What Women Need to Know about Hormone Replacement Therapy

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Thank you. I'm excited to be here.

Okay. You know, we're a group of women here who like to know the dirt. So really, I want to know why, why this, why are you choosing to do this on any given day when you could have chosen maybe any career vocation? What got you here?

Oh, wow. Well, if I'm being really honest, it was an all-expenses-paid trip first-class, actually paid trip to Vegas to a hormone conference years ago. And I, at the time, you know, I was working in emergency medicine. I was working with a hospitalist group. So I was, you know, one of those people that takes care of sick people that are admitted to the hospital and then discharges them and so forth. And, but I had, I had kind of ventured out into, the wellness world with a colleague of mine who is doing weight loss. And we were approached by our local compounding pharmacist, and who said, hey, you know, hormone therapy goes in really well with weight loss, and if you guys want to attend this conference, I'll send you first class and, you know, put you up in the suite at the Bellagio, etc., etc. So I was like, sure, I'll do that, you know, with really not a whole lot of thought around hormones. Um, But I was sitting in the audience listening to a doctor, and I can't remember her name, but she wrote a book called Awakening Athena. And she was explaining just this incredible life change in her female patients with natural bioidentical, bioequivalent hormone optimization. And I had just this moment of clarity that this is, this is what I'm supposed to do. I had become kind of disenchanted with our what I call our sick care system, where we're just kind of prescribing a lot of drugs to band-aid a lot of symptoms. And I never really felt like I was getting to the root cause of a lot of my patients' issues in the hospital. We were just kind of in this churn of keeping them on all the drugs and adding more drugs and this, that, and the other. So, um, this idea that hormones, um, could be a basis of chronic disease prevention really intrigued me at that time. And so here I am.

Very cool. Love that.

Okay.

Can we ask this? My mother would have said this is never polite. Don't ask that. But it's so relevant here. Can I ask how old you are?

I am 55 and I will be 56 in September.

So we'd like to know that you're legal to be here.

I am. And I have 7 kids blended and 4 grandkids. And yeah, no, I'm, I'm fully in. And I'll tell you, I've been managing and optimizing hormones and women for about 8 years before I went through a menopause transition. And wow, when you experience it, it sure does make it a lot more real.

So yeah, yeah, I'm there. And it is so relevant. And I think that is just, you know, I think anybody here, you know, we can say the same about their, their health coaches and their personal trainers, right? It's like, it's so fun to get those 20-something redhead cute women giving advice on how to, how to work on your core. And we're just—

oh yeah, honey, honey, honey, there's so much I could say about the exercise piece as we age. Maybe we'll talk about that later, but right, different.

And, and I will call myself out, I was just ageist. I just did it to a younger person, so I apologize for that. But I'm trying to catch myself. But I think it's— we love it when somebody's got the experience and you're in the boat rowing. We know you get us. And I think that so hard. Like, the get-you factor is really the thing that we're looking for. That— so being here with us, this makes this first question I wanted to ask relevant. And I thought, hmm, is it or isn't it? What do you think is the biggest misconception about hormone therapy for menopause?

Uh, the biggest misconception is that hormones are dangerous and they're going to cause cancer and all kinds of problems. Um, that is just huge. So it's wrong.

I'm going to throw something out, and I'm literally throwing this at you and the audience members. She didn't know I was going to bring this up in advance because this has been a surprise to me too. Very recently, a colleague who is much respected in the area of bioidentical hormones and thyroid health threw an idea out to me And it was a good thing I was sitting down. But he said, you know, 5 years ago, 10 years ago, I might have said yes, bioidentical hormones. But he said, I think your body just might be telling you you're done, and maybe they're not for everybody. He said, in my, my mindset about hormones has really shifted. And I was just like, what? So rather than continue to try to get it right, you really think that the research isn't compelling about bone density and supporting lean muscle mass. You said, as a, as a medical exercise specialist, strength and conditioning coach, I've actually seen it with clients. I know who gets better results, and I know personally, you know, when I'm, I'm not getting the right cocktail, I can tell it from my workout. But what are your thoughts about that?

Well, that's a, that's a big statement. Well, which, which part do you want my thoughts about? Because you said a lot.

So yeah, I think one of the things he said that really shocked me was— and by the way, he and I are gonna do a podcast. I said, would you come on and talk to me about this? Because I think we really need to unpack this. If you feel strongly, then I don't want to be right. I, you know, and nobody else does either. We want to be giving the right information or the best information for any woman to make a decision. That's the whole point. And, you know, he said, there's just, you know, as I dive into the research, this was his statement, there's not compelling enough research to say that it really helps bone density. And I really said, really? I, I don't know. But that was one of the things. And he said, if you're not having hot flashes or night sweats and don't need it to help with symptoms. I don't know that there's a health benefit beyond that.

My first question to him is, is he married to a woman who has transitioned through menopause? That's question number one. Um, and, and I'm, and I'm being serious but a little facetious, but, um, let's just address the studies part. So, you know, I think I said before we came on the air, one of, one of the things that I do is I have a company that trains doctors and healthcare providers across the country in how to optimize hormones naturally. And it's a 2-day, really intensive training with ongoing education. And the first 6 hours of our training is all reviewing the current literature around hormones. So I can tell you with absolute confidence that not only does optimizing all of your hormones— and it depends on the type of hormone. There was a really great study that came out in 2023 that was addressing The role of estrogen in brain health and Alzheimer's disease prevention, but they made a very good point in it— the modality matters. But not only do— is there a plethora of evidence to show that estrogen with testosterone and progesterone in women increase bone density, but also that the three of those together are synergistic in the brain, preventing strokes, Alzheimer's disease, heart attacks, and even breast cancer. There was a, a 2020 2020 paper that came out that completely flipped all the Women's Health Initiative scare around estrogen and breast cancer, and they actually stated estrogen is the only drug that's ever been shown to prevent breast cancer. So everything's kind of flipping on its side with the whole hormone conversation, and I'm so grateful because these are the things that I've researched and taught, you know, for well over a decade. So I would, I would respectfully disagree with his opinion. And I will also say that once the symptoms of menopause go away, that doesn't mean you don't need the hormones. That just means the initial fluctuations in your hormones which causes the hot flashes are, are over. The fluctuations are over, and now your tank is empty. So it's like, it's like a battery that's sputtering on its last, you know, leg, and you're getting a little juice out of it, a little juice out of it, and then all of a sudden the battery's dead. Well, that's what happens with the female ovaries with estrogen during perimenopause, um, is you're having huge fluctuations in estrogen, uh, and then that's where the hot flashes and a lot of these symptoms come from. And that's during perimenopause, which can last 2 to 8 years. And then once that time frame is over, those symptoms go away. But that doesn't mean you don't need the estrogen. It just means you're not having the symptoms of low estrogen that are tangible. But bad things are happening in your body because we do need those hormones.

Yeah, and I think that was such a great analogy, and I don't think that's ever been said like that before here. So, you know, let's say that again, right? And I think this is— the analogy is almost like, um, fitness, right? Somebody wants results quickly, and really the thing that they think they want— think, think that you want, listeners— as a weight to change, right? But before the weight changes, you also are going to start potentially sleeping better. You're going to— your mood is going to stabilize, your energy during the day will stabilize, you're going to— you're going to focus and concentrate better, and your waistband actually may dig less into you, you know, before the weight changes. So you've got an indication that things are going in the right direction even before you see the scale, which might be what you're measuring. And then the flip side, you know, it's you, you have the signs and the symptoms. Okay, that's obvious, you know, but what is it, Terri? There's 34 identified quote-unquote symptoms, and some of those— right, and some of those are just like you would never tie that to that means I'm in menopause. And right, and so some of those were, were having— many women are having them and making no association with, you know, hot flashes and night sweats. It's like, okay, I got that. Even belly fat, now everybody understands, okay, I got that, that's probably related, it's hormonal. But that was just such a rich statement, so thank you for, for sharing it in those terms.

Absolutely. You know, it is a roller coaster, and when I went through it, that's exactly what was happening. You know, you And being a healthcare provider, you know, when it's happening to yourself, it's hard to diagnose yourself because I'm like, what's happening to me? But I'll tell you, you mentioned something about the symptoms, and that is so accurate. There are so many vague symptoms that are related to hormone decline, especially with moods and anxiety and depression. I mean, we have people, and women would— can resonate with this, that will say, I feel depressed and I have the blahs, and I have no reason to. I have a great life, I have a happy, you know, marriage, and etc., etc. So Depression, mood swings, anxiety, difficulty staying asleep at night, extreme fatigue, especially in the afternoon around 2 to 4 o'clock in the afternoon, is a, is a hallmark, uh, hormone insufficiency. Joint pain, um, we— you already said belly weight and some of the obvious ones, but depressed mood, anxious, irritable, can't sleep, can't focus, brain fog. You know, where did I park my car? Where did I put my keys? Why did I come into this room? You know, these are all subtle symptoms of hormone decline. And a lot of times when we go to our healthcare providers to, to look for solutions, we're kind of just put on medications to Band-Aid symptoms which have other side effects and exacerbate other things. So it's a really important conversation. And the other part is these things happen well before perimenopause because the first hormone that a woman loses, and it starts in her 30s and is exacerbated after that second pregnancy and that second child is testosterone. The female ovaries make testosterone. You start losing androgens in your 30s, and in your 40s you start losing progesterone. And estrogen is the last hormone to kind of peter out, if you will, at the end. So this hormone conversation can actually start a lot younger, uh, you know, than our mid, mid-40s to early 50s.

Yeah, yeah. And I think a lot of people just wait right? I think they wait even to ask the question. They figure, well, I'm gonna escape the other things, right? If I escape this, then I actually don't need to, and I'm gonna skate through. Yeah, I— and I think, um, you know, I know better, but I was that cocky. I was like, oh, it's not gonna hit me, I'm fine. And then I was 56, and then I was like, oh, here you are. I see you.

And you found me. It's annoying.

Yeah, you got me.

Yeah.

Well, I love that you're a science, science woman. So how has research evolved? You've been doing this for a minute, but in regards to hormone therapy— and I think this is where we come back to the, the first response you had, and that everybody is fearful of this because for so long it was put out there that we were talking about synthetics and the risk that they put. But now that we're talking about bioidenticals, and we, we've here for listeners probably identify what is the difference between the two, but Terri, if you could do that, that would be very helpful for listeners.

So I'm, I'm gonna differentiate the two first, and then I'll, if you don't mind, I can tell you how we got here, um, and then what's happening to answer your initial question in, in the science world of unraveling from some things. So the difference between a synthetic and a biosimilar or natural or bioidentical hormone is simply how it's made. Synthetic hormones are created in a lab with chemicals. For instance, the big primary synthetic estrogen is branded Premarin or conjugated equine estrogen, and this is This is made from the urine of pregnant mares and works well to band-aid symptoms. But this was one of the hormones that was studied in the Women's Health Initiative trial, which I'll get to in a minute. And then bioidentical hormones, and, and it is, are, um, they're considered natural because they're plant-based. So really interesting, the, the 5-ring carbon structure on the cell of a yam plant not the green part, not the potato, is identical to human hormone. It's really fascinating. So when, um, those plants are compounded down, the powder's compounded down, they— it, it has the same chemical structure as human hormone, whereas synthetic hormones don't have the same chemical structure. So the way I like to describe it is like a lock and key. So if you've ever had a key that fit in a lock that but didn't turn the lock, you know, and hormones are the same way. So synthetic hormones fit in the lock, so they can fit on the hormone receptor, but they don't open and unleash all the benefits that the natural hormone does. It simply is a Band-Aid to symptoms like hot flashes, things like that. So that's kind of a, you know, a lay, high-level, lay, you know, description of the differences between the two. Now, one of the things that can confuse people is in, in the pharmaceutical world, in some of the, um, you know, the big, um, the big, um, things like ACOG, American College of Obstetrics and Gynecology, and some of these, um, big women's groups, um, you know, bash bioidentical hormones, not realizing that, um, you know, patches, estradiol patches and oral progesterone, progesterone are both bioidentical, and those are commercially available from a regular pharmacy. So typically, um, they're talking about compounded bioidentical hormones. So there's commercially prepared bioidentical hormones, and there's compounded bioidentical hormones, which can be a little more dialed in. So that's a, you know, 50,000-foot view of the differences of those two. Um, and then, you know, what got us here with all of the fear around hormones was the Women's Health Initiative trial. Now Before the WHI, and I'll just abbreviate it from here forward, Women's Health Initiative trial is WHI is the abbreviation. Before that, the primary hormone that was being utilized in this country was Premarin, which is a branded version of conjugated equine estrogen, and then its sister Prempro, which has a synthetic progestin. And I emphasize progestin because it's different from progesterone. And so those two medications were the primary hormones that were being looked at and studied. They were the, the two hormones that were studied in WHI because what physicians had been noticing for decades— these medications came out in the '40s and '50s— was that women who were on these hormones had much lower rates of heart attacks and cardiovascular disease. So the trial was actually initiated to prove that estrogen prevented cardiovascular disease. And they also wanted to look at estrogen's role in osteoporosis and bone density. And then the last thing they were looking at with the trial was safety as it pertained to breast cancer risk. So you're humming along a few years in the trial, and in 2002, the progestin arm, or the Prempro arm, the data that was coming out of all of the women that were on Prempro was it drastically increased breast cancer rates, Alzheimer's disease, heart disease, Everything opposite of what we thought. And what happened is rather than the media taking a look at the trial results and showing that the estrogen-only arm, the Premarin-only arm, actually protected women against breast cancer, strokes, Alzheimer's disease, and heart attacks, it was just the progestin arm that had all of the negative consequences. But the way it was extrapolated, and the way the media reported it was all hormones are bad. So they basically, you know, said that hormones had this single class effect. And unfortunately, what happened is women were throwing away their, you know, hormones and doctors quit prescribing. And it has literally taken over a decade to start slowly unraveling from that misinformation. And part of the problem was, you know, in In, in '06, it was just— it was plastered on the front of Time magazine, uh, and it, you know, said, you know, hormones are riskier than what we thought. What's a woman to do? You know, so here's the media just going, you know, here's— is all bad, and this is the problems it's causing. But in none of these reports did they report that it was just that synthetic progestin arm that caused the problems. And so now here we are in 2013, a paper came out that said huh, well, we're looking at the Women's Health Initiative trial and we think we might have misconstrued some information. And it looks like that women in the Premarin-only arm of the trial were actually protected against breast cancer. And then 2017, they kept that conversation going. And then in 2020, a huge article came out in JAMA, which is Journal of American Medical Association, that boldly stated not only is estrogen the only drug that prevents and protects against breast cancer, but also against death from breast cancer. So this is a huge statement. And they're talking about a synthetic estrogen, not even natural estrogen. And unfortunately, Time magazine isn't, you know, shouting that from the rooftop, right? Because if we could just get a big media outlet to plaster it on the front of their magazine— but negative news sells, right? Um, so, and it takes— there's a study that showed that it takes in the medical community up to 13 years for solid data to be out before the medical community will change their practice.

I think it's 17, Terri.

17. It's too long is what it is, you know. So, you know, it, you know, I— that's really kind of, kind of the, the crux of it. And so that's, you know, what I'm here to do is reeducate people that not only is it safe but very effective and very preventable for many, many chronic disease processes.

And I think what I'd like to remind our listeners of is that we're it, you know. We haven't had an example. We have nothing where we can say these 80-year-olds, these 90-year-olds did, they didn't. We can't look at that. We're going to be it. For those, those younger women who are 30 and 20 right now. Yeah, absolutely. So important. Okay, so let's talk about some different forms and preferences, or who, who each might be appropriate for. So there's pellet therapy, there's shots, there's creams, there's trochee, there's patches. You've mentioned some of those earlier. When do you decide which one to use or which one to use first?

The, the first choice would be where do I decide to get my help or who do I decide to see? Because some— not all healthcare providers are educated in all the modalities. So, um, there are, you know, and, and I work with doctors across the, the specialty spectrums, and one of my good friends, it's a gynecologist, an OB-GYN, that, that teaches and trains with me, um, she'll— she says it so beautifully that, um, we're not trained on how to optimize hormones in medical school. We're taught basically, uh, that a woman will start having hot flashes and you can just give her this prescription for some estrogen until the hot flashes go away. That's kind of the extent of training around hormones in women, unfortunately. Um, so you really need to try to find somebody that's gone to some expanded education in hormone optimization because it's so much more than just giving you a pill for a little while, while— till, till your symptoms go away. So that's the first thing. And then once you are there, there are some differences and there's some different choices. It just kind of depends on, um, the, the patient and what you're looking for. Um, I prescribe bioidentical hormones only. Um, I prescribe them primarily in the form of pellets, which is, you know, um, I can talk about pellets in a minute. And then I also use a lot of Rapid Dissolve tablets, oral micronized progesterone, which is a bioidentical progesterone. I have some guys that, um, that prefer shots. Now, shots are synthetic, but they're very, um, very well studied and, and safe, you know, when done properly in men. I don't, I don't like shots in women. The side effect profile is pretty high, uh, in women. It's not my first preference. And we're talking about testosterone there. So basically you have testosterone, estrogen, and progesterone, um, as far as the sex hormones. And testosterone and estrogen come in, um, they come in bioidentical pellets, patches, creams, orals, troches. And it really just kind of depends on the patient and, and convenience factor. And then progesterone comes in a couple of different forms, but the only form that's been really studied to, to, to be safe and get the levels that you need and protect the uterus and protect the breasts is actually the oral form of bioidentical micronized progesterone. So I prefer personally pellets because number one, they've been around since the '30s. It's the longest studied modality. A lot of people don't know that. They came on market before even Premarin and, and the synthetic estrogens did. And they were being studied in women who had had complete hysterectomies. And then in the early '40s is when researchers discovered that the female ovary actually made testosterone. So these women that were getting estrogen pellets, they started giving them testosterone with their pellets and exponentially saw improvements in all of their symptom profile. I like them because the roller coaster effect that I talked about before, you don't have that. So once pellets are placed and levels come up very slowly over the course of 4 weeks and they stay steady state for anywhere from 3 to 5 months depending on the patient. So there's a convenience factor there. Now, some people don't like the thought of having something that's in them lasting that long. So the next— my next favorite would be oral rapid dissolve tablets. I prefer those because you want any kind of modality that's going to go direct into the bloodstream and avoid what we call first-pass metabolism through the liver. So anytime you swallow a pill, you know, you've— there's things that happen to that medication. You're not absorbing— you're absorbing maybe about 50% of it, and then it has to go through the liver for metabolism. And, um, you know, there's— this is where some side effects can come from in the form of estrogen and testosterone. Um, and then creams are okay. Um, creams are really hard to get patients, um, optimized on because it's— the absorption is really variable from person to person. It's difficult to monitor. Um, so you just kind of have to monitor symptom relief. So that's kind of my, my least favorite modality just because it's harder to dial in. And then again, shots for testosterone— shots for men are another option. So those are kind of the differences in the modalities that are available.

And you don't like a testosterone shot for women?

It's not my preference. And the reason is— so one of the, one of, one of the things I'm really trying to achieve with my patients and even when we teach other providers, is as close to what we call hormone mimicry as possible. And the way our bodies— when our bodies are operating, you know, on all cylinders, when we're in our— typically in our teens or in our early 20s, before we've, you know, been on this toxic planet for long enough to mess things up, um, we're slowly and steadily releasing hormone. Let's just take testosterone for a minute. There's a basal level of testosterone that's always there, and then in times of stress or exercise, good stress, bad stress, it doesn't matter. You get surges of testosterone. And estrogen and progesterone are cyclical, you know, according to whatever you're in your cycle when you're still ovulating, when a female is still ovulating. So there, there isn't a time when your body is functioning normally that you get a dump of hormone into the system. So one of— that's why my, my least favorite really is as far as non-oral modalities as shots, because when you give yourself a shot of testosterone, it dumps a bolus of hormone into your system now, and, and that hormone has to do something. And the two active metabolites of testosterone are estradiol, estrogen, and dihydroxytestosterone, DHT. Those are the two active metabolites that exert their actions on the cell, and men men convert estrogen and need estrogen as well, um, just like women do. But unfortunately, in shots, women convert more DHT, and that DHT, um, can cause a— is what causes a lot of the side effects. When you get a bolus of DHT in the system, it can cause more hair thinning, it can cause more acne, it can cause more voice changes, and sometimes those are hard to come back from. So my preference with testosterone is just kind of a slower, steady rise. Now, there are some practitioners that are using small microdoses of injectable testosterone in women daily. That seems to do better, and it seems to have a less side effect profile. So, but, you know, not everybody wants to do a daily shot either. So I think there's ways you could do shots safely, but the synthetic nature and the conversion to DHT with the side effects is really what I don't like about it. And it hasn't been studied in women really, so we just don't really know long-term with shots in women, but we do with men.

Well, I know if I've got listeners out there who are beyond— they're not right in this heat of the moment— that I'll do them a disservice if I don't ask this. And so in your opinion Is there a time when it's too late for someone to begin taking hormone replacement therapy?

Great question. There is not. I have patients that cross the age span from 20s all the way to 90s. There used to be an old recommendation that went away in 2017 for the, the lowest dose of hormones for the shortest amount of time possible, and women should stop their hormones at 65 and don't start your hormones after 60. All of that has refuted now in the medical literature. So now what I would say is the further a woman is out of menopause, that you— she still needs her hormones. But this is where the art of hormone optimization comes in. You definitely want to slowly wake up those hormone receptors. So say if I had a 65 or 70-year-old woman who went through menopause at 50, so now she's she's 15 to 20 years out of menopause, I wouldn't give her the same amount of hormone doses that I would say a 52-year-old who's just transitioning through menopause. So there is an art to it. You can't, you know, you can't give everybody that. It has to be really individualized medicine. Um, so I think— did that answer your question? I'm assuming you were talking about someone later in life.

Yeah. Yes. And I'm so glad that you actually use that range, that number because I think a lot of times someone is maybe 10 years beyond and they think, you know, somebody told me that that's the line and I can't do this anymore if I didn't. And so using 15 to 20 was just fantastic. Love that. Okay. But I asked you that question in fairness. In your opinion, is there a time when a woman should go off hormone replacement therapy?

Another great question. I get the question all the time. So we're living longer. Um, the average age span, I think, for females is what now, 86, somewhere in the mid-80s. And we start going through a menopause transition in our 40s and late 40s, early 50s. And if you're lucky, later. But that's the other side of the bell curve. But on average, most women start menopause transition in their late 40s. So we're spending almost half of our life post-menopause. And it's a quality of life conversation. It's also a disease prevention conversation, of course, because all of the chronic diseases that are typically diagnosed— most women and men are diagnosed with those in their 50s, right? Because we've gone, you know, a good decade without some key hormones. But then it becomes a quality of life issue with pain, joint pain, energy, memory, um, you know, mental focus, mental clarity, moods. So, you know, it— for me, and for, you know, when people ask this, I, I say I will have a pellet in my— under— in my fatty tissue until I'm in the grave. I'll be buried with a pellet in me. Um, I will not stop my hormones because there's no reason to. Um, they're not unsafe, and I, I want to be strong and vital and have vitality throughout my life. And so it really is an individual question of how do you want the, the, your quality of life to be in post-menopausally, in those, you know, 20, 30, 40, and even sometimes 50 years after you've transitioned through menopause.

So good. Okay, so I also want to ask this last question because I'm going to sneak in as many as I can. How long on average does it take to get a woman's ideal hormone cocktail dialed in? So, you know, you mentioned with a woman who might be 20, 25 years past, you'd start them on a lower level. So probably there's some kind of let's find your sweet spot. How long does that take on average? Is that a hard question to answer?

No, it's not. It, it really depends on the— not only the individual, but the modality. Um, of hormone that you're using. So, um, I, I can dial in pretty well with hormone pellets. I've done this, you know, we've— I think the last count was we've done over 65,000 pellet procedures since we opened our clinic. So we, we kind of have this down. Um, but it, it, it takes a couple of months really. Now initially when you first start, um, especially if you're paying attention to thyroid hormone, you, you can't just look at one thing. You have to look at the whole body. The other thing that we do and that we— that I teach, um, is you also have to look at gut health. There is a huge connection between the gut and hormones. In fact, I just was reading, um, a, an article the other day when I was doing some research, um, that the gut is now considered a full-fledged endocrine organ because it plays such a role in estrogen metabolism and hormone metabolism. So So there's a lot of things you kind of have to pay attention to with that patient and address. It's not hard, but it's kind of an art. But once you kind of dial in on some of the basic things, you know, making sure, you know, the gut is, you know, working relatively well, and you just kind of can prime the pump with some of the key hormones that are missing depending on what the patient's symptoms are, you can really get a lot of symptom relief in a person. And feeling a lot better actually pretty quickly, within a couple of weeks. So some of the initial symptoms you can really, really dive into within a couple of weeks, but some of the other ones, some of the other nuances of hormone optimization might take a little bit longer, maybe 3-4 weeks, you know, just kind of depending again on the modality that you're using. But it's not an overnight quick fix. It's not like I have a headache and I take I take, you know, some aspirin and my headache's gone. Now, most hormone modalities, from a band-aid perspective, let's just talk about hot flashes. You know, whenever you start pretty much any estrogen modality, your hot flashes are going to be gone pretty quickly. But some of the other things that estrogen is responsible for with memory and mood and joint pain and things like that might take a little bit longer. And again, the modality is important because if you're taking something, if you're utilizing a modality that has to be taken every day, that peaks within a few hours,, and then drops off by the afternoon, and then you have to do it again to get your levels back up. This roller coaster makes it a little more challenging to be— feel fully, you know, kind of balanced. So that's also part of the dance is what kind of modality are we using? Are we using a patch that's going to last, you know, 3 to 5 days of estrogen? Are we using, you know, a pellet that's going to last 4 to 5 months? Are we using an oral that's it's going to last 4 to 5 hours, right? So, um, it's, it's kind of a big answer and it has a lot of variables, but by and large, depending on what you're trying to address, it can be anywhere from days to 2 weeks.

So good. Awesome, Terry. This has been so fantastic. I'm sure you're going to have a bunch of next best friends coming after you. Where's the best place for them to find you?

Uh, um, Evex, our, our web, my clinic, um, if you're local, we're in the DFW Metroplex. And we've also trained, um, over 3,000 doctors now across the country, doctors and other healthcare providers. And, um, they can be found at evexias.com, E-V-E-X-I-A-S dot com. There's a find a provider locator and you can put in your zip code, and those providers have been trained in a lot of everything I've been talking about today.

So yeah, fantastic. Well, thank you so much for your time. Okay, listeners, I am sure there's a question. I hit a lot of them, you got to give me some credit here, but yeah, I'm sure there's a question you also have. So listener, I'm turning it over to you. I'd love for for you to put your questions at the show notes, and that'll be at flipping50.com/womenneedtoknow. Women need to know. And what are you waiting for? Let's start flipping 50 today.