Hormone Health Secrets Every Woman Needs to Know

Coming up on this episode of the Doctor's Pharmacy.

I think that one of the things that people are always arguing about or questioning is, well, that Women's Health Initiative was using Premarin and Prempro, right? It was using those non-bioidentical hormones. And if we give hormones that are bioidentical, right, identical to what the own body makes, would that be safer?

Yeah.

And of course that would be safer. Is it safe enough?

Hi, I'm Dr. Mark Hyman, a practicing physician and proponent of systems medicine, a framework to help you understand the why or the root cause of your symptoms. Welcome to the doctor's Pharmacy. Every week I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting discussions with other experts in the field.

So let's just jump right in.

Why are women's hormones so screwed up. And by the way, men's are too. I see like 20 and 30 year.

Olds with testosterone levels of like 80 year olds. And I'm like, what is going on here?

But a lot of it's due to poor metabolic health.

So let's talk about women because it's.

A little more complicated with women.

It's not just about, you know, bad diet.

It's about a lot of things that are influencing their hormone function. Well, I mean, each hormone is going to have a different thing that's messing it up is the way that I look at it. So I think the best place to start this conversation is to realize that men are really driven by one hormone, which is testosterone. And testosterone, you know, is made in the outer layer of the testes, goes up to the brain and converts to estrogen. Women, we've got testosterone, progesterone and estrogen made in not just the ovaries, but the adrenals and some of the peripheral tissues. So we have to really address different lifestyles when we're looking at these different hormones. When we look at why women are struggling right now, a large part of that is there's a one-size-fits-all approach to healthcare. I walk into my doctor's office, I have high cholesterol, I have high glucose or high insulin, and we're never asked what part of our cycle we're at. So we have a real challenge just being able to get medical care that can bring in this hormonal picture. So more women are suffering. I don't know if you saw the New York Times article on menopause recently, but one of the things that really stood out to me is that there was this line where they said that we have a societal acceptance of women suffering with their health.

Yes, 100%.

100%.

I'm like, you don't need to suffer. Absolutely.

So we, you know, a woman when she's suffering goes into the doctor's office. and they're given a one-size-fits-all approach. So we have that issue. The second issue we have, and this is a big part of what I'm trying to teach women, is that when you look at your menstrual cycle, estrogen has vastly different qualities and lifestyle habits she wants us to live by, whereas progesterone completely wants us to do something different. So let's just use cortisol as an example. Estrogen is pretty forgiving of cortisol. If you decide to run a marathon or do a really long fast when estrogen is coming in, it's not going to really affect estrogen too much. But progesterone that comes in the week before your period, it does not like when cortisol shows up. When cortisol goes high, progesterone goes shy. Like she's out. She's not going to make her appearance. So then we start to see women losing their periods. and then, or having really difficult periods once they start because of the lack of progesterone. And that's just with cortisol alone. We could do the same thing with glucose, insulin. I mean, you can take exercise, we should be exercising according to our cycle, but we have to look at these three hormones through the lens of our lifestyle to get them back in balance.

Yeah, so important.

And, you know, I think there's a.

Lot of other things that affect women's hormones too. Obviously, the stress, sugar in our diet, alcohol, environmental toxins, sedentary lifestyles, all these things affect our hormonal balance. And there are things that we can usually do something about. Toxins in the environment, we can reduce our exposure. It's a little harder, but pretty much everything else, whether it's smoking or caffeine or alcohol or sugar or how we manage stress or sleep, all these are things that are within our control. And I've seen so many patients just recover from years and years of misery.

And thought they just had to live.

With PMS or I thought they had to live with all these menopausal symptoms.

And, you know, it's important to realize.

That you actually can fix it. How do we decide, you know, when you need to use hormone therapy? What ways that we can use lifestyle that actually work better than hormone therapy, whether it's the pill, pre-menopausal or hormone replacement after, you know, what are the things you're finding as you're helping women through this process of regulating their hormonal dysfunction with food and lifestyle.

So my philosophy is always lifestyle first. Do lifestyle, clean up your lifestyle, and then see if you need the medication or you need the hormone therapy. So that's my approach. Now, what is a big challenge that we have right now is that I strongly feel as our hormones start to decline around the age of 40, that our lifestyle has to dramatically change. And this is another piece of education that's not getting out to the world. And so there are five things that I recommend women over 40 start to do. Fasting is one and cycling their fasts, going in and out of high carb, low carb, and making sure that-- Really?-- yeah. So going into low carb so we can balance estrogen and then going into higher carbs so we can keep the thyroid happy. and we can keep progesterone happy. And then making sure you're eating enough protein for sure. And then the third one is you gotta, most women when they get into their 40s, they've got to repair their microbiome. They've been on birth control for decades. They've been on multiple rounds of antibiotics and steroid use. Their microbiome is in bad shape and you need that as you move into those perimenopause and menopausal years. And then you mentioned it, detox. another one. We got to start teaching women how to look at all their beauty products and what are they doing for detox in general. And then the last one is what was actually a phrase coined by Dr. Libby Weaver and it's called Rushing Woman Syndrome. We got to bring in more mindfulness tools. We've got to learn how to chill out a little bit more. And so we got to start with those five steps first. And then if that's not course correcting, now you can go in with more success, whether you choose bioidenticals or hormone replacement, it's up to you. But we've got to stop looking at those tools as being this, I'm going to absolutely do it or I'm not going to do it. Because as we go along the journey, there may be a time you want to pull it in, but you're still going to have to fix your lifestyle.

Yeah, there's no way around that for sure. I think a lot of people just don't realize how powerful it is and it works better than most medications. And I can't tell you how many women I've helped with all sorts of hormonal disorders from menstrual issues, PMS, heavy bleeding, painful periods, cramping, to really more serious issues like fibroids and infertility and PCOS. and it's just amazing when you start to apply these principles that a lot of women out there who struggle with these issues can get better and not using hormonal therapy.

Right, right. And I know this is like a hot debate right now, especially amongst women's health groups, is really this idea of should I do hormone replacement? Should I not? I know we're looking at it a little different. But what we have to realize about hormones is that there is the production of a hormone, then there is the breakdown of a hormone, and then there's the hormone being able to get into the cell. So if all you're doing is focusing on the production of a hormone through a medication or through a hormone therapy, you're still got to have a good microbiome to be able to break that down. You still got to have a great functioning liver to break it down, and you got to still detox so that hormone can get into the cell. So this is why I, you know, doesn't matter if you're going to do it or not do it. It's a personal choice, but those five steps have to be considered. Otherwise, you're going to end up in one of those situations where you're like, I took it, it's not working. You're going to say, and women as women, unfortunately, what we do is we start thinking it's our problem. It's our fault. It's our fault. We did something wrong. And that has to stop as well.

Totally. Amazing.

So, where do women start?

How do they start thinking about working on this for themselves? How do they begin a strategy? What are the steps they should take? You have this five-step program.

Kind of walk us through what it would look like.

Yeah, so the first place, it depends on your age. So this is the other complicated thing about talking about women's hormones is that we've got women that are in their fertile years, the 20s, 30s, teens, 20s, 30s, we've got the perimenopausal years, the 40s, and then we have the postmenopausal. So the first is you got to know where you are and what your hormones are doing. If you have a cycle, make sure that you, you're tracking your cycle. I'm also a huge fan of, of a urinary hormone test so that you know where your hormones are at. Highly recommend that because then you know what you need to work on and you, and you can get to know these. This is why I call them the personalities. Like, we got to get to know the personalities of these hormones and when they're showing up, like, progestrone is going to make you really hungry and crave carbs. And estrogen, estrogen is going to make you very verbal and want to go out and, you know, and put your party hat on and be out, you know, socializing all night long. And testosterone is going to spike your libido and increase your motivation and drive. So get to know these personalities because they're coming in and out every single day. Once you know that, now how do you pair your lifestyle? And this is the five steps that I wrote. I actually wrote that in a book called the Menopause set. And so that's that was my book before fast like a girl. It's all written out there. But start to take these five steps and ask yourself, am I fasting? Am I varying my foods? Am I working on my microbiome? Am I detoxing? And am I slowing down? Start there. I mean, that could be a decade. That could be a long time working on that. And then from there, you can start to figure out, do I need to supplement? Do I need to go into more hormone therapies? from that point you can navigate. And it's not a linear absolute approach. And this is perhaps why we have been giving women one size fits all. Because it's much easier for the doctor to say, your cholesterol is high, your blood pressure is high, take this medication. Then, hey, you're gonna need to eat different, you're gonna need to vary your fast, you need to stop stressing, repair your microbiome and detox. Most women are like, what? I have to do that.

Right, right. It's a lot, right?

It's a lot. But it's where health exists. I mean, it's putting the responsibility back on us. And then the other part of that is all of us. I love this idea of women doing health as a community because when we are in community, we're raising oxytocin. And when you bring oxytocin up, you bring cortisol down. And when you bring cortisol down, you regulate insulin and now you can regulate your sex hormones. so women are so good at connecting in community. Let's do it all in a community and learn from each other and share our stories with each other.

I love that.

I love that. I think it's really important because I.

Think when people feel isolated, they feel on their own, they feel like they just have to figure everything out, you know, and that they're not getting the answers they want from their doctor.

And I'm curious, like, why do you think it is that the medical system.

Is just so blind to hormonal regulation for women?

Well, I think the first part is that we look for absolutes in our healthcare system. You have this symptom, I'm going to give you this diagnosis, and I'll give you this pill or surgery. So it's very linear like that. I call that more of a patriarchal or masculine approach to health. When we look at a more feminine approach, and I love this, I actually heard Sarah Blakely speak last year, and she was saying that one of her desires was to bring a feminine approach to business and be able to integrate the masculine and the feminine together in business. And she believes that that was one of the reasons why Spanx was such a huge success. I would say the same thing needs to happen with healthcare. We need to bring the feminine back into healthcare. And what that looks like is us understanding our own natural cycles and then not giving our power away to the doctor and just saying, Hey, Here's my symptoms, tell me what to do, but actually to start to collaborate with our doctors and say, tell me why this is showing up at this part of my cycle. Tell me what I can do that affects the different aspects of my cycle and become educated and have an educated conversation with your doctor. So I really see an integration of the feminine, the masculine together that's going to change this conversation within the doctor's room. But what's happening is within the doctor's room, it's absolutes, it's guilt, it's shame, it's one size fits all.

That has to stop.

And it's not their fault, honestly, because I never learned about any of this in medical school. And I think one of the things.

I'd love you to talk about a little bit is hormonal testing, because I think we don't know how to manage hormones through testing, whether it's saliva testing, you mentioned urine testing, blood testing. What's the best way to get a handle on hormones? The Dutch test, there's urinary estrogen metabolites, blood work that you can do to look at hormone levels.

Talk us through some of that. Yeah.

So if you're a cycling woman, a blood test is not that helpful for you. I think that your door in is more a Dutch test. I'm a huge fan of the Dutch test. In fact, I don't know what your feelings are on the Dutch test, but I feel like if we could get a Dutch test into every woman's hands somewhere around in her 30s and her 40s, she could really start to see if her lifestyle was working for her or against her. And one of the reasons I love a urinary Dutch test over a blood test is that it can tell me the estrogen metabolites. And the estrogen metabolites are how is your estrogen breaking down. So you can go and get a blood test and your doctor might say, oh my God, your estrogen is so high. It's probably coming from toxic estrogen, maybe an endocrine disruptor. But when we look and compare that to a Dutch test, which we've done a ton in my clinic, we start to see, well, maybe it's high because you've been eating really well and you actually have a lot of the good protective estrogen and not as much of the bad estrogens. So the Dutch just gives us so much. more than a blood test.

And that's a saliva test or is that?

It's a urine test. Yeah. It can be both. Saliva is really for adrenals. A lot tells us a lot more about adrenal function, which is also important for hormonal health.

Yeah.

I mean, it does a test so much, that's all the cortisol hormones, it attests the sex hormones.

It gives you a really pretty good.

Picture of where things are. And it depends on where you do it in your cycle if you're premenopausal, right?

Yeah, so that's the other thing is Dutch will have you do it somewhere between day 17 and day 21 so that we can see what progesterone is doing, which is really, really important. You also get like DHEA levels, you get an organic acids test with it now so you can see dopamine and norepinephrine. These are things you just don't get on a blood test. You're just getting a big broad picture whereas Dutch is giving you the details.

And so what exactly does the Dutch.

Test look for that's different than you'd get on a regular panel of hormones that your doctor would check like FSH, LH, estrogen, estradiol, progesterone, testosterone, how is it different and why is it better?

The way that I look at it is I think the Dutch is a more functional. So remember, if we go back to this idea that hormones need your gut, they need your liver, they need the support of the other hormones, So, we can't, when we just look at LH, FSH, and we just give it a big broad picture, we're not really looking at the supporting actors. Let's put it this way. If estrogen, progesterone, and testosterone were the stars, we need to know what the adrenals are doing. We need to know what the liver is doing. We need to know what the thyroid is doing to affect that. And that is what the Dutch gives.

You as opposed to a blood test. And it measures different things too, right? Not just, it measures different kinds of sex hormones, not just the ones we typically look at, right?

Yeah, so it looks at major ones are estrogen, progesterone, and testosterone. It looks at cortisol. It also will tell you your cortisol pattern, which is super cool because you can see if your pattern of when cortisol comes in is actually in regulation with what it's the circadian rhythm of the day, what is actually supposed to happen. We've read thousands of Dutch tests in my clinic. And one of the biggest things we see is that women will have high cortisol at 8 o'clock at night and very low cortisol at when she wakes up in the morning. And no wonder she can't sleep and she needs coffee to wake up in the morning. So it's really helpful for showing you that pattern. And then it also will show you methylation pathways. So we can see like, are you able to detox efficiently? Or is your body working really hard to detox? Or maybe it's been exhausted because it's been detoxing too much. So, I mean, I could go on and on. There's so many nuances in the Dutch test that you just don't find anywhere else. That's powerful.

And it's not easy to interpret.

There's a lot of numbers on there and the average doctor will have trouble.

So, yeah.

Do you use them? Have you, are you familiar with Dutch test?

Yeah, yeah, we use it in our practice for sure all the time, and I find it very, very helpful as an addition to sort of the overall picture. But, you know, what's really quite encouraging for me and hearing you talk is how powerful lifestyle is and how things that are within our control without even hormone therapy can make such a difference and that there, you know, there are such simple ways through, you know, this basic five-step program that you've mapped out with fasting, personalized nutrition, stress management, detox, and lifestyle changes that can basically optimize women's health, men's health too, by the way, and basically slow the aging process. I love this idea of personalization and customization. It's central to functional medicine. I also love talking about how we can use fasting in different ways at different times for different results. We covered, for example, just basically time-restricted eating. as a way to optimize metabolism and hormone balance, but also deep cleaning fasts, which are three to five, maybe longer fasts.

I 72 hour fast is something I.

Want to try again, but I get nervous because at 63, I don't want to lose too much muscle. And so I think that there's always.

That kind of balance.

And I think we do need a time to sort of give ourselves a rest from food, and then we need to refeed, as you said, to Dr. Yeah.

Let me know when you go into 72 hour fast, call me. I'll coach you through it. I'll make sure you do it successfully. But, you know, I want to really highlight this idea around lifestyle. And I so appreciate that that is so much of your message because I feel like we have lost the art of healthy living. And we can say that it's causing all kinds of chronic disease problems. But when we bring the hormone, the conversation of hormones to the surface, We can't, we have to start with lifestyle. Otherwise, you know, we've got women that are chasing down supplements that are great. I'm not, I'm not opposed to them. Or we have women that are either so scared of hormone replacement or they're like, it was the greatest thing of my life. Or we've got women that are taking thyroid medication and they're not seeing any results, but their doctor saying, but your thyroid tests are completely normal. It's because we're missing lifestyle.

Women have to suffer a lot more hormonal chaos than men for a lot of reasons. Their hormones are changing all the time with menstrual cycles, with menopause, with puberty. They're much more sensitive to environmental toxins and how those impact hormonal function. They're much more affected by stress, they're much more affected by alcohol, by dietary changes, by lack of exercise, by smoking, all these things mess up hormones. So it's important for me to understand what their hormones are doing, how they're affecting them, why they feel what they feel. And we see, you know, incredible array of hormonal disorders in women that cause so much suffering. It really isn't necessary. It, you know, women should not have screwed up hormones that cause all sorts of symptoms like PMS or fibroids or PCOS, which is polycystic ovarian syndrome or infertility or menopausal symptoms or menstrual cramps. I mean, these are, these are things that, that are not a design flaw in humans. It's because of how we're living and what we're doing, and then we have agency over. So, you know, I've written a lot about this. I used to be a doctor at Kenya Ranch, and I basically, that was my whole population, was women between, like, 30 and 60. So I got a really good sense of what's going on and was measuring a lot of hormonal tests and could see changes over time. You know, think about it. 75 of women have some PMS symptoms, which is nuts.

Why?

Why is that an, something women have to suffer from? It's not. And I had a, a patient recently who had severe menstrual cramps, and things were really out of balance for her and she didn't really realize what was going on. And there's ways to fix that. So we were able to fix it for her, change her diet, adjust a few things, and she has no more menstrual cramps. So the body has an incredible capacity to repair and heal. We just have to know how to activate it. So one of the tests we look at for women, a few of the same ones, but also different ones. We look at estrogen, we look at progesterone, we look at also testosterone, we look at DHEA sulfate, we also look at pituitary hormones like FSH, LH. sex hormone binding globulin, and a few others I'll talk about in a minute. So that gives us a really complete picture of what's going on. So we can tell, for example, if women are having something called estrogen dominance, this is a really common condition in the world because a lot of things we do cause us to produce too much estrogen in relation to our progesterone, particularly in menstruating women and even postmenopausal, by the way, postmenopausal women can have high estrogen levels. And what causes high estrogen levels? Well, sugar and starch. Okay, they're the problem. We know that from, if you listen to me, you know, that's kind of basically a good problem for everything. So too much sugar and starch raise insulin, which causes more fat deposition, more fat leads to more estrogen production because you're, there's something in your fat cells cause called aromatase, which actually causes your sex hormones to turn into estrogen. That's what happens to men, too. Their estrogen gets converted. I mean, testosterone gets converted to estrogen. So when you have too much fat tissue, particularly belly fat, you get higher levels of estrogen. If you drink alcohol, it poisons your liver and you get higher levels of estrogen. If you don't exercise, you may have higher levels. If your gut is not healthy and you don't have enough of the healthy bacteria in your gut and fiber, you might increase your estrogen levels by re-circulating estrogen that you from your liver into your body and raising your estrogen levels. It can be because of stress. Cortisol will increase estrogen levels. Certain environmental toxins will do that as well. There's a lot of things called xenoestrogens, which are environmental toxins like all the plastics and pesticides and petrochemical toxins all, all can screw up your estrogen levels. So we have, we, we really need to understand that our, our hormones as women, I'm not a woman, obviously, women's hormones are highly variable, change over their life cycle and are highly influenced by our lifestyle and what we do. So we have tremendous agency over changing those things and fear on what to do about them. So knowing your numbers is really important when it comes to this. And we see, for example, if I want to know if a woman is having like estrogen imbalance and they may be having heavy bleeding, they may be having clots, they may be having menstrual cramps, they might be having fibroids or maybe all these issues. And I know that may be as high as high estrogens. I want to check their estrogen and progesterone ratio. If they have high estrogen, and low progesterone relatively, that's a problem. I also can look at the other numbers like LH and FSH. This is common if you have a woman with PCOS, which is really common. It's a cause of infertility. But we'll see with those women a high level of LH and FSH being low. So the ratio of LH to FSH goes up and that's a clue that there's this problem of PCOS. So we can tell a lot from these numbers, from the patterns in the numbers. We also look at something called prolactin, both in men and women, and this is a pituitary tumor that has a broad impact on our health and is influenced by many factors. And we've actually found people with tumors in their pituitary that are benign tumors, but they actually produce prolactin and that can cause all sorts of health and metabolic effects. So it's important to kind of get a picture of these numbers. We also looked for women also at the IGF-1 for the same reasons, and we also looked at another test that's unique to women. called anti-mullerian hormone. Anti-mullerian hormone is a great indicator of your fertility. The higher the number, the more fertile you are, the lower the number, the less fertile you are. So a lot of women wanting to know their fertility status can actually get this test. Also, we also check testosterone because just as we check estrogen in men, we also check testosterone in women. And a lot of women tend to have low libido or low sexual function or decreased arousal or lower orgasms. And and that all can be because of hormonal effects. And often treat people directly with hormonal therapy with this or with other things that boost testosterone. But it's fixable. And, and sometimes, you know, lifestyle can be very effective, as we mentioned, and sometimes you need bioidentical hormones, both for men and women. So I will prescribe hormones for men, testosterone. I will prescribe a combination of hormones for women, estrogen, progesterone, testosterone, depending what they need. But it's very personalized. and it's very individualized. So in the guide that you get with your function report, you actually get to know, you know, what are the things you can do about these numbers, but it's really about finding the nuances. And then there's a lot of supplements that can help both with men and women. Men can, there's a lot of great supplements that help with libido and sexual function. Also for women, same thing. A lot of women, women can take herbs to help with regulating estrogen, progesterone imbalances, with various kinds of hormonal disorders. For example, chaste berry is great PMS and there's other other therapies we use, but it's a combination of things.

So I had a woman who came in to me the other day and said, well, should I be taking hormones and if so, what should I take? So I think, you know, as you were mentioning, it's really important that we treat everybody as an individual and try to figure out what issues they're dealing with and think about what ways we can help them through some of their symptoms.

Yes, we look at a lot of different things, including the nutrition. of things like B6 and folate that have effect on estrogen metabolism. And we look at things you might not think of looking at like poop. I mean, how does a stool test help? Well, I've seen women, for example, with really abnormal gut flora, particularly have high levels of certain bacteria called Clostridia that basically unwraps the estrogen that's wrapped up by your liver and excreted in your in your gut and it's supposed to end up in the toilet, but it goes through your gut and it hits this bacteria and the bacteria literally unwraps it from its packaging and you reabsorb it and so you get high levels of it. So sometimes it's increasing certain types of fiber or certain types of probiotics like saccharomyces or increasing maybe taking even some herbs to kill the bacteria or even medications sometimes to kill the bacteria that can help to improve estrogen metabolism. So we have to look at this holistically, toxins in the gut and nutritional levels and all these other variables that affect hormones to optimize your own hormone levels.

And then if we need to, we'll.

Think about hormone replacement. So, yeah, talk about your patient who came in with, with menopausal issues and how you approach that, how you decide. Does this woman get hormones? Does this woman get herbs? Does this woman need, you know, pills or shots?

Or vaginal or topical or how do.

You sort of navigate all that?

Yeah, so as we were talking about, it's really important to take a really good detailed history and think about what their issues are because every woman is an individual. And then if we do choose to use hormones, we need to pay attention to those questions of how is that person handling it? Is it a safe thing for them? And how can we give it in a safe way? I think that One of the things that people are always arguing about or questioning is, well, that Women's Health Initiative was using Premarin and Prempro, right? It was using those non-bioidentical hormones. And if we give hormones that are bioidentical, right, identical to what the own body makes, would that be safer? And of course that would be safer. Is it safe enough, right? So those are those questions that- and.

Tell us, what is Premarin?

So it comes from pregnant horse's urine. So it's an equine estrogen, and it's not identical to what?

Premarin, pregnant mare's urine.

It's not considered identical, which is what your own body, the structure of hormone, the estradiol or estrogen that your own body makes, it's not the same. And it was also an oral estrogen, and we know that oral estrogens are more pro-inflammatory in general. They have to go through your liver.

They have to go through the liver.

They increase inflammation for some people even more than others, but they increase inflammation in the body and they're associated with a higher risk of blood clots.

Inflammation, they affect your triglycerides, but it's the liver function test and if you drink alcohol with it, it's nasty and.

It really spikes your hormone levels, right? Right, right. so then people will argue, well, if we do it transdermally, if we do a patch.

Topically.

Yep, right, exactly, topically through the skin. If you do a patch or a cream or an oil of estrogen, wouldn't that be safer? And I think probably yes, but we have to also pay attention to is it without any risk? Probably no, right? So you're always really looking at each individual woman and determining what their issues are and do they need hormones? And how does it affect them?

What do their blood levels happen after they take it?

Exactly.

I mean, in the same dose, given in the same way, whether it's oral or topical, can have profoundly different effects on different women depending on their genetics and their nutritional levels and all these factors. So, you can't really tell unless you measure how women are and then what are the estrogen metabolites which we measure in addition to normal estrogen. We look at the urine and we can say, oh, this is being metabolized well and not causing a problem. Or no, this is producing cancer-causing estrogens.

Yes.

Right?

Exactly. And so we do know that even bioidentical estrogen or even our own body's estrogen impacts our risk of breast cancer. For sure. So giving extra estrogen is not without risk, that's for sure. sure, right? When I'm working to decrease a woman's risk of breast cancer, I'm always thinking about how I can help them metabolize and get rid of and lower their total body's estrogen. So we do recognize that even if it's a bioidentical, safer estrogen, there is some risk, right? We don't know how much yet. We need better studies because even they did, I was looking at a meta-analysis that was done in 2019 looking at bunch of different studies in tons of women, and there was a slight increased risk of breast cancer for the women on estrogen and progesterone therapy.

Even bioidentical.

Well, see, that's the thing, because this study was throwing all these women in together. Right. So a lot of them were on some of the non-bioidentical estrogens, and so we just need more research on the bioidenticals, I think, to really tease this all out.

Yeah, but here's the problem. They're basically not patentable.

They're... Well, there are, I mean, some of the transdermal estrogens that you get at CVS or any local drugstore that you can get by prescription are officially bioidentical, right?

They are, but they're more likely that there's generic forms of them. So, nobody's wanna spend $100 million doing a study on it. So, it's hard to get the data.

It's hard to get the data.

Yeah.

Like we said, everybody's so different, right? So, I mean, I always explain that to women that the word bioidentical just means it's identical to your own body's estrogen, but, and we often give compounded estrogens, but we also, meaning you go to a compounding pharmacy, but sometimes we'll use estrogens that are bioidentical that you.

Can get at your local prescription local drug store.

Or estrace patches.

Exactly, yeah. So tell us how, you know, decide whether you do it orally or topically or vaginally or under the tongue.

There's a lot of ways to give hormones.

So estrogen, I typically don't give orally because of that increased risk of inflammation and blood clots. I usually give it transdermally if I'm going to give it. And the main reasons we're using estrogen is for hot flashes, sometimes sleep, and definitely bone density. So for those women, we, you know, we do that it can help improve bone density. So there's a subset of women we may use it for. And then we'll use vaginal estrogen for vaginal dryness.

That doesn't get absorbed so much.

It's really got a low systemic absorption. Of course, probably some of it does, but there's been multiple studies on vaginal estrogen with high-risk women. So women who've had breast cancer, who have breast cancer, a lot of them, because of all the therapy, the treatment, the tamoxifen or the chemotherapy, you know, really struggling with vaginal dryness. So they've done a lot of studies on vaginal estrogen in that group of women. And there really is a very, very low, if any, risk. And so most oncologists feel very, very comfortable with that high-risk group of women using vaginal estrogen if it's needed.

Yeah.

And then there's other hormones we might use progesterone, testosterone. Yes.

Yeah.

So progesterone, we can give orally, we can also give it through the skin. Typically, I'll use progesterone orally if a woman's really struggling with sleep. It's very, very calming.

It binds to the same brain receptors as valium, right?

So it's like calming. Our progesterone is high with when we're pregnant. And then we can use it through the skin also. That can be used both to regulate periods. If somebody's still in perimenopause, it can be used for anxiety, it can be used for sleep, it can be used along with your estrogen. So if a woman still has her uterus, it's necessary if you are going to give estrogen that you give progesterone along with it. And then like you said, Testosterone, testosterone's.

A nice-- Wait, before you go on, so the progesterone that was prescribed when I went to medical school and it was part of these studies is called Provera or Medroxyprogesterone, which is a synthetic progesterone that makes women feel horrible. I always joke, it makes them fat, hairy, and depressed. They get facial hair, they gain weight. It's actually what they use to stimulate appetite. cancer patients, something to eat, and it actually also causes depression. So it's not a great drug, and if a doctor wants to prescribe that for you, run away in the other direction.

Right, so with the micronized progesterone or the natural progesterone, you may get some of the, you'll get the benefits of progesterone without those side effects. So that's what typically use, you're absolutely right.

I've seen it incredibly work for premenstrual migraines, sleep anxiety, heavy periods, cramping, heavy bleeding, all that. And I think so in the testosterone you're going to go into a little bit because I think that's really important.

Yeah, one of the great things about testosterone when we use it is it can help us use less estrogen. So testosterone can be helpful because it can get into estrogen, but also then you just don't need as much estrogen for somebody's symptoms. So we'll see that sometimes. We can use it from a libido standpoint for some women. It's helpful from a vaginal dryness standpoint for some women. And so sometimes when we give a transdermal hormone therapy, we'll use an estrogen, progesterone, testosterone combination.

Yeah, little drops, little magic drops. Magic drops. Yeah, so it's important to understand that this has got to be personalized. that there's a lot of factors that you can do that have nothing to do with taking hormones to fix your hormones, which is what we do in functional medicine. We're good at diagnosing what those issues are that, you know, maybe seeing weird things that you don't think about like fixing your gut or getting rid of environmental chemicals in your life or taking the right nutrients to optimize your hormone metabolism or to mitigate risk. So often, if I do actually put women on hormones, I'll mitigate the risk by using the right nutrients to help them metabolize their hormones properly like diindolmethane and various things like lignans from flax seeds and other things you can add to the diet or to supplements that.

Actually help with- Metabolize it.

Demetabolize it. And if you need to take hormones, sometimes it's also the question of how long, right? So you might need a short course of hormones through the worst part of menopause. If all the traditional lifestyle and other factors aren't working, that's okay. Because the risk, the The risk of cancer with estrogen really is about the dose, the delivery mechanism, oral, and the duration that you take it. So I always want to use topical, the least amount possible for the little, as shortest time that I can to help with whatever symptoms there are. And then if they need long-term vaginal estrogen and a little topical clitoral testosterone, that usually does it for most people. And I think it's, you know, for.

Me, I get really angry when I.

See women suffering from these problems that have solutions, right? Whether it's PMS or fibroids or dysfunctional bleeding or PCOS or endometriosis or menopausal symptoms or perimenopause or osteoporosis, like these are not the curse of being a woman. These are things that are out of balance that need to get assessed and fixed. And that's what functional medicine does. And it's really different than just going to your traditional doctor saying, pretty much before menopause, everybody gets the pill, which has its own problems.

And then everybody after gets hormones and.

Often they'll get the antidepressants.

Or they get antidepressants, right?

That'S right.

Or they'll get hormones that are problematic.

Like oral hormones or Premarin or Provera, which are so commonly prescribed, which is shocking to me.

And I think that this is a really important area for people to understand.

Particularly women and people who live with women, because it just creates such disruption in people's lives. It's so unnecessary.

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