FDA Updated Guidance on Estrogen Therapy: What Women Should Know

Probably the biggest disservice to women's health care in the last century was how we responded to this very narrow segment of the Women's Health Initiative study. We reacted to that one subgroup taking a certain synthetic drug at a certain time in our life that we shouldn't have done. We changed the entire face of women's health care for 23 years. We come up with a whole multi billion dollar drug industry to treat the symptoms of menopause when we can use generic medication to treat the cause. And we're looking at even in US Studies more recently published in the last five years have shown that women on hormone replacement therapy with testosterone as the primary driver have about a 30 to 70% reduction in breast cancer rates. 30 to 70%. This kind of nails the coffin in the idea that hormones cause breast cancer. The FDA is removing the black box warning from all estrogen containing products. Let's talk about it. Yeah, so let's give a little history and context on this. So we were looking at this black box removal for estrogen, saying it caused cancer, dementia, heart disease, strokes, blood clots, which was wrong. But why did they say that? And why were you having this discussion in the first place? So back in the 90s, there was two large studies that looked at the benefits of hormone replacement therapy in women. So women go through menopause and they have a, you know, the menopause, you're fine is no period for a year. They have their uterus and ovaries removed and they have a insipidus drop in estrogen, testosterone and progesterone, those three hormones. And at the time, the common drug being used for hormone replacement really wasn't necessarily human hormone, but it was called Premarin. And Premarin, pregnant mare, urine, or conjugated to quinine estrogens. This was the synthetic form of hormone replacement that we're using for women. Quite popular. And progesterone, progesterone is a naturally occurring hormone. And a study called the PEPI trial, PEPI trial was looking at how does this affect women's risk for cardiovascular disease, cancers, diabetes, this sort of thing. There's a study carried out and published in 1996 and they saw women on estrogen only conjugated quinine, estrogens only have lower cardiovascular risks, substantial and lower diabetes risk. So all their markers for diabetes and cardiovascular disease got way better. Women on conjugated equinine, estrogens and progesterone had about the same risk reduction. And then women on conjugated equinine estrogens in a synthetic non human progesterone called medroxyprogesterone. They lost some of that cardiac protection and lost some of that diabetes protection. And then there was a placebo arm. What they found on those four arms is that women on estrogens alone did great. The problem is they had too much overgrowth of their uterus, which is kind of a risk for uterine cancer. So that's out. We can't do that. Then the next one is estrogen plus progesterone. They had reduction in all cardiovascular risk factors and in diabetes risk factors. The synthetic one, which was called Provera Medroxyprogesterone, it's not really a hormone at all, but it gave the opportunity for the manufacturer that made Premarin to make a patented version of progesterone that they could sell to the public. And it was almost as good, not quite as good, but almost as good. So that became the dominant player. And the summary of that study was that if you're in menopause, you should be taking hormone replacement therapy and you'll have a healthier life. So that was pretty well known. About the same time 97, a large study was published that showed that regardless of what estrogen was used and regardless of what progesterone was used, long term use of hormone replacement therapy was associated with lower risks of dementia and Alzheimer's, up to about a 50% reduction. So now we got less cardiovascular disease, less diabetes, less Alzheimer's. And Alzheimer's is definitely related to diabetes. So that became kind of a standard of care. And about 30% of women who were eligible in the 90s were on hormone replacement therapy because we knew they would be healthier, they'd feel better, so they'd have less vasomotor symptoms, which is hot flashes, night sweats, less weight gain, have less heart disease, less diabetes, less dementia. And then what happened? In 2002, another study called the Women's Health Initiative Study came out, and it was largely misinterpreted. And probably the biggest disservice to women's healthcare in the last century was how we responded to this very narrow segment of the Women's Health Initiative Study. So the Women's Health Initiative study was designed to see whether or not we can use synthetic drugs instead of hormones on older women who've never been on anything, and what kind of effect would it have on their health. And they stopped a study and found that women, a very narrow segment of women that were on the synthetic estrogen, conjugated quinine, Estrogen and the synthetic progesterone, which is not a progesterone, also a synthetic one that were started about 15 years after menopause, had a slight increased risk of heart disease, stroke, possible neurocognitive decline and breast cancer. It was about 8, 100 to 1%. So the absolute risk was very small. And this led to public outcry, media outcry. And the FDA responded by putting a black box on estrogen products to say that they cause heart disease, strokes, possible dementia and breast cancer. Well, hold on a second. There was also an arm in that study that was estrogen only. And those women had reduced breast cancer and reduced heart disease. Additionally, women who were in the WHI trial who went on hormone replacement therapy, any type. And again, any type. There was only two types. It was conjugated estrogen alone, which was for women without a uterus and conjugated equinine estrogens and, and this medroxyprogesterone. So two synthetic drugs. If they had a uterus, in both cases, they had reduced colon cancer, reduced fractures, reduced mortality from colon cancers and fractures, reduced cardiovascular disease. They had reduction in cardiovascular disease of almost 40 to 50%. Reduction reduced all cause mortality. In other words, they were less likely to die, about 35%. They also slightly reduced breast cancer. And we look at what the FDA did, they put this black box on it. Because what happened is it was an outcry in the media about estrogen causes breast cancer. Well, there's nothing in the study that suggested estrogen causes breast cancer. Yes, In a subgroup of women who took this synthetic progestin, which is not a hormone at all, that started it later in life, did have an 8,1001% increase in risk of breast cancer, no increase of fatal breast cancers. But that led to this black box warning which immediately doctors stopped prescribing hormones to women. There was a large study called the AWARE trial. Aware. And they looked at prescribing habits amongst doctors. And prior to 2002, it was standard of care to put women who hit menopause on hormone replacement therapy to preserve their heart, reduce diabetes and protect their brain, protect their bones and help their symptoms. And. And after 2002, because of the FDA's misstep, they stopped prescribing hormones, started using like SSRIs and antidepressants, things women wouldn't really care about anymore. In fact, we started treating menopause like a mental illness versus a hormone deficiency. And that was abrupt. So in 2023, a study looked and there's rate about 2 to 5% of women who are eligible on HRT and of that same group, about 27% of them are on antidepressants to treat those, those menopausal symptoms. So in November 10th of 2025, the FDA came out with a new really the purpose change. It started about 24 and 2324 were the North American Menopause Society, American College of Gynecology, other endocrine societies, major medical societies pressured the FDA to remove this black box warning because it was really making doctors afraid to prescribe stuff when instead it causes heart attacks even though it doesn't. We know it doesn't. Doctors don't want to make an independent decision if they're being told by an expert, you don't, don't do it. And they perceived the FDA as experts, which are not healthcare experts, but they pressured the FDA and they would do nothing. And then in about June of this of 2025, they convened a group of experts to look at the data. And it was overwhelmingly clear that we've harmed millions of women by telling them these drugs, these medications, which really aren't even quite hormones. I mean this is, these are estrogens from horse based estrogen and a synthetic progestin. But looking at all estrogens and all progesterones reduce all cause mortality. In other words, you're more likely to live on them than off of them. You're less likely to get breast cancer, you're less likely to die of breast cancer, you're less likely to get heart disease, you're less likely to get diabetes, less likely to get colon cancer, you're less likely to have fractures and you're less likely to develop Alzheimer's, dementia, get dementia at a later age if you do so all these things happen. The whole generation of women were not given the opportunity to have hormone replacement therapy because their doctors were scared off by the fda. And quite frankly, there's a whole generation of doctors that have no idea how to prescribe hormones. And it's quite simple, but they're just, they've been burning their brains. Oh, this causes cancer. And that's the big buzzword. Breast cancer was kind of a political hot potato back in the, in the 2000s. And when the media said estrogen causes breast cancer, which keep in mind the study did not show that, they showed something quite different. A drug called MPA caused breast cancer, not an estrogen at all. But when the media said estrogen causes breast cancer, interestingly, the study showed women on estrogen only had Less breast cancer. But again, the media jumped on that they labeled these products even vaginal estrogen as causing breast cancer, which is nonsense. I mean, it's absolute nonsense. There's zero evidence to support what the FDA did. They did this in response to political pressure from the media. This was a media driven healthcare shift. And we've seen that in recent years. How behaviors change by what the media is really kind of talking about. So what happened since the WHI trial in 02 and 04? Well, a few big things. So first off, in Europe, they did not have this paranoia about hormones like we did in America. Now, America, we're using mostly drugs that were copies of hormone replacement, that is conjugated equinine, estrogen and synthetic progestin. That was the number one drug in the, in the country at the time, which was a big money maker for drug companies. But actual hormones were always available. Estradiol, which might be the patch or the cream or pill, is a bioidentical estrogen, means exactly what a woman already had. And progesterone, back in the 70s and 80s, it was kind of hard to absorb progesterone orally, but they figured out they call it micronized progesterone right about the 80s and 90s. So estrogen and progesterone were always available in the United States and were used, but they weren't being pushed as much as the drug copies. Well, in Europe, they were more likely to use the actual hormones, likely because of universal health care. They were interested in lowering health care costs, so they would use a less expensive generic version versus a more expensive, you know, synthetic version. And when we look at the data in Europe, there's a large Finnish trial, large Danish trial, and a large British trial they reported in the last seven years or so. And they found a few things were quite interesting. First off, they were more likely to use a skin based estrogen, which means a patch or a pellet under the skin, than oral. In America, we were kind of fixated with pills. What happens when you eat your estrogen? It goes to your liver and does something called first pass effects. When you eat a hormone, you got to use much higher dose, about 100 times higher, because the liver starts breaking it down. It creates a lot of inflammation, a lot of extra products like sex hormone binding, globulin, and these things actually have some negative effects on your cardiovascular health. And even though that happens, even eating estrogen lowers your risk of heart disease. But if you take it as a dermal or subcutaneous, like a patch, Or a pellet. It even reduces your risk of cardiovascular disease more than pills. Same thing with Alzheimer's disease. So they were using more likely to use that. What they found was that the longer a woman was on hormone replacement therapy, the more cardiovascular protection they got. One year of hormone replacement therapy was reduced, associated with about a 10% reduction in cardiovascular disease mortality over the next 10 years. And being in a 10 to 15 years lifetime, it reduced her risk by about 54%. So really a dose duration. So this is something you began the rest of your life. Another thing that happened in the US is that they told women, well if you do go on it, go on it as short as possible and don't start it later in life. Okay, well that's probably true for using these synthetic oral mpa, the medroxypogesterone. But we look at the European studies at any stage of life, even starting hormone for the first time in your 60s reduces your chance of having a heart attack and dying. You just have lower all cause mortality. And the longer you're on it, the more reduction in cardiovascular disease. And that goes the same for you know, bone disease like fractures, colon cancer, diabetes, weight gain and obesity and dementia. So the net negative is virtually non existent. Maybe the cost of the medicine and a net positive is overwhelming. And we've learned from that is that you probably should be on a skin based estrogen, but oral estrogen is okay. It's better than nothing. You should take an actual progesterone versus a synthetic copy. I think that's not disputable. Now doctors still write the synthetic copies because we're used to using drugs instead of hormones, but it's still better than nothing. But I would recommend a micronized progesterone. And the last one is your most dominant hormone, let's say when you're a 30 year old woman is actually testosterone. So you make about 95% of your estrogen comes from your own testosterone and you have about 20, maybe 10 to 20 times more testosterone than estrogen when you're young. And why do we pick estrogen versus testosterone? Well, it was really a matter of practicality and we look at history. At first we used ground up sheep ovaries to treat hormone replacement for women in menopause because we didn't really have big drug manufacturing at the time. Then they started finding that a five year old pregnant horse, the urine had they urinated out when they're pregnant a lot of estrogens and that's where we got the conjugated equinine or horse estrogens and made that into a pill and eventually synthesized that from, from soybeans. So it was just always practical. But if we look at during the time we had a cessation of hormone replacement therapy in America, other countries doing more of a practical approach to hormone replacement therapy and also using testosterone in women. Now, testosterone has been approved for women since the 1950s for treatment of breast cancer, invasive breast cancer, refractory breast cancer, recurrent breast cancer, and metastatic breast cancer. Because it's such an anti cancer hormone, it blocks the estrogen receptor and downregulates the receptors. And in Europe they were using testosterone, in Europe and I think Australia too, they're using testosterone along with estrogen, in some cases testosterone alone. And they saw a significant reduction in breast cancer rates versus women taking nothing or standard hormone replacement therapy. And we're looking at even in US Studies more recently published in the last five years has shown that women on hormone replacement therapy with testosterone as the primary driver, with or without estrogen and progesterone, have about a 30 to 70% reduction in breast cancer rates. 30 to 70%. This kind of nails the coffin in the idea that hormones cause breast cancer. So the synthetic estrogens by themselves reduce incidence of breast cancer. Synthetic progestins in a certain subgroup increase the incidence of breast cancer. So we shouldn't be using that. And testosterone substantially reduces the incidence of breast cancer in observational studies. So our approach is using testosterone, estrogen and progesterone. The way I would think about them is like this. So your symptoms of menopause, we typically call them vasomotor hot flashes, night sweats, brain fog, difficulty sleeping. And estrogen is very effective for relieving all those. But it also protects the brain, reduces colon cancer risks, helps reduce the possibility of weight gain. So it's protective in all those aspects, makes your skin better, makes you feel better, makes your skin more radiant, makes me more feel more like a woman. And progesterone protects your uterus because the estrogen would grow the uterus, but it also helps with mood and sleep, reduces anxiety. It protects a receptor called gaba. GABA and helps you to feel more calm. And testosterone helps with energy, motivation, improves your metabolic features, blocks cancer, and makes you much more easy to arouse, sexually energetic and have orgasms. And sexy, you're more interested in sex. So all three of these together are what you had, but. And when you lose it in menopause, we can replace all three of these. Now, there's a couple different approaches I Recommend is good, better, best. So I'll start with best. And that's based on really 20 years of experience and looking at the literature. Best is if you can get. Get a hormone pellet. It's a basically a little slit, gets made in your skin, usually in your butt cheek. A little piece of rice of testosterone and estrogen goes in and this gives you a nice steady state over the next three months or so. There's no peaks and valleys or not as much peaks and valleys. And then taking oral progesterone. So that's, that's best. That has the most sound science or evidence, observational evidence of reducing the risk of breast cancer. Getting the most cardiovascular protection, probably the most brain protection. Same in both oral and topical. Are good for bone health, lower colon cancer, reducing symptoms, then number. That's the best. So a pellet with estrogen, testosterone and then oral progesterone. Now, some people might live in a community where they cannot get a pellet. They don't have a doctor in the community that does that. I think they'll change as we remove this black box. But if you can't get that, the next best thing is using an estrogen patch. These are commercially available. They work quite well as pure human estrogen. This is not horse estrogen. The patches are human estrogen. For some reason. We prescribe the horse as a pill, horse pill, and we use patches. We use actual human estrogen and there is human estrogen that you can take as a pill, but as a patch is more appropriate. And then using a testosterone cream. A testosterone cream is not going to get to the same level that a testosterone pellet will. So we can't say how much breast cancer protection you potentially get from it. But you'll have lower breast cancer, basically. We would assume you'd have lower breast cancer because we know estrogen. Only arm has lower breast cancer. Testosterone, breast cancer protective. And then taking oral estrogen first was best. This is better. And then just good is go to your doctor and get a prescription to eat your hormones, which would be taking Premarin. And I would say get a micronized progesterone, not the synthetic progesterone. I think that should be taken, in my opinion, off the market because there's a natural hormone that's widely available. There's a brand name called Prometrium, but it's also generic. And I checked on Amazon as well. Amazon's got a health Mark Cuban's got the healthcare drug companies and they're very inexpensive. So that's my thoughts on this. And I can see now, when we look at different things that have happened, the big upswing in the use of GLP drugs like semaglutide and tirzepatide that we see now lowers mortality rates, lowers heart disease rates, lowers, obviously you're not gonna get diabetes if you're overweight and you're on these medications, lowers autoimmune disease rates. And they're very expensive. And these are actually going to lower healthcare costs long term, but also improve human existence. And hormone replacement therapy, because it's been around so long, is just not so expensive. It's not thousands of dollars a month. It's usually $100 to $200 a month. You might even have insurance coverage to cover a big portion of that. And if I told you I made a pill, say a medicine that given to the proper population, would reduce the risk of colon cancer, 20 to 40% fractures of the hip or knee, which, as you're older, if those happen, those lead to mortality of, let's say 35 to 45% breast cancer, 20 to 30% neurologic decline or dementia, let's say 30%, make you feel better, make you less likely to get obese, less diabetes. What's holding us back? Well, those are all conservative numbers, but every form of hormone replacement therapy, with possibly the exception of one in a certain subgroup of women, accomplishes that. And we reacted to that one subgroup taking a certain synthetic drug at a certain time in our life that we shouldn't have done. And doctors wouldn't normally prescribe that way. It was part of a study. We changed the entire face of Women's Healthcare for 23 years. And I think it's going to take about five years for doctors to come around. Because right now, the most common thing we hear about women, we have a big practice. You know, we've interacted with hundreds of thousands of women, and the most common thing we hear is that they're feeling great on the hormone replacement therapy, best they've ever felt. And her doctor says, well, you can't take that. It causes breast cancer. It's like, well, it doesn't. And it reduces it by roughly 30 or 70%. But it's response to what the government has said. They responded what the government told them. There's a black box warning means they put a black box saying, this is like when you see the cigarettes, and it says, may cause heart disease and lung cancer. It's kind of like that on the drugs, which again, the FDA corrected them and I give them a Lot of kudos for that because the FDA tends to be very arrogant when they make an institutional decision. Even when it's wrong, they stick to their guns and they'll drag it out for potentially forever. Because it is embarrassing to say that we, you know, I mean, roughly 2 million years of lifespan was cost by that decision. 2 million years in America, which is, you know, again, the most significant harm to women's health that we've seen in the last century was, was this decision something that if they had left things alone, that study that was, you know, really misinterpreted by doctors would have just been, you know, swept under the rug as numerous other studies. And it's very rare that the FDA bases one study, even though there's countless before and after it makes an entire decision on it. Again, this was a political hot potato. They responded to what the media was pressing for by, you know, because the media went after the hottest selling drug. Like, for example, we look at these drugs like say, you know, Zepbound and Manjourno and Wegovy and Zempic. And if one little thing happened in a small subgroup of people, you hear about it, you know, you hear about it everywhere. And when it first came out, there was more detractors than benefactors to these drugs. Now we look at the outcome in human existence that for the appropriate people, they're going to live longer. But if the FDA responded and said, well, we heard this small subgroup of people had this small disease, even on their first warnings, they label it potentially causing pancreatitis. Not true. So I think this is something that we have the chance to correct it. It's going to take doctors a while to come around because they were trained for years. And I can imagine the family doctor, internal medicine or gynecology office been telling their women for 20 years they got to use antidepressants for menopause. It's kind of hard for them to go back on that. But those doctors are retiring and new generation will come around. Women will seek out other alternatives to get there. And even with the advent of telehealth, there's a lot more options for patients. So I'd say, you know, if you're a woman interested in this, share this video with them, but look into it yourself. Do a little deep dive on it and think about being the chief executive of your own health. And I think people love themselves more than their possessions, then they might have to put a little energy into finding somebody that can treat them. You know, even it costs a little bit of money to Buy these medications. Again, a lot of times they're covered by health care insurance. So this is something that, you know, again, the significant reduction in all cause mortality. I mean, just like if we look at life extension, I'm really interested in longevity. We have two things, lifespan and health span. So lifespan is how long you live and health span is how many years you have that you're not sick. And as lifespan goes up, your health span extends a little faster than lifespan. So typically somebody lives to be much older, had a shorter period of time where they were really sick and not able to do their normal things. And if you look at the lifespan implications of using testosterone, estrogen, progesterone, it's roughly 4.75 years of additional health span. But just even estrogen and progesterone alone, which is way more accessible to people, roughly three and a half years. So you can actually have that many more years of healthy life based on calculations of morbidity, doing something as simple as making yourself feel a hell of a lot better so you get to feel better longer. So we look at the way we've been treating menopause since about 2003, has been going from treating the condition, which is the absence of hormones, to treating the symptoms, which is hot flashes, night sweats, bone demineralization. So we've come up with a whole multi billion dollar drug industry to treat the symptoms of menopause when we can use generic medication to treat the cause. And prior to 2003, like in the 90s, pretty much all women were offered hormone replacement therapy because we knew they'd live longer, have healthier lives. And about 30% of women were taking them. And right after the FDA's intervention, that went down to less than 5%. If we look at antidepressants such as SSRI drugs, they went from about 3% of the population to more recently 27% of the population that's in menopause. So we started treating menopause with antidepressants and also sleeping pills and bone mineral pills, all kinds of other drugs that were designed to treat the symptoms, symptoms of menopause, but not the underlying problem. And when we put somebody who is on these drugs and in menopause on hormones, they actually kind of wean, they don't need to sleep in pills anymore. They start weaning themselves off their antidepressants, typically can't to stop those cold turkey, but they wean themselves off the drugs they're taking for bone mineral demineralization. They can get off, they have a Lot of side effects they can get off those. I was talking to my best friend Colin yesterday and he's doing kind of a similar practice to us and we're talking about how long does it take? Because I really haven't scientifically validated this. So you're chatting with your colleagues. He's a doctor in cosmetic surgery and has an anti aging practice. And it's over a year, a year period. So it's not instantaneous. It's kind of like these hormones have to build up and you have to kind of reduce your dependency on these antidepressant drugs. But typically you can get yourself off those. And that really, I think, to me is a real goal is getting women off of drugs that just basically paralyze their brain. And that's what these antidepressants do to make it. So you don't really, you don't really care that you're not interested in sex, for example. And that's how we've attacked it. But the actual problem is the absence of hormones. If you take, for example, let's say we took something similar like say hypothyroidism. And if you're hypothyroid, you're going to get more cardiac disease, more obesity, more depression. So we could either give you thyroid medicine or we could put you on obesity drugs, cardiovascular drugs, diabetes medications, something for your heart, some anti lipid medicines, do a heart catheterization, bypass surgery, or we can just treat the hypothyroidism. We've chosen to treat hypothyroidism because the FDA has not intervened in saying, well, hypothyroid medicines cause X, Y or Z. So that never happened. It was never a political hot potato. But what other conditions, you know, if we have high blood pressure, we treat the high blood pressure, not the outcomes from high blood pressure. If we have diabetes, we treat the diabetes, not the outcomes of the diabetes. If we have low hormones, we treat the outcomes of low hormones versus the low hormones, we have an option to treat the cause. And it's not like lifestyle is going to fix this thing. So once you've gone through menopause, what happens every time you have a period when you're younger, your body goes through a cycle where your ovaries put out a bunch of testosterone, estrogen, progesterone in a certain cycle and you have a certain number of eggs. And once you get about your 40s, late 40s, you're in perimenopause, which really is defined as having your period, the time between your Periods is getting longer, which means you're kind of running out of eggs. And eggs you have. They've been there a long time and they're kind of tired. And once you go through ovarian failure, which is menopause, there's. You still do have estrogen, but it drops down precipitously. Testosterone drops down way before then. In fact, about 10 years before menopause, we see drops off in testosterone and progesterone gets real erratic. So in the perimenopausal women, that's a common question I get when you start hormone replacement therapy, really when you feel the symptoms of running out of hormones. So typically a woman who's perimenopausal, we're going to use testosterone and progesterone because testosterone actually aromatizes or turns into estrogen. So we give them a testosterone pellet and some oral progesterone, and that normalizes their symptoms. They still have, you know, less periods. And then once she goes into full menopause and we add in estrogen because the testosterone, even though it converts an estrogen, the evidence is overwhelming that estrogen is so safe. Even if you think you're getting enough estrogen on your testosterone, it makes sense to add estrogen anyways. It's because the overwhelming cardiovascular and neurocognitive or brain protection of estrogens, we want to get that level up a little higher than testosterone. Could do it alone. So I look at hormone replacement therapy as a dual track. So on one hand we have symptoms women have in perimenopause and menopause, and then me as a doctor, what kind of outcomes I want to see, and I want to see you feel better, but I want to be healthier too. So when women's in menopause or perimenopause, the first, most common complaint we get is the weight gain. I mean, that just. It just starts happening. We know when the estrogen and testosterone drop off, you know, the weight comes on. And numerous studies have shown that estrogen, testosterone, or both together reduce the weight gain. I used to have to do some intervention. Things aren't going to be the same anymore, but they do reduce weight gain. Even a study done in, I think it was in Sweden, where they looked at just taking a 100 milligram testosterone pellet in women who are perimenopausal, around 54 on average or 50, 50 on average. And they put one group on a testosterone pellet, one group on nothing, didn't do any other intervention. And at the end of six months. The women on nothing gained about six pounds and women on testosterone lost about two pounds. They also had better body mass ratios. So the weight's not going to necessarily fall off, it's going to prevent as much weight gain. We know that topical estrogen is better than oral estrogen for slowing down weight gain or prevention of weight gain. So those two together. So weight gain, that's number one. How you're feeling, sleep, big issue there, sleep. So estrogen helps with sleep. Progesterone specifically helps with sleep, really calms you down. In fact, we have people take it at night because it has a mild sedating effect, activates a receptor called gaba, which is kind of a calming, relaxing hormone. Makes you fall asleep easier, makes you feel less mental fogginess and forgetfulness, makes your skin look more radiant. We have estrogen receptors in our skin. Even we have women apply estrogen right on their face and helps with their face skin thickness, amount of collagen production. So really, from a how do I feel standpoint, when we hit menopause, some women say I feel almost the same. Maybe they'll have weight gain or something, but they feel almost the same. And other women have really severe symptoms. They're having hot flashes, night sweats, et cetera. I put both those women in a similar category of are you in menopause or not? And if you are, even if you don't feel worse. Now we look at what happens in menopause with your health. Not only does weight go up, risk of diabetes goes up, heart disease, breast cancer, colon cancer, osteoporosis, the beginnings of neurocognitive decline maybe a decade or so later. So from the standpoint of feeling better, that's part one. But then in terms of your health, we'll talk about how health leads into longevity or longer health span. If we look at hormone replacement therapy, the way we're using it, we use a combination of estrogen, testosterone, progesterone. So I'm going to give you some rough figures, how it affects your risk, taking the medications. Over, let's say a 10 year period, we see about a anywhere from a 10 to a 54% reduction in heart disease mortality from heart disease based on what formulation, how long you're using it for. Reduction of breast cancer, anywhere from 20 to 70% reduction in breast cancer rates, reduction in colon cancer, pretty much all the forms do. Reduction in fractures of the hip and knee back with reduction of fracture related mortalities and reduction in dementia or delay in dementia, reduction in Alzheimer's as reported up by the government as up to 54%. The FDA released that. So that leads into better health and potentially lower health care costs. Then after that we look at lifespan and healthspan. So lifespan is determined by a lot of factors. We can look at biological age. There's all kinds of ways you can measure age, but we see is that if you have less likelihood of dying of a heart attack, less likelihood of dying of cancer, less likely of dying related to a fracture, less likely of dying related to Alzheimer's, somehow your lifespan grows. And that reduction doesn't mean for the forever, but it means for some period of time. So let's say we look at a 20 year study and we say what's the reduction? We can calculate out the lifespan. If we look at a 10 year study, it's a little more crude, but that's how we scientifically calculate out lifespan. So you would live longer. And looking at the cessation of using hormone replacement for menopause probably cost an average of 2 years of lifespan for the average woman who went to menopause between 2003 and 2025. Two years health span, on the other hand, is how long do you live without major disease? When I say major disease, something that impairs your life, like having having had a heart attack or having had a stroke or having had, you know, obesity, having had diabetes, having it where you're not the person you were, it's anywhere from three and a half to 4.7 years of additional health span, depending on what type and form of hormone replacement therapy we use. How long you take it, when do you start it? So the earlier you start it, the better and the longer you're on it, the better. But even studies, the Danish cohort study, which is 2.2 million women years, I just want to put this in perspective. The study that causes us to stop hormone replacement therapy in America for the most part because of the FDA, was 250,000 women years. The study was published a couple years ago with 2.2 million women years. So almost 10 times as big. And to show the longer somebody's on hrt, regardless of when she started it, the more cardiovascular prevention she had in terms of death from heart attacks and the lower the all cause mortality, regardless of what age she started it. So even she started in her 60s, still lived longer, even she only took it for a year, still lived a little bit longer. That's why I think if you're thinking about this, there's a net positive, no matter how we slice it. But even if you go on HRT for a short period of time and then you decide it's too much of an aggravation or it's too expensive, you still get a net benefit for your lifespan and your health span. You may have a lot of questions about this content. If you do, put it in the comments below or contact one of our offices to speak with a provider.