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Hey everybody. Welcome back to the youe're Not Broken podcast today. This is a recorded lecture that I gave on how to prescribe hormone therapy. So it's about an hour of a lecture and then I do some Q A at the end so that'll seem a little more disjointed because I'm kind of chopping from from question to question, but lots of things about the different doses, the different routes, what is a contraindication, what's not a contraindication, and tips and tricks for hormone therapy. So if you are a prescriber or you're just want a little in more depth, take a listen to this podcast and I hope that at least you'll find one or two things that you didn't know and you can share it with other people. So thanks so much for coming to the youe're Not Broken podcast. The second book, the Menopause Moment Hormones, Science and Mindset for optimal Longevity is now available for pre order on both Amazon and Barnes and Noble. The book comes out September 16th. And if you want to join me in person in Sedona in October, I have two spots left. We're going to talk all things hormones, sex, med, social media, whatever you as a prescriber want to know. And if you are not a prescriber and you just want to know more about all those things, come on along. We had two non prescribers at our first retreat last year in 2024 and it was super fun to have them. So only two slots left, that's Sedona, that's October. Check out the website or my email for more information on that. I love you so much and without further ado, I a longer podcast today talking all about hormone prescribing. Enjoy. Welcome to the you are Not Broken podcast. I'm your host Dr. Kelly Casperson, a board certified urologist, thought leader and conversation starter on midlife living, hormones and sexuality. Enjoy the show. Thank you everybody for being here. I wish I can't see all of you but I Heather told me I'm like Heather, I can't tell people how to prescribe hormones if they're still afraid of hormones. And she assured me that you guys have had a lecture, understanding the kerfuffle to call it very kindly of the 2002 WHI. But I can't do. I I literally can't say let's start giving hormones without backing up. Like why I'm so incredibly passionate about this, how incredibly safe it is. I argue all the time, can we even call these Medications if they're, if we're just giving back in small amounts what our body makes. So maybe just a short chat of like, are you, are you a hundred percent comfortable with this topic? Have we never prescribed hormones before? Do we still think it causes cancer? Can I get like a litmus test of the audience of like where you are, how warm we are to this idea to like I give it every day. Where are we? 100, 100. Confident. Often. We love hormones. Awesome. Oh my God. Very comfortable. Love them. Okay, awesome. Love it. Prescribe all the time. Oh, fantastic. I don't know who knows this but women are 50 of the population like this. We need all hands on deck to be doing this. We don't have enough healthcare providers as it is, let alone to start taking in the wave. Oh, everybody's awesome. Okay, so I'm just gonna go through the, the slight kerfuffle then. But I won't. And hopefully you'll learn some new things about how amazing it is. But then we'll really get to the meat of prescribing and hopefully have time for Q A. So you guys, questions. I'm based in the States, I use States products. Somebody says, I thought we were talking about testosterone today. Testosterone is a hormone. We're going to talk about it. I have an entire like 4 hour courses on just how to prescribe testosterone for women and I can give you resources on that too if you want in the, at the end. So I'm in America, I use American products. I know they're not available universally and we'll try to our hormones real. I love it. But so I'm a little American based. I do know, I do know Australia and UK pretty well. I know Canada pretty well. But I don't know what's available all around the world. So like that'd be my only bias is I'm used to the products that we have available here, but I do kind of know what's coming down the pipeline. So that can be exciting to talk about as well. How did I get here? Well, sex got me into menopause. I am a urologist. And about seven years into my career I got what an attending said was coming, which is a seven year itch, which was boredom. Oh my God, I'm just going to see recurrent UTIs for the rest of my life. What did I do all this training for? And the universe knew I was ready for something new. And so they, the universe delivered to me one of my patients who I had cured from bladder cancer and she was crying in my office because of sexual health issues. Wonderful marriage, sexless marriage. And I didn't know how to help her. And so as I'm handing her the box of Kleenex, I'm realizing, is everything I learned about women true, that they're difficult, they take more time. We don't know anything about them anyways. We haven't figured them out. And keep in mind, I'm the person who gives all the Viagra out and all the testosterone out. And I'm like, well, if 90% of men are heterosexual, who's taking care of their partner? So I really got into female sexual health about five years ago. I started a podcast to share what I knew because I was like, seeing people in clinics not going to change the world fast enough. Then I started an Instagram just to get people to listen to my podcast, and that's exploded. And then just last month, that's what all these pictures are. I got the great opportunity of speaking at the Sydney Opera House stage about vaginal estrogen and testosterone. So basically what I'm doing is I'm. I'm teaching all the people the truth. And the doctors do need to catch up because we have about two decades of untrained people now because of the whi. But we, the Gen X and the older millennials, not taking aging perimenopause or menopause sitting down. The boomers are pissed because they missed hormones and we can talk about that. But by and large, Gen X is changing the conversation about hormones and they're going in and demanding it, which is actually way faster than changing the healthcare education system because we've got so many people that we need to educate on the safety and other health benefits of. And it's not, it's not even that. It's just safe. It's like, these are ridiculously good for you because they're just what your body naturally makes. So I would say my opinions are my own. They're pretty darn evidence based. But I also see patients in clinic, and so I have years now of clinical experience. So sex got me into menopause because everybody kept saying, well, you know what happens to your sex life after menopause? And I'm like, no, I don't. What does. And so I went into, like, the role of hormones and does hormones matter for sex life? So I always joke, I got here from. From sex. So this is the first thing that has to be said. The fear of breast cancer is the primary driver behind most menopause health decisions by women and Doctors. We have 10 minute doctor appointments in America. By and large, it's a heck of a lot easier to tell a woman no than to explain the complexity and the fear that happened in 2002. So these are more objectives for me. I want to be able to cover testosterone today. I want to be able to touc perimenopause. I want to be able to touch on, can we start greater than 10 years post menopause? Is that a myth? And then how to counsel patients appropriately. This is what I always say. I'm not here to convince anybody to take hormones. And in most of my patients who come to see me now are incredibly well educated because they know about the podcast, they know about the Instagram, they know what books to read. So my patients are already. They're like, give me all the things, what state of the art. I want what you're having, basically. But I'm not if a pat still coming in with fear. I'm not going to push through that and prescribe to them the same day. I believe in education. And when you make the decision for hormones, you're going to do it because you want to and you understand the fear is minimal. You're not do I never want somebody to be like, I'm on hormones because my doctor said I want people to be on hormones because they want to be on hormones. I think this is a huge body autonomy issue. And to me, I'm like, ideally we're going to live 30 to 40 years post menopause. And that's a heck of a lot of time to be doing what your doctor told you to do instead of doing what you want to do. So I think there's a big, awesome empowerment thing in all of this. So we have tons of hormones. We have three main ones that we can prescribe. Probably don't have time to get into DHEA more than vaginal today. But by and large, three that we can prescribe, they're all important. They're all made by the ovaries. And so I will be talking. When people talk about hormones, they kind of mean estrogen. But so many women tell me my doctor said I couldn't have hormones. What they mean by that is estrogen. So I'm always like, what about progesterone and testosterone? Because they even have like less contraindications. So we stereotype estrogen as the dominant hormone. And it is not true. All of all of these are important. So here's some marketing from pre whi. This is the 1960s marketing in the be in the middle of the century was very marketed towards men as far as the man should be interested in getting his wife on estrogen because it'll. The myth is it'll keep you young forever, it'll keep her the way she is. Very paternalistic marketing practices that happened. But by and large, women were not taking hormones because their husbands told them to or because their doctors were told them to. They were taking hormones because of. They actually made them feel better. And in doing that, they said, hey, these women tend to have less heart disease, but we don't have a randomized control trial. Let's do a wh. Let's do a whi. And that's the. For people who don't know, that's the Women's Health Initiative. So this is the some claims data on what happened to hormone Prescribing when the WHI hit in 2002, Premarin was one of the top sell. It was one of one of the top five drugs in America being sold. About 80% of women got taken off their hormones. Anywhere between 40%. It's about 40% of women were on hormones in the 90s. And I always joke like, listen, I'm just trying to get us back to the 1990s. Like I'm not even trying to do anything radical. I just. Let's just get back to how things were before the big fear came in. So they menopause conference in kind of the fall of last year, they announced the glaring statistic that less than 5% of American women are on hormones. This does not count compounded hormones. A lot of women in America now are on compounded for various reasons. And we can brush on that if we have time. But it is very, very low percentage of hormones. So we have as much as the menopause noise is kind of screaming hormones. It's like the fear is still so pervasive and the lack of education among providers is so a big hill to overcome. We still have. We're nowhere near where we were in the 1990s. So this is the paper. It is free online. Anybody can go online and read the original WHI paper that was published in July of 2002. Remember, the media dropped the bomb. The media said estrogen causes breast cancer. That was said before the paper was published. This paper is free online for anybody who wants to read it. And this is what the authors say in the conclusion. Conclusion. The results do not necessarily apply to other formulations. It is possible that transdermal estradiol and progesterone, which more closely mimic the normal physiology, may provide a different risk benefit profile. The paper says this probably doesn't apply. In addition, the risk of breast cancer was not statistically significant. So you can look through all of this cancer, invasive breasts, we've got confidence intervals. Touching one and crossing one breast cancer was not significant. And then in the subsequent years follow up it was even less significant. So that's what the whole fear was. And we went from about 40% of women on hormones to less than 5 from an insignificant paper that said, hey, maybe the conjugated equine estrogen and synthetic progestin that we used, maybe that the data wouldn't even be that if we use the transdermal and the progesterone, which they didn't have or study in the wha. So in the paper it says our natural hormones probably don't apply. So we, we are at the point where we want to blow this paper out of the water. This is where the fear in the ether is. So the most read New York Times article of last year was the article about being misled about menopause. So you say the people and the doctors have been misled about menopause. Because of that, Nobody prescribes hormones. 7% of OB GYN's internal medicine and family practice residents felt prepar to provide menopause care. This was in 2000, this is 22. So there's not enough OB GYNs. The myth that that all humans should go to one type of doctor is insanely incorrect. They're busy taking care of bleeding babies, birth control, all fibroids, endometriosis, all the other things. They're too busy. There's not enough of them. Got 80 million women in the United States greater than 40. And if you only relied on the certified menopause practitioners, there's nowhere near enough people. So the myth of men or the the term of menopause, that it's a year of no periods, it's outdated. That came up in centuries ago when we couldn't measure lab values, when people didn't have IUDs, they didn't have ablations, they didn't have hysterectomies. That was what they termed menopause. I argue that the lack of periods, natural periods, is a symptom of what's actually going on. It's a symptom, it's not the thing. It's a symptom. But people don't know what actually menopause is, which is a profound lowering of the ovary producing hormones compared to childbearing years. So Think of the menopausal woman in your head. If you close your eyes, you're going to think of like, if you're anything like me, you're going to think of like Betty White in the golden girls, who's like 70. These are women in their 40s, average age 51. That means 50% of people happens before age 51. And there's more and more data coming out. It's not common in the population, but even a hysterectomy, that it's ovary preserving because of likely blood flow issues or surgical trauma, earlier menopause, even if you have ovaries. So things to think about. Perimenopause is real. I have seen so many women. They say perimenopause is not real. Perimenopause is hormonal chaos. They call it puberty 2.0. They say puberty is when your ovaries are coming kind of coming online. Perimenopause is coming offline. It's real. Some people will argue they're the most symptomatic. We should not fear hormones in them. Birth control is not the only answer. And you can help their quality of life significantly. So there's this thing, it's a little complicated, but it's called the loop phenomenon. Basically what this is showing you is because of the chaos in the ovary trying to get eek out the remaining eggs, you can have high doses of estrogen happening in your body during perimenopause. So that's why just throwing people on estrogen patches might not be the first line for everybody. These are the people who are like, oh, my breasts hurt. And I'm like super teary. And it's so they, they're not going to. I hate the word estrogen dominance because it makes people think that you're always dominant. No, you might be dominant on Tuesday. Right. And then it changes. So I hate the term estrogen dominant, but I want to show this of like, the perimenopause is chaos. And you can at sometimes have super high estrogen that can make people very symptomatic. And so listen to the patient. What are they talking to you about? It tends to be the second half of the menstrual cycle. Your progesterone goes really low, your estrogen can go really high. And pe. These women feel awful. This is an important old slide. We need to. I don't, I can't see you for feedback, but I, I believe that you're there. Testosterone is the. People say estrogen is the dominant Sex hormone in women. That's not true. Testosterone is the dominant hormone in women to the tune of four times the estrogen that we make during nor our normal cycling years. So this shows if you take, and here's the problem, and these conversions are different in different countries, but if you take testosterone and you convert it to picograms per mil, which is how estrogen is measured, you will then see, oh my gosh, I have so much more testosterone in my body than estrogen. But in America, testosterone is milligrams per deciliter. Off the top of my head, I forget. But it's. They're different values so you have to convert them to actually see, oh, I have way more testosterone than estrogen. And testosterone doesn't fall off a cliff with menopause. It's a slow, gradual decline from your 20s. Therefore, arguing that we could should be thinking about testosterone in our perimenopause women, people who poo poo testosterone, they'll be like, nothing happens with menopause with testosterone. That's true. Testosterone slowly starts to go down after your 20s. There's no cliff drop after you haven't had a period for a year. And then what the rest of the slide goes is when we're replacing these things, we're replacing like a little bit, but we're not replacing crazy amounts, we're just trying to restore enough for function. So premature menopause, this is people who are or early, before 40, they do horrifically without having hormones replaced. They die basically, they die faster. Heart disease is crazy high. Dementia risk is crazy high. We need standardly estrogen, I would argue everything but estrogen up until the time of average menopause. Because these women do, they basically die more if you're not replacing them and they're going in to premature menopause there they make up terms for how many symptoms you have with menopause. It's like up to 63 or something like that. But symptoms are real, suffering is real. Women have been ignored or poo pooed because the doctor doesn't have these symptoms. They tend to tell the patient, it's not that bad. Right? It's not that bad. How bad is palpitations, vasomotor symptoms? 80% of women can be very devastating associated now with cardiovascular disease. We used to say it used to last a little bit. I've got women in their 70s and 80s who still have hot flashes and they come to me now saying, can I be treated? I've had these for years. I don't want to live this way anymore. Linked with sleep issues, depression and osteoporosis. So it's vasom motor symptoms aren't benign. It's a big question of is this a canary in the coal mine or is there something about them that, that does trigger more? We don't know cuz women's health research is so underfunded. But they're real and they have strong associations with bad things. We can treat them. 80% of women have them. We can treat them. So big cardiovascular risk factor too. Just, and they look. Is it just age or is it age in menopause? Because some people will argue that it's not menopause. But if you look at people different ages and if they've gone through menopause or not, their cardiac risk factor goes up significantly. Specifically because of the risk factor of menopause. Our hormones are needed to treat our mitochondria, to dilate our blood vessels and to help regulate our lipid metabolism. Sleep, we'll go real quick. Sleep is probably one of the biggest issues that we can help women with. We don't go to work because we're tired. We have made more accidents because we're tired. You fall more because you get up at night, because you can't sleep. Mood disorders, let alone libido. Do not expect a sex life if you are not sleeping. It's not how libido works. Just to know it skyrockets. Perimenopause. Also not just menopause. The big myth that I want people to dispel is like, because I see it all the time, I was told I can't be on hormones because I still have my periods. There's nothing magical about a period. Nothing is magical about a period. And I'm like, what about the women who have IUDs and hysterectomies? How come they get all the hormones easily but the natural occurring women, they like have to wait till they stop bleeding. It physiologically makes no sense. You can have hormone chaos and still have periods. So sleep in menopause, absolutely awful. So the, the, the research shows that hormones help sleep not just because they stop hot flashes, but it actually helps the sleep centers of the brain. Progesterone is kind of our big, big one for sleep. Estrogen certainly can help some people. Testosterone is kind of a mixed bag. Some people will say it makes them not sleep and some people say that's that was the secret and it makes them sleep. We do not have enough data on testosterone and sleep in women yet, but that's Just kind of the knowledge. Musculoskeletal syndrome menopause finally got published in 2024. This is real. And not only is it real, it's crazy common. The risk of risk of osteoarthritis goes up when you have untreated menopause. If that's not reason alone for me to want to be on hormones, I fear frozen shoulder. I took care of my mom who had frozen shoulder. I fear frozen shoulder like I I would be. I would like a fair enough argument for me to be on hormones would be I do not want to get frozen shoulder they call it. These are all the reason estrogen works on the musculoskeletal system. They call frozen shoulder the 50 year old shoulder. But horrifically under research because most orthopedic surgeons are male. But we know it's not just muscle, it's muscle and bone and they work together. One in two women in America. There's more hospitalizations every year for hip fracture than heart attack and stroke combined. It's insane. So here's our frozen shoulder. We first published the association with hormones in 2022. So very, very new. Weight gain, metabolic syndrome, diabetes and menopause. I'm going through this fast because I really do want to spend time on prescribing. But it'll all be here to come back. So our this is how I think about it. This is my nice way of thinking about it. Our body is smart. Our body needs hormones. When our ovaries decrease estrogen and testosterone, we actually may. And those are derived from cholesterol, right? So our cholesterol goes up because we're trying to make more hormones and we start putting on fat because fat makes crappy inflammatory hormones. But it does make crappy inflammatory hormones. So that's why people are like, why does it happen? It happens because our body's smart and it's actually trying to get the hormones that we need. The whole like we don't know why it happens, we don't know why it goes up. We do know why it goes up. It's our body's trying to make hormones. So you actually give people hormones. Their cholesterol goes down, their lipids get better, their lipoprotein A goes down. We have that data in men as well and the adipose tissue body. So it's not always that you are going to gain weight, but your body composition will change. Your body's prioritizing, putting on the fat. Cuz fat makes crappy inflammatory hormones. To me I'm like help, help. A help a sister out, give them some hormones. It's not as easy to say, let me put on these hormones so you will lose weight. No, that's too broad of a brush. We know that weight gain is, can be complex, but by and large, it will decrease insulin resistance, decreases the risk of developing diabetes, and can really help support the lean body mass of bone and muscle. So incredibly important. But we can't, we can no longer be like, I don't know why it's happening. It's happening because you don't have any hormones and your body needs hormones to function properly. So they're. Your body's trying to push, push hormones through. So it's increasing cholesterol, increasing fat tissue to try to make crappy inflammatory hormones because ovaries, ovary hormones are the best brain. Okay. Lisa Moscone, Ph.D. in New York, had a paper come out, I want to say, two years ago. Now, it's a meta analysis of all available data, and we're mostly coming out kind of stuff swinging at this point. If you start hormones early, it appears that at best, you are decreasing your risk of Alzheimer's disease by about 30%. Why are we not screaming that from the rooftops when people are like, oh, the, the amyloid hypothesis turns out to be wrong. After we spent billions of dollars, we've got crappy drugs, we've got no cure. In Australia, starting next year, Alzheimer's disease is going to be the number one killer of Australia. I learned that when I just went over there. We have no cure. The only prevention, best prevention is exercise, which is fantastic. Second to that, it's hormones. And the younger you start, the more it protects. Hormones are crappy at treating disease. And that's where kind of Western medicine messes with it, right? Because we're like, come back when you're sick. It's like, once you have dementia, hormones aren't going to do much much. You have to work. It's blood flow and it's cellular function, it's mitochondrial function, it's protection of the neurons and the supporting neurons. And in addition, we have data saying women who take hormones have a decreased risk. And this is more like insurance data because these would be very expensive studies to run. Decreased risk of multiple sclerosis, decreased risk of Parkinson's disease, basically all neurologic issues. Hormones protect neurons. So it is not FDA approved for the prevention of dementia. And that's where people will start to split hairs and they'll be like, it's not FDA approved for that. It's like, if you want to sit around and hold your breath for FDA approval for prevention of dementia, you go ahead. But we have to use the data that we have. People are incredibly fearful of their brains. And smart women want to keep working, keep women in the brain, in the. Keep their brains in the workforce. So Moscone's work with scanners showing significantly decreased blood flow after menopause in the brain in all the very important memory issues, mental health, huge issue with depression and mood disorders, especially in perimenopause, because perimenopause is chaos. We should treat perimenopause just like mood disorders in postpartum, in puberty. All of the places where hormones go crazy because the. It's not so much your hormone level as the change in fluctuation of the hormone level that drives the brain nuts. I have a picture of Sinead o' Connor here because she died by suicide several years ago. And it is published in the media that she said, I begged doctors to help me after my hysterectomy. Nobody would give me hormones. And then no menopause expert thinks it's a coincidence that the highest rate of death by suicide is in the perimenopause to menopause transition. Mood disorders are real coincides with hormone chaos. And there's actually published data to say SSRIs are should not be first line therapy for mood disorders and perimenopause Treat their hormones. That tends to help a lot. We are likely over treating. We have data that after the WHI and hormone prescribing went down, SSRI data shot up. Women are seeking help. Help for their, for their hair, for their brain. Here we go. Hair, skin, derm. Incredibly important. Nobody talks about it. I did a podcast with the dermatologist and I'm like, Dude, 50% of women post menopause lose hair. He's like, yeah, 50. And I'm like, but dermatologists don't care about hormones. And hormones doctors don't know anything about hair. Like there are. People are literally not. We have no data on. If I start hormones young, you know, 50, am I going to lose. We have no data on that. But incredibly important to people's body image. Wanting to show up, wanting to be seen. Collagen, collagen, collagen, collagen. And hair goes away. When our hormones go away, skin changes. We could, if we have time, we can talk about off label, off label Estriol for skin. Because it's a thing and you should know about it. You should know that it's safe. Other Skin, the vulva and the vagina. Genital urinary syndrome of menopause can start in perimenopause starts way before your period's end. It's real, treat it. My argument is when you're 50, here's your mammogram, here's your colonoscopy and here's your vaginal estrogen. It's incredibly low dose skin care for down there. If 80% of women are going to get GSM, which is leakage, pain with sex tracts, recurrent urinary tract infections. If the incidence is that high, why are we not preventing it in the first place? Why are we waiting for women to suffer? And then once you're suffering and you decide it's bad enough to see a doctor, it takes a long time to see a doctor in America now. So to me I'm like, this is over. Vaginal insurance over the counter in multiple countries, including the uk. So we lose our elasticity, we lose our collagen, we lose our blood flow. All domains of sexual function can change because of lowering of hormones. So we're going to talk about prescribing now. 2022 Menopause Position Statement is pretty darn helpful. The newer paper by Jim Simon pretty darn helpful about how to prescribe hormones. So you've got a lot of, and these are all the societies that have endorsed the guidelines. You've got a lot of power in backing you up to say like, hey, we've got a lot of data to tell us that us that we are doing this safely. So again, we got to remember why women are scared. If you ask women, why are you scared? They don't know, they won't tell you. The 2002 Women's Health Initiative study, that was not statistically significant but the media took it ran fear. They're not going to tell you that. They just, it's in the ether. But again, that study was not on young symptomatic women. It was on average age of 63. Most of them did not have hot flashes and they weren't even looking for breast cancer in the first place. And it wasn't statistically significant. So people be like, well since we stopped everybody's hormones, didn't we like decrease breast cancer a lot? No, breast cancer continues to go up for a multitude of reasons even though we're not using hormones. Again, this is looking at all the benefits of hormones. This is WHI data. So estrogen alone versus estrogen with medroxyprogesterone acetate. Keep in mind we don't commonly even use these medications are still available. But these aren't the basically bioidentical hormones that our bodies use. Most people who are menopause experts don't even use these hormones anymore. But the oral nature of them is why you did see increases in clot. Now most hormones are given transdermal, so you've eliminated that risk. But, but all cause mortality, my friends. All cause mortality. If there isn't a better reason, then like you're going to live longer than the people who don't take it. This is a great way. This is a paper that came out saying how do we actually tell people what a 50% increase risk is? So these are like movie theaters with a thousand people in them. And you can see two dots in one of them and four dots in the, in the second one. That's what 50% increase looks like, right? Absolute versus relative risk risk. So in explaining the risk of hormones, that's what you would do if you even used those medications. And even if it was statistically significant. But when you say there's a 26% increase of breast cancer, they don't know if it's statistic or not, you know, or like what is the actual relative versus absolute risk increase. So this is what, 20% increased risk of breast cancer, which was not statistically significant in the estrogen progestin arm was. It was one person out of a thousand. And this is all the people that the hormones benefited. 900 out of a thousand. Right. So when you put it in graphics like that, you're like, okay, right. Hormones at best are rare to very rare. Frequency of adverse drug reactions. These are the safest, some of the safest medications we can give. We give less safe medications every single day. So transdermal does not increase clot risk. Vaginal estrogen does not increase clot risk. Testosterone does not increase clot risk. Oral micronized progesterone does not increase clot risk. We've got well published studies saying that transdermal with estrogen is not increase your clot risk. Really important to know. What about the women who say I was told I can't have hormones because I've got Factor 5 Leiden or other pro thrombic mutations. Patients, they can take transdermal. I say this, I, I cannot make your risk be zero, but I can make it no higher than it already is. So prothrombin mutations are not a contraindication to transdermal estrogen. Ideal window of hormone therapy. You've probably heard of this, the healthy cell Hypothesis, hormones don't treat disease, they prevent disease. That means you've got to get it in the body before disease. So that's where this healthy cell hypothesis came from. Originally studied on in monkeys. So they call young menopause within 10 years of your last menstrual period hard to do in a third of women because they have hysterectomies, IUDs and ablations. But that's where your decrease in dementia and your decrease in cardiovascular disease and you're all cause mortality is going to, you're really going to win with that. What did the WHI actually show about breast cancer risk? Well, if you were just in the estrogen alone, it actually decreased your. You got breast cancer and you were on hormones. I tell women this all the time. Listen, breast cancer is common. People are going to get breast cancer. I don't want to downplay that. But in the WHI study if you were on hormones, estrogen alone when you got diagnosed, you had 40% decreased risk of death from this stuff. Multiple theories why? So we had a, a non statistically significant increased risk of incidence of breast cancer in the medroxy progesterone acetate, that's their synthetic progestin arm. So if buddy's the baddie, it's the synthetic progesterone but not statistically significant and no increased risk of death. Again, that's what 20% increase risk looks like. But that is the 26% increase is what scared most of the world off of hormones. Are you pissed yet? So this is more critical review looking at it once they cleared out the placebo arm because remember a lot of the placebo people had previously been on hormones. Hormones, hormones decrease your risk of breast cancer. So you clear out the placebo arms of people who've been on hormones and then the progesterone estrogen arm did not have any increased risk of breast cancer. So it's that the placebo arm was flawed and actually had less breast cancer because many of them had previously been on hormones. Because remember in the 90s lots of people were on hormones. Hormones. All right, so other things to know. If you are a treated BRCA patient, you've had your surgery. Do not withhold hormones from these people. We've got multiple papers saying they can take hormones. Family history of breast cancer, not a reason to withhold hormones. So we call who's the stereotypical menopausal Barbie the ideal candidate. This person is easy to prescribe to. She's basically like classic age of menopause. She's got symptoms. She doesn't have any past history. Everything's great. There's like, you're basically going to make her live longer and have less, less disease. We have, we have data that women who take hormones take less. Other prescriptions. And I use that a lot with the women who are like, I don't want to take any drugs. And I'm like, can you actually call this a drug? It's just what your body makes. And furthermore, you're going to take less drugs by being on it than if you don't take hormones. But we're all weird Barbies prescribing hormone therapy in the modern world. Hormones are not, they're not the one all like, you can eat like crap and not sleep and not exercise. Because I'm to have an estrogen patch on. No, it is a toolkit. They're cell helpers. But you still need to do all the other things. But do not deny hormones until the woman dials and everything else. It's kind of like men, right? If anybody gives men the testosterone, like these men, they're like, I can't lose the weight. I can't have no motivation to go to the gym. You start them on testosterone and they're like, oh my God, I actually feel better. I think I can sleep better now. I can actually go to the gym. Right? So there are tools to help you do all the other healthy things. FDA approved indications for hormone therapy. We've got four FDA approved reasons. Vasomotor symptoms prevention of bone loss. We have people be like, don't. You can't use hormones for prevention. We have an FDA approved indication for prevention. Prevention. Prevention of bone loss. And in the whi they did s significant decreased risk in fracture in women who had not had a diagnosis of osteoporosis. So it's like bones can break before you hit the osteoporotic level. Right. And estrogen helps all, all bones. Not just, you know, don't wait till you get to osteoporosis. Prevention and treatment of general urinary syndrome and menopause. And then for the premature mature menopausal women, absolute versus relative contraindications. Unexplained vaginal bleeding. That's a no brainer. You got to work it up. Active serious liver disease elevated LFTs a little bit. This is not a big contraindication. This was more concerning when we mostly gave orals. Transdermals are not. And what I mean by orals is estrogen, Oral micronized progesterone doesn't hurt the liver. Most testosterone is not given oral. It doesn't go through the liver. So serious liver disease. Yeah, but that's really coming from the oral data. Active hormone dependent breast cancer and serious cardio. I had a recent stroke or heart attack in the last six months. And then personal history of unprovoked PE or blood clot. Those are our current contraindications. And all the experts would say, say going back to this, that this is not an absolute no for everybody. But this is kind of the, if you have to take a test, these are the current contraindications to hormone therapy, contraindications to vaginal hormones. So low dose doesn't increase your blood level of anything. Uterine sarcoma, it's a rare one, but it's literally the reason why I can't say everybody can be on vaginal estrogen. There is some data showing increased recurrence with vaginal estrogen. That's not your normal endometrial cancer. That's a rare uterine sarcoma. But it's like the reason that I can't say everybody can be on. On vaginal hormones. Active breast cancer currently treated with aromatase inhibitors. The guy, the, the oncologists get a little spooked about it. There is some not great retrospective data showing higher rate of recurrence, but not death. But by and large most data says it's safe. Even in current aromatase inhibitor use. I always use this ACOG position statement saying post treatment for breast cancer, it's completely safe. Helps quality of life, doesn't increase recurrence. So here again to summarize me and everything. Hormones help with many, many, many, many, many things and we should not be afraid of them. That's the takeaway. But we'll get into prescribing now. A family history of anything does not preclude the use of hormone therapy. In fact, it often provides evidence for using hormone therapy. How many women say I can't be on hormones because of my mom or my aunt or my sister or my blah, blah, blah. A family history of anything is not a contraindication. Strong, strong, strong words. There is no age at which you must stop hormone therapy in women. I see it all the time. The doctor said I'm just old enough now. What? So that you're like you, you've out, have. Do we ever outlive Viagra? Do we outlive any other medication? There is no data to support an arbitrary age cutoff as long in the 2022 position statement. As long as the benefits outweigh the risk risks, you can continue. So we actually looked at the Medicare data. This is 10 million women greater than age 65 on hormones. This was published last year. Estrogen alone, less breast, colon and lung cancer, less heart issues, less dementia decreased all cause mortality by 20. This is our older women. So these are women again who. We've kept them on it. We didn't start them late, we kept them on it. 20% of women eeked through, grew after the WHI. And again we, they did show some data with the estrogen progesterone. Progestin increased risk of breast cancer but not death. And progesterone alone actually decreased the risk of breast cancer. So the data is a little mixed in there, but that's what people will throw out to be like, I don't know about the progesterone, it's probably not significant, but it is in the page paper. So again, we've got to treat the premature menopause. Most to lose, most to gain. They do so poorly without hormones, get hormones in their body. Surgical menopause. Dr. Louise Nome in the UK just did a study last year looking at all sites of hysterectomy. In the UK, 5% of women were offered hormones after they had ovaries put in a bucket. It is dismal right now. All right, so I put little hearts next to the most common ones. I start with estrogen, I'm starting with oral just because it's cheap. Most people don't use oral, but there's really nothing cheaper than oral estrogen therapy. It's been around forever. Again, the conjugated equine estrogen was what was used in the WHI study. Very safe drug. The only thing you're going to get with oral that you're not going to get it with the transdermal is that increased clot risk. So your normal Barbies. Normal Barbies. If, if I was standing stranded on a deserted island and all I had was oral estrogen, I would take it. It's not an unsafe drug, it just has an increased clot risk. That increased clot risk is less than your clot risk with pregnancy and it's less than your clot risk with birth control. Just to clarify how it's still a very low risk of clot. So some people just don't tolerate transdermal or can't get their, can't get their symptoms controlled. They just need oral. So I, I don't want to poo poo oral because it's There, I think in some countries it's all they have with the patch shortages that are happening in Australia and America, it's something to think about. Do not fear it like it's a dangerous medication. I just would say it's in standard, standard menopause therapy. It's not first line at this point. And if you can do estradiol, probably closer to what your body makes than the, the conjugated estrogen. So again, this is systemic. I would say the gold standard, at least in America right now is the estradiol patch I like twice a week because it's a smaller patch and you get a better steady state than if you are using the once a week patch. You tend to get a drop off at the end and it's a bigger patch. Second to the patches would be the gels. Again, depending upon insurance coverage. But a lot of people gel is pretty well covered and, and does pretty well for them. There is a spray at the bottom called Eva Mist. Expensive, but it's really cool. For your perimenopausal women who, like, they just know, like, today I need one spray, today I need three sprays. You can actually kind of dose it nicely. Like you can't really dose the other ones. For women who are like super symptomatic in the week before their period or something like that, where it's like they can't sleep, I would think about that. So this is just a pro and con of routes of administration. I put it here so that people can think about it. There's pros and cons of all of them. Some people hate the sticky residue that the patch leaves. I, it doesn't, it doesn't bother me at all. I'm not out in my bikini every single day. Basically, it's what controls their symptoms. Now, second conversation is if we're doing this for prevention, right, which is, I think, where the modern, that's where the modern experts are going. But that's not where you're going to get like governmental support, except for in the prevention of osteoporosis. Right. You can't feel osteoporosis. How do you know you're on the right dose? There is a, a whole talk to be given about what dose we think is best for Bones. But so basically they're like, there's not one dose that everybody needs. You're going to absorb differently, especially with the transdermals. And that's the same with men. 20% of men do not absorb transdermal testosterone. Well, Luis, Nome just published that data, some women need higher, what they people call higher doses to actually get pretty low therapeutic doses in their system. So the combination, remember if you have a uterus, you need combination. I think it's very dramatic and very wrong to say that estrogen causes uterine cancer. If you actually look at the data, it technically increases your risk of uterine cancer. But most people still don't get uterine cancer. So I think it's overly aggressive and scaremongering to tell people you'll get uterine cancer if you don't take a progesterone. Especially we, we had a oral microns progesterone shortage the beginning of 2024 here and women were like, is it okay to go a month without progesterone? Yes, probably. Probably. The actual data on uterine cancer was much higher. Synthetic estrogen used in the mid century last year. So we actually have. But nobody's going to do the study of like what's your actual risk of uterine cancer on a transdermal estradiol low dose patch. It's probably very, very low. But standard of practice is to have progesterone with estrogen when you have a uterus. So there actually is an oral estradiol progesterone combo pill. It's called Bijuv. You know, you comp, you, you combo things in a pill and the price goes up even though they're both generic. But so that's an option if you want to do that. Most I would say standard of practice now is a low dose estradiol patch with oral micronized progesterone. But not everybody can tolerate oral micronized progesterone. The biggest issue is peanut allergy or nut allergy because it is made in, in a peanut oil base. You can compound it to get the peanut out of there. But in America currently and in most countries all that's available is oral micronized progesterone which is contraindicated in peanut aller allergies. But so this is a whole list of combo oral. Again most people do transdermal amazing medication called du. In other countries you can just buy basadoxaphine without it being in with a conjugated equine estrogen. But in America we do not have that. So these are the. For the people who are freaked out about progesterone, can't take progesterone. It's actually a tissue selective estrogen complex. It's basically a serum. Works really well for people who get breast tenderness or bleeding with progesterone. You're younger perimenopausal people. They're actually studying this medication in people with DC and saying if we give people DU a V before we do their surgery for dcis, are they going to have less significant pathology? So something to know about. You can actually get it for pretty cheap in America. But for your people who are like, let's say massive hot flossers, they're super afraid of breast cancer, but they got a peanut allergy, you know, like you just can't do all your standard things. Do a V is, is underappreciated, very safe and works very, very well for people in America. We'd love to just have the basodoxify to use. Like can we, could we do a transdermal estrogen patch and basodoxifene for people who can't do progesterone. These are the things we talk about. Oral micronized progesterone for your progesterone. Progesterone never been shown to have a breast cancer risk. Incredibly safe. Is a miracle worker for sleep. My friends call it God's benzodiazepine. Most people will use now the oral micronized progesterone. That is our body identical, safest one. Some people will still use the synthetics again. MPA down there, medroxyprogesterone acetate. That's the baddie of the whi. But I showed you the women in the theater, it's still not all that bad. Tend to have more bleeding breaks through bleeding when you're using. Nor you know what it called bioidentical hormone therapy than the synthetics. Synthetics tend to work better for bleeding. You can use it off, off label vaginally. For people who are like, I really get bloated on the progesterone or I get. I super groggy on progesterone. There's those people, you can do it vaginally or rectally. Lots of different things you can be the takeaway of this is women who are like, hormones didn't work for me. I tend to never believe them. I tend to think you just, we didn't find the right thing for you. We didn't find the right dose, we didn't find the right route, we didn't find the right compound. So again, oral micronized progesterone, peanut allergy is the big thing to know about it. Testosterone, two way, two main ways to do it in America there's more ways, but two main ways is you either micro dose the male packet, ideally in A tube and not in a packet because how do you dose it? 110 of a ketchup packet? It's very difficult but very true. Cheap. And the other option is compounding. I compound now because my pharmacists are jerks. What are you doing? Are you transitioning? Do you know what you're doing? Do is that safe? Like bullying at the pharmacy was what happened. So either if I'll do the. I'll microdose the mail and just get it delivered to their house with Amazon so they don't have to deal with a pharmacist. Pharmacists are not educated in modern hormone therapy. They've got computer generated things they have to click that say these things cause cancer all the time. They're obstructionist about you. Can you be on a systemic dose and a vaginal dose of estrogen? Yes, of course. About 30% of women need to do that. Pharmacists raise hell because they don't know. So I tend to compound just because my compounding pharmacists are. They're nice, you know, it's safe. Don't forget the vulva and the vagina and the sexual health. About 30% of women on systemic hormones still need vaginal hormones to function at their best. Whether that's estrogen or testosterone. It helps all domains of sexuality. It helps bladder leakage, it helps getting up an ATP. Vaginal estrogen is a great thing. And all of the. I put down here the side note we have for anybody who says we don't have enough safety data for testosterone in women. You can say, well you know what we actually did? We actually gave a bunch of women who volunteered 10 times the dose and we watched them and we got 30 year paper and we got 50 year safety data paper. They're called trans men. What other medication do we voluntarily dose people at 10 times the dose for half a century? Publish safety data and then say we don't have enough safety data to know if this is safe. Right. The discussion around testosterone's insane. But we have very good safety data at 10 times the dose. There's actually very interesting data looking at decreased risk of breast cancer. Testosterone is breast protective, so it's a fascinating topic. Don't forget the vagina. Lots of different options in America. The cheapest one is the cream. Some people don't like it because it's messy. I like it cuz you put on the clitoris and the labia. Women freak out when you tell them that their labia dissolves after menopause. You can probably get it back with the right amount of hormones. But there's no studies. So labia menorah are important. Take it to the grave again. Estrad cream is the cheapest Mark Cuban cost plus drugs in America. You can get it for. I just got mine for $13.20. The vaginal tabs are available. It's called Gina G I N A. Available now over the counter in the uk. Uk. Which is awesome. This is a medication called. If I'm doing any branding in my. In my talk, this is intrarosa. Which is the generic is prosterone. They made up that word. It's actually just dhea. But you can't patent that. So they made up a word called prosterone. It's just dhea. It's a hormone that converts to estrogen and testosterone. But look what they did. They actually said intrarosa is the only non estrogen prescription treatment. They're still marketing the fear of estrogen. Guess what DHEA does. It converts to estrogen. So they say it's the only non estrogen prescription treatment. And then it says the ability to convert into both androgens and estrogens. So it's like don't use that as a marketing thing. Just tell. Just tell women the truth. Hormone starter pack with Dr. Heather Hirsch teaches all about this a lot. Stacking. Don't start. If you come in with a super savvy woman. She's savvy. Let's say you've got like an edge educated physician or something. Give her all the things at this. At the. She's ready for it. She's ready for testosterone and her vaginal estrogen and her estrogen progesterone combo. Most people aren't. You don't know what this they're getting side effects from. Get them happy on estrogen and progesterone first or get them happy on vaginal estrogen first. Right. And then see them back. Add other things. Don't forget about the power of IUDs for estrogen for the uterine protection. IUD when I help you with sleep or all the other amazing things that progesterone does. But you can do transdermal estrogen with a progesterone secreting iud. That's a great thing. Perimenopause. Some people will say birth control until your periods are done. There's no evidence in that that said birth control is essential if you have sperm in your life and you do not want to be pregnant. It's also essential if you've got crazy bleeding 20% of women will have very heavy bleeding, especially in the end of perimenophone menopause. Don't say you don't know why it's happening. It's happening because of hormone chaos. People are like, I don't know why the heavy bleeding's happening. It's happening because of hormone chaos. And those loop cycles we talked about. So the uterine lining builds up and builds up and you don't release an egg and so everything gets thrown off and then you have a, then you have a flood. So birth control is awesome. Probably better than natural hormone therapy for basically leveling out the bleeding. But to tell a woman she can only be on birth control. Birth control is clot risk, right? If we're so afraid of clot risk, birth control is way more clot risk than oral estrogen does. But start normalizing using hormone therapy in perimenopause. Even I, I had a woman a week before her period. Life was hell. She was angry, she wasn't sleeping, her energy was low. It was horrible. I gave her a low dose estrogen patch just the week before her period. I'm like, just throw this on the week before your period when you know, like the, the ick is coming. And I'm like, how's that week before your period? And she's like, it's my favorite week of the, of the whole month now can I be on that thing the whole time? And I'm like, of course you can. Right? We're just trying to mellow it out. Common side effects, three Bs, bleeding, bloating, breast tenderness, tend to all resolve with time. Just give it some time. Um, the boxed warning on estrogens, we are actively working on changing that. Exciting and not exciting things are happening at the FDA right now. One of the exciting things is they just changed the label for to testosterone. And so we think we are. I remain very optimistic that the, the boxed warnings are on there because of the Women's Health Initiative, and they're basically all wrong, especially for vaginal estrogen. If you do not educate your woman and she goes home and reads the label, she will not start vaginal estrogen because it says it's trying to kill her. All right, Absolute contraindications. Currently unexplained vaginal bleeding, active treatment for breast cancer, severe liver disease, history of pe, stroke and MI high. They're not, not everybody with the remote history of heart attack, the people are doing transdermal, but it's still party line that, that's a contraindication. So relative contraindications, smoking, cardiac risk and a history of a dvt. This is more risk benefit conversations. But the cardiac risk I see a lot is a blank. I, I can't be on hormones because of high cholesterol. Not true. I can't be on hormones because of my calcium artery score. No data on that. Not true at all. Especially those are going to be people you're going to choose transdermal, you don't want clot risk on them. But telling women they can't be on a hormone because of a blood test or a coronary calcium score, that's not supported by any data. BRCA treated BRCA fine relative with breast cancer, fine fine. Vaginal estrogen, pretty much everybody except for that rare uterine sarcoma. And if they're currently being treated with an aromatase, check with their oncologist just to make sure nobody freaks out about it. Best practices, don't forget you got to use estrogen and progesterone. If you've got a uterus, you can continue for life. I get mammograms in everybody before because remember, hormones don't cause cancer, but they can feed an existing cancer. Hormones are just, they're supportive, they're supportive for life. Right. I, I like a baseline mammogram. That's my policy. I just want to know if it's there. If somebody has a high car, calculate their cardiac risk, it's a great time to talk about diet, lifestyle, exercise to get your blood pressure under control. It's not always a contraindication to hormone therapy, but it's a great opportunity to talk to people about optimizing their health. All right, how do you follow up? I like to see people back in about two to three months, depending upon how booked out we are, change things that then don't tend to get labs except for testosterone. Testosterone, we get a baseline before we start and we get a follow up lab, a whole host of things on testosterone. But basically your lab value is going to say high when you are in a testosterone range that a woman feels good on, she's got a good libido on and that the data supports. So lab values for female testosterone, they're a problem. I have to tell women. Okay, I'm glad you finished. Great. Your lab says high, I'm very fine with this level. But if you go to another doctor and they yell at you because your testosterone is high, say I know what I'm doing, I'm seeing an expert, it's fine. And you might need higher doses of estrogen and hormones in younger people than in older people because they've got less receptors and they've been without hormones for a while. So it's okay to have higher doses in young people. Here's the question. Am I too old to start? The boomers are pissed. This is an incredibly awesome paper I highly recommend published last year. They reanalyzed the WHI and the risk in the older women who got started on hormones. This isn't continuing hormones. This is can I'm 73, can I start? Incredibly safe. It's incredibly safe. I would read this yourself so that you don't just take my word for it, but I start many healthy 73 year old women on transdermal estrogen. And remember, testosterone and progesterone don't have any age cutoffs. Also, they're freaked out about their bones. All their friends around them are breaking hips. They want to do something and it does make a difference. So I have a podcast episode called the boomer should be pissed because the boomers are pissed. Great time to to check on their heart risks. Start low dose. Don't forget the other hormones. What does a patient want? Body autonomy. Just putting this in there. The tide is turning. We've got about 5 million breast cancer survivors in America. They're dying of heart disease. They want hormones, they want body autonomy. We are getting closer and closer to risk, benefits, benefit. Saying for most people it's safe. Feel free to refer these out to experts at this point. Just know it's a conversation that's happening. So we're not all normal Barbies. Some of us are weird Barbies. But once you know the magic of hormones that you're simply just supporting your, your, your body. Women are so grateful. So grateful. We are not over treating menopause, we're actually under treating menopause. Women who are under treated tend to take more time off of work, have worse mental health and take other med. There's simple questionnaires that they can fill out for you if you want. This is from Luis Newsom's clinic. It's online. You can take it. Don't think you can do this all in one visit. And I again, if a woman's freaked out of hormones, I can, I can educate her, but I'm not going to force hormones on her. I want this to be her decision. Last slide. I think the Economist just did an article about longevity. $5 billion was put into longevity startups in the first half of 2024. Estrogen increases lifespan by 2 to 4 years. Years if given between the ages of 50 and 60. Not once is that mentioned in here. The cheap in your face things we already know are not even mentioned when we're like, what's new with longevity hormones? People will say that menopause happens because you run out of eggs. That's not entirely true. Menopause happens because of the hormone producing cells of the ovaries retire. And so perimenopause is basically those cells kind of going offline, shooting down, you know, low levels. So then your FSH and your LH in your brain start pumping out more to try to get the ovary to do its job. So the whole point is IUDs aren't stopping that. IUDs will stop heavy bleeding and will stop pregnancy, but won't stop what's actually happening physiologically to the hormone producing cells of the ovary. You know, I see women and like, they're like, they have urinary retainers, tension basically. And nobody's done a pelvic exam and they're like, try they're peeing through a pinhole because the labia is basically, they call it agglutination. It basically is like fused in the middle and you're peeing through like this teeny little thing. If it's significant, you do need a surgeon to open that up. And then you need copious hormones to try to keep it open. Otherwise it'll read here, you know, and patient compliance because like when you sit, your labia touch, right. So you have to keep kind of opening it up. Not very common. I see. Much more common to have labia resorption, where it's gone. And labia minora, number one, they protect the vagina and the urethra from microtrauma. And then number two, their sexual structures. So there's actually a paper coming out on the medical importance of labia minora. Dr. Rachel Rubin Publishing it. I, I think it's coming out like next week or next month. But I'm like all over it because I'm like, these are important structures that are completely IGN and significantly go away. Like before I got all this education, I'm a urologist. I do surgery of the pelvis. I just thought there were like a lot of 70 year olds that were born without labia minora. Like I didn't get taught that labia minora went away. And then I was like, oh my gosh. Turns out they just go away when you don't have hormones. But some will adhere and can cause urinary tract infection. Urinary retention or urine trapping. So you'll pee, it'll kind of get stuck in the vagina because it has a pinhole to come out of and then it, it'll just dribble out afterwards. Birth control is not hormone replacement therapy. Hormone replacement therapy is not birth control. There's two totally separate things. So people who say I can't take hormone therapy cuz I can't take birth control, or I had horrible experience with birth control, that'll be the other one. Birth control by and large is like a hormone blocker with some replacement, but synthetic replacement. Literally. I always joke, I'm like, literally, the side effects of birth control, which is infertility, would be unacceptable, acceptable if we weren't using that drug for in to make us not fertile. Right? Like it's a crazy medication, but we give it away like commonly because we're so comfortable with it. But I tell and so I'll tell women, I'll be like, hey, birth control is not hormone replacement therapy. They're completely apples and oranges. Like pharmacologically, which is good news. But that's usually where you'll see that migraine thing is like, I can't be on birth control because of migraine with aura. Multiple papers showing that hormone therapy, because hormone therapy smooths out the chaos. And again, what I said earlier is it's the delta change, it's the hormone fluctuations that likely trigger the migraines. So that's why migraines will get worse in perimenopause and early menopause is because of the, the chaos that's happening. If you can mellow out that chaos, you actually make migraines better. We actually have a paper looking at testosterone, testosterone improving. Testosterone is very great for pain, which is interesting. So we've got data looking at the way testosterone helps migraines and then if we can mellow out the fluctuations, you actually can make her migraines better. But it's a big ask because they've kind of been indoctrinated that they can't be on birth control because of migraine with aura. And transdermal estradiol is a completely different animal and is you've got safety data and papers to back you up that you can use that in migraine with aura. But that's a, that's a common myth of who can't take hormone therapy. So bioidentical by and large is a marketing term used after the whi to make women feel comfortable and safe with taking hormone therapy. All it means is this is exactly what your ovaries make. It's all it means. And so when I talk about testosterone, oral micronized progesterone and estradiol, that's bioidentical hormone therapy. It's exact same stuff. It's FDA approved. It's what most people use. Women will be marketed to and they'll be like, but, but my. I have to have this compounded bioidentical. It's like, no, most people don't. And. And what we use is bioidentical. The UK actually, like, they hate the term bioidentical because they think it's confusing. Because it's confusing. So the UK uses biosimilar similar, which I just. I like that term better, but by all bioidentical means is it's exactly what your ovary makes. And that's what modern hormone therapy is. It's estradiol, oral micronized progesterone and testosterone. It's all bioidentical. When we talk about the WHI and the synthetics that were used, that's not bioidentical. Birth controls, not bioidentical. Right. Most medications, statins aren't bioidentical. Most medications are not bioidentical. But insulin, insulin, thyroid, that's. Those are bioidentical medications. We just don't call it that because we're not trying to market it to people. For some reason, medoxyprogesterone acetate from the WHI was probably the baddie. That again, wasn't that bad, but got the bad reputation. So then we just said, all progesterone's bad. You only need it if you have a uterus. And then people were like, but it helps me sleep and it helps my anxiety. Anxiety. And actually, we actually have bone data on progesterone. Right? So, like, it's just like everything. We have receptors everywhere. We have receptors everywhere for progesterone. So the. But the. That's where I wanted to explain the. The timeline of where people were like, you don't need it if you don't have a uterus is like, people didn't really want to play with progesterone after the whi, right? And so, but now we're like, can I have it even though I had a hysterectomy? Yes, absolutely. You just don't, like, air, quote, need it. Like, you have to protect it. A uterus that needs both hormones. But more. It's becoming more and more common that a woman with a hysterectomy will be on the progesterone will choose to be on progesterone. We're actually replacing to like very low doses compared to like what pregnancy was and what your cycling period was. So that's the, that's the always the big question for, for like a lot of like very rare cancers will be like, was castration part of the cancer treatment plan? And they'll be like, no, like, okay, then why can't she have hormones? Was she allowed to get pregnant and have periods? Yes. Okay, right. And then you're like, I get the physiology now. Okay, right. So if castration wasn't part of her congenital heart defect treatment plan and she lived 30 years half happily with periods and pregnancy, she's, you know, we always say transdermal. Probably gonna be the best, but likely very, very safe. Best thing that's ever happened to you financially. Go easy. Sold my car on Carvana. Amazing offer, really. I hit 200 on a scratcher. Did the scratcher come to your house and hand you a check? No. How many scratchers did you hit to get that? I hit a button on Carvana.com once. Okay, that's fair. It's like the lottery, except you always win. Not like the lottery at all, actually. Exactly. Inexplicably good offers worth bragging about. Sell your car today on Carvana. Pickup fees may apply. When you start thinking, you know, and I, I brushed over it cuz I didn't have time. But like you start thinking about like the financial considerations of all of this, right? And insurance coverage, which is abysmal. And it's like, listen, for me, $40 a month for a patch, that's not good crazy, but for some people that is. And then you're talking 30 years. At the end of the day, oral estradiol is the cheapest. So how can we make that the safest? Maybe, you know, stick it in your mouth until it dissolves. So yes, I, I can't. It's, it's a little data free zone, but the theory is oral pill put under the tongue till it dissolves is a transdermal. It's not going to go first pass metabolic. And that's where you're going to get the liver. The clotting. The clotting risk comes from liver metabolism. So you completely get rid of that when you don't swallow it into your GI system. So a genetic clotting disorder is not a contraindication to hormone therapy. Transdermal is recommended. We've got papers on that to back you up. And how I tell people is I'm not going to increase your clot risk, but I'm not going to decrease. Decrease it. You can still get a clot because you've got a genetic clotting disorder, but I'm not making your risk higher with transdermal estradiol. But smoking is not a. I, I put that under, under what is it? What. Not an absolute contraindication, but like the, like qu. The question mark. Yeah, it's not. Smoking is not a contraindication. But use transdermal. And when I say that, I mean Escher, estrogen, testosterone. There's really, there's no data in women in testosterone saying that smoking's contra, contraindicated. And same with progesterone. Most things. When we're saying transdermal, we're meaning estradiol. All medications have a therapeutic dose. Right. And so it's like you go too high, you're going to get more side side effects. So where, and I'm going to speak in American terms now because that's where I am. I'm just comfortable with our lab values. But where the data is for low desire and sexual function with T is really high, mid to high double digits in our lab values. Once you start going into mid-100s, certainly 2/200 with the pellets. Pellets easily put women between like 250 and 400. Remember, male level goes to 300. Right. You're going to start seeing more androgenic side effects. Most women who complain of hair loss, it's their pellet users I have not seen. And I mean, again, it's complicated. We've got, don't give any women hormones and you've got a 50 risk of hair loss in menopause. Right. So it's like give them nothing. Flip of a coin, they're going to experience hair loss loss. So it's always hard to suss that out. You know, you started them on hormones, but now they're 56 and they're noticing hair loss. Is it really the hormones or is it that they're postmenopausal and they still don't have a lot of hormones, so it's, it gets complicated very easily. But most experts would agree if you keep that Woman's testosterone below 100, I, I'm pretty liberal because I've done this a lot. But keep below 130, they're not going to experience hair loss. Now just to get Nichy, we don't know about your testosterone receptors. We don't know how well you convert your testosterone to dht, do we have some strong converters and they might be more prone to hair loss. Yes, but we're in our infancy of who those people are. In addition, we, like I said, we have no data. The dermatologists don't know a damn thing about hormones and the hormone people don't care about hair. So we've got like a posity of like, if, if I, if I start you on estrogen, am I going to, are you going to have less hair loss than your sister who didn't start on estrogen? Right. And, and is estrogen going to counteract if you take a high testosterone? There's so much we don't know. But fear of hair loss is not a reason to not give a woman testosterone unless she's already like, if she's already has the female pattern hair loss, if she's already had like, she might just not want to mess, mess with it. And you can get into like derm stuff with hair and stuff like that. Here, here's amazingly complicated. Like there's a lot happening to have a good head of hair, truthfully. So perimenopause is a moving target, right? So, so, so a lot of women will want their hormones tested either because the Internet told them to or the big reason is like they just want to feel like something's being done. You know, like they just want to feel like they've got some agency and then somebody looked like there's something very therapeutic about, about just running some labs and I think it's a great time like, dude, get some labs. What's her A1C? What's her cholesterol? What's her, you know, L.P. little A. Like we should look, we should know, right? But the problem with lab testing and perimenopause is Tuesday is different from next Wednesday. Per menopause is a roller coaster and then people will get. So test labs at your own peril. If you are going to latch on to that one lab value and then just call yourself estrogen dominant for the next five years, years, that's doing it wrong, right? Because you were estrogen, you had high estrogen on Tuesday, maybe because you were ovulating, right. Like, so it's, it's diff. You can do it. You know, if you're on your first day of your period, you can get a baseline, see how low your estrogen. You know, you can get a little niche with that. Most people will say you don't need to test labs especially to start somebody on. Listen to the woman, what she complained complaining of. Is she complaining of, you know, moodiness and trouble sleeping. Maybe just start 100 milligrams of progesterone at night. Right? And a lot of perimenopause experts, again, because that estrogen can be pushed really high with those loop cycles. Sometimes people will start with progesterone and testosterone, be like, how are you feeling? At some point we'll add estrogen, but if anything tends to be, you know, I hate the word dominant, but dominant in perimenopause, it's estrogen because the we're, the ovary is trying to stay on the job. You know, it's doing, it's doing a crappy job, but it's trying to stay on the job. So most experts won't test, but you can test just to validate the woman, just to get a baseline, just to see where you are. But even fsh, which is our best marker for menopause, that's a moving target in perimenopause, you know, so it's like if you have, if you're still having periods, like, why check an fsh? You can see it trending up and be like, well, eventually you're going to hit menopause. Cause. But I could tell you that without checking your labs, you know, and then to, to take the question further, what's the point? In a postmenopausal woman, you're 62, you haven't had a period in five years. I know what your labs are. Your hormones are low and your FSH is high. Right? I don't need labs to tell me that you're menopausal because like, clinical symptoms are important. Now that said, current standard practice for testosterone, testosterone, check a baseline testosterone, check a testosterone six to eight weeks after you've started her testosterone to make sure it's okay. I always joke like I'm, I'm here to find the mythical perimenopausal woman with high testosterone because they say she's out there. I don't know where she is, I have yet to find her. But, but I check a baseline testosterone, everybody, because that's what the guidelines say to do. I have yet to find a high testosterone woman. And when people are told they can never have hormones again, that's a good sign that it's coming from a non hormone expert because pretty much everybody can have vaginal estrogen. Most people can have testosterone, most people can have progesterone, right? So don't forget about all the wonderful things we can still do even if we can't do something by the books. Because of an estrogen provoked blood clot. So what this question is saying is, is somebody was on birth control and they got a blood clot. That's until proven otherwise, that is an estrogen provoked blood clot. So that is on the. If you were taking the test, the test is you can't take estrogen hormone therapy. Now transdermal probably still very, very low risk. What some experts will do is they'll say, say, you know, she, let's say she really wants to be on estrogen, she's got horrible symptoms or she cares greatly about her whatever. She's got a reason that she's actually like interested in doing this. You can send them to a hematologist to be like, can you just get a clot workup to make sure you don't have anything else, like anything that we're supposed to be knowing about? Great, get that. Okay. Your risk is lower trans. If you're gonna do it, you're gonna do transdermal. And then if you're gonna do it, you're gonna document like this is a, A, you know, red zone area, whatever you want to talk about it. Risk is not zero. She thinks benefit always a risk. And this is always a nice thing to document. Patient requests trial of treatment she wants it, she wants to ask for it. And that's where we really get into body autonomy of like, listen, estrogen looks like estrogen makes us live longer. Like if that's not a big reason to want to be on this medication, but you've got, got a, you know, you've got a red light. Does that mean her risk probably is still not that high, but it makes many people nervous. And I think many people would be like, let's look at what we can put you on, right? While we're working up clot. Now the other question is we've got somebody who's anticoagulated, right? Let's say she's got a clot thing. She's anti co. If you're anticoagulated, you're transdermal estrogens probably as safe as possible baseline. Because now you're actually like taking something to not clot with transdermal estrogen. So that's another thing to think. Not that I would put somebody on an anticoagulant if they had a blood clot from a. Like, it gets complicated, but those are the things we think about. You know, I've had people be like, well for X, Y and Z, this person's on anticoagulation. You're like, oh, they're anticoagulated, their blood hot risk is pretty darn low. And let's use a transfer dermal. But don't forget vaginal estrogen's fine, testosterone's fine, progesterone's fine. Ah, yeah, it's a great question. I just did a podcast episode on this last week with a PCOS endo expert. Might be worth checking out because she's like, she's basically like we're completely under treating these people. Their hormones go down in midlife and menopause just like everybody else's. The history of pcos, I'm might, they might be my mystery high testosterone and per menopause person in, in my clinical practice that's not true. But those are the things I'm thinking about. Like are they, are they high? But we, we're, we're likely under treating. The other thing that makes me think of is endometriosis is not a contraindication to hormone replacement therapy. Especially treated endometriosis. Endometriosis. You know I've had, I have women who, they've had their endosurgery, they're asymptomatic, they're 48 and they're on hormones. They're doing great. So endometriosis is not a contraindication. There's actually very interesting data looking at testosterone for treatment of endo. That testosterone really helps endo. So again I'm not a huge expert in that but, but it seems to be thought provoking. Uterine fibroids, not a contraindication. They might be more prone to bleeding in the perimenopause. So again going just to summarize cause I think some of the most frustrated people especially if you don't say like hey, bleeding can get, we're giving you hormones. Uteruses love uteruses love that they want to do their job right. So it's like you can, if you kind of normalize it it versus like oh my God, you got bleeding. But so in the perimenopause, the very early menopause, you put people on hormones, they might bleed a little bit. Tends to, tends to mellow out. The body will adjust. It's your, it's your like hey, I've been on hormones for like eight years and now I, now I just had a period. Work that up. That needs to see a gynecologist. Work that up. There are many and they're to reminder there are many risk factors for endometrial cancer that are not hormones. Age is this arbitrary made up thing, isn't it? And we put people into all these boxes and like the data, you know, if, if anything from that I tried to get across in the PowerPoint is like, the young women who aren't given hormones, they die. Like, they die at a much higher rate. And that's very dramatic way of saying, like, hormones, we need hormones to function. And, and so many women, like, you know, late 30s, they're like, Louise Nome, Dr. Nome in the UK, her youngest menopausal person was, I think, 28 years old in their 20s. And the stigma that they have. Like, these are hypogonadal people who are dismissed because they're not old enough. Enough to have that disease. Right. Like, you know, you don't have, you don't have cancer, you're not old enough to have it yet. You know, like, we do that, we do that with things and we're frankly, we're killing them. The, I mean, her data saying that of women who have their ovaries removed, only 5% are given hormones currently in the UK, I'm a urologist. I. For cancer reasons, most, mostly we cut off testicles. Zero out of a hundred times. Do we not give men testosterone when we cut their testicles off? And I always liked, to me, the hormones is a big gender equality issue of would we treat men the same way? And if the answer is no, we need to rethink about what we're doing. Did I answer that question? Yeah, there isn't really a, there isn't really a too young. I mean, age is so arbitrary. It's the same with, like, you can't start hormones because you're 10 years in one day post the early cell hypothesis window. Like what, like it's not even science at that point. Like, it's totally made up. Yeah, I love the topic. There's so many people to help. The wins. Like you get wins with hormones and it's like the best part of your job. You, you, you literally get, you get women. Like, I've gotten lawyers off the couch, you know, like, I, I joke and I'm like, I change the world by getting women to feel better so they can go change the world. Like, this is a very big deal. And like, you know, we, we, we spend 5 billion on longevity startups and you're like, estrogen increases lifespan by two to four years and it's completely ignored. Like that data is completely ignored. That's insane data to me. If I can plug. So if you guys, if this, if this wets the appetite, but you really want to get into like the data and the niches. So you're not, so you're treating, you know, not just normal Barbie, but the atypical Barbies. The Heather Hirsch Academy is phenot. I think it's the best education in a, in the world for menopause. It's evidence based, it's practical, it's by experts. So she has a, A, like a kind of a 101 course. But I mean it's literally like 10 hours long. It like goes into all the studies. So her 101 course and then she's got, there's an osteoporosis course, there's a breast cancer course. I did a testosterone sex med course which I think is 12 hours of CME. It's like, it's if, if you like me, if you liked me for two hours, that's me on with 12 hours there. They say osteo, osteoporosis, breast cancer, cancer, musculoskeletal syndrome of menopause. Like all of those courses are there and you can use CME dollars because that's all. You know, just continue a medical education. I don't think there's better, especially if you're like, especially if you're like, I've got the 101, I know it's safe, I know how to do an estrogen patch. I need to start getting into the niches of like, you know, her academy. Besides me having a course on there, which that's, that's my shameless plug, I don't get any benefit from otherwise recommending her. I just simply think it's the best education out there. And she actually had. I'm just going to keep plugging her because she's impressing me. She just moved. It was, there was a Facebook group but now it's being moved to like a more private platform. And so you're in like once you've purchased her course and done it, you're in basically a, that you have access to like people who just prescribe all the time. It's invaluable just for being like, hey, I've got a 47 year old with a blah blah, blah and a blah, blah, blah and like people like, you know, answering those questions and stuff like that. So that's also a huge asset. I think it's a nominal amount of money a month to then be in that support group. So especially people who are like, I feel like that might be we. Yeah, I, I want to say probably because otherwise you're going to Be like, what's an estrogen patch? Like, you need a certain level of. A certain, you know, is vaginal estrogen safe? Like, you know, you should have a certain level of knowledge before you get in, but especially if you're practicing alone or practicing with people who don't do hormones, you know, to put yourself in a community that's supportive is amazing. Again, I haven't been on Instagram my whole life. I got on it to just to promote the podcast like four years ago. And it really opened my eyes to like, we all think we're doing a good job. I think I'm doing a good job. Everybody else think we all think we're doing a good job. And then you open up your phone to the world and you hear the suffering and you say, I'm on my fourth doctor, I'm on my fifth doctor, my doctor told me this, blah, blah, blah. And you're like, oh, we all think we're doing a good job, but we're actually not doing a great job, you know, and it was very eye opening to me of like, the burden that is put on women because of the lack of education of how to care for them. And again, you know, I was joking. Like, this is not the gynecologist's job. There's just simply not enough of them. You know, this is, this is all. Yeah, like, this is all. All women if we have the. The. So the point, I just, I think, like, the cardiologists need to know heart palpitations are the number one visit to cardiologists for midlife women. You know, like, how many are actually told? Like, an estrogen patch can fix this if we don't find anything else. Hey friends, if you love the you're Not Broken podcast, please show me your support by liking, subscribing and sharing it with someone you care about. Your support helps more people find this empowering information. Information for courses, clinic info, and all things midlife mastery. Head over to kellycaspersonmd.com and don't forget, you can grab your copy of youf Are Not Broken. Stop shoulding all over your sex life at Barnes and Noble, Amazon or ask your local bookstore to order it for you and a friend. While you're there, make sure to pre order my upcoming book Menopause Science, Hormones and Mindset for optimal longevity. Coming September 16, 202025 Medical Disclaimer the youe Are Not Broken podcast, Instagram and content created by Dr. Kelly Casperson is presented solely for general information, education and entertainment purposes. The use of information on this podcast or materials linked from this podcast or website is at the user's own risk. It is not intended as a substitute for the advice of a physician, professional coach, psychotherapist or other qualified professional. This podcast does not diagnose or treat treat you. Users should not disregard or delay in obtaining medical advice for any medical or mental health condition they may have and should seek the assistance of their healthcare professionals for any such conditions. And as always, I got you, I got your back and you are not broken. Thanks for listening.