Menopause Relief: Hormone Tips Every Woman Needs To Know Now | Dr. Mary Claire Haver

But the data is clear that Dr. Hyman, like on mental health, like you are better off giving her balancing those hormones than giving her an SSRI. It is more effective for the perimenopausal patient with new onset mental health changes. I just refuse to let people suffer.

Welcome, Dr. Haver to the Dr. Hyman's Hormone Health Podcast. It's so great to have you here with us today. Thank you for having me. You know, you are now a shining light in the field of women's health and menopause. You're everywhere and you're talking about things that often have been neglected and when we went to medical school, we never learned that women were different than men. All the research was done on men. And so we really kind of had this whole field of neglected suffering that I would call it, that women endured without a lot of help. And it was like, take the pill or take Prempro, which is Premarin and Provera. And those were like the two kind of options. And of course, I'm oversimplifying, but it was basically that. or if you have menstrual disorders, take the pill. If you have menopausal stuff, take Prempro. And there was like, that was kind of it. There was no discussion of diet, of lifestyle. You know, you have background in culinary medicine. You know, people didn't understand the complexities that happen in women's health and the role of insulin resistance, the role of inflammation, the role of the microbiome, the role of toxins and endocrine disruptors. Like none of that was stuff we learned. And yet it's so important. And so many women suffer unecessarily from symptoms that have simple solutions. And what's so great about your work is that you help people really navigate that and talk as a physician, but also as an obstetrician and gynecologist in a deep way about this. And you've also had your own personal experience as a woman. So, that adds a lot of flavor. I mean, I'm just a guy and probably shouldn't be talking about this, but I think my experience as a physician was shaped by my work at Canyon Ranch where basically for almost 10 years I worked taking care of people between the age of 35 and 60, which was sort of the majority of women. And I learned a lot about issues and it sort of struck me that so many women were suffering needlessly from things like PMS and dysfunctional bleeding and menopausal symptoms and osteoporosis and mood changes and sexual dysfunction and just a whole bunch of stuff that just never got fair air time in traditional medicine. So, I kind of would love to sort of hear your perspective, just taking us through kind of your, let's call it your indoctrination. I'm not gonna call it brainwashing, but it's kind of brainwashing. You know, we learned a lot of good stuff in medical school for sure. And it's the foundation, but like, but like, what, where did you get from, from what you learned there to where you are now? And how did you sort of, yeah, how did you kind of shift your perspective and what was the sort of the things that kind of catalyze that change in thinking?

So I, again, traditionally trained, super proud of everything I learned, but as I grew older and my patient population was growing with me, we're all all becoming perimenopausal and menopausal together. You know, when I started out, I was having babies. My patients were having babies. You get all the new OB patients, you know, in your early days in family medicine, you get that. And then you, you kind of get your set of patients and off we go together. So here we are, mid-30s early 40s and there's this litany of complaints that myself and my patients are starting to go through and. I thought back to my residency training where there's a very shameful story of I was a new intern with my little white coat in gynecology clinic and the upper levels would run to the charts back when we had paper charts and shuffle through to find the surgery cases. You know, they wanted the surgeries because they had to get their numbers to graduate. And then that kind of left everything else in gynecology for us. So that was discharge and irregular periods and, and, you know, all the things. And then the interns got the very end of the pile. And it's what my upper levels would call a WW. and I didn't know what that was. So you're up a level, WW. And so they called it a whiny woman. And we didn't write it in the chart and no professor ever said it. Other parts of the country called it whiny geniuses. So women are coming in with these multiple vague complaints. They're all somewhere in their late 30s to 40s. They all have this kind of laundry list of very vague complaints, not sleeping, low libido, weight gain, tummy fat, that's new, not just, disrupted mood, disrupted relationships. And we were taught that, well, this is just something women go through, and there's not much we can do about it. And pat her on the knee and tell her to sleep better and lose weight and have some wine, and everything will be okay.

Have some wine. Well, that's gonna fix it. Yeah, that's gonna make it a lot worse, actually.

So fast forward 20 years, and I'm sitting there, you know, and it clicks in my head, I'm like, I'm a wanting woman. These are wanting, no, there's more to it than this. So that's where I started opening my mind, changing my perspective and realizing, Dr. Ahmed, that there is a huge gap in my own knowledge and training and I would have sworn 10 years before that I was a great menopause doctor. I made azel on my test, blew the top off my boards, but I didn't know what I didn't know. And so the more I dug and then started to grow on social media because I started talking about it, when 10,000 people tell you, My frozen shoulder started at, you know, right when my periods became disrupted and perimenopause. I don't blow them off. I go look. It turns out we have evidence for multiple organ systems that are really attributed to, you know, when the hormones start changing, all the things that can go awry, not just hot flashes and night sweats.

I think you're so right about that. You know, one of the stats that just blew me away was that, you know, 75% of women have some degree of premenstrual syndrome or PMS, right?

Oh, yeah.

And I said to myself, you know, what's going on here? Like, this is not a design flaw. Like, whether you believe in, you know, we were evolved from whatever or God made us or whatever, it's. Nature's not that stupid. God's not that stupid. Like, why are all these women suffering? It's not something universally attributable to being a woman. It's something going on in our environment that's driving these changes. And there's things that can be changed in women's behaviors and their environment and their diet and their lifestyle and toxins. that will make a difference. And so I kind of was like, it kind of made me angry to see all these women who had all these issues that were not being dealt with effectively. So for you, when you kind of had this insight, what was the next step for you in kind of changing your practice? How did you start to kind of shift in your head to kind of think about this differently? And what did you do differently? What did you learn to do that you stopped doing? And what are you doing now that you didn't do?

So kind of my toe in the water was my patience and my frustrations with what at the time I was calling the unexplained weight gain. Now I know it's a body composition change, but everybody was complaining of the same thing. And it was one of my, besides the hot flashes, night sweats and joint pain that I was having, my pain point, having been a thin person most of my life and having that thin privilege, then all of a sudden not being able, despite no changes in diet and exercise, Actually, I was doubling down on really destructive behaviors, probably, calorically restricting to ridiculous levels, you know, doubling down with the gym without any real results. And so finally, it was my husband who's an engineer who thinks very, you know, and he's like, Honey, your daughters are watching. So my kids were, you know, teenagers and preteens at the time. And he said, you know, you're getting up in the middle of the night to pee and I see you weigh yourself. You're, you know, this is not healthy. You're a scientist, figure this out. So I called the nutrition department at the University I was employed at and I was their doctor, right? So I called my friends who I delivered all their kids and the PhDs and I said, what is going on in menopause? Everyone's complaining of this. They led me down a rabbit hole of inflammation, how estrogen deprivation is related to inflammation. I've never been taught this information in my life. It was never in our CMEs. It was not, you know, menopause was hot flashes, night sweats, general urinary syndrome, and some osteoporosis. that's it. And I'm like, wait, this isn't my fault. This isn't because I'm lazy. This isn't because, you know, and they're like, oh, by the way, this visceral fat deposition is leading to cardiometabolic risk that you never had before. What's your cholesterol doing? You know? And having come from, I was a PCOS patient, had fertility treatments for my kids, you know, learned all, that's where my toe in the nutrition space started because I was on these online forums, like, I couldn't, figure I couldn't take enough Metformin to, you know, I'm like, there's got to be a better way. And that's where I learned about how nutrition is playing into this as well. And so, you know, starting to talk to my patients about it, them getting excited, you know, looking at changing our nutrition. Are you getting enough fiber? Are we getting enough, you know, instead of counting calories, let's, let's look at nutrients and see what happens. And that led to, you know, the Galveston diet, and then You know, but then the conversation just exploded around menopause in general.

Yeah, you know, it's interesting. I wrote an article years ago because I think, you know, this sort of change in thinking happened to me too. And, and I, it was called the life cycles of women. And it was talking about all the changes that happened at different periods of women's life, you know, when they're going through puberty, when they're in their 20s, their 30s, their 40s, their 50s, or 60s. And, it really is different in every stage of a woman's cycle. And it's something that that is not well appreciated by women, it's not appreciated by most doctors. And yet, when you begin to understand the physiology and the biology of what happens, you can start to intervene and help people actually deal with some of the suffering. So your focus is mostly on menopause, but I'm sure you've obviously dealt with PCOS, you've dealt with PMS, you've dealt with dysfunctional bleeding and all these things that happen. What do you think are the biggest causes for this sort of epidemic of hormonal dysregulation and suffering that women have to go through that is, I would say, usually avoidable or preventable or, or treatable if it's not.

Right. So, you know, definitely our nutrition, it's so much of it is the quality of our nutrition, you know, too much caloric intake for a lot of, for a lot of patients, you know, having, when your body composition changes and you have these, you're, you're leading to increased insulin resistance, which directly affects the function, you know, the insulin receptors. the ovary, which leads to PCOS. So, you know, I think nutrition, exercise, how we kind of move, how we think, how we eat as a culture is really pointing to a lot of the disruptions that we're seeing. Yeah.

You know, I don't know if this is true or not, it's just as kind of folklore, but I've heard that in Japan, they never had a word for hot flashes.

It's rare in Japan. Yeah, they have different symptoms, a lot more musculoskeletal. than we do. But yeah, in culture, they eat a.

Lot of soy, they eat a lot of Omega-3s, they have less sugar, they have more nutrient dense food. So maybe it's our ultra-processed food that's driving a lot of the dysfunction in our microbiome and insulin and inflammation. And so these are things that happen below the surface that most people don't realize but that are actually driving a lot of hormonal dysregulation. so do you, do you think that, do you think you have a perspective on that?

I definitely know that culturally, you know, and cultures tend to eat a certain way, tend to exercise. Of course, there's outliers and everything. We see a different catalog of symptoms. You know, people who live in the blue zone tend to have less obvious menopause symptoms. I mean, every woman is born with a finite set of eggs. Right? And we're all going to run out and that's our menopause. And then we live 20 to 30 years without the, you know, benefit of the estradiol produced in our ovaries. But how our body reacts to that loss of estrogen, that's where, you know, in my practice, we call it the menopause toolkit. Replacing hormones is one prong there and it's not for everyone, but we, you know, we go hard on nutrition, movement, stress reduction, sleep optimization, things that they really didn't teach us in medical school. Right.

Right. And those are true. Those are key. And I think those can get you a lot of the way there. And, you know, I think that some things that also are relevant, that are things we're also not taught in medical school beside nutrition or things like environmental toxins and how they disrupt our hormones, they're called endocrine disruptors or the microbiome and hormones. How have you sort of learned about those things in relation to the sort of epidemic of hormonal dysregulation, including infertility.

PCOS, and all these problems we're seeing? I think we need so much more work in this area. You know, just like you said, putting band-aids on everything without really looking for, and I know this term is misused, but the root cause, you know, why is this happening to this woman? Like you said, God's not that mean. They're certainly outliers, but why is 20% of our population, 10 to 20% have PCOS, polycystic ovarian syndrome? Why is that? We were not designed for this to happen this way. We were designed to have a very predictable monthly ebb and flow of hormones until perimenopause and then, you know, and so why is it that that's happening? And I think we need so much more research in this area. I think it's a, I think it's a traffic circle with environment, some toxins, you know, nutrition, everything is feeding into this negative feedback cycle.

And so what are the ways in which these, these various environmental factors affect women's hormones and how, how does it affect them in their 30s, 40s, 50s? Can you kind of walk us through how you think about this.

So when we reach perimenopause, we reach a critical threshold of the amount of eggs that we have, that the normal signals that come from the brain that tell the ovaries to ovulate, what doesn't happen in PCOS, right? We almost become PCOS-like in perimenopause because our level of egg supply at 30, we're down to 10% of what we're born with. By 40, we're down to 3%. And so, PERI begins when the normal signals don't work anymore, we become resistant. Now, we can definitely make that worse with, we know, you know, if you have inflammation in the abdomen through surgery, chemo, radiation, you know, that definitely helps. If you are insulin resistant and not managed with diet, that will definitely contribute to how your ovaries are going to respond to this environment and how they're going to produce the hormones. I have less training and stuff on the exact toxins. I know the usual things like radiation and chemo will affect, but if those things affect, certainly others might affect as well.

Yeah. There was a book I read years ago called Hormonal Chaos by Theo Colburn. It was sort of like a silent spring book. I encourage you to check it out because it really describes how she was a research scientist who was looking at what was going on in animal populations. and the ways in which these pesticides and plastics and so forth that we're all poisoned with are endocrine disruptors and are causing abnormal genders and hermaphroditism and infertility and, you know, trouble with all sorts of populations from frogs to birds to alligators. And it was fascinating and I kind of got me to really think about it. The thing that I think that happens with this changes in the eggs and the cycles and the hormones is interesting because as, as in I'm practicing, what I would notice would be often we would have high levels of estrogen and low levels of progesterone. They would have an, what we call an ovulatory Cycles. This is like what you get in, in PCOS, where you don't ovulate every cycle, and then you don't make progesterone, which is what happens in the second half of your cycle. And that was sort of the thing that led to a lot of these symptoms of fluid retention and breast tenderness and premenstrual migraines and then heavy bleeding and irregular cycles. And it's this big kind of almost continuum of hormonal dysfunction. And, and, you know, I, I wonder, sort of what your perspective is on this, this sort of phenomena that I, I think is a lot, you know, in the world of functional medicine, we talk about estrogen dominance or estrogen excess or imbalance, and it's, it's not, it could be in a relative or excess, relative or absolute imbalance between estrogen and progesterone, and, and that seems to what's led to a lot of the symptoms. And a lot of the toxins and a lot of the dietary things drive an increase in estrogen, right? So these estrogen mimicking toxins and then sugar causes fat deposition which leads to excess estrogen produced in the fat tissue. So can you kind of walk us through what is this whole phenomena? How should we think about it? And what can women start to do to kind of address it?

I think you hit the nail on the head. These are most of what you would call estrogen dominance is chronic anovulation or oligo ovulation, meaning you're just not getting that monthly ovulation cycle going. And so, you know, in PCOS and Perry, people will ovulate in PCOS occasionally, right? It's very, very similar multiple levels to what a woman's going to go through in perimenopause as far as where her hormones are. So we have, you know, much higher levels of FSH because the brain is constantly trying to get that egg out, you know, to get those estradiol levels up so that spurt in FSH will then give you these much higher estradiol levels than a regular, only ovulating woman would have. And then after ovulation, the progesterone never quite gets to where it used to be. So, yeah, she has this whole cascade of symptoms, heavy periods, light periods, no periods, too many periods, you know, everything's on the table as far as her cycles, breasts become enlarged, fluid retention, you know, gut microbiome becomes disrupted. and treatment options through that really vary from patient to patient. There is no one size fits all. So this is where I think a lot of patients are getting frustration. A, they're not being offered any treatment at all because you haven't had a period for a year. Or they're just, occasionally a birth control pill might be helpful in certain situations, but it should not be, I don't think, the panacea go-to for all Perry and PCOS patients by, you know, our lack of training and education around how nutrition, how diet, looking at what she's eating, when she's eating, how she's eating, how she's moving, making sure, you know, she's getting the right kind of exercise. Most of my practice focuses on, you know, 35 plus in that perimenopause to menopause range. And, you know, we're plotting out, of course, to decrease the risk of osteoporosis and sarcopenia, you know, so that's where my exercise recommendations are going more heavy lifting, less intense cardio, you know, more zone two training, and how, you know, we can balance her, her hormone levels through this transition. So she's not suffering.

Yeah. And, and, and so, so there's things that raise estrogen and there's things that kind of reduce ovulation. So it's sort of like working on both ends of that, right? and, you know, traditional, a traditional OBGYN will typically just give women, if they're pre-menopausal the birth control pill, and if they're post-menopausal, and that's what they're trained to do. Yeah, that's what they're trained to do. It's like, and yet, you know, if they're not looking for contraception and we can discuss the pros and cons of the pill, but, you know, it may not be the best therapy because it comes with risks and also side effects. So, you know, one of the things that I, you know, I, one of the things I did when I was sort of early on in this field, it was like 1996, I met a guy named John Lee. have you ever heard about this guy? And he wrote this book. And interesting to get your perspective on this. He wrote a book called what yout Doctor May Not Tell youl About Menopause.

And I've heard of the book, but.

I haven't read it. It's a great book. And I heard him speak and I was like, this is interesting. Let me try this out. And essentially he was talking about the use of low dose topical progesterone or sometimes oral progesterone as a way to help a lot of women with all these symptoms.

In perimenopause, it's very effective.

Yeah, for sleep, for hot, just heavy bleeding, for fibroids, all this stuff that, you know, and it's not something I learned in medical school. So how do you think about this whole sort of approach of using progesterone and is it safe, is it effective, is what should we be concerned about, and how do we sort of know when to use it?

Great question. I really, really like it in early perimenopause, especially if she's still kind of cycling regularly, but she's having disrupted I love it for sleep. I love it for regular and heavy periods. It does wonders. Traditionally trained, you don't need progesterone if you've had a hysterectomy. However, I use it all the time.

Because.

What it does for the brain in sleep is amazing. And there's new data coming out looking at, we have a 40% increased risk of mental health disorders through perimenopause when she was completely either worsening or new onset of mostly anxiety and depression. And progesterone can be very helpful here. Also, a low dose estrogen can be really helpful here as well, even if she's still ovulating, something like a low dose estradiol patch, just to kind of shore her up through those dips, you know? That's how I explain it to her. Now, as far as how I prescribe progesterone, transdermal, so we have progestogens, which is the big category, right, of all of our progesterone type medications. We have progestins, which are, quote, synthetic, you know, and I like having options, but I usually do oral micronized progesterone. The topical progestogens are natural, but it's a really big molecule, and there's not great data showing we get enough penetration through the skin if you're giving estrogen at the same time to protect the lining of the uterus. And I like, really like giving that pill at night for sleep. My patients love it. They really, you know, especially if they're sleep disrupted outside of hot flashes, they, and my personal bias, it is the best thing I've ever done for myself is the progesterone at night.

It's kind of a miracle. It was kind of a miracle pill and a miracle drug that I never learned about really using in medical school other than in combination with Premarin.

And.

The synthetic form of it called Provera. which my joke was it made women fat, hairy and depressed because it had a lot of side effects, you know?

So, yeah, not many of us in, in the modern menopause space use Provera, you know, very, very rarely. I pretty much just use progesterone. You know, I'm trying to give the patient as close to what her ovaries used to make as possible. You know, I don't love the term body identical, but it is by the identical.

So, you know, that's a really important point. It's a use stuff that your body knows what to do with, and it doesn't have all these untoward effects. And, I think the thing you said, I just don't want to skip over it, is that you're doing something that's really unusual in one's health. You're actually combining topical low-dose estradiol or the most common form of estrogen with oral or even topical progesterone, and you're doing it before they end their menstrual cycles, before they get to the definition of menopause. And, the data. which is really kind of a little bit heretical. It's like, take it to the bank.

I just refuse to let people suffer.

That's it, right?

Not only, but the data is clear, Dr. Hyman, like on mental health, like you are better off giving her balancing those hormones, then giving her an SSRI. It is more effective for the perimenopausal patient with new onset mental health changes. So, and then the cardiovascular data is looking good. Like, if we can get this thing shored up, before she completely transitions, she is going to do better in multiple aspects of her life. Why are we waiting till people are symptomatic? Why are we waiting until they have osteoporosis? Why are we waiting until they have genital urinary syndrome? Well, we could be preventative.

What do you mean? That's what we learn to do in medical school. Wait till someone's sick and then give them a drug. I don't know what you're talking about. So totally clear why we do this. I mean, what you're saying is this sounds so common sense, but it's often sort of not how we learned and how we practice. And I think, you know, what you're talking about is something that's so rewarding because for anybody listening out there who's a woman or who lives with a woman, you understand it's not always fun. And there are solutions, but often the solutions are not getting to the people who need them because of the way in which traditional medicine is practicing. how we're trained and yet the solutions are relatively simple, very inexpensive and very effective. I mean, I would say other than like delivering a baby, which is so fun and a positive experience, you know, giving someone hormones and having their life turn around is like one of the most satisfying things as a doctor, right? Because you're just 100% agree. You're just like they all of a sudden they're having symptoms, their sex drive comes back, their energy comes back, they don't have mood changes, they have all these benefits that occur. And we went through this period, I want to come back to this because there's a reason we've shied away from hormones and women are suffering is that hormones had a good RAP and then a bad RAP, and now they're coming back to having a better RAP. And I think there's a historical reason for that, which was a Nurses Health Study that was an observational study that didn't prove cause and effect, but the women who seemed to take hormones did better than women who didn't. So everybody's like, you gotta take 'em. And I remember a woman in my practice who said, at Kenyon Ranch, she said, if I don't take hormones, my doctor says it's malpractice. If you don't prescribe hormones, it's malpractice. And that was the Nurses Health Study. And then it shifted all in like 2002, there was a Nurses Health Study and it was like, I went to the Women's Health Initiative, which was a big study of a billion dollars and 100 I do not know, 20, 40,000 people, women. And it kind of gave us some country data. And that meant like 50 million women overnight stopped taking it and it led to sort of a catastrophe. So can you walk us through like what should we actually know from the Women's Health Initiative, which is a randomized control trial? And what do we know now that's different in the intervening 22 years that has changed our thinking?

So this was one of the probably the best cases of something going viral before social media. and, you know, kind of this path of misunderstood information or misinformation. So WHI, you know, they started enrolling patients in the late 90s. We knew from observational data that women on HRT tended to have less heart attacks and die from heart attacks less. And so they said, all right, well, is it just because women on HRT are healthier and wealthier? Is this an artifact? Or can we prove this with a randomized control study? First time aging women had ever been studied with that level of and they used Premarin and Prempro, which at the time were the two top, that wasn't unusual at the time. Those were the two commercially available formulations that they did. So that's one problem. They used one formulation. The Premarin, if they didn't have a uterus, and then Prempro if they did, versus placebo. Average age, so the outcome of the study was not safety. It was measured, but that was not the primary aim. The primary aim was to see if they would get cardiovascular disease or not. So they started with a much older population. the average age of the study was 63. They enroll the patients, get started in the primar and Provera arm. They did notice a very slight relative, relative risk increase of breast cancer in that population, not in the estrogen only arm. They called a press conference. They didn't release the study data at the Watergate Hotel. And it was on the COVID of every newspaper, every news story. I remember I was my chief year of training. I was 2002 is when I graduated. It, like you said, it was this massively disruptive, it was the top news, medical news story of 2002. And it said estrogen causes breast cancer. Well, turns out the estrogen-only arm kept going and they didn't see an increased risk of breast cancer. So now, you know, but that notion just went crazy. No one would prescribe it after. Everyone was terrified. Those data points have been refuted, as you know, throughout multiple studies throughout time, but we're just having a hard time, like, getting the world to catch up to this. But it is not the forms of.

Hormones that cause some of the increase in breast cancer.

Was it the forms of hormones that caused some of the increase in breast cancer?

Right.

And so, you know, Levy and Simon and Levy just published like the contemporary view of hormone therapy. You know, formulation matters, type matters, age matters. We have a window of opportunity for protection for cardiovascular disease. And basically, it's the time away from estrogen where the problems start for females. So the longer my body is away from estrogen, the more likely I am I had to have a stroke, cardiovascular disease, diabetes, the whole every cardiometabolic disease. Estrogen is protective. Once those diseases start, estrogen is great at prevention, not a cure for some of these things. And so the older women in the study didn't see a cardiovascular benefit because they probably already had heart disease. They missed their window of opportunity because they started older. Their acceleration of their diseases had already occurred. so now we know if you want the cardiovascular prevent protected benefits, you probably should start within 10 years of your menopause. If you want the neurologically protected benefits for decreased Alzheimer's and dementia, you need to start within the first 5 to 10 years. Lisa Mosconi has new data published on this just this week in nature. Probably it's a bigger window than we thought. If it will always protect your bones, it's always going to protect your general urinary system. It's always going to protect your muscles. You know, but you still have to do the work. So I never want anyone, any of your listeners to think, oh, I'm just going to take hormones and go about my day and I'll be perfect. No. You must exercise. You must eat right. You know, this is a tool in the toolkit. So that, because here's the fact of the matter. Women live longer than men, sure, okay? But we spend 20% of our lives in poorer health than our male counterparts. And that's not okay. and that's the gender health gap. And that's where we have all this is where the work needs to happen.

Yeah, I think this is so essential. And I think, you know, as I was sort of learning about the Women's Health Initiative, I actually already had kind of gotten a little bit biased because I'd read this book about bioidentical hormones, about using hormones that were the same as your body's own hormones to bind the same receptors that have less side effects like Premarin, which was used in that original Women's Health Study. That actually has to be metabolized by the liver. and it actually increases inflammation. See a reactive protein increases triglycerides, increases your risk of breast cancer, I think because of its effect on alcohol metabolism and lots of things. So, if you drink a glass of wine, your hormone levels would jack up really high. So, I think there was a lot of problems with that, but now the topical or bioidentical hormones seem to be better tolerated, more effective. Are you worried at all about them? concerned that there is some unknown risks that we haven't determined from the research yet about whether or not these actually may increase breast cancer risk or ovarian cancer risk.

Not in the estrogen family. Not if you stick to, you know, not in the estradiol world. Okay. It doesn't look like it's actually protective for breast cancer, especially if you start young. The progestin seemed to be where there's a lot of variation. And, you know, these studies are being done. We have lots of data coming out from Europe and other places, but they're all using different progestins. What I want to see is a head to head of estradiol plus my oral micronized progesterone and let's follow those women for 20, 30 years and see who lives longer, what the risk of breast cancer is, et cetera. But what's happening is bikini medicine in my world where women are little men with breasts with bikini medicine. So the only thing we need to worry about in women's health is the bikini area, the breasts and everything under the bikini. You know, the bikini bottom and it's like you said, we're not testing these drugs, you know, cardiovascular drugs on men. So let's take a statin, you know, my cholesterol went up through the menopause transition. I've been able to get it back down with HRT and diet. Okay. Very successfully. But my doctor recommended a statin. There is no data to suggest that statins decrease the primary risk of a heart attack in women. HRT does. And that was actually perimenopausal, like not the best. of our options out there. So, I could go on and on about this.

No, it's good. It's good. It's good. I think it's good because I think, you know, we have to sort of empower women with the knowledge that we have now and not be stuck in this old story that we shouldn't do it. Now, the question I have really is, is if you're going through, you know, menopause and you have no symptoms and you're good, should you take hormones?

I would have a balanced conversation with that patient and that's what I do in my clinic. I'm going to talk to her about, even though it's not recommended by the societies yet except for the American Heart Association, well, they're a little bit on the fence, but I talk to her about the known protective benefits of hormone therapy, her bones, her brain, her heart, if she's in the right window of opportunity. And I'll let her make a decision for herself. We'll talk about the risks, her family history, her needs, her wants. what's happening is the old menopause was HRT only for the shortest time, the lowest dose only if you have severe symptoms and you're going to jump off a roof, okay? But what about the woman who kind of, luckily the 15% who don't have the cliche symptoms, but I also say, what's your cholesterol? How's your insulin resistance? How's your joint pain? Because those symptoms are just now being recognized as part of the hormone deficiency that's going on. And maybe we can help those things.

Yeah. And so, so to flip the question upside down a little bit, if, if a woman starts on hormones, is this something they should stay on long term? And is this something that all women should do after menopause? Is this something we should kind of move towards thinking that all women should be done? Or is this more of a personalized approach?

I definitely think it's personalized. I definitely right now in the US, four to maybe eight percent of women who are eligible are on HRT. and people are saying that's over medicalized. And I think that's ridiculous. We're just allowing your body to work in the fashion that it used to work before you went through this change and before you lost your eggs. And so I think every woman deserves that conversation and to be allowed to make a decision for herself. And then if she decides to do it, I review it every year with them. How are you doing? How are you feeling? Have we developed any new medical problems? But it is absolutely possible that a woman could enjoy benefits of hormone therapy until she dies. I might die with an estradiol patch on. I don't know. And let, you know. And, but that's my personal choice combined with my knowledge level and my family history.

So I'm hearing the subtext, unless someone has significant reasons not to, like breast cancer risk or they've had breast cancer and it's contraindicated or ovarian cancer, or uterine cancer, which are hormone-dependent cancers that do flourish in this case. Right.

That would feed your cancer would be fed. Yeah.

Right. It seems like what you're.

A severe liver disease, a recent blood clot, you know, your.

Yeah.

And, you know, a recent DBT or PE.

Yeah.

So really, contraindication.

Yeah. But for pretty much everybody else, what I'm hearing you say is it's a good idea.

It's something to consider, and it is something I discuss with every single patient. Yeah.

The other thing is women might have a sort of like the frog in cold water that gets turned up slowly and they don't know they're boiling to death. The changes can happen and be subtle and you think this is just a normal aging, but then you get them on hormones and go, wow, this is a different me, right? This is a whole new experience.

That is what I see in my clinic and that is what the menopause CC, we have this little friend group of clinicians and we're multidisciplinary. The menopause. And we text all day long. We share patient stories and ask questions and articles and, you know, it's fun. And so, you know, it's retrospective. It's all these women saying, oh my gosh, I didn't realize that. My tinnitus, my vertigo, my palpitations went away, you know?

Yeah, yeah, yeah.

It's pretty exciting. It's exciting stuff.

So let's talk about testing. you know, you know, what I found is hormones fluctuate greatly. And, you know, when I was sort of in medical school, I know, don't worry about testing so much because they're all over the place. And, you know, you only want to test after they've stopped having their period to confirm they're in menopause. How do you see testing hormones in women and, and when should women start testing? What should they be testing? And if you're checking hormones, it doesn't matter when in the cycle your chest testing, like, should it be day one.

To three or day 18 to 23 to see what's happening with ovulation?

How do you sort of think about this?

Here's my fantasy is that we have a CGM type thing, a continuous CHM, a continuous hormone monitor. You know, why not? Why not? There's actually, I talked to someone who's trying to develop one where you start having symptoms, you pop that bad boy on, you follow yourself for a couple months, it's tracking all the things, your estrogen, your progesterone, whatever. But, you know, we have these kind of poor panaceas for that right now in the form of You know, you need to do testing over multiple days. It's hard to read. And so the way I diagnose perimenopause is I talk to the patient. I absolutely believe her. I do a lot of blood work to rule out other things like autoimmune disease, hypothyroidism, inflammatory disorders, nutrition. But like a spot hormone test because of all that crazy chaos is not going to help me that much. Certainly if I can't use her period to help kind of guide me a little bit, I'm doing hormone testing. you know, to see is she really postmenopausal and we missed it because we don't have a period to judge. But I, you know, I don't have a great, you know, easy blood urine saliva test that I think is 100% reliable. I really just listen to the patient, believe her, go there with her, you know, make sure nothing else is going on or overlapping with all the blood work, and then we just drive into treatment.

It's interesting for, for, you know, premenopausal women, I think, you know, who were having a lot of symptoms. I always found that if I checked hormones sort of in the second half of the cycle, like day 18 to 23 of a normal 20 day cycle, that I could see what's going on with their ovulation because their progesterone would often be low and their estrogen would be really high. And that would kind of give me a lot of clues about what's going on. And then I might just try progesterone with those women, or I might try that and a tiny bit of estrogen and, and that seem to be a good sort of indicator. Is that a good practice?

That's very reasonable. If you can get it on day 18, just with modern, we are lucky in the type of clinics we have. But sometimes the access that patients have to that kind of thing is pretty limited. Yes, but I think a really high estrogen with a really low progesterone is classic anovulation, right? Or oligo ovulation. That's either Perry or PCOS. for us. And, you know, giving her progesterone often is miraculous for those patients. They're so happy.

You can always see the ratio of LH and FSH change where you get high LH and low FSH, which is often correlated with PCOS. And we see that, too. So it's kind of a, what about, you know, early on in the cycle? When is it indicated to do testing day one to three?

You know, typically, I learned that was for fertility. And interestingly, you know, we've, fertility does a lot of work with AMH and anti-malarial hormone. Anti-malarial hormone. They're actually looking at analogs of that or block, I think they're blockers. These, there's two biotech companies that I know are working on, you know, medications that work with AMH to extend the life of the ovary because it seems that rise in AMH is accelerating the the loss of the follicles in menopause. And if they can figure out a way to block that process, they think they can extend the life of the ovaries so that we can enjoy more of our natural estrogen. But again, that's all in theory and.

They'Re testing it in animals. If you measure AMH, it should be lower in order to indicate better fertility when it's higher.

Right, which means longer, you have a longer time until you're menopausal. So I think there's a lot of work to be done there in the menopause space. So I'm excited to see what that's coming in the future for that.

Let's talk about sex. I think, you know, one of the.

Things that, we didn't talk about testosterone yet.

No, that's what I want to get into. So, you know, you know, you've said before that, and this is sort of well known if you're a physician, is it? Maybe not actually most doctors is that testosterone, absolute testosterone levels are higher than.

Estrogen and progesterone levels in women. And women, it's the precursor to estradiol down the synth, you know, down the down the pathway to create estradiol, testosterone is the last step before we aromatize it to estradiol. So yeah, our natural testosterone levels are actually higher in picograms per deciliter than our estradiol levels.

But then we lose those too. Yeah, and there's a lot of reasons for libido issues and sexual dysfunction in women. I once heard a woman, Susan Love, who wrote a book about women's health years ago. She was quite amazing. And she said the biggest sex organ for women is between their ears. And I think there's a lot of truth in that. But also women have vaginal dryness, they have lower testosterone, they have arousal dysfunction, there's all sorts of stuff that gets.

Kind of... Orgasmic dysfunction.

Yeah. And men got Viagra and all this stuff, but women kind of don't really seem to have this addressed very effectively. And what I found is it can be really effectively addressed by addressing overall lifestyle issues and relationship issues, obviously. sometimes using testosterone can be very effective and it also is great for bone health and mood and energy and focus and has a lot of benefits. So, I'm curious about your perspective about the use of testosterone and how you use it, how you prescribe it. You know, one of the things I learned was that you could use it topically on the clitoris and you can get it compounded and if women use a couple of drops every night over a few weeks, it really increases their arousal orgasm. And I, I think it worked because the women I prescribed it for would always call me back for refills. So I figured that it was working. Yeah.

So my friend. So in our menopause, we have three or four urologists who are females, you know, they're in Ishwesh, the sexual wet medicine Wellness conference, and they love topical testosterone in the vulva, especially if they're having, it's, there's so many testosterone receptors in that lower in the introitus as well. They love it for the clitoris too. So like doing that, if you look at the vulva, they call it 12 to 6 when you apply the cream and they have it specially compounded for that. They're huge fans of that. Especially if they have GSM, generally urinary syndrome of menopause, a combination of estrogen and testosterone or the DHEA, which gets converted down the pathway to both is helpful. So I love testosterone. I'm a huge fan. Clearly the data for HSTD, Hypoactive Sexual Desire Disorder, which is the organ between our head. Oh my gosh. It's that, you know, but you know.

Does she have a good relationship?

Doctors like to give these names. Yeah. Is she having pain? You know, we're ruling out all the other causes, making sure she has a stable relationship with a partner who she used to have a good libido with or, you know, layman's term libido, making sure she's not having pain. We got to fix that. And so all those things are addressed. And then testosterone really does seem to be helpful for the hypoactive desire.

Issue.

So the brain part for females. Also, I use it off label. If my patients come in, I have a monitor in my office for muscle mass and visceral fat. I have an M body scanner, electrical impedance scanner. So if she's coming in and she's, she's had a bone density and she's got low bone mass and she's sarcopenic, you know, I am recommending it off label because the data is very promising in combination with, we know that women with higher just natural testosterone levels have less of those diseases. So I'm just trying to help her, but she's got to eat the protein and lift the weights and do all the things as well. And that testosterone can be additive in that.

And you use it topically or how do you use it?

I do. So yeah, only on Ducanohate is, and it's not even approved in the US, is safe, you know, for the liver toxicity part of it. So, so, so therapy should be transmucosal or transdermal. for safety reasons. And then in the US, there's no FDA approved formulation for women. So in some states than others, it's easier to get. Sometimes you can do the male version of like T T stem gel and you have, but it's hard to dose, you know, it's like a pea size amount or so most of my patients, because Texas, we really have a hard time getting the T stem from the pharmacist, will go around the block and do compounded creams. so I'll do a transdermal testosterone cream for the patients and we'll kind of dose adjust, you know, based on her.

Levels and her symptoms.

And it doesn't cause women to grow mustaches and beards. If you stay in a physiologic range, if you don't overdose her, sure, if I give her enough, she will grow all sorts of things.

But I try to keep my patients in a healthy physiologic range. I think that's so important. That is such a key statement and is to use hormones in a way that kind of matches your normal physiologic state for optimal health, not an excess amount. I mean, you see these muscle heads and gyms that have huge levels of anabolic hormones that this is our super physiological and they're a new way of thinking about women's health. You know, it wasn't something I intended to go into, but it just became something that I was very much immersed in because of the population that I was dealing with. And I just learned so much from my patients and, you know, often the best source of learning is listening and asking what's going on with them, them telling you, and then learning about the condition and how to sort of adjust your treatment to match that. And I think, you know, it's been a dark period because of the women's health initiative. There's been such a fear and such a resistance to hormone therapy across the medical disciplines. And now it seems like it's shifting. Is this just on the fringe or do you think this is changing within traditional obstetrics and gynecology?

I definitely see it changing. I see like in the American ABOG, American Board of OB/GYN, the Council on Resident Education. I was a program director for like 10 years. So they are pushing to have a menopause curriculum. I see, you know, more and more people contacting me, other clinicians who are like, Help me, help me. I want to learn more. You know, the rate of people signing up to get certified by the menopause society is skyrocketing. I think people are becoming aware, mostly due to social media platforms, the news, and patience. This generation of menopausal and perimenopausal woman is not putting up with it. She knows there's a better life for her, that she doesn't have to suffer, and she wants more information.

So, what's on the horizon? What are we looking at in terms of new advancements in medicine, in nutrition, supplements, in other therapies that could help with women's health and hormones and menopause. You're kind of on a leading edge and you're hearing about things that are emerging. What are you excited about?

Well, I talked about the ways to improve the shelf life of your ovary naturally, to hang on to the follicles that you have for as long as possible. So, that's one of the most exciting things too. My daughter is a medical student. She just started her second year.

Mine too.

And, yeah, fourth year. It's really exciting. And, she just seeing her class and how excited they are about learning more about menopause and aging women, males and females, you know, all the people in her class, how into this that they are and they see the tide changing. I'm like, this is the next generation. They're going to be doing my surgery in 20 years. Like, and that, that what I see is other medical society really starting to put a toe in the water and study the aging woman outside of what a man does. and how that's just going to broaden our understanding so that we can close that health gap between men and women.

Yeah, that's great. I mean, I think there's some kind of cool therapies out there that I've seen, like certain things for arousal disorder like Viibryd, there's other drugs that are out there.

Oh, yeah. And Viibryd are pretty cool. So, yeah, Viibryd for HSDD. Yeah, so there's two FDA approved medications for the treatment of hypoactive sexual desire disorder. They are, they were studied in premenopausal patients, but we are using them off label for menopausal patients. So Vyleesi is a medication that works on melanocortin in the brain, and it's an injection you give your, yeah, yeah. So injection you give yourself 30 minutes before, you know, activity. And when it works, it works great. Like the patients absolutely love it. And similar to how Viagra would works because you need a certain time before the medicine kicks in and the arousal, you know, be and begins. And then Addyi is a medication you take every day, and it works at the level of neuroreceptors in the brain. I'm changing. Is it dopamine? I can't remember. I should know this. And so, that's a medication you take every day, like a vitamin, to just shore up your levels so you're more interested and ready when the opportunity presents itself to you.

Dr. That's great. It's great. I think it's about time. and, and I think, I think the other thing I wanted to sort of just before we wrap, I wanted to talk to you about PMS, because in my experience, seeing women in this sort of transitional period, it gets worse. Like, it may not be bad in their 20s and then in the late 30s, 40s it starts to accelerate and they get premenstrual migraines, they get fluid retention, they get breast tenderness, they get, you know, mood changes, they get sleep disruption. And it, to me, it's sort of like almost like kind squishes up against the sort of whole perimenopausal phenomena because it's often related to this imbalance with that you get in hormones from the lack of ovulation every cycle. And, and I'm curious about how you, how you approach that and what you think.

So I know from her history, if she had severe PMS symptoms, and we go to go through what those were, that these tend to become accelerated when she hits perimenopause, that whatever pathology was causing that, you know, how her body responded to that hormonal milieu in her. But this is gonna like, especially if she has depression or anxiety, you know, she had to be treated for that. We know that we, I need to be on the lookout in Perry that this may be the first sign of her perimenopause that she has sudden worsening of these symptoms. And I'm going in for, I'm going in for hormone therapy very quickly on.

So as a treatment for PMS, you use Hormone therapy?

So it's been a while. So now I, you know, not doing a lot of pre-menopausal patients now, but back in the day we kind of had two options like squash her hormones with birth control pills. And for some that gave them symptomatic control or do an SSRI either every.

Day or just otherwise known as Prozac.

Two weeks out of the month, you know, when her PMS symptoms would have been the worst. But as far as like any real research as to why the hell this is happening other than you're just a woman. We got work to do. Yeah. I mean, from my experience as a.

Functional medicine doctor, it seems pretty clear that it relates to a lot of the lifestyle factors, environmental factors, toxins, diet, the gut microbiome that are all modifiable. And then by fixing all these things, get people's nutritional status up, get them to be six, magnesium, a lot of the things that help omega-3 fats, a few supplements often can really be helpful. In fact, I had a cocktail they don't make anymore, but it was a cocktail of Chinese herbs that's from perimenopause and hormone imbalance and PMS and magnesium, taurine and B6, which all help with estrogen excess and metabolism. And it would be like a miracle pill for this. Also, I use Chase Berry, which is an herb, vitamins can be helpful.

Yeah.

And then, you know, sometimes giving even a little bit of progesterone can be really magical for these women, even topical or, or oral, if they need a little more and and so it's really about getting the whole person healthy. And I think, you know, it's easy to think of jumping to hormones, but I think what you said before was really important that it's not about just jumping to hormones. It's about understanding the full panel of phenomena that are driving these changes and then working on those. What you're eating, exercise, stress, sleep, nutritional status, your gut health, all these things will help to regulate your hormones because they're influenced by all these things. and that's sort of, they're not just randomly going haywire, there's reasons for it. It's not like I said, a design flaw. And so we can actually really do a lot of good for people by helping them do that. And by the way, the side effects of all those things work for every other known disease.

Right. I give a lecture to medical students and residents, you know, thank God programs are inviting me and I go through the menopause toolkit and we talk about the big six: insulin resistance, cardiovascular disease and how menopause plays in here. And, I'm like, you're going to see the same things repeated. 25 grams more fiber in your diet per day, lower your, you know, get adequate sleep. I'm like, this, all these things work for all these diseases, right?

And so, you're going to see a pattern here and there's a reason for it. Yes, it's not like there's one diet for preventing cancer that causes heart disease and other diets that's for heart disease, it causes diabetes, and other diet for diabetes, it causes dementia. No, no. It's like the basic principles of running and operating a human being are pretty the same, right? In your car, you need oil, you need gas, you need air in your tires. It's not that complicated. But it's again stuff that we just don't know anything about. I mean, my daughter's in medical school and I said, Rachel, how much are you learning about nutrition? Nothing. I learned about fatty acids and amino acids and I'm like, what are you going to tell your patients to eat for lunch? What are you going to eat for lunch? Right? And then I said, what about your microbiome? Well, not really. How about toxins? Well, no, no, not about that either. And I'm like, wow, you know, it's even though, you know, the science is out there. and it's not hard to find. You just go to the, you know, the internet. You go to PubMed and search for anything, and you'll find it, and you'll find what the data on there.

My daughter got her undergrad in nutrition science.

Oh, wow.

She was going to become a registered dietitian. And then, like, halfway through, she's like, Mom, I think I want to take the MCAT. And I was like, go for it. You know, she thought she could be more effective with her nutrition background going to an MD than. Than an RD. It was more. More of her interest level. so, yeah, she talk about, you know, whenever I talk about nutrition, she can't. She follows every word and double checks me and is throwing articles at me. It's just really fun having her, you know, double, triple check everything I say.

Yeah. Well, yeah, they're, they're good to kind of keep you on your feet.

Right?

Yeah.

Yeah.

So if you could kind of have a final word to women out there who are struggling with menopause and menopausal symptoms, perimenopause, menopause, PMS, like what kind of sort of would you advise them as a sort of an overall sort of menopause framework and strategy? Kind of how do you kind of...

Menopause is inevitable for all of us and, but suffering is not. And you can live your best life. I am almost 56. I am the healthiest, happiest, best relationships, beautiful sleep, you know, multiple reasons for that. It's not just an estrogen patch I'm wearing. and I want everyone to feel the way that I feel right now. You know, I want everyone to enjoy the life that I have, you know, and it's, I changed everything when I hit menopause. I changed how I ate, how I thought, how I stress released, I gave up a lovely job that I cared about that was killing me, you know, and, you know, so I, I, and I want that for everyone. And so, you know, finding a menopause educated provider, to help guide you through this and be your partner through this transition is going to be key.

Well, thanks for your advocacy and your work and your insights. You have a wealth of resources. Your new book is really tremendous. It's really kind of lays out a map. It's for women. It's called the New Menopause: the Latest Research and Best Treatments for a Healthier, Better Life. You can find everywhere you get books. You also have a great website. Right. And it's, thank you. Maybe share with the pause life with everybody. Yeah. And a pause life.

That's the pause life.

The pause life. That's great.

Yeah.

That's great.

I wanted to put a positive spin.

Great. And so I think it's great that you're out there talking about this because it's not enough people, particularly from, you know, more of a traditional academic background who will really understand this and are helping people through it. So thank you. And it's great to hear that you and I come to the same conclusions after 30 years of practice. I really appreciate your work. And thanks for joining us on the Doctor's Pharmacy.

Thanks for having me.

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