HRT After 40: The TRUTH About Hormone Therapy & The WHI Study

Today I'm joined by Dr. Suzanne Gilberg, a double board certified physician with nearly 30 years of clinical experience. She's an OB GYN with a board certification in integrative and holistic medicine and is also trained in Ayurveda. She's the founder and author of the Menopause Bootcamp. We're going to dive into what you should know about the menopause transition, hormone replacement therapy, how to be an advocate for yourself and your doctor's appointments and, and the major flaws of the Women's Health Initiative. Dr. Gilberg, one of the biggest misconceptions within menopause is that it's just hot flashes. Can you explain why that is so far from the truth?

I mean. Well, first of all, let me talk about hot flashes because let's not disparage the hot flash. The hot flash is a harbinger to your cardio metabolic and your brain health. So it is not just an inconvenience, it is a red flag. So let me just say that. But yeah, menopause is a full body transition. It is a transition from a reproductive state. Whether or not you wanted to reproduce, you did reproduce, your body doesn't have feelings about any of this. Okay? Ovaries make very specific hormones and they make them in very specific ways and very specific amounts at very specific times. And so when you do your puberty transition, you now are using those eggs that are in your ovaries, you're making a very specific sequence of estrogen and progesterone related to your brain hormones. You do that for many decades, then you stop doing that. You do it very unpredictably for maybe 10 years and then you just stop. And the thing about it is that loss of estrogen and progesterone have an impact on every cell in your body. Because, Brigid, you have estrogen receptors in every cell in your body. Your bones, your brain, your heart, your liver, your gut. Yes, your vagina, everywhere. Your lungs, you have them in your lungs. So you have them in your. You have them in your eustachian tubes, which is why people get it to yours. So it's not just hot flashes. It's not just inconvenience. It is a transition in terms of your longevity and your health.

So helpful. And I think too that, like, it highlights how because of having the estrogen receptors and in every area of your body, that the symptoms can vary for every single woman, which sometimes makes it difficult to identify with this idea that, you know, historically thinking, oh, it's just hot flashes for Menopause, where women don't understand why they start to have the frozen shoulder or the anxiety or the joint pain or the disruption in their sleep that you see earlier on. Is that right?

Correct. Absolutely correct. You know, something like 15% of women will start to have genitourinary syndrome of menopause symptoms. So urinary symptoms, you know, feeling like you have to pee all the time, incontinence, burning, thinking that they have a UTI bladder infection and they don't. In addition to actual vaginal dryness, whether it's vulvar dryness and discomfort, discomfort or pain with sex, they'll have that well in advance of changes in their menstrual cycle. It's not a huge number, but it's a big enough number. 15% of us, so. So again, people may be thinking, oh, I'm having, why am I having so many yeast infections and self treating or why I'm calling in the doctor Friday afternoon, you know, getting a bladder infection medication. They need vaginal estrogen, you know, so it's really important for people to understand the impacts that they may experience. And you really nailed it. Sure, there are lots of data sets and large amounts of women who have very similar experiences, but we each are unique individuals. My Ayurvedic training really helps me understand this better. In Ayurveda and the ancient healing tradition of India, we don't see every single person the same way. We're very uniquely constituted and we formulate our understanding of that person and how we can bring that person into a state of balance and health based on that person specifically. Obviously we all have a human experience and women who have ovaries are going to have this experience. We're all going to have this experience, but it has a unique flavor for each one of us.

And I love that you have such a strong foundation as a obgyn, as a, you know, conventional doctor, but then also layered in the Ayurveda, the integrative approach, like being able to weave it all together in the way that best serves the patient.

Yeah, I feel very, very grateful to my curiosity and my training. I've been in the conventional space for my entire career. But I also very early on, for my own purposes, sought out more traditional indigenous holistic medicine. For a variety of reasons. I felt like there was something missing. I'm like, I always have to have a project. So some of it was my own boredom. I don't know how a new doctor with two small children was bored, but apparently my ADHD was in high drive. Right. And I really just did it for my own curiosity and really found something so beautiful and resonant that has been a through line through my entire career and really supported my capacity to serve my patients and to understand people with that integrated knowledge. I mean, the best of integrative medicine is taking conventional, empiric, materialistic, science driven, that modern version of science driven, and bringing in that those more traditional ideas about how we are a whole being, how we are part of a larger system, the community, nature, and then, you know, really looking at other modalities that we can use that are evidence based, but also are based in the evidence of thousands of years of wisdom traditions. I mean, I could go on, I always knew this. But I'm working on my next book, which is on botanical and plant based medicine. And what I'm really finding doesn't really surprise me. But talking to various integrative and also traditional holistic practitioners from a lot of different traditions, there is so much through line like the idea of nature being a part of who we are and us being a part of nature, the idea of communal health systems, the idea of spirituality, the idea that we interact with the environment through the plants and always have. That's where 30% of our pharmaceuticals come from. Where do people think that pharma just dropped in the 20th century? And boom, we got medicine. We've been practicing medicine the whole time we've been on the planet.

Yeah, that's such a good point.

Yeah, yeah.

And even I would say, because integrative practitioners in my experience were so advanced as far as, like, recommending hormone replacement therapy and advocating for the, the, you know, importance of thinking about women's hormones and the gut microbiome. And some of these things that I feel like have now become very popular in the last few years with more women and more doctors like you and many of the ob gyns that you're in the menopause with that are bringing this information to life. But I feel like the integrative practitioners like yourself were the ones who have been saying this all along.

Well, I mean, here's the thing. I was trained. My medical training ended. I graduated OBGYN residency from Cedars Sinai Medical center in 2000. 2000. The Women's Health Initiative was published or halted in 2002. So I was trained in an era where hormones were not a dirty word and we didn't have the best mom pause training. That's definitely true. But I distinctly remember learning about hormone therapy and the power of hormone therapy. And then there was Like a record scratch. So the thing is, in conventional medicine, we were using hormone therapy. What happened, I think, was that the integrative community was able to. Because the otherness, honestly, and especially I want you to imagine 25 years ago, the integrative medical community, it was a different community. It wasn't, you know, there wasn't an Internet that everybody was on. People weren't talking about it as much. It was more niche, it was a little more outlier. But you're right, there were a lot of people who are more progressive and it was okay to look at things with a critical eye and say, well, wait, this has been working. We have data to support it. And, and why are we all freaking out now and stopping something that we know is a powerful giver of life and healthcare opportunity? I mean, this is a really big conversation. But I think that they were able to hold their own in the integrative community. But also, I want you to understand that when I came out of my residency, I was very secretive about studying ayurveda. I was very quiet about doing integrative medicine because it was considered weird. And I certainly, especially as a young female professional, wasn't trying to distinguish myself in any way, shape or form. I really wasn't. I needed to be more excellent than everybody else because I was a girl. And unfortunately, I don't think that's changed that much. I didn't have a menopausy around me. You know, I didn't have necessarily people, colleagues that were hype women all the time. And I had needed to be careful. What happened is the patients heard and found out and they flocked to me because they were like, she listens, of course, right?

Because of the desperate need for women to feel heard by their providers. And then the second that you as a provider does that, you know, it's like everyone goes to you.

Well, and it's very validating for everybody. And also my patients taught me a ton, of course. Oh, my God. I just really, I didn't do anything that, that crazy, in my opinion. I just, like I said, I. I was taught to listen and I did listen. I knew what I knew. I knew what I didn't know. Some of them knew. I mean, I remember, like, this is going to sound so stupid now, but I remember my first patient who was pregnant, who was vegan. Okay, this is like how old I am and me saying, you know, I don't know much about it, but you, you are healthy, so you know more about being a vegan than I do. So let's work with this together and make sure that you're getting what you need. Like, why? What else was I going to do?

Be like, you're.

You can't be vegan. Like, what? First of all, she wasn't going to listen, and that's just lame medicine. Like, how about just learning about veganism? Which I did. And then it was like, oh, she's the one who's cool with the vegan. I mean, it was really that basic. It sounds so crazy. In 2025.

I completely understand because I went to a functional medicine doctor 20 years ago, and so I was like a patient around that time. And I understand, like, even just as a patient, where I try to explain to people that I work with now where it's like, Amazon didn't exist. Whole Foods didn't exist. Like supplement manufacturers. You had to go to these, like, you know, very earthy stores that carried the supplements that you would go to to to get them, that my parents were going to. To get ours. And even, like, there has been such an enormous shift in the last 10 years because I think back to even being at the Cleveland Clinic center for Functional Medicine and some of the things that you're talking about where in 2014, 2015, like, the second that we opened the center, it was like we had 2,000 people on our wait list because it was like, for people felt heard, and they were like, let me tell all my friends that, that they're going to hear me, that they're going to listen to me, that they're not going to dismiss me. And for so many women who the functional medicine doctors were prescribing the hormones for that then were literally like, arguing with the other doctors in the other areas of the Cleveland Clinic that were like, no, you can't have them on hormones. It's going to increase cancer risk. And then the functional medicine doctors try and provide the evidence for, like, why this is so important, how beneficial it's been and how it's clearly helping the person. And even just then it was so than it is today. It's. We're so fortunate to have the Internet, to have the access to the information for people like even just medicine, to be embracing integrative and functional medicine like never before because of really, I think it's a grassroots effort of it being driven by women who are like, this is what it feels like to be seen. And we need more of this in medicine.

Absolutely. It's 100% grassroots. And I say this often, but, you know, I have been fortunate to practice in an era of great change and a lot of strides. And I have watched women's health open up in many, many areas. And it's, you know, it's the zeitgeist. It's a lot of different things that come to play. But anytime there's been a big shift in how we care for women, it has come from collaboration with the community. And honestly, it's usually that the women come to us and say, look, this is how it's going, and it's not going well. We don't like it. Labor and delivery practices changing, having birthing balls and aromatherapy and one of the biggest labor and delivery units in the country. Okay, you know, understanding that doulas, labor support decreases C section rates and increases good outcomes in labor. That came from collaboration in the community because the patients were like, hey, guys, we think you're trying to do the right thing, but actually, we don't feel heard and seen. Can we figure this out together? Breastfeeding in public, sexual health, period. Products, talking, saying the word vagina out loud, knowing that there's a difference between the vulva and vagina. Okay? Now, menopause, perimenopause, healthy aging, all of that has come from, in my opinion, the grassroots level and people demanding better. I love my organizations. I appreciate the leadership and the research that they support, but not one of these things has been from the top down. Sorry, folks, it's not. It's grassroots always.

No, it. Absolutely. I completely agree. I was. I was actually at dinner a few weeks ago with some of the obgyns that you're friends with, and I said to them, how is it that when you are going to a doctor? Because I still, like, cannot understand this for as long as I've been in this profession. Is it because people will say it's just the lack of education around menopause or around nutrition, nutrition that's provided in medical school. And I was saying to them, it's not just the lack of information, because, like, you're saying your patients are coming to you. When you are seeing so many women with osteoporosis every single day, and then you have one patient who's reversing her osteoporosis, and you're telling her that, like, doing the vibe plate and osteo strong and in hormone replacement therapy and other things are just, like, a waste of her money. Instead of getting curious around, why is she the only person that's improving the outcome? I'm like, how is it that. That. That is the common mindset around physicians where they're just so dismissive when they see something working right in front of them that they could lean into and learn more from. And they were like, at the top down, they're like trying to break you into just like thinking inside the box. And if you step out of that thinking, you're like the ugly duck that's, oh, you're punished.

It's so I just wrote a substack on this. And can I tell you, I have been thinking about this since I was in medical school. Because I got to medical school, I'm gonna sideline you a little bit. So I was out of, out of college for four years before I went to medical school. Of course, at the time, I thought I was so old. I mean, I was 26, but I was older, substantially older than most of my classmates. There was a very small group of us that were older students, right? I wasn't really old, but I'd had some life experience and I was super idealistic. I'd worked at the Haight Ashbury Free Clinic, you know, and lived in San Francisco. And I did research at ucsf. And I was like, oh, I'm going to save the world, right? And then I was at LA County Hospital in the 90s when the murder rate in Los Angeles was at its highest. It was just crazy town. It was the most amazing experience. However, I was like, what? Who are these people? Everybody there was super smart, super committed. You don't go to medical school because you don't care. Okay? This is really you. There's much better way to spend your time unless you really, really, really, really are compelled to do it. However, they were so freaking lockstep. And I was like, these are not my people. I was so excited. I'm going to meet my people. I'm telling you, I did not meet my people in medical school. I did not. They were wonderful people. Many of them are amazing physicians to this day. Not my people. I was shocked because the way you get into med school is you follow the rules. The way you get through your medical training is you do not stick a nose hair out of liner. You're busted, you're humiliated. And also you're told it's life or death, you're going to kill somebody. And then I went into a surgical field where two people are your patient. So, wow. It's just fear based. It's super military. And then you come out and you're supposed to be thought leaders, and you're supposed to be critical thinking leaders. And you're what? That's not real. That's not how it works. So that's, that's. You can read my substack if you really want to hear how I feel about it. Although now you know. But I think that's right. And I think the other big, big, big issue, the elephant in the room is the reimbursement system. And if you need to keep your practice going, not get in trouble, do the right thing, follow the guidelines and make money. When you are being paid by insurance companies who are robbing all of us blind and providing zero service, they, I'm going to say it out loud, they're a cartel as far as I'm concerned. You don't have to agree. I own my own. I'm accountable for my words. I'm kind of in a spicy mood.

Today, but I can tell, I love it.

And your doctor needs to see. I was seeing before I moved into my own membership based practice. 27 patients a day and I was on the low end in my practice. So how are we expecting doctors to do all the screening, check all the boxes and then lean in to learning about nutrition or hormone therapy or understanding why the Women's Health Initiative maybe doesn't apply to a 47 year old. You know, it's really unfair. It's unfair to our clinicians and it's unfair for us to be constantly pointing the finger at them because they are suffering and physicians specifically are leaving the field in droves. This is not good. We already have clinician and specifically physician shortages. So it's a big problem and part of my work is devoted to that. But if people are looking for great care in midlife, they're gonna need to really collaborate with their practitioner and come in not guns blazing, but come in as like, hey, let's work together. What's the best way for us to do this? Can I make a separate appointment to talk about what's going on with my body? Cause it doesn't feel right and I'm not sure what's going on. You know, that kind of thing. Like, let's, let's try to collaborate because most of your doctors, that's really all they want. They want to help you. But yeah, they don't have the education, but they also don't have the time to have the education and they don't have the time to provide the education that you require and you deserve. It's not, it's not good.

Yeah, it's not good. I completely agree. And you're right. It's definitely a, it's a top down Issue, I think is what you're alluding to, that it's not an individual person. But sometimes it does feel extremely frustrating when the individual person across the table from you is like dismissing you and telling you that the, that what you're trying, that you're fine and that your labs look normal. And you know, gaslighting women, I feel like especially has happened in. And so many women have gone into, especially women that are 50 and up have gone into menopause specifically completely blind because, you know, they're like having, there's a few conversations happening. They're, they're not talking about the symptoms that they're having with their friends, their doctors are dismissing them when they're going into the doctor's office and they're, you know, the doctors weren't even trained extensively in nutrition or menopause or other things. And so I feel like that has contributed to less of the conversation or the advocacy for women's health because of that, that top down issue. Would you agree?

100%. And I think that is what is. That's why the Internet has been magical. And I have a lot of theories about how this whole menopause explosion occurred. And I think some of it was everybody was online because of the lockdown. People who weren't previously online very much were literally living online. I do think there was a lot of awakening around me too, where women were like, whoa, whoa, whoa, wait a second, I've been dismissed. I've been gaslit. Like all of a sudden there's like a light bulb went on because we're so used to being people pleasing and we don't even know. Even if you don't identify as a people pleaser. And I want you to turn back the clock six years, right? Cause everybody knows if they're a people pleaser and everybody knows their attachment style now. But six years ago, people didn't know that. And I think for a lot of us, they're like, whoa, what is going on? And now we're all online all day, every and a bunch of us are Gen X and we're like, whoa, I feel like shit, you know, like, what's happening? I'd been working in this area for quite some time prior to that. And actually the wild thing is that I was starting to really, I was seeing in Los Angeles in my community a lack of education and awareness. And I knew like, I can't provide this education in an office visit and these people need to know. And so I created Menopause Bootcamp in order to just like Teach people. And I thought I was educating people. And I mean, I was, but what I was doing was creating community and helping people destigmatize and normalize. And this all started happening, you know, and I was like, oh, this is a book. And I sold the book and you know, I wrote the book proposal. And then all of a sudden the lockdown happened and everybody was online talking. So it was so many different cultural forces that came to bear around us. And then we started saying things out loud that we previously were afraid or thought we were the only one. And then we started hearing all these stories, right? So women were like, okay, when I go to the office, the doctor is like not taking me seriously, patting me on the head, because that's a real thing. I'm not saying that that doesn't happen. I'm just saying as a physician, I feel a responsibility to also explain. Aside from the physicians, of course. And again, now we talked a little bit about the toxicity in which we are trained. You know, the three most powerful words I have ever said to a patient and for whatever reason I had the constitution and fortitude to do it, is, I don't know, I don't know. It's okay to not know everything a hundred percent. And then you learn with your patient. Then you're like, well, you know what, let me look into it and I'm going to portal message you or call you or whatever it is. Most of us are motivated by what our patients need, even when we're overwhelmed. So I think all of these things swirled together and came together and women all of a sudden were like, okay, you're not listening to me. But these 100,000 women on this account are having the same experience I am. And oh my gosh, this doctor gets it and she seems to know what she's talking about. And then it just kind of exploded. And it's been really fascinating. I think it's been amazing. I think it's another demonstration of grassroots and you know, from sitting at whatever meal you had with some of my colleagues and friends that it has not gone over well in some of the organizations for a number of reasons. And I, I don't know them personally well enough to psychologize them, but I think it's about control and power and fear and not trusting themselves enough to trust their patients. Like, I don't know, is everybody online a predator? That's ridiculous. And women are grown ass adults.

Because what you're alluding to is that there's a little bit of a division within the I Don't know if you just would say the ob GYN community, where there's.

I think it's advocates community in general. Okay.

Medical community in general, where there's advocates like you and your friends like Dr. Mary Claire Haver and Dr. Kelly Casperson and Dr. Rachel Rubin, who have been such big voices in this space. But there. I actually didn't realize until having this dinner that you're talking about that there is opposition coming from the other side. Can you explain, like, what the pushback would be? Because before I heard this, I was like, why would anyone be upset? This seems like it's like net positive for every woman.

Yeah. I mean, I'm about to make myself never on a committee at the Menopause Society. Okay. But whatever. I'm a member still. I mean, I was at the Menopause Society meeting this year. First of all, the last two years is sold out. And I believe their membership has doubled in the last two years. And if you don't think that's a direct result of some of the people that you just named, come on. And if they don't think that either, you're right. Why would they be mad at that? It's bringing professionals into the society to learn. People are thirsty to hear. What is the science? How can we better take care of these women? How can we better do our jobs? It's just so weird. But there's this. It's framed as concern. And it happened again, even with the FDA removal of the black box warning. Well, again, how is that a bad thing? I mean, it didn't remove the warning. It took the black box away. There's still warnings going to be on the package. It's just not going to be inappropriate. And just like every other medicine, it requires counseling. I mean, what. It's just so cuckoo balls. But there's this panic, like, oh, my God, everybody's going to be confused and they're going to be getting the wrong medicine and we can't trust our colleagues to prescribe properly. And like. Like what? Like 4% of women in this country are using hormone therapy for menopause right now. That's down from over 40% in the late 90s before the women's Health Initiative. And I want to just point out that in the decades that we stopped prescribing hormone therapy, breast cancer did not go down. It went up. We don't know exactly why that is, but it's definitely not from taking hormone therapy. That's just like. Yeah, that's an observational study. And it's a not a study, and I didn't publish it. That's just like the data. It's there. So it's some crazy stuff. And I do, I do think that it's motivated, partly out of concern, but it's a very paternalistic perspective on how women should be cared for and how women should approach their care. And it's coming from women, too. And there are older men, older white men who are not doing that, by the way, or saying that. So it's just this. They've adopted this narrative of we have to be in control if it's not coming from us. And it wasn't published as a guideline, which, by the way. So for your listeners, guidelines are not laws. They're guidelines. They're guardrails. We all have to do lifelong learning as physicians. We have to do maintenance of certification. I have to take a quiz, read articles, and take a quiz every damn year in order to maintain my board certification. I read things that are the new literature. I mean, they provide the literature that they want us to read. Every single one of those things is not going to be something that you do or I do. Everything isn't codified as law. This is not legal profession. It's the practice of medicine. And we have to be nimble. We have to go back to what we were talking about. Look at the person across the desk, the table from us. What's, what's her personal history? What are her health goals? What's her family history? What's her lifestyle? What are her desires? What kind of a person is she? What is she willing to do? And now we're going to come up with a plan again. If you have seven minutes to do this, it's going to be really hard to do that. And if you don't really know your patients and they don't feel like they can come to you and be honest, it's real hard to do this. But that's actually what medicine, what health, what healing is, and weaponizing terms like wellness optimization. It's counterproductive. It's not helping us do our jobs. So I think that there needs to be more willingness to have an open dialogue, not create a witch hunt environment where, again, if you've stepped outside of the bounds, like you've decided that you're not, you're reading the publications, but you're not going to publish in the traditional sense, but you're going to go directly to the people and educate them. Why is that? Why is that bad?

Yeah, it's very confusing. So what you're saying is that certain people in medicine are looking down upon terms like wellness and optimization and other things is what is what you're saying, and that there's a lot of strange things happening. And so for people that are totally, like, not following and are maybe like, new to just learning about menopause and trying to understand, understand what this increased awareness has done, why it wasn't there before. Can you. Let's start there, actually, and then let's get into the Women's Health Initiative, because I do want to. For anyone that maybe, like, has never heard of the Women's Health Initiative before and doesn't understand how hormones were used and then taken away and then added back, can you walk us through, like, exactly why there has not been a lot of conversations around menopause prior to this with the lack of education and research and those things, and then the deficiencies of the Women's Health Initiative, what the conclusions were, the impact that that's had on the field of women's health?

Yeah, well, actually, the Women's Health Initiative has had a freezing effect on research in the area. So part of the reason that there hasn't been a lot of conversation is that it's when we had the Women's Health Initiative. I'm putting the cart before the horse. But I think it's important for people to understand if we're not continuing to research and learn new things about ovarian function and hormone receptor function and the big, you know, the big ticket health risks as we age, all humans, men and women, you know, brain health, dementia, specifically cardiometabolic health. So, you know, heart disease and diabetes, you know, insulin resistance related diseases and bone health and osteoporosis. I mean, I'm really like, categorizing them largely, right. If we don't, if we don't, if we can't look at how aging in women, which is menopause, impacts that, and we can't look at how hormone therapy, replacing the hormones that we've lost or have diminished, then we can't. We're not really having much of a conversation at all. Right. And there's 20 something years, 25 years where we weren't, we weren't doing it, we weren't funding it. So that's, that's a big problem. I think the other thing is that, you know, OBGYN specifically, and obgyns are not the only doctors that take care of women. Well, first of all, let's start there. Women's health has been siloed into obgyn Right. As if all the other doctors aren't seeing women and their bodies don't function a little bit differently because we're biologically different. So there's a problem there. Like, women are not little men. You've heard this a million times. There's all sorts of data and stats out there. A very large number, for instance, of cardiologists don't feel comfortable with looking at women's heart disease, which is different often than men's heart disease, like a large number. So we've got big problems there. Like, why is women's health all like in OB gyn? Because everybody's touching women. Women's health specialists. It's a four year subspecialty and we are doing everything from obstetrics, so learning how to care for the patient while she's pregnant, while she's trying to get pregnant during the pregnancy itself. Delivery, which is a huge amount of work right there. We do pelvic surgery, we take care of cancer. You know, there are subspecialties where you do extra training, you know, maybe three, four years extra. A lot of. But there's a lot to squeeze into four years. Right. And I think because menopause, as I mentioned earlier, it's really not reimbursed. Menopause care is time sensitive and time related. It's. It's speaking to somebody. It's not procedure oriented. So billing codes are different. So there's just. I just think there's been a no will to put attention into that area. Older women. Are older women prized in this culture? No, we're not. So there's just like, it's so complicated. And I'm not saying that anybody is doing any of this overtly. I mean, there's some people who are, but in general, people just are not aware of their biases either. And so it all comes to play. So now you have the Women's Health initiative and it was just the perfect storm of, okay, well, we'll just gonna put women over a certain age over here. Like, I don't know what. There wasn't a thought process. It's been very reactive, not proactive, which I think is different for you because you have been in the integrative space for a long time. I mean, you're a person living on the planet, so it shouldn't surprise you, but that's the opposite. Like, there's a lot of proactive. The attitude and the philosophy in integrative medicine and a functional medicine is prevention. You know, maintenance and sustaining a function is a very different outlook. In conventional medicine, it's like diagnose and treat. And I'll tell you a story. When I was making the change that I made in my practice toward the end of last year, one of my patients. And I've been coaching my patients through menopause and how to talk and advocate for themselves with their other physicians for years because I knew they were going to need that support. And cardiometabolic health is a huge thing because it's the number one killer of women. I was just tired of my patients not getting screened, not having things picked up. And one of my patients came to me and said, look, I'm breaking up with my primary care doc. I had this really. I've been having a hard time because I've been going and saying, hey, can we look at this? Can we test that? What about this? Da, da, da, da, da. And she was getting frustrated. And then she finally said to me, and I really respected her for saying this. I mean, she literally said the quiet part out loud. She said, listen, this is what she said to. This is the primary care doc to the patient woman about 53. She said, I feel like you're looking for healthcare. We provide medical care. In other words, when you get your diabetes, we're happy to treat it. And I was just like. And seen.

Yeah. I mean, that's the way that all of the entire medical structure is built. You can't even actually, through Medicare, get a dietitian appointment covered until you have diagnosed type 2 diabetes. It's like, no, we don't care about that. When you have pre diabetes, we're gonna wait until. Have, like, worsened pancreatic function and worsened insulin resistance in order for us to. To give you anything that will help you.

Right. So you can imagine if you're 37 and you're like, my period's a little bit weird, or my PMS has gotten really out of control, or here's another big black box one. Maybe you're 41 and you just had a baby and. And you're feeling like crap. This is globally. And you come in and really, you're in early perimenopause. Sure, you're postpartum, but you're also in early perimenopause. So stuff that's really, like, mushy and not so easy to unwind, and it's going to take conversation time, maybe some lab work, really understanding. You can imagine how that's not going to get addressed.

Yeah, not going to get addressed. And then you're going to need to feel like the Silly one. Okay, so with the Women's health initiative in 2002, they stopped the Women's Health Initiative because they had found an increased risk of a variety of different diseases. And then that was when there was a halt to using hormones. There was a lot of demonization around the use of hormones because doctors were basically told that it increased risk of cancer. Heart disease, is that right? Yes.

General disease, yes. Specifically breast cancer. What happened was this was the largest study of its kind. They went into it, trying looking at, well, it looks like hormone therapy is really helping women. So let's look at, does it decrease risk of cardiovascular disease? Does it decrease dementia? And what they found. Well, they started looking at the numbers. First of all, the average age of the women in that study was 63, more than 10 years past menopause. Okay. Many of these women were now initiating hormone therapy more than 10 years past their final menstrual. Menstrual period. Many of them actually had been on hormone therapy and then stopped. Many of them already had big risk factors like obesity, which are risk factors not just for cardiovascular disease, but for breast cancer. And the breast cancer data showed that there was an increase of 0.8, not even one person per 1,000 users. So it was statistically significant, but that's not really clinically significant. And that was in a very specific arm. They also were using Premarin and Provera. I'm not mad. You know, that was the prevailing. That was the. That was the, I think the number one prescribed medication in North America at the time. That's how many. I told you guys, over 40% of women were on it. Over 40% of women were on that hormone therapy. And that's just what was used. Right. So it's not necessarily what we use in that same. We don't use it really the same way we don't not use it, but we don't use it really very much anymore. Especially the Provera, the non bioidentical progestin. And I actually think that was more the culprit than the estrogen. Because if you looked at the women who had a hysterectomy, did not have a uterus and did not use progestin, the women in the conjugated equine estrogen, which is biologically identical for a horse, it's not, you know, it's not. Not bioidentical. Those women who are on estrogen only had lower rates of breast cancer. So estrogen doesn't cause breast cancer. There are receptors on the tumor. That's not the Same thing. So everybody freaked out. The patients freaked out too. I mean, I remember that day in the office. I was a newbie, I'd been in practice like two years and I was like, oh shit. And everybody in the, all my colleagues were like, oh my God, this is not what this means. It's not true that all like OB GYNs were like, oh, no, no, no, no, that's not what this means. But everybody else, like, especially internal medicine, oncology, like everybody else was like, danger, no, stop. So. And those. There are people still out there saying that. And I have so many patients over the years who have come to me and said, well, you know, my mom had breast cancer and it was caused by hormone therapy, so I can never use breast, I can never use hormones. Like, oh God, that's literally not what this study said. And that's also. God bless your mom. Not why she had breast cancer probably. So, yes. It just got misinterpreted. It got published. It's a really crazy story actually, but it got published behind the backs of some of the other. And not even all the investigators were aware that this was gonna get published in the New York Times. It just was crazy. It was just like clickbait before clickbait was a thing. And it shut everything down. So it made it really hard for people to feel comfortable prescribing, feel comfortable using, and to understand, you know, what really was gonna be the right path forward for them onwards. Yeah.

So you said that only 4% of women are now on hormone replacement therapy because of all the fear mongering that came from the Women's Health Initiative. Percentage of the population would you say should be on hormone replacement therapy? If we're talking about the age of like 45 and up?

I mean, I think here's. I'm not going to answer the question because I think what should happen is that every woman at 20 should know that they're going to go through menopause at some point if they're lucky. Right. You have the privilege of being on the planet. I think women should be educated well in advance. We don't like kids going to puberty and not slide that, you know that book under the door, right?

Yes.

They're getting talked about it at school, at the doctor's office, at home, everywhere. They're prepared. You can never be totally prepared, but they don't know it's not happening. So number one, we're not educating women. Number two, we're not educating them about the options. I don't have an agenda about how many people should be on hormone therapy? I don't know what that number is. Every single woman over a certain age should already know that that's an option for them. And what would their specific risk factors be? Do you have a strong family history, history of osteoporosis? Well, I mean, I think estrogen needs to be on the agenda for you. But I could dip you in estrogen all day, every day. And if you don't eat well, manage your stress sleep, maintain social connections, lift heavy weights, get your protein and your fiber, be nice to yourself, hormones aren't going to fix much. Right. It's a tool in the toolkit. So everybody needs to know what the tools in the toolkit are for them. I want every. I want 100% of women to know that this might be an option for them so that then in consultation with their practitioner that they have a trusting relationship with, they can decide when and if they want to use it and understand the risks, the benefits and alternatives. That's not happening right now.

And tell us the general, the biggest benefits of hormone replacement therapy when it's used appropriately in the right person.

Well, we know that estrogen specifically decreases the risk of osteoporosis and osteoporotic fractures. And that's not a small thing because 50% of us are going to be at risk for a fracture. And I don't think a lot of people know that. Osteopenia, which is that stage of bone loss before osteoporosis. About 50% of fractures occur in people without osteoporosis. It's an osteopenia. So not to scare you, but this is why Lifestyle plus hormones. There's no controversy at all around estrogen's positive impact on reducing the risk of osteoporosis and fractures. Okay. So I feel like everybody just needs to know that. I think, you know, look, the brain health, the dementia and the heart health are less well understood. Lisa Moscone and her team are looking specifically. We know how estrogen impacts the brain at midlife. We know estrogen receptor density changes at midlife. The receptors increase in areas like the hippocampus, which is memory. Right. Cognition. And it seems like that could be because they're, like, thirsty for any available estrogen. We know that women postmenopausally have much higher rates than men at the same age of Alzheimer's. Dementia specifically, we cannot say definitively that estrogen therapy will decrease dementia. Am I on it to decrease dementia? Yes, I am, because it seems pretty obvious to me I'm just telling you the truth about how I talk to myself and my patients. Right. We get to have a conversation for things like musculoskeletal impact. Many women have musculoskeletal and joint pain, not just the bone loss, but also ligament and muscle pain. We have muscle loss. A lot of women report that they have decreased pain and they're able to do their activities of daily living and also have better lifestyles when they're on hormone therapy, sleep. We know estrogen and progesterone impact brain receptors. So progesterone impacts the GABA receptors that helps with relaxation. There's plenty of data showing that it does impact all of these thorny problems that are part of the transition, but that are also gonna have long term impacts because we know, for instance, if you just look at hot flashes I mentioned earlier, hot flash severity is associated with heart disease. And we know that if we're having night sweats, we're not sleeping, we're decreasing our capacity to take care of ourselves, we're increasing risk of diabetes, of heart disease. So like they're to say like this does that. It's, it's a whole body experience and the estrogen specifically is playing a role in a lot of basic foundational physiologic events that are going to have a big impact on our capacity to take care of our health. So it's not easy to answer this, but I think I'm making the case that women should really be seriously considering using hormone therapy. You know, I mean there's, there's a small number of us that really shouldn't and can't use it, but it's less than people think.

So I polled my community because hormone replacement therapy is a very confusing topic for a lot of women. And I'd love to be able to just go through kind of rapid fire. I know that obviously there's a lot of nuance these questions, but general like rapid fire responses that you think of initially that obviously people need to go much deeper with, from their physician and working one on one. And obviously you, you only have so much and you can't provide medical recommendations from just one question alone. The first question is how early do some of the women that you work with start hormone replacement therapy? Do you recommend hormone replacement therapy as early as 35 years old for women who seem to be experiencing perimenopausal symptoms?

If people are in their mid-30s and they are, we've decided it is perimenopause. Yes, I will, I will treat.

Does hrt improve heart rate, variability in perimenopause.

Ooh, I don't know that data. I don't know. That's a great question.

Are bioidentical hormones safe?

Oh, yes, I think they're safe, yeah.

And so for people who don't know, there's synthetic hormones and then there's bioidentical. And do you want to explain the difference?

I would really like to explain the difference. So, first of all, bioidentical and synthetic are not opposites. Anything that is synthesized, that is produced, that is manufactured, is technically synthetic. I think people are confused about the hormones that are identical biologically to what your ovaries were making. And that's what body identical or bioidentical was or is. And that's not necessarily natural. I mean, we're not. The only thing that would be natural is if we were taking somebody's human ovary and not being facetious and grinding it up and using that for your medication. And that's not how it is made. It's made in a lab and in a regulated environment, and it's made to be exactly chemically identical. So natural from a yam isn't better. It's. I mean, it's from a yam. Are we yams? We're not yams, but we make some of these products from plant based medicines and some of them are not. So it's confusing. And I also want to point out that synthetic or non bioidentical isn't always better. Like, for instance, progestin. Progestin is far better at controlling bleeding. Far better at controlling bleeding. Conjugated equine estrogen, the old school Premarin in combination with another medication is right now being studied and looked at in the prevention of ductal carcinoma in situ. Much more complicated. So be very careful about red flag, okay? Someone's like, this is bad, this is good. Red flag. Red flag.

Okay, that's helpful perspective. Next question. I'm 61 and from a generation where hormone replacement therapy was not offered. What can I do now?

It depends. It depends on how long. Because if you're 61 and you're less than 10 years from your menopause, then you're still within 10 years. And if someone's trying to deny you hormone therapy, that's actually not evidence based on. But if you're 61 and you're 11 years or 14 years from your menopause and you don't have a reason that you can't be on hormones and you have a reason you want to be, whether it's to prevent osteoporosis or you're still having hot flashes, I would treat you and you shouldn't be denied.

That's helpful.

60 is not a magic number.

Next question. I'm postmenopausal 66 and I get night sweats. I did hormone replacement therapy at 50 for about 10 years. Should I go back to HRT?

I think if it worked the best for her. And again, she doesn't have a reason that she can't be on the hormones. There's no reason that she can't restart.

What instances would you not recommend hormone replacement therapy?

So in anybody who has a genetic predisposition for blood clots and has had a blood clot and anybody who had something called an unprovoked blood clot, in other words, it wasn't like they were on a long flight and they were on the birth control pills or they had surgery. So we don't know why you had a blood clot and you had a significant blood clot. Somebody who's currently being cared for in treatment for a hormone sensitive cancer. So like if you're two months into your breast cancer diagnosed and being treated and you have a hormone sensitive cancer, you shouldn't be treated. There is a world in which post treatment, some breast cancer survivors can be treated. There's one particular kind of uterine cancer called sarcoma, which you probably shouldn't be using hormone replacement therapy. So not a lot of people, you've had a stroke, you've had a heart attack, but even those people, depending on the reasons, they may be a candidate. Now let me say this, all of these people are candidates for vaginal estrogen or vaginal hormone therapy for genitourinary symptoms that estrogen, and sometimes it's DHEA or testosterone is not absorbed into the bloodstream and does not affect the rest of your body. So there's pretty much nobody who can't use vaginal estrogen.

So helpful. What type of breast cancer risk or family history would you not recommend HRT.

Breast cancer? Family history is not a contraindication. If you are a genetic carrier of a high risk gene and you haven't been treated, that's a little more nuanced because often we'll do prophylactic surgeries. But I. That's not, that is not a thing. That's a misconception.

How do you know which dosage to take if you're always in flux and can't really determine your level?

That's a great question. It's not at this point about determining a level. It's about clinical symptoms. So if you're in perimenopause, that's more likely what's going on because your levels are fluctuating. And this is why it's so important to work with somebody who's really adept at dealing with this because it is a moving target.

If labs show normal estrogen but symptoms say otherwise, should you start estrogen?

Yeah, we don't treat based on lab levels, we treat based on symptoms.

Is there any negative to doing hrt?

Is there any negative? It depends on the person. There's a lot of upside. I mean, I think we sort of touched on the negative. Some people don't feel well on it. Some people don't tolerate progesterone, for instance. Um, some people have side effects on estrogen and they actually don't feel better. So we find something else. But I think again, you're not going to know until you try.

Does estradiol patch and vaginal estrogen do the same things? Can you use both at the same time?

You can use both at the same time. They do not do the same thing. One is treating the local symptoms, the vaginal and urinary tract. One is treating the entire body.

And that's like super helpful. Is around the recurrent UTIs is so many women that don't realize when they're being put on rounds and rounds of antibiotics that vaginal estrogen can actually help with decreasing the frequency of them. Right.

Not only that, we're not killing your microbiome.

Exactly, exactly. What are optimal levels for testosterone?

Oh my goodness. I mean this is like a clinical practice thing. It depends on why we're doing it. But generally speaking, you know, like 40 to 80 is where most people are gonna feel better. But again with testosterone, that's the only thing that we do follow levels for because we don't want people to have extra high levels. But the truth is, if you have a testosterone of 36, then you're feeling better and your sex drive is restored and then great.

So when it comes to testing, there is obviously testing is a big topic. And since there is not one, a one time perimenopause test that can tell you if you're in perimenopause. Can you explain how a physician you diagnose and can tell if a woman is in perimenopause? And then other tests that you use to rule out other things that could be looking like it's perimenopause, but it's actually A thyroid issue or a nutrient deficiency or something like that.

So I mean, a lot of it's based on a thorough history, you know, family history included. Because a lot of times people will come in and it turns out they've got three people in the family who went into menopause at 42. And so at 33, they're having perimenopause symptoms and everybody's like, nothing is wrong with you and they might be having a regular cycle. So some of it's based on historical data, including family history, if it's available. And then it is really about excluding other things, making sure thyroid's okay, vitamin D, B complex, antinuclear antibody, ferritin. So iron studies are actually really important because a lot of what people come in with is like body aches, sleep disruption, fatigue, the vaginal dryness, things like that, which, I mean, I would treat vaginal dryness at any age. Right. You could be 32, postpartum and breastfeeding and need vaginal estrogen, by the way. So you just have to exclude other things and then it's fine to try. If you're sexually active with men, you need to have birth control methods still. So if you're 35 and you're a good candidate for hormone therapy, but you're sexually active with men, that's not birth control. And I will say doing things like anti mullerian hormone, which we look at for fertility purposes, I mean, sure, you could do it, but it's not, it's, you know, it's going to give you a window of three to six years. It's not helpful. Really. Yeah, I'm not, I'm, I'm not opposed to doing labs as long as, like in my practice I have time to sit with you and explain to you why this is interesting theoretically, but we're not treating that. But if you really want to know, I'll do it now. When I was in my insurance based practice, I really was like, can we explain why this is really not going to do much for you? But I mean, if people insisted I did it, but it was like, this is not how we treat. It's not like thyroid. We're like, you need to live in a narrow window. You know, that's not how it is with hormone therapy.

Yeah, that's helpful. And I think too that it can be confusing because like you said, so many of these symptoms, like the fatigue and the joint pain and the, you know, the mood changes, like, I mean, a lot of that even just with the programs that I run with like blood sugar imbalances, like I will say so many times before, before you ever even think about hormone testing or having conversation about it, like, understand what your blood sugar is because of how much blood sugar imbalances exacerbate these hormonal imbalances that you have control over through your lifestyle.

But this is also where history is so important because the other thing that I see is like, women who've had gestational diabetes frequently don't realize how high their risk for type 2 diabetes is later in life. And this is when you start to see a lot of instability. So maybe they're not gonna have an abnormal A1C yet, but which is, you know, the average of your blood sugars in the previous weeks, but their fasting blood sugar may be up or their insulin is up. So I mean, I have a comprehensive panel of labs that I do on everybody which includes, you know, C reactive protein and some other cardiac markers. We also will start to see. And again, I'm not gonna treat you with hormones for this, but you start to see LDL and ape, you know, APOB going up. I mean, we could get into the weeds with this. But this is where I wish women had access to this kind of care.

All of us, you know, it's so true. And also I think, why, for as much as maybe you don't agree with the increased information being beneficial, I do see like such a case for a lot of the direct to consumer lab testing companies playing such a pivotal role and people being able to better understand their body and like tracking things too, because then you have the ability to track over time. If you're getting your blood work done every single year and you can see these patterns that are, you know, starting to change. And a lot of times you'll go to the doctor and then they're like, oh, well, you're not, you're not in the red range, you're not out of range. So it's something for us to look at. And it's like, but in, in relation to where I was five years ago, this is not normal for me. And we need to look at these warning signs and like what my body is saying in order to better understand, like what is happening underneath the surface.

I don't have a problem with the testing. I have a problem with people having nowhere to go with the testing. I mean, I think that that's for sure. And I think the only thing that's actually really interesting right now that's starting to really happen. I had a conversation yesterday with Some founders about this, that a lot of the. And you said tracking, that's cycle tracking is the biggest tool that I use with my patients in this age group. So I have them, if they are getting a cycle and they don't have like an IUD or on the birth control, I have them really trap for at least two cycles. Sleep, bowel habits, mood, body pain, because they start to pick up their own patterns and they see like, ovulation, there's a bump in PMS or from ovulation on, their mood is foul and their fatigue is. These are so obvious. That's hormonal. That's hormonal. And it helps them connect with, oh, how can I understand my own self? It really moves the locus of control back to them, which is where it should be. I mean, agency is super, super important. I'm a collaborator here. I'm the Sherpa. But you know your body better than I do, so that is a huge thing. But there's some really interesting data starting to emerge in some of the furniture. Fertility lab testing, home testing, where they're able to track what's going on as people start moving into perimenopause. And they're finding that there are specific phenotypes, people who have. People who have more mood symptoms, people who have more physical symptoms. And they're starting to work on if they can correlate that with specific lab levels. So I think it is coming. We don't have it now, but it's coming and it's going to be fantastic. It's going to really help us take better care of people. We can truly do individualized, precision care.

100%. Yeah, I'm excited for that as well. So excited. Okay. What is the most important advice that you have for women in my community who are like me, who are 35 years old and looking to be proactive in reducing symptoms and the cardiovascular impact and the cognitive impact and the osteoporosis impact and all the things throughout perimenopause and menopause.

Oh, my goodness. I think, actually, I do think getting labs now, including this is gonna sound crazy, but I think we should just. For our own data collection purposes, we can't use it for treatment right now. But do all your labs, including get some hormone levels. I mean, right now, I would say do it in the first half of your cycle. You know, do follicular labs day, day one through five of your period. Right. And just see where you are. Right. But definitely know what your blood sugar, what your cholesterol, what Your ferritin what your vitamin D is really double down on lifestyle. If you can get information on your family's history and how other women in the family experience menopause, if they're willing to talk about it or even remember, this can be helpful because here's the deal. You're not going to prevent menopause. You are going to go into it educated and not fearful. If you are resourced and you know what, you know, your body of body confidence and you know what works for you and you have sort of at least a window to what the future might look like, you can start planning. It doesn't have to be some big disaster and you're running around last minute trying to figure everything out. You know, lift get bone density. This early is too early. I don't think there's enough data to support that. But I also the other thing about bone density, do not wait till you're 65. Oh my God. No, no, no, no. Do it. If you're skipping periods, you know, consistently and you're in your 40s, I would get a bone density because there again, these are things we can get on top of and we can create an action plan now a hundred percent.

And also even just because of the muscle loss that happens throughout pregnancy and postpartum, you know, with breastfeeding and things I having that baseline is definitely not something that you want to wait until 65 for, which unfortunately so many women have been kind of like forced to do because of the lack of information that's been out there. Okay, this has been so helpful. Dr. Suzanne Gilberg, please tell everyone where they can find you so they can benefit from the work work that you're doing.

Well, I mean the easiest place is to go to my website probably and all my socials are linked there. I'm probably most active on Instagram it's Ask doctorsusanne A S K D R S U Z A N N E and the website I'm sure you'll link it is thedrsusanne and you know, just follow along comment. I'm happy. I'm really excited to be interacting a lot more with younger people because they're really. I mean this is an opportunity for us to help you go into the next chapter with flying colors. Let me just say this too. Like, do I look like I'm not thriving? I'm doing great, girl. I'm killing it. I'm going to be 60 in a couple soon, soon. Which is crazy. Proudly. I'm fine. I'm not only fine. It's awesome. So don't be scared. That's the other thing. Anybody who's making you feel scared about aging, don't follow them.

I love that. I love that. Dr. Suzanne Gilbert, thank you so much for being part of the Being Bridget show, and we will see you soon.