10 Things Your Doctor Won't Tell You About Hormone Replacement Therapy (But Should)

You know, midlife isn't necessarily the beginning of the end. It's actually a time of radical transition and also a time of ownership. And so one of the biggest levers we have in reclaiming this ownership is hormone replacement therapy. So today's episode is all about the 10 questions and things you should be looking at if you're doing hormone replacement therapy. So after 20 years of practice within my clinic, where I've had clinicians prescribing hormone replacement to tens of thousands of patients, and then also with our telemedicine company, Minerva, we have identified areas of concern not so much for should you do hormones or not, but how to optimize hormones and make sure you're getting the right amount for you. So what we're going to go through Today are the 10 questions and the 10 things you should know about hormone replacement and where you need to go and ask questions and what you need to do if your practitioner isn't really aware of how to take care of you in a highly personalized way. We're going to be talking about natural bioidentical hormones and the difference between that and synthetic and or Premarin, which is horse mare urine, and how to use premarital precision in guiding hormone replacement therapy. So let's get into the 10 things you need to know. So one of the things that gets said a lot in the media, especially online on Instagram, we have two camps. You've got the pro hormone replacement camp and the pro bioidentical hormone replacement camp. And then you have the raw dog. Menopause is a natural transition. Just go through it naturally and narrow do the two meet. But let me make some clarification about hormone replacement therapy and where that information is true and not true. So the first thing that happens is you will often get a practitioner that'll say, bioidentical is a buzzword. Well, that's not true. So, number one, bioidentical is not a buzzword. It is biology and biochemistry. Most women never learn that bioidentical hormones are molecules that, that are identical to your molecules that you make. So while bioidentical isn't defined by the FDA as a particular standard, bioidentical means that the chemical structure of the hormone that has been made in a lab is identical to the chemical structure of the hormone your body made. Now, why is this important? Number one, Pharma, all your pharmaceutical companies do not really want to make bioidentical formulas. You may ask yourself why. Well, they cannot patent chemicals that exist in nature. So to Make a bioidentical estradiol or a bioidentical estriol and estradiol or bioidentical progesterone or bioidentical testosterone doesn't make them money. What does make them money is when they alter the chemical structure, slightly moving a molecule or adding a molecule to it or altering it significantly at that moment, they can patent it. And when they can patent it, they can keep other people from making it, and they can jack up the price to whatever price they want. And that has been the MO for pharma for decades now. So bioidentical, what you need to understand, it is not just a marketing tool, but it is actually the definition of a molecule found in nature that is identical to the molecule that's made by our body. Your receptors recognize them. That's why it's important. So imagine that bioidentical hormone is a key. And just like a key for a lock, there is one key made for one lock. So when you go to put that key in the lock, the receptor, the lock hole, actually recognizes that hormone. Exactly. When you have a chemical that is different and not biologically the same, you actually have a chemical that jimmies the lock and may get it to turn, but doesn't work really well. So bioidentical chemicals made in a lab that are identical to what your body makes has receptors that understand them and can recognize them. Also, your body's own metabolic pathways that utilize those hormones and then package them to get rid of them, otherwise known as biotransformation or commonly known as detoxification. Those pathways understand exactly how to manipulate and maneuver those ingredients, those bioidentical byproducts, to get them out of the body. There is no confusion. There is no slowing down or increasing the metabolic pathways. Your body has already been doing that every single day of your life. So your body's detox pathways, recognize them and your body will respond predictably. Right. You already had estrogen as a hormone for the majority of your life at physiological levels. Same thing with progesterone, same thing with testosterone. Your body knows exactly how to handle those hormones in a predictable way. And if we were to look pre menopausal, let's say your 20s and 30s, we would understand that what would your body kind of predictably do with those hormones? Because your body already processed those hormones for years before your ovaries ran out of fuel and ran out of eggs. So when you have a synthetic hormone, it's not going to be as predictably handled as it would be if it was a bioidentical form, this is the take home message. If you get told by a provider that bioidentical is a buzzword, they are trying to subterfuge and hide the fact that bioidentical hormones are identical. Or if you're in England, body identical, are chemically identical to what your body makes birth control IUDs, synthetic forms like medroxyprogestins are not bioidentical and therefore do not act the same and your receptors don't recognize them. Your detox pathways are going to handle them slightly differently and your body may not respond as predictably. This is the basis of how we've treated patients in my clinic for 20 years and how we do it online at Minerva with all 50 states and women from everywhere across the United States. That's the first one. Number two, your symptoms that you are experiencing anywhere from about your mid-30s on through your 50s are, are not random. They are metabolic signals. Things like belly fat, weight gain, sleep interruptions, anxiety, depression, heart palpitations, joint pain, irritability, hot flashes, night sweats, brain fog, fatigue, they are all metabolic signals. They're signals that there is a hormone shift going on. Now, in some cases, there might be other exacerbating hormones. And if you've listened to menopause mastery, you know, I talk about this all the time about our hormones being a symphony. And anytime we have a significant amount of stress for a prolonged period of time or an extremely stressful, restrictive diet, we're going to see changes in my adrenal response, which is cortisol stress response. We're going to see issues with my thyroid. And guess what, when those two things are occurring, we will also see sex hormone changes as well. So when we have metabolic signals of change, we have to start looking at what is my overall picture here. So if a doctor is dismissive of your metabolic signals that something is going on with your hormones, then you may have somebody that doesn't understand the nuances of how our hormones act together. And so they're signals, right? So when we have these symptoms that could be signs that your progesterone is declining, loss of muscle mass, muscle fatigue and poor recovery could be signs of testosterone, declining, estrogen's crazy bungee cord experience. And then fall is going to result in a lot of those other symptoms, like hot flashes, night sweats, insomnia, mood regulation, all of those things. And those are all signs. And then I would say secondarily, and this is where our team has added a lot from a Paradigm and framework standpoint is we have to look at those other symphony players. Your adrenal response, how's your stress? What's your sleep like, what your. What your thyroid is doing? If the thyroid is not dialed in, you know what? Fertility got this a long time ago. When you have fertility issues, one of the first things a fertility doctor is going to test is your thyroid function. Because not having appropriate thyroid hormone amounts consistently can result in period changes and including missing your period or not having it, and regulates ovulation and fertility. So the thyroid often interacts at perimenopause and menopause. And if your doctors are overlooking it, they're overlooking the signals your body is telling you. So you intuitively often feel this. You're like, okay, I'm having hot flashes, night sweats, all of these metabolic signals as something's going on. I think it might be perimenopause. But I also have a feeling that it could be my stress, it could be my thyroid. And if your doctors are not paying attention to that, you might be in a situation where you're not being completely looked at and completely cared for. And you should demand to have those things tested and evaluated. And if your doctors say no, that's time to fire them. Right? This is your body, your life, your choice. All right, so number three, the whi, otherwise known as the Women's Health Initiative Study, the scare about that was about synthetic hormones and pregnant horse mare urine. There we go. So if you weren't sure about that, we're going to go into it. So let's talk about it. So the world paused. Hormone replacement therapy, that had been standard of care since the 1940s. The first prescription for estrogen replacement for menopause was in 1942. So hormone replacement therapy was standard of care, given out like candy all the time, without reservation until the 2002 Women's Health Initiative. But here's the thing that you don't know is the Women's Health Initiative and basically all the subsequent research that includes Women's Health Initiative data actually was about Premarin, which is made from pregnant horse mare urine. And premarin contains 13 different estrogens, right? So your horses make 13 different estrogens. Now, humans, we make three. We make estradiol, estriol, and estrone. Only now horses make those estrogens plus 10 others. Now, that product, just so you know, had been on the market for decades and had been the standard of care. So Premarin had been used without reservation, again with no indication of increased risk for breast cancer or breast cancer mortality. No increased risk. However, there is some increased risk based on studies looking at much older women know, 15, 20 years postmenopausal using Premarin orally because of what we call first pass liver metabolism. So the synthetic form of the progestin, even if that was left out, when we look at premarin. Premarin has 13 estrogens that your body must metabolize and detoxify. And some of those estrogens that our body doesn't naturally make go through the lever and produce both byproducts. Right. When they produce those byproducts, There's a couple that we believe may actually be what we call SERMs, selective estrogen receptor modulators. And serms are part of the treatment process, like tamoxifen for estrogen sensitive cancers. So there could be some metabolic byproduct that is made from those 13 estrogens found in Premarin that could be advantageous in a breast cancer treatment. Now, have we done a bunch of deep dive in that? No, we have not. But what we do know is when a woman takes Premarin who starts at, let's say, 75 or 70, there is an increased risk for stroke and heart attack, and especially if they have what we call aortic stenosis, which is narrowing of the aorta, which is the major artery at the heart. And it's. So it's a very, very, very small population, but it's not something that we could ignore. So oral Premarin in much older women do carry clotting and cardiovascular risk. If you've never been on hormones before, right? Now, what was the other big thing that we found in the Women's Health Initiative that is completely separate from bioidentical hormones? Synthetic medroxyprogestins or progestins, they increase clotting risk in women. And we know that that arm that was on Premarin in six synthetic progestins had an increased risk for stroke and heart attack. So what we know is that synthetic forms of progestins and Premarin with horse mare urine is not an ideal dose or strategy for any woman. Right. But the Women's Health Initiative then lumped all that data and tried to claim that it was the same for everything. Now, we've had subsequent studies. There was a 10 million woman study that came out in 2024 looking at hormone replacement and longevity and mortality. It was actually published in the Menopause Journal. And what we found is bioidentical forms. So Body identical forms of estrogen do not carry clotting risks. Right. So Premarin does. Prempro does things like prometrium, which is the pharmaceutical version of micronized bioidentical progesterone. Not my favorite because it's got peanut oil in it. However, it is one that can be prescribed and picked up at any classic pharmacy is not going to carry clotting risk or increased risk of mortality. Body identical and bioidentical forms of estrogen in the form of estradiol or biased, which is estriol and estradiol either in patch, cream, oil and even pellet. Not a huge fan of pellets, but even pellet form can and does not have any increased risk for women to have clots and heart attack. Even if you're older. We have research now indicating that from observational data. Now, the right thing to do would be to do studies on clinical trials to guarantee we understand it completely. But we have plenty of data showing that women on bioidentical forms do not have an increased risk of mortality from heart attack or stroke. And what we do see is an improvement in bone mineral density, cognition, and when started appropriately, in that first decade after menopause, we also see a reduction in cardiovascular risk and cognitive decline. And so this is where the disconnect came between the FDA approvals and the current research. And this is why it, it's become hard to ignore. And it is why the FDA actually asked for the removal of black box warnings on estrogen products a couple weeks ago. And this is why women need updated information. So if you talk to a doctor and they whip out anything about Premarin, Provera, Prempro, or you can't take it because you're too old, because it's an oral form or a synthetic medroxyprogestin, they are not informed. And this is a good time to find somebody else who is informed. Number four, your gut and estrogen are in constant conversation and are intimately connected with each other. So this was the area of research for my PhD dissertation. So I have spent over two and a half years immersed in the literature in a way probably nobody else on the planet was. Now, you know, estrogen metabolism obviously is my playground. And your microbiome, right. So we have microbes in our gut. Think of that as a jungle. And our jungle has lots of animals. The more animals we have, the better off our gut is, especially when we have a lot of each one. Right. Now, the microbiome goes through some shifts when we enter into menopause. And one of them is the change to a group called the estrobolome. The estrobolome are microbes that actually make an enzyme called beta glucuronidase. Now, beta glucuronidase actually exists in lots of places in the gut and the rest of the human body. So beta glucuronidase as an enzyme made in the gut is primarily made by our microbes. Although we have beta glucuronidase enzyme activity in our bone and lymphatics and other tissues in our body. Here's where it becomes important. So beta glucuronidase alters, particularly the gut microbiome levels of available estrogen that can get recirculated from the toxins being slated to be excreted out through the stool. It allows it to get unwrapped and thrown back into what they call hepatic recirculation. So liver recirculation going back into your bloodstream. Now, when we go through menopause, this actually increases. We see an increase in these bacteria. Now, you may ask yourself, why? Why would we possibly see an increase in this? Well, there's a couple things that we see. This is important because the body needs more estrogen, and this is a symbiotic relationship between the microbes and our body. So when our estrogen levels decline, our microbes try and help by supporting more beta glucuronidase and more mobilization of estrogen compounds back into circulation. Now, that becomes problematic when you have xenoestrogens and environmental toxins and plasticizer, herbicides, pesticides, fragrance, phthalates, all that look like estrogen in the body. That increases the risk of overall exposure to toxins that are a different key. Remember I was talking about the receptor? The key in the receptor needs to work. When we have toxins like that, they kind of look like the same key, but not completely. Now, this is really important to your treatment long term, especially when we look at going through menopause and beyond. So if you're looking at hormone replacement, it's important to also understand your gut health. And this is in true of basically everything. Your gut health defines your health. You cannot be really healthy with a really jacked up gut because your body can only make things like proteins, enzymes, and other structures in the body based on the nutrients it can take in, digest, and then assimilate. Right? So your gut is responsible for that. So the gut is really, really important to not only getting nutrients, but it also will help you determine how well you metabolize your estrogens are you able to use them and then get rid of them appropriately, whether your body is recirculating too much or too little, leftover sort of funky estrogens that were slated to get trashed. So we have to evaluate your health of your gut. Now, that doesn't always mean stool testing, but if you're chronically constipated or you have chronic diarrhea, or you've got IBS or other things that will impact the quality of your hormone replacement experience. So gut diversity matters. Your detox pathways, the ability for your body to get toxins out and whether you're nourishing them properly will make a difference. So if you have doctors or other providers that are recommending a lot of detox support products without supporting data, you may be moving these pathways in ways that you don't want. Same things. We want to know, do I have too much of this bacteria producing beta glucuronidase or too little too much on either side is actually problematic. And we want to know what my level of inflammation is like. Am I chronically inflamed? When I'm chronically inflamed, that's going to affect things like my detoxification pathways, inflammation and inflamma. Aging also impacts our microbiome. We have a relationship together. We're symbiotic. If we are inflamed, they are inflamed and likely producing inflammatory other byproducts, enzymes and other things. And so that microbiome and our gut are intimately tied to how well my hormones are being managed and packaged to get thrown out. So if you went on hormone replacement therapy and maybe you've got some gut stuff now, the truth is you could still have gut stuff and not have symptoms. But if you have gut stuff and you went on hormone replacement therapy and your symptoms are not quite what they should be, or maybe you're getting a lot of symptoms, this is the area to start looking in. The other thing is, if you're taking oral progesterone, right, oral things like prometrium, or you're taking a bioidentical compounded progesterone, either compounded in oil, micronized, slow release, and let's say whatever you're taking and it's not working properly, the gut is often where we have to examine what may be going on. You may not be able to break it down and utilize it properly coming out of the gut. We need to see this. So your standard care never looks at this right? So your standard of care of just hey, you got hot flashes, night sweats, here's your hormones, let's go. They do not look at this. So if you especially are symptomatic, this is an area to start looking. And it takes diet, lifestyle appropriate nutrients to feed your microbiome, especially in this season of life. Number five, testosterone is a woman's friend after 40. Now here's what's important is testosterone doesn't radically change in perimenopause and menopause. We talk about it in this time period because we have an entire medical system, both in the United States and Europe, that ignores the fact that testosterone is made three to four times the amount of estrogen at any given time on any given day in a woman. It just happens to be about 10% of what a man makes. So it's patriarchal medicine at its best. But here's the reality is testosterone levels slowly decline in women from our peak in our early 20s, and it declines pretty steadily. So by the time we get much older, we are at a much lower level. Now, if you take a 35 year old and compare them to a 55 year old, you may not see radical differences in the levels because again, it's on a steady decline. But what we do know is testosterone is a woman's friend. Now the FDA in the United States has not approved testosterone for women. And, and it's approved in Europe and England for sexual dysphoric disorder or lack of libido. And so therefore it is prescribed off label in the United States for low libido and lack of sexual interest. Now that again is highly rude when we know that men have, I think it's like 17 different forms of testosterone for every possible reason under the sun. Because the assumption is if a man's hormone, primary hormone, is declining, then we must replace it. But a woman's primary sex hormones like estrogen, progesterone and testosterone declining is just a raw dog experience. So here's the reality. FDA has not approved a testosterone replacement for women in the United States for treatment for other than lack of sexual desire. So what does testosterone really help with? So testosterone helps with energy, motivation. It is as much a brain hormone as it is a body wide hormone. That's why it improves libido. Libido is a mood, not a sexual thing. It is a mood and so it's really important to that. It also improves muscle structure, muscle building and bone density by design. So improving muscle contraction, muscle building capacity, the ability for the body to put on muscle will improve both bone and muscle. It helps with insulin sensitivity, particularly at the muscles, which is our largest user of glucose. And obviously libido is super important, right? And I think it's even more important now in this season of life. You know, some of our inhibitions and our fucks go away. I don't care whether people like me or not. I don't care if you like what I look like in a bathing suit. But I do care about how I experience my life and my joy. And that also includes my libido. So. So testosterone can help with that as well. It improves cognition, mental sharpness, and mental acuity. And it's highly utilized for motivation. So many women will tell you when they get put on testosterone as a treatment, they're like, oh my God, it's like my brain turned back on, I'm back, right? And so testosterone is necessary. So if you have a doctor gatekeeping testosterone or telling you you can't have it, you can, right? There are multiple ways to prescribe it. So conventional physicians will prescribe off label and use things like Androgel, which is a male dose of, of testosterone, and try and get you to use minuscule amounts. You have to kind of guess your way. They're not a fan of that because I don't think anywhere else in medicine would we guess our way to a dose. However, that's what conventional like menopause society trained clinicians will do. Now, you can also have compounded bioidentical testosterone dosed for a woman, Starting at a low dose, working up to a moderate to higher dose, dosed for women. And that comes from a compounding pharmacy and usually is either done in a cream, an oil or a pellet. Our team at our clinic and then our team at the telemedicine company uses compounded bioidentical forms. To me, it seems asinine to prescribe something that's not prescribed at the right dose for you because that leaves the patient, the one person who didn't go to medical school, trying to figure out if they got their dose right. And it leaves you where you could have fluctuating levels. And so that's what we recommend. But testosterone is part of that picture. Now, some women may experience hair loss, chin hair growth. Hate to break it to you, chin hair and fuzz is part of menopause whether you do hormone replacement or not. Now, there can be situations where a woman produces more androgens like testosterone, androstene, dione, dhea, where you got a test. So the other part is if you have a prescriber that's just handing you testosterone without testing, you leave yourself at risk for not having balanced levels. We don't guess anywhere else in medicine. And how dare the medical establishment assume that we need to guess on hormone replacement for women? Testosterone is the same way. It needs to be looked at, it needs to be addressed, and it needs to be tested on a regular basis. And it's important to have it because it is metabolic power. It's not masculinity. Ladies, if you're noticing more fine lines and wrinkles, it's not just about aging. It's about the loss of estrogen. And that affects our skin structure, making it drier, thinner, less firm. But here's the great news. I've created Biased Mastery Cream to help. This luxurious bioidentical estrogen cream support supports your natural hydration and elasticity. It's packed with nourishing oils like olive, jojoba, aloe and coconut. So it feels amazing and helps soften those lines and bring back that healthy glow. I've been using it and let me tell you, my skin has never looked or felt better. It's smoother, more radiant, and those little cracks and creases are way less noticeable. If you're ready to give your skin some extra love, check out Bi est Mastery on the Metabolic Blueprint website. And that's metabolicblueprint.com BI EST mastery. That's B I E S T mastery. M A S T E R Y and your face will thank you. Okay, number six, hormone replacement therapy, whether it's bioidentical or not. Now of course you know that I'm a bioidentical fan is not a one size fits all plan, right? We know that from research. Dr. Louise Newsom out of England, who is leading up menopausal care therapy for the entire English medical system, did a study out of her own patient base and what she found was the standardized dose that was recommended in England because they're ahead of us, they have a standardized hormonal therapy dose. What she found in her population was that 50% percent of women using the standardized high dose in that system would be under treated to protect the brain, the heart, the bones, and 25% would be over treated. So the reality is we don't know how much hormone you produce naturally when you were 20, 25, 30. We don't know exactly how much you need to dose of whatever delivery mechanism, whether it's cream, oil, pellet patch for you to achieve ideal dose. It depends on your personalized absorption, your metabolism, your microbiome, your gut and so precision is required here. And how do we understand precision? Number one, we test. We don't guess. We use blood labs to identify if we're at a therapeutic range. Based on the research, it's not the best place to test, but it is where we can identify if we're in those ranges that we know from research that protect the brain, the heart, the bones. And we're also testing other things like thyroid and blood sugar. Now, the other part is we want to test urinary hormones. That tells us how we're metabolizing. What are those? Estrogen pathways. Am I able to package the leftover xenoestrogens and the ones that my body are making or taking and can I get rid of them? We want to know your methylation status, like your B vitamins and sulfation, which is the last exit route for estrogen. We want to map out cortisol patterns and your thyroid. We need to understand how those interplay. A lot of women come to us and they've been on hormone replacement therapy, but they're not feeling better. And it's because there's usually something missing in the mix, because there are a lot of practitioners out there talking about hormone replacement like it's the panacea for everything. It's the magic pill. And it's not just about your sex hormones. That may have been the straw that broke the camel's back, the one thing that pushed us over the edge, but it is not at an absolute. And it's also really important to understand that your hormones, like estrogen, progesterone, testosterone, interact with your brain chemistry like dopamine, norepinephrine, epinephrine, serotonin. And that there's receptor activity that is similar, there's metabolism activity in your detox pathways that are similar to. There's action in your gut that are similar. And if we're not getting the right outcome, there may be other areas that are being overlooked. And you have to also look at if you've got an overload of toxicity or an immune system and detox system that doesn't work well. We have to understand that some women will experience histamine increase as estrogen levels fluctuate and decline. Some women will experience a heightened immune response that shows up as MCAs or overlap syndromes, where we have more allergy, more immune stimulation, hormones. All of those things interplay. So if you've been diagnosed with some of those more complex health problems, hormones are part of that picture. But there's other things that are being overlooked. And just restoring estrogen levels are not going to be the only thing. But what I can tell you is it is probably part of the picture for most people dealing with those types of health problems is it's very hard to manage histamine control, allergic response, inflammatory response when you have no estrogen and no progesterone on board. So it's important. Hormones don't live in a vacuum, but they are not a one size fit all panacea for every possible problem that may occur in a woman over 40 on average. All right, number seven, timing matters. Your hormone timing, when you start hormone replacement has its most possible best outcome the earlier you start in that therapeutic window. So basically we have good research showing that starting hormone replacement early and in some cases this often means long before your periods stop. So one of the most insidious things that I found in my research and in my own body as I went through going back for my PhD and really digging into the literature and is number one, even as a functional medicine practitioner with some of the most luminary practitioners in the world, it was commonly thought that if you had hormones and a period, right? So if you were having a period and mine at the time was coming every 21 days, that you have plenty of estrogen, right? In many cases you were estrogen dominant. And I'm air quoting that, and that maybe progesterone is the thing you need when periods come closer together. That's usually the case. However, the prevailing wisdom at the time was also that if you're having a cycle, you still have plenty of estrogen and you might be estrogen dominant. Well, guess what? That may not be true. There was a poster session that was brought out during the Menopause Society meeting not too many weeks ago, and it looked at 120 million women's records. And what we're starting to understand from observational data is that we may be replacing, placing estrogen too late and that might be better to start low doses earlier on. Now, that usually still means after progesterone has been started and it may mean after testosterone has started. But the timing matters, right? The timing matters because we want to do is make sure we're intervening early in protecting the brain, protecting the heart and protecting the bones. What we've seen in research is that bone loss accelerates in the couple years prior to the last time you have your period. So it doesn't happen after the periods end. It actually accelerates in that last window of the menopause transition. And so when we look at the therapeutic Window. The take home message is the earlier you start, the better you are using precision and lab testing to identify where you need to be on this and that we want to start as soon as possible to that menopausal window. And so for many of us that means maybe starting earlier. If you happen to be listening to this and you're sort of in the throes of perimenopause now, our best case scenario is within 10 years of menopause. And that is because you've had arterial aging and bone loss, right? And you've had cognitive changes because the brain shrinks and remaps the brain as we lose estrogen. Now that's your best, most therapeutic window. So the earlier you start, the better. Now, what it doesn't mean is it doesn't mean you can't DO hormone replacement 15 years post menopause. What it does mean is we may have a diminished therapeutic window of seeing the best possible outcome, but we still have good data showing it helps with bone mineral density. We still have observational data that shows it improves mood, sleep, anxiety, depression, brain fog. We have plenty of other reasons that we may examine hormone replacement therapy. Even if you're, let's say 70, 75, and you went through it years back, you have to use topical forms of estrogen and we want to use non synthetic forms of progesterone, we want bioidentical. But our therapeutic window is earlier rather than later. And I know, I've talked to so many women that, you know, were part of that Women's Health Initiative BS that we were told. And so they never started hormone replacement. And now they're heartbroken and sad and angry because they feel like they were robbed of that therapeutic window. So here's the deal. The sooner you try and sooner you get sort of balanced back with testing with precision, the better the outcomes. However, we have women, we've been doing this for over 20 years in my clinic. We have women that we put on hormone replacement in their 60s who are in their 80s and still rocking it, right? So it doesn't mean that we don't lose therapy, it's just the best possible outcome seems to be earlier. Now that the Women's Health Initiative data has been rolled back at the FDA and we're taking that black box with warning off, we'll actually be able to start doing studies again. We haven't done any real clinical studies in 20 years because of that stupid black box label. So we'll also be able to provide more data and more information later on. So Timing matters more than people may think. But that doesn't mean you can't have it if you don't hit that perfect timing. Hormone replacement therapy delivery method makes or breaks results. So bioidentical hormones are. And hormone replacement therapy come in the forms of patches, creams, trochees, which are under the tongue, injectable pellets, oils, right? And then there's oral forms. I am not a fan of oral forms and especially not the synthetic medroxyprogestin and especially not Premarin because of first pass liver metabolism. When you take something orally, it moves through the digestive tract to the liver form, first gets metabolized through your detox pathways and then hits the bloodstream. And especially Premarin and some of the other medroxyprogestins. That's where the concern is, especially in older women. We get byproducts from the liver that you don't really want. So and then we do have oral estrogen, we have oral bioidentical estradiol. For somebody that no other form works, you can use oral estrad, but again, it's subject to that pathway. And now the good thing is, is it's only one and it's what your body makes, so it can be used. I still prefer topical forms, but you can, you can kind of imagine what you would like with that. Now, how do we know whether the method is right for you? So this is a little bit of trial and error. I will give you our clinical experience over 20 years. So me personally, I've had every brand of pellet put in my butt. So, so soda pellet, Avexa, Pel Biot, all of those different brands. The pellet is easy, right? The pellet goes underneath the muscle tissue, or actually the fat tissue right up against the muscle and it's a little tiny pellet. And it gets absorbed over time, usually about three to four months, and it absorbs slowly. Now what we see is it depends on the pellet manufacturing whether that absorption is steady. But what I have seen clinically, both in myself and others, is that you get a slow sort of buildup, particularly of testosterone. And so those, those levels need to be really monitored because you can often get super physiological levels that can change things like hair and other things. So pellets are easy, but not the preferred form. Now we have other ones like creams, right? So bioidentical creams that are compounded with testosterone and then also your estrogens depend on the cream itself as the carrier. Now all of these contain solvents and emulsifiers to keep it suspended so the hormone and the cream doesn't separate. Now those are endocrine dissepting, but there's not much we can do about it because they have to be in there to keep it from separating and to also keep it from going bad. So creams depend on the delivery and what's in the cream. There are several standardized bases. Everybody's a little bit different. One person will absorb it, great. The next person person will not. And so if you try a cream and it doesn't seem to work, the next step would be to change pharmacies or compounded base and then you can identify if that's working or not. Now, the estradiol patch is often a preferred method from conventional medical and conventional pharmacies. Because it's a patch, it goes on twice a week, usually like Sunday, Thursday, or some people do Monday, Friday. And you just put it on and it's slowly absorbs through the skin and absorbs fairly well. Now, if you're somebody with a lot of allergies, adhesive allergies, MCAs or something else like that, it's probably not the best form for you because it does have endocrine disrupting ingredients and possible immune reaction to the active adhesive. Troches gets absorbed in the mouth and it absorbs into the mucosal barrier and that's how it gets utilized. So you get absorption here and you should switch swallow very little of it. Whatever gets swallowed does get subject to detoxification pathways. Now this depends on absorption. Sometimes we hyper absorb out of the mouth. So again, testing is really important. So troches are the other choice. And then you have injectable forms. This is usually most commonly used for testosterone, cypionate or several different kinds. And then there's also estradiol injection. Injections. Most people are a little bit needle phobic. And usually the injection is a couple times to one time a week. What you will get is sort of a peak and valley to that dose. You know, some people love them, other people do not. You know, our hope is that we've got other choices that don't require injection because that also is harder to transport if you are traveling. Now, the last and the primary hormone that we use both at my clinic and also in at Minerva, is hormones based in jojoba oil. Jojoba oil is just that, it's a waxy oil substance that that stays in suspension very, very well. It absorbs quickly in the skin and absorbs into the tissues. And so the hormones that we use are basically jojoba oil and hormone. No other ingredients, no toxins, no emulsifiers. And it's just that now we studied it for two years in our clinic, and we started using it there and then also in the telemedicine company. And what we find is we get really great absorption. It travels well. It's very easy to meter out exact dosing, and it's very, very effective. And so your delivery mechanism makes a difference. And so if you try deliveries, right, here's the thing. Transdermal and even oral micronized progesterone, they absorb differently in people. So if you're doing hormones and you're trying certain ones and they don't seem to work, change the method of delivery, change the. The base, if it happens to be a cream, and possibly the pharmacy. Not all pharmacies are the same. And again, some people use a particular base, and if that one's not working, you probably can't use that pharmacy use a different one and definitely look at the absorption and how it's used. Now, the other part is, you know, how it gets made, how it gets utilized, whether it increases clotting risk can be mitigated by using topical forms of estrogen, by using topical or sub Q forms of testosterone. That's why we don't use oral. Now, progesterone can be done orally as long as it's micronized and you get good absorption and you don't increase liver burden. So if this is important to you and you've been trying it and you don't seem to get the right kind of expectations and support, try a different form. And if you like pellets or want to try pellets, just make sure they're testing you and making sure that testosterone does not get too high. I've seen a lot of people over time. It was great in the beginning, and then they start to see things like hair loss. This is why personalization really, really matters. So number nine is BHRT works best when you address the big five. So what are the big five? So hormones open the door, but these are the things that keep you thriving. And these are the things that will also contribute to maybe not feeling your best when you do start hormone replacement. So number one is insulin and leptin sensitivity. So let me start with leptin, because not everybody has heard of leptin. So leptin is a hormone made by our fat cells that talks directly to the brain and the hypothalamus, and it sets hunger and it Sets fat storage very, very important. This hormone is actually one of the major survival mechanisms in the human body. Now, leptin is sensitive in a very healthy, metabolically healthy person, meaning as your hunger levels climb, your leptin levels climb with it. And as you feed, they go down. What's really interesting is the finding of leptin happened in 1997, and it was actually because we had genetically engineered rats to be healthy rats. And these were rats that were going to be studied. And in one of the rat cages, they found one rat that was eating uncontrollably, was overweight compared to its genetic brothers. So they euthanized the rat and started looking for differences. And what they found was that this rat was missing a hormone called leptin that all the other rats had. And so this started one of the greatest pharmaceutical races ever done on the planet. The idea being at the time is they thought, well, humans must not have enough leptin or have leptin. So therefore we're missing this control. So essentially what happened is they started creating leptin and they injected leptin into a genetic brother of this rat, and lo and behold, it lost weight, right? So lo and behold, the control mechanism of leptin controlled hunger and satiety, and. And it was fine. Now flash forward into the arms race of leptin dieting and leptin drugs, which there aren't any on the market for a reason. So what we found was that leptin in a human made by your fat cells that talk to the hypothalamus, becomes dysregulated, and when it does, you get leptin resistance, which means the brain no longer understands hunger and satiety and gets the message to store fat first. This is very much driven also by poor sleep shift work, insomnia, high cortisol levels associated with sleep problems. So you can pretty much guarantee that leptin control is not going to be working very well if you have sleep issues. Now, leptin is also tied to insulin. Now, insulin is the shuttle that carries blood sugar across the cell wall into the powerhouse, the mitochondria. And we become insulin resistant also, which means our muscle tissues at first become less sensitive to glucose, and we get less glucose burning, more fat storage. Now, different organ levels become insulin resistant at different times. The muscles are one of the first places, and then it works through different organs. The liver is one of the last to know, along with the brain. And when they become resistant, we get fat storage in the liver and, and then we get kind of Dysregulation of the whole system and you start to see things like type 2 diabetes. Well, as we go through menopause, we become more insulin resistant and therefore often a little more leptin resistant. And so really working on the sleep, the exercise and dialing in blood sugar control by eating a high fiber, adequate protein and low processed food diet, along with adequate exercise, particularly after meals to help help burn off glucose, will help. The other thing is all of your body operates with cells, right? Every organ in tissue is made of a cell. A cell is made of mitochondria. And the mitochondria are your energy producers. At its very basic minimum, they are very easily damaged by oxidative stress. So the ravages of aging, the loss of estrogen, the lack of antioxidants will damage your mitochondria. Enforcing and improving mitochondrial health. By making sure we get the right nutrients in the right place, things like CoQ10, your B vitamins, adequate protein, making sure that the cell membranes are healthy, that we have good phospholipids from things like choline in the diet, omega 3s, we will have mitochondria that aren't functioning. And if my mitochondria aren't working well, my hormones are not going to work that well. Same thing with muscle mass and resistance training. Frailty and lack of muscle is one of the biggest drivers of aging and loss of independence. Older in life and loss of muscle mass accelerates as we enter into the menopausal transition. And if we're not actively trying to put on muscle with strength training, we are absolutely going to lose muscle, which makes us more prone to insulin resistance, leptin resistance, fat, weight gain, lack of energy, mitochondrial dysfunction, it's all wrapped up together. So muscle mass, strength training, and I would throw in agility training and flexibility also. Those are all things that start to decline as we get older. Stress and the physiology of stress and the cortisol curve. Menopause is a cortisol excess time period relative to your sex hormones. So when your hormones like estrogen, testosterone and progesterone decline, cortisol is going to either stay at the same place, if not increase, based on your psychological, physiological and environmental stress, but just in general it is high relative to your sex hormones. And if we aren't trying to address those things with lifestyle, like eating appropriately, not doing overly long fasting, time periods, not over exercising, you know, protecting your sleep like your life depends on it, all of those things will affect that cortisol curve. And when that's in better control, your hormones work better. And then last but not least is inflammation and other areas of inflammatory response. Now, most everybody will tell you from their own experience is we can't have as much of an inflammatory lifestyle as we may have been able to handle when we're 30. So that is things like the alcohol consumption and wine. So many women tell me that, you know, I could handle it before, but now I can't because it's inflammatory. Right. Being in environments that are toxic are inflammatory, having an inflammatory diet with highly processed foods, we aren't going to respond as well. And so we have more immune stimulation. And that immune stimulation can also be excess histamine and also increased mast cell activation and other things that drive what autoimmunity, allergy, hives, and other breakouts that were never present before. And really, estrogen and progesterone are part of that control mechanism. But if we have a more inflammatory life, our HRT is not going to work as well. So we have to address those things, too. And so when all of those things are in sync, they don't have to be perfect, Right? Okay. Perfection's not real. But if we're putting energy towards my insulin and leptin sensitivity, making my mitochondria work better, proving muscle mass, and doing strength training, if I'm working on my stress response and maybe learning boundaries and other things, and I'm eating a less inflammatory diet, my hormones are actually going to work better. And ultimately your outcome becomes better and becomes more predictable, which is even more important. All right, so the last number 10. So when you're looking at hormone replacement and you're looking for your perimenopause to menopause and beyond, journey number 10 is the goal isn't to feel younger. It's to feel more like you. One of the things I often hear from our patients, whether it's in our clinic or our telemedicine patients or women at speaking engagements and online, is that they often want their energy, sharpness, humor, sex drive, ambition back to where they were. Right. I almost always hear I loved my body when I was in college. Well, there's a couple things there. Number one, 18, 19, 20 years old, you're not even at sexual maturation yet. Your body was not fully developed yet. It might have been close, but not 100%. The other thing is, is we never will go back from where we are, but we can absolutely become more of ourself and a better version of ourself to today. And I think that is the focus that I want Every woman to think about. It's like, how can I be? Have more energy, sharper, more witty, my humor better, have better sex drive, align my ambition with my passion and my purpose, and have stability. Right? The women that really thrive in this time period don't want to be 25 anymore. What they want to be is the best version of themselves today. And when we come at it with that mindset, we come at it with the right mindset. We want agency over our body and over our experience. We want natural bioidentical hormones to support that expression of ourself. And that's the fastest way to get it back. But it's again, getting back to whom I'm supposed to be right now, not 25 years ago. Who am I supposed to be right now? And when your biochemistry aligns with your identity and your purpose, your mission, your passion and your goals, that's where it feels like that world completely opens up. So we don't want to necessarily feel younger and go backwards in time. We want to feel like a better version of ourself today with the energy, alignment and purpose and passion that aligns with who we are today and who we want to be. I think when we come at it from that mindset, we get the right mindset. All right, so Those are your 10, your 10 anchor things you want to address if you're doing hormone replacement therapy or considering it in this perimenopause and menopause journey. It's also the 10 anchors that you want to make sure that your provider that is helping you navigate this time period is paying attention to and personalizing to you. And if you're starting this journey and you've been given confusing, outdated, or dismissive information, especially if you've been gaslit, just know that there's a whole new body of science that supports you living longer, stronger, more vibrant, and hormonally supported. And we do have data, right? Yes. A lot of the data that we're looking at that's occurred in the last 22 years is observational data, meaning that we're looking at the expression of individuals and their diagnoses, their treatments, and looking across, often retrospective, so backwards in time, to figure out when certain things occur at the same time. Are they correlated or not? Those are still valid studies, right? We have a lot of understanding today, observationally, of historic data, Both with the 10 million woman study that came out in 2024, and then also in some of the new data that's coming out this next year in 2026, where we understand that hormone replacement therapy done in that therapeutic window has the best possible outcome. But even if a woman is significantly outside of that therapeutic window of the first 10 years, we still have a lot of data showing that women that start hormone replacement therapy with the body identical forms used today in the form of topical estrogens, oral micronized progesterone and testosterone when appropriate and with the right dose, have better longevity, have reduced risk of cognitive decline, better bone dexas and better bone density and reduced cardiovascular risk and I would say all other risks with better quality of life. And when we look at that, this stage of life really is not about slowing down, it's about becoming. It's about being this better version of yourself. So let me know if you this is really resonating with you, if this is the information you needed. I've also included the same information with a downloadable top 10 guide for you to download from this episode. You can find it in the show notes so you can have this so you can really take it and look at it yourself and sort of score yourself on how well you're doing. And then ultimately if you're struggling and you need help and you're not finding the help in your own hometown. And this is the reason why we created Minerva. And Minerva is really designed to help women across the United States and all 50 states Predictive care for your hormone replacement and your health in this next season. And so I will also include a link in the show notes below so you can talk to somebody about your hormones and find out if Minerva is right for you. And you can find all of our information@gethormonesnow.com or where you can schedule a time to talk to one of our team and find out how we work with women. You know, my goal has always been, over these last 20, almost 22 years was not only to create the next generation of healthcare, but to really help each individual woman feel more like themselves and have the best possible health span. And so that's really what we're here to do. And I want to thank you for listening or watching Menopause Mastery if you happen to be watching this on YouTube, don't forget to subscribe so you don't miss the next episode. And then also if you've got questions or comments, please leave them below. Again, if you need any information, we have some additional information in the show notes that can help you with this navigating this next season. And then if you happen to be listening on your favorite podcast platform, please don't forget to leave us a five star review that helps us reach more women and helps us get the information out. So thank you so much from Menopause Mastery, and I'll be back with you next week.