Exclusive Dr. Hyman+ Ask a Doctor: Weight Loss, ADHD, Hormone Replacement Therapy and More

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Hi, everyone. Thank you so much for tuning into today's episode. My name is Melanie Heroldson, and I'm one of the producers of the Doctors Pharmacy podcast. we are excited to have Dr. Elizabeth Boehm back to answer your questions this month. As many of you know, Dr. Boehm is a medical director of the Ultra Wellness Center in Lenox, Massachusetts, and has done several deep dives for our Community as well as our AMA episodes. So, Dr. Boehm, we are so excited.

To have you back for this month's episode. Welcome. Thank you, Melanie.

It's great to be with you and with all the listeners. So thanks for having me. Thanks. So we've collected our Community's top questions, and we are here to ask you anything. So let's get started with the first question. so this comes from a Community member who went into premature ovarian failure at the age of 34 after going through a few extremely stressful and traumatic events. She's 42 years old now. She's been taking HRT for the past four and a half years and estrogen, a low dose, one pump a day, and progesterone. Is there any concern about her being on HRT versus bhrt? And I don't know if you want to kind of explain the difference between, between the two, but just if, if there's any concern about her being on HRT versus B HRT. And then is there any concern about her being on HRT long term since she's in her early 40s? Would it be safe to continue taking it for an extended period of time? And are there any long-term risks associated with it?

Yeah. So HRT is, is, is short for hormone replacement therapy and BHRT is short for bioidentical hormone replacement therapy. But there's a lot of hormone replacement therapy, even ones that you can get from a conventional pharmacy that are officially bioidentical. So I'm not sure exactly what progesterone she's on, but her estragel is actually an estradiol, which means it is bioidentical. It's bioidentical to what your own body makes. And so if that's as opposed to some of the hormones that were popular a bunch of years ago, Premarin, Provera, that was not bioidentical to your own body's estrogen. It came from pregnant horse's urine, and it was a different structure. So many of the hormones out there, whether they're patches or creams, are considered bioidentical. And as I said, you can even get them compounded at a compounding pharmacy, but also they're available at a lot of regular pharmacies. Probably the estragel she's on, she's getting from a regular pharmacy. And it is, as I said, an estradiol. So it is bioidentical to what her own body makes. I hope that that helps sort of clear that one up because it's a little confusing. But in this situation, because she went through premature ovarian failure at a young age, it does make sense for her to be on some hormone therapy until she reaches the average age that a woman goes through menopause. So the average woman goes into menopause or stops having their period between the age of 45 and 55. So it's great for her to be on hormone therapy. And this is, you know, at least the estradiol is a bioidentical until sometime within that age range. And that's to prevent any of the risks from the deficiency of estrogen that can occur when you go into menopause at an early age. So and then and that's largely bone density, right? So, So I don't have concerns. Of course, with any therapy, including hormone therapy, you're always weighing the risks and the benefits, right? But this seems like a pretty good treatment for her to be on at this period of time.

A follow-up question that she has is, if she wants to focus on losing fat, particularly in the midsection, is it better to work out strength training in a fasted state in the morning or after a small meal? Any other advice on losing belly fat? Yeah.

So, you know, exercise and strength training is a great way to lose belly fat. You know, exercise and strength training improves your insulin sensitivity. And when you have insulin resistance, the body likes to put weight around the belly. So, so great job with getting the strength training in. And what I will say is there's been a lot of research to show that when you do your exercise first thing in the morning, you're more likely to do it. if morning exercise time is a good time for her, then we really just want to do it, right? Just do it. And one of the things I get concerned about is too many rules. So sometimes when there's a lot of rules in play about timing of food and exercise and all of that, sometimes that gets people confused and then they just don't exercise. So first of all, the most important thing is to get the exercise in. And if the morning is the best time for this person, morning is great. Not everybody feels comfortable eating in the morning. Some people get nauseous or they're just not hungry. And so I think that exercising and doing strength training in the morning, either fasting or with a small meal beforehand, both are great. There is some research to suggest that that small meal before strength training in the morning may help us put on more lean muscle mass. And the reason the reason is because you're less likely to break down your own lean muscle mass if you're in a fed state versus a fasted state. So people who have fasted all night long, of course, and then they start strength training first thing in the morning, there is a potential risk that in order to have the nutrition and the calories to exercise, they might be burning up some of their only muscle mass. So that's a potential concern. But so if somebody wants to have a small meal before exercise, a great thing to do is 200 to 300 calories with about 15 grams of protein. And so that may be like a banana and some nut butter or a small smoothie. And those are things that people might enjoy having first thing in the morning. But, you know, honestly, just exercising in the morning is great and you're doing a good thing for your body in terms of helping prevent the the weight gain around the belly.

Okay, thank you so much for that. So the next question is, do you have any thoughts on a postmenopausal female struggling with ADHD symptoms, focus, task completion, and horrendous anxiety? Are there any supplements that would be helpful? Any thoughts on taking both a stimulant Vyvanse and HRT? Are there any dangers to be aware of?

So I guess I have a few questions. So I would wonder, when did these symptoms start? So did they start when this woman went into perimenopause or menopause? Or have they been lifelong symptoms, right? So is the attention issues and anxiety worse now that this woman has gone through menopause? And how long has this woman, how long has it been since she had her last period? Those sorts of things help me determine what's going on and why. there may be this increased issue with attention and anxiety. So definitely hormone shifts can be at play here. So we do think about hormones, especially if it seems like the timing is, went through menopause and then these things got a lot worse. But there's a lot of other things we can really work on. So I wonder about her protein intake. Is she getting protein at every meal, right? So both animal and vegetable protein, beans, legumes, nuts, seeds, soy, eggs, fish, chicken, beef, protein at each meal to help balance blood sugar and help with the attention and focus. Also focus on making sure you're getting enough omega-3 fats. Those omega-3 fats really help brain health. So, you know, your fish oil, your fatty fish, your ground flaxseed, really wonderful for omega-3 fats, lowering inflammation, and brain health. I'd make sure that she had some basic labs done. You know, what's her thyroid like? What's her iron like? Her cortisol? You know, maybe even do a sleep study to rule out sleep apnea because we know that sleep apnea, where somebody has these apnic episodes at night and they stop breathing, that actually can be a major contributor to having problems with attention and even anxiety at night. So, you know, a sleep study can be a really helpful thing to look at if somebody's really feeling poorly in that area. Progesterone is a hormone and progesterone, when you take it orally, can really help with anxiety and sleep. And so that may be a hormone that you consider, you know, in this situation, or maybe even a comprehensive bioidentical hormone replacement. In terms of supplements, I think, oh yeah.

I was just going to say so I this so this question is from the same individual as the previous one. I just kind of yeah, so we just kind of broke it up to make because they're kind of separate questions. So I think the same thing applies here where she is taking the estradiol or the estradiol along with the progesterone.

Ah, okay. Okay. So I guess I'd be curious as to what type of progesterone they're using. and if it's oral or transdermal, and if it's transdermal, meaning through the skin, oral might be more helpful for the anxiety. And you could also make sure you got the progesterone compounded in a bioidentical progesterone. Sometimes that helps more than other forms of progesterone.

Okay.

Yeah. In terms of, thank you, that's helpful. In terms of supplements, there are amino amino acid supplements that we often use for focus. So they are combinations of amino acids that help with making neurotransmitters that help with focus. So they will have tyrosine in it, tryptophan, taurine, and they can be very helpful if somebody's not on an antidepressant or if they're not taking Vyvanse. So if they're looking more for a supplement treatment, those can be really helpful. I also use a lot of magnesium, magnesium glycinate or magnesium threonate to help with calming and anxiety. And maca can be also really helpful as well. But I guess I'm curious as to the timing of the attention issues and if they are really related to menopause or it makes me think that something else may be going on if these issues weren't lifelong.

That makes sense. And then is there any dangers to be aware of if they're taking, like, say, both Vyvanse and HRT, or that's okay together?

Not necessarily together. Not necessarily together, you know.

All right, awesome. Thank you. So kind of following along the same line of menopause. So this question comes from a community member who had surgical menopause in 2021. She's currently 56 years old. she's currently experiencing the following symptoms: no energy, no sex drive, mood swings, and hot flashes. What is your advice for addressing her symptoms should she look into taking BHRT?

Right. So, you know, 56 or when you've recently gone into menopause is actually the time you want to think about hormone therapy. So you don't want to wait too long after going into menopause. The research shows that hormone therapy is the most helpful when somebody is perimenopause, so when their periods are irregular and they're starting to go into the change of hormones, as well as an early menopause. So typically if we're going to start hormone therapy, the general recommendations are to start before the age of 60. So this is a great time to think about it. And, you know, hormone therapy definitely can help with hot flashes, especially that's kind of like they can definitely help for that as well. And so this is a time to look at the risks and benefits of hormone therapy. But the other thing that I think is really important is that we step back and we look at this person as a whole. And that's really what we do in functional medicine. We get a really detailed history of what their timeline is, what their life experience is, what are their personalized lifestyle factors like. You want to really focus on the bottom of the matrix we talk about in functional medicine all the time, because when you support those personalized lifestyle factors, that really helps support all the hormones in the body. So, you know, that is making sure somebody's getting adequate sleep, making sure they're doing daily and regular exercise, making sure they're getting the right food choices, balancing their blood sugar, getting enough nutrition, getting the right nutrients, avoiding too much alcohol, right? All those things we know that can change how we're feeling significantly. Doing some stress reduction techniques every day and having good relationships and networks, all of these things really support all of the hormones in the body. They also support your adrenal glands. And remember, we have these two adrenal glands. They sit up on top of our kidneys, and the adrenal glands are these glands that help us with all sorts of things in the body. So the adrenal glands secrete cortisol, and they help us with managing stress. And when you have good working adrenal glands, that process of going into menopause is often smoother. And so focusing on those adrenal glands and supporting the adrenal glands and what what is called the HPA access, right? That supporting that part of the body will help this process. And so really good research to show that 15 minutes of breathing exercises twice a day helps with all these symptoms. They can cut hot flashes in half, both the amount of hot flashes and the severity. That breathing exercises can help with sleep and they can help with mood and irritability. And the other thing I find really helpful for a lot of women in this timeframe is acupuncture. Acupuncture is a great modality that can help support hormones during this transition. And then we sometimes use supplements that support the adrenal glands. They'll include things like adaptogens, which include rhodiola and ashwagandha, B vitamins that have some methylated folate in it, and maca. All of those things can be really supportive as well as hormone therapy. or instead of, depending on where that person's coming from and their individual risks and benefits and what their goals are.

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