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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. All right, welcome to author Q and A for the menopause moment. See also you are not broken, which was the first book, which is also very beautiful, but not that. But now this book, the you're not broken, just won an award. So now, now I'm an award winning author, which just seems so much more fun to say. Just talking before we hit record about how the menopause moment is a bigger baby. I clearly had more carbs going on when I ate this baby, when I made this baby than when I made the you are not broken baby. The you're not broken, like literally was inside of me and just needed to come out. So like with before the. This is 190 pages hard cover. You are not broken. And then this one was. Was more research, but also like a lot besides like the facts, which I got down accurately as possible, was also in me. And this was again, this is hardcover before the references. Hold on. 313 pages. It's a bigger baby, but there's a lot to know. This took a. The menopause moment took a whole nother day of audio recording than the you are not broken one did, which was, which was amazing. So how the menopause moment happened is the publisher was talking to me about my first one and they were like, will you write another sex book? And I said, yeah, but I would really like to write a menopause book. And this was, this was probably two, two to three years ago now. And the way that the menopause world's moving, that was a long time ago. So it was, was Mary. I'm not Even sure if Dr. Haver's book was out. It might have just come out. So, like that happened. I'm not even sure that one was out when I was like, I want to write about menopause. And now it's like boom, boom, boom, Fast and furious about menopause. And this book really is. I think the 101s about menopause have been written. They're amazing. How to menopause by Tamson. Dr. Mary Claire Haver's book. Amazing. This is the 201. This is the, like, here's the facts, ma', am, tell me again why you don't want to be on hormones. And throughout the book, there have, there has been some people who've read it. So far, I don't tell you, you should be on hormones. I basically question you if you choose not to because it's, you know, 150 pages of how hormones are good for you. And I truly believe, like, I see the people. This is what's interesting. I don't think I say this in my book. I see the people. And I had this happen literally last week in my clinic. I see the people who run into my clinic in sheer panic with a diagnosis of osteoporosis or severe mood issues or whatever it might be, and they ask if it's too late. Like, that happens all the time. And so to me, I'm like, know what's gonna happen? It's not 100% gonna happen. Some people swing through life and they do great, but, like, know what's gonna happen to make the best decisions to try to prevent those things. Because I see you when you come barreling into my clinic asking if it's too late and will hormones help. And I'm like, if I can help all those 50 year olds before they're 61, like, we can still help the 61 year olds. But I don't want to see you in panic down the road. So, like, that's what this is. This is like education for not running into my office and panic 10 years post menopause and be like, is it too late? Because now we, we can no longer say we don't have the information. Like, that said, we have 80 million women over the age 40 in America alone. It's a lot of people to educate. So it's fair if there's somebody five years from now who says they don't know. But we're trying to do like, we're publishing books, we have podcasts. Right? We're trying to do our best to be like, we have enough data now. This is like my soapbox of the week is people are like, we need more women's. Women's healthcare research. Agreed. I will never disagree with that. And we have a lot of research. It's just not getting out. It's just not being utilized. It's just not known. Like, we have a lot of randomized control trials. We have tons of huge observational data studies. We have tons of insurance database claims. Like, there is a lot of research. Stop saying there's no research. It's. The research is just behind paywalls and not being, you know, trickled down to the real world. And so that's what this book is. This book is, we got data. You just need to know it so then you can make the best decision for yourself. Somebody said, I'm a great mix of information and entertainment. Oh, you noticed? Why do you think I'm doing so well? It's like, if you can communicate well and you know something, the world's your oyster, my friend. If you can communicate well and you know a lot about something, you get paid to be on stages. It's very, very fun. Why isn't everyone taught this in med school? Great question. I don't know if you notice, but women are 50% of the population. This is my second soapbox, soapbox of the week. Somebody speaking of stages, Somebody contacted me because they've got a big stage, and they're like, we're really. We're really getting into women's health this year. And I got so. I think I just get so pissed at this point because I'm like, you realize it's 50 of the world. Like, women's health is not a niche. Can we stop being like, look at us, we're getting into women's health. Like, it's 50 of the world. It's human health. Stop calling it women's health. It's human health. I'm sick of it. I'm sick of us being a niche. And like, oh, if we've got time or money for the women's health, that program will get on it. It's like this. 50% of the population. Knock it off. Okay, so going back to the. Why isn't this taught in med school? So 2002 was the women's Health Initiative explosion. This was a randomized placebo controlled trial started in 1993 to the tune of $250 million back then, aka a billion dollars now. And in 2002, they came out and they said, we stopped the. And again, these are synthetic medications that are rarely used these days, but we stopped the synthetic estrogen, synthetic progestin trial because we didn't like the amount of breast cancer. Basically, we didn't like the amount of breast cancer that was coming out of it. The media took that and exploded and said, hormones cause breast cancer. The data says. And this data. This is what's so effing crazy about this. That paper was published in 2002, and it is free online. You can go look at the 2002 Women's Health Initiative. Rousseau is the lead author. It's published in jama. It is free online. And if you took the time to read that, which I don't expect most lay people to do, but physicians certainly can, it says that it became close to statistical significance now anybody who knows anything about research says when you say close to statistical significance, it means not statistically significant. So we basically we took 80% of women off their hormones and stopped teaching hormones in medical school for two decades after. After close to statistical significance. If you're not pissed, you're not paying attention. What was the most surprising thing I learned in putting this book together? Or what was. I would ask you guys if, if you have a really good question, type it in the Q and A and not the chat because there's like 150 of you in the chat. Somebody asked, I gotta go find it. What was the most surprising thing I may have learned in putting this book together or what you felt? No one was talking about that. I included, I think this is in the book, but I can't remember. But I like reread it today and got feisty about it. So I'm going to use that as my answer. How many people know that women on hormone therapy, or pet therapy as we call it now have a 50% decreased risk of pancreatic cancer? And I re looked this up today because I'm reading the new textbook on precision hormone therapy which for any clinician, I highly recommend it. It's gold, but it's, it's pretty advanced. Like you should probably know what you're doing first and then read it. But they're talking about the impact of estradiol on pancreatic beta islet cells. And I was like, huh? You know, they say pancreatic cancer is because of metabolic syndrome. And like you're, if you're metabolically unhealthy, you're more likely to get pancreatic cancer. And so if estradiol helps metabolic syndrome and estradiol helps decrease the risk of diabetes, doesn't it make sense that estradiol would also decrease the risk of pancreatic cancer? So I looked that up today and there's actually multiple studies on it and it's anywhere from 40 to 60% decreased risk of pancreatic cancer. Now I fully acknowledge that pancreatic cancer is rare, but pancreatic cancer is mostly deadly and it's awful. And so to me I'm like, dude, we talk about. Most people don't know that being on hormones after menopause decreases your risk of colon cancer by about 30%. That's well published studies. But the decreases your risk of pancreatic cancer by like 50% is pretty shocking. And I don't think many people know that. So I hope that, I think that's one of the more profound things. The other thing I put in the book to answer the question more thoroughly is my mom and my grandma both have macular degeneration. So basically like you start losing your peripheral vision and it's, it's more women have it than men. It happens the more old you get. And I'm like, well, I wonder if hormone therapy decreases that risk. And there are a couple of studies that being on hormones because hormones are really good for the eyes. Testosterone actually is very good for the eyes. And so there are several studies showing that hormone therapy decreases the risk of macular degeneration. And I'm like, well that's something that is in my family. And like that sounds shitty. So it's pretty, pretty huge. This show is sponsored by MIDI Health. When we experience perimenopause, menopause and midlife issues, we feel unheard, dismissed and unserved by the traditional healthcare industry. And here's the powerful truth. It's time for a change. It's time for miti. MITI is not just a healthcare provider. It's a women's telehealth clinic founded and supported by world class leaders in women's health. MIDI is leading the way by providing expert personalized insurance covered virtual healthcare for women in midlife, empowering us to thrive and experience our second act with vitality and confidence. Ready to feel your best and write your second act script? Visit joinmidi.com today to book your personalized insurance covered virtual visit. That's joinmitti.com MIDI the Care Women deserve. Now back to the show. That wasn't a book that I mentioned regarding estrogen and pancreatic cancer. That's multiple studies. I show that. And I can't remember if I put that in my book or not. I remember. But yeah, it's like something that like, you know, pancreatic cancer is so devastating and so deadly but it's still very rare. We don't go around saying like hormones decrease pancreatic cancer, but they do buy a lot. So okay. Oh, somebody's holding the screening of the M Factor in their community in the next few months. I am so excited for you. There is a prequel of the M Factor coming up March 2026. It's going to be on PBS again and it's called M Factor 2.0 before the pause. And so it's all about perimenopause. So it's before the menopause. So it's a prequel which is super adorable. And they were in her, they were in my clinic last week filming me. So we'll see if I make the cut. Can women in their 70s benefit from starting hormone therapy? Yeah, Tamson Fadal did that one too. Yes, there's always a benefit. Everybody's benefit and risk is different. So as people who pre ordered the menopause moment on September 1st, you will all get a link for the five. I did five summer schools this summer. Let's see if I can name them all. Perimenopause, general urinary syndrome of menopause, women's sexual health, testosterone and mitool for hormones starting greater than 10 years post menopause. That's all fine. So they're for sale for people who want to watch those videos, but they will be free to anybody who pre ordered because it's my big thank you for you and you should watch that video because I did a whole hour on safety of hormone therapy greater than 10 years post menopause. And the too long didn't read is for transdermal estradiol, testosterone, vaginal estrogen and oral micronized progesterone. The risk of starting late is very, very small and there's usually a benefit to people. What'd somebody say? I'm 72, started six weeks ago on estradiol and progesterone and vaginal estrogen and will start testosterone in six months. Look at you. I love it. Everybody else is is cheering her on in the comment section. That's awesome. All right, let's go to the Q and A's. And I'm not going to answer any individual medical advice questions just so you know, in case you were curious about that. This is not a doctor's appointment. This is general education about the book and my thoughts on menopause. What's my favorite vaginal estrogen brand to prescribe? Oh, generic estradiol, obviously. The cream. Obviously. Because I want that on your vulva. I care about your clitoris, I care about your labia. I care about that 6 o' clock spot that gets tender with intimacy. And I think the cream can best address the labia. So generic estradiol because it cream because it is the cheapest as well. Mark Cuban cost plus drugs. It's like 13 plus. What, what is it now for shipping? $5 or $7, something like that. So even if you're, even if you're insurance, your insurance will likely charge you more than the cash price. Don't get me started. I just heard this week that somebody with United Healthcare had to do a prior auth for an effing generic estradiol patch. Absolutely insane. Absolutely insane. Somebody said, I prescribe estradiol like I'm Oprah. I'm stealing that. That's very good. I'm livid that my insurance will not cover my testosterone dose for females, but will pay for my husband to have it. You should be pissed about that. That's gender bias. And for any insurance that says they're not going to do it because it's not FDA approved, ask them if they cover it for transgender care, which they should. My argument is they should cover it for everybody who wants it. But you can't pick and choose. I don't cover it if it's not FDA approved because it's not FDA approved for. For transitioning and it's not FDA approved for women. And they're only picking one of those as a reason to not cover it. And I think that is absolute bullshit. In addition, we will, in America get a female dose testosterone product probably within three years. Unless I'm wrong or the sky falls or something. Mark my word. At that point, then insurance will still not cover it because they'll come up with some other shitty reason. So good. Good news is it's pretty cheap. That's my story. I listened to Dr. Lisa Moscone on Alzheimer's and menopause. Have you listened to it? Dude, listen to everything Lisa Moscone's done. She's been on like 80 million podcasts. You have to be more specific. She speaks about women who are more than 10 years out and how the estrogen receptors are not prolific enough for estrogen to have an impact in this area. Okay, good. Good comment though. Okay, so here's what I think you're saying. Even though I didn't listen to this specific Lisa Moscone in perimenopause and early menopause, the brain is starving. The researchers term, not mine. I'm not. I'm not even being dramatic. The brain's like, what the fuck? Where's the estrogen? So the brain upregulates estrogen receptors and you could literally, like. Not that you scan people, but the amount of estrogen receptor upregulation is directly related to how symptomatic they are in menopause. Like Lisa Moscone's done. That research is fascinating. What they're saying here is over time, the brain adjusts and down regulates the estrogen receptors. So, yes, if you want estrogen's benefit on preventing dementia and all neurologic disorders, Parkinson's, multiple sclerosis, other types of dementia. Right. Well published, you need to start early. So if you start at age 72, you will get benefits from hormones. You'll always get bone benefits, you'll always get sleep benefits, you always get, you know, for people, that helps moods, you'll always get mood benefits. So don't let anybody say that there's no benefit. But you likely won't get the preventative health benefit on heart and brain like you do when you start early. So, yes, I agree with everything you said there. Is it beneficial to use estradiol on the vulva if taking systemic hormones? Yes, because again, systemic hormones is not a lot of hormones. And the genitals need some direct care and love, so it's, it's very, very common. I don't know how many times I have to say this math problem, but I'm going to keep saying it until people effing get it. So if you take systemic hormones and it raises your blood serum levels to X, right? And then you use vulva, estradiol, dhea, whatever you want to use local down in your vulva, that raises your serum estrodial. Your hormone levels zero. Okay. Systemic raises it to X. Local raises it to zero. What's X plus zero? X? Like, I can't make it any more simple than that math problem, you guys. That's like fifth grade algebra. If you, if you add skin care that doesn't add anything to your bloodstream, you can add it because it's still just X from the systemic. So I hope that somebody. Somebody filled out that equation before I even said it in the chat box. Well done, Chiba. I love it. Okay, what else? That's a good question. Okay. The more patients I see and prescribe hormones to, the more I hear someone has told them that what's mp? That MP is dangerous without a uterus. Jennifer, what's mp? As much as I educate. Oh, micron progesterone. Thank you. I should know that. No, Micron progesterone is not dangerous without a uterus. That's absolutely insane. How would the rest of your body know if you had a uterus or not? Like, seriously, it's simple math equations for most of this. How does your body know that you don't have a uterus when you swallow medroxyprogesterone or micronized progesterone? I love that. All right, there's no data to support that. Micronized progesterone is dangerous. It's literally what your body makes. It's insane. What do you say to the clinicians stuck in 2002? Just tell them the facts. Like, you can't. I'm here just to give people the facts. Like, I'm not. I, I don't care if you go on hormones at the end of the day. Like, I don't care. I care that you're educated and you know how to advocate and you get to do what's best for your body and you have body autonomy. Like, I can't. When people are like, how do you deal with the people who don't want to know? Listen, some people don't. Some people think the earth is still flat, right? Like, I'm not going to go around trying to convince them the earth is round. Like, that's their, that's their journey. All right. My doctor says she won't prescribe testosterone for anyone. Okay, you do. You might, might, might lose a lot of patience that way. Okay, So I just read a paper. I. This was. This is in the new again for, like, advanced clinicians. This is in the green book I just bought which precision hormone therapy that they looked at. Surgical menopause. I'm sorry, Bilateral oophorectomy. So surgical removal of ovaries post menopause. So it's not technically surgical menopause because you already went through menopause. But so you let's. You're done with periods. You. You don't have estrogen, and now you got your ovaries removed, which is a common scenario. Those women had more Alzheimer's disease than the women who didn't have bilateral oophorectomy. What do ovaries still make after menopause? I'll wait. What do ovaries still make after. No more periods. Yes. Testosterone. Testosterone. I think testosterone is the missing link for the dementia is multifactorial. Don't get me wrong. Like, you better be exercising. You better not be drinking alcohol. But I think testosterone is a missing link for dementia. And that paper just helps emphasize it to me of like, why does removing your ovaries after menopause put you at higher risk of dementia? Because now you make less testosterone. Best sources to share with my doctor on testosterone. I would do the international guidelines for testosterone with low sexual desire for women. That's 2019. Free online. It's excellent. Transdermal testosterone doesn't get metabolized through the liver. If you went to med school, you should know how liver metabolism works. And that transdermal stuff doesn't get filtered through the liver. It doesn't go through your hepatic circulation. So sometimes doctors need to be remembered of the things that they Were taught. I know you were taught that in medical school. Physicians. Transdermal testosterone does not impact the liver. All right. I have a whole ch. Speaking of alcohol, I have a whole chapter in the menopause moment about alcohol. It's not chapter one. I don't. I gotta. I gotta warm people up to liking me before I. So chapter 19. Alcohol is toxic. 255. Right. It doesn't. It's not until 2. 55 that I get into alcohol and talking. The paper for testosterone 2019 International Guidelines on Testosterone for Low Sexual Desire in Women. You could probably Google it. It'll pop up that way. All right, chapter 19. Alcohol is toxic. Don't drink it. Not good for you. It's a poison. It shrinks your brain. It kills gray matter and white matter, which are brain cells. Don't do it. All right. So there we go. Let's go. Oh, they're saying that the Dr. Moscone article was on Tamson's podcast. Excellent. Yeah, great. Great podcast. Okay. Is it safe to go from lowest dose estrogen patch to 0.0375 for a 65 year old who has afib and is on a blood thinner? So that's an individual medical question. I'm sure you know, but the difference between a.025 and the.0375 is not that much. In addition, any menopause hormone expert is going to know that people absorb differently, so they might need a higher dose for symptom relief. If you're on a blood thinner, you don't have any increased clot risk and the data supports that In a patch of.05 or less, there's no increased clot risk over baseline, so. Oh, this is an interesting one. Can you comment on the recommendation by some experts in the field that progesterone should always be cycled rhythmically or cycled, including postmenopause? They say that all the time. Progesterone is not physiologic and likely to negatively impact estrogen receptors, resulting in a loss of health benefits. So there's no data on that. If there's data on that, send it to me. There's no data on that. Here's the deal. Here's the deal. Physiologic arguers. Before birth control and controlled family planning, did we have 12 periods every every year? No, we were pregnant most of the time and then we were breastfeeding. So that's a low estrogen state. And then we were pregnant again and then we died. Euphoric. Following me. So for experts to say we should do what is like a normally cycling every month, period thing. That's not physiologic. That's not how we. We evolved. Right? So I think it's a very weak argument. Is anybody following me on that one? So to me, I'm like, I. I think it's a pain in the ass to cycle progesterone two weeks on, two weeks off. A lot of people forget. And also it really helps with sleep, helps a lot of people with mood. So for telling them they can't. But to use the argument of naturally cycling as the default when that's not naturally cycling is not how most people lived in the first place, that's a very weak argument. And I. And the receptor thing doesn't make any sense either. They're different receptors, so I would have to see more before I actually believe that. All right, somebody says they like their sleep too much, they're not cycling. Hell yeah, sister. Me too. Also see also, living past the age of 60 is not natural. Like, we're all here because of antibiotics, clean food, shelter, excellent, excellent medical care for trauma and for cancer. Like, don't throw natural on me. I have a whole chapter. I have a whole chapter in my book on natural. Did I name a chapter about that? I should have named a chapter fuck natural. But what did I actually name it? I think I just get into it in chapter two, which is what is menopause? That's probably where I basically destroy the grandmother hypothesis and just destroy that the word menopause is actually useful because most one third of women don't have natural periods to know if they're in menopause or not. Yeah, natural, Exactly. God. Socks aren't natural. Like wearing glasses aren't natural. Like flossing isn't natural. Like it falls apart. Clean water for the most part, once there's enough humans around. Not natural. So, like, I'm. I'm sick of it. Okay, what method for hormone testing? The best data is serum. At this point, there's more expensive ways to do it, but they're not proven to be any better. So if you want to keep making people wealthy, continue to pay them hundreds of dollars every quarter to give them your saliva and your urine. But until I see the data, serum is the best that we have right now. September is Sexual Health Awareness Month, and a key issue tied to sex worth talking about are urinary tract infections. Sex is the most common trigger for UTIs in premenopausal women, and the risk only increases during menopause as estrogen declines, your vulvovaginal tissues become thinner and more delicate. This also leads to a drop in Lactobacillus, a key protective bacterium. All these factors together lower natural defenses and increase the risk of UTIs. While vaginal estrogen is my first line therapy for menopausal women, I also recommend Jenna MD by Solve Wellness. Jenna MD defends against UTIs in a different way than vaginal estrogen does, so together they offer maximum protection. Jenna MD is also a great standalone option for premenopausal women who aren't experiencing estrogen decline. Jenna MD is clinically backed and contains the proven 36mg of soluble PAC from pure cranberry juice extract. Many of my patients take it daily, but for those whose UTIs are linked to sex, there's also a sex related dosing option. To learn more about Jenna MD, visit jennamd.com that's G-E-N-N-A-M-COM where new customers can get 20% off their first purchase and for an additional $5 off, use coupon code Dr. Kelly5. That's D, R, K E L L Y5. Providers can request patient education materials and samples by visiting jennamdhcp.com oh, somebody said I'm one who got trapped in natural. Oh, I'm so sorry. Like, most of this stuff, you guys is like one logic puzzle away from realizing reality. Somebody said doing it natural made me miserable for years. Yeah, well, I wear clothing and I wasn't born with clothing on. So not natural. All right, do I have any tips on prepping for the Menopause Society certification exam? Yeah, read their book. Read the book. It's a lot of primary care. I, I think it doesn't actually teach you how to prescribe hormones. If you want to know how to prescribe hormones, these are my top three tips. Number one, come to, I do one retreat a year. 2026 is Sedona in October. It's already booked out. It's been booked out for like six months. And I will be releasing the location and the dates for 20. Sorry, that's 2025. I will be releasing the location, the dates for 2026 this fall. Number two, Heather Hirsch's course. Heather Hirsch Academy. Great, great. Like, her intro on prescribing hormones is superb. I have a course on there for sexual health and testosterone, which people are loving. It's like 12 CMEs just for testosterone and sexual health. Basically. Like, by the end of my course, I'm like, I'm going to teach you the data so people can stop saying there's no data. And I'm going to teach you not to be afraid of this. There you go. And then number three would be Rachel Rubin has a hormone course on how to prescribe hormones, which is excellent and I love her. So the point being, the Menopause Society certification is zero proof that you actually know what you're doing in the how to prescribe hormone realm. Get it for other reasons. See you at the menopause conference. And. But actually if you want to get good education. Oh. Also. Okay, so number four would be the Harvard. Harvard has a menopause course now and it is long. It's like a freaking week. This is like how doctors are, you guys. Doctors are really good at learning for very long periods of time, basically. So the Harvard course is literally like 8 to 5pm for five days straight on the Harvard campus. I want to say it's March 2026. I forget, but I'm coming. I'm probably talking about female sexual health. I might be talking about testosterone. So that would be the four options for you for actually learning how to prescribe hormones. All right. Is there such a thing as starting hormones too early? That is a fantastic question. Probably. I mean it like hormone therapy is not a ton of hormones. And if you already have hormones, like it probably won't do much or you'll just feel like too much hormones, which can be like moodiness, breast tenderness, like it's kind of unpleasant. But I mark my word, within five years we're going to be treating per menopause a heck of a lot more. Again, proving that the word menopause is like this completely arbitrary line in the sand. There's nothing magical about a last period. Your hormones have are already changing and fluctuating for years before your last period. So I think we're going to. I and I. So I don't think perimenopause is too young. It's a moving target. Can be a little trickier. I'd say the most miserable people symptomatically are the perimenopause people, about onethird. So in my clinic, this is rough math which does not add up exactly to 100%. But I don't want to do the math. I have about a third of per menopause people, a third of women 70 years or older. The pissed boomers know who ask if age 70 is too old. And then a third of your traditional 50 to 60 year old menopause people and then about 5% men. So that did not for anybody keeping track that did not add up exactly to 100, but there you go. Estrogen dominance and HRT. Can I still use estrogen patch? So the menopause expert Zeitgey says, there's no such thing as estrogen dominance and hope. Keep listening. Don't turn off. Don't turn this off because I said that perimenopause has periods of estrogen dominance because as the ovaries trying to stay on the job, it'll shoot out a bunch of estradiol from the follicles to try to get ovulation going. It's called a loop cycle, and you can have symptoms of high estrogen. But I just. I just did a podcast with somebody this week who was like, I'm estrogen dominant. And I'm like, no, you weren't. You were estrogen dominant on that Tuesday that you got your labs drawn. But that's not a permanent thing. You cannot keep saying you're estrogen dominant when you're 80 years old. There's no estrogen. There's very little estrogen for most people. So that's my long answer. So estrogen dominance and hrt, yeah, likely you'll have high estrogen and then low estrogen, and that's. You throw the patch on. Some people just do a patch like, one week out of the month in perimenopause when they have low estrogen. So. But, yeah, estrogen dominance is. That's not a fixed state. It's not eye color. You will not have estrogen dominance forever. So stop saying that. Stop saying it like. Like you own it. All right, what are your thoughts on the new cholesterol marker as a potential to predict onset of Perry? Yeah, that's going to be very interesting. Right, so we know as hormones go down, cholesterol goes up because we're. Because the body's smart. Hear me out. The body's smart. It's trying to make hormones because the ovary is failing, so it increases cholesterol pathway. And so there is some talk about seeing, Seeing the people who are like, I have no symptoms, but my cholesterol's up all of a sudden. And I haven't done anything different with diet and exercise hormones. Most research estradiol can. Can improve lipid profiles. All right, I'm still in perimenopause. I'm using the 0.1 patch. I've been on it since June. My breasts are still tender. Yeah, play with that. Maybe it's too high. Go see your provider. Can systemic estrogen be started in perimenopause for severe joint pain and tendon popping. Even when blood work shows low normal ranges of estradiol. You guys, blood work is one day. I'm just going to say it's Tuesday. That's Tuesday. It doesn't tell you what two weeks from then on a Thursday is going to be. And that could be low estrogen state. Perimenopause is not a fixed state. It's a moving target. So to check a lab on Tuesday and then tell a woman she can't be on hormones because of that lab on Tuesday is not good medicine. That certainly is not understanding perimenopause. Right. And I would also say to that person, consider testosterone. Testosterone helps musculoskeletal aches and pains a lot. You can't do a Q A with Dr. Kelly Casperson without somebody asking this effing question. We were like completely under treating women and then. But we always have to ask, like, but is the penis okay if I'm on vaginal estrogen? Yes, the penis is okay. Just don't remember. Men have more estrogen in their body than a postmenopausal female. Men have around an estradiol of around 30. Postmenopausal women have estrad like 30 and under, 20 and under. Right. So men have estradiol. Go back to my math question. X plus 0 equals X. Vaginal estrades 0. So they've done the study though, because we're really worried about penises. So we've actually put money into this study. Not me personally, probably my tax dollars, but they had a woman insert estradiol cream, then have penetrative intercourse with a penis, and then they measured the penis owner's estradiol like eight hours later or something like that. And it slow. It increased it a little bit, but not above normal male values. So my party line is don't use it as a sexual lubricant. But if you happen to use your vaginal estradiol cream and then the mood strikes, you don't have to say no. Unless you want to say no, Then say no. But you don't have to say no to protect the penis from anything. Okay. I love that people love that so much. Okay, how much will the book talk about helping the man in your life or ways to communicate to your man about menopause and symptoms, etc. Great question. Let me find the chapter for you. Chapter 11, Part 4, Special Considerations for Hormones. Chapter 11, how to Talk to men in Midlife. It's a very short chapter. You basically say, listen, cut your Testicles off. See how you feel. That's what menopause is. This is a biologic issue. Support me through it. I need you to hold space for me. We're going to get through this together. Communication is key. That's the end of the chapter is very, very short. All right. What is the book that physicians should read that I just mentioned? Well, the advanced one that just came out is called Prince. It's Principles of Precision Hormone Therapy. I think it's a green cover. It just came out. It's excellent. I'm about 25 of the way through it, and I'm planning on interviewing the editor for my podcast when I'm done with it. Yeah, it's excellent. But it's not a beginner. It's not a. It's not. A physician who's new to prescribing it does not tell you. I haven't gotten to the point where it tells you how to do it yet. It might be in there, but this is really like, here's all the data to tell you how important hormones are for you again. Okay. Somebody said, I told my husband to cut his balls off because I'm in surgical menopause and see how he feels. He thinks I don't need all the hormones. Yeah, yeah, yeah. No, I don't actually cut people's balls off. You will make the national news, probably. And I don't want my name associated with that at all. It's a. It's a metaphor. We're all adults here. But ovaries make hormones. Testicles make hormones. When we remove them, especially surgically, then they make zero hormones. Hormones help cells function. Hormones help mitochondria function. Hormones help brains function. End of story. No. Lorraine Bobbitt chopped off a penis. You guys not. Not testicles. Oh, you guys are awesome. Okay, I am seven years post menopause, but will be 60 next week. I watched the FDA panel. Thank you very much. If you haven't watched that, go watch it. It's awesome. And it seems under 60 is the benchmark for HR. I'm confused. Is it less than 10 years or under 60, or is it both very confusing? Thanks for clarifying. It's not any of it. It's just the sooner you start it, the better you're going to get health benefits from it. There's no absolute cutoff. Anybody who says there's an absolute cutoff is not quoting the literature. It's. It's. It's an ar. It's an arbitrary place where they divided the women's health Initiative age groups. But again, go to my website and read sorry and watch my video on am I too old for hormones. I break down the data. So there's three. There's three main things we're afraid of when starting older people on systemic estradiol, cardiovascular disease, clot, stroke and dementia. Right, fair. I address all of those things with and the actual risk with transdermal estradiol and then you get to make your decision. Why can't women stay on birth control pills forever? Great question. Well, they're a synthetic medication. So if your body doesn't need them, why put them into your body? It's nearly impossible to get pregnant after the age of 55 physiologically because of ovarian failure. And they're actually high dose birth control pills are much higher dose hormone than pet therapy or progesterone, estrogen, testosterone, hormone therapy. So why would you want to take that if you don't need it to not have the pregnancy thing in addition, because they're a high dose synthetic hormone, your risk of blood clot goes up with age. So that's why this is a real good story about Bronx and his dad Ryan, real United Airlines customers. We were returning home and one of the flight attendants asked Bronx if he wanted to see the flight deck and meet Kath and Andrew. I got to sit in the driver's seat. I grew up in an aviation family and seeing Bronx kind of reminded me of myself when I was that age. That's Andrew, a real United pilot. These small interactions can shape a kid's future. It felt like I was the captain. Allowing my son to see the flight deck will stick with us forever. That's how good leads the way do is estriol as effective as estradiol? Probably not. Estrad is your body's most biologically active hormone. So give it, give it that. There won't be a. There likely will not be a head to head trial because these are all generic and nobody's doing the research. If so estrogen and breast cancer. Yes, read it. I have a whole chapter in the book the menopause moment on breast cancer. The too long didn't read of that is see a trained clinician. Breast cancer is an. Breast cancer is an ass. What I mean by that is it comes back late. A decent amount of it comes back years and years and years late. And so you're here suffering from low hormone symptoms and then everybody says you can't be on hormones because your breast cancer might come back. And even if you don't take hormones, breast Cancer does stupid. Like coming back super late. So you have to understand that correlation doesn't equal causation. And you have to understand that there's benefits to hormones and there is not significant data that being on hormones significantly increases death from breast cancer. So you need to understand that. Chapter 13, breast cancer, page 177. So you need to understand that and that it's not black and white. And here's the other thing about breast cancer. Everybody's got a different type of. We just call it all breast cancer. Is it, you know, is it invasive into your lymph nodes? Is it metastatic? Is it dcis? Is it triple negative? Right? So to save. To say, a huge umbrella of breast cancer. Breast cancer can't. Or breast cancer can. It's too big of a circus, right? So you need to understand your, your unique recurrence risk and decide what's best for you. So I hope that, I hope that helped. All right, I have all the symptoms associated with lack of hrt. Frozen shoulder, bladder, aching joints, ear ringing. I've been on hormones since I had my hysterectomy over 10 years ago. Are there other things I should be exploring or looking into that may help? As I know a lot of these are caused by lack of hormones. I'm on estrogen, testosterone, progesterone. I would want to know what your serum levels are. Are you on a high enough dose? That would be the first thing that I'd be looking at. There's a large population of women who feel that they are not eligible for therapy because they are past the 10 year rule. They have osteopenia or porosis, hot flashes, night sweats, joint pain, etc. Do you touch on this in your new book? I do. In the menopause moment. I think I named the book the Boomers should be Pissed. Because that's like, that's an older podcast episode of mine now, but it's called the Boomer should be Pissed. And it was. It's a very popular podcast episode. And then they listen to it and they're like, we are pissed. Thank you very much. What is it? Part three, Hormone Deep Dive, Chapter nine. Why the Boomer should be Pissed. The timing hypothesis. So that's page 135. Let's see what I say. Will I start with a William Shakespeare quote? How good is that? Better three hours too soon than a minute too late. William Shakespeare. There you go. Yeah, I have a whole chapter for those people. Get the book, read it, send, buy it to give it to your aunt Gen X and I'm pissed. I went to so many doctors. Yeah, yeah. No, the. The difference is. And I'm speaking very broadly, and I hate to speak for an entire generation, it's hardly fair. But Gen X is actually doing something about it. So the boomers raised us properly. How about that? My mom's 76. She's pissed. Yeah, yeah, yeah. It's a. It's a. It's a disgrace what we did to women and the way we controlled women is to keep them in fear. What's the best. It's amazing, like, how many people I asked this question to. They don't know the answer, but somebody. So I asked. I asked this to somebody yesterday. I'm like, what's the best way to control women? And they said, legislate against them. And I'm like, o. O. That might be better than my answer. But my answer is make them afraid. Keep them afraid. Books. Book In Australia is September 18th. It's only two days later than America. You can hardly get to Australia on a boat in two days from America. Yeah, I'll legislate the fear. That's exactly right. Gen X is getting it done. Don't mess with the X. I love that. The term pet is new to me. I'm used to HRT. When did it first appear? We made it up. 20 hormone experts had a zoom call and we said, we're effing sick of the word menopause because last, menopause means. And I talk about this in my book, menopause means the end of natural periods. That's not what. You're not having symptoms because of your period stopped. You're having symptoms because of ovarian failure. So to actually call it menopause is actually wrong. Menopause is a. The end of your periods is actually just a symptom of what's happening, which is ovarian failure or living longer than your ovaries, however you want to talk about that. And the other problem with menopause therapy or HRT is that it excludes the perimenopause people and mo. And when most people think about hrt, they think about estrogen. They don't think about testosterone. And so pet is actually very, very inclusive to the people and the types. And to really stop having your last period be meaningful whatsoever. This episode is brought to you by Progressive Insurance. Do you ever find yourself playing the budgeting game? Well, with the name your price tool from Progressive, you can find options that fit your budget and potentially lower your bills. Try it@progressive.com Progressive Casualty Insurance Company and affiliates. Price and coverage match limited by state law. Not available in all states. That's a good question. Where can we find how to best apply vaginal estrogen? Is there an applicator? It makes me horny and I like it. Good job. Attend anonymous attendee. Probably the best place to stay is anonymous. When you say vaginal estrogen makes you horny, but vaginal estrogen makes a lot of like it. It improves blood flow. Like, it really does improve arousal for many people. And it also decreases pain, which makes sex more pleasurable. So, yeah, it comes with an applicator. A lot of people don't like the applicator, so they use their finger. Do I discuss T prescribing in my book? You better believe. I discussed T prescribing in my book and you better believe. Do you know me? T is the first hormone I discuss in this book because I'm sick of estrogen getting all the effing attention. Our bodies make four times the amount of testosterone than estrogen, my friends. Four times the amount. Why are we talking about estrogen all the time? Okay, part three. Hormone deep dive. Sorry. Part two, Meet the Sex Hormones. Chapter four, Testosterone the forgotten Quarterback Pet. Pet hormones or pet therapy means either precision endocrine therapy or progesterone estrogen. Testosterone. The other reason we renamed it is because I'm so effing sick of the word sex hormones. Although I say that in my book Meet the Sex Hormones. And I'm active a lot on Instagram, and you can hardly say sex on Instagram without getting flagged or shadow banned or whatever Instagram does. So, like, one day I was just like, I'm so sick of the word sex hormones. And the other thing that the word sex hormones does is it diminishes the importance of these hormones because you're like, oh, that's just for sex. That's like extra. And especially women in the doctor's office like, you don't. We don't really need that. Right? And it diminishes the fact that these are metabolic hormones, neuro hormones, bone hormones, muscle hormones, cancer decreasing hormones. So I was. I'm like, I just got pissed about the word sex and wanted to re change it. All right, yes, somebody said I say reproductive hormones, but yeah, it's so much more than reproductive hormones. Right? Like, we spend 40 years of our life past the age of reproduction, unnaturally, I might add. So when I talk about that in my book, I'm like, don't let anybody tell you that you being without Hormones is the natural thing because you living to 84 is actually not natural on a global scale as a population. Even when fact factoring in infant mortality. And I talk about that in my book. All right. Ooh. Somebody says they have a colorcoded diagram of where you put the Estrace cream. I love that. That is very cool. All right. I'm doing better on systemic and local hormones, but still have a lot of discomfort with all feminine products. Tampons, pads, period underwear, cups. It's all bad. Expecting to cycle for several years. Still, what can be done? See an expert if it's. If you don't like the products. Iud, uterine ablation, maybe you've got pelvic floor issues that are making your pelvis react to those things. So pelvic floor physical therapist. Lots of options with that. Just started. Testosterone. But my doctor has really scared me about using too much in transference. Listen, you're probably using a female dose testosterone so you can't give a guy any because they have 10 times the dose. So that's not a problem. Wash your hands before you touch small animals and small humans. That's where I put most of my testosterone. Just lateral thigh and then wash your hands. So the worry is overblown. Women have been using testosterone for 80 years. We're gonna be okay. This is, this is not new. All right, do my understanding correctly that Estrad patch is a gold standard for administration of estrogen by and large. It's not that people who don't do that, like some people can't tolerate the patch, some people need higher doses, blah, blah, blah. But it's kind of the gold standard of like you're nor, you know, your normal Barbie, right. You're like stereotypical post menopausal person. Estrogen patch is. It's just so low risk and it tends to be so cheap. But it's not gold standard in the fact that like somebody's doing something super bad. Like there's options for a reason. And yes, systemic estrogen is FDA approved for the prevention of osteoporosis. Okay. Does your book cover with the numbers to look for on lab results and recommended treatment? Not specifically, because any expert will tell you lab results are only so meaningful. It doesn't tell you how many estrogen receptors you have. It doesn't tell you how sensitive you are to an estrogen product. And we don't have the lab value for dementia. Prevention is probably going to be a different lab value than osteoporosis prevention, et cetera, et cetera. We don't have that yet, but we really are turning from we don't need to check labs to. Yes, check labs. The other reason is this book is being sold internationally and US numbers are different than Europe numbers and UK numbers and Australia numbers. So did that answer that question? So yeah, that's why I did. Why, that's why I wasn't like, you need an estradiol of 50. No, but I think where we are moving with estradiol and again these are American numbers is between 60 and like 100 to 150 for bone protection. All right, what supplements do I recommend for women in menopause transition? Great for you to ask. I have an entire chapter in my book on supplements and this, the chapter following the supplement chapter is called and adjacent. Because you guys are all spending way too much money on supplements, I'll tell you that much. Okay, where is it? Chapter 20. This is part six. Lifestyle changes aren't scary. Chapter 20 is more tools, Non hormonal medications and supplements. And then chapter 21 is and adjacent non hormonal solutions. So see, my personality is in this book. This is why it's the 2.0. Creatine, man. Creatine is just, it's cheap. I was like, I'm always like, it's cheap, it's inexpensive. Those are the, those are the same things. It's cheap, it's inexpensive, great for muscle, great for brain. Another paper just came out to like today looking at cognitive performance and creatine. Yeah. Order the book for your doctor. The Fiat and the other supplements that I think have good data. Vitamin D, magnesium, omega 3 fiber. If you're not getting a fiber. But don't be so focused. Here's what I want to say. Don't drink alcohol, effing exercise, prioritize your sleep, get on some hormones. Supplements are the ex. Like supplements are like the candles on top of the cake. Like not necessary on most cakes, but nice to have but the cake. But the candles don't make the cake. Right. So I hope that, hope that has worked and like, you know, if the supplement works great for you, awesome. But a lot of supplements don't have a lot of data. Does birth control pill provide same bone, brain, etc benefits as pet therapy? Maybe, but they're two different populations. One's a population of like people who are trying not to get pregnant and then the other is a population of like older people that don't have any pregnancy risk. And birth control pills have increased. Birth control pills are high dose synthetic medications. The only reason we use Them is to prevent pregnancy and heavy bleeding. And we use them off label for, like, skin care. Why? Because it blocks your effing hormones. Right. So it is birth control pills and pet therapy really is a little apples and oranges. Don't think they're all saying everything's hormones is not being accurate in this. Creatine daily. Yeah, creatine daily is what it's looking like. You don't just need to do it when you're exercising. All right, we're going to do one more. That's the name of the book. Principles of Precision Hormone Therapy editor Frank Mavis Jarvis. God. One hour later, we finally get the whole day. Thank you, Jamie. Thank you for googling that. What is your response to women in perimenopause who asked for their estrogen progesterone levels checked after telling them how these levels fluctuate so much? Well, you explain things to them and then you check their labs because that's their blood and their money and they feel validated. Like, it is not. I was volunteering in Uganda at the end of medical school, and a Rotary club had donated an X ray machine to the clinic because it's a hell of a lot easier to, like, donate things that cost money than, like, actual humans and resources, right? So people came in and they wanted an X ray for everything. Chest pain, X ray, you know, whatever. What else did I see a lot of syphilis, X ray, malaria, X ray. They just wanted an X ray for everything. And the long story short, is it validated? They just wanted it for validation. Yep. X ray looks great. Oh, great. Nice. So trip people's labs, do it, but explain to them that it's a moving target in perimenopause. Heaven forbid somebody gets told they're estrogen dominant. And now when they're 82, they're gonna be like, I'm estrogen dominant. And you're like, no, you're not. But, like, check their labs, validate their questions, get a baseline, see where they are. Like, there's. Why we are gatekeeping over labs is beyond me. And furthermore is what's funding these massive online companies that like, check a thousand shit tons of labs for a grand, and then people, like, don't have any doctors to go to anyways. But it's like, people are curious. It's their body. They should have access to the their labs. I just had a insurance company not cover. It was like, vitamin D, testosterone, and like, hemoglobin A1C or something. Like, not crazy. These are not crazy, ridiculous labs. And they didn't like my diagnosis of menopause. And I'm like, listen, I can't control what insurance is going to cover or not, but if you want the labs checked, I'm happy to order labs for you. All right, you guys, I love you. That's an hour, not enough time for sure. 99 plus questions. I love it. So come back, you guys. We have two of these, so the next one is in September. And thank you so much. I mean, we're here right now because you guys care and because you bought the book. And hopefully you bought the book for your doctor and you bought the book for your sister and all of that. But we're. I'm. You're here because you care. I'm here because I care. And I truly know that this is how we change the world. We get women feeling better so they can go out and change the world. However, that looks like they do it in a million different ways. Hormones are simply hormones. Healthy living, stopping alcohol, all the things are simply a way to get you feeling good enough so you can go out and change the world in your unique way. And that's why I'm doing it. All right, guys, I love you. And until next time, you are NOT Broken. Hey friends, if you love the you are Not Broken podcast, please show me your support by liking, subscribing and sharing it with someone you care about. Your support helps more people find this empowering information for courses, clinic info, and all things midlife mastery. Head over to kellycaspersonmd.com and don't forget, you can grab your copy of you are Not Broken. Stop shooting all over your sex life at Barnes and Noble, Amazon, or ask your local book bookstore to order it for you and a friend. While you're there, make sure to pre order my upcoming book, Menopause, Science, Hormones and Mindset for optimal longevity. Coming September 16, 2025 Medical Disclaimer the youe Are Not Broken podcast, Instagram and content created by Dr. Kelly Casperson is presented solely for general information, education and entertainment purposes. The use of information on this podcast or materials linked from this podcast or website is at the user's own risk. It is not intended as a substitute for the advice of a physician, professional coach, psychotherapist, or other qualified professional. This podcast does not diagnose or treat you. Users should not disregard or delay in obtaining medical advice for any medical or mental health condition they may have and should seek the assistance of their healthcare professionals for any such conditions. And as always, I got you, I got your back and you are not broken. Thanks for listening.