Everything Women Need to Know About Perimenopause, Menopause & Hormone Therapy Compilation TUH #277

Hey guys, welcome back to the Ultimate Human Podcast. I'm your host, human biologist Gary Brecka. Today we're doing something a little different, and I'm fired up about this one. What you're about to watch is a compilation, 3 conversations that I've been wanting to put together for a long, long time. Because if there's one area where women have been let down by medicine, by media, by system, it's menopause. 50 million women have unnecessarily suffered for decades because of one misquoted study. That's not a headline. That's a quote from the chairman of the FDA. Let that land. So today I'm bringing you three of the most important voices in this entire space. First, Dr. Jessica Shepherd, a board-certified OB-GYN, menopause expert, and someone who completely has rewritten the playbook on women's hormonal health. Then Dr. Vonda Wright, a board-certified orthopedic surgeon, will tell you why a frozen shoulder is not just a joint problem— it's your body screaming that your hormones are in crisis.

And finally, my wife Sage, who lived this, tested this, and came out the other side.

By the end of this episode, you will know what perimenopause actually is, when it starts, what to test, why standard blood work misses it, and what to do when you find the answers. If you're a woman or Or you love a woman, stay in your seat.

This one matters.

My first guest changed the way that I understand women's hormonal health and honestly, the way I show up as a husband. Dr. Jessica Shepherd is a board-certified OB-GYN and menopause specialist who didn't stay in the system when the system was getting it wrong. She blew the whistle. She founded Modern Meno. She wrote the book Generation M, and she's made it her mission to capture women before they fall off the hormonal cliff and give them the building blocks to thrive at 60, 70, and 80.

Here's Dr. Jessica Shepherd. I know that you're a classically trained physician. Yeah. Um, but at some point there was a shift, um, in your career and your career choices. And I'm always fascinated by that because, um, comfort would dictate that you just stay in the system.

Yeah.

Do what the system tells you. Um, you make a good living. Kind of keep your mouth shut. Don't raise your hand. But I wonder if there was— what preempted that shift?

You know, there are really pivotal moments in your life where everyone gets choice in to decide what they want to do with that moment. And my background, a little behind the scenes about me, is I got my undergraduate degree in kinesiology, exercise physiology. So I really understood what the body could do, what it could adapt to when it's optimized. So I feel that the beginning of my medical career was in the best of the best of what the body can do.

Mm-hmm.

And so going into medicine, obviously we know how to fix train wrecks. We deal in illness and disease, which is great. We do need that side to society. So now practicing 15 years of seeing the worst and fixing disease and operating, I did a fellowship in minimally invasive gynecology. So I was a high-volume surgeon. But what I really started to understand is the story, the story behind the scenes of all these women that I would see in the exam room. And I knew deep down, I was like, there's something else going on. And that something else is all the behind-the-scenes thing that allow people to show up with disease, whether that's with nutrition, exercise, stress, emotional, issues that are going on actually feed into how we present in chronic disease as well. And so I think that that was the pivotal moment that I said to myself, I have to do something different. And that's when I ventured more into looking at root cause, looking at lifestyle, being able to actually educate while empowering women about their life, especially in midlife.

I think most say, I still have a period, I can't be in that. Phase.

Yeah, I think we affix a period or a menstrual cycle to functionality in the sense of nothing's wrong, right, or nothing is changing. And that's really not even biologically how our bodies work. Nothing shifts overnight. It all is a process. And so when we think of perimenopause starting in our latter 30s all the way through our 40s, I think it's very astounding even when I tell my patients that that is really the duration of what happens, they sit and think about it. It's like you see the light bulb go off because, one, either they're going through it and have been for years, or two, really sitting to say, oh, my body is going through a transition that took years. That's how the cells work. That's how we see changes in the body. And especially with hormones, when we see the flux between estrogen and progesterone, whether they're, you know, counteracting each other the way they didn't before, or on a decline, That takes years.

And, you know, I, I think if there was just one way to torture a woman, it would be like the estrogen lever, right? Oh yeah. Oh, saggy skin, mood disorders, libido leaving the building, poor sleep, brain fog, you know, crushing fatigue, all with one little lever. Yeah. And, and, and, you know, testing for it, I think, is also something that's really poorly understood. I think most people will do blood tests that are snapshot in time, and I can't tell you how many women came through our functional clinics and their blood work was quote unquote fine, you know, within normal limits.

And that's what you'll typically find is that you're just fine. I, you know, classically trained as a physician, that's what we were taught is we're really looking for abnormalities. And I said that before, as we live in the world of illness and disease. So we're always looking for something that is really wrong when really what we should be looking at is the human body as it transitions for both men and women. But, you know, for now, women is even in the moment of it looks within normal range, how are you feeling? So we have not kind of brought the experiential part of perimenopause onto the actual fundamental science behind it. And that's where we are now, is being willing to hear women when they say, I feel A, B, C, D may not show up in a lab as a hormone malfunction or dysfunction. It actually is experientially what the receptors to the hormones are experiencing, which gives them the symptom. So we just have to listen more. Yeah. Imagine that. Yeah.

Listening more. We're— men are classically trained to not do that. Yeah. Halfway through your sentence, we're getting out the toolbox and we're going like, let me tell you how to fix that. Right.

So imagine that laundry list that you were talking about of sleep, of anxiety, of periods changing, of hot flashes, night sweats. That list is pretty hefty. So imagine going through that list when you're in a doctor's office but there's nothing on a lab to say, yeah, I understand what you're saying.

Yeah. I wonder if we could just back up, and for, especially for the women and for the men that are listening, um, where do they start? Like, what are some of the early warning signs? Is it mood changes? Is it weight gain, water retention? Is it all of the above?

It is.

It's really all of the above. I say that, you know, every woman who enters this midlife phase is really a moment for them to be more self-aware. Self-aware in the sense that I'm actually going to pay attention to me. Imagine that, right? So pay attention to what's going on in my body, 'cause guess what? The story is gonna be different for the next one beside you and thereafter. And so that can come in the brain fog. I would say even for me, my journey, it was brain fog. So imagine this, I'm a board-certified OB-GYN, menopause expert, wrote a book, And my first symptom was that brain fog, that executive functioning, clarity, memory. And it took me roughly about 6 months to put the pieces together, right? 'Cause there's also denial that goes with this, right?

Yeah, yeah, yeah.

Oh, that's so real.

The plumber always has a leaky faucet, right?

Yeah, you know, there's nothing really going on. Or you attribute it to something else. I'm stressed, this, that, this. And finally I was like, holy hell, Jessica, you know, you are perimenopausal age and you are having symptoms. The good thing is that I had the kind of the self-awareness to kind of put the pieces together, but I also had the tools and the resources. So immediately I was like, well, hormone therapy is what I'm going to choose. But for women who maybe don't have that luxury of knowing everything, and I'm sure we'll dive into that, is the symptoms that start are very subtle, but in that is the consistency behind it, right? Symptomatology usually is based on not a one-off or something that happens and you never experience it again, is now it's coming, maybe not as frequent, but I notice that it's there. And so not to dismiss those feelings of what you're feeling and then finding someone to discuss that with you, someone who, again, is going to put the experiential part of hormone changes in midlife onto you are actually going through it. So that can start anywhere from latter 30s, 38. I'm not even going to put an age out there, but latter 30s. And going all the way up until you actually hit, like you said before, that wall of menopause, which is where your estrogen now is like flatlined. It's like, we're not here anymore. But all before that is the fluctuation. It's high, it's low. It's like, I'm going to stay steady here, now I'm going to go lower. So all that time is when you're going to start to feel these symptoms either start, become more frequent, more intense, or more severe. So testing is a little tricky because again, the estrogen and progesterone are still there if you have a cycle, right? So we know in menopause you do not have a cycle anymore, which states that the ovaries are not eliciting enough estrogen release to give you a cycle. So while you're still having a cycle, whether it's infrequent, if it's irregular or regular, in the perimenopausal phase, we know that estrogen and progesterone are giving off enough to give you a cycle, just not enough where the rest of your target organs, your brain, your muscle, how your fat is distributed, are now actually responding to that flux. So the goal is, in testing, is not necessarily to tell you, am I perimenopausal? It's a good starting ground for a conversation, because what, at the end of the day, is the most important? The experience of what you're doing. So I can come on the back end and saying, I still think you're worthy of hormone therapy if that's what you choose. This is where we're going to start. Now, the Dutch test, I think is good for looking at metabolites or variations of your estradiol and your progesterone and what they're actually doing, right? It's a good follow-through to see exactly where the peaks are, where it's maybe going down a little bit. That is more extensive. But if someone's just basically trying to see where am I, I always say yes, your estrogen and progesterone, your FSH is good to look at, but also things like cortisol. Thyroid, also your vitamin D, because now you're going to start to see deficiencies in other parts of your body because you're going through this transition. In medicine, what we typically do, like I said, we are good at disease. I am really trying to capture women before they hit menopause to give them the best building blocks so that at 60, 70, and 80, they are optimized instead of waiting for it to be a catastrophic fall off the cliff. That's really what we're trying to do when we think of longevity, looking at hormone therapy, in mid-age is really that opportunity, that chapter to say, my next chapter is coming. 40% of our lives are spent in the postmenopausal phase. What I want this chapter to look like, let's start mixing up the recipe a little bit.

Yeah, and I think it's important to note that these are not things that jump out of the labs, right?

Do not.

And I think we always want it to be so black and white. Okay, hemoglobin A1C, 64. That's what we've told women. Yeah, this is insulin dependent. It's not that. It's the whole picture. And I love how you are talking about the symptomology, the subjective part of the health history that says, this is how I feel, this is how I wake up, this is how I think, this is my mood, my emotions, my libido, my energy levels. I mean, those are all classic signs. And I think just as adults, I mean, men and women, we intentionally try to sometimes ignore these.

Oh, we are classically trained as men and women, as humans to—

Humans, yeah.

Ignore what your body is telling you until it tells you something where it's catastrophic. And that's when we say, I may need to take care of that. So it's trying to kind of front-end that with being like, let's pay attention to our bodies so much that the moment something is changing, we can start the conversation and not wait till it's a train wreck.

Yeah. And I think so the blood panel testing, I will say that 3 weeks, almost to the day after my wife started hormone therapy.

Complete game changer, isn't it? And you were seeing this firsthand.

Yeah. I mean, libido came back. Yeah. And I think sadly, in a lot of marriages and relationships, when libido leaves the building, they think that love and attraction has left the building and it starts to create a lot of unnecessary friction in a relationship. So libido came back. Her sleep almost immediately in that period deepened. The frozen shoulder went away. And after the 3-week period, probably 10 days after that.

That's amazing.

I mean, she went from here to just being able to put her hand straight up in no pain. And these were adhesions. Wow. And I've been down the rabbit hole of what is the mechanism of that? Because I just thought I never made— drew that correlation. And then I think, like we talked about, when the FDA—

Yes.

You know, removed the black box warning from female hormone therapy and the chairman of the FDA came out and said, "Hey, 50 million women have unnecessarily suffered because this study was misquoted." And the mainstream media loves controversy.

Oh, they love sensationalizing.

This is gonna kill you and they were gonna die. And I think so many women, millions and millions of them, completely hormone therapy was off the table because of Gary Brecka.

I think we look for, you know, in general direction, especially when it comes to your health. That's what we've always idealized medicine as, direction in order to give someone what they need to do in order to be their best health. So when the WHO, you know, kind of came out with this kind of catastrophic message, it really did, one, misalign what providers thought, you know, we do no harm. And if we're thinking, oh my goodness, I gave something that may be of substantial harm to a patient, the first thing we'll do is saying, I'm not doing that anymore. So now you have kind of the director of this relationship between physician and patients being like, I can't give that to you. And then patients also seeing it on their level because it was brought in the media way that it was brought was to everybody, right? So now the public is like, Oh my God, now I've done something to harm myself. And so that really annihilated the benefits, which we now know and have known for years of what hormones can really offer you, not only for symptoms. And that's, you know, something that we can discuss is hormone therapy. Yes, there are symptoms that we've discussed over and over again now, but also longevity. What does it do for preventing chronic disease? What does it do for brain health or bone health later on in life? Those are the conversations that we really should have focused on when looking at the benefit of hormone therapy.

I think a lot of women, um, you know, they're, they're getting into this too late. And I've heard you talk about target time frames. Yeah. Um, where like there's a good, better, best, right? There's never a time where there's no hope, but there's a, there's a time where it's good, a time where it's better, and a time where it's best. And, and relative to hormone therapy, what does that look like? For women.

That was one of the things that the WHO did get wrong in the study, because the ideal fundamental of the study was cardiovascular risk and what can we do to decrease cardiovascular risk, because heart disease is the number one killer of women. So that, you know, when we're looking at a study, we're like, this is good. We're going to look at something that has great outcome. Unfortunately, who they used hormone therapy in, in the study were not the best, when we're talking about good, better, best, of who we should have been using. These were women who were, on the average, older than menopausal age. So they were way in their elder 50s into 60s, smokers, people who had history of heart disease. So again, that's not ideally who you want to start hormone therapy in. Who you do want to, for anyone who's listening, is in that late perimenopause into early menopause transition, which could mean, if you wanted to put a tag on it, on age, maybe, 45 through 55. And that is when we start to see the flux in hormones. And perimenopause, you're still having your cycle. Into that early time frame, probably within the first 5 to 10 years of not having a cycle, is the ideal time. Do you want to know why? I think you want to know why. He's like, I kind of already know, and my audience wants to know why. But we, we're, we're dealing with symptoms, so we're minimizing and resolving some of those symptoms, which can make a woman's life very frustrating. But the other part and benefit of estrogen and progesterone and testosterone is that it has such stark relationships that are beneficial when we think of glucose metabolism, brain health, decreasing inflammation. Estrogen really is one of those robust hormones that is an anti-inflammatory, right? We know that inflammation is one of the main causes of disease.

Root of all evil.

Yeah, but it is, and it Then we talk about glucose, right? So sugar, like, how is it manifesting in a way where it's going to control your glucose better? And then the last thing is your organs need estrogen. There are estrogen receptors all over. So we're losing muscle mass. So when estrogen is lost, we're not able to kind of get our lean muscle mass that we like. Our gut health— gut health is imperative for future and disease prevention, but also heart muscle and brain. So bones even. So I could go on and on about the receptors that are needing estrogen. So when you lose it, your body is like, what do I do now? Yeah. So I really think that timing is important, that 45 through 55. And that's, that's loose numbers. That's not saying if you start after the age of 55, that's right, you're not going to get the benefit, right? But we want to get you before the body starts to have the inflammatory response. Now you've been exposed to your heart muscle not being optimal, so you're increasing atherosclerosis and things that are going to cause heart disease.

Now here's what's fascinating. Dr. Shepherd just gave us the why behind hormones. But you might be sitting there thinking, I'm not having hot flashes.

I don't have all those symptoms.

I'm probably fine. But what if your body was already sending you distress signals that no one was connecting them back to your hormones? My wife, Sage, had frozen shoulder for almost 9 months. An orthopedic surgeon wanted to put her under anesthesia and break the adhesions. Never once, not a single doctor connected that back to menopause. Until Dr. Vonda Wright. Dr. Wright is a board-certified orthopedic surgeon who has taken care of nearly 100,000 people in her career. And she will tell you, your bones, your joints, your muscles, they're all talking to you about your hormones. Dr. Vonda Wright is one of the rare orthopedic surgeons who treats the whole person, not just the body part. When a 46-year-old woman walks into her clinic with frozen shoulder, she doesn't just ask about the shoulder. She asks, how are you sleeping? What else are you feeling? Because she already knows what's going on. Please welcome Dr. Vonda Wright.

In my own practice, whether honestly it's— I have separated out my time, whether it's my orthopedic practice, and I'll give you an example, or whether it's my midlife menopause or my Precision Longevity practice, we always assess where you are now. So I'll give you an orthopedic example of taking care of the whole person. And we can go into why many doctors can't do the whole person approach if you want to. And it doesn't have to be due with our desire. It frankly has to do with time, but—

Time and compensation.

Time and compensation, if we're honest about it. So if a woman comes to me and she has the dreaded frozen shoulder, which means—

Oh my gosh, my wife had that. So I wanna go down this rabbit hole.

Awful. So what happens in frozen shoulder, it's an inflammatory response to midlife or inflammation, obviously, because it also happens in people with diabetes, but how it presents is, Out of nowhere, Gary, nothing happened. You did not bang your shoulder into the door. You did not work out hard. You have quick onset of excruciating pain. Unbelievable. Unrelenting. And you cannot sleep. And then with very short amount of time, you can't move your arm, right? It's this motion people come in with.

Which is exactly what happened to my wife. Exactly. I mean, exactly what happened to Sage.

In a quick amount of time. So when a person comes into my orthopedic clinic and I know, I read, "Oh, 46-year-old woman, shoulder pain," almost without pause. I know what's going on. So I'll go in the room and I'll say, "How can I help you today?" But I do not focus on the shoulder first. We talk about the fact that she's 47 or 46 and how are you sleeping and what else are you feeling? And because I am interested in helping her identify that she is in this critical time period of her life when her ovaries are stopping their production of estrogen and things are changing. If I were to do the typical thing, which is just say, "Oh, your shoulder's not moving. You've obviously got a frozen shoulder. Let me give you an injection, send you to therapy, blah, blah, blah." I miss the whole picture and I'm not taking care of the whole person. And so for me, my style of orthopedic surgery is taking care of the whole person. So we're talking about how the fact they're not sleeping, they're anxious, they've never been anxious, right? But all of a sudden they feel different. And within 5 minutes, Gary, of starting a whole person approach to the frozen shoulder, these women are crying in my office. And it's not because I'm the meanest doctor they've ever seen. It's because finally Finally, they feel heard and seen. And it's so hard. And almost without— almost to a woman, Gary, and men say this to me too, because I take care of both men and women, but people will say to me, "But you know what? I have a very high pain tolerance." Because there seems to be some badge of honor that is handed out on the— Oh, I've got a— they say, I have a very high pain tolerance and I thought I could do this. I didn't want to come. But the reality is people wait and wait and wait and suffer when we could have intervened really early. And so I think that's why coming in with a frozen shoulder, treating someone like a whole person and not a body part, they are quickly telling me about how they really feel. And crying sometimes.

Yeah, no, that was my wife.

I feel like that is the way people deserve to be treated, as not a sum of body parts, whether it's your liver, your pancreas, or your heart, or your shoulder. I want people to understand the biology of what's going on.

Yeah, and also maybe we can talk a little bit about dispelling some of the myths of the link between estrogen and breast cancer.

Oh, let's do that.

There's a lot of fear around that.

One of the things that we discussed before the camera started rolling was I found those studies too and actually followed the very same study that, uh, linked breast estrogen at the time to breast cancer, decoupled it, and fell in the polar opposite camp, that there was actually a reduction. And I think there's a lot of women listening to this and a lot of husbands that are curious about this too for their wives, um, is the hormone therapy a viable option?

Well, let's— do you mind if we start back at— No, let's go back to square one. Why does this even happen? So I think the fascinating, almost legendary thing that happens when you birth a female baby, a baby with XX chromosomes, is housed within her eggs, her ovary. Her ovaries are all the eggs she will ever have. More than 2 million.

Still fascinating.

Isn't that fascinating?

That is still fascinating.

So the legacy of your entire family exists within the ovaries of these baby girls that we have, right? So it's the natural history of ovarian life that, you know, and to contrast it, the analogous structure in an XY person, a male, is testicles, but you build 1,500 sperm a day or minute. It's rapid, right? Right. A female child is born with all the eggs. The natural history is that by puberty, we've lost a large percent of those. And then what we are designed to do, which we don't always do, is every month cyclically, as hormones predictably rise and fall, we use and exhaust a percentage. But here is why. Midlife is so profound for women and so different between men and women, because it is wrong to say that the physiology of men or women are the same. My own data show— I couldn't agree more. —down to the stem cell level that they're different. So by the time a woman reaches 35 to 40, you start to not feel like you've always felt because we have less than 1% of our eggs left. Estrogen, by and large, a very tiny percent is made in the adrenals, but most of a woman's estrogen is made in the follicle or the eggshell of an egg. So when you have so few, you're just not producing the same level, healthy levels you've always produced. And the reason that's important, and if there's one of several things I want your audience to walk away with, is estrogen, progesterone, and testosterone are not sex hormones. They are hormones, just like thyroid hormone or any hormones our body makes. They're not specifically sex hormones. There are estrogen receptors, alpha and beta, on every tissue of the body. So imagine every tissue in the body becomes rapidly starved of one of its key ligands, of one of its key signaling pathways, for all the good things, such that we know from the work of, of Lisa Mosconi and Robby Brinton that without estrogen, your brain not only stars, but changes its chemistry. The heart without the influence of estrogen has 30 to 40% more microvascular disease. And let's— I'm a, I'm a, I'm an orthopedic surgeon. Let's talk about bone. We will lose 20% of our bone density in the time between perimenopause and menopause. Wow. These are profound, profound biologic changes. So we started this conversation talking about frozen shoulder. Why do people walk in so inflamed? Why are women so inflamed in midlife? It's because estrogen is a profound anti-inflammatory. So when women walk into my office bringing it back and we take the time to listen, how are you sleeping? What's your brain doing? How do you feel in general? And they say, I don't feel like myself anymore. From a human biology standpoint, it makes so much sense. Yeah. If every tissue in your body is affected, it makes sense that we should be having longer conversations about the restoration of the most natural way of living which is with estrogen. It's not a byproduct. It's not something we should suffer through. If we're truly interested, Gary, in preventive health for women, we must talk about estrogen and we must talk about it earlier because my generation of women, I'm a Generation Xer, you know, baby boomers have lost out because of this study. Xers are not sitting down. We are going to change the future so that millennials and my 17-year-old daughter, my 18-year-old daughter will never starve our brains, will never have 60% more microvascular disease in our hearts, will not lose our bone density so that we end up frail. It's almost— listen to me, Gary, how passionate I get. It is a war cry, a mantra to me that I am gonna save the health of the women coming after me.

I definitely wanna close the loop on female hormone therapy though, because having had such an intimate experience with it and how it revolutionized my wife in such a short period of time, and knowing the number of friends that she has that are her age that are either still suffering or just haven't figured it out, and my female audience, you're a fan of hormone replacement therapy. Yes. And testing for the hormones, and how soon can a woman reasonably start hormone therapy, estrogen, progesterone supplementation?

I want to premise this entire conversation with the thought that women are sentient beings with agency to choose. So I demand not that every woman go on hormones, although if I were the queen of the world, every woman would go on hormones and go on them early. But every woman is sentient and has agency to choose, but you must choose out of facts, not fear. You can't glom on to some cultural mantra and go with that. You must be more curious and must be wiser in the decisions 'cause it's your body. So that's my disclaimer. Number one, some women come to me and say, "Well, I wanna do it naturally." I don't wanna put artificial things in my body. To which I say, what? Let's unpack that statement, 'cause I hear it dozens of times a day.

I'd rather be miserable and natural, you know?

Miserable, well, what's more natural than giving your body the building blocks it always has had? You have always had estrogen, progesterone, and testosterone. That is the natural state. What's not natural is not having them. So then the next thing people say to me is, "Yeah, but you know, I'm not a pill person. I don't want to take pills. I'm going to eat some soybeans and some yams." There you go. Okay, we'll do that. But do you know where body-identical estradiol comes from? It is a plant-based harvesting of the hormone your body makes. You cannot, so what's more natural than taking the hormone your body makes? That's natural, not eating yams and soybeans to try to get at what your body makes anyway. Oh, and by the way, we harvest estradiol, the molecule, which is the body-identical hormone. It's the same molecule. There's only, you know, bioidentical is a marketing term, but when we say body-identical, estradiol is, a chemical structure. We're not making this stuff up. Right. Nature made this stuff, right? Right, creation made this stuff up.

I was fascinated when I found out it came from yams too.

Yeah, right.

So, okay, estradiol, your body's— there are 3 or 4 kinds of estrogen, but this is the main one to restore to your body. If you have a uterus, you must protect the endometrium micronized progesterone, not artificial progesterone, micronized progesterone. And then testosterone is a female hormone. It's a hormone, men and women have it.

And let me tell you something, everything came back with her. Oh, this regimen— Not to get too personal, but things got a lot better with her.

No, and I always talk about my own hormone journey. These 3 systemic hormones is where we start. But that's not where we end. To prevent the genitourinary syndrome of menopause, which is vaginal atrophy, the loss of sensation in our perineum, the loss of tissue, our labia will reabsorb. And yes, I'm so glad you said that. 80% of all women suffer from incontinence. Nobody talks about it. Nobody talks about it. Vaginal estrogen, which is safe for every person, including people who have breast cancer. That's the fourth component. That is the fourth component. And then, you know, frankly, I'm as vain as they come. We lose 30% of the collagen in our face as estrogen walks out the door. Yes. Microdoses of estrogen on the face can restore the collagen build. To an extent. So much better than superficial things we pat on, you know? So facial estrogen, vaginal estrogen, estradiol, progesterone, testosterone is the complement that gives our body back the building blocks that it needs. And how early can we start? You can start in perimenopause, which can, in some women, can start at 35. The average age of perimenopause is 45, but we do not have to start— we do not have to wait until menopause at 51 or 52. We can start much earlier. And the opposition to that that I hear all the time is, why are you going to start a young woman on hormones? Blah, blah, blah. She needs to. Yeah, but let's think about that. There are generations of women who have been put on birth control pills, which I'm not opposed to. However, It's synthetic, it is not natural. Those are artificial types of estrogen at 10 times the dose of menopause hormone therapy. So in menopause hormone therapy, we're giving you—

At 14 years old too. Oh, right.

15, 16 years old. For decades, right? So we're taking body-identical hormones in very low doses It is not an argument when people bring up to me, "Yeah, but why are you giving hormones to young women?" Well, you're giving birth control to young women, which is 10 times the dose. We do it for decades and decades, starting at teenagers. Much lower age. Right, and I don't want people to think from this conversation I'm opposed to birth control. I am not, but I want people to be more curious and just don't slam on a mantra they hear somewhere that, oh, hormones, Well, you're taking them anyway. So let's think this through a little bit, because if I can, Gary, there's new data that I'm going to present at this conference that was presented at Zeno's. That was Saudi Arabia. Saudi Arabia. Well, it's being currently, as we speak, presented at the menopause meeting in Orlando that's going on this week. New data in 120 million women. It's a retrospective analysis of a vast database.

120 million. 120 million.

Wow. That shows that you can decrease the odds by 60% of the following diseases by starting hormones earlier in perimenopause: stroke, cardiovascular disease, heart attack, brain death, mm, and osteoporosis. Going back to the— astonishing ability of early hormone decision-making and truly being preventive disease modalities. And I want women to be literate themselves. I think gone are the days, long gone are the days, maybe when I started practicing medicine, we were still in it, but gone are the days when a person can just blindly take advice. I encourage all people, men and women, to become experts in their own health, to become literate, to read. Citizen scientists. That's right. To understand so that they can make the best choices for themselves and to do it early. Right. To your point, we think perimenopause can, which is the time when we're— when we have so few eggs, can start in their 35s. Who would suspect while we're still having children? But many women, we understand now, including myself, I had my last child when I was 40, go right from postpartum to perimenopause. And— Wow. But I don't, I'm gonna say this now because we're gonna unpack it, but I want women listening to understand that it's, you can feel better again. I mean, I, in a silly way, say I went from menopause misery to midlife mastery. I have mastered this.

Yeah, I am back in a way that— I like that.

Yeah, I am back.

That's the title of your newest book. I get 15% of it because you said it on my podcast.

But that's— listen to you.

Menopause Misery to Midlife Mastery. I love it. Yeah.

You've now heard from two of the most qualified voices in women's hormonal health. You know what perimenopause is, why it starts earlier than anyone else tells you, what your bones and joints are going through, and why hormone therapy isn't something to fear. It's something just to understand. But sometimes the most powerful thing you can hear is not from an expert, it's from someone who lived it. My wife Sage is one of the most organized, energetic, and driven people I've ever known in my entire lifetime. And then menopause happened, and I watched her become a different person, not just because she was broken, but because her hormones were. She couldn't get out of bed. She had frozen shoulder for 9 months.

She couldn't even raise her shoulder above level.

She had mood swings that neither of us could understand.

And then we did the testing and everything became clear.

This is her story, and I think it might be yours too.

The issue with menopause is that lots of things can crash at the same time. One of the things we noticed was rapid shift in mood, exhaustion in the morning, brain fog, libido left the building, and you were just not the same person.

And I think it was just like a feeling of being overwhelmed constantly. And I kept thinking it was because of something else. And I think the main thing that forced us to really look at it was my frozen shoulder. My arm was stuck right here for almost 9 months.

And just so you know, we were doing all the things—

red light therapy, sauna, cold plunging. We have a hyperbaric chamber. She eats extremely clean. When I went to doctors—

so we tried acupuncture, cupping, physical therapy. I mean, we tried so much stuff.

When we did this Dutch test, getting that test was a game changer. When it came back, it explained everything.

And I remember, like, crying with you when we got all these results back because you saw it finally. It wasn't just me saying, I don't feel good. You were, holy cow, I can see it in the science. I feel bad for guys because— You feel really bad for me? No, because we didn't know what was going on with me. And you can attribute so many things to other things. So if I was really upset about something or really sad about something, maybe we'd go, "Oh, well, you're PMSing," or, "Because you didn't sleep well that night," or, you know, you can always just find another excuse as to why it's happening. But it got really intense over the last year. And I think the main thing that forced us to really look at it and start reading about it was my frozen shoulder. So the only book that I read that linked frozen shoulder to perimenopause was Dr. Mary Claire Havers' book, which I think is brilliant, and it's called "The New Menopause." And I think she's coming out with a new one called "The New Perimenopause." Don't quote me on that one. Anyway, "New Menopause" has a list of, like, a long, long, long list of symptoms that I started reading through going, "Oh my God, I have that, I have that, I have that." And all these things I could checkmark off, and I'm like, Am I in it? Because I kept thinking I'm not old enough to be in it. Turns out you can be in perimenopause in your 30s. Like, this shit probably— sorry, language— but this stuff probably started happening a long time ago.

Yeah. So, you know, one of the things we noticed was rapid shift in mood. You know, Sage is totally on her game. We built a business together, we ran a massive clinic together, we've traveled the world together, and She literally couldn't remember one thing.

Not a thing. Not a single thing.

Not from one minute to the next. Words. Words. And she had trouble with words. Sometimes I would walk in the bathroom and she would go, I just want you to know that I am furious with you and I have no reason to be furious with you, but I'm just going to be honest. And I would go, thank you for the warning.

We sat in the kitchen one night.

I will be on the other side of the house.

And you had not done a single thing wrong. And I just looked at you and for whatever reason, I just— my blood started to boil. You had done absolutely nothing wrong. I mean, usually you do something wrong, but this time you had not. And I was like, I don't know why I'm mad at you, but I am. But it's kind of scaring me. So I'm going to leave the room. I'm going to walk away and I'm going to go to the bedroom and just, you know, get my book or get in the bath or whatever it was that I did that night. And I've never had that happen before.

And thankfully it has not happened recently. So being the best biohacker in the world, I said, we need to really take a deep dive here. Let's get a full picture of the hormones. Let's look at everything and not just take a snapshot. So not just take a blood test. So we did this Dutch test. We, she did this blood test, Dutch test. And I had to pee on a stick 5 different times throughout the day. And frustrated her and made her mad because I'm such a perfectionist. Maybe now would be a good time to apologize for that. I don't think I ever got an apology.

There's so many instructions with it. I'm going to just tell you this right now. If you're like particular like I am, it's, you know, I like it all laid out. I like it at the right time. You have to set alarms. Yes, I'm a perfectionist. So yeah, that was a lot. But then I also had my blood work done within like a month of each other. Um, gene test we already knew about, and the mold test was last year. So yeah, a lot of testing to figure this all out. So we— I'm trying to shortcut this for a lot of women that I know. Exactly, because not everybody can afford all of these things.

Yeah, but it— but getting that test was a game changer. When it came back, it explained everything. So let's head back to the whiteboard and let's take a look at what we learned from this test. So this is Sage's Dutch test, and this is a 24-hour urine test. I think this is the gold standard for women's hormones, especially if you are perimenopause, premenopause, or postmenopausal and you want to get an accurate picture of your hormones. The reason why is this doesn't just take a snapshot in time, it looks at the ratio of hormones. And listen up, women, the ratio of hormones is as important as your levels, because at sometimes during the day they can be at different levels. So when you just take a blood test and you just get a quick snapshot, you don't really get the true picture. And then it's hard to prescribe hormone therapy because you don't have the full profile. Hormones are not just manufactured. Hormones need precursors. There's raw materials in a woman's body that are used to make hormones. One of them is called pregnenolone, and we make cortisol, we make aldosterone, we make other hormones from pregnenolone. But it's this DHEA, it's this precursor in the body that acts like a construction material. And I don't care how good your contractor is, if you don't, you know, deliver materials to the job site, they're not accomplishing anything. And it's the same in a woman's hormonal system. If you don't have the precursors, the raw material, the construction product that you need to build other hormones, they become deficient. And what was shocking about this test was we discovered that she had virtually no cortisol. And so in the morning, cortisol is our waking hormone. It's responsive to light. One of the reasons why I love to get first light in the morning— you love to get first light in the morning. I generally encourage people, when you wake up, within 30 minutes, get outside, get natural sunlight in your eyes— is because that sunlight actually helps your cortisol rise and helps your melatonin get lower. What we realized was she had so little cortisol. When you look at it on a chart of a normal cortisol pattern climbing in the morning, you see that yours was flatlined. She had no waking hormone. And at the same time, you couldn't even register any more melatonin in your system. Your melatonin was off the charts. She wasn't even taking melatonin, but her melatonin was off the charts. So imagine that it's like taking an Adderall to go to bed and then taking a sleep medication to wake up. That feels exactly what life was like. Yeah, and you were, you were a lot more energetic at night than you were during the daytime. Yeah, sometimes the labs don't tell the full story. I talk about this a lot with heavy metal, mold toxicity, viral pathogens, bacterial infections, and, and other kinds of toxins that we put into our body that don't necessarily show up on the labs, but they have other manifestations— brain fog, weight gain, water retention, fatigue, sometimes crushing fatigue. You go and get your labs done, the labs are normal, the doctor tells you everything's normal, you're actually very healthy, your liver and your kidneys are fine, your, your CBC, your complete blood count, is normal, your comprehensive metabolic panel looks normal, nothing is jumping off of this page, so we really don't have a reason for why you feel that way.

Well, and that's what got so confusing, is because we also did a Vibrant Wellness test, which was the mold, mycotoxins, parasites, whatever. We did get rid of all those. But that, when that hit, my mold was like where a 9 was high, I was a 49. I mean, I was off the charts for mold. So that was probably contributing to the brain fog too. So we didn't think so much about it being hormones 'cause we were like, it must just be mold. But then when I started to clear that out and the symptoms weren't going away, it just was confusing. So to have the full picture and have as many, You know, not everybody can get all the tests done, but I think the blood test says a lot. I think the urine test says something different. And I think the, you know, the other mold and mycotoxins has a whole nother picture. If you can do all three, that's what saved me at least. And then also the gene test just helps like account for a lot of it too, because so much of your genetics, your methylation is tied to hormone balance.

You're a lot more energetic and super back on your game. And your frozen shoulder is gone.

Yeah, that is a game changer. That was brutal, frozen shoulder. But when I went to doctors, so we tried acupuncture, cupping, physical therapy. I mean, we tried so much stuff. And then I went to a doctor that said, "Well, we'll just push you under anesthesia or a light twilight, whatever, and we'll just rip it out." Yeah, it's called manipulation under anesthesia.

Oh, don't do that. Yeah. So you see a video of manipulation under anesthesia. Holy shit.

Yeah, I saw a video and I was like, I'm not doing that. That's insane.

It looks like they're breaking your shoulder.

It looks like they're breaking your arm. So the fact that I got on hormones and 3 weeks later I already was able to move up without pain is wild. Here's the wild thing.

The night that we started the hormone therapy. Yeah. She was like, okay, we're in a log cabin at 10,500 feet without another soul around except me, of course, to receive the brunt of it if it didn't work. There I was, just call me the catcher's mitt. And so I'm like, let's do it. And she took the hormones, passed out. I mean, passed out cold.

Like it's 7 o'clock or something crazy.

Yeah, 7 o'clock at night and slept all through the night. And I was like, hallelujah, we got it. We're on something. Truthfully, it was all uphill from there. I mean, in a good way. It was all positive from there. You know, as they started to regulate, his pregnenolone started to provide the raw material for cortisol. Her sleep cycle started to normalize. As her melatonin started rising at night and falling in the morning, she was less exhausted in the morning. I noticed that almost right away. She was more on her game. You know, we have a huge project going on in Colorado, and she was managing all the contractors, and that took a nosedive for a little while, um, and She was just— I think even the GC was like, who's this? Who's this chick showing up today with the long laundry list of things to check up on? And she was just all of a sudden back on her game. And then the greatest thing was over the next 3 weeks, the frozen shoulder thawed.

Yeah. Yeah. So there's a freezing, frozen, thawing stage is what I've learned about.

It can take a year and a half for frozen shoulder to thaw.

Some women up to 3 years if they just don't see anything, you know, change with it. So in my head, I was like, oh my God, I can't do 3 years of this. Mm-hmm. It's already been 9 months.

But so, ladies, it's okay to do hormone therapy. Yeah, I agree. And I think—

don't make yourself suffer unnecessarily. Oh, hot flashes. Of course, that's just like something that all women, I think, go through. But that was the only thing that was ever like really pinpointed. It was like menopause, hot flashes. But that's the only symptom anybody would ever talk about. So growing up, I just thought that you just get hot flashes. And I always thought, well, I'm always very chilly, so maybe I'll enjoy that. Don't just jump straight to hormones. Don't just— I think that it is important to get your methylation in balance, figure out what raw materials, simple raw materials might be missing. What kind of B12 is good for you? What kind of, you know, do you need 5-methylfolate? Those are such important pieces to the methylation balance that leads to the hormones getting out of control. But also recognize, like, when you're in your 30s and you're, like, probably in baby-making phase, you're not thinking about menopause. Menopause is, like, years away. That's, like, grandma stage, except I'm 47 and I don't feel like I'm a grandma, which is so weird. No, you definitely not. But back when I was in my 30s—

You're a spoken hot grandma.

Thank you, thank you. But back in my 30s, 50 felt so far away. Now it's 3 years away. But I think this stuff started back when I was probably 37. When we met, I think it was starting to hit, which is wild to think that. Yeah, but things were different in my late 30s.

So women just don't need to suffer unnecessarily. Husbands don't need to suffer unnecessarily.

No, learn about it together. I send you a lot of memes. Oh my gosh, actually, I have a funny one on here. Um, I send you a lot of things from Instagram. Is shockingly helpful. I'm not a TikToker, but I sometimes just to make him laugh. We do have a group chat with Josh and Victoria, and it's just so that Josh and Gary can, you know, suffer together and know that we've formed a male support group.

It's a support group.

Yes. But I do believe that men need to educate themselves as well and then just help your, your person through it. Yeah.

Lots of hugs, lots of back rubs, and a lot of honesty.

A lot of hugs. I mean, honestly, anything, you can get through anything with a good hug. You can. Yeah, it's true. What is it, 20 seconds of hugging?

Yeah, oxytocin.

Raises your oxytocin level. I love that.

That's what they say is in Cupid's arrow. Yes. That's the psychosomatic response. Oxytocin, dogs have 100 times the oxytocin that human beings do. That's why they're so loyal. Yeah. We can learn a lot from our dogs.

Yeah, as a female, go get information. Do not let someone tell you you're fine. Don't let someone tell you nothing's wrong with you.

Or it's all in your head.

Or it's all in your head. Or you need these prescriptions that antidepressants, anti-anxiety, sleep medications, heavy, heavy, heavy stuff, because it might be just simple things that you can get back in balance. And I think, By getting all of those things in balance and replacing the raw materials and the hormones that you really do need, you can become the ultimate human.

That was a great answer. Okay, good.

Okay, if you made it this far, you know more about menopause than most physicians. Let me recap what you learned today. One, from Dr. Jessica Shepherd, perimenopause can start in your late 30s. Standard blood tests miss it. The Dutch test doesn't. Hormone therapy is a critical window, and the women who benefit the most started early, not late. Muscle is your metabolic currency. Build it, lift heavy, and don't skip the self-care. And secondly, we heard from Dr. Vonda Wright. Your bones, your joints, your muscles— they're all estrogen dependent. The frozen shoulder, it's not just a shoulder problem. Bone loss triples in menopause. The critical decade to act is 35 to 45 years old. Bioidentical hormones are plant-derived. Safe, and potentially disease-preventing. New data from 120 million women backs that up. And last, we heard from my wife Sage. Even if your labs look normal, your body may be in crisis. The Dutch test shows what blood work hides. Hormone therapy can change your life in 3 weeks, and no one— not one doctor, not your partner, not your own denial— should be allowed to tell you that you're fine when you know that you're not. If you want to go deeper with all 3 of these experts, Check out the individual episodes in the link below. Follow Dr. Shepherd at Modern Meno and on Instagram at Jessica Shepherd, MD. Find Dr. Wright and her book Unbreakable on Instagram, everywhere books are sold, and join our VIP community at theultimatehuman.com/vip, where you can submit your questions directly to future guests and get access to my personal protocols. Women, you don't have to suffer to be natural. You deserve to thrive at 40, 50, 60, 70, and beyond.

And that's just science.