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- [00:04]
Dr. Kelly Casperson
Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a
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board certified urologist, thought leader and conversation
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starter on midlife living, hormones and sexuality. Enjoy the show.
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Hey everybody. Welcome back to the you Are Not Broken podcast. I have for the first time ever, a pharmacist on my podcast. I have PharmD. Tara Thompson, welcome.
- [00:29]
PharmD Tara Thompson
Thank you. Thank you for having me. I feel honored to be your first pharmacist ever. Hopefully more to come.
- [00:35]
Dr. Kelly Casperson
Here's the disclaimer. We're not going to get it all in today, but we're going to start and try to make a difference. We met because you are on the Ishwish thread thing that like Ishwish members have for people who don't know. International Society for the Study of Women's Sexual Health. And then if you're a member you can be on this like thread where people ask like clinical questions and you are there to offer insight into pharmacology and all things.
- [01:02]
PharmD Tara Thompson
Yes, I am one of the only pharmacists. There's a couple of us now I think because I've been spreading the word about ishwish, but I'm one of the, one of the OG pharmacists to join ishwish and get that sort of healthcare profession modality into isshwish. So whenever there's a pharmacy question on the forum or somebody's talking like about drug dosing, your interactions, I have to chime in.
- [01:27]
Dr. Kelly Casperson
How did you get into ISSWISH as a pharmacist?
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PharmD Tara Thompson
Oh my goodness. I got into ISSWISH a long time ago, 12 years ago. I want to say it was really small. They were still like in the hotel lobbies and stuff like that. And really I was self teaching myself women's sexual medicine and sexual health.
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Dr. Kelly Casperson
Did you have like a patient? Was this personal, like how did this happen?
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PharmD Tara Thompson
Yes. So as we all know, I'm sure you experience the same thing in medical school and same for pharmacy school. We get like one slide of sexual health, both men and women. So actually there's more for men obviously, but for women it was just glazed over. And so when I got into the, into the field in the profession especially what I do, I specialize in compounding, which is we get a lot of vulvodynia, vestibulodynia, pelvic floor. I mean just tons of these patients who, and prescribers who were asking me questions and I'm just like, I have no idea what you're talking about. So I really had to educate myself and like, figure out treatment modalities and protocols. And that's sort of where I got plugged into Issuish. And I was like, these are my people. They're talking about the same things that I want to learn about. And so it was just a really great marriage there. And I'm so glad that I found it.
- [02:44]
Dr. Kelly Casperson
I love that. I was at the Menopause society meeting in 2024 and they had a statistic about. Currently it's like 2.8% of women are on hormone therapy. And we're thinking it's probably higher because of how many women get their system. And this is, I'm talking systemic, not vaginal, but systemic hormones compounded. Do you think it was the WHI scare, scaring women off of prescription medications? So, like, there was like the air quotes that compounding was safer or why do you think there still so many systemic hormones being compounded? And do you have any numbers on that?
- [03:21]
PharmD Tara Thompson
I think the WHI had a huge part in the initial scare, but once it was sort of found out the difference between synthetic hormones and equine estrogens versus bioidentical hormones or those that have the exact same natural structure as what our bodies already make in the first place, I think that kind of, I don't know, maybe like reset the framework of what hormones could actually do and help with so much as you know or may not know, compounded medications are not FDA approved. So we don't have all of those statistics and we don't have all of those clinical trials in humans that can prove this or that. Really as a pharmacist and really as a chemist, I'm a scientific chemist that uses mechanisms of action to, to figure out how these drugs, how I'm going to get them into the body systemically or vaginally, and then what they're going to do when they get there. And then once I figure that out, what doses, what strengths, how are we going to be as safe as possible, as effective as possible? So I think your statistic is a lot higher than the 2%, honestly. I mean, just from what I'm seeing.
- [04:33]
Dr. Kelly Casperson
But we have no way to measure how many women are on compounded systemic hormones. But there isn't any, like, checkbox where you're like, there's another one.
- [04:41]
PharmD Tara Thompson
No, I mean, unless you're doing nationwide, nationwide polls. But then, you know, still, that's not really accurate. And then thinking of like all of the different pharmacies that are making compounded hormones and then how many Patient or compounds in general. And then how many of those patients are HRT patients? Or on. And then, and then you have to break it down into who's on the estradiol, estriol, testosterone, DHEA, pregnenolone. Like, it's higher than 2%.
- [05:09]
Dr. Kelly Casperson
Yeah, yeah, it's higher than 2.8%. I believe it. So in going to like, you know, let's go to our commercial pharmacist for a little bit, if you can speak on the, like the state of the nation. Because what I hear over and over and over again is that the pharmacists aren't trained in hormones and knowing that these things are safe and women finally find a doctor to give them a fricking estrogen patch and then they go into Walgreens not to pick on Walgreens. And then they say like, do you know that this is dangerous? What are you doing? This is too high of a do. Like, the pharmacists are getting in the way of like, they finally got a fricking prescription and now they're being fed fear again at the pharmacy. What's the state of pharmacists education? And like, women are like, what do we do about this?
- [05:53]
PharmD Tara Thompson
It all boils down to education. Like, if it's not taught in school, how are pharmacists, how are, how are docs, how are our mid level practitioner is supposed to know about these things without having to like go into some sort of specialty or educate themselves. So for me, one of my huge passion projects is getting into pharmacy schools and changing that curriculum and saying like, let me come in and teach your students all about the hormones, just the steroid hormone cascade in general and like, what drugs are out there that are FDA approved? Because there are estradiols on the market, which so happy about, but then there's also like esterified estrogens and then the equine estrogens and synthetics and things like that. But it's important to know those too because they are FDA approved. They are options for our patients. I think we need to know what all of our patient options are. But just like getting in there and teaching, like how to answer those questions that our prescribers and our patients are asking us, like, is this natural? Is this safe? How does the patch compare to the or oral form? Or is there a topical version I can use? Or like, oh, I see there's also a vaginal estrogen. Is that the same thing? Nuances like that to where we're actually looking at the chemical structure and drug and that's what we need to be basing our education on really, versus like all these random brand names and generics and compounds and everything that's getting put into this bucket of hormone replacement therapy when it's all just completely different depending on dosage, form, drug, mechanism of action. There's so much that needs to be learned and I don't think it's like well taught.
- [07:29]
Dr. Kelly Casperson
Yeah, totally. And the media certainly perpetuates that too. I just saw Medscape published like yesterday. They were like hormone replacement therapy increases your risk of lupus. So I frickin pull up the study. Estrogen alone does not. Vaginal estrogen did a little bit, which tells me that the association study is just crap. And then it was the synthetic progesterone which most people don't use for that study to be distilled into hormone replacement therapy increases your risk of lupus is absolutely incorrect and wrong and bullshitty.
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PharmD Tara Thompson
Oh, I see studies all the time and it's like, or like HRT can decrease your risk of this or like if you're looking at this particular hormone, it can increase your risk of this. And I'm just like, how is a patient supposed to analyze all of this literature that's coming out? Or even me, even you. How are we supposed to analyze all this and the full picture summary of like what is good and what is bad? Because I'm seeing contradicting stuff here. But yeah, I, I completely agree with you.
- [08:29]
Dr. Kelly Casperson
Like I'm an expert, you know, and it's incredibly hard just to give people answers to it is like you have to find somebody that you trust and it kind of comes down to that. But realize like they're also limited in their knowledge. Like nobody knows everything. Maybe Louise, Dr. Louise Newsome in the UK knows everything. It's quite possible. Short of Dr. Louise Newsome in the U.K. knowing everything, nobody else knows anything.
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PharmD Tara Thompson
They can't all go to go see her, unfortunately. I wish we could we don't get
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Dr. Kelly Casperson
me wrong, we know a lot. Okay, so the other problem that came up in a, in a big box pharmacy is Amazon is throwing, I think this is state specific throwing stickers on their estrogen patches that say hazardous medication. And so one of my women who got that in the mail like pushed them and was like what's with this sticker? And they're like, oh well it's beers criteria which is a warning for people over the age of 65 and the FDA boxed warning. And so they then have to put, they feel like they have to Put stickers that say hazardous medication on their hormone replacement therapy. What's up with that?
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PharmD Tara Thompson
Yeah, commercially, yes. There are so many nuances that are popping up that patients have to be warned. Even ascorbic acid, vitamin D, isopropyl alcohol, rubbing is all hazardous. So I know from vitamin D is a hazardous vitamin D. It's a hormone, it's hazardous. Yeah. So it can affect biological processes. That's sort of the. They tie hazardous drug to a couple different categories. So if it falls within one of these categories, reproductive risk being one of them, then it is considered a hazardous drug.
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Dr. Kelly Casperson
Whether or not you're 72 years old, when you're taking your estrogen patch, doesn't
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PharmD Tara Thompson
matter, falls in the bucket. And so therefore it is gospel to all in compounding. Specifically for all hazardous drugs that are in those buckets, we have to do the same. You have to include a sticker or something on the label or in the packaging that says this is a hazardous drug. And it actually requires a completely different set of USP guidelines that we have to follow called USP 800 for hazardous drug. And it requires a different type of build out pharmacy, requires a different lab, different guarding.
- [10:42]
Dr. Kelly Casperson
So what that means is it increases the cost to the consumer.
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PharmD Tara Thompson
Oh my gosh. Absolutely. It does. Yeah. Even if one of the drugs in the drug combination is hazardous, the whole thing becomes hazardous. So the sticker is correct on there because that is a hormone. All hormones are considered hazardous because of the reproductive risk. And it's not, they all fall into a bucket. It's not singling out one is more hazardous than the other.
- [11:05]
Dr. Kelly Casperson
Well, because testosterone is, is used in fertility clinics, when appropriately dosed, actually makes you get pregnant easier. So it's dosing that matters. If you take a man's testosterone dose that might be hazardous to a fetus, but we actually use testosterone in infertility.
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PharmD Tara Thompson
Right. It's a bucket.
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Dr. Kelly Casperson
And it's a bucket.
- [11:26]
PharmD Tara Thompson
It's a bucket. And I hate it. Because even like testosterone, for example, as you know, is a controlled substance. When you're shipping as a pharmacy, we ship all over the US when you're shipping a drug to a patient that's controlled, they have to sign for it. Like you have to have an adult signature over 18. It becomes a problem for a woman who's maybe on a milligram a day that it's a controlled substance. Like, how is this drug gonna get diverted? Like, are we selling a milligram on the black market? No.
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Dr. Kelly Casperson
Is she winning a gold medal in pole vaulting on her Milligram of testosterone,
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PharmD Tara Thompson
but yet it still falls in that bucket. And that bucket requires a signature. And it's like we're not giving 50, 100, 200 milligrams to these patients. It's like a milligram, two milligrams, let
- [12:13]
Dr. Kelly Casperson
alone the vaginal dosing of it. Okay, so let's talk about that, because testosterone is one of my pet projects, but because we only have a male FDA approved product and it's a restrictive medication, so you can't give out more than 90 days at a time. If you were to write for 1/10 of a tube a day for testum or androgel of the male product, you're gonna go to a pharmacy and the pharmacist is gonna say, number one, I can't. Cause if I give you the whole box, it's greater than 90 day supply. Number two, I won't break the box, meaning split it up. Cause they'll lose money, cause they have to waste half of it. Or number three, I'll give you nine tubes, but it's gonna cost you the same amount of money because I can't lose money off this product. That's what my women are coming up against when they go into a pharmacy to get a male dose product, to try to dose it to the female dose.
- [13:04]
PharmD Tara Thompson
Right? Yeah, that's. You're exactly right on all those fronts. It, it all comes down to that. It's a business too. It's a business thing. If they break that box, they, unless they get them, you know, the reimbursement, the patient has to pay, obviously at the end of the day, but they lose that drug. And also there are restrictions in stateside pharmacy, pharmacy, stateside regulations that they see female on the profile and automatically it kicks a big red flag saying, do you want to override this? You know, is a male, FDA approved male drug. And so the pharma, a lot of pharmacists are like, oh, you can't be using this, you know, for your patient. This is for men, Insurance won't cover it for women and all this kind of thing. So you do run into a lot of issues because of that indication.
- [13:48]
Dr. Kelly Casperson
I compound my testosterone cream now because my compounding pharmacist is lovely and nice and they're not asking very personal things to my women, like, are you transitioning? What's your plan? Blah, blah, blah. And I just tell them, listen, it's going to be cash, but it's not that expensive. Certainly is cheaper than pellets. You're not going to get the runaround at the, that the big box pharmacies with the male product.
- [14:09]
PharmD Tara Thompson
Most compounding pharmacies are very competitive in their cash price. Like obviously they know the patient's paying cash. They know it's not insurance reimbursable. So I feel like prices are fair monthly. And then a lot of pharmacies will work with the patients to offer discounts on like two and three month supplies, for example, like a discounted or free shipping or something like that to where it makes it a little bit more feasible for the patient. So I think that's, I think that's fair. Plus your patient's getting, you know, your patient's getting the right dose every day. They're not trying to like separate a packet into like 100 doses. So I think there's pros and cons obviously, but yeah, it's a good way to, to do and you know you're getting the right dose.
- [14:49]
Dr. Kelly Casperson
Yeah. Let's talk quick about the allowed difference in products between a generic and a brand name. And what's coming up a lot right now is women are saying, hey, the oval progesterone doesn't work as well as the round progesterone doses. And those are two different companies that are making this oral progesterone. There's an allowed variability between generics and brand names or even different generics. Correct.
- [15:15]
PharmD Tara Thompson
In a way we have in pharmacy in general, you have your generically equivalent substitutes and legally FDA approved generics have to follow the same. I mean, you have the same. If it's supposed to be a 200 milligram progesterone in the oval or the round one, it has to be 200 milligrams in the circle one. You can't really alter strength like that. So it has to be substitutively equivalent in order to make that list to where the pharmacist can substitute something. Instead of prometrium, for example, we're going to give them this. Progesterone is funny because it is lipophilic. It's a fat dissolving drug. So it just acts differently in the body. But one of the things is that the, the oil filled caps are the appropriate dosage form because you know that the progesterone in those is fully solubilized.
- [16:10]
Dr. Kelly Casperson
Is that what the explain to people what micronize means? I think that word in front of progesterone throws them off because they're like, is that bioidentical? What's that mean?
- [16:18]
PharmD Tara Thompson
Yeah, micronize is just the size of the drug molecule. So progesterone, if you see the word progesterone spelled like that with O N e at the end, not progestin, that's different. Progesterone, that is the bioidentical exactly what your body produces, produced or has produced in the past. Progesterone. Just putting the word micronized is just. It has been through a process that breaks the drug into a smaller molecule just so it drives through the skin the gi everything better. It's better absorbed micronized wise. So you want to get. We use the big non microgyzed progesterone for more of like the pelleting and stuff like that. But. But if you're taking anything orally, topically, vaginal, you won't micronize.
- [17:05]
Dr. Kelly Casperson
The party line right now is to not use progesterone cream because it's too big of a compound to get in. You need too much of a dose. Now I see this, it's over the counter first of all on Amazon. And I always say Amazon over the counter. Buyer beware. It doesn't actually mean that's in the product. But I see some people say that my hot flash has got better on it or whatever. I think too thing can correct me on this, but this is what I tell people. Two things. Number one, placebo works for hot flashes 50% of the time in a lot of hormone studies until it doesn't and then it wears off. So that could be number one. But number two, it might help enough to help with some hormone symptoms, but it's not enough to protect the uterus. And that's why it's not recommended to do the cream. Can you break that down a little bit better?
- [17:49]
PharmD Tara Thompson
You're exactly right. So getting into the bloodstream is key. Getting systemic is key. That's where we want it to be. The topical preparations are very difficult. First there's a lot of degrees of like what bases they're in. Are they penetrable through the skin? Patients have all different types of skin, like different skin matrix there. I've seen patients in my practice that their skin doesn't absorb anything. Their skin matrix, their tight junctions are so close that there's nothing getting through anything. So those patients have to do like oral or vaginal therapy. Whereas some other patients, the same dose for someone else would get absorbed all systemically. So it really depends on the patient. It depends on what base the drug is in. Progesterone is difficult because you want that depot lipo effect. So you're needing to put it on a fatty area of their body, like the inner thighs, things like that. Statistically, the way that progesterone is built and then some of like the kinetic studies that are, you know, out there in some of these trials is that when you're comparing oral progesterone with topical progesterone, you're definitely not getting the absorption that you're getting with the oral. Like, the oral can peak in four hours, whereas the topical, you're looking at just like sort of a steady state, like maybe small increase then back to baseline. So it's a lot of technical stuff, but really oral is going to be your best route of absorption and you don't have to use such insane doses to get to the same level of efficacy.
- [19:26]
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- [19:55]
Dr. Kelly Casperson
Yeah, I mean, I still think a lot of the more like natural pass the not people who do hormones. But I don't think are students of it like, you know, you and me are. I still see a lot of progesterone cream happening. I still see a lot of women attached to their progesterone cream. I don't say it doesn't work. It's just not rec. I mean, we've got several studies saying increased risks of uterine cancer at rates that are different than systemic oral.
- [20:20]
PharmD Tara Thompson
It is different. You can do topical or transdermal progesterone. You can do vaginal progesterone too. You can get it into the body that way. You can get it systemic that way. It's just not in the C max, like the concentration max that you're striving for. So is it really helping the patient? You'd have to use a whole lot. And then of course, you know, with more drug comes more responsibility, more increased risk for side effects, more increased risk for the things you're talking about.
- [20:49]
Dr. Kelly Casperson
So interesting if you put. If you do so some people, if they get gi Upset, bloating, whatever, the progesterone. Some people call it progesterone sensitivity. Some people think it's just a huge dose of progesterone quickly with the oral micronized. If you have an opinion about that, Please share. But my question is, when you use it vaginally, then if you don't tolerate it orally, is it still going to offer like the cognitive sleep GABA benefits or is it more acting locally like uterine protection?
- [21:16]
PharmD Tara Thompson
I love this question. The only sleep benefits that you'll get from progesterone is if you use it orally. You have to use oral progesterone to get a sleep benefit because of the way that it's metabolized. It has to go through GI first pass and everything. There's a metabolite that breaks off of progesterone only when taken orally that binds to the GABA receptor. And as we all know, the GABA receptor is a very downregulating receptor. So when that metabolite binds to it after oral consumption, that's what causes the sort of downregulating the sleep, the calm. So for women who are having issues or men having issues, sleeping oral progesterone at night is a great alternative if they need the progesterone. If you use it topically, vaginally, sublingually, sublingual progesterone is also actually has really great absorption. If you look into that later on, we can, we can have a whole other podcast about this. But sublingual progesterone, those aren't going to get you that metabolite that breaks off. So you don't see the sleep benefits with those. So no.
- [22:20]
Dr. Kelly Casperson
So let's say I have a woman and she's just like, I can't handle the oral micronized progesterone. Let's say it's not because she's too sleepy, but she gets bloated or she just says, ah, I'm progesterone intolerant. Would you compound an Extended Release 1? I know it not available in this, this country. I think it's available in India. The extended release progesterone. Or would you change more to like a sublingual to like get it into her? Well, better than a cream. But like it's not going to give her that oral GI side effects.
- [22:48]
PharmD Tara Thompson
You could certainly do a twice daily progesterone if you. It kind of starts to leave the body orally about 8 to 12 hours. Not leave the body, but not, not have the clinical efficacy at about 8 to 12 hours it starts to head back down to baseline. So you could do an ex. Most of the progesterone oral that I've built in my pharmacy is extended release. It's formulated with a Particular filler in the capsule that almost forms like a gel matrix around the active drug after it gets into their stomach and gi. So it almost forms like a protective gel coat and then it slow that way it's slowly. Your body breaks it down slowly or over time it kind of chips away at that gel matrix and it just makes the progesterone last a bit longer in the body. So I would try that just to maybe see if that helps with some of the GI issues or the bloating or whatnot. But that's probably more due to like the actual levels of, of hormones in her body, I would think, like if she's. Progesterone naturally bloats people sometimes if it's not balanced correctly with estrogen. But an extended release isn't a bad idea. And it's not called extended release. It's just built in a certain formulation that like makes it last over 24 hours versus over 12.
- [24:03]
Dr. Kelly Casperson
What's it called? How do you, how do you get it?
- [24:05]
PharmD Tara Thompson
The, the filler that is in There is called E4M and it's basically like a methyl cellulose matrix that it's a powder, but once it touches water it sort of makes that little gel capsule around the active ingredients that are active that you kind of want to like encapsulate. So it's E4M is the technical name. I don't know but you would just say like a Progesterone capsule in E4M filler.
- [24:31]
Dr. Kelly Casperson
Are you, when you are doing it, is it because people are intolerant to the oral micronized or are they wanting like the more mellow anti anxiety mood during the daytime too? So they just want it to last long. What are the reasons you're making those?
- [24:44]
PharmD Tara Thompson
I don't see a whole lot of intolerance to oral progesterone, honestly. Unless it's just sort of like a annoying side effect that they kind of want to try to avoid. I would put all patients on the extended release one, whether or not they have any.
- [24:57]
Dr. Kelly Casperson
Just because you want the benefits 24, 24 hours.
- [25:00]
PharmD Tara Thompson
Yeah, and we want to. And you know, we want them to get the best possible outcomes from the medication. We don't want it to hit their system super fast in four hours and then leave in the next four. So you know, it just spreading it out over time and making that a 24 hour dosage form is more beneficial for just steady state levels. You don't get all those peaks and troughs which might be what's making them feel so Horrible. All hitting their system at the same time.
- [25:25]
Dr. Kelly Casperson
I think India has one. I was like. Because I was reading research on it and I'm like, where was this studied?
- [25:31]
PharmD Tara Thompson
That would make sense? I mean, India, Australia, they have such like, progressive. I see some stuff over there, like sublingual sildenafil in Australia, and I'm like, why don't we have that here?
- [25:41]
Dr. Kelly Casperson
We have a sublingual dissolvable PDE5 inhibitor. It's not. It's not. It's not sildenafil, but it's incredibly expensive.
- [25:49]
PharmD Tara Thompson
Oh, gosh. Well, sildenafil is like such a cheap drug. Like, why can't we just make that one?
- [25:53]
Dr. Kelly Casperson
Like, yeah, you could probably compound it. I had never thought to compound it.
- [25:58]
PharmD Tara Thompson
We compound it, but there's no FDA approved version on the market.
- [26:00]
Dr. Kelly Casperson
And I'm like, no, there is in America.
- [26:03]
PharmD Tara Thompson
Oh, sildenafil. Sublingual.
- [26:05]
Dr. Kelly Casperson
And it's not sildenafil, but it's a PDE5. I never prescribe it because insurance doesn't cover it.
- [26:10]
PharmD Tara Thompson
I'm just like, why? Why not the sildenafil though, or the tadalafil? Like, how convenient would that be for our patients?
- [26:17]
Dr. Kelly Casperson
Yeah, you might not be able to. You can't patent somebody else's drug just by changing the formula, can you? That's probably why it doesn't exist.
- [26:26]
PharmD Tara Thompson
Oh, so somebody already has a patent on those generics.
- [26:29]
Dr. Kelly Casperson
Well, yeah, but if it's generic, there's no money in it. We digress. I hope people are interested in our mental masturbation. About business, politics and pharmacology. What's a trochee? Why does it have a stupid name again?
- [26:43]
PharmD Tara Thompson
Politics. Can we call it a lozenge? Can we call it a gummy? It's a buccal dosage form. It's almost like a sublingual dosage form, but it's more like a. If you think like of a lawsuit, like a cough, like a cough drop or a lozenge. It's like that. It's almost like a. It's a solid dosage form that you just stick between your gums and your cheek in the buccal pouch and just let it dissolve over time. There's a lot of capillary blood vessels there that can take drug in and get it going into systemic circulation. So.
- [27:16]
Dr. Kelly Casperson
So it's not. Is it considered not oral then? Cause you're not putting it through first pass metabolism. I mean, it's kind of like transvaginal.
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PharmD Tara Thompson
It is. It is very similar. It's it's called buccal. It's called buccal dosage form.
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Dr. Kelly Casperson
It's. Okay. So officially, we're calling it a buccal dosage form.
- [27:33]
PharmD Tara Thompson
That is what it's called because you. You call it the area that it. It sits in.
- [27:38]
Dr. Kelly Casperson
So it's. It's unique. Me trying to make it something else is actually incorrect.
- [27:42]
PharmD Tara Thompson
I like that you're. I like where your head is going. But transdermal would be on the skin. Transvaginal, you know, buccal. Buccal. Buccal pouch. Sublingual. Sublingual space.
- [27:52]
Dr. Kelly Casperson
So why so many troches again?
- [27:55]
PharmD Tara Thompson
I think it's just trying to get that drug delivered into a way that's convenient for the patient that makes sense for the patient. We don't have data on a lot of stuff, but the way that the mechanism works and like, how the drug. You got to look at the PK of the drug. Pharmacokinetics, absorption, distribution, metabolism elimination. If you can get it into a space and get it absorbed properly there, it's a viable route if you're trying to get that medication into the system. So it's just another way to keep your patients compliant. I'm guessing.
- [28:26]
Dr. Kelly Casperson
Why do a testosterone troche instead of a compounded testosterone cream?
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PharmD Tara Thompson
I'm not quite sure.
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Dr. Kelly Casperson
I would.
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PharmD Tara Thompson
I would pick transdermal.
- [28:35]
Dr. Kelly Casperson
Okay. It's very popular on the west coast over here.
- [28:39]
PharmD Tara Thompson
I would pick transdermal preparations for testosterone over. Over any type of, like in the mouth. Oral absorption topically for testosterone has been studied, and it's very effective route of administration for testosterone just because of the
- [28:55]
Dr. Kelly Casperson
nature of the drug, especially for female doses, where you don't have to get a huge amount in. It can be more challenging when you're trying to get a Testosterone up to 800.
- [29:02]
PharmD Tara Thompson
Absolutely. And we know testosterone can pass through the skin especially. It loves alcohol. It loves alcohol gel. So, I mean, putting it in there is a way. There's other bases that it can go in. It just has better data, and I know that it can get better absorption just because of studies and seeing levels and things like that, transdermally or topically on the skin than in the mouth. So, like oral testosterone, for example, if you actually swallowed it, it's like 3% bioavailable. Like, you don't even get any of the drug that you're putting in your body. So when I see oral testosterone gets a little cringey to me. I'm like, oral testosterone, the new.
- [29:38]
Dr. Kelly Casperson
I mean, the. The brand name ones that are lymphatically processed. They don't go through your liver. So those are good. Those are good to go. But they're like advanced pharmacokinetics. I agree. We should not be doing oral testosterone unless it's the ones that are lymphatically metabolized. So they're not going through the liver. Because there's three brands on the market currently for men that are oral testosterone and safe because they don't go through the liver.
- [30:04]
PharmD Tara Thompson
Right. But women aren't. Women aren't taking those. And they're like 200 and something milligrams a day or twice a day. I think.
- [30:12]
Dr. Kelly Casperson
Yeah, they're for our needle phobes. Okay. Yeah. Because to me, I'm like, I don't. Where's. Where are all the papers on the trochees? So I can understand this better. Troche versus transdermal is very, very interesting to me.
- [30:24]
PharmD Tara Thompson
For those, I'm thinking they're probably extrapolating off of sublingual data, like sublingual drop data or sublingual troche or rapidly dissolve tablet data. Because the buccal data, I'm not sure that I've really seen that. I think it's just using that drug's mechanism and knowing that it can be absorbed buccally is how they're getting it through.
- [30:48]
Dr. Kelly Casperson
Got it.
- [30:49]
The concern of starting on estrogen and it messing with thyroid and needing your thyroid to be redosed is that only with oral estrogen preparations.
- [30:59]
PharmD Tara Thompson
You know, if you're taking a thyroid medication orally and you get started on HRT orally or an estrogen orally. Thyroid interacts with everything. Just because of the nature of the drug hormone. I would definitely separate them by several hours. You have to separate thyroid anyways, as thyroid takers and listening know, just separating it from food, separating it from, you know, it should be the first thing you do in the morning when you wake up and separate it 30 minutes to an hour from anything else. I would do the same with any medic. Other medications that you're taking, including hormones. But even if it wasn't an oral estrogen, even if it was a not vaginal, I'm talking about like systemic estrogens. But anytime you're changing your hormones in general in your body, everything is connected. So you think about the triad. There's the sex hormones like testosterone, estrogen, dhea, preg, everything on the steroid hormone cascade, that's a piece of the triangle. Your thyroid is a piece of the triangle. And then your adrenals are a piece of the triangle. Anytime you're changing a piece of that, a corner of that triangle, it's going to skew and affect the other piece of it. So I wouldn't say like we need to change thyroid medication today when we start this estrogen, but we do need to monitor it over time and just watch those levels because there may be slight adjustments that need to be made. Oral or transdermal or buccal or whatever dosage form you're using.
- [32:29]
Dr. Kelly Casperson
Perfect. Okay, good. So here's something I see popularly, because it's cheap, is women using the Androgel testosterone pump. It kind of comes in that like plastic pump jar. It's a testosterone 1.62% pump and they'll titrate it to once a week or every three days. And my question for you is like that product, it has like a peak and a trough. And if you're trying to get a less of a one pump out, first of all, that's a problem. But number two, if you separate it by days, like you're going back to baseline and then redosing like. Am I accurate in thinking that Androgel is not a steady state testosterone delivery mechanism?
- [33:14]
PharmD Tara Thompson
It will not get steady state if you're trying to dose female every other day or every three days. I mean, testosterone is certainly a daily application for men and women. So you would have to do it every day. If you're trying to get a certain amount out of the pump, I don't know, dab or dot or whatever you want to call it, you would need to do that consistently every day. And I mean even like, even as far as to say like the same time every single day because you don't want to hit those peaks and troughs as as much as possible. That's just gonna cause mood swings and issues and energy here, but not energy here. And definitely keep it at a daily dose if you want to keep systemic, like good steady state levels for patients and. But there are patients, you know, who just want like I just need it like on Wednesdays or something. It might give them that initial surge of maybe just some energy or libido or whatnot. But probably not over time. Definitely. I would, I would say yeah.
- [34:18]
Dr. Kelly Casperson
Okay. Thanks for confirming my. I'm like, just cause it's cheap doesn't mean that's the best option for you. Who is getting injectable estrogen? Do many people. I mean I see it used, but I've just like with so many other options that aren't injectable, what would the benefit of injecting your estrogen be.
- [34:39]
PharmD Tara Thompson
So there are certain estrogens that when particular esters are added to them, it does increase the half life of that molecule. So I guess a benefit that they're looking at would be, would depend on the half life. But the once weekly dosing or the every three day, every other day, twice a week dosing or something like that would probably be the benefit that they're looking for. I have seen it mixed with testosterone in men and women who are looking for that testosterone dose. The estrogen is already in there with it. And yeah, that's a weekly or bi weekly injectable. So I think it has to do with perhaps a convenience factor of getting to steady state and staying there. Yep. I love it.
- [35:26]
Dr. Kelly Casperson
I mean, there's so many different ways to do this. Like, that's my. The theme. As she shakes her head on the podcast, I'm like, I'm thinking, you know, in my new practice, I'm like, I literally want to have like a laminated menu. You know, like the fancy restaurants with like the heavy menus where you're just like. And then you could inject it and then you can put your estrogen with your testosterone in your injectable.
- [35:53]
PharmD Tara Thompson
What do you want to. Like, I have, I have docs call me all the time and they're like, teach me HRT right now. And I'm like, like, first of all, I'm like, where do I start? Like, what do you want to filter by? Do you want to filter by disease state? Do you want to filter by drug? Do you want to filter by dosage form? Like, we have to start somewhere. But there's so many ways to skin the cat that like, you really just have to narrow it down to like, what exactly are you looking for? Like, are you like, oh, I just want to get, I just want to get drug in the body. I'm like, you know, there's just so many different ways to skin it. So it's kind of like you have to. It's like an elephant that you're slowly like chipping away on.
- [36:31]
Dr. Kelly Casperson
Yeah. Just because it's how I did it. Of like, if you want to truly be an expert at hormones, you have to get into it and just get. Keep reading and reading and trying and reading and then trying and then asking questions of like, it isn't just one course or one conversation with the pharmacist or, or what. And you know, that's why the, the hope for women is like, you know, the women who are like, I tried hormones. It didn't work for me. My belief is that's never true. There's so many different ways to try. Most women will give up before the
- [37:04]
PharmD Tara Thompson
options wear out, especially if they're, if they're, if they need the hormones, if they're off balance or. I feel really inclined to educate patients who are like, oh, I'm allergic to that medicine, or like, I'm allergic to progesterone or I'm allergic to estrogen. I'm like, well, probably not the actual drug, but maybe the base is what the problem is, you know.
- [37:27]
Dr. Kelly Casperson
So I see that a lot with the vaginal estrogen. The shelf stable prescription products have some things that are irritating in them.
- [37:35]
PharmD Tara Thompson
Definitely, yeah. And then even when you get into like I had a question yesterday that was like, can I use the oral diazepam to be inserted vaginally for my vaginismus or pelvic floor patients? And I'm like, technically you can do that. However, that drug wasn't meant to be. Tablets aren't meant to go vaginally. So how do we know that like that's appropriately getting absorbed, that the ph is right, that you're not messing up other flora or anything that else that's going on down there? I mean, how do we know that all that dose is getting into the, you know, so there's just like, you have to debunk a little bit, but then be like there's better ways to do it. I think like we can get this in an appropriate way to the patient to achieve what you're looking for. It's just you have to think outside the box a little bit. I think that's why I love like being on this side of pharmacy, because you do get to kind of the
- [38:29]
Dr. Kelly Casperson
compounding pharmacists are the, like the, they're the people who think they're also the creative ones. Is that the same with. Because some people have suggested, because the brand name Intrarosa Vaginal dhea, which is a lovely product, is very expensive and that we should just use over the counter supplemental DHEA because it's a supplement in our country and we should put that in the vagina. What are your thoughts about that?
- [38:55]
PharmD Tara Thompson
It wasn't formulated to go there. So we can't guarantee that there's going to be that clinical efficacy using a dosage form that's not meant for the vaginal area. So using the intrarosa, using their particular preparation, the way that it's formulated has been specifically designed for the vaginal route. So they know how it's getting absorbed, how it's melting or dissolving. The timing that's involved, the correct dosing. If you're looking for a different dose of the DHEA or the prosterone vaginally, you could get that compounded. I wouldn't go get a supplement and just tell the patient to pop it in. I mean, that's not. You don't want to start messing with the vaginal floor, the microbiome, because that can cause a whole new slew of problems. Oh God.
- [39:41]
Dr. Kelly Casperson
A cycle of despair is what it can cause. Loading DOSE ON VAGINAL ESTROGEN I don't do it because I think people are atrophic and they get a big systemic dose and they get systemic. And then I get phone calls. I found in my. Trying to look this up, going way back, way back. Who created the loading dose? I think it's not necessary. But do you know why the loading dose exists?
- [40:05]
PharmD Tara Thompson
I can't figure out the loading dose except that in the beginning, in your mind, you think the patient needs a lot of estrogen because they're atrophic. And you're like, I need to replenish that area. I need to get that all built back up and get it healthy again. When in reality you're gonna get there anyways. Just using the daily, like standard dosing, the loading dose isn't necessary. Plus, like once you saturate the receptors like that extra is not giving any
- [40:32]
Dr. Kelly Casperson
added benefit and it's goopy AF and they hate it. But in my research looking it up, the past loading doses were actually higher than the current loading dose. So the current like standard loading dose is one gram a day times two weeks, one gram twice a week for life. Previous loading doses were 2 to 4 grams a day times two weeks than 1 to 2 grams twice a week.
- [40:59]
PharmD Tara Thompson
That's a lot of cream. Like a gram is like a quarter size dollop. Four of those. It takes time. It's not going to be an overnight. I have to try to tell patients, like, it's not going to be an overnight. Probably change that. You're going to see like tomorrow, like it's going to take time. Sticking with your regimen, staying compliant with it, you're going to help build up that vaginal mucosa and get, get the estrogen replenished in that area as it should be and help with lubrication pools and all of that.
- [41:28]
Dr. Kelly Casperson
We have to wrap it up and I would like you to come back because people have a million questions, but anything that I missed that you want people to know about hormones, sex, med, compounding, troches, putting things in your vagina.
- [41:42]
PharmD Tara Thompson
Yeah, yeah, definitely a lot of that going on. But no, the I think just the one takeaway is that and, and I tell this to my pharmacy students and residents and things is that we should never turn a patient away or think that the patient think that they're at the end of the road, like there's no other options for them. That is just something I'm like, there is always an option to get access to the medications that you need. Maybe your insurance doesn't pay for it, maybe it's $5,000 a month, I don't know. But there's other options. Like we can Compounding is a great option. It's highly regulated by the states using FDA registered facilities for all of our active ingredients. I mean it is something that it gives your patient an option that they otherwise may not have at the regular retail or commercial pharmacy and in the event of a drug shortage. So something to keep in the back of your mind if you feel like you're at the end of the road or you don't have any other options. It would be something to consider for sure. And finding a compounding pharmacist that can help you.
- [42:46]
Dr. Kelly Casperson
Oh, that's a great way to end. Thank you so much for joining us today.
- [42:51]
PharmD Tara Thompson
I had fun. Thank you for having me and I really appreciate it. And yeah, let's. Let's rendezvous again sometime.
- [42:57]
Dr. Kelly Casperson
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 Masterclass 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 in 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.