The Menopause Myth Why Testing Isn’t the Answer

I want to talk about women in menopause or perimenopause and hormone replacement therapy and how it applies to doing laboratory work or blood work. So I hear a lot of people saying they're getting their blood tested regularly to see where their hormones are at, and maybe they're taking bioidentical hormones or some kind of hormone medication. And they're wondering why we don't do a whole lot of blood work for women in menopause to determine if they're in menopause and if hormone therapy would work for them. I'll tell you, it's a very simple answer. The blood tests are usually worthless. And you're spending money on something that's not medically necessary, that your insurance typically won't cover. If it's not medically necessary and you shouldn't be paying for it if it's not, there's no necessity. Let's go over what labs are being checked. Typically, the hormone replacement therapy for women in menopause is usually estrogen, progesterone, and sometimes testosterone. We pretty much always use testosterone as well. That's your dominant hormone. But what does a blood work tell us? Well, menopause is defined as having no period for a year, or surgical menopause where your ovaries are removed and you no longer have the ability to make those through your ovaries. And that's the definition. Perimenopause early onset is typically when your periods start getting longer than the usual 30 days, expand by about seven days, so they're getting further apart, and late. Menopause is typically described by having gaps of two months at a time where you're not having periods. The laboratory studies in the perimenopause phase are very difficult because if you tested it 10 times on 10 different days, you get 10 different totally vacillating answers. It's so erratic. So it's just a snapshot in time, and it's useless. You know you're in perimenopause because you're having symptoms. You're at the right age. You're having the symptoms of menopause, yet you're still having occasional periods and you haven't stopped altogether. You know you're in menopause when you haven't had a period for a year or your stuff was removed. The definition is. Is a clinical definition. There is not a laboratory definition of menopause. So that is very misleading to think that now there is some typical patterns we see, and we might do blood work in certain settings. For example, a woman's having menopausal symptoms in her early 40s and maybe she hasn't had a period in a year. Well, yeah, we're going to work her up and figure out what's going on. A woman who's had her uterus removed and she still has her ovaries, well, now we can't tell if there's period because there's no uterus. We might do blood work and we check two blood tests in that setting, typically estradiol, and it's measured in certain units. And typically the estradiol is going to be less than 20 picograms per milliliter. And FSH, follicle stimulating hormone, which will typically be say, over 20 or 30, usually over 30 international units per liter. And if that's the case, if you have over 30 and less than 20 with estradiol, we can safely say this woman is in menopause. If she doesn't have a uterus or she's younger and maybe a little younger, we expect in menopause, that would be a laboratory definition. There isn't a laboratory definition for testosterone for menopause, but it drops as well. But it's simply not well spelled out. So your ovaries make principally your testosterone, which turns into estrogen, and you make progesterone separately. And as you go to menopause, those things drop off. There's no reason to check progesterone to see if you're in menopause. It's not relevant. And I think what happens is that in conventional medicine, when a woman is in menopause and maybe she's treated with a menopause drug such as estradiol and some kind of a probera or a progestin, we're not check in the labs, there's no necessity for it. But in the bioidentical space, which is doing bioidentical estrogen, estradiol, bioidentical progesterone, bioidentical testosterone. There's sometimes a lot of laboratories testing being done, and I feel it's totally unnecessary. It's very expensive, very confusing, pretty much useless, can be very misleading. So we're not recommending it other than when there's an unusual case, or we might check the labs when somebody symptomatically improved with their hormone replacement therapy and something seems amiss, we might check it, or somebody's been given hormone replacement therapy, we're titrating it to their symptoms and they're just not seeing the response that they'd expect to see. We might See, is this person burning it off too fast or something? Or maybe there's signs of estrogen excess. Well, instead of checking the estrogen level, we just back it down. If somebody has too little testosterone, there's clear symptoms that occur. Too much testosterone, more agitation, oily skin. This is adjusted dose. Too little estrogen, hot flashes, night sweats, brain fogginess, too much breast tenderness, breast swelling, hand swelling. So we could base this more on symptoms than on labs because labs are generally not helpful and again, very misleading and I know they're done. But you really have a certain amount of capital you want to spend on your health. And if you put it on labs, I think you're in many cases wasting money. We could put it towards taking care of yourself. So for that reason, I'm not a big fan of this over excessive testing, not saying it should never be done. I'm saying I think it's maybe overdone in the bioidentical hormone world because we know we should not do that in conventional medicine for the exact same condition with a similar evening, less, say, less safe treatment, which would be a, say an oral estrogen or something. Another subject I want to talk about is what patterns do we see of hormone replacement therapy for menopause versus other treatments? So menopause is defined by no period for a year or surgical menopause where your ovaries were removed and you're no longer having cycles of estrogen, testosterone, progesterone. And the treatment had been for years using, I mean, in the early days we're using some animal products like ground up sheep ovaries and some stuff from horses. And then we started using primer, which is a pill for hormone replacement therapy. And we knew in the early days that using any kind of estrogen plus progesterone, women had lower all cause mortality, they were less likely to die, they actually were healthier, they gained less fat, they had better quality of life. And prior to 2000, about 30% of women were put on hormone replacement therapy when they went into menopause. And this was very good for society. And then in 2002, a paper came out called the WHI Study, and it was grossly misinterpreted or misunderstood by doctors and the community. It was a very politically hot potato that suggested that HRT was not safe. And this led to a complete abandonment of hormone replacement therapy by doctors and patients in spite of decades of evidence that women live longer on hormone replacement therapy. And in my opinion, this was the biggest disservice to women's Healthcare in the last century because we have a whole generation of women that were subjected to shorter lifespan, more obesity, more diabetes, more breast cancer, more colon cancer, more fractures, more heart disease because they were not offered hormone replacement therapy. And what do we offer instead of antidepressants? The number one drug for menopause now is called SSRIs. These are drugs that make you less depressed. And what happens is that a woman has menopausal symptoms, she's put on the antidepressants and now she just doesn't give a shit, she doesn't care. And this has led to people not complaining about their menopause anymore. It does not treat the cause, it does not lower mortality. And if we look at the patterns as the hormone therapy was at a very high level prior to 2002, it dropped off to 7% in 07, then down about 2 to 5% currently. And the the use of antidepressants has climbed in the same pattern to represent the same amount of use as HRT was 30 years ago. So this is a concern I have is that there's a whole generation of doctors that don't know how to prescribe hrt. There's a whole generation of women that were told that HRT caused breast cancer or heart disease. Where in fact, of course there's nuances to this. How do you use hrt? What are we using? Are we using a drug or an actual hrt? But if you replace testosterone, estrogen and progesterone, there's overwhelming evidence that women will quite frankly just live longer, have less heart attacks, less strokes, less breast cancer, less colon cancer, less fractures and less all cause mortality and have an extended health span and lifespan. They will live longer and be healthier longer than they live longer. So actually they have a shorter period of being sick before they die. We think about how do we want to exit this world. I want to have my unhealthy period be as short as possible and my health period being as long as possible. And bioidentical hormone replacement therapy, even just using estrogen and progesterone alone, which was the kind of historic way, is safer than taking nothing. And using estrogen, testosterone and progesterone is even safer than taking estrogen progesterone alone. Another thing we've learned from the European experience, in the American experience, in America we were using pill forms of hrt. We used Premarin, which is basically a horse derived estrogen and progesterone. At one time this switched over to Premarin and a fake progesterone and women who are more than 10 years in menopause have a slight increased risk of certain conditions when they're taking this aggressive drug form, in synthetic form of copies of hormones. But the European experience, the Europeans did not participate in the study the way we did and they did not abandon hormone replacement the way we did. And they didn't go strictly with pills the way we did. They were using more topicals and pellets and creams for hormone replacement therapy. So now we have 20 years of data after we cease treating women in America with menopause as if it was menopause, we treated like a mental illness now in America. So in the Danish, the UK Polish registries, we see that women on topical hormones or intradermal hormones like pellets at any age being started in menopause had less all cause mortality and less cardiovascular disease. In fact, the longer you're on the hormone replacement therapy, the more cardiovascular protection there is. So in a large Danish study, there was between a 18 and 50% reduction in cardiovascular events in women on hormone replacement therapy, specifically not pills, something other than pills. But then the longer they were on it, the more protection they had. Studies in America looking at and other countries looking at testosterone replacement in women in menopause, reduction of breast cancer with or without estrogen. So in other words, women on testosterone and estrogen or testosterone alone both have a dropped risk of breast cancer, but the women on estrogen and testosterone have also a drop risk of cardiovascular disease, probably a more profound drop in fractures or osteoporosis and better quality of life. So we recommend using all three hormones that you had when you were pre menopausal, starting it in menopause. Now, what about perimenopause? Previously I said perimenopause is described as, or perimenopause is described by having menopausal symptoms but still having periods. Once periods have ceased for a year. Now you're in menopause. Early menopause, the cycles get longer and longer. So we had a 28 or 30 day cycle, now goes a 40 day cycle, 45 day cycle, that's early menopause. Once it goes 60 days between periods, now we're in later menopause. This might start in the early to mid-40s and might go on four to eight years. And typically when that's occurring in early perimenopause, we might just use testosterone and progesterone. Reason being is that estradiol might cause excessive bleeding. In later menopause, we'll actually treat it as if it's menopause with testosterone, estrogen and progesterone. And again, there's no laboratory that confirms that's all purely symptom based. The labs are useless in perimenopause. Now I'm not saying labs are useless in general. I'm saying for perimenopause to diagnose it, laboratory is useless. It might be useful for checking other things, your thyroid and everything, but not for your sex hormones. So perimenopause, menopause, improve your all cause mortality and your health span. I really think about this as patients are coming to us because they want to lose, they want to lose weight or gain less weight. And women on nothing in menopause and perimenopause will gain weight much faster than women on hormone replacement that can still gain weight, but it'll occur at a lower speed. Women who want to preserve muscle and bone mass. Testosterone is very good for preservation of lean muscle mass. Estrogen very good preservation of bone mass. Women want to sleep better and have less what we call vasomotor symptoms, hot flashes, night sweats. Progesterone is great for that. Women who want to just feel better. Estrogen and testosterone both make you feel better. Libido, there's also an estrogen and a testosterone component to that. For estrogen kind of makes you feel like a woman. And testosterone makes you a little bit more libido, more sex drive. And then the downstream of that is less all cause mortality, less cancers, less fractures, less cardiovascular disease. And there's, you know, the old mindset had been if you start menopause, hormones you should stop them as soon as possible. I think that's really passe. We know that the longer you're on them, the more protection and benefit you get. And those are really based on the original recommendations of stopping it quickly was based on using the oral drug forms, which really are not as safe or beneficial. They were still safe and beneficial for women in menopause but for a shorter period of time. Whereas if we use bioidentical hormones, something other than pill, there's way more, not just safety, but life protection. So if you have menopause, you should talk to your doctor about your options.