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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. Hey, friends. Welcome back to the you're not broken podcast. Today I'm super excited to have my friend on Dr. Eve Henry. She's an internal medicine physician and my God, we need more internal medicine physicians in the women's health, longevity, hormone discussion. She did her residency in Stanford. She resides in California and she's currently a clinical partner with Peter Attia working on optimizing health span. Welcome to the podcast.
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A
Thank you, Kelly. Great to see you.
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B
Yay. Do you want to tell everybody how we met? Because it's super cute.
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A
It is actually really cute. I answered your manifestation.
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B
I manifested on January 1st, my January 1st podcast. Totally.
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A
And I always remember I was driving my oldest to like soccer or something and I heard your manifestation and I was like, you know what, I think Kelly might need me. I think I might be the answer to this manifestation. We need a friendship. And then I, like, cold emailed you through your website and was like, hi, I just heard your manifestation and I'm a random doctor, so I thought maybe we should talk. And you answered, which was very kind.
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B
This is how I make friends. I basically just put myself into the world and I just see what the universe brings in and it works out for.
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A
For me.
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B
So I'm very excited that Dr. Henry is my friend and wanted to be my friend. Do you remember what I was manifesting? Like global improvements in female health or something?
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A
What was the medicine piece that caught me? You were manifesting kind of moving from just absolute straight sexual medicine to more of a holistic, all preventative care view, which is my cup of tea. That's my thing. So that's why I was like, huh, Kelly needs me. I will answer this call.
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B
That's so true. I mean, you know, for, for you to have kind of bent your career in thinking about health and, you know, med, say medicine, but like the role of the physician to help you optimize and prevent health, whereas the, the overriding Dogma of the western medical system is let us know when you're broken and we'll try to patch it back up.
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A
Yeah, I mean, that's been the driver of my whole path. I got into medicine because I feel so strongly about wellness and disease prevention. Like, how do you get that feeling of when you're 23 and you can take on the world and have that last until you're 73? What is that? And then when I did my residency, I went to medical school, I was really disappointed by the focus on disease management. And if you look at the way that internists are taught to do physicals for 35 year olds, it's very basic advice on please wear a seatbelt, don't smoke, please come back for a flu shot. And when you're 50 and have 15 diseases, call me because then I have a whole lot to say to you. But nothing on how do I get from this 35 year old to this 50 year old and escape this path that seems inevitable for Americans with the diseases and the medications and everything just snowballs. So I did all sorts of like, interesting things with Chinese medicine and integrative medicine, and that's how I eventually ended up working with Peter. Is that focus.
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B
That's awesome. I mean, I think we've really normalized frailty. We've normalized taking medications, we've normalized taking medications that don't work that well. Like we. All of this is, is like, I think we're just starting to have these conversations and that's why I'm so excited you're here. Of like, have these conversations. Of like, do we need to wake up? Because when are we going to realize what we're currently doing isn't working? Yeah, I see these women and they're like, I'm on my like third, not consecutive antidepressant, but like current three SSRIs trying to solve something. It's like, when are we going to stop just giving people SSRIs for. I'm over generalizing on SSRIs, but like, the women aren't coming back and being like, I feel amazing on all of these prescriptions.
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A
Right. 100%. And I think part of it is we have to start earlier. You know, we wait until things get bad enough. We don't think about things before they've even begun. And I think that's like a big part of the problem is we don't, you know, we wait until, just to use hormones as an example, until someone has florid hot flashes, they're not sleeping. They're miserable. They're banging on their doctor's door saying, help me now. I'm at the end of my rope. That's when we're like, okay, let's talk about it. We're not like, hey, you're 40. We're starting to see some very subtle changes. Let's prepare you now.
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B
Totally. And it's such a subjective thing, too, of, like, number one, you don't want to be a complainer to your doctor. So you already have that. But then the doctor's like, is it bad enough? Which I think is a nice way to actually have somebody diminish their symptoms.
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A
Right.
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B
Like, no, I don't want to be the worst person.
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A
You know?
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B
So it's like, when do you start the conversation? And I think where we're moving, where I see 20, 24 moving, is to break the barrier of actually saying, could hormones be preventative medicine?
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A
I mean, that's a big mode shift. I mean, right now, I mean, hormones went from being the thing that you don't do to women ever. That was like, what it was when I was in med school and residency. It was like, the only thing we'll tell you about HRT is never do it. Then two, you can do it, but only if someone is absolutely going to jump off the bridge because of symptoms, and you've tried everything else. You gave them the ssri, you gave them gabapentin, you did all the things, and they're still miserable, then you can consider it. And now I feel like we're shifting towards thinking, is there benefits outside of symptom management and a reason to think about this for people maybe who aren't even suffering so terribly.
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B
Yeah. And I mean, I think for people to listen because it's like, it's tough to have the discussion on a global or national scale. There's no. I've been thinking about this a lot. There's no medical society that I think is ever gonna say hormones for preventative health again. I think they got burned when the WHI hit the fan. And, you know, like, cardiology was pretty strong on prevention in the 90s. Internal medicine was pretty strong on prevention. I pulled up all these articles for, like, the book of, like, they're talking about hormones as preventative health in the 1990et. And then the WHI hits the fan, Pfizer gets sued right to the tune of billions of dollars, and it's like, I don't think anybody's going to stick their neck out again, but we can't sit around waiting for somebody's permission to make the right decisions about our health. And I see tons of people on hormones for prevention for improved quality of life, energy, mood, lean body mass. Sleep's not really prevention, but like, you can't feel your bones becoming weak. You can't do it. You just have to decide. I must at a certain age. And I want to protect my bones. There's no test unless you want to wait till osteopenia, Right? Then I guess it's not prevention. What, what are you seeing as far as, like, because it comes from the educated women, it comes from, like, the people who know. What are you seeing in people coming to you saying, like, I want to. I'm 50, I want to start. I'm 45, I want to start.
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A
So there's so much more education now around perimenopause that actually the conversation's now happening way younger, like early 40s. People are starting to come in and say, I want to start thinking about this because they want to avoid the rollercoaster of suffering. They're like, I'm getting like a little taste of some suffering. Like, I'm not sleeping that well. My mood is changing. Suddenly I have swollen, tender breasts before my period. Like, something's not right. Let's not let this get worse. Let's kind of jump in now. I think there's been more of an understanding around potentially this link with dementia. And so a lot of women, when they come in asking, they're saying, my mom has dementia. This is my number one fear. I want to be on hormones as potentially preventative around that. And that really sparks their interest.
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B
I mean, I think Lisa Moscone's meta analysis was that 2023, 2022, 2023. Very recent Moscone meta analysis saying, you young hormones prevents Alzheimer's dementia by 32%. When you look at all the studies, it does not prevent it. When you're older, it's probably a wash. The data of it makes it worse, I think is soft. What are your thoughts when people are like, do you have data to show me? Like, do you use that paper? What do you say? Thumbtack presents uncertainty strikes. I was surrounded the aisle and the options were closing in.
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There were paint rollers, satin and matte
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A
I do use that paper. But I also am very honest about the fact that, like, a lot of this is either bad data or mixed data or we're in a data free zone, unfortunately, especially, I mean, I would say estrogen.
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B
I am taking that data free zone. Sweet.
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A
I mean, I was going to say estrogen. Of all the hormones, you probably have the best data for, but you try to find data on progesterone. Anything on testosterone that doesn't have to do with strict hormone libido benefits. Like, there's just not a ton out there that's really looking, in my opinion, with like, great quality studies looking at prevention. So a lot of it is not like evidence driven, more like evidence guidance rather than evidence proven.
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B
Yeah, I mean, we've got data on older women, testosterone and mood, cognitive ability, visual spatial improvements. And from there I extrapolate and just listening to women come back on testosterone, like, testosterone is a brain drug. Me and my texting to Lisa Moscone, I'm like, you need to do testosterone next. I guarantee you there's dementia improvements with prevention with testosterone completely.
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I'm laughing because the audiences know that you and I were talking about this very thing, because I just started myself on testosterone with the help of a doctor, and it feels completely different in my brain. To me, after having this experience as a human, as a woman, there's no longer a question that there's cognitive benefits. Like, it's.
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There's cognitive benefits. And to all the people who, who are like, we just have evidence for libido. What's libido? It's a mood. Moods are in our brain. It's a brain hormone. Like, you don't have to go, like, that's not even like one step separated.
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A
Right. It's not like a jump.
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B
Right, Right. That's what we're saying. It helps libido, therefore, it helps your brain. Tell me about your, your love affair with perimenopause. Did you see it as like an underserved area that, like, women aren't being helped in, or was it your own journey? Like, where did kind of your passion for perimenopause and maybe define that for people in case they've never listened to this podcast before?
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A
So perimenopause is that period of time prior to menopause. That's really what we're talking about. And I think it's dramatically underserved and surprising in terms of the age in which people start to develop symptoms. So when I went through training and when I was starting to think about menopause, like menopause to me was like a 53 year old woman. And that was like when I kind of thought that someone would develop symptoms. You know, as a physician, I was looking at my 50 to 57 year old crap.
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B
The dogma was your periods end, then you have symptoms.
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A
Right, exactly right. What I was not thinking about was all of those women that I saw at age like 40, 43 who were coming in saying that they were depressed, were anxious, they weren't sleeping well, they suddenly felt like they couldn't handle stuff that they could handle easily. Three years ago, they were having heavy periods. That whole demographic of women, I didn't know what was wrong. In the whole start of my career, I gave those women SSRIs, I sent them to gynecology. Like I had no idea what the issue was. And it wasn't until I started going through it myself and I started to have friends go through it and I started to be exposed to more perimenopause literature that I realized that a lot of what they were experiencing was the dip in progesterone. That's the characteristic of perimenopause. And that if you just gave them progesterone, that a lot of these symptoms and their suffering go away.
- [13:29]
B
Yeah. And it's cheap and insurance covers it. And like these medications are, have been around for a long time. And the progesterone that we use now, most common is micronized oral progesterone, which is body or bioidentical. It's basically what your body makes. We're just putting it back. The first time we chatted, you were the one who really kind of brought to the forefront the most significant loss of bone since actually before your periods end, you talk about bone loss and perimenopause just to just to like get everybody's attention on this podcast, because I don't think anybody knows that.
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A
I actually found that super surprising when I learned that. So if you look at the rate of bone loss, so how fast are you losing bone? The peak rate of bone loss actually occurs in perimenopause before you've gone through that year where you didn't have of period. So if you're waiting to step in with hormones to prevent bone loss by the time someone hits menopause, you've missed this incredible bone loss period. And you've missed a big part of the boat, let's put it that way. And it makes perfect Sense. If you think about how bone responds to different hormones, it's a beautiful dance. Estradiol prevents bone resorption. So at the start of your cycle, you have high estradiol, so your bone is quiescent. You're not reabsorbing it. The estradiol falls off and you start to resorb your bone. But then progesterone picks up. And progesterone is a bone stimulant. So now all of a sudden, you're building. And so when you're 28, the beautiful dance that occurs gives you a net bone loss of zero, like if the average is out. But then when you get to perimenopause and that progesterone peak is not there and you have this unopposed low estrogen, that's when bone loss starts to get serious.
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B
So much about perimenopause and menopause, we don't know. You know, I'm talking to the PhD people who are researching ovarian longevity, and I'm asking them questions and they're like, we don't know. That's why we're doing the research. Right. Like, it's embarrassing how actually little we know about our body. But from all that you've read, why do we know why progesterone goes down first?
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A
I think it has to do with
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more an ovulatory cycles, because the ovulation, the egg being released from within the follicle is what triggers the follicle to produce the progesterone.
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A
Yeah, it's called the corpus luteum. So basically you burst out, you grate your leg, and then the kind of remnant of where that egg was starts to produce progesterone until it's very clear that there's not going to be a fetus implanting. And then it gives up, cycle starts again. What ends up happening as a woman ages is that you have more and more cycles where there's dysfunction and then actual no ovulation. Like it doesn't work or this doesn't happen. And so all the little pieces that need to go into creating that progesterone peak don't happen. So you have these low progesterone gluteal phases.
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B
Tell me, explain to me, if you can, the. They call it the loop cycle. So it's like where your estradiol rises in preparation of an egg being released. An eg. Egg doesn't release, so you don't get the progesterone, but then you get more estradiol to try to keep making it happen is that this kind of loop phenomenon they're talking about, where your estrogen gets really high and you have low progesterone.
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A
Yes. So loop phenomenon, first of all, incredibly common in early perimenopause. It can be as much as 25% of cycles. So. And we don't know because we're not like, routinely checking women's hormones. But in my practice, I actually do routinely check women's hormones. I check them usually about four times a year. And so I actually catch all these loop cycles. And I'm seeing estradiol levels of like 500, 700. And if you call these women and you're like, how do you feel? They're like, I'm pregnant. My boobs are huge. I feel miserable. I don't know what's going on. What that is, is it's a symptom of disorganization. So the way that our body is kind of set, we're set to ovulate at all costs. You can think about it from an evolutionary perspective. That's kind of the goal of the ovary is to have one single egg successfully released per cycle. These loop cycles are disorganization. It's like it tries to get you to release an egg. There's a problem, there's not an egg ready. It doesn't seem right. You get this kind of second fsh peak, and then you end up having these two simultaneous recruitments of trying to get an egg to ovulate. And this kind of downstream effect is almost like you took ovarian stimulation, like people do for reproductive endocrinology. It's a little like that. It's like you stimulate the heck out of the ovary. And the end result, there are these crazy estrophil levels which you can catch on blood work randomly.
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B
And the treatment, if they were to come to you and be like, dude, for half of my cycle, I get bloated, I get breast tenderness, I get moody, maybe I get heavy periods. The treatment, if that's the right word for it, is to give the woman some progesterone because you want to balance it out. It's not that we're trying to lower the estradiol so much as raise the progesterone. Am I thinking about that right?
- [18:42]
A
Well, a loop cycle is just this kind of like random event which will self resolve. So, you know, the next cycle, everything will kind of go back to normal in terms of what's going on in perimenopause. And the symptoms, all those symptoms that you described tend to be symptoms that are secondary to the decline of progesterone. Perimenopause is very complicated because every cycle is a little different. So you can have cycles where you have really high estradiol, cycles where you have really low estradiol. FSH is all over the map. But progesterone pretty uniformly is lower than it was before. And so, yes, to treat a lot of those symptoms, poor sleep, mood changes, heavy periods, breast tenderness. Progesterone is the first hormone that I use.
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B
Do you find that checking a progesterone lab is useful? Because, like, the reference range is so small anyways. And this is a bigger topic because people are like, should I get my hormones checked or not? And I think us as experts, we do a bad job because it's like you don't actually have to check hormones to diagnose perimenopause. It is a clinical diagnosis. But if you do check hormones, know that where you are on Tuesday, it's not a fixed state.
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Right.
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It changes. And so if you're gonna check hormones, I think it's sometimes just checking. Checking labs is validating to people. There's nothing wrong with that. What's your statement on labs?
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A
I would give anything for there to be like a perimenopause test that would be so easy and wonderful. And instead it's like a little bit frustrating how unique every cycle is in perimenopause and how challenging that makes it in terms of checking progesterone. There's not a ton of value there, especially with a serum blood test. You could argue that potentially checking a urine test may be better because you get more of a look back and they can look at metabolites, but the science there is not clear and it's complex. If you're going to check a serum level check at day 19, checking the very start of your cycle is meaningless because even in a younger woman, progesterone is like less than 1 often in that time period. So you want the luteal phase you want around day 19 to see, but really, as you said, it's a clinical diagnosis. So there's criteria. You need like three of the nine criteria points. So if I have a woman in the right age range with the right symptoms, I at least try progesterone because, you know, really, really, really quickly. If it works like two weeks and it's either a new day or it's not worked at all, and then you need to kind of rethink it.
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B
Why do you think progesterone has been sidelined you know, we were talking about like, it being the like, ugly twin of estrogen of like, it's just as important, but like, people only want to look at estrogen.
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A
I know. So the short answer is I don't know. I mean, it's the most. It's like a classic example of how reductionist medicine is. It's like we have this hormone progesterone. We have receptors all over our body, in our brains, in our bones, et cetera. But for some reason, we fixed on one purpose of progesterone, which is to protect the uterus from building up too much interventional lining in the setting of estrogen. And that's its only purpose. So if you don't have a uterus, you don't need progesterone. It's a very, very, very, very narrow view of a very complex physiology that actually doesn't make any sense in terms of how our bodies work.
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B
Yeah, there's so many myths around perimenopause, but like, number one is you don't need hormones as long as you're having a period. That's a myth. You don't need progesterone if you don't have a uterus. That's a myth that a lab is going to tell you where you are or when menopause is going to happen. That we don't have that data yet. Any other big myths about perimenopause that always come up in your practice, the
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A
when to start myth? Well, I don't know if it's a myth or if it's just like the never ending question, but women, and I think culturally we're so used to thinking of menopause as like a 51 year old issue, that talking to women at age 40 or 42 about starting hormones still feels kind of strange to them. And they're like, is this something that I'm signing onto for life? Is this something I should start now? Are there any downsides of starting now? Questions around the when to are really big. And then the other question that always comes up because it's like true in this population is a lot of women in this age group are still fertile. And so the other question is like, do you need contraception? And how does that play a role in the choices that women make?
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B
That's kind of at the top of my flow sheet because it's like, if you need, if you want to protect yourself from sperm, we got to have a sperm protection plan. Either progesterone secreting IUD or, or a low dose Birth control pill. And people are like, I haven't gotten pregnant. It doesn't really matter if it happens. Like the people who are like, eh, just be like, you can get pregnant. Especially if we give you just a little boost on your hormones, you might be more likely to get pregnant. So to me, like in the perimenopause hormone discussion, the like, what's your sperm? Do you have sperm in your life and do you care about that is at the like top of my flow sheet.
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A
Yeah, me too. And there's a lot of confusion because women are used to taking hormones in the setting of birth control. So I always have to repeat, like, the hormones that I am giving you are not birth control. We are not in the same playing field. You will still ovulate. Like there has to be a second plan.
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B
Yes, totally. So let's say a woman wants a birth control pill. Birth control pills tend to have ethanol estradiol, that's the synthetic estrogen used. But what varies in birth control pills is the type of progestin.
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A
Right.
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B
What ones do you think are the best for perimenopause? And again, all of this is off label. We're not giving anybody individual medical advice. We're just kind of starting a discussion about options for women in perimenopause.
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A
So if I had to pick an oral contraceptive, I tend to use low estrin. I don't have a ton of reasons other than I just have a really great clinical experience with it. But to be totally honest with you, I don't love oral contraceptives in this age group. I try to pick a different method if I can. The reason why is that there's a fundamental difference between progestins and micronized progesterone. And a lot of the symptoms of paramedic, such as mood changes and poor sleep, tend to not respond very well to the progestins. So a lot of times I'll put people on low estrin, for example, and some things will get better. Their boobs won't hurt. Their periods will be a lot lighter, they'll be super regular. They appreciate that. But the sleep and the mood benefits are not there.
- [25:24]
B
Can you do a low estrogen and then a micronized progesterone for the sleep issues?
- [25:29]
A
I don't, I don't know. I mean in theory maybe what I do do that's kind of similar to that is I will have someone get an IUD placed and then I will give them micronized progesterone.
- [25:41]
B
Yeah, My pro tip for IUD just for everybody listening. Because gynecologists in a lot of places are hard to come by these days. If you have a Planned Parenthood in your town, you can actually get very cheap IUDs placed. So shout out to Planned Parenthood for the perimenopausal person as needed. My thought on why progesterone is like the forgotten stepsister of this all, I think it comes from the whi. My theory is before we understood the flawed placebo arm of the combined estrogen medroxyprogesterone acetate arm, people said, okay, it's the medroxyprogesterone acetate, it's the progestin that increases your risk of breast cancer. Therefore all progestins are bad. And I think progesterone. And so they're like, only if you have a uterus should you use the micronized progesterone. We were like, we have no compelling data that micronized progesterone is proliferative in the breast. But that's where I think this like dismissal of this hormone came from, was from the medroxyprogesterone acetate arm of the whi. That's my theory.
- [26:46]
A
No, I think you're right. I mean, I think it became viewed as it's very high risk. And so then it became viewed as like, only take that risk if your hands are totally tied and you have this uterus and you're already taking estradiol. We have to protect the uterus. But anyone else don't take that risk?
- [27:04]
B
Yep, totally. Let's talk about progesterone intolerance. Let's say about 4% of women are. Would be. Is are intolerant to micronized progesterone. They just, it either makes them sick. It's got a peanut base in it. So you can compound it. If you have a peanut allergy, just get it compounded to get the peanut out of it. Do you think it is that what you say? About 4% are intolerant to the oral micronized progesterone?
- [27:26]
A
Maybe. I actually find it to be super rare. I have yet to meet someone who's truly intolerant. I know it exists. I have friends who have taken care of patients who are truly intolerant. But I have found that especially I do compound progesterone quite a bit in the sustained release formulation that I can lower the dose with compounding and that tends to resolve a lot of the intolerance issues.
- [27:51]
B
Nice. And the sustained release formulation is not Available on the market. So you have to compound it. Can you take that in the daytime then? Because you're not getting your drowsiness from it. Because the whole point of compounding a sustained release is that it works 24 hours a day, has a much longer half life, a longer half life and
- [28:09]
A
a lot of prometrium, which is the FDA approved product that you can get for just like normal progesterone. Progesterone, it's a very short half life, so you take it before bed. Really strong onset. I love it for clients who have trouble falling asleep because the out of the box effect is really strong, like out of the gate, but it's not a lot there the next day. So for my clients who are noticing or really interested in mood benefits, I actually find they do way better on SR because it's with you that whole time. So the mood benefits stay nice and
- [28:44]
B
mood benefits most commonly anxiety.
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A
Yeah. And irritability.
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B
Love it. Other options for progesterone intolerance, again off label, but the progesterone secreting iud, some people will take it vaginally. Again, you're going to get the uterine protection, but I don't think. Do they get systemic then or they just don't get first pass metabolism. Does putting it in your vagina help your mood?
- [29:08]
A
Maybe. I have never prescribed intravaginal progesterone because
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B
you're like just compound the sustained release.
- [29:18]
A
Yeah. And it works so well. And you can, you know, you can when you're compounding, you can make whatever dose you want. So I will compound 25 milligrams very frequently. This is something I commonly do is I get a woman who's just starting and we don't know, know how she's going to respond, what, how she's going to feel. I'll give her a bunch of 25s and say let's start with one, see how you feel and then go to two and we figure out where her dose is.
- [29:42]
B
Do you think that 25 is, is uterine protective? You think it's enough?
- [29:46]
A
No, I don't. There's some data to say that 100 milligrams is kind of like where the uterine protection is.
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B
Got it, Got it. Let's talk about cycling because perimenopause people all, not some, not all, still have either regular periods or they're bleeding. Let's talk about cycling the progesterone and like, you know, what do you like to do or why people talk about doing that in perimenopause.
- [30:12]
A
They talk about doing it because they're trying to mimic their natural cycle. So in the follicular phase of the natural cycle, progesterone is very low and then it picks up in the luteal phase. So basically what we're just trying to do is recreate what we were doing before. Now it's way easier with compounding than with non compounded products just because you get dose variability. So if you did it with just prometrium, you would do nothing the first half and then starting at around day, let's say 14, you would start taking 100 milligrams. And then when you started to bleed or you got to day like 26, you just stop it, repeat next cycle. What I do when I compound is I put women on a really low dose during the follicular phase, 25 or 50, then I go up to 100 or 150 for the second part of the cycle.
- [31:04]
B
Got it. Love it. And then people talk about cycling in menopause. I know that the standard hormone experts say there's no reason to do that because you're not having a period and you're not cycling. I think it's more like the niche people who still think they want to cycle post menopause. Do you see there's any role for that post menopausal?
- [31:23]
A
It's not something that I do, honestly. The cycling tends to annoy people because you're having to track your days and you're like, oh no, it's day 21. I'm still in the 50, you know. So a very common feedback piece that I get from clients is like, when can I stop cycling? Can I just take this every day? Plus the mood and the sleep benefits tend to be so profound that women are like, I'm miserable in that first half of the cycle. Like it doesn't feel right. So I will often give up on cycling, especially as someone ages. Like, what's really what works at 40 is not what's gonna work at 47, that's for sure. And the doses change. I go up on my progesterone doses. People age, they just need more. But so cycling is a moment in time that I do kind of in a younger 40s. And then I usually give it up and we just do every night.
- [32:09]
B
Nice. And then Dr. Pryor, kind of like the OG endocrinologist of progesterone, she advocates and you know, we, we know that it's safe, 200, 300 milligrams of micronized progesterone at Night, if you need for sleep and stuff like that, do you find that you have to do do those doses? She would argue. I don't want to speak for her. She would argue that those are the more natural doses.
- [32:33]
A
Yeah, that's physiologic dosing. The 100 milligram really came out, like, all things to kind of fit with our focus. So the 100mg is thought to be the amount that you need to protect the uterus. And since progesterone's only purpose is to protect the uterus, that's how we dose it. But if you're thinking about what was happening when you were 28 and any other reasons for having progesterone in the body, 100 milligrams is a very low dose. You would really need like 200 or 300 to get closer to physiologic levels. So the short answer is, yes, I often increase the dose. Not always. Some women are happy on 100 and I don't mess with them. But as it gets really close to actual menopause, I often go to 200.
- [33:18]
B
Got it. Awesome. For cycling, when you're going to be off it and then on it, on it, it's 200 for uterine protection. Is that right? And then if you're continuous, it's 100. But if you're going to cycle, it's off for two weeks. So you have a period, you count 14 days, day 14, you start 200. Is that right?
- [33:37]
A
Yeah, if you're taking estradiol. So this would be not common in the perimenopause period of time. But if now you're doing combined hormonal therapy with estradiol and progesterone, and for some reason. So at this point in time, my patients are all on nightly progesterone. I'm not doing cycling anymore. But if you were, you have to be more careful with the dose amounts because of the estradiol. And you're right, you do need a higher dose if you're going to just only do it for a short period of time.
- [34:08]
B
Yeah, well, I mean, I think the other thing to mention is like the data on increased risk of endometrial proliferation followed by endometrial cancer because of unopposed estrogen was, number one, very high doses of estrogen. This is decades ago where this came from. And these weren't people who were having periods. Right. And when we're talking in the perimenopausal timeframe, you're naturally shedding your lining. This has never Been studied in the perimenopause of, like, if you're still bleeding. You know, I have some people, some people who are like, they do a little bit of estrogen, especially like the week before their period, because it kind of gives them a little bit of estrogen. And we're like, you don't really need to be on progesterone yet. If you don't want it because you're having. You're shedding your uterine lining, then you can say, we don't have any data looking at this in the perimenopause. As far as, as far as the risk of unopposed estradiol when you're having natural periods.
- [35:02]
A
Yeah. I mean, I would say I find estradiol and perimenopause to be the greatest challenge. And it's in part because of things like this loose cycle where you can have cycles where you have, like, such low estradiol and then that the patch or the gel or whatever you want to use is fantastic. And then two cycles later you have an estradiol of 700 and you're miserable and you're like, do I take it off? Like, you don't even know what's happening.
- [35:27]
B
I hate this estrogen, right? Like, you have a lot going on right now. I mean, I think this speaks a lot to, you know, the current state of our fee for service insurance base. Like, people can't get a primary care doctor for like four months. And that's like, you're established with somebody and it's like, to truly be happy with where you are with hormones and perimenopause, it requires adjusting. Sometimes it requires testing things. It requires a provider who can, who's willing to. To do that with you. And I think it speaks a lot to the concierge cash based of like, you want somebody who's going to dial this in with you because it's not one visit once a year saying, here's an estrogen patch or you don't need hormones till you're done bleeding, that I think the current medical system can't handle this. Is that too strong of a statement?
- [36:19]
A
No, I think that's really accurate. I mean, perimenopause is exhausting to manage as a physician because you get it right and then three months later, the body changes. So I'm always telling my patients, I'm so happy that you're so happy today, but I know that in three months or in six months, you're going to be like, this isn't working at all. We're Going to be right back here, you know, and that's the way it is until you hit menopause. And then hormones are easy, then we can find you on a drug. We can just push you forward. We don't have to talk about it every three months. But the perimenopause period is incredibly challenging.
- [36:57]
B
Yeah. And the reason for that, again, for people who don't know, like this, is literally redefining what menopause is. Because defining menopause as the end one year, no periods, it doesn't make any sense. Anything what we've said doesn't make any sense until you understand the ovaries are at the end of their natural lifespan and it fits and starts as they're kind of downloading to retirement. But that's not the definition. Like, that is what menopause is. But if we just call it no more periods, like, that's actually a symptom of what's going on.
- [37:31]
A
It's like the end of a very long journey, but we ignore the decade of the journey beforehand. It's like counting, like, a pregnancy at the moment of birth, Right? Like, yes, that is the moment of birth, but there were nine months where a lot of stuff happened and there was a lot of things in there that were symptomatic and problems. And you have to look at the whole process.
- [37:54]
B
That's a really nice analogy. I think the other talking about stereotypes of perimenopause is like, people, if you find somebody to help you, more than likely they're going to pick estrogen first because they think that's the hormone. Right. Which our argument is probably progesterone and testosterone often will come before the estrogen comes in perimenopause, because you're running low of the those other two before you're running low of estrogen. I'm, like, overgeneralizing all. All people with ovaries right now. But, like, by and large, we shouldn't think estrogen is the first thing we do.
- [38:27]
A
No, I mean, I would say it even stronger. I have, like, yet to see a scenario in which you would ever give estradiol first. Progesterone goes low for so long, we're talking years while people are still having high estradiol, low estradiol, high estradiol, low estradiol. And testosterone is a little bit of its own beast, meaning it has its kind of own timeline. But for the majority of women, that has also declined to a level where they're symptomatic from it well before they need estradiol. Support.
- [38:57]
B
Yeah. Once you see that you have 50% of your testosterone at 40, in your 40s than you did when you're in your 20s, and realize really what the benefits of testosterone are and realize that the testosterone going down has nothing to do with the egg dance of the estrogen progesterone.
- [39:13]
A
Right.
- [39:14]
B
It's like its own separate ovarian function that starts a lot earlier. We do not know why at this point that's happening. You know, even calling we're so myopic saying testosterone's just for libido, but then we're more myopic saying it's for. Testosterone's for postmenopausal women with low libido.
- [39:31]
A
Right.
- [39:33]
B
Is like, there's nothing magical about the last period where you can now get testosterone. It makes no sense. Once you understand the physiology. Testosterone's got its own host of things just because of the DEA restriction, the gender bias behind it. Like, it's. You need to find a practitioner who cares about testosterone and knows testosterone. And at this point, it's a little slim pickings, but we're working on it. So many questions about dhea. I've done the reading that I can do on it in America. It's a supplement, so unregulated, comes in lots of different doses. 10 milligrams, up to 100 milligrams in the supplement doses. What's your take on DHEA?
- [40:16]
A
So in early perimenopause. And again, we just spoke about testosterone decline to be really different person to person. Can we start earlier, Yada, yada. But when I'm looking at someone who's experiencing symptoms that are making me think that their testosterone is low and I can measure it all the hormones. Testosterone is pretty darn easy to measure. It doesn't change with your menstrual cycle. So you can pop into clinic, get it measured. Whenever I'll start to think about how can I support this person to make more testosterone. So if their DHEA level is low, I'll think and often try to supplement that first and see what we get. Now, I often get libido benefits. So even if the testosterone number does not significantly change on the page, oftentimes women come back and say, I'm starting to have spontaneous sexual thoughts again, I'm more interested in my partner, et cetera. And sometimes we'll leave it at that. We'll be like, well, that's a win. Great, go forth. Other times it does nothing. And I have yet to figure out or if there is a way to figure out who that person is, who's the person who's going to get a symptomatic benefit from DHEA and who's not. It doesn't closely correlate with numbers. Although if someone has high DHEA on paper, I don't even start there because making it even higher doesn't make a lot of sense. So I try that and that if that is not working, et cetera, then I go straight to testosterone.
- [41:45]
B
Yeah, I agree. I think if there's a role for dhea, it's perimenopause. I think the studies haven't really shown that giving DHEA post menopause is doing much. I think, like the factories aren't making anything. So like giving them DHTAs, they're like, what do I do with this widget? Right. So I think, I think if anything it's a perimenopausal role. I like that idea of checking the dea. It's dea. Hyphen S is what the lab value is.
- [42:13]
A
Yeah, DHEA hyphen S. DHEA hyphen S
- [42:17]
B
is the, is the lab value that you ask for. And if that's low, then supplement it.
- [42:23]
A
And caveat of like, I'm not sure that the reference ranges on that lab are helpful in terms of what is low. I look for 150. If you're less than 150, I will play the game of trying to supplement it to see if it makes a difference. If you're rolling in a 250, I ban, of course, because it's not gonna make a big difference.
- [42:42]
B
Yeah, that makes sense. Oh, I had a couple of women say really oily skin with DHEA that they didn't like. But you know, they come to see me after they've tried supplements from somebody else and I don't have labs. I'm like, it would have been interesting to know what your levels were on that supplement. You know, we don't have anything to, to show, like, were you super high? Did it, did it kick your Testosterone up to 175? Like, we don't know.
- [43:05]
A
I do find that a lot of people and supplements are very high dose DHEA. So when I use DHEA, I tend to start with 10mg. But I've even had clients take 5mg and adequately bump their DHEA. I personally played around with taking 20mg and my serum DHEA level was sky high. But you'll see a lot of people advocating and a lot of people selling 50 milligrams as the basic dose. That is a lot. So that's one thing is I would never start that high, especially because we can measure. I would always start much lower.
- [43:40]
B
Yeah, I mean, I think these supplements are on the market for men, too, right? Again, DHEA supplements in men. Also, the data doesn't support that. It moves the needle, much like your testicles are making so much testosterone. DHEA is not moving the needle too much. So I think it's really individualized. But, yeah, like, a guy just asked me, he's like. I'm like, it's unlikely to hurt you, but it's unlikely to give you much benefit. Until I see more studies on that. The other thing I want you to talk about is your lens is not just hormones. Your lens is really cardiac brain protective, just midlife optimization for longevity. What do you want women to be thinking about? Like 40? Let's say somebody's turning 45 in two days.
- [44:26]
A
Okay. Hypothetically, if someone were to be turning
- [44:30]
B
45, if somebody was turning 45 in two days, what should they be thinking about?
- [44:37]
A
So what I really want this hypothetical person to be thinking about is how do we look at the diseases that are coming and work our way backwards? So that's just like the frame shift. When you think about preventative medicine, that makes the most sense. So cardiovascular risk, frailty risk, dementia risk, metabolic risk. Those are like the four buckets that you can kind of just. Just think about. So I urge anyone in their 40s to go and get lab work and know where you are, because you'll never know just based on how you feel, if your hemoglobin A1C has been climbing up for this last decade, if your cholesterol is high, all of those things. Women in their 40s also tend to have really low ferritin because of this heavy bleeding, which can make them feel fatigued. Thyroid problems pop up and therefore 40s. Like, if you've made it to your 40s without a doctor, which many of us have, we're like, only seeing our OB GYN. Your 40s is when you have to throw in the towel and say, I need blood work. I need a doctor that can be my partner. It's time to really get serious about these risk factors.
- [45:45]
B
I love it. I think this is the first generation. I'm going to call out Gen X. It's the first generation that's like, maybe we don't just show up and write it till the end. Like, maybe. Maybe we actually try to make this, like, good and an enjoyable life. And I think, you know, the Gen X are looking at their parents and they're like, the years of frailty and struggle does not look appealing. And they're starting to ask, like, is there another way? Is it possible that frailty is not the standard? What if frailty can become the exception?
- [46:25]
A
Yeah. I think people are starting to feel more empowered. That's the thing that makes me the most optimistic about healthcare today, is that finally people are saying, it's me, it's my job, it's my life, it's my data. And if anyone's going to fix this problem, it's me. And there's like, a whole wave of ownership over our health that prior generations didn't have. They were just waiting for someone to give them a pillar to tell them what to do. And the culture around that has totally shifted.
- [46:55]
B
I love that. Like, you know what, like, grates my. My chalkboard is when people are like, my doctor put me on blah, blah, blah, or, my doctor stopped blah, blah, blah. I don't know why. Right. Like, I want a woman who's like, I decided that hormones were right for me, and I'm partnering with my doctor. And we're. Right now, right now we're trying this. Because this whole, like, I tried something. And I think this goes back to, like, perimenopause. And even in menopause, when people are like, I didn't tolerate hormones. It's like, you didn't optimize your hormones. You didn't find the dose that works for you, the route that works for you, the right combo that works for you. But, like, it grates my chalkboard when people are like, my doctor did this. It's like, you are not an inanimate object to be painted on. I want you to say, I want hormones. I want to understand why we're stopping this. And I think that goes directly to what you're saying of, like, that's how health optimization can look.
- [47:57]
A
Yeah. It starts with autonomy. It starts with owning it. And I think now there's so much. We have so much more access to our own data with CGMs, with sleep trackers, with companies that sell lab tests directly to consumers. And you can get them all the time. Like, it's a totally new day with us having as humans and consumers and patients holding the reins when it comes to our data and our physiology.
- [48:25]
B
That's awesome. CGMs are supposed to be coming over the counter this summer.
- [48:29]
A
I don't know if that's 100% true. I haven't. That's very exciting.
- [48:33]
B
I heard that, but I Heard it a couple months ago. I keep, like. Like, I keep walking into Walgreens being like, where's your CGM aisle?
- [48:40]
A
I would think that would come with a wave of a whole lot of advertising. So I think we would know.
- [48:44]
B
Yeah, right?
- [48:45]
A
Yeah.
- [48:46]
B
When you get. When you get a new. A new patient in, are you throwing a CGM on them in the beginning just to get that awareness? Are you having them? 3. Three questions. CGM Dexa scan as a baseline. Nice to meet you. Let's see where your dexa, what your DEXA is, and then a coronary calcium score. As far as, like, diagnostics. Good to get.
- [49:06]
A
Yes. I like all of those things. CGMs.
- [49:10]
B
What did I miss?
- [49:13]
A
CGMS I find valuable for almost everyone because there's two phases with CGMs. One is, like, the insight, and the other is the maintenance, even if you don't have insulin resistance. So if I run labs on you and I'm like, listen, Kelly, it looks great. I don't see anything here that tells me that you have insulin resistance. It's so still nice and great feedback for you to know how you're responding to your diet. I first did one when I was pregnant, and I was absolutely shocked by how high my glucose went to rice. I grew up in a family where brown rice was just stable, and so I thought I was eating healthy during pregnancy. I was having brown rice and beans and all these things, and my blood sugar was going crazy. That was a learning moment. Everyone has learning moments when they give it.
- [49:58]
B
Mine was s'. Mores. Did you know that s' mores can spike your blood glucose? It's profound. I know.
- [50:07]
A
That's me.
- [50:07]
B
Like, I'm gonna throw out a CGM and have a smore. So, yes, massive spike with s'. Mores. And then white rice is literally like a candy bar for me. And, you know, we think we're like, oh, rice and veggies. Now I'm like, chicken and veggies. Because the white rice is, like, bing.
- [50:26]
A
And for me, it was like, I kind of figured out, like, if I was gonna, quote, unquote, spend that, you know, like, if I was gonna create a spike, like, I didn't want brown rice. I wanted ice cream. You know, like, oh, my God, like, forget it. Who needs brown rice? I will eat something else. Like, I will save that for actual ice cream and then enjoy it way more.
- [50:47]
B
Yeah, totally, dude. My Haagen Dazs mint chip, which is like, my drug, my sugar drug, doesn't spike, and I think it's the fat content.
- [50:55]
A
Yeah. Yeah. That's another key. Learning. Not everyone is so sensitive. It's interesting. There's like some interesting genetics there. But for many people, combining fat really mitigates the spike, which then is something that you can have. Like if I do have rice, for example, I will often eat an avocado because that combination is way better. Or if I'm, like eating french fries and I'm out and I'm ordering, I will order a burger with avocado to try to mitigate the fry spike that I know is coming.
- [51:25]
B
Yeah, I love it. And did I miss anything that you think is important? So dexa, and not just for bone health, but it also tells you lean body mass.
- [51:34]
A
Yeah. Which is a pain. It's actually very hard to get a DEXA that does all of the above. So if you go to places that do kind of like body composition dexas, they will often give you what's called all the total bone mineral density. Just a very kind of vague metric. If that's off, then please go get a real bone mineral density. Dexa, which looks at segments of your bone and is done differently. So I usually sometimes have to order two dexas, one for their bone mineral density to get that done well, and then also for body comp. To look at their lean mass, their visceral fat, and then their total subcontinent. So those are really key. You mentioned cac. That's a great study. A little age dependent. There's not a lot of value in ordering a CAC when you're 30, because if that's positive, that something is really, really, really, really, really wrong. But for the vast majority of people who are too young, in terms of the process of how atherosclerosis starts to really have calcified plaque at that moment, you're actually better off ordering like a CT angio in that age group, looking for soft plaque just based upon how the disease progresses. The thing you didn't mention, which I also find a lot of value in, is a VO2 max to see where someone's VO2 max is.
- [52:49]
B
Yes, I need to do that. I need to get down to Seattle and get on a bike.
- [52:56]
A
It's good to get a baseline to say, is it humbling?
- [52:58]
B
Have you done it?
- [52:59]
A
Yeah.
- [53:00]
B
If it's not humbling for you, you're like, I'm solid.
- [53:03]
A
I am humbled. First of all, athletically, I am humbled all the time. I am not an athlete.
- [53:11]
B
I mean, I think the first time
- [53:12]
A
I met Peter, I was like, listen, prior to today, all I'VE ever done is the elliptical. And he was.
- [53:20]
B
You had other good attributes that made you an excellent team member. Your VO2 max was not what got you in the dark.
- [53:26]
A
No, my ability to weightlift, not the intro that I started with,
- [53:32]
B
but as far as like markers of longevity and longevity slash, not being frail, lean body mass and VO2 max are two huge
- [53:42]
A
indicators and they're modifiable. So that's like the key thing to know. If you're 45 and your VO2 max is not great, you have time to fix it. You have time to dedicate to training that will increase that. If you're 70 and your VO2 max is not great, it is much harder to build up reserve at that point. The time to build up reserve is younger. I love that.
- [54:07]
B
Let's say you're turning 45 in two days and you get a coronary artery calcium score. Is that reversible with lifestyle changes? You get a scan, it shows coronary artery calcium. Can you reverse that? I have to think yes, but where are we with understanding the reversibility of that, what you've already accumulated?
- [54:30]
A
Okay, I paused because I think this is actually still an area of controversy. The dogma, the predominant thought is, no, that is not reversible. That what you can do and should focus on is preventing further plaque deposition, but that no magic is going to come and clean those arteries. Now there was the work of Dean Ornish. I don't know if you're familiar with his work, but that he did a very complex study where, I mean, kind of the underlying mechanism of that study was like, let's do all the lifestyle things at once. So he put people on a plant based diet that was like really strict and rigorous. They had social support. Like, they did all the things. And he did CT angios and what he found is actual plaque regression. So it's interesting. I think there's like a proof of concept that maybe plaque regression is possible. It is certainly not common like in my career. Am I ordering cacs and seeing that number go down? No, not seeing it go down. I am seeing it slow down. So I may see any other stock which is optimal. I get a cap on you, it's a score X and 10 years later it's still score X. That's great. That's a win. Sometimes I'm still seeing worsening over time, but the rate that it's worsening is much slower because I've lowered their lipids.
- [55:52]
B
Got it. Super helpful, dude. Thank you for helping us and helping all the women and the men and all the people. Like, this is the future. I'm not convinced our current medical system's gonna get us there. I think this is gonna be individual driven, saying it's coming from me that I want to optimize. You know, I. I'd say like the COVID epidemic for what it was worth. Like, we missed our victory garden moment of really encouraging all humans, Americans, all humans to get as healthy as you can. Be resilient so you can fight when you get knocked down. Yeah, it's not gonna come from top down. Like this change. And I just like the menopause movement and hormones. It's not coming from top down. It's coming from women. Like, I don't want to age. Like I've seen these other people age. Is there a different way to keep living? And that's where this is coming from.
- [56:51]
A
Yeah, I mean, we are the only people incentivized to keep ourselves well. Unfortunately, like the medical system is not incentivized to care about 30 years down the road. The only person who cares about your future medically truly is you. And you have to take ownership of won't ever come from top down.
- [57:13]
B
That's beautiful. Truthfully, it's better that way. Again, going back to like, my doctor made me get a cac. It's like, you know, like you should be invested in what your lean body mass is.
- [57:25]
A
Right.
- [57:25]
B
And what's your VO2 max. Cause that's a marker of your longevity. And do it cause you want to do it, not because somebody else made you do it. Dr. Eve Henry, thank you so much for finally coming on my podcast.
- [57:36]
A
You're welcome.
- [57:38]
B
We'll put your, put your Instagram, your LinkedIn. Keep talking. You're wonderful at it and people need this info.
- [57:46]
A
Thank you, my dear. Happy almost birthday.
- [57:50]
B
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Masterclass where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth exclusive content, more time with yours truly. A private podcast, coaching and educational empowerment. And you can watch my interviews live and get them immediately without advertising. Head over to www.kellycaspersonmd.com for the membership and adult Sex ed Masterclass members get the master class for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast are not giving individual medical advice or practicing medicine. See and consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you. Using the information on this podcast or any of my platforms is at your own risk. Until next time, remember, you are not broken.