Using Hormones for Perimenopause and Menopause: Helpful or Harmful?

Today on Midlife Conversations, I've got my favorite hormone doctor back, Dr. Anna Kabeca, also known as the girlfriend doctor. I wanted to bring her on and have this conversation right now because I am a huge, huge fan of looking at hormone replacement for women, especially in perimenopause, menopause, and even possibly beyond. But there's a lot of controversy around it. And I also believe that from everything that I've learned that there's a right order to doing hormone replacement. And it's not about just guessing. It's not about just going to any random doctor and doing this. It's about truly testing and then doing it in the right order, meaning cleaning up your diet first and your habits first, even looking at your gut health and then really getting into, where can we fine tune and tweak with hormones? And what I love about Dr. Anna Kabeca is she is so aligned with that and she is so good at breaking things down simply and explaining it, telling us what we actually really need to know. I know there's so much information overload out there. So thank you, Dr. Anna, for being here today.

Oh, it is great to be here with you always. Thanks for having me.

So I want to start with just sort of the, the, the elephant in the room before we even get into all the good things I want to ask you about. There's so much controversy about hormone replacement. It's almost. It reminds me of when we were in childbearing years and would have anesthesia epidural and some would not. And it was like this badge of honor if you didn't, you know, and it was like, I'm always like, when someone says, oh, I had three pregnancies, no epidural, I'm like, but do you want a cookie or something? Like, it doesn't. Like, some people do it epidural. It's not. So there's. There's an either. But it reminds me of that same, like, nitpicky where there's women like, well, I don't do any hormone replacement. And I'm thinking, well, that doesn't necessarily make you a better woman than someone that does. Like, in fact, it could be quite the opposite sometimes. So I want to get into that. Like, why, when, where did this breakdown come where people think this is, like, cheating and bad for you. Help us understand all that.

Yeah, it's like, you know, the whole concept of I'm just powering through, I've got to make it, you know, God designed me this way. And so I, you know, this Is must be natural, right? This right. I've got to do it the natural way. And without any intervention, without any help or support. And we can feel miserable. We can feel miserable for 10 to 15, if not longer years. And what we know now is how we transition in menopause affects the quality and longevity of our life. So while menopause is natural and mandatory, suffering is optional. Yes, suffering is optional. And when we have symptoms, there's always a reason. There's a reason for the symptoms. One of the things I was teaching on this weekend at a medical conference on hormone therapy was like, for example, cholesterol. When cholesterol, if cholesterol is too low, our hormones will be in insufficient levels. And if it's too high, we have to ask why? So cholesterol is high, we have to ask why? Because cholesterol is a precursor to our major hormones and a reproductive steroid hormone such as pregnenolone and progesterone. So, and it's being suppressed too low from stata medication or otherwise, we have to support healthy cholesterol levels. So there's like, there's this nuance, there's this kind of, we say the Goldilocks formula, not too high, not too low, and we want to make sure that it's healthy.

So when women go to the doctor right now, and I'm speaking on behalf of lots of women, because I've seen these messages, they go to the doctor and they say, I'm dealing with perimenopause, or I'm dealing with menopause, or I don't feel good, I'm tired, I'm foggy headed, I'm gaining weight, I'm achy. They list all the symptoms, all the things. It seems that like, and I'm, I'm really generalizing here, but it seems like there's a huge amount of doctors that just say, either deal with it, it's menopause, deal with it, or let me put you on birth control pills and antidepressants.

Right, exactly. And that's often first line therapy. So apparently the number one prescribed drug to women in our 40s now is a antidepressant, antidepressant medication. And, and so that you have to think about that, like, how is like these symptoms, these neurologic symptoms being the, how they're being addressed versus getting to the underlying reasons for these symptoms. So for example, the PM worsening pms, the anxiety or mood swings with our menstrual cycles are in perimenopause, when that's happening and What? You know, the first line of treatment is, okay, let's put you on a ssri, which is a selective serotonin reuptake inhibitor that functions in our body to kind of block the receptor site. So say, for example, you just kind of COVID the holes. And so there, your body's supposed to think there's more serotonin available because we're. We're blocking those receptors, we're covering those holes. And so now there's more serotonin that's available versus making more serotonin or addressing the reasons why we don't have enough serotonin to begin with. And serotonin is that hormone of anti anxiety. It's a precursor to our melatonin, which is a hormone of sleep. So when clients are coming in, they're struggling with these mood swings, irritability, PMS symptoms, anxiety, depression. And the first line therapy is, is an ssri. Birth control pills. That's what we're taught. We're taught that at, you know, and I went to one of the leading institutions in women's health in the world at Emory University is where I trained. And I hate to say it's still what's being taught.

So what can. Because some people are hearing this going, okay, well, I heard, I hear you. And it's just kind of like you have a fever and you take a Tylenol. Like there's different trains of thought. Like, you can blunt a fever with the Tylenol or you could let your body do its thing and ride it out. So how. Some women are listening, going, okay, what? My doctor gave me an SSRI and I, I'm on birth control pills. What's harm in that?

Yeah, and I love the analogy of the Tylenol. So you have a fever. Why do you have the fever? Is there an infection that needs to be addressed? Is it bacterial? Is it viral? Is there something going on with your thyroid that's causing you to have a fever? I mean, what's going on with that fever? So we just give you a Tylenol. We've never addressed the underlying cause of the fever.

That's right.

So the same is exactly true with we. When we're looking at our hormones, what's the underlying cause of the imbalance to begin with? What's interfering with your body's natural function with its own operating system?

So if we do synthetic hormones, I'm going to talk about that in the necessary. Specifically, like, what could go wrong with synthetic hormones? So we're, we're just. Is it because we're now muting and not. We don't know what's underlying cause. Is there an issue with the synthetic hormones? What can that create in our bodies?

Yeah, and this is a really big thing. And especially, for example, birth control pills contain synthetic progestins. There's not currently a bioidentical birth control pill. So birth control pills, some of them contain bioidentical estrogen or body identical, identical to what is produced in our body, but the progestins are not. And this was the whole issue with the HERS trial and Women's Health in the 90s and the Women's Health Initiative in the 90s and 2000. They used a synthetic progestin, and they also used conjugated estrogens, over 30 different estrogens that are in this pill called Premarin from pregnant mare's urine. So Premarin is from pregnant mare's urine. These horses that were contained and urine, you know, and forced pregnancies, and then, you know, collected their urine and their hormones from the urine and then metabol and then created into these capsules known as Premarin. It was considered the wonder drug for women. And that was.

It was a combination of progestin and Premenin. Premarin. It was a combination of these two things.

Okay, There's Premarin in and of itself. In the Women's Health Initiative study, for instance, there's Premarin, which isn't body identical. And there was also the Premarin Provera arm. So the Premarin estrogen only was given to women who had had a hysterectomy, didn't have a uterus for whatever reason.

And.

And the Premarin Provera was given to women with a uterus to protect the endometrium from unopposed estrogen from getting uterine cancer. Because what we found when Premarin was like, being prescribed like wildfires that then women started getting endometrial cancers. And so they said, okay, well, we need to oppose this estrogen effect on the endometrium. So let's create a, you know, a patentable synthetic product or chemical that will work to oppose estrogen on the endometrium. And that's where the Provera came in. And we now know that Provera is a very toxic progestin. It sometimes gets confused as a progesterone, but it is not a body identical or bioidentical progesterone. It is a progesterone in. And it has negative effects on the breast, such as an increased risk of breast Cancer, it has negative cardiovascular effects, such as increasing risk of stroke, of heart disease, and the list goes on. With progestins. It was really powerful in this conference to hear other hormone specialists, other leaders in the field of hormones, talk about, you know, how bad progestins are, how we should not be using them today. And yet they're still.

This is what's so wild to me. Okay, so women are saying women think they are. And doctors are telling this they should not do hormone replacement or bioidentical because it causes cancer or it increases your risk for cancer, but what actually increases the risk for cancer is the synthetic junk that they think that they're giving them. Is that accurate?

Exactly. Exactly.

Because this. The study that people freaked out about years ago had nothing to do with bioidentical hormones. Is that right? It had to do with.

Right.

Wow. And then I also heard, Tell me if I have this information wrong, that that study years ago was also done on the wrong group of people. It was done on postmenopausal women. Is that accurate?

Yeah. The average age of women in that study was 63 years old who had.

Not been on any therapy for years. And now all of a sudden, we're putting synthetic hormones in them. Is that accurate?

Some of them, yeah. There's a. There's a range. But I would say the majority were put on this Premarin Provera combination for the duration of the study.

So when we hear that that study has been debunked, is that what this means? Like it's debunked because it was based on those specific things, not what we use in bioidentical right now?

Well, they. They did so many things wrong. Right. It was funded by Wyeth there. You know, I used to work in Pharma pharmaceutical as a. As a chemist, as a bio biologist, and a chemistry in the drug metabolism department for Wyeth Erst, the makers of Premarin and Provera before I went to med school. And so, you know, it was very much aware of what was going on and what wasn't being. It occurred to me later what wasn't being said. So there are many flaws to this study, but what we know now from following this study is that estrogen, even the conjugated equine estrogens, the Premarin did not. Does not increase your risk of breast cancer at all. Estrogens are, you know, is not the culprit for the breast cancer. The Provera, the synthetic progestin is.

So why are so many doctors still so scared of this. And they're so. They like really train themselves like, I'm not even going to go there. I'm not. And they tell women that they're going to get cancer by going on these.

Yeah, because. Well, I think that's the. It's been the fear. It's also our medical legal system in the United States. In Europe, it's different. In Europe, bioidentical hormones are what's used and what's prescribed.

So you know what's fun? Interesting. I shared something on Instagram. I think I screenshot and sent it to you. Dr. Anna, I. Somebody had. I was writing something about bioidentical hormones and somebody said, I would like to see proof that it doesn't cause cancer. And I'm like, wait a minute. That's such a weird statement. It would make sense to show proof that something does cause it. But to say that proof, that's like saying, I'm going to. I want proof that broccoli doesn't cause cancer. I want proof that breathing air doesn't cause cancer. I want like, that's such a backwards way of thinking. And I'm thinking we've really messed people up with this, these weird beliefs that now we have to prove that things don't cause it.

Right, Right. And it's important to know. But we do have research to show that, you know, again, even the. This poor form of estrogen, but body bioidentical estrogen does not cause cancer. And I want to differentiate the way we take in our hormones increase or decreases our risk factors too. So I'm going to come back to that. But in this study, they used oral estrogen. So they saw that oral estrogen does not increase your risk of breast cancer, but it increases your risk of stroke. Oral estrogens increase inflammation in the body. So many of us in the hormone field are like, okay, we're not giving you oral estrogen after a certain age or at all because of the increased risk of blood clots and stroke. So we're taking oral estrogens off the table for menopause and postmenopausal management. We have other options, pharmaceutical and compounded, that are very, very safe and beneficial. And the other thing is the progesterone. There are studies in 2008, an 88,000 person study, the French study, it's called the EPIC trial, and it looked at estrogen and progesterone and the risk of cancer. This was studied by Dr. Fournier. And so 88,000 people. 88,000 is not a small study. It is a multicenter trial looking at long term, looking at these risk factors long term and what they found out and what they did. This is so brilliant. And this really opened my. The initial publication was in 2005 with 50,000 people and then the 88,000 follow up study in 2008. And so what Dr. Fournier did, he looked at people on the estrogens and also progesterone and progestins and including broke down the progesterones into three different classes like higher risk, medium risk, lower risk. And these are in technical terms the pregnane and norepregnane derivatives of progestins compared to bioidentical micronized progesterone. Oral, all oral. In this study, all the hormones that were given were oral. And so what they found is that bioidentical micronized progesterone was not at all associated with an increased risk of breast cancer. And the progesterone stins were absolutely showed an increase with the Provera arm. So the pregnane derivatives with an up to four, you know, four times increased risk of breast cancer. The norepregnane A 1.5 to 2.5 increased risk of breast cancer. So like norithendrone is a norepregnane derivative. And if you look at your birth control pills or you look at your hormone prescriptions and you have any of anything that doesn't say progesterone or micronized progesterone, you're increasing your risk for breast cancer.

Wow.

But bioidentical again in this 88000 person study did not increase your risk of breast cancer.

Okay, good to know. Okay, so we know. So synthetic is going to increase your risk. It's also muting things. You don't actually really know where you are in the stage with doing synthetic. Talk to me a little bit and then we'll come back to hormones. About just the downside to SSRIs. I know that you mentioned that and we're not talking about people that actually need them for depression or the reason you're on. We're talking about people that are using them because menopause or perimenopause. So we're muting things. But what is the downside of doing that? Because some people still listening like well I'm fine, my doctor said I'll just Do you know the birth control pills and the ssri?

Yeah. So let me give you an example of a patient, a 43 year old patient who comes into her gynecologist or her primary care provider and is having worsening PMS with her menstrual cycles. Irritability, mood swings, depression during the last week of her cycle. And this is always where I say, you know, physiology affects behavior. So if you only hate your husband or your partner two weeks out of the month, it's probably related to your hormones. And you're likely not bipolar. If there is a, you know, for sure relationship, I definitely can.

I notice that with me, like, I notice there's certain weeks that I'm not as nice as others. So I get it.

Yeah. Yeah. And so we have to look at. Okay, well, why. And this. And with. With issues of low serotonin. First of all, we're not testing. Yeah. And that I do. But many people are still not testing the neurotransmitters or not imaging the brain or not, you know, looking to why is the serotonin low to begin with? And that's an important question. So SSRIs, because they're blocking receptor sites. And what happens is your body's not making serotonin. So then the SSRI may work to a degree. And then all of a sudden it's not working anymore. So what do we do as physicians? We increase your dose so we block more of those receptor sites. So by blocking receptor sites, it's been shown that that can affect your body's natural getting your own ability to use your serotonin. So we can damage the receptor sites. So that's a downside. And also, you know, these are. The nice thing is you don't have the high anxiety or the low, you know, the big low depression, but you don't have the high lows of life.

No.

You don't have the high enjoyment.

You kind of start not caring about things. You don't feel things. Yeah, right.

So what I found in working with this patient. So for this 43 year old patient that comes in with those symptoms. So sure, the, the options are SSRIs, like, say I could prescribe Prozac, you know, Zoloft or Cymbalta or another one of the medications, Wellbutrin even, depending on their symptoms. But. And I could prescribe birth control pills to help them regulate their period and kind of knock out the ovaries so that they don't have their own muting everything. Muting everything, inhibiting your body's natural hormones. Or I can support your body's natural production of serotonin and I can support your body's detoxification of any hormone disruptors that are affecting the Receptor site and get your body.

I choose option B.

Me too. Right? It makes sense. And so as I started doing this in patients, I mean, I was trained to do that exact thing. To put them on an ssri, to put them on birth control, even up through menopause. Wow. Just, you know, keep them from complaining, basically, and improve their symptoms. We want to do good as physicians. I mean, your physician wants to help you, genuinely wants to help.

No, I remember my OB gyn, my regular OB GYN before she was genuinely. I could tell she was there. She was trying to help me, and she said, why won't you go on synthetic birth control and ssri? I'm like, Because I don't want. Like, she. We were in this disagreement because she's thinking, I can help you. And I'm thinking, I don't. I know too much. I don't want to do this. I want a different option. But she just wasn't the right person that's knowledgeable enough to prescribe what we know about hormones.

She goes through her own menopausal journey, and I think that's why menopause is coming more into the news and more people are talking about it. You know, when I went to med school, I. There were 15 women in a class of 115. So 100 men, 15 women. And so. And prior to that, there were smaller numbers. And now more of the women, my peers are all going through menopause. They get it through menopause. Once you go through it and you see what we've been doing and you'll hear them say it. Like, I realized what I was doing for my patients wasn't helping me. And because I went through an early menopause transition or, you know, at 39 years old. So that was back in the early 2000s. You know, I experienced. You know, I experienced it myself a lot earlier than my peers. And so I had to find answers because I didn't want to go down the path. My mom. I saw my mom go down with heart disease, with antidepressants, being on 11 medications at the time of her passing prematurely and really struggling the last 15 years of that. So I didn't want to go down that path. So I had to find the answers and understand my mom. You know, I was taught to ask why, to understand, how is it as a chemist? What's the mechanism of action? So I think it's because we. We don't have those tools in our doctor's bags when we come out of residency, typically.

Now, I've asked this question of other guests. But I'm going to ask you this specifically because I want to hear. I still don't think it's fully registered in me. I don't. No one's fully answered in a way that I completely understand. What is the difference between bioidentical and then just straight hrt?

So bio, like when we're talking about and also the term hormone replacement therapy, I don't like that term. You'll hear, you'll hear me say I do hormone replenishment, not replacement. And so when we talk about straight hrt, we're typically talking about pharmaceutically available hormone replacement regimens. And so it's typically a estrogen and a progestin. And that's it. That's all that they pretty much talk about. And they're leaving out dhea, they're leaving out testosterone, they're leaving out pregnenolone in that conversation, when we talk about bioidentical hormone therapy or body identical. Because now the NAMS is using the term body identical. So the national association of Menopause, the National American or something like that, Menopause Society, NAMS for short, is now using the term body identical. So what's identical to what our body. So bio body. I think it's the same thing. And when we're referring to body identical hormones, we're talking about when we're replacing with estrogen or estrogens, they're identical to what our body's doing. So making E2, for instance, estradiol or estriol, which is E3. And there are definitely pharmaceutically available forms of body bioidentical estrogens. So in some of the formulations like the combi patch or estrogen gels or mist they're using, and some creams they're using by, you know, identical E2 to what our body produces. Okay. So when we're compounding, we typically will sometimes compound straight E2 or combine it with E3, which has other protective benefits.

So, okay, so I use compounded bioidentical. Why are so many places anti compounding? Or you have doctors that are anti compounding and some states don't allow it. Like, what do you know about that?

It's, it's pharma. I really is follow the money. Okay, so compounding pharmacies came under attack by pharmaceutical companies. And this is because it competes with them, basically because it competes with them. It affects their bottom. Bottom line. Right? It does affect. Affects their bottom line. And so they want to say these are the fda, the federal, you know, The Food and Drug Administration approved products and these, these HRT pharmaceuticals go through FDA approval, which can cause cost millions of dollars because you have to go through phase one, two and three trials, and that's millions of dollars. But, you know, the argument is like, you know, do we do that with our food? Do we do that with our, you know, our supplement? I mean, we want to look at what's natural to us versus what's not natural. And to have to prove that one, you know, that bioidentical hormones need to go through. I mean, and they have gone through phase three trials. Do you think we're used for generations? Our body's been making them for centuries. That's a huge thing.

We're at risk for this going away, for compounding. Going away.

Yeah, we're at risk. We do need to fight it. You need to stay aware. You need to support compounding pharmacies because that's an art of medicine. Yeah, you know, that is an art of medicine and pharmacies that can customize our hormones for us. I mean, that's part of the fine totally to our individual and it's, it's powerful.

Now when you. I know it's also a little controversial when someone says balance hormones, is that possible to do and what, what constitutes naturally balancing them if there is.

So like, we don't want straight line hormones. We want fluctuate. I mean, our body is constantly fluctuating in hormones.

To me, I wanted to mimic how we were when we were younger, like this the way that your cycle works.

Well, we want to work with. And then in menopause and post menopause, it's more consistent. But we also want to not blunt our hormones. So when talk about balance, what is balance? Balance is like a seesaw, you know, I mean, really, there's that, you know, balance is riding a bike. I mean, you've got to continually navigate. And so that's like the, you know, what is balance? Hormone balance is. I look at hormone balance as your body is making what it needs to make and using it efficiently. And then we replenish in the areas that we need replenishment when we, when our body isn't keeping up for whatever reasons. And it's often toxic toxicity, estrogen and hormone disruptors, it's gut dysbiosis, it's. It's mold toxicity, it's thyroid imbalance. And so we want to, we want to support our body on a regular basis and we want to be able to adapt to our life circumstances to the best of our ability and this is where, you know, you know, definitely menopause is natural and mandatory. And we look at the people that have lived over 100, you know, 100 years plus the blue zones in the world, the highest concentration of centurions, they're not on hormones. Those hundred year old women, they're not on hormones. But what are they doing? Their lifestyle has, you know, they've created a lifestyle that supports longevity. And so they're not in nursing homes. They're, you know, they're in, In America, our lifespan exceeds our health span. And on rankings with the. We are the number. We spend the most money in the world on health care and we're number 35 in quality of life and lifespan.

Wow.

Last I checked.

Wow. So I can actually physically tell you probably can too when someone is on hormone replacement or not. Like if some, if you look at somebody who's in their late 60s, 70s, their skin looks different if they've been on replacement. Is that are, is that a thing? Am I just crazy and I'm saying that, is that. Do you, do you know, because to me it's like it almost. It changes people's skin when they're on hormone replacement in a better way.

Well, hormones help support collagen production and elasticity of our skin, you know, the big natural elasticity. So it helps with collagen, helps with skin, you know, formation. But also again, it's, it's variable. Natalie. I would say it's really variable because.

You can see people that aren't taking it, that do the right things and then they don't it. Okay, but you don't think it's a badge of honor to not take it. You think it's whatever need people need for support.

I think there are very few patients that leave my practice without a prescription of hormones.

Wow. Because you're, you're none.

Yeah, but I want to, I'm, I'm in the, you know, I'm in the longevity space. So I want your, I want you to have strong bones, strong mind, strong muscle. I want you to, to be, you know, your. I want your health span to equal your lifespan.

Now does that change if someone had breast cancer in your mind, like if someone had estrogen positive cancer because. Or do you just. Because of the studies and what it's saying you're saying that doesn't matter now.

Same thing like I say with cholesterol, you know, if a patient has cancer, why did they get cancer?

So you're still looking at why not. Not what we're doing looking.

Why And I tell clients this and I, I teach this. I don't hold someone's cancer against them.

Yeah, I like that. So I want.

It's true, I mean, because I see cancer patients from around the world and many physicians are like, oh, hands off, not touching you or you know, not doing anything for you. And the research. And I teach on this. And this is where I got into 1999. You know, really working with hormones and compounding hormones. I mean again, I wasn't trained this way. But in 1999, my first year in private practice, one of my first patients who came to visit me, she's a 63 year old woman who was 5 foot 10, 155 pounds, silver haired, you know, black, eyeglasses, CEO of a biotech company. And she'd had a history of ductal carcinoma and situ of the breast cancer which was diagnosed at Emory several years earlier and was told no hormones, no estrogen, no anything, nothing else was offered to her. And she said, Dr. Anna, I'm a woman of the 60s. I love my husband, I can't have sex with him. It hurts every time I even think about it. And I rather die than live this way. Help.

Wow.

And she brought me research, she brought me some study. She opened my mind to what was possible. And with consent, I worked with her on balancing her hormones, on addressing, well, what could have caused this cancer to begin with. You know, I always want from the functional medicine approach get to the root cause so that I can help her create a body that is inhospitable to cancer. That's what I'm going to do. I'm going to support you to create a body that's inhospitable to cancer. And then I used DHE and testosterone with her. And I told you when she was 83 at, you know, her 83 year old followers up. So 20 years afterwards, I seen her and she'd been skiing the black. So she was on crutches. I'm like, wait, your bones are, are as good as they were 20 years earlier. What happened? She goes, I was skiing the black slopes and took a nasty fall. And I was like, God bless you. At 83. And she published her memoirs and she's still lobbying on Capitol Hill. That's quality of life. And we didn't intervene. At 63, what would have happened? She would have had worsening osteoporosis, a loss of, you know, her intimacy and sex life. A brain. Who knows what would have happened to her brain health. So you know what caused the ductal carcinoma in situ to begin with. You know, you have to address those things, too. And that's where inflammation and, you know, adrenal dysfunction really is part of the assessment of every patient that I see.

So good. So here's the deal. I could. I could stay on this session, this podcast with you for 24 hours. I have so many topics that I could ask about, but what. What Dr. Ann and I had decided to do, I wanted to cover this on the podcast. This was really important. This is like the. The most questions I get about hormones. But what I like to do is the live forum. We do like a live interactive podcast, a masterclass where anna goes deeper. Dr. Anna goes deeper. We really teach on things like optimal, what the labs aren't telling you, major ver, minor hormones, just all the things you need to know to have. She calls it a magic menopause, like, empowering. So we are going to hold a free masterclass. And this, depending on when you're listening to this, it's going to be on March 25th. And all you have to do to sign up and save your spot for this is go to midlife conversations.com forward slash magic. So midlife conversations.com forward slash Magic. If you found this podcast interesting, you'll definitely want to be on that session because not only is she teaching, she'll be answering all of your questions. Questions. All of your questions. You're not gonna. If you've attended any of my master classes before, you know, we go really deep on things and then we do questions. So this is the perfect next topic. Thank you so much, Anna. I can't wait for the masterclass.

My pleasure. It's always good digging deep. And again, I want to, you know, get rid of any of the myths and misconceptions around optimizing our health in menopause before, during, and after menopause, that we really can live out the highest quality of our lives with people we love.

Thank you.