Dhru Purohit Show - Experts Share Top Tips for Navigating Perimenopause, Menopause, and Beyond and Explain the Profound Benefits of Hormone Replacement Therapy

Episode Date: August 12, 2024

This episode is brought to you by Cozy Earth, One Skin, and Manukora.  Today on the Dhru Purohit Show, we have a special compilation episode featuring Dhru's conversations with several podcast guests about hormone replacement therapy and the changes women undergo during perimenopause and menopause. Dr. Sara Gottfried explains why women experience shifts and how managing insulin resistance and muscle composition can unlock better health in mid-life. Dr. Mary Claire Haver shares insights on hormone replacement therapy and how to determine if it's right for you. Dr. Lisa Mosconi discusses powerful research on hormone replacement therapy and brain health, highlighting its importance since women are more susceptible to Alzheimer's after menopause. If you are looking for the latest research on hormone replacement therapy and its potential benefits, this episode is for you. Dr. Sara Gottfried is a board-certified physician who graduated from Harvard and MIT. She practices evidence-based integrative, precision, and Functional Medicine. Dr. Gottfried is the author of four New York Times bestselling books about trauma, hormones, and health.  Dr. Mary Claire Haver is board-certified in Obstetrics and Gynecology and is a Certified Culinary Medicine Specialist. She is the New York Times bestselling author of The New Menopause.  Lisa Mosconi, PhD, is an associate professor of neuroscience in neurology and radiology at Weill Cornell Medicine and the director of the Women’s Brain Initiative and the Alzheimer’s Prevention Clinic. She is the New York Times bestselling author of The XX Brain and Brain Food.  In this compilation episode, Dhru and his guests dive into (audio version / Apple Subscriber version): Women’s Lives After the Age of 40 (1:46 / 1:46)  Traditional Symptoms, Treatment, and What Causes the Fears (9:38 / 6:10) Perimenopause and Symptoms You May Not Realize Are Correlated (15:49 / 12:30) The Charlie Angels of Hormones (22:39 / 17:20) Women Are Living Longer but Not as Healthfully in the Last Third of Their Lives (31:49 / 26:30) Why Dr. Mary Claire Feels Medicine Is Up-to-Date on Women’s Health (33:30 / 27:44) Fears of Breast Cancer (35:50 / 29:46) The Protective Effects of Estrogen (40:14 / 34:55) What Kind of Practitioner to Look For, and Is HRT Suitable for You (43:10 / 37:42) Testing, Dose and Timing (47:49 / 42:30) Dr. Lisa Mosconi’s Views on HRT Research ( (58:49 / 53:30) HRT, Brain Health, and Reducing the Risk of Alzheimer’s (1:03:49 / 58:30)  Also Mentioned in this episode:  The Charlie’s Angels of Hormones Dr. Mosconi’s Slideshow  This episode is brought to you by Cozy Earth, One Skin, and Manukora.  Right now, get 40% off your Cozy Earth sheets. Just head over to cozyearth.com/dhru and use code DHRUP. Right now, One Skin is offering my community 15% off; just go to oneskin.co and use coupon code DHRU to save 15% and give your skin the scientifically proven, gentle care it deserves.  Upgrade to the creamiest honey, packed with antioxidants and prebiotics. Just go to manukora.com/dhru to get $25 off the Starter Kit and boost your energy, immunity, and digestive health today! Learn more about your ad choices. Visit megaphone.fm/adchoices

Hi, everyone, Drew Brod here. I am super excited to share today's episode with you. Hormone replacement therapy and the changes that happen through perimenopause and menopause have become hot topics lately, especially for our audience, and for the right reasons. Women in their 40s, 50s, and beyond often experience a whole host of symptoms like weight gain, insomnia, anxiety, and even more that leave them feeling confused and like their health is thrown off.

Well, today I'm featuring three leading experts that I've had the pleasure to talk to to talk about hormones, menopause, and women's health, and to talk about how women can reclaim these years with optimal health and vitality, potentially with the use of hormone replacement therapy and lifestyle interventions. On today's episode, we have Dr. Sarah Godfrey who shares why women start to experience shifts in their body composition and how managing insulin resistance and muscle composition can unlock the key to better health in midlife. We also have Dr. Mary Claire Haver, who shares her wisdom on hormone replacement therapy and how to know if it's the right fit for you.

And Dr. Lisa Musconi. She talks about the powerful research on hormone replacement therapy and brain health, which is especially key since women are more susceptible to Alzheimer's and dementia than men after they reached their menopausal years. These three incredibly powerful and intelligent women have changed the lives of so many people that are out there with their cutting edge information on women's health. So be sure to tune in and send this to all the women in your life. Let's get into it. What the heck is going on with my body and why is it so much bigger for them than just gaining a little bit of extra weight in our bellies and other parts of our bodies that we typically

didn't used to. There's a number of events that conspire against us after 40. I think the biggest one is the change in estrogen and progesterone. So as estrogen starts to decline, you get this redistribution of your weight. So it used to be before you went through menopause, like through your 20s and 30s, that as a woman, you deposit fat at your breasts, at your hips, at your buttocks. After 40, as estrogen starts to wildly fluctuate and then go down, you don't distribute it there anymore. You distribute it at your waist. So along with that, you also gain about five pounds of

fat and you'll lose about five pounds of muscle every decade unless you're doing something about it. So that's one change. Another change is you become more insulin resistant. So glucose is start to go up. And this is really the metabolic health crisis that's going on. It's related to how mitochondria are functioning. Some women notice it in terms of not being able to zip up their pants, that sort of insulin resistance where you store fat no matter what. Other women notice it more in their brain. They've got more brain fog. They've got what Lisa Mosconi calls cerebral hypometabolism. You just don't use glucose the way that you once did. There's also a cortisol problem. You get more stressed. You may find that you fly off the handle more easily. Cortisol tends to

rise as you get older. Not for everyone. There's some people who get a burnout state with cortisol and it can become low, can even be high or low within the same day. But that tends to also drive blood sugar. And then the fourth issue is your thyroid. So thyroid. Thyroid tends to become less functional as you get older. And most of the people who are affected by thyroid dysfunction are women. Do you feel that for those that are listening in today, if they stick around for this conversation and get a chance to hear all your incredible expertise that you have on this topic, that there's a different way of being, that this common way that many people, not just women, right, just going broader in the population, are aging in a way that makes people all. almost afraid to age sometimes, that there's, it doesn't have to be that way. That's the crux of this conversation, Drew, because it doesn't have to be that way.

So I think a lot of us look at the aging process, especially after 40, as this burden, you know, all these hormones that are changing. Do we want to take hormone therapy, bioidentical hormone therapy? Yes, no. Do we want to be working with our hormones in a different way? And I think the problem is conventional medicine just isn't set up to solve this for us. And I know because when I was struggling in my late 30s, I can still remember being 39, going to my primary care doctor and saying, I can't lose the baby weight.

I had my second baby at 38. I feel stressed all the time. I've got premenstrual syndrome that's on steroids. It's way worse than it ever was. What do you have to help me? and I was offered a birth control pill. I was offered an antidepressant, a selective serotonin re-uptate inhibitor. And he told me to exercise more and eat less.

And that was the moment where I just realized, okay, if I'm not being served well by the advice from conventional medicine, then there are millions of women who are also not being served well. And so that was my moment where I just, I stood up and said, okay, we got to do this differently. We've got to find a different path that allows us to navigate these hormonal changes and to do it with grace and to do it in a way that is natural and healthy doesn't cause any long-term problems and really allows us to serve our purpose here on the planet, not just kind of disappear and melt away and become more fat as we get older. You know, you made a video recently on YouTube and you shared it beautifully there.

You said that you regularly hear from patients that they go to their doctors. Obviously, this is before becoming a patient with you with symptoms of perimenopause. Like, I'm gaining weight. I can't sleep. I'm more moody. I don't have energy like I used to. I'm so hot all the time. I have night sweats.

I've lost my sex drive. And they take these to their doctor. And often their doctor is not super helpful. In fact, many women, including like yourself, feel that they were dismissed. Let's zoom out a little bit big picture. And we're going to come back to weight gain and some of the strategies and tips that you've implemented in your own life and that you teach your patients.

But let's zoom out big picture. What did you learn as a medical doctor about these combinations of these symptoms, especially as women are gearing up for perimenopause? Well, the conventional approach that I learned is that that, there's this laundry list of symptoms that women start to experience. And it kind of depends on how sensitive you are, whether you notice more or less of them. And those can start as early as 35. It can start with your period getting a little closer together. And that's a progesterone effect. As you make less progesterone, you run out of ripe eggs. The other thing that I learned is that

the conventional approach is really to give a birth control pill and not usually to offer bioidentical hormone therapy. So I was really taught to tell women, this is just part of the aging process, get used to it. But I found that totally unsatisfying. And when I was there myself and struggling with a lot of these symptoms, I realized there's got to be a better way. There's got to be science behind a better approach that allows us to navigate all of these hormonal changes and to do it in a way that really allows us to live our best lives in middle age. So that's what I said about doing. And I think what you're asking is, what did I learn when I kind of took that right turn,

when I turned away from conventional medicine and said, okay, I've got this low progesterone. My periods are getting closer together. What can I do about it? oh, there's this herb called Chaseberry for a randomized trials, show that it helps with PMS. It helps to raise your progesterone levels. It helps to kind of nudge your ovary to make more progesterone when you're in that early perimenopausal phase. So that's just one example of some of the things that I learned when I took to the science

to be able to answer some of these questions. So I think that's what we have to do because if we zoom out a little bit, part of the problem here is that women were part of a vast, uncontrolled medical experiment for about 59 years as they were going through parimenopause and menopause. So they were given synthetic estrogen and progesterone, peremerine and pro vera without a randomized trial to show that it was safe and effective. And so many women were taking these hormones. In fact, Premarin was the number one prescribed medication in the United States for decades. So we finally had a randomized trial that was published in 2003 that showed that it was potentially dangerous and risky. And then millions of women came off of their hormones and they weren't offered really any alternative. So we have to find the middle path here.

what's science-based and what can be the most effective to help us with these symptoms. And I also learned there's more than 100 symptoms that you can experience through perimenopause and menopause. It's not just a few that I learned when I went through my OB-GYN training. So we need to be tuning into this bigger picture. And then if I put my hat on as a precision medicine doctor, what we now know is that there are these dramatic, vast changes that occur not just in your hormones, but the entire matrix of your body. Your immune system, your metabolic system, your neurological system, and your hormones

are all changing in concert. And we want to be aware of all of those changes so that we're not just focused on, okay, what's your estrogen level? What's your progesterone level? We want to be thinking, okay, what's happening with glucose metabolism? What about upstream with insulin? How estrogen talking to your insulin? How much stress do you have? Are you someone who's experienced trauma? And you've got a dysregulated response with cortisol. And we need to address that. We need to clear the trauma. So we want to be thinking about all these threads that lead to a woman who's going through this change. Typically, sometime around 35 to 45, this change into perimenopause and needs our help. You know, it needs a way to navigate it and not just be told.

hold, oh, you're getting older, get used to it. So that's dismissal. And then it can even become more like gaslighting of, well, that's not what I see in my other patients. And I don't think that's related to perimenopause or menopause or I don't think we need to check your levels because they fluctuate so much. It's not worth it to measure it. So there's lots of behaviors that happen, I think, in conventional medicine. I'm not blaming them. I'm just saying this is the way that we're trained, and it's not serving these women.

I wanted to take this opportunity while we're setting the stage for the big picture. Recently I saw you give a presentation. There was a couple graphics that I thought would be extremely helpful. And if we can pull up the first one, Tessa, is talking about some of the symptoms of menopause as they relate to aging,

first starting with, I believe, perimenopause, right? And then over time. And I think this could be very helpful to ground some of the conversation visually, especially for those that are watching on YouTube. Could you walk us through this graphic over here? Oh, I would love to. So I think it's critical to realize that we're starting at age 35. So depending on how attuned you are to these symptoms, you may notice that you're having more cramping. Your period might get a little heavier, might get closer together as we talked about. Maybe you're not sleeping quite the way that you used to. Maybe you're having vaginal dryness or waking or you've got fibroids that are growing. So all of that can start

around 35 to, you can see a dotted line on this particular graphic right around age 43. And 43 is important because 43 is when the brain becomes more resistant to the function of estrogen. So there's less glucose metabolism. So the mitochondria, the powerhouses in your brain cells just aren't picking up glucose the way that they once did. Glucose tends to rise peripherally. So if you have a continuous glucose monitor or you're checking a fasting glucose, you might find that it's climbing over this period to about age 43. So all of those things are happening in the background. And then if you keep in mind that age of 43 and then you look at the symptoms that are listed on

the upper half of this graphic, most of these are brain symptoms. So mood swings, loss of libido, hot flashes, insomnia, night sweats, even the irregular periods, depression, all of those are brain symptoms. So a lot of people think that the action is in the ovaries, that you're, you know, not producing an egg every single month. You don't, you're running out of ripe eggs. And so estrogen and progesterone levels are changing. But it's really, I think of it more as this bigger system, a network between the brain, the hypothalamus, and the pituitary, the way that it's talking to your ovaries, the way that it's talking to your adrenal glands, which is where you produce cortisol, as well as these other sex hormones that we're talking about, estrogen, progesterone,

and testosterone, and cortisol. And it's also involving your gut. Because your gut is a really important source of hormones. A lot of people don't realize that. They don't know that, you know, the fiber that they haven't been getting in their diet might be leading to excess estrogen in their system. So we want to be thinking about, I call it the HPA TGG, so hypothalamic pituitary adrenal, thyroid genital gut access. Now, that's a total mouthful.

but just to understand that it's not just the ovaries we're talking about. It's really this bigger system that we want to be considering. So those symptoms that are happening from about 43 until I would say about 55, those really tend to concentrate on the brain. And then after that, you get these more long-term consequences of running low on estrogen. And that includes osteoporosis, more vaginal discomfort, maybe even recurrent bladder infections. You can have breast cancer, you can have heart disease. So those are some of the things that we tend to track, especially in the randomized trials that are done, like the

Women's Health Initiative. And those are things that we think about in older women. And as I said earlier, there's about 100 symptoms that you could map to pari menopause and menopause, but these are really the ones that are the most common. And so in that period, if your last period is somewhere around 51, 52, you really have a dramatic decline in estrogen. The lower half of the graphic illustrates this significant decline in estrogen. And that's critical because estrogen is the primary regulator of the female body. The primary regulator. And so as estrogen declines, a lot of women just find that they don't feel as vital as they used to. They've got more moodiness. Maybe they've got depression. They may have more anxiety.

That's not listed here, but it's a consequence often of insomnia, and it also is related to which estrogen receptors are being stimulated because some estrogen receptors are anxiolytic, so they reduce estrogen. Other estrogen receptors are anxiogenic, so they increase anxiety. So there's all these symptoms that women are experiencing, and we want to be looking at the total picture and not just saying, oh, you have insomnia, let's give you an ambient. That's not a solution. That is masking symptoms. It's not getting to the root cause. You know, you have a incredible graphic. It is the hormonal Charlie's Angels. And I think the visuals are also very helpful.

Again, if you're listening on audio, we'll link to maybe this image with your permission. Sure, of course. In the show notes as well. So let's describe this image here, the Charlie's Angels of hormones, as just a little bit of a recap of what you were sharing. Yeah, I mean, there's so many hormones that are critical for women, but these are the three that I focus on the most as a clinician. So cortisol is the main stress hormone. It is the priority in the body. And it governs your blood sugar. It's also involved in managing your blood pressure and your immune function.

So a lot of people who are trying to get their hormones in balance and they're making their way through pari menopause, they kind of leave out cortisol. and that's not doing them any service. So you want to focus on cortisol really first and foremost. So you can get away without having estrogen. Like your body will survive without estrogen. Your body will not survive without cortisol. It is the priority. So it's not a democracy in the body with all these hormones.

I would say the two most important are cortisol and insulin. So when you think about the female, body and these three hormones, the Charlie's Angels of Hormones, cortisol talks to thyroid. So a lot of women experience, especially after 40, what we call thyrapause. So that's this gradual change in terms of thyroid function. Usually it's in the direction of low thyroid function or hypothyroidism can sometimes be in the other direction hyperthyroidism. And somewhere around 90 to 95% of thyroid dysfunction is related to autoimmune disease. So I'll just kind of asterisk that. Maybe we can come back to autoimmune disease. Absolutely. But thyroid is, you know, pretty much every cell in your

body has thyroid receptors. It affects your metabolism as kind of like the gas pedal. If you think of your car, your body is a car. It's critical to energy production. And then we've talked a little bit about estrogen. It is the primary regulator in the female body. It regulates menstruation. It builds the uterine lining to prepare for pregnancy if that's something that you want. And if you don't get pregnant, then you shed your lining. It also keeps women lubricated in terms of their joints, in terms of their vagina. It's got about 400 jobs. So I just have two that are listed here. But we want to be thinking about, you know, okay, maybe you notice your shoulder has become more stiff. Like you don't have the mobility that she used to have in your shoulder or maybe the same thing in your shoulder. Or maybe the same thing

in your knee or your hip. And if you're someone who's in that age range of like 40 to 45 to 50, you want to be thinking estrogen. You want to be thinking about, okay, seems like my lubrication just isn't what it used to be. And so we can track all of these hormones. We can track these Charlie's angels of hormones. And one interesting thing that I learned from your content is that also for women, testosterone plays a big role in their health. And is it accurate that it's the most abundant? Like, it's more abundant than estrogen? Yeah, testosterone. If you, you know, if you're someone like me who gets a hormone panel once a quarter and you look at the concentrations of your different hormones, the one that has the highest concentration is testosterone.

It is the most abundant hormone in the female body. We think of it as a male hormone, but it is so critical for women, so critical. And if you think about confidence, and agency and just feeling like, you know, you get up in the morning and you're ready to face your day. A lot of that is testosterone. I didn't pay as much attention to it when I wrote the hormone cure because my testosterone levels were fine. And then I found, you know, as I wrote more books, my last book in particular, women, food, and hormones, that my testosterone was on the decline. So that got me to pay a lot more attention to it and to track my levels over.

time and then once I dip below a certain level, I started to use bioidentical testosterone. That's made a huge difference. So yes, testosterone is so critical. We think of it as important for muscle growth, for, you know, it's one of the growth and repair hormones. It's an anabolic hormone. So especially at night, it helps you with, you know, seeing a response. If you're someone like me who likes to lift weights, you should see a response and testosterone is one of the mediators of that. Certainly it's involved in sex drive. We all think of it in that regard. And that's true for men too in terms of their sex drive, their muscle response to exercise. It's also critical in terms of mood and anxiety. So men need to have a certain level of testosterone and women do too.

So even though men have a lot more, you know, somewhere around 10x what women have, women are still exquisitely sensitive to it. And so we want to make sure that they've got the right amount of it. So back to, you know, what women are up against. When you've got this decline in progesterone that happens in the first half of perimenopause, that can cause sleep disruption. So you're running out of right bags. You don't make as much progesterone. if you do a serum progesterone level on day 22 of your cycle and you check it every three to six months, you might notice that it's not quite as high as it used to be. It may not be 15 anymore. Maybe

it's nine, maybe it's seven. Maybe ovulating, you may not be. And so the first thing I like to do in someone who is having trouble sleeping and say they're between 35 and 50, I'll do progesterone. because progesterone is nature's valium. It's really like an anti-anxiety medication. You'll prescribe them progesterone? So it's a somnolent, meaning that it helps you sleep. And there's multiple randomized trials that show that it's really helpful for women who are impairing menopause.

So that's typically where I start in someone who's cycling. I'll add a little progesterone because they're probably not making enough. And we can confirm that. And is that typically topically or is that in pill form? prefer oral because I think that helps with sleep much more than transdermal. The thing about transdermal progesterone is that it's really not well proven to make much of a difference in terms of your serum levels of progesterone, kind of what your receptors are seeing. I use it sometimes women who've had a hysterectomy, but otherwise if you have a uterus, I like to use oral,

or if we're treating sleep. I like to use oral. So you mentioned that was in like 35 to 50. And what What about for women 50 plus? So 50 plus, that's where we're going to start to bring in estrogen. So I like to start in the first part of perimenopause with progesterone only as treatment. And you could do an end of one experiment. You could try progesterone for three months. Just see if it affects your sleep. And side note, I love to be tracking sleep so that we're looking at some of the metrics you mentioned, like deep sleep, REM sleep.

How many interruptions are there? what hours are you sleeping? How consistent are you? Is it lining up with your chronotype? So I like to measure sleep because I think when you look at it with that perspective and you've got objective data, you can really track it and you can do these N-of-one experiments and see if progesterone makes a difference. So after 50, kind of depending on the woman and what symptoms she's having, if she's still cycling or not, I'll add in some estrogen. And typically at that point, if we're addressing sleep, it's going to be an estrogen. patch, a bioidentical estrogen patch, such as the, can I mention brands? Yeah, absolutely. So, Vival dot, I love 0.0375 milligrams in that sort of situation. So progesterone, I'm assuming there's some estrogen dominance and a small dose of an estrogen patch, and then we see if it improves sleep. And some of the things I'm looking for in terms of symptoms, I'm looking for insomnia,

so changes in sleep. I'm looking for objective data. It's one of the reasons I wear an aura ring. You have a whoop. And I'm also looking at night sweats, hot flashes. And in women who are still cycling, sometimes what they have is night sweats, just the week before their period. And that might be when they need extra progesterone, just during that week.

Whereas women who are older, they're more likely to have hot flashes, like during the day, not just at night. You know, one of the most mind-blowing facts that you, been shouting from the rooftops that will surprise a lot of people when they hear it is that, yes, women are living longer. And there's a but though, but they're not living as healthy as they could be, especially in the last one third of their lives. Tell our audience what you mean about this. You know, that statistic. I learned about that actually fairly recently. I knew that, you know, we lived about six, four to six years longer than our male counterparts. But what I didn't realize

the statistics would support is that 20% of our lives are lived in poor health than males. So men just kind of live and then die. We have this protracted period of progressive frailty, dementia, you know, and we're much more likely to end up needing long-term care and then our male counterparts. And, you know, so my big focus now when I talk to my patients in clinic is they're looking at their mothers, their aunts, the women and their family and how they've aged. And they're like, a lot of them are really scared. And like, what can I do now? Nutrition, health, recommendations, whatever, so that I can limit my time of needing

long-term care. Now, when you were going through this research yourself, going back to your story and you're learning about this and you're talking with the team at the hospital that you're at you're scratching your head and I think you even mentioned before like asking yourself like why didn't anybody tell me about this what were some of the answers that came to you genuinely of like why weren't you being told about this how come this wasn't part of your own education process You know, I don't think that medicine is up to speed on the clinical impact, the true clinical impact of menopause on females. They know it happens, right?

But I don't think they realize how it accelerates our path to certain disease states and that we can actually intervene, not just with hormone therapy, but with, you know, things specific to women that work in women so that we can decrease her risk of disease and she can improve her health span, not just her lifespan. You mentioned at the beginning of the podcast that when you would treat these patients that would come in, that you would generally be referring them to other individuals. You'd be sending them to other experts out there. And occasionally you'd bring up the topic of hormone replacement therapy with a big caveat that, hey, this probably won't work for everyone. and maybe even for some people, it's going to be a little bit of the roll of the dice of whether or not it's going to increase their risk of breast cancer. Let's talk about that for a second. There was a well-intentioned, very large study that happened many years ago that contributed to this idea. And this idea is still out there. A lot of women have avoided the topic of hormone replacement because there's still a sense that,

that, hey, does this increase my risk of breast cancer? Let's talk about this study. Yeah, the fear of breast cancer is driving the majority of health care decisions for women at my age and older without any consideration of any other body part. And this is due to, so up until 2002, so that study was the Women's Health Initiative, the WHOH, it was National Institutes of Health. at the high age, you know, finally we were going to study women. They had a female director for the first time. Finally, you know, we knew from observational and anecdotal evidence that women who were on hormone therapy had lower cardiovascular disease. We knew this.

And lower death from cardiovascular disease and lower all-cause mortality, meaning death from any cause versus women who were not. And so the study was designed to see because that's observational. That's not proof in medicine. Proof is a randomized controlled study with a placebo, with equal groups of people, and then monitoring them for disease improvement or not. So the WHOHI was designed to see if hormon therapy really, really did help decrease the risk of cardiovascular disease, and it wasn't some artifact, right, from healthier, wealthier patients being able to afford hormone therapy and beyond it and whatever. But here was one flaw. Because they were looking for heart disease and women don't get that

until they're older and is very expensive to run these studies, the average age of the woman in the study was 62 years old. They excluded women with hot flashes. So that's 85% of the population. They excluded women with hot flashes because they would know if they were on placebo or not because their hot flashes would stop. So, and the women with hot flashes, you know, so that was two things. So they start the study and they have two arms, women who have a hysterectomy. And so they get estrogen only or placebo. And then women who still have a uterus, and they got estrogen and a progestogen, and then placebo group. And they took off rang. They had women as old as 79 or 77 in the study, much older patients than we would

usually consider starting hormone therapy. And they did have some in their 50s. They saw in the estrogen and progestogen arm what they thought at the time was an increased risk of breast cancer. They called a press conference at Watergate Hotel in Washington, D.C. They made a very elaborate announcement that estrogen causes breast cancer. And for that group of patients, an average age 63, it did not appear to decrease their risk of cardiovascular disease. And we've known for a while that older patients have a slightly increased risk of stroke with estrogen. So they didn't talk about the decreasing colorectal cancer or anything like that. So the study gets called off. They kept the estrogen-only arm on for a while, and then they stopped that one because of the

increased risk of stroke. So that one study and that announcement saying women will die for breast cancer if they take hormone therapy, that was the headlines. And what it actually was, there's a difference between relative risk and absolute risk. So relative risk is a statistical risk, you know, if your listeners don't understand this, that looks at populations. And so it basically was four out of a thousand was placebo and it went to five out of a thousand. and I may have the numbers not exactly right for estrogen plus progesterum. So that is a 25% increased risk, okay? And, but that's relative risk.

The absolute risk for a human being to take the estrogen, it was a 0.8% risk per year. And no increased risk in the first five years of therapy. And so that's kind of what got misreported. You know, it was kind of the first viral misinformation thing in my mind. But that's what I remember. Doctors weren't even allowed to review the study. They did this before the paper was actually published. And so the damage was done.

80% of women saw the headline, saw it was the number one news story in 2002. Stop their Mormon therapy. Threw it in the trash. I'm going to get breast cancer. And every woman who got breast cancer after that in the U.S., who had ever been, you know, had slept in a room close to a box of hormone therapy, was told that caused your, I'm being facetious. That caught, you know, so there was all of this talk, talk, talk, talk.

that disrupted the health of women for the next generation. That was the year of the last year of my training. And I was terrified, terrified to prescribe hormone therapy. Like I was doing something wrong. I couldn't convince her otherwise to do it. Now they've stratified the study. If you start hormone therapy within the first 10 years of your menopause, you have a 50% decrease risk of cardiovascular disease per year.

Okay, the risk of breast cancer is statistical at best and not for the estrogen-only arm. You know, estrogen fees a breast cancer. It's not carcinogenic. The highest of woman's estrogen levels ever are in pregnancy, and it's the extreme rarity that a patient will develop breast cancer during her pregnancy. So that's not the conversation. And all of the protective benefits of estrogen, it will always protect your bones. It will always protect your general urinary system.

If you take it within five years, your menopause, you're going to have a decreased risk of dementia and Alzheimer's. So we have a window of opportunity for protection from certain diseases, and we need to start having this conversation now. So important. You know, we're incredibly thankful for therapeutics like hormone replacement therapy, and we'll get into some of the nuances. Not everyone's a good fit, but what you're really highlighting and what you and many other contemporaries of yours are saying is that a lot more, and probably even most women could benefit from it if it was applied at the right time and stage. It's not to say that lifestyle interventions are not of the most important, too. Those are very important. We're going to get to them as well. So we're so thankful for

modern medicine and things like that. But zoom out a little bit more. Is this the way that things have always been for women? Are there unique things that are going on in our world? the way that we live today, the environment that we're surrounded with that are contributing to a situation where both perimenopause and menopause are now, if we just look around, a very extremely tough time for many women that are out there. Has it always been this way? So I think so, you know, when we look at kind of how we got where we are today and why, you know, we have what's going on in society, how we view and judge aging women. what responsibilities we're taking on as females, you know, in this kind of age group.

We are taking care of aging parents who, you know, who are not doing well. We are also still raising children. We are 50% divorce rate. You know, more women are entering the workforce and all of those responsibilities. So we can't negate the societal pressure that a woman's going through. But, you know, what my patients are telling me is that, you know what, I had it all handle. It suck. You know, it's hard.

I have a lot of things in my life, but I was managing and now I can't. And so I think the rugs getting pulled out from women who were otherwise productive and, you know, dealing with all of these things at this point of our lives and then go into their doctor. Look, something's not right. And the sad thing is because of the lack of education and awareness in the health care system is they're getting sidelined and dismissed and gaslit and told it's all in your head or, you know, or this is just part of aging. And just get over it. You're lucky to be alive. It's going to be helping a lot more women out there than you previously were sort of led to believe earlier on in your practice and career as a physician. And yet still, you've talked about it may not be the right fit for everyone.

So what question should a patient be asking their doctor to navigate that aspect of hormone replacement therapy and whether or not it's a good fit for them? First of all, you have to find a doctor who's willing to have the conversation with you. And so, so that's, that's the first barrier is find a doctor who's menopause educated. So one resource is go to the Menopause Society website, which is menopause.org, and look for a certified provider. Okay. Now, there are other providers out there who aren't certified who are fabulous, but how do you find them? So this is one way.

You go to their website. You look for the certified check. That means they took the test to become certified. Call ahead. Talk to the office. Say, listen, I'm coming in to discuss menopause. is this physician going to discuss hormone therapy with me? You know, there's no guarantees.

We have resources on our website of my followers have turned in testimonials of wonderful clinicians who've helped them. So, you know, we have lots of ways. There's some really wonderful online menopause providers that are doing telemedicine, and that may be another option. But you cannot, sadly, right now, expect to walk into your fabulous OB-GYN's office who delivered your babies and did your surgery and, you know, took care of you to be menopause educated.

worth having the conversation with them because a lot of them are realizing, whoa, like me, I got to get up to speed on this. This is bigger than we thought. And I want to be helpful. Or they just don't have the time. I mean, you're so busy delivering babies and running back and forward to the OR that how it really takes to unpack someone's menopause trauma and get to the bottom ever of everything is becoming a luxury. Yeah. So step one, finding the right physician. And it's okay to sort of prescreen. I always tell people, you know, it's not. create a pre-screen and have a early appointment with somebody with any kind of physician that you might be working with and see if there's a match, obviously, that's one component, but also does this

person have a track record of helping people make the right decisions and choices that will ultimately end up leading for help? Okay, so now somebody has a doctor that's more open-minded, potentially certified in this approach on the menopause.org website. Let's start off with the obvious. Is there, you know, who are typically the archetypes of people and their, their health situations or unique life circumstances that hormone replacement therapy truly would not be a fit for them? If we're speaking in broad strokes, everybody knowing this isn't a medical appointment here, always talk with your own doctor, but what are the broad strokes for who it's not a fit for? So there are absolute contraindications to almost every medication.

So for menopause hormone therapy, so specifically talking about estrogen plus or minus progesterone. We are anyone who has undiagnosed vaginal bleeding, meaning if you have postmenopausal bleeding and it's not been evaluated. If you have dysfunctional uterine bleeding, like something is off with your periods, this could be malignancy or hyperplasia. We don't want to feed that with hormones. We need to go get that tested evaluated. Most likely it's not that. But so that needs to be evaluated before you start hormone therapy. So any abnormal bleeding, abnormal to you.

the second is an active hormone-sensitive cancer. So if you have active breast cancer, if you have active endometrial cancer, if you're having active ovarian cancer, you are not a candidate for hormone replacement therapy at this point. Another is if you are in the middle of a blood clot, like if you have an active deep venous thrombosis, at least within, you know, and you're still being treated for those first six months, active DVTs or the first six months of a DVT, you are not. going to be a good candidate. Now, after your treatment and everything's settled down, you might be a candidate for a transdermal option of estrogen because it doesn't increase your clotting factors

like the oral forms would. If you have severe active liver disease, a lot of estrogen is metabolized in the liver, and if you can't metabolize it, that's a problem. So I'm not talking about mild fatty liver disease and mild elevated liver functions. I'm talking serious liver disease. You're not going to be a great great candidate either. And if you've had a stroke, especially a thrombotic stroke, you also may not be a candidate as well. Great. Fantastic. Thank you for that. The good news is that's not going to be the vast majority. That is still a population set. That's not going to be the vast majority. Let's talk about the vast majority of people that are there. When individuals are now choosing, and let's say they've decided to go down this pathway, of course, you know, again,

I'm starting at the basics here for a lot of people that don't know about these things. And also, too, the men, because every men that's here has a mom, has a woman in their life that they love, has sisters, has cousins, has friends. So the more educated we all are on this topic, the better off the entire world is. How is the doctor sort of determining what is the right makeup of what drugs you'd end up getting when it comes to hormone replacement therapy? Sure. So we look at estrogens. We look at progestogens and we look at androgens when we're talking about replacing hormones. So the primary hormone and where most of the research is done and the safety profile is done on estrogen. So we'll start there. So estradial is the hormone that your ovaries

used to make. So for most of us in my space, what I call the menopausee, we pretty much stick to forms of estradiol because it is most similar to what your, it is what your ovaries used to make. And I'm just trying to give you back the water you used to drink. I don't really think of hormone therapy as medication as much as just allowing your body to continue some critical processes, you know, metabolic and indignant processes that kept you healthy. And so we have oral and non-oral forms. So they both work great as far as benefits, but oral does seem to carry a slightly increased risk of blood clots, maybe seven or eight out of 10,000 per women, but we can negate that increased risk with a non-oral formulation.

So for most of my patients, I start with a transdermal option, usually a patch. I have several straits. They're FDA approved. They're generic. They're very affordable. And people can use their insurance to get them. Now, for progesterone, if you have a uterus, progesterone is mandatory. If you don't have a uterus or you have a marine IUD or a Schuyler and a progestin-containing

IUD, it's optional. And so we found that progesterone is actually really helpful for sleep. also helpful for nighttime erasing thoughts and anxiety and can be really calming. So for those patients, I'm often recommending oral micronized progesterone. You never want to do a transnormal progesterone. Again, we're going with the body identical type because it's a humongous molecule and it does not absorb through the skin. So those of your listeners, if anybody's been prescribed progesterone cream, that is probably not your best option. If you're also on estrogen, I would call your provider immediately, you are not protected against endometrial cancer with that.

Testosterone's a little different. We don't have an FDA approved option for testosterone for women. There are men's, of course, available. So if you are in a state where it's easier to get the T-STEM or the gel in the men's option and your insurance will cover it and the pharmacist will actually prescribe it for you, they don't know. In Texas, it's tough. Nobody likes to get involved in women's health care more than a Texas state legislator than a Texas state pharmacist. They like to put up a fuss for things. So to get around that, because it's not made for women and they're very uncomfortable describing it, I will often do a compounding option of a cream, which absorbs very well through the skin and is very safe. Fantastic. You know, last item that I want to touch back to on this topic of hormone replacement therapy

is that really when you intervene and the age is a big part of this conversation that's here. Just retouch on that topic in the context of us talking about it as an intervention. So as far as long-term protective health benefits, we have to look at things a little differently instead of how old, how young. It's your time away from estrogen where the disease processes accelerate and start. The way I explain to patients, we don't want to put estrogen on top. of cardiovascular disease, pre-existing cardiovascular disease. You don't want to put estrogen on top of a stroke or a vascular issue in your head, you know, or dementia. You know, if you're already having plaques or vascular dementia, you don't want to give a patient estrogen for that. It's better at prevention than cure. And so the younger you start, the closer to your natural menopause or even in perimenopause, the better your outcomes are going to be for all of these disease states. And so,

When we reach maybe around 60 or 10 years from natural menopause, we start losing the cardiovascular benefit of protection. It doesn't mean it's not safe. It just means I can't tell a patient, I can decrease your risk of cardiovascular disease at this point. What I'm also doing is getting a full lipid profile with an APOB, with an LP little A, maybe out of ordering a calcium cardiac score so we can make sure that there's no calcifications in her carotid artery, you know, in her arteries around her heart are to carotid so that, you know, that makes me feel better that we're not, you know, potentially increasing risk there. So, but so if a woman's been on hormone therapy and done well and has not developed any of

these diseases, I will continue her hormone therapy as long as she wants. So I might die with an estrogen aisle patch on. I'll be lucky if I, you know, if I, if I don't develop a contraindication, I have no intention of taking estrogen out of my life. I want to live in long, healthy life, and this is part of it. In addition to some of the protective benefits, the improvement in sleep, are there any case studies of patients, stories of people you've worked with where this before and after idea of what their life was like, of course,

with all the foundational lifestyle things that we're talking about here, you're not just throwing medication out of this situation. you're really restoring the body's natural access to the hormones that it previously had. Are there any stories that come to mind or examples that you might want to share with our audience? So yesterday I got a package at my office from a patient who came on the menopause cruise with us. And the package was for my staff, a little tiny sweet gifts. I mean, we don't expect that from our patients. But she wrote this letter that was incredible.

And I get these types of letters all the time, every day, of... her quality of life, how she looked at herself, her body, her future has dramatically changed. It's not about a bikini. It's not about, you know, though that would be nice. This is about her functionality, how she processes relationships, how she's functioning at work. You know, her level of stress is down because she's not worried about, you know, her cholesterol being so high anymore. Like, we are seeing improvements across the board. Patients, are much healthier. And there is, and I'll tell you this, there is a big fight in the menopause world right now against old school menopause, like, researchers and those of us on the front lines.

And we are not standing for it. They're just published in the Lancet, which is a big British medical journal that, you know, the headlines look great. The conversation around menopause has to change. And it was the most misogynistic, paternalistic thing I've ever seen. Basically, at the end of the day, only if she has severe hot flashes should you give her estrogen. She just needs to suck it up and get over and get on with it and learn how to live without estrogen. And we are putting our foot down on the front line. We have over 300 signatures on this thing. We've written a rebuttal.

And this is not what's happening in clinical practice. These women are thriving. They're getting their lives back. They are so happy. All aspects of their health are better. You know, I'm not privy to seeing that fight firsthand, but thank you for telling us about it. And I think I would be, if I didn't ask this at least, you know, to touch on this because this is where the conversation started, what is still driving that way of doing things? Is it ego? Is it?

These are, and these researchers were female. And I think they're just so entrenched and they're not seeing patients. You know, they're just, they're statisticians and, you know, and I think they're just entrenched in their mentality and their research and maybe they had easy menopazas and why are we making such a fuss about this, you know, internalized misogyny. I don't know. It's like those of us who are actually doing menopause care at all ages are like, this is ridiculous. You're taking options away from women and they're going to be less healthy. Well, chances are, what is that Upton-Sinclair quote? You know, you can't get a man to change his idea or a woman in this case. You can't get a man or a woman to change their idea on something if their job depends on them,

not changing it. And so chances are if you are a senior lead and your name is on this paper that's being published, your entire career has been built on a specific way at looking at things. And it's part of the story, but it's not the whole story because evidence-based medicine, as I've understood from hanging out with incredible practitioners like yourself, one part of that is traditional clinical research. Another part of that is clinical experience. you're learning something by actually working with the patients, hearing the stories from the front line. And so you cannot look at any one aspect and just say, I see. It's like the old analogy of the blind individuals trying to describe what an elephant is and one's on the trunk and one's on the leg and ones on the tail.

And they're all describing different things. You are leading a movement of women and the men who love and support them, of course, to say that, It does not have to be this way. There's a different way to exist, and you're doing it through community, and you're doing an incredible job. One last item on that topic of community. You've shared how it's so important for women

to understand that you don't have to suffer in silence. Like, go and start talking about this. Meet other women, connect other women. Any lasting tips that you want to share on that topic of community and how it's so important, especially for this demographic and population, either in menopause, post-menopausal, or even in perimenopause.

You know, so many of my patients now can't tell me what their mother's experiences were because they didn't talk about it. Or, you know, these are things we don't talk about in our culture and our family, you know. And their mothers couldn't even tell them when they went through menopause. It just was this fugue state. And that they realized that we have to change. It's time to tell our stories. This is an important part of our story.

And if we don't educate the next generation, they're not going to be prepared. And most of the regret I see in my patients now who are metapuzzle is that they weren't prepared. They had no idea all these things. They just thought it would be a few hot flashes and they'd missed their period and it would be over. And they had no idea that it could catastrophically affect so many aspects of their life. And that, you know, if they just would have known, they would have been prepared, like known the questions to ask, you know, had this army of information. behind them so that they could go in and advocate for themselves. All right.

We teased about it, but let's talk about prescription interventions. Let's talk about it. Give us the big picture on that, and then we'll get into some of the details. Well, the reason I mentioned prescription meds is that there's a little bit of a movement right now to revamp HRT, hormone replacement therapy. And as with everything that's been shunned for a really long time and is having a comeback, Now, everybody's interested in hormones, and some people may even downplay a little bit, some of the risks and side effects.

So I think it's important to get the full picture and know what we're working with, what we know, what we don't know, what kind of research has been done, and what kind of research has not been done. It's important to know about things. And I, again, I specialize in brain health, so I'm going to stick with brain health when it comes to hormone replacement therapy. But so what we know about estrogen in particular is that it's a very versatile hormone. And we think of estrogen and testosterone progesterone as sex hormones, but that is really kind of a mistake.

So the history is that estrogen was discovered in the 1930s by scientists who were studying reproduction. And so they realized that this hormone was important for women's fertility in bank. they just named it as a sex hormone, and we've been stuck with that definition since, which was really an issue because in the 1960s, 1990s, sorry, it was discovered that those same exact hormones that were so important for reproduction were also just as important for brain health, right? And so it turns out that estrogen has, serves a number of roles and functionalities that have nothing to do with having kids and everything to do. do with having a healthy brain.

Right. So this has been missing for the picture for a really, really long time. And it's a problem because the biggest clinical trials of hormone replacement therapy or estrogen replacement, which is the Women's Health Initiative, was launched before anyone had any clue of what estrogen could and could not do for your brain. So in the 1990s, the NIH, the National Institute of Health and other subdivisions launched this enormous clinical trial. It was testing hormones for prevention of cardiovascular disease, heart disease, and also

prevention of dementia, among other things. And within just a few years, they had to stop the studies because it turned out that the hormones were doing exactly the opposite of what the scientists thought they would do. the risk of heart disease and stroke was actually increased. And so was the risk of breast cancer and the risk of dementia. Now, those results were inflated by the media. And that's how estrogen replacement therapy really came to have a bad rap. To the point that today in the United States, only 4% of all women going through menopause

are being offered or at least are being prescribed hormones for relief of the symptoms. And that is a bit of an issue because we do know now, years later, now that the research has been done and now that we do understand how estrogen and testosterone actually work in the brain as well as the rest of the body, we do know that they can actually help during menopause and that they are safe to use for women who are eligible. So according to the North American Manopause Society and other professional societies, they specialize in menopause, taking hormones for relief of menopausal symptoms in women who are going through pari menopause or early postmenopause of women,

as long as the symptoms are active and you are within 10 years of your final menstrual period, taking hormones is safe and well tolerated by most women, not all, so you need to obviously check, and usually it can provide significant benefits and relief. So this is something to consider because so many women don't realize that, and we're stuck with the women's health initiative, and people think that hormone replacement therapy is some kind of poison that's going to give you cancer. so it's really important to have a clearer picture of what hormone replacement therapy can and cannot do for you. Right? It's not a miracle. But there are benefits. So I think it's important to know when to use it, how to use it, what to use, and for how long. It's not a miracle, but I mean, just the women in my life that I know, you know.

Oprah. She loves it. Yeah. They actually felt like it was a miracle for them in many instances. So we don't want to underplayed it as well? It made a massive difference for a lot of women. For a lot of women. Obviously, there's foundational health issues that are there. If somebody's not living a healthy life, et cetera, those things. But for the women that have a lot of that, and they went on it and just dialing it in with the right doctor, it was a game changer for them.

For many women, not all. Not all. I know a lot of women who would love to take hormones and they don't do well on hormones. But I would say that they're not in the majority. They're more like exceptions. How would somebody know if they do well or not do well? Would they just have to try it? You take it.

Yeah. Yes. It takes three months, more or less, to get a sense whether or not it works for you. And if you have side effects or if you feel horrible on it, it just means, you know. I mean, you can try to change the formulation first. Of course, you can try to change the dose. But for some women, it just doesn't work. However, for many women, it does work.

So I think it's worth considering and it's worth knowing that it is only. the table for many women who are eligible and at the right age. We're studying hormone replacement therapy for brain fog as well and for Alzheimer's prevention. And I will show you what we found. Yeah. Yeah. So you're bringing up an image. I'm bringing up an image that was very well received. This is a study we just published. It was featured on CNN and the New York Times and the Wall Street Journal that shows that this is important to women, right? We need to know this information. This is the largest, to my knowledge, is the largest meta-analysis or the effects of hormone replacement therapy,

which is now called menopause hormone therapy, on the risk of Alzheimer's disease and dementia. And this study included over 6 million women, I believe, globally from all over the world, and over 50 studies that looked at the effects of HRT use relative to risk of dementia later on in life. And the effects are quite interesting in that there are two factors that really matter. The type of hormones that you're taking and when you're taking them. So for women who do not have a uterus, usually we only prescribe estrogen alone. For women who have a uterus, then you need to take a progesterone. It's got a progestogen in medicine, in medical terms, but it's effectively progesterone.

So there are these two possibilities, only estrogen, estrogen and progesterine. And then you can take it when you should, which is during menopause or right after the transition. Or you can take it more than 10 years after the final master period, which is not recommended, but is what a lot of studies did, like the women's health initiative. They were just testing the hormones of women who were more than 10 years postmenopausal. And they didn't know back then that there's a window of opportunity during which estrogen has positive and beneficial effects. But once the window closes, once it's too late and your system has been dismantled, like we were saying before, at some point this neuroendocrisy system shuts down, then reintroducing the estrogens may not be beneficial and can actually be harmful in some ways.

So once you break it down and stratify by these parameters, you can say that, This is estrogen only to the left, and we're looking at graphs that summarize the results. And the left portion of the panel is what estrogen can do for you if you take it within 10 years of your final menstruate period, which is a 32% reduced risk of Alzheimer's disease and dementia later on in life. A 32% is a lot. That's a lot. It's a good reduction.

And it really goes back to what you were saying, the timing of it. The timing is important. Yes. Now, if you start taking the estrogens after this window of opportunity and this only estrogen, then the effect is overall neutral. Doesn't really increase your risk of Alzheimer's, doesn't seem to lower it either. If you look at the estrogen and progestogen formulation, and these are mostly synthetic forms of progesterone, which means non-bi-identical, non-bi-identical, then if you take this combination therapy in midlife, less than 10 years, from the last menstrual period, then there is a 23% risk reduction of Alzheimer's disease and

dementia, which is still good, and at least it's not harmful, right? The concern is always that the progester makes it worse. But if you take this combination more than 10 years post-menopause, then there is a possible risk increase that was not significant, but it was present and needs to be further investigated. Like the tip of the curve is the Women's Health Initiative, where studies that were done afterwards did not show such a big risk increase. And now we're trying to tease out what was actually driving those effects.

And this seems to be the kind of progesterone that they were using, that is no longer used in the United States. So bioidentical progesterone seems to be safer overall. And bi identical estrogen also seems to be gentler on the system. So the key takeaways here. Timing is a big portion. Timing is important. Getting involved earlier and using biodentical hormones. If somebody has access that and finding a practitioner who can work with you, that's where

you're going to get the biggest bang for the buck, whether you do estrogen only or estrogen progesterone. That's correct. Hi, one, Drew here. Two quick things. Number one, thank you so much for listening to this podcast. If you haven't already, subscribe, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the way.

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