Master the Art of BHRT - Dr. Priti Nanda Sibal

Good evening. Good evening, everyone. If you can hear me, please give me a yes in the chat box. Yeah, great, thank you. Thank you, Padma. Thank you, Anchika, and thank you for joining. So before I tell you what's my agenda today, I want to know from you. You have joined this webinar. One, and secondly, which language will you be more comfortable in? English, Hindi, or mixed? Padmajaya is English, others are Hinglish. Perfect. And what is it that you want to gain from this webinar? Beautiful, Anshika. Yes, anybody else? What is that one myth about BHRT? If that can be cleared today, you will be happy that, you know, it was worth investing your time. Great to understand more about BHRT. Very, very nice. Perfect. So I have Mahesh also with me here. Welcome, Mahesh. And yep, I'm going to pin you. And thank you for being here.

No problem, Doc. I know you're doing this session despite having one of those seasonal flus, so So thank you from all of us for doing this. Anyway, I'm happy to be your voice, happy to take questions, whatever it takes.

Great. So, so before wasting, you know, without wasting any more of your time, let me start. What is it that we want to do? Okay, so in the chat box, can you tell me Are you doing BHRT right now, or you have no experience with BHRT? Because that will help us, you know, simplify it to the level where it becomes meaningful for you. So if you can just let me know. And, um, Mahesh, if you can just tell me if you can see the screen.

Yes, of course. So, um, Ashwini is saying done in the past with Bela Sante. Dr. Mayur says no experience. Padmajah, no experience. Dr. Rohit Sharma, no experience. So for the large part, I'm sure we'll get more answers as well, but likely that nobody has— at least few, very few people have prescribed by themselves.

So I can with confidence say that today is going to be a life-changing webinar for you. Right, and why I'm saying this, and Mahesh is smiling, because I think between me and Mahesh we bring together about 16+ years of using BHRT, right, Mahesh? Yeah, yeah, 8 years back I started, 8 years back you started, 8, 9 years actually. I started for my own reason, right, and you started for your professional reasons, but I think for me this has been a game changer. Also for me, this is the reason today that I get more smiles from my patients, right? And all of us want that. So I feel anybody who is in the area of healing, in the area of wellness, in the area of medical practice, not knowing BHRT is bad, but not giving the benefit of BHRT to the— to your patients is criminal. So any one of you who agrees with me on this— I know there's a very bold statement, and Mahesh doesn't like bold statements, right? But I always speak what I feel, and I strongly feel this what I've said. So it's not a bold statement, it's the truth for me. Yeah, uh, so anybody here who thinks differently, please voice, because remember, this webinar is not to teach you something. This webinar is to open up something for you and your patients so that after this webinar ends, you are not the same doctor, and from tomorrow morning, your patients are not the same patients. Right? So anybody who thinks differently and who feels that BHRT is all bullshit, it's very risky, it should not be done, there is no benefit in doing this, please hold on. I will come to this question again when I end this webinar, right? So what are we going to talk about today?

There is one, you know, let's take the people who are actually speaking up. So Anshika certainly says agree with it, that it can be life-changing for some patients and give them a much better quality of life.

Yes. And you know what, Women Health Initiative— I'm sure all of us know about that study, right? I was— so I do webinars, and most of you who know me, they know that, you know, I, I'm— I don't do PPTs, right? But I study a lot before my webinar, and somehow I think it is some God's grace that before the webinar, just the right studies come on the screen for me. So today I was going through this data which said that before the, you know, Women Health Initiative study, 40% women that time were on hormonal therapy. And unfortunately, after that, only 4% are on hormonal therapy when we look at allopathic data, right? And this paper, the author had specially mentioned— she's an OB-GYN doctor from US— and she had mentioned there that she feels so sad that this transition has happened. And, uh, you know, she is now trying everything possible within her scope to bring hormonal therapy back in place, BHRT back in place. And I agree with her. So what we are going to talk today is mastering hormones, practical BHRT for only 3 areas. Right now. Gut health, estrogen balance, and longevity, right? So, so of course, you know me, I've got some awards, I've written some books. Mahesh is very, very academic and he's done so much work that, you know, um, you all can later go and see what both of us bring for you. But let's talk about hormones right now. So we know that there are about 50 hormones, but there are about 7 important hormones. And out of those, I think sex hormones are the most important hormones which we really want to talk about, and also which we see in our scope. Sorry, I had— okay, yes. Yep, wait. Yeah, so the slide I've just put in to give you just a very brief idea about what are the hormonal values which we want, right? So that if you plan to do BHRT, you should know what is it that we are aiming at and With this chart, I also want to tell you that I did my hormone test recently, and, uh, I discussed it with Mahesh because I think he's the only guy, you know, with whom I can discuss when it comes to hormones, huh? And I discussed with him and he said a line. He said, Dr. Preeti, your hormones are perfectly okay. If you want your hormones to be in menopausal phase. But if you want your hormones to be the way they were at 30, then you really need to do BHRT, right? Thank you for pushing me, Mahesh. And, uh, that's when, you know, I started incorporating BHRT in my protocol. But these are the numbers which we want to achieve. So for testosterone—

so, Doc, we're not seeing your screen yet. Maybe you're seeing it and you're thinking that we are. So yeah, go back, keep it double-clicked, and then hit share on Zoom again, and then select that screen.

Okay, thank you. So now you can see the screen?

Yes, yes, now we can.

Thank you. Yes. So these are the numbers. Though our body needs hormones in very, very little quantity, or amounts, but that is what changes the whole thing. So if you see that for women, right, because we mistakenly think that BHRT is only for women— how many of us here think that BHRT is only for women, or hormonal issues are only for, you know, women face them? And please do interact, because if you don't interact, then the whole purpose of my coming, despite, as Mahesh said, being down with 103 fever since yesterday evening will not make any purpose, right? Uh, so how many of you think that it's only women where we need to balance hormones and it's not men? Anybody here?

No, doc, I think you're asking too many sitting duck questions. I think you should ask the opposite way around. How many people—

you know, you can have that, Mahesh.

Yeah, so honestly, you know, um 'I didn't know that,' says Binti. Yes, yes, Binti, you know, you are right. Most of us do think— whenever we think about hormones, we think about only women. But even in women, how many in the group— and I know there are lots of functional medicine practitioners here, so we are preaching to the choir— but tell me, how important do you think testosterone is, for example? Right, so you've got testosterone right here. And how many people believe that testosterone is important in women only for libido? And these are open-ended questions. You can put it in the chat box. Even simpler, unmute yourself. You know, you don't have to come on screen. You can speak. We're all among, you know, colleagues, and this is a perfectly safe and open space to have any discussion. So we are here to try and help people understand you know, where we come from. That's basic purpose of this. So please go ahead. How many people believe that testosterone is not really something that's needed beyond libido for women? I would like to just give in my— I mean, what I thought was testosterone's function in females was a lot help in muscular strength. They help build muscle. That's why we, you know, encourage women to do the strength training. Yeah, so that's my understanding of testosterone in females. Superb. That's one more. Thanks so much for, you know, unmuting and speaking, Binti. Certainly does. Anybody else would like to contribute? Any other functions of testosterone in a woman? All right, I don't see anybody else directly speaking up. Doc, you want to give anything else that you have noticed beyond libido and muscle?

You asking me?

Yes, please.

Oh, so for me, testosterone is extremely important for women with urinary incontinence. With multiple UTIs, when you are stuck, you know, estrogen, testosterone balance has to be done. Even in low dose, it helps. So I use testosterone very effectively also in women where they are saying that, you know, they're missing— they're not able to make decisions.

Yes, that was the— that was the clarity. Yes, you're right.

Exactly. So, um, you know, they doubt their own decisions and they're not able to make decisions. They're not able to make muscle mass. Um, they don't enjoy the sexual life. And, uh, so testosterone has loads and loads of functions, but these are the 5-6 things which I generally check for women whenever they come to me for any type of consultation, because I know this can be game-changing if she needs it. Maisha, have I lost you?

No, no, I'm still here, Doc. Absolutely. Yeah, so I thought you were switching slides. Yes, go ahead.

No, no. Okay, so second thing I want you to know is if you will see your progesterone changes— early follicular, pre-ovulatory, and mid-luteal— but your DR does not change. It is consistent from the beginning till the end. Anybody here who thinks that DR is important? And if it is important, available over the counter.

Yes. Right.

And that's the reason I want to bring this forward that after today's webinar you feel comfortable and you know that BHRT is that missing link in your practice to heal that 30% of patient who is not very, very, very happy with you.

Yeah. Right.

And 30% is a big chunk. So in those patients I want to tell everybody here because they've not used. You've rightly said Yes, stress, definitely. Patient will not be able to handle stress. But I'm not— I'm talking about group of diseases which is now becoming more prevalent than even cancer.

All the autoimmune diseases.

Exactly, Riddhi. I think we all can clap for you. So that was an eye-opener for me 4 years back. And see, I've been doing BHRT honestly for last 8-9 years now, but 4 years back I came across multiple studies which were trying to tell me that You know, if low on DR, then autoimmune disease chances are of course much higher. And therefore, for all autoimmune cases, you need to figure out what's the DR value and how much do you want it. Now, when this is clear and we agree on this, anybody who's used DR and seen that a woman comes back and says in 2-3 days that, so I've been losing hair in the last 2-3 days Like anything. Anybody who's seen this type of patient after they've started Dia?

No, ma'am.

Right.

Um, well, I certainly have, and early on in my practice, I, uh, you know— oh, there's somebody. Let's hear the group. So, I've used Dia and it gave me great sleep and more clarity, says Ashwini.

So, exactly, exactly. So DHEA is something which is at the top of the hormonal cascade, right? And see, the rule for hormones is start from the top. Cholesterol— you must make sure that people are not on statins and cholesterol levels of 70 and 80. I've also seen that, right? Then from there, DHEA is extremely important for stress management, for managing cortisol levels. Because DHEA is also produced by adrenals for aging. So it's said that by the age of 30, we start making less DHEA, and by the age of 60, we've already decreased our DHEA production by about 40-50%, right? And it is extremely important if you don't want to age fast. But using DHEA, making sure that you are using DHEA for the right reasons Knowing how you can assess whether DI is getting metabolized to the right hormone, which we want to get the right result which we are aiming at, is very, very critical. And that's where the confidence is. You will have confidence or you will lose confidence, right? Having said that, has any one of you seen a patient of maybe ED who came to you, you put them on DI, and you suddenly realize that his condition is becoming worse?

Doc, I think actually people who have practiced BHRT are few and far, not at least in this group. So, you know, I think even Ashwini is basically, I think, used it for her own purposes more than prescribed it to anybody else, right?

Right. But Mahesh, why I'm saying these cases is that people, when they start using Dia, they say it's available over the counter. Yes, right. And that's the reason I want to bring this forward, that after today's webinar you feel comfortable and you know that BHRT is that missing link in your practice to heal that 30% of patient who is not very, very, very happy with you. Yeah, right. And 30% is a big chunk. So in those patients, I want to tell everybody here, because they've not used— you've rightly said that it's not simply just giving a prescription of DR because it's below the range. You have to understand where it gets metabolized to, what is it becoming into, how the body is using it, and that is when you have to use it. Also, second, you know, I initially start use DR which was available over the counter.

Yeah.

And I did not get beautiful results.

Yeah, yeah.

And then when I used— started using bioidentical, dear, my results suddenly changed dramatically. So that's another thing I want people to know, that quality is extremely important when we take supplements or when we do hormones. So this is just to tell you, this is where we want our hormones to be. And, uh, but let's look at some cases now. Right, so 52-year-old female came to me with complaints of fatigue and insomnia, right? She had just had surgery to— of the right foot. Family history, we look at mother has Graves', father is healthy. So mother has autoimmune condition already, right? Works as a school teacher, has lots of stress at her job. She's on progesterone 300mg. Sustained release, but she is still complaining of fatigue and insomnia. Yeah, right. So this is what— when we did the testing, this is what we found. Low testosterone, you can see. Estrone and estriol were normal. Progesterone was on the higher side.

Yeah.

Yep. So anybody here, what would you want to do? Anybody here, if you think that you can make sense of this? So there is one more data point here. Yes, and this is this melatonin. Because of insomnia, we did check her salivary melatonin. So what is— and this was her salivary cortisol and DIA. So if you look at DIA in the morning, was low, 7 to 9 AM. DIA in the evening was even lower, right? And if you look at the cortisol, see how the graph is going.

The opposite of what it should be.

Exactly. So it should be in the green range. And look at when she rises, how high the cortisol is. And when she's about to sleep, even then the cortisol is high. Yeah, right. So what do you think in this case I would have done with this patient? Should I go back? Yes. Any ideas? And otherwise, I'll request Mahesh to very simply suggest what, you know, we could have done. So the answers here I'm getting are: I've also tried non-BHRT, DHEA, and it has not helped much versus BHRT. I agree with you. I was prescribed DHEA to control cortisol levels and improve adrenal stress. Good. Improve melatonin and DHEA along with cortisol. Yes. So, okay, improve melatonin and that— sorry, Mahesh, you were saying something?

No, I said, is the lady menopausal? I know age-wise she sounds—

yes, yes, yes, the lady is menopausal. Okay. So this is here. So yes, Mahesh, you want to—

I'm still not able to see the values very well, doc.

So, okay, so what I did in this is, right, I actually decreased the, uh, dose of progesterone, the first thing. And remember, whenever we start BHRT It takes about 3 months for the progesterone levels to stabilize, but if we are trying to balance cortisol, it takes about a year. Never promise your patient— at least I don't— that cortisol, you know, will be balanced in 3 months or 2 months. It can be, but it can take longer too. And I gave this patient very low dose of testo, extremely low dose of testo, decreased progesterone dosage, Started her on some chamomile tea and some ashwagandha and herbs. Made her go in the sun morning and night, right? And for this melatonin, I asked her and she said that she had not switched on the light when she wanted to do it, so this test was not, um, correct. So it's very important when we do BHRT that we give right instructions to the patient so that we get right information. But still, even without this information, we know that we have to balance her cortisol. We did herbs and all, decreased progesterone, added Dia for her, and 3 months later this lady was sleeping for 8 hours a day every night, and she was happier. She had started losing weight, um, and her energy levels had dramatically increased.

Why had she been put on progesterone in the first place, doc?

So I don't know, there was some other doctor who had put that on. So yes, but also very good question, Mahesh, because you know what, people think BHRT for sex hormones is all— is about giving progesterone. You are being very naughty. Okay, so, and that is not right, girls. And everybody here who is here, because sometimes it is not about progesterone at all. Also, I have seen patients where E2 is lower than 50, and if that is the case, you will never get results of energy and, you know, bone health and heart health. So you have to know what are the values of E2. In fact, in this case, what I, what I remember is there was another patient where I realized that her E2 was fine but E3 was very, very low, and I had to put that patient on 90% E3 and 10% E2. Because when we do bioidentical hormone therapy, we can personalize and customize it according to the patient's requirement.

Yeah, as well, doc, you know, on the same subject of how you test, like you mentioned, Anita wants to know, do we test the hormone levels from Dutch tests only?

No, we don't. So there are certain hormones which in blood are also fine, especially for the Indian community. I've realized that it's not always possible to go for Dutch, but wherever I can, I do go for Dutch because it gives me a lot of confidence that the metabolism is happening on the right track, because that's where I don't want to go wrong.

And this is the interesting thing, right? So again, Dutch is a little bit like a Janampatri, right? So it's like something that more or less in general will not change too much. So what do I mean by that, right? So let's say you want to give somebody estrogen. You decide that in your practice, let's say the lady is having very poor mood, she's menopausal, there's dryness everywhere, vaginal dryness, bone density shows that she's becoming weaker on the bones. And most important, women don't realize that estrogen is the multitasking hormone. So as soon as you hit perimenopause or menopause, the minute you get irritated, like you're doing one thing and somebody calls you and you're getting irritated, that's usually estrogen that's gone missing. So let's say you want to give estrogen to somebody, but you're worried, are you going to increase their cancer risk? For this, especially if the patient comes with a family history of cancer, it would be a wonderful idea to get one Dutch test at least done. I'm not asking you to repeat it repeatedly. Why? Because once you get a Dutch test, it tells you once you put estrogen into this person's body, and naturally whatever estrogen is there, is it going down a 2-hydroxy pathway, a 4-hydroxy, a 16-hydroxy pathway? And this can make a big difference if it is going down one of the unsafe pathways, you can counsel the patient accordingly. Even then, it's not that you can't use estrogen. You just have to know how to make sure that the estrogen that you give gets metabolized down the safe pathways and not down a naughty pathway. And this is the use of the Dutch. So, Anita, I don't know if that answers your question. Please feel free to unmute yourself.

But also, I want to tell you, Anita, when in the beginning I start, I do progesterone, E2, testosterone, cortisol, DHEA in blood. Yeah, pregnenolone at times if I know that the patient is old, growth hormone, IGF-1, all this. But importantly is we need to know that E2 levels keep changing in blood. Yeah, so salivary is also more reliable. But more than that, what is important is that, like Mahesh said, where is it going? What is— where it is metabolizing? That's very important. Second is when we use BHRT in form of creams the values will not increase in the blood.

Yeah.

So when you repeat it, it will not be very reliable. So you will have to then, you know, as you see more and more patients, then you know the moment the patient enters, you know whether it's harmoniously balanced body or not, from the face, from the walk, from the body's tone, you know, everything. But till then One, one that is not a bad idea.

Any guesses from anybody? The lady who was on 300 mg of progesterone, what is— why was she feeling so dull and without energy through the day? Any guesses? Just think about, you know, where the hormone is going. Just think about what you have heard. Progesterone is Yes, please go ahead. I'm sorry, somebody unmuted themselves, but you've gone back on mute.

I think Riddhi did it.

Adrenal stress, says Dr. Rohit Sharma.

Yes.

So, you know, I'm Of course, the adrenal stress, and Ashwini says, is it estrogen? I agree, both of those things are possibilities. My own experience has been that if you give a menopausal woman progesterone, especially if you give it as a cream or if you give it topically, and you find suddenly that she's becoming sleepier or that she's feeling low energy through the day, it may well be that she is metabolizing the progesterone down the beta pathway. So there's an alpha pathway and a beta pathway of pregnenolone for metabolizing progesterone as well. And if you already favor a beta pathway, you will take all your hormones down a beta pathway. The beta pathway crosses the blood-brain barrier. So once it crosses the blood-brain barrier, it's going to show GABA action, and it's going to make the person sleepy. So if sleep was what you were going for, if you really, you know, this lady had a huge problem in sleeping well, either falling asleep or staying asleep, and you used progesterone, it may well make sense. But in a lady who was actually complaining of daytime grogginess, you would run into trouble if you used progesterone. And you saw this, and if you don't know the pathway, then you don't know if the progesterone's causing it or not, right? So Um, that's basically what I have felt. Doc, is this your experience?

Yes, Mahesh. But I also wanted to tell them here, I think most of you know that low acid and high acid gives you the same symptoms. Do you know that? You— I'm sure we all know that, right? Anybody here who does not know that, or anybody who's come, who's heard this for the first time?

Yeah.

Yes, we know. Great, Dr. Rohit. So this is the same thing with progesterone. High progesterone and low progesterone will give you the same symptoms. So it can be very, very confusing.

Absolutely.

And we must know this when we are using progesterone because people think progesterone is the safest bet. And I, I know of a lot of people who say progesterone can be given to anybody, anytime, anyways, right? But I don't think that's the way. Also, it's very important that if we give progesterone cream to be used at night and the woman is sexually active, then it should not be done. So you need to ask the woman about her sexual life before you decide the time. So in BHRT, one very important thing which is important is what form you are giving, what dose you are giving, and what time you are giving, right? Do you agree with me, Mahesh?

Absolutely. And it's all because you're giving bioidentical. You're trying to match what the body would do naturally. And if you're going to try and mimic what the body does naturally, timing, timing, timing, right? And the way it's delivered— where is it going to go in? If you give it sublingually, where is it going? If you give it as a capsule, where is it going? If you put it on the skin, where is it going? And this can make all the difference to your clinical results. And honestly, the only reason the patient is with us is for clinical results. It's our job to make sure that they are safe and we aren't increasing cancer risk or anything else. But as far as they're concerned, they're here because they have a felt need. Something isn't working in their life. Doc, isn't that the reason why we even look at BHRT in the first place? We do all the other things functional medicine doctors do. We fix the gut, we fix this, we fix that, and yet there aren't results in some people.

Exactly. And also, I've seen, Mahesh, that at least in gut health cases. I have worked with a lot of functional medicine doctors for their own cases, and what they were not doing was they were not doing hormones. Until they were not doing hormones, their mold infection, their gut dysbiosis was not settling. Only it, it used to settle, it used to come back, it used to settle. And I remember in one doctor's case, I just gave cortisol, Hyzone, for a while And the whole game changed. 3 weeks of Izone and the— right? So very, very, um, cautiously, to the right person, at the right time, in the right form, in the right dose, if it is given, it can make a huge change. The second case I've brought is for a male because I am sure a lot of people think that males don't need BHRT, and if they need, it's only testosterone which is important for them. Right, so I thought this is also a very important thing which we should cover. So this was a 64-year-old male with chief complaints that he falls asleep after dinner. Um, he was on testosterone 17mg cream, DR 20mg, pregnenolone 50mg, and other than sleep, there was no other problem. But if you look here, right, his testo was a little higher, his cortisol in the evening was speaking up. Yeah, right. So what will you do in this patient?

This person was already on DHEA when he came to you, doctor?

Yes.

These are all US cases, so your ranges are all US ones, so I need to recalculate them in my head.

Right. So what we did in this was very simple. Right, uh, we, uh, worked on his stress, decreased his testo dose, right? And, uh, after 3 months, he started feeling energetic and his sleep was much better.

What was it? What were his complaints when he came in, doctor?

Just the moment he used to enter home, he used to have his dinner and go off to sleep. He had no urge for anything else in his life.

Isn't that surprising with an evening cortisol that's high? Why do you think that, you know, kind of happened to him?

So my thing was maybe, uh, that one is his testo is pretty high there.

Yeah.

And where it was going, I don't know how it is— it was being metabolized.

Yeah, yeah. So it's actually the salivary testosterone is on the low side, right, at 90. So What's maybe happening here is that the lot of the testosterone— I don't know whether the cells catch the DHT or not, but if he's taking all of the testosterone down towards DHT, yes, towards a DHT pathway, you will get this kind of a reaction. And it would be interesting again to see whether he had this.

Yes, and you had— basically, in this case, we gave zinc Ah, yeah, absolutely.

I mean, again, so, you know, for us, uh, and that's beautiful, Doc. So the practice of BHRT involves also making sure that the minerals, vitamins, cofactors that are crucial for hormonal pathways to work well— that is as important as just using a testosterone. So just using a testosterone will get you nowhere if you use testosterone and it goes down a DHT pathway, a dihydrotestosterone pathway, because it is favored by the person, and you don't have a 5-alpha reductase inhibitor, which is your zinc, which is your saw palmetto— if you do not have those ones, you will end up either balding the person, or the person gets prostatic enlargement, their urinary urgency goes up, and whatever reason you gave the testo for, that really isn't being achieved. So you do need to, you know, uh, while we support the wisdom of the body, the fact of zinc Right? We don't do enough— enough of us don't do zinc testing, at least in India. It's not that popular.

Yes.

You know, at best go by alkaline phosphatase as a surrogate marker. That also is only known to a few folks in the functional medicine world. But it's so important to see the hormone through to the result, right? You want results for your patient. If for any reason you tried BHRT and it didn't work, it's most likely you did not see it through to the result. You gave it at the starting, but there are so many little junctions it has to go through before it does its job finally.

Thank you, Mahesh. And Mahesh, now this I put in here for people to know. I got a report— I— a patient came to me with a report and said, my testo is low, please prescribe me testosterone, right? And he did not have his E2 values with him. He was obese. Okay, right. What— anybody here who would tell me what would I have done?

I think again, you know, some of the people who might be even currently interested in BHRT and studying— I think Dr. Kanur is here. Um, anybody else who might, um, just go back, think, put on their functional medicine cap Uh, so yeah, what would I have done?

That's the only thing I want to know.

But very, very interesting answers, uh, all, you know. Um, yeah, so Dr. Rohit Sharma saying, can we hear about the details again? So, Doc, what Dr. Preeti was saying is that here is a man who comes in with low levels of total testosterone in serum, and he asks for testosterone replacement therapy. But he does not have his estrogen values tested, so we don't have serum estrogen. And the person clinically— the second clue given to you is the person has obesity, so they have abdominal obesity, fat retention around the waist. So that's the case recap. Anshika has a nice, uh, input. She's saying he's aromatizing his testosterone, but aromatization will come later.

No, I don't have the E2 value only. So what I told him is I said you need to go back and check for some other tests. But yes, Anshika is right. Testosterone, if you don't have enough zinc, it will not aromatize, right? And when you have visceral fat, the estrogen increases. And for men, it is very important that the testo-estrogen ratio is 10:1 or even more. Yeah. And I rarely find, Mahesh, people actually doing the testosterone-estrogen ratio.

Yeah, they will come with testo values, but they will come in without E2, and they will say that they have low libido. So low libido plus serum testosterone total low, they will present that as evidence to the doctor and therefore ask for testo replacement. But if you do not have a testosterone to estrogen ratio, especially in obese patients, all of us in functional medicine have read somewhere at least during clearing our exams, if nothing else, that there is visceral fat produces estrone. It is a form of estrogen. It is weak, of course, but it can hugely change the ratio between testosterone to estrogen, and that again can have an impact. Such men will also have higher degrees of inflammation, which again can fuel the DHT pathway instead of actually going towards, uh, contributing to all the good things that testosterone may do.

Exactly. And also remember, fat or obesity impacts your hormones. It increases aromatization, it increases conversion into estradiol, which will lead to increased E2, which will lead to lower ratio of testosterone and E2, and it will create a full imbalance.

Yeah, and but Doc, let me play the devil's advocate since, you know, uh, others are all being very polite right now. Let's say initially, why should I not try to make the person lose fat by non-hormonal means? Why are you giving them hormones?

No, look at what we did. We gave zinc, we told the patient to exercise, right? Improved vitamin D. Got it. We told him no non-organic poultry, no dairy, Hey, avoid xenoestrogens and also avoid all plastics and toxins. And we detoxed him and we gave very little dose of testosterone.

Got it.

And after 3 months, he was a different person completely. He had improved energy, he had lost inches, right? Muscles had grown. Feeling of wellness was there, and testosterone in the beginning when he had come to me, it was 180.

Ah, that is low enough for replacement.

Yeah, exactly. But without doing all of that and without making sure what you asked me, right, there is no point doing BHRT. And why I'm— I talked about this case, I did not get to put it properly in this PPT because, you know, yesterday only we decided we will do— finally do it today. Right, but I wanted to bring this up because this is very, very, very critical, that BHRT is not the, you know, final solution for everything. No, right? But BHRT is that missing link which can bring smiles to your patients. And when you are doing so much in functional medicine, we do so much, we take care of everything from sleep to lifestyle to diet, and we get them off dairy, of gluten, of soya, of eggs. So much we do, right? Um, we detox them, everything. Then why not give them that support which can change the way they will live? Also, I think we think that BHRT, you know, should be done when we have achieved menopause or andropause. Yeah, but that's not the case. DHEA starts declining at the age of 30. Yeah, these days we see low testosterone in 30-year-old men. Yeah, in 18-year-old females I see low progesterone. Yeah, right. So we must have this as one tool in our toolbox.

Yeah. And what is the— what is the difference, doc? What is the speed of results you get when you add this final and when you don't?

So one is, I would say that the percentage of success I get increases by almost 2x. 2x. And I call this smart working. That one pin which was not there, therefore the circle was not complete, having done everything, but the circle is still open, you know.

Yeah.

So that is what BHRT does for me. Yeah, and for my patients. So what I want people to know, I want to talk to you about is I just brought these 2-3 cases just to tell you how despite doing everything in functional medicine, which I do, you know, people who are here, most of you know that me and Mahesh actually set the baseline first even before we do any second step. But this has been a game changer. And I wanted you to see how, you know, things happen. And of course, for not for everybody I do Dutch. I do blood test also for a lot of them and work accordingly. Yeah, the only place where I definitely want to do Dutch, and in 80% cases I do Dutch, is when I start biotestosterone, progesterone, DR, GH, everything in a menopausal patient. I want to know where it is metabolizing.

Correct. And honestly, I, I do it where biased is needed. Yes, I can manage everything else through blood. Yeah, and it's reliable. And salivary testing is also becoming accessible today. The only place where I do feel that it's very important, both because of the social context we live in— all of us somewhere in the back of our mind have that tomorrow if the patient has a hereditary cancer also, they will blame us if we have started them on hormones. So you start first, you be first clear. You forget around evidence for medical, legal, etc. First thing is you be clear that you have not caused it. And that confidence comes from if especially the patient has a family history among females of cancer and you're going to start them on some estrogen therapy because you're absolutely clear estrogen is low in absolute numbers, not just by ratio to progesterone. So there is a real estrogen deficiency in the lady and that there is a family history of cancer. Only then you do the expensive Dutch test. Otherwise, most other hormones starting from DHEA, thyroids, testo, etc., can all be managed with regular blood work and some few screenings initially.

Also, Mahesh, I think why BHRT is becoming more and more important is almost 50% of our life we live without hormones. Yeah, right. This was not needed. I was surprised today to read in 2002 there were 40% women on hormones, right? And imagine now at 40, and between 40 and 50 we achieve menopause, and we are not talking about andropause, but that's the same age when we achieve andropause also, right?

Yeah.

And we live 50% of our life without them.

Yeah. And I think biggest disservice that has happened is that somehow we believe that these are unnatural, and therefore putting you on them is going to cause some terrible side effect, and that therefore you should somehow make the body make its own hormones, right? So, you know, I usually ask my patient this question, Doc, the same thing that I asked you: are your ambitions currently at this age those of a 30-year-old, or are they those of a person on the verge of retirement? You pick the answer and you pick from the menu what are the things that will get you there.

So I'll tell you something here. Sorry for intervening, but I can't resist, right? So you better listen to me. So what happened yesterday, you know, I was with my sister and my sister-in-law and we were all sitting and my granddaughter's photos came, right? And people, everybody was like, you don't look like a grandmom. And suddenly when you said I need to make a choice, I remembered that and I thought, of course, I don't want to look like a grandmom.

Yeah, yeah. And there's absolutely no reason to not do all the basics, right? Right. It's not an either-or. It's not that either I will do BHRT as a shortcut, or I will do gut cleansing, or I will set my vitamin D3, B12 levels, my digestion. Okay, it's not either-or. You did all of that and it improved you, but your own ambitions for yourself are higher, number one. Number two, or that the results begin sliding back after a short period of time. Now the choices are open to you. The real questions to ask is, does DHRT increase risk of cancers? Does it actually make the person somehow compromised? And this is the beautiful answer, right? So here's for everybody who wants to know. So the simplest thing, and this was of course the Women's Health Initiative, and just like they have now gone back on fat is bad, you know, now they are claiming that fat is good, cholesterol is good. The same people have now turned around the initial results from the Women's Health Initiative. The press picked up one sentence which said that in women in whom synthetic hormone replacement therapy. In those days, they didn't call it BHRT versus HRT. They used the urine from pregnant mares. They used progestins instead of progesterone. And even then, it's only when they initiated hormone therapy 10 years after menopause that finally the hazard ratios went up. Everywhere else, the cardioprotective, the bone protection that was received by women was actually positive even with those sorts of hormones that they used. There is reanalysis. You please, you can go ahead and look it up. We'll, of course, you know, those who will be part of the course, we are more than happy to share all of this because nobody wants an unsafe practice. Why would you want to practice something that's going to get you into legal or medical trouble tomorrow? The fact is, DHRT absolutely identical to those produced in your body. Which means it can't be patented, which is why Big Pharma is not really interested in it. Exactly how they turned BHRT. So what Doc said, that for 40% of women were on BHRT, that was when you just took, for example, a wild yam extract, and you, you know, created bioidentical progesterone from it, and you gave it to a woman at that stage, you could not patent it, because it was already a known molecule. So they take it back into the lab, tweak it, turn one or two, uh, you know, benzene rings on their head, uh, add a molecule here, a carbon atom there, and you have a progestin. Now you start calling that progestin also, uh, hormone therapy. You don't call it bioidentical, but you call it hormone therapy. And this is what happens, you know. So there's an old story of Amul and Babul, you know. It's just What's the difference between the two butters? Kuch nahi, it all sounds the same. India is a country of fakes, right? We know the Bisleri, Birlessi, and all these water bottles we get at railway stations. These two things are not the same. The bioidentical ones are extremely safe. We use it ourselves, we use it with our family, we use it with our patients. We do it with care. It's a monitored Schedule X drug.

Exactly.

To be prescribed by a medical doctor, only an allopath. Preferably, and it should be monitored by the same allopath. But that doesn't stop me as a non-allopath from doing all the groundwork, holding, getting up to the prescription, and holding the chart for Dr. Kadambi or Dr. Preeti, who are licensed professionals who can use it. And that's perfectly how you do it, and it's extremely, extremely safe. This has just been my experience and such a game changer for so many women perimenopausal And again, I've not gotten to fertility, but the magic we do in fertility, so much of it is owed to BHRT.

Right, I thought we should keep something reserved for people who join the course, right? Because unless they show interest in knowing more about this, it will not make much meaning. So there's another myth. People say BHRT worsens gut health and inflammation. Do you think so? Not at all. In fact, for me All complicated gut health cases who come to me, I start them on first BHRT and then work on their gut health. Estrogen and progesterone play key roles in gut barrier function. Cortisol and DHEA plays a huge role in gut barrier function. So if you want to work on your gut patients, this is important. Third myth is estrogen dominance only affects women in menopause. Definitely not. I have women with 18 years of age who have estrogen dominance. It can affect women of all ages. And remember, we just saw even men can be affected because of xenoestrogens, toxins, chronic stress, gut dysbiosis. And beauty is that BHRT can help restore balance when paired with liver detox and gut repair strategies. So again, I want to reiterate, we are not saying BHRT is the solution. We are saying BHRT is that missing link with the other things to give the ultimate result to the patient and actually— yeah, right, for which he left his allopathic doctor and came to us. Now of course, Mayesh has spoken about this. BHRT increases the risk of cancer. I think BHRT, when properly administered and monitored, do not increase cancer risk. And in fact, it has been shown that it is protective in many cases. Estrogen metabolism and detoxification pathways are key, so liver and gut are very, very crucial.

So this is a beautiful doc, right? So it's the staging that matters. If you use any powerful tool without setting the groundwork, of course you'll run into trouble. But that's not the reason to not use the powerful tool. The correct—

yeah, it's like absolutely. So you can spend a lot on the interiors and everything, and one small shake will come and the building will be out.

Yeah, and that's the beauty, right, Doc? You— why would you refuse to give testosterone to a guy?

That beautiful house is all BHRT.

That's right. And you know, let's say even BHRT is treated as the penthouse, right? It doesn't matter. You refuse to build a penthouse to a guy who didn't show you his foundations. If he's not ready to show you the estrogen levels and just ask for testosterone therapy, he doesn't get it because you need a strong foundation before you can put the—

Exactly, exactly. And I told him, you have to work on your insulin resistance, your weight, your ER, and come back again, guy. I am here only to help you, but I won't do it wrongly, right? Only women need BHRT for longevity? Of course not. Men also experience hormone imbalances. Low testosterone, high estrogen impact their gut health, their energy, and cause aging.

Yeah, and remember, reverse is equally true, doc. How many people here believe that testosterone can improve ED? Anywhere, show of hands. You can raise a hand, you can put a word in the comment. You know, how many men come to you saying, I have, uh, you know, problems in the bedroom and somehow it has to do with testosterone? Anybody at all? Well, since again, you know, we have a quiet group at the moment, I will say that most of the people who know that we are doing work that includes BHRT will come to us. Fertility patients even will come to us and say, the man will say that I have a problem, that I have erectile dysfunction, and I believe I need testosterone. But in truth, many times, Doc, as you've experienced it, no doubt, you give testosterone, the libido goes up. Libido is not the same as erection, and it's going to happen unless you've optimized all vascular factors including estrogen in a man. If you don't have the right estrogen levels in a man, you will end up not getting vasodilation, and you will not have the kind of, uh, you know, ED solution that you're looking for.

Mahesh, interestingly, you know, for the benefit of everybody who's joined and they've given us their valuable time, for me, history of ED is not only complaint of ED, is not complaint of ED. It's telling me that he's not away from heart attack. Yeah, or heart problem. That's the first sign which comes in men, and nobody talks about it.

Absolutely.

Especially in this type of environment where I think a lot of people are just going anywhere, we are still not talking about ED being the first sign or a very, very important sign that your heart health is not optimum. Do something about it.

Absolutely. So all metabolic disease causes microvascular damage, not large artery disease. And if you understand the blood vessels of the male member of the penis, then you will understand that the same thing is happening to the heart muscle and to all the collaterals.

Exactly. So what I really want to tell you is people think BHRT does not have to do about anything else, but that's wrong. True hormone optimization involves a holistic approach. Gut health, liver detox, stress management, nutrition, and that is when it can become your tool for longevity. So did you learn anything today, or did you feel that you felt a little closer to BHRT which nobody had spoken to you before? And guys, I want you to be awake now. The time is already up, and of course I will not take a lot of your time. But anybody here who thinks that they know a little more about BHRT or are feeling a little more curious about what you can do in your practice? Great, Gurpreet. And I think you are more curious means everybody else is feeling more curious. They are just also feeling a little lazy because their hormones are not balanced. Super, super, right, Mahesh? Thanks, Ashwin. So what I want to offer to you is, 8 years since I've been doing and helping my patients, I want more and more doctors, and Mahesh also wants more and more doctors and health coaches both to be prescribing functional medicine. I know that health coaches are not legally allowed to prescribe But that's where the role of teamwork comes, and we will help you create that infrastructure so that when you know that your patient needs it and that's the missing link, you will have a partnering doctor with you who will help you, you know, do it the right way. And we are launching this 3-month course. Initially we had said it would be offline, but I got a lot of requests for online. So we've changed it to online. The start date is 3rd May now. The first session is 3rd May, 7 PM to 10 PM. We will have 3 hours class every time because hormones, you know, take a lot of time just to create the base. So a smaller session will not be meaningful. We will have one class every fortnight. But that's not all. After 4 classes, we will connect offline and online both, and we will do a BHRT marathon. This BHRT marathon means we will do 1 case, 2nd case, 3rd case, 4th case, 5th case, 6th case, 7th case, 8th case, 9th case, 10th case. So many cases that your mind, mind will start working, and you will immediately know which patient, what hormone how to do it, how to set the base, and you will start rolling. Uh, I promise you, you will love it. Your patients will love it. And if you want to register, so this is it: 3, 6 online classes plus one 12-hour BHRT marathon. All of you will have to do 3 cases in this 3 months with Mahesh Sharma. To get your certificate, which means we are going to be with you to do this. And if you're not able to do this during the BHRT marathon, we will help you think about your cases and make you do it there. So point is, this is not a course where, where we are going to teach you and leave you like many, many other courses. I did it from A4M, they taught me and left me. and I had to study all over again, right? And when A4M did that, I'm sure there are many others who do like that. I believe in practicality, and Mahesh believes in the same. So it's not about teaching you BHRT, it's about helping you reverse Hashimoto's case successfully. Yeah, right. How to use your Thyronorm and your bioidentical thyroid interchangeably. So that you can decrease the antibodies, right?

You will get to know in this course when to use T3 and when to use bioidentical thyroid to help your patient lose weight, and when to use that, you know, very little used and very often abused top of the pile DHEA. It's such a beautiful molecule If you know what to do with it, and if you are able to manage the cascade that happens under it, it's so safe that it can be used. I mean, it's literally being sold.

And it's beautiful. Beautiful. So all of that will happen, guys. And today, if you've attended the webinar, though the discounted price had lapsed 2 weeks back, and we already have few registrations. But for all the participants who joined today, the discount is back again— 65,000 plus GST. But this discount is only applicable till tomorrow evening, 24 hours from now. So if you want to register, you have all the details here. You can take a screenshot, and, uh, I will share a number in the chat box You can speak to her, Akriti, 9868478149. She will help you. And, uh, I look forward, with Mahesh, seeing you in this course, helping you bring smiles to more number of your patients. And, uh, you know doing BHRT with you.

Again, we know that this is obviously, you know, we are doing it because we truly believe that this can be a very powerful tool. But you may have further questions, you may have just dropped in because you are curious. If either of you wants to have a chat, you know, Doc is currently got the flu. I unfortunately will be on a flight from 1:30 PM onwards tomorrow. But you know, feel free through the team to reach out to us. If you'd like to have a deeper chat, understand what we are going to do on the course, how are we going to share what we're going to share. You may be a doctor who truly needs a health coach to help you practice BHRT because the foundations are missing, or it could be vice versa. It could be a health coach who needs BHRT but don't want to get into any legal trouble and want to know that, you know, won't it be another headache adding one more layer? Happy to discuss the practical stuff. We are here to create an ecosystem of BHRT. You know, I said the same to Dr. Vivek Kadambi, who's been a mentor to many of us in many ways. So we are all part of that same ecosystem. We are doing our bit to expand it to, you know, beyond just a few hormones, make sure that there's a larger way in which we can use all of this. So go ahead, you know, make the most of this opportunity. We are here happy to discuss. Happy to— we'd be very happy to see you guys there.

Yes, all the best, and, uh, thank you for joining. And we can promise that the ROI you will get is more than 3x, because I think both of us calibrate ourselves and our work too much ourselves only. So if you are in doubt, then just jump in. Any questions you can ask now, or you can call us later. You have our numbers, or you can call Akriti, and from Akriti, you know, she will connect you with names.

I think we are all part of either IAFM or functional medicine group or something. You all have our numbers in the group, so feel free. Whoever would like to reach out and understand more, anybody here who came through Facebook Uh, Ashwini says she came through Insta.

Okay, thank you. So I was just trying to see if something worked. Ashwini, thank you, Ashwin. And of course, for your own treatment also, you can get in touch. That's not a problem. But I strongly believe BHRT is a long-term solution. You must understand it first so that you can do it for long term and in the right way. So even if you want to do it for yourself, it is that 40, 50 years you will use this. Might as well invest some hours and study it and just understand it, right, Dr. Mahesh? Because I think when you understand, you get the confidence to do it on yourself. Yeah. Great, thank you very much. Have a great evening, and thank you, Mahesh, and thank you. Bye-bye, take care.

Bye-bye.