deprived and not getting any sunlight?
- [34:50]
Dr. Alicia Robbins
Yeah, yeah, yeah. You're going to have decreased levels of testosterone with testosterone. Right now the indication is for postmenopausal women for hypoactive sexual desire disorder, hsdd. So low libido. But the reality is it's such a, it's again with the guidelines. You know, if, if we were to follow the guidelines, there's so much more benefit to testosterone than low libido. And not only that, why do we have to wait till like I know, okay, the study son was in menopausal woman. But we can, you know, it's a natural hormone. It's a female hormone. A lot of people are surprised to hear that. When I, I've been prescribing testosterone for years. 1mil I do what's generally 5mg daily is the standard female dose. Now depending on the patient, if she's sort of. I found that more active, more muscular patients tolerate more or tolerate that fine. Some need less and the react. The response is. It is variable, like some women. So when I do testosterone, I track the labs just to ensure that it's staying in a peak female range. And a lot of women feel great benefit, but not everyone does. It is difficult to predict who's going to feel benefit from testosterone. You just sort of have to try it and see. And then once we ensure that the levels are actually at peak female levels, then we decide if, you know, they're feeling enough benefit to continue or not. But I would argue there are benefits to being on it it other than libido in terms of energy. I've seen a big, for some women, a big improvement in brain fog and cognition from being on testosterone.
- [36:20]
Louisa Nicola
What is the range? Because I've heard varying things.
- [36:23]
Dr. Alicia Robbins
I use total testosterone, which is not it. You can use free or total. You just have to be consistent with whichever one you pick. And basically a peak total testosterone for a female is 70. Most women are going to be total total testosterone.
- [36:37]
Louisa Nicola
Total testosterone is 70. And what about free?
- [36:40]
Dr. Alicia Robbins
Free is going to be. Honestly, I never look at free, so I just picked total testosterone. But you can use, I mean free is the more active one, but you can use. They, they're, they correlate to like, they're, they're, they correlate to each other. So as long as you use the same one and just are consistent and you know how to, you know how to test for it consistently. Then you just pick one and use that. So I use, I just use total testosterone. For whatever reason. I have found that most women, there's a sweet spot between getting it around a total of like 50 to 100 or so. That's usually where most women find improvement in energy fatigue, brain fog and libido. Potentially. There is a wide range because there's people out there doing pellets where they implant little pellets of testosterone under the skin. And you can get women that have testosterone levels in the hundreds, even thousands. And that's not recommended, of course, because you can really give women irreversible side effects. And that's, you know, so that is the problem is women feel so great on it, you know. And I had one patient say, like, like she had come to me using pellets and we transitioned. Well, we didn't transition her. We switched her over to using FDA approved, sort of the appropriate dosing of, you know, testim gel. But she was like, when she was on the pellet, she's like, I felt so great. I was like, is this how men feel all the time? Like they're just walking around feeling this vibrant? But, but yeah, but I do try to, you know, keep it in safe female ranges.
- [38:05]
Louisa Nicola
Mine was 12. Yeah, that's low. That's low, that's low. And my friend's was nine.
- [38:10]
Dr. Alicia Robbins
Yeah. But it's tricky because depending on everyone's genetic susceptibility, again.
- [38:15]
Louisa Nicola
Yeah.
- [38:15]
Dr. Alicia Robbins
Like you can have someone with. I've had patients with, you know, low testosterone with single digits and they feel fine.
- [38:22]
Louisa Nicola
That's what I mean, there wasn't.
- [38:23]
Dr. Alicia Robbins
Yeah, yeah. And then you can have women who are. I, you know, I increase their dose and. And they don't really feel much benefit. They're still struggling with some of those symptoms. So it is, it's tricky. And I think part of that is because there are so many other things that cause brain fog or fatigue. Like, it can be a variety of, you know, etiology.
- [38:40]
Louisa Nicola
So, but that can also be added to the mix during the perimenopause stage. Progesterone, estrogen, testosterone.
- [38:47]
Dr. Alicia Robbins
I find that in perimenopause women in their late 30s, early 40s, mo. One of my favorite regimens is progesterone with testosterone. You know, I end up adding estrogen later because they're losing estrogen more slowly. And so I generally start with progesterone, then consider testosterone and then add in estrogen if they're having signs of estrogen deficiency. But A lot of times, some of the even symptoms that are associated with estrogen deficiency, like brain fog or fatigue can be improved with, with testosterone.
- [39:19]
Louisa Nicola
But don't they compete with each other? So what happens if you end up. Don't think. Aren't they antagonistic towards each other? Like, if you have too much testosterone, does that.
- [39:29]
Dr. Alicia Robbins
No, I mean, some testosterone is converted to estrogen, but it, it also depends, like the balance, you know, I mean, your balance of hormones is affected very much by your lifestyle. So stress, you know, elevated cortisol levels or stress is going to decrease your levels of estradiol. So it also is going to decrease your levels of testosterone. So I don't think it's so simple to say that they antagonize each other, they're affected by different factors.
- [39:58]
Louisa Nicola
And it's not to be confused with injectable trt, because I think when people hear the word, like a lot of women, when they hear the word testosterone.
- [40:04]
Dr. Alicia Robbins
They think you're going to. Yeah, it's like really aggressive. No, I mean, if you're going to, you know, some. Look, there are providers out there that are giving women unsafe levels of testosterone. I think that's why it gets a little weird, you know, and so you have to just make sure that you're finding someone who's giving you appropriate female doses. And that's why I usually, I don't recommend pellets. Injections are fine. Some women prefer them. As long as you're injecting the correct dose, it can be a little bit more convenient. But in terms of if you're doing appropriate doses, you know, you're just going to preserve some lean muscle mass. You'll have a little bit more energy. You're not going to bulk up, you're not going to, you know, develop, you know, you might. Those side effects that can happen even at female ranges, though, are a little bit of acne sometimes and even a little bit of hair loss. So I do counsel patients with that, even at female doses.
- [40:55]
Louisa Nicola
The route that I went on, because I also had a low dhea. Now I know DHEA is a precursor. Precursor, yeah. By low I think it was like 112 and it needed to be, I think maybe 160. I'm not sure. So then I went on 75 milligrams.
- [41:11]
Dr. Alicia Robbins
Oh, yeah, that's a good dose.
- [41:13]
Louisa Nicola
Yeah.
- [41:13]
Dr. Alicia Robbins
So how did you feel?
- [41:14]
Louisa Nicola
Yeah, great. I feel great.
- [41:16]
Dr. Alicia Robbins
Yeah, you feel great. Dhea, I've had mixed results with. I think for someone that can be helpful, you know, it is like, you Said it's a precursor to testosterone. It's one way of trying to increase the testosterone levels. I think, unfortunately, a lot of supplements are so unpredictable that that if we do dhea, I generally try to compound it because I think it might be a little bit more reliable. But I've had mixed results with it. And I think, again, similar to testosterone, it really just depends on how much of that DHEA they're converting to testosterone, what their genetic susceptibility is. So I guess the point is, I think, you know, there's two points here, which is really, women know their bodies. They should be listening and really paying attention to their symptoms. When we talk about, you know, precision medicine and everything being personalized, it really is personalized. It is so variable. Like, it is very individualized how a woman responds. Most women do feel better if they're going through perimenopause and menopausal and hormone therapy, but not everyone does. So it's kind of hard to compare your story with your friends. And I would say you just don't really know until you try it.
- [42:22]
Louisa Nicola
Yeah. And I also, I heard that it helps with antral follicle count. Having a high testosterone.
- [42:29]
Dr. Alicia Robbins
I honestly didn't know that. But that's so fascinating. I guess.
- [42:33]
Louisa Nicola
I guess during, like, for women who are trying to conceive who have a low testosterone reading, than getting them on, like, preconception, getting them on androgel, I.
- [42:43]
Dr. Alicia Robbins
Would have to look into it. I don't know. But that's fascinating.
- [42:46]
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- [44:53]
Louisa Nicola
1.
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- [45:30]
Louisa Nicola
Women lose strength and power not because they're lazy.
- [45:33]
Dr. Alicia Robbins
Yeah.
- [45:33]
Louisa Nicola
But because the signal is gone, right? We know that there is a clear correlation between estrogen loss and strength and power. As I'm becoming more advanced in this area by talking to so many experts like yourself, I'm finding that everything is a cycle and bidirectional. For example, loss of estrogen means fluctuations during sleep. Fluctuations during sleep affects next day performance, but also affects Alzheimer's disease pathology because we don't activate the glymphatic system. Same with, okay, loss of estrogen means maybe loss of energy and desire and desirability to go to the gym. Then that also increases the risk of sarcopenia and, you know, muscle loss, muscle strength loss, power loss. And these are so vitally important as we age. What are you finding in your practice with these women who are coming to you? Are you finding that it's hard for them to maintain going to the gym?
- [46:33]
Dr. Alicia Robbins
100%. And when I listen To a woman, tell her story. I want to. One of the first things I want to zone in and try to get improve is her sleep. That's the first thing if there's any sleep issues. Because if you're not sleeping well, I can't ask her, her to lift heavy weights three times a week and eat a nutrient, you know, colorful plant. Like, it's like I just, you know, if anyone has suffered from insomnia or difficulty sleeping and I have. So I'm very empathetic to this, you know, that, you know, you're stressed, you're, you tend to pick poor food choices. You're not going to have the motivation. It's a ripple effect, it's like a downstream effect. You're not mentally resilient. You are, you're eating, you're having more, you know, cravings for sugar and comfort food. You're definitely not going to go to the gym. So it's very difficult to ask a woman to do all these things if she's not sleeping. And unfortunately that is one of the things that I find gets affected by perimenopause very commonly.
- [47:30]
Louisa Nicola
Yeah, it's. I was talking with Vonda Wright last night and we just kept going on about how important it is. And actually there's a wonderful study, there was a twin study where they tracked female twins mid age and they were testing them based on muscle power and muscle strength in the lower legs or actually no quad muscles. And what they found was, and they tracked them, I think it was over a 10 year period. And what they found after the 10 year period, the, the twin who had greater leg strength and greater leg muscle power preserved her cognitive functions.
- [48:07]
Dr. Alicia Robbins
It's. Well, that's why they call muscle, I mean muscle the organ of longevity.
- [48:10]
Louisa Nicola
Right.
- [48:11]
Dr. Alicia Robbins
Because it does, it's such active thing. We just think of it as, you know, it's on our bones, but it is so, it's involved in, it's so metabolically active. You know, it's so important in terms of preserving your insulin sensitivity, your metabolic health. You know, one of the best ways I think for women in midlife to maintain their weight is to lift weights. And it's not just because you're exercising, it's because you muscle is a great utilizer of glucose. And so when we start losing muscle mass, we start having much more glucose in our bloodstream. We need more insulin, we become more insulin resistant. If you start preserving and gaining muscle, you don't need as much insulin, you're not gaining as much weight. So it's One of the best ways to maintain weight, especially when I have patients who are on GLP1s, you know, not to mention inter. How protective it is in terms of osteopenia, osteoporosis and, and, and frailty later in life. And you know, we haven't touched upon that. I don't know if you want to, but I have now that I focus on perimenopause and menopause, I am seeing. Oh, because like back to the guideline, you know, the guidelines for looking at osteoporosis are to do a bone density at 65. I mean, this is outrageous. This is so dumb. And now that you know, I better understand the pathophysiology, what's going on. I've been doing bone densities in especially if anyone has, if they have risk factors, especially like a family history as soon as 40. And I cannot tell you how many patients I am seeing with osteopenia, even osteoporosis. I had a patient last week, 40 years old. Osteoporosis. I mean, this is preventable by lifestyle and estrogen. And once you have osteoporosis, it's very difficult to reverse. And once someone breaks their hip, it's very difficult to recover from. Yet we could, we can be preventing this.
- [49:57]
Louisa Nicola
What is the issue then? Because I know some of our mutual friends actually testified at the FDA not long ago. What's the issue? Why are we, why, why is there no specialty on menopause?
- [50:11]
Dr. Alicia Robbins
There should be. I mean, I personally think OB and GYN should be separate components. They're, you know, because I, I mean, dare I say it, I don't think as a society we value midlife, like health, you know, we value other things. You know, we have so much more research on men. And so when, if you look at funds, because really the funds, where the funds are allocated is where the research is going to happen. And that, that's, you know, where the attention is going to be placed. And so if you look at research funds, snippets of re of. There's already not as much funds dedicated to women's health, but whatever is, the vast majority is pregnancy and infertility. There's single digits allocated to midlife health. And so doctors aren't taught to do this. You know, I do think though that things are shifting. I've had a lot more, I've had a lot of younger physicians reach out and be like, how can I learn about menopause more? How can I learn about midlife? You know, where did you learn about all, all this. And so, I mean, I think social media is a great tool in the sense where women are becoming educated faster than a lot of providers. And so they're pushing providers to, you know, to learn more.
- [51:21]
Louisa Nicola
Unless you go to one of those providers that says stop listening to Internet influences.
- [51:24]
Dr. Alicia Robbins
Right, right. But, you know, I mean, women are smart. Like, they, they, I think that a lot of them can sort of filter what's legit and what's not. And I think with longevity, you know, it sounds sexy, but the reality is longevity are the things that we kind of know about. It's just we don't. Sometimes it's like you gotta do the work. You know, I love all, I love longevity and I love all these cutting edge treatments that start coming out. But the reality is you're gonna get so much benefit from doing the basics, from walking, from resistance training, from eating nutrient dense diet, you know, and that just takes consistency and work.
- [52:02]
Louisa Nicola
Do you think there's this, this ploy against women? Like we don't want them to maintain their cognitive functions as they age because that means then the future really is female.
- [52:12]
Dr. Alicia Robbins
Honestly, don't. I mean, maybe I'm a conspiracist, but I think that women, if they were able to have the tools that they need to have to excel and thrive in midlife, yes, there is so much more that we could do. It's such a perfect storm. And it's really unfair for women because just as they, they're coming into an phase of their life where their hormones are starting to work against them, they're the caretakers of their parents, they're taking care of the kids, the spouses, they're trying to peek at their careers. It's just so much going on. And at the same time, they're not feeling like themselves physically. They're not functioning. They're not. You know, I had a patient who came to me, very high functioning executive for like a, a big, you know, publicly traded company who said I can't even conduct meetings because the brain fog is so bad. I'm losing the train of my thought. And it's embarrassing. Like, I can't, I'm losing, I feel like I'm losing, you know, my, my, my, my team doesn't know what's going on. And so it's really unfair to withhold hormone therapy, especially when it's not even based on science. The last 20 years show us that hormone therapy far outweighs the benefit. There was a meta analysis. I think his name is Dr. Hodes, who looked and showed that all if you could, all things. If you compare all women, women who have been on hormone therapy versus those who aren't, have an all cause mortality reduction of about 20 to 30%. I mean that is huge.
- [53:46]
Louisa Nicola
That is huge.
- [53:47]
Dr. Alicia Robbins
I mean that is. And the fact that we are making women see five, six providers plead for hormone therapy, then deny it for a new for reasons that are not based in science is pretty, I think, unethical.
- [54:02]
Louisa Nicola
Unethical, lazy, scary. And there's gotta be something else behind it. I mean, how many drugs do we have for erectile dysfunction?
- [54:11]
Dr. Alicia Robbins
We have about 26. We have two for low libido for women. And most doctors and women don't even know that they exist. And so yeah, it is a double standard for sure.
- [54:22]
Louisa Nicola
Has anyone that this is going off script here? Has anyone looked at the correlation between divorce rates? And the only reason I ask is because I have. I grew up with a lot of guy mates back home in Australia and we're really close and they talk to me, they ring me up about the, their marriages. And I'm like, she's, you know, it gets to a point where I remember one of my friends, he's like, she's becoming insufferable. Yeah, he loves his wife so much, but he's like something's changed. I don't know if I did something to the point and I think to myself, do you think a woman's unknowingly going into perimenopause, doesn't recognize herself, becomes so irritable that it could cause a marriage breakdown?
- [55:07]
Dr. Alicia Robbins
1,000%. And there are some studies on this that I can send you. Oh my God.
- [55:11]
Louisa Nicola
What is it saying?
- [55:12]
Dr. Alicia Robbins
It shows that there is a much higher correlation of divorce in women in our 40s and 50s. And if you think about sort of makes sense because you're not sleepy, you're more irritable, sex hurts. You have vaginal dryness, you have pain, you have your recurrent urinary tract infections. So if sex is uncomfortable or painful, why are you going to desire it? Sometimes that also can affect with orgasm and sexual pleasure encounters. And so yes, absolutely. If you are not sleeping and you're having pain with intercourse, you know, intimacy is a big part of relationships that. And there's a biological process. No one's telling her. And honestly, the solutions are there. The solutions are there and they're quite simple.
- [55:57]
Louisa Nicola
I can't think of a reason why a woman wouldn't start hormone therapy when she has these symptoms. So let's play devil advocate. What are some of the things that you're looking out for? Like do you take the BRCA gene into consideration at all?
- [56:12]
Dr. Alicia Robbins
Well, we do, but it's also not a contraindication actually. Women who have BRCA 1 and 2 often have prophylactic mastectomies or oophorectomies which puts them into surgical menopause. But they are still candidates for hormone therapy. And that is a general consensus, that is a guideline by the menopause society. And there has been studies which show that even BRCA patients previvers put on hormone therapy does not increase risk of breast cancer. You know, and we should. I always want to say there's are a small subset of women that are not candidates for hormone therapy and those are women who are undergoing active treatment for breast cancer. Although, although once they're done with treatment the conversation is becoming a bit more nuanced and two sided, which is great. But while they're undergoing hormone sensitive breast cancer, they're not candidates. Or there's some other exceptions, women who've had a heart attack or women with really serious liver disease. But let's talk about the breast cancer patients for a bit because they are a big proportion of the population. One in eight women will develop breast cancer when they're if it is hormone sensitive, which basically means it's not. The hormones didn't cause the breast cancer, there was a mutation that caused the breast cancer, but hormones can worsen it. And so a lot of these women are put on medications that put them into menopause and it's abrupt and they are struggling. No one's telling them they're going to have pain with sex. No one's telling them they have sleep issues, they're going to have mood issues. And it really I feel for them because they're seeing all. Everyone sort of talk about hormone therapy and the benefits and they're not candidates. However, you know, there are, are non hormonal options for them. Vaginal estrogen is always an option for a breast cancer survivor. Even an active treatment that is local vaginal estrogen, that can be really important for quality of life, sexual health. And so they're always candidates for that and a lot of doctors still deny them unfortunately.
- [58:03]
Louisa Nicola
Okay, so you've provided such a beautiful overview and we've gone deep actually this is the first time that we touch on menopause, but we haven't really gone deep into hormones and perimenopause and menopause. So thank you for, for that. If a woman is listening and she's approaching late 30s, early 40s. Maybe she's got symptoms, maybe she doesn't. Who's the first person that she sees? Is it her primary care?
- [58:25]
Dr. Alicia Robbins
I would say if you have a physician, whether it be primary care or obgyn, if they're open to considering hormone therapy, then yes. But if they are not, I wouldn't spend too much time trying to convince them. I would try to find someone who is, has been prescribing hormone therapy and is comfortable doing it and that is okay. You don't necessarily. You can use a telehealth company. There's not. You know, the great thing about hormone therapy and perimenopause is it can be done over telehealth. You don't really need in person visits. So, you know, you don't need to break up with your OBGYN or your primary care. You can just supplement your care with someone who knows how to manage hormones. You know, our practice is specialized in that, but we're only yet in New York and Connecticut. But there are a lot more physicians applying for becoming certified by the Menopause Society. So I think you're going to see more, more resources and options for women. One resource is going to the Menopause Society website where they have a list of certified providers. So I think at Mount Sinai they're opening up a menopause clinic as well. So there's going to be more and more options. But I think a woman starts by trying to just track her symptoms, you know, especially if she's, if they're related to her cycle. It can be very helpful for a provider. If we have someone who comes in and says, I know that, you know, these are the symptoms I have. This is when it happens in my cycle. You know, unfortunately, you still have to advocate for yourself. If you don't get the answers you need, you just have to keep advocating for yourself. And I think a lot of women unfortunately know that it's difficult to find a provider. A lot of them have experienced being turned down for hormone therapy. But there are resources, telehealth companies, you know, more and more practices opening. And so I think that it's actually a really, it's a really good time. Sometimes this conversation can get really negative and heavy. But I want women to know that, you know, people are listening and that things are slowly changing, but the future is looking brighter, you know, and a lot of times I'll, you know, because when I prescribe hormone therapy for women in perimenopause, which is technically off label as a Side note, I think, you know, when I have patients that are other colleagues that are very purist about the guidelines, I'll say, well, one FDA approved recommendation or approved indication for hormone therapy is prevention of osteoporosis. And almost one in two women will develop osteoporosis at some point in their life. So therefore, I can justify using hormone therapy in that regard, but I don't even have to do that. The reality is, if you're having symptoms, you should potentially, you should be able to have that conversation and consider it, you know, with your physician.
- [61:01]
Louisa Nicola
I have to say thank you. You've provided said, like, the most sound understanding. I don't even think that makes sense. But what I want to say is, like, I used to be scared to talk about this.
- [61:11]
Dr. Alicia Robbins
Yeah.
- [61:12]
Louisa Nicola
I don't know why, but you have made it. You and a lot of our mutual friends and colleagues have made it not as scary. And I think that's what every female probably wants to hear. It's not scary scary. Vonda and I were together last night and she said, louise, there's. There's three things that a woman will inevitably go through. That is death, taxes, and menopause.
- [61:37]
Dr. Alicia Robbins
Yes, right, exactly.
- [61:39]
Louisa Nicola
The three certainties.
- [61:39]
Dr. Alicia Robbins
And perimenopause.
- [61:40]
Louisa Nicola
And perimenopause. That's a fourth one. So it needs to be discussed.
- [61:45]
Dr. Alicia Robbins
It needs to be discussed. And it shouldn't be scary.
- [61:47]
Louisa Nicola
Just periods.
- [61:48]
Dr. Alicia Robbins
Exactly. And I want, you know, I do foresee in the future, and I think in my lifetime, a world where a woman starts having these symptoms. Perimenopause. She goes and sees her doctor, she gets her hormone therapy, she feels better and she moves on. And she. She kicks butt at whatever she's doing.
- [62:01]
Louisa Nicola
Moves on to the next phase of.
- [62:02]
Dr. Alicia Robbins
Yeah, that's the goal.
- [62:03]
Louisa Nicola
I love that. And that's what you're here to do. You're in Greenwich, I'm in Greenwich. Love that. Thank you so much.
- [62:08]
Dr. Alicia Robbins
Thank you, Louisa.
- [62:16]
Louisa Nicola
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