Ologies with Alie Ward - Emmenology (MENOPAUSE & PERIMENOPAUSE) Part 2 with Monica Christmas, Mary Claire Haver and Sarah Witkowski

Episode Date: July 23, 2026

Hormones or no hormones? Itchy ears. Disappearing pussy syndrome. Estrogen by land, by sea, by patch, by pill, or by cream. When is it T time? What's the deal with herbal remedies? Should your moisturizer have hormones in it? Is HRT safe? Four experts weigh in on bioidentical versus synthetic, getting better sleep, what to put in or around your vagina, tips for trans folks, protein research, and why you should go pick up a brick or something. OB/GYNs and menopause experts Dr. Monica Christmas and Dr. Mary Claire Haver – who wrote the book The New Perimenopause – are back for this Part 2 all about science-backed fixes to your menopausal probs. Joining the chat is Smith College exercise physiologist Dr. Sarah Witkowski with a cameo from anthropologist and bone expert Dr. Daniel Wescott.  Again, bonus Part 3 this week will be tips for your loved ones. We’re all in this together, kiddos. Start with Emmenology (MENOPAUSE) Part 1 Browse Dr. Christmas’s papers on ResearchGate and follow her on Instagram Visit Dr. Haver’s website and follow her on Instagram, YouTube, TikTok, and Substack Buy Dr. Haver’s books, The New Menopause, The New Perimenopause, The Galveston Diet Learn more about Dr. Sarah Witkowski’s work Donations went to the Center for Food Equity in Medicine and St. Jude Children’s Research Hospital and the Menopause Society RosebudWoman.com (owned by my wonderful in-laws!) will give you 15% off with the code OLOGIES Tortoise Sword from Jarrett Sleeper’s JB Stink brand shirts More episode sources and links Other episodes you may enjoy: Urology (CROTCH PARTS), Gynecology (NETHER HEALTH), Neuroendocrinology (SEX & GENDER), FIELD TRIP: Alie’s Mystery Surgery, Surgical Angiology (VEINS & ARTERIES), Cardiology (THE HEART), Biogerontology (AGING), , Biological Anthropology (SEXY APES), Evolutionary Anthropology (METABOLISM), Thermophysiology (BODY HEAT), Somnology (SLEEP), Mnemonology (MEMORY), Attention-Deficit Neuropsychology (ADHD), Molecular Neurobiology (BRAIN CHEMICALS) 400+ Ologies episodes sorted by topic Smologies (short, classroom-safe) episodes Sponsors of Ologies Transcripts and bleeped episodes Become a patron of Ologies for as little as a buck a month OlogiesMerch.com has hats, shirts, hoodies, totes! Follow Ologies on Instagram and Bluesky Follow Alie Ward on Instagram and TikTok Editing by Mercedes Maitland of Maitland Audio Productions and Jake Chaffee Managing Director: Susan Hale Scheduling Producer: Noel Dilworth Transcripts by Aveline Malek  Website by Kelly R. Dwyer Theme song by Nick Thorburn Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

Oh, hey, it's still the Band-Aid in the public pool. Try not to think about it. Allie Ward, here is part two of Eminology. We're talking menopause, perimenopause. Last week, we had on three ologists, Dr. Monica Christmas, Dr. Mary Claire Haver, and Dr. Lara Dirkovich, to talk about why menopause happens from an evolutionary perspective. We talked about the symptoms that are often overlooked, the mental health aspects, so much more. And this week we cover what to do about it. So you feel like yourself again and also so you don't die. So start with part one. These episodes took like a year to make. So listen to part one first. So part two makes more sense. Great. Okay. So for this part two. We have one ologist, Dr. Monica Christmas. Monica Christmas, she her. An associate professor of obstetrics and gynecology and the director of both the menopause program and the Center for Women's Integrated Health at the University of Chicago. We all. also have on Dr. Mary Claire Haver. Dr. Mary Claire Haver, she, her, who is a long-time health care provider in obstetrics and gynecology. She authored the New York Times best-selling books, the new

paramedopause book and the new menopause book, and she hosts the podcast Unpaused. We'll also sit down with Smith College Professor and Exercise Physiologist, whose concentration is menopause in cardiovascular health, who will give you all the inspiration you may ever need to give you. You your heart some love and go lift some heavy stuff or jump around. And that is Dr. Sarah Witkowski, she, her. And a note up top, I mentioned this last week, but trans men can go through menopause. Non-binary people can go through menopause. Not all women have uteruses, myself included. And many times you'll hear female or women in terms of describing a patient in these episodes. And just know that that refers to the majority, but not the entirety of gender identities going through this.

Also, on the topic of health care, many, many folks don't have access to it. Can't afford it at all. And I'd like to just give a huge kudos to Planned Parenthood, which, yes, provides menopause-related health care as well to people. And you can ask about their sliding scales. Planned Parenthood, we love you. And before we go any further, let's say a quick thank you to patrons of Ologies who are signed up for a buck or more a month via patreon.com slash ologies and who submit questions that

help steer the show so much, and for $0.00, you can help the show out just by leaving us a little review, and I read them all for real. And to prove it, thank you, AJ Price, who wrote a review in haiku. Oh, hi, says the host of my favorite podcast, or sometimes, oh, hey, AJ Price, 17, thank you for that. And thank you to sponsors of the show for enabling us to donate to not one, but three causes this week. Okay, for a complete list of our other 500 plus episodes, just head to ologies.com for assorted menu, but you're here now for this one, so let's hit it. Hormones or no hormones. Disappearing Pussy Syndrome. When is it tea time? Estrogen by land, by sea, by patch, by pill, or by cream. You learning from my personal mistakes,

hopping around your kitchen to stay alive. What's the deal with herbal remedies? Tackling perimenopausal and menopausal depression, bioidentical versus synthetic, getting better sleep, what to put in or around your vagina. Same thing, but with ears. How long does one stay on HRT? Menopause tips for trans folks, talking about protein, eating the actual bones, and why you should go pick up a brick or something. Again, bonus episode.

Number three this week will be tips for your loved ones. Let's hit it with Mary Claire Haver, Dr. Monica Christmas, and a cameo from Dr. Daniel Westcott, and introducing Dr. Sarah Woodkowski. Okay, so let's start with a question that's been driving us bonkers, which is going bonkers, or feeling like it with anxiety and psychological symptoms in addition to the physical. So Anastasia Press, Erin Soren Sorenson, Dr. Lisa B. Rebecca Jackson, Jessica Gonzalez, Kristen, Terence Selch, Frances Hurst, Brubaker, Megan Ratcliffe. And first time question askers, Evie, Michelle Fox, and Fred Wax all wanted to know about this. But Aaron Bagley wondered, why do you?

Do I feel like a volatile, rabid honey badger? Obliot asked, is anxiety a common side dish to menopause, or am I just extra lucky? And Mandy Viscousi asked, do I ever get my fucks back? And Jenna Condon simply wanted to know why does it suck so much? And this is Dr. Mary Claire Haver. So when it comes to perimenopause, what are some recommendations that you give your patients like front line, you're feeling a little out of sorts? Is it to continue on birth control? Is it to think about an SSRI?

Like, what can you do? So it depends. So if we're going to, like, try to stabilize her hormones, right? And there's two ways to do that. So there's a big difference between the way birth control pills work and what they're made of versus menopause hormone therapy. So if she's having a reason for me to give her birth control pill, like she needs contraception, like her life would end if she was pregnant, right?

Her husband won't get a vasectomy, whatever. Like, she needs contraception. we're going to talk about it, okay? If she has really heavy periods, you know, and they are disrupting her life, birth control pills can be a lifesaver for this time period and give her some relief of some of the symptoms. So you do see hot flashes get better on birth control pills and all that. But ethanol estradiol, which is the estrogenic component of most birth control pills, acts very differently than plain estrogenial. It binds to the receptor with 300 times the effect. Oh, wow.

Yeah. Yikes. So I love it for contraception. It works. But, you know, I'm very realistic about side effects. I mean, we see decreased libido because your SHBG goes up and your testosterone's not exactive. I mean, you know, like everything is nuanced.

There's no cookie cutter. So say she has an IUD or her husband had a sex with a contraception's off the table and she doesn't have crazy periods. We're talking about menopause hormone therapy. Mm-hmm. Okay? In perimenopause, it won't stop an ovulation. It's not high enough dosing.

But it does tend to stay. some of the chaos, right? You're calming the brain down a bit. You're giving it back some estrogen, so the pituitary in hypothalamus calm down. Nice. Now, you'll still ovulate, there's still stuff going on in the background, but for mental health, the studies are clear coming from Australia. It is more effective for a new onset of mental health changes like anxiety, depression, than an SSRI. Wow. And this Australian study, hormonal agents for the treatment of depression associated with the menopause, explains that there's an increased risk of depression and anxiety during perimenopause and the menopausal transition with perimenopause depressive symptoms being

more severe than pre or post menopause. And again, that perimenopause, that can last a decade. And it continues during menopausal transition, the impact of fluctuating estrogen in the central nervous system can have negative psychological effects for some women, traditional first-line management, it says, of menopausal depression involves antidepressants with modest outcomes, and the positive effects of estrogen treatment are becoming increasingly recognized, the study says. Now, a 2024 study in the journal Menopause titled, Does Menopause hormone therapy improve symptoms of depression? They detail that a specialized menopause clinic found that MHT, or menopausal hormonal therapy, was associated with significantly improved depressive symptoms, both alone

and in addition to an antidepressive medication. And they say that younger age, lower education, attainment, and smoking were all associated with higher depression scores. And also, I was reading this super old study in the International Journal of Women's Health titled Optible Management of Perimenopausal Depression. And it opened saying, only recently has the paramenopause become recognized as a time when women are at risk for new onset and recurrence of major depression. I was like, dang, historical doctors simply did not care about mental health.

Oh, but wait, the paper was from 2010. So Kesha already had a major pop career, and doctors were still like, I guess half the world going through a massive physiological transition might also be, like, fighting for their lives mentally? I don't know. So ask your doctor if being not depressed is right for you. Now, Dr. Haver, who's a strong advocate for hormone replacement, continues. And can you tell me a little bit more about the necessity of pairing estrogen and progesterone?

Yeah. So progesterone, if you have a uterus and you give someone estrogen is mandatory. Some kind of progestogen. So that could be progesterone or one of the synthetic progestants. Okay. Northendron and Mederoxibroxidone acetate have been studied for intemitriot protection and just plain progesterone. So we know about those. In our clinic, we use a lot of just plain progesterone. And then if she doesn't tolerate it, then we can consider a moraine IUD with the progestin in it. We can do basidoxifine, which has a serum, which is protective, which is do of V in the U.S. And then we can do a combi patch, which has the north end drone in it. So again, lots of nuance, lots of counseling.

But, you know, it's about 10% of our patients who don't tolerate the progesterone, but most people tolerate it really well and like it because it's so helpful for sleep. But say you don't need it. Say you have an IUD. you've had a hysterectomy, whatever. It can be a magical for sleep. So we're always having that conversation. So if you have a uterus, you cannot take estrogen without progesterone.

Okay? So your options are progesterone, synthetic, or an IUD. And when you're on estrogen therapy and you have a uterus, there are a few kinds of progesterone you can take. One is medroxy progesterone. That's a synthetic progestin known as provera or sometimes MPA. when it's taken for menopausal symptoms, or the Depro-Pravera shot is used as a birth control or treatment for other hormonal conditions, and that's medroxy progesterone.

Okay. Now, the other option is a more natural form of progesterone. Brand name is called prometrium. And while studies, and a lot of doctors say that the synthetic midroxy progesterone, brand name Pravera, shouldn't have mental health side effects. Some users report anecdotally that it worsened depression and anxiety. For me, madroxy progesterone reeked a bit of havoc. I was having crying, jags, and anxiety, and the natural form, prometrium, or just progesterone, I did fine on. In a few minutes, we'll talk a little bit more about why that might happen. I got to say, prometrium, wow, you take that in the morning on accident, and you feel high. You're sedated. Yeah. I'm like, whoa, dude. Yeah, so I have it at the bedside. It is on my nighttime table, and I do not take it until I get another cover.

It's like a gummy. It really is. I really am like, dang. You've got that good GABA receptor, like, you're still young. You know, your GABA receptors are like, woo. Just like, bye. And a heads up, if you take progesterone, either for menopause or for maybe transitioning, as a lot of people do, or for other medical uses, the brand name for it is usually permitium. It's fat soluble. I just learned this. So if you take it with food, you may feel even woozier. and in my experience, full on stoneed. I didn't understand why sometimes it made me feel that way. I realized it was when I took it with food or breakfast to not recommend taking it in the

morning with breakfast and hopping on a Zoom meeting. I've done that and I felt plenty weird. But I'll take that a thousand times over to progestants, that more synthetic form, which again is usually called madroxy progesterone. For some people, and I am those people, Medroxy progesterone can disrupt the neurochemicals that promote calmness. And so some people may experience way worse moods when on medroxy progesterone. No one told me this for roughly six years when I was on it.

And during quarantine, simply couldn't handle the anxiety spikes from madroxy progesterone. So I fucked around and did not take it. And I found out by flirting with endometrial cancer and needing a total hysterectomy in case you missed the field trip Alley's mystery surgery episode. which goes into greater detail on POI or my freakish early mid-30s menopause. And I can call it freakish if I want because it's my junk. But if you're taking estrogen and you have a uterus, you need to also be on progesterone. Or you risk your uterine lining or your endometrium growing too much and having higher risk for that uterine cancer.

And as we learned last week, research on female reproductive health is scant comparatively. But a 2020 paper titled Progesterone, Reproduction and Psychiatric Illness in the Journal of Best Practice in Research, Clinical Obstetrics, and Gynaecology notes that a subset of women may be vulnerable to depressive effects on the progestin, adroxy progesterone acetate, especially at the lower doses, but that research is lacking on women with psychiatric illnesses. So don't worry about it. We'll just scream the anxiety out in the car. Now, the paper also notes that for hormone replacement therapy, historically, medroxyprogesterone acetate or MPA was used, but it says this is no longer recommended based on results of the Women's Health Initiative study, which found that it was

associated with increased risk of breast cancer, cardiovascular disease, and elevated lipids. We'll touch on those things more in a bit, but yes, for me, Prometrium, aka. Just progesterone, worked much better than Prevara, aka. Medroxyprogesterone in terms of mental health. So talk to your doctor and also know that it's not your fault if you feel like you're hanging off a cliff by your fingernails. So many hormones, so little time, we're doing our best. Now, what about testosterone? Where does testosterone knock on the door? Because I feel like that's a relatively new thing on people's minds. The best data we have, and it's not replacement as much as getting you back to physiologic levels that you had at 30. It doesn't fall off a cliff, right,

like estrogen and progesterone. It declines with age. Okay. And for like younger women who've lost their ovaries or POI patients, for your libido, it's critical. So if you're not on testosterone, we should talk after this is over. Oh, I got it. I'm on it. Okay. Yeah. I'm like, like that's like malpractice if you're not on it. Yeah. I wasn't for the longest time. Just only a couple years ago. Like night and day. No one mentioned. Yeah. Now, there's observational data that is suggestive for brain health. Definitely like when we look at natural testosterone levels, like women still have it, right? So you're going to have women who have higher levels, women have lower levels. Women with higher natural levels of testosterone have better muscle mass

and better bone strain. So looking at that data, I was like, and I'm a naturally thin person. I don't have great muscle mass. I, you know, did take care of myself in my 30s and 40s. I was always dieting, trying to be skinny, and here we are. Now I'm like all about, I don't want to end up in a nursing home like my mother and grandmother from frailty. So like, I've got to work on this now. So like, let me try this and let me tell you. It works. It's like heated rivalry level. Like, and let me tell you, I would miss it if it was gone.

For sure. You know, and everybody's happier. No one was complaining, but everyone's happier. That plus, I mean, you also just feel like yourself is back a little bit, you know, like something comes out of hibernation where you're like, there you are. Yeah. And so for people who asked about libido, yes, according to the 2020 paper in the British Journal of General practice titled, Should we be prescribing testosterone to perimenopausal and menopausal women?

A guide to prescribing testosterone for women in primary care. Testosterone can be important in women for bone density and muscle mask, cognitive function, mood, sexual function, and energy. So for people in menopause with low sexual desire, it says in tiredness, you can ask about getting some testosterone up in there. Again, because I went through it early, I have gotten to see lab work over the years, and without my transdermal. testosterone dose, which is just a quick cream I rub into my arm or my leg a few times a week,

my testosterone would not even register in my labs. It was like, I've never heard of her. I was raw dog in it for years, no idea. But a lot of what's used on women in menopause is man's testosterone therapy mixed up at a compounding pharmacy, but in much lower doses. Now, in terms of testosterone implants or pellets, proceed with caution. And by that I mean maybe not at all. As from the studies I've read, you can see the 2025 testosterone pellets in women, revisiting safety and clinical outcomes. The release of testosterone can be a lot right after you get it, which can lead to mild androgenic events like acne, hair growth, hyperreactivity, and rare transient voice changes in hair loss, as well as increased agitation. So, cream it is, for me at least. And there was this fresh 2026 paper from Cedars-Sinai Hospital, and it notes that while testosterone

therapy is widely prescribed for men, the benefits for women haven't been sufficiently investigated. Viagra, available since 1998. And yet no FDA-approved testosterone therapy for women in the year 26. Big shrug. Now, is the rage hormones, or is it a sane reaction to an absolutely bat-shed world? of greed and misogyny and racism and incompetence and cruelty. We'll never know because we'll never study it. Now, hair loss tips, if your itchy ears perked up in the mention of hair loss, yes, androgenic alopecia can be at the root of menopause-related hair thinning because your estrogen

and your progesterone naturally declined. So the androgens that you do have could have become more dominant leading to the follicles shrinking and your hair thinning. So for patrons, Haley Rose Jones, first time question asker, Carrie Kimo and Teresa and David, doctors say you can try monoxide or other pharmaceutical approaches, gentle shampoos, making sure your diet is nutritious with enough protein, more on that later, or you could wear a space helmet with lasers. It's called, futuristically, photobiomodulation, and the 2014 paper, the growth of human scalp hair in females using visible red light laser and, LED sources. This was in the journal lasers in surgery and medicine. It explains that they got some volunteers with some lady hair loss and designated a patch of scalp to look at. Hairs there were trimmed to three millimeters in height. The area was tattooed and photographed and the active group received a top hat 655 unit containing 21 diode lasers and 30 LEDs in what they call a

bicycle helmet-like apparatus. Now, the placebo was just regular, tiny incandescent bulbs. This was called the sham group, which how sad to be putting a bicycle-like helmet on your head that did nothing, simply as a control group or a sham group? But, okay, so these 50 volunteers were this thing every other day for 25 minutes for four months, all right? Did it even work? Okay, the paper reports low-level laser light therapy of the scalp at 655 nanometers. That means red, significantly improved hair counts in women with androgenic alopecia at a rate similar to that observed in males using the same parameters. So hence it was called a top hat 655. That was 655 nanometers. Red, it's close to infrared. So evidently, the light can open up blood vessels in the skin and the hair

follicles and that helps deliver blood and nutrients and the support they need to renew. And consistent use over several months can lead to noticeable changes, right, which is great news, bad news. Those diminish if you stop wearing your space helmet. And like a tractor beam, I was lured and then mesmerized. I was like locked in scrolling through so many before and after photos of happy, hairier people. And I was like, dang, it's really coming in. Now, a 2025 paper in the Journal of Cosmetic Dermatology title, the use of light-based therapies in the treatment of alopecia looked at over 400 articles. They crunched the data to find that in androgenic alopecia, which can also affect people assigned male at birth, low-level laser light therapy improves hair density and follicular responsiveness

with even more enhanced outcomes when it's combined with monoxidil or finasteride, which are rogain, and propitia. Mish the Fish asked about texture change. Doctors say that declining estrogen means less sebum to hydrate your hair, leading to more frizz and brittleness and breakage. So moisturize, ask whomever cuts your hair or read it about oils to quench it, or visit your local apothecary which, or try a doctor, which brings me to a question from patron Limberbutt McCovins, who asked, why do none of my health? care providers know any of this stuff. Why do I have to explain it to them? Now, what about people who don't know to ask these questions? Are most GPs or most obese? Not educated. Yeah. I received zero

education on testosterone except it was bad. Like, what? You know, I had higher testosterone levels when I was younger because I had polycystic ovarian syndrome. And like, we would track my response to medication by my testosterone level. And it was acne and all the things. And I guess I had a high libido at 25. Who, you know, what is that? And so, you know, got that all managed and under control, the PCOS. So I was a little hesitant. Like, do I really want to put this back in my body when I fought it for so many years? But my levels were really low. And I was like, oh, shit, okay. Well, let me just get up to like a normal 30-year-old range for a normal 30-year-old. And, yeah, it really seemed to turn to key in a lot. Yeah. I mean, I look at my blood levels and there were just like

zeros across the, you know, just like, poor baby. I mean, it's been a journey, but it is helpful to friends who are going through somewhat similar things. But listener mims asked, are bioidenticals really better for you than synthetic hormones? Can you talk to me a little bit about bioidentical versus synthetic? I feel like there's a lot of like mis- Okay, everything is synthesized, by the way. We don't like eat a bunch of yams and estrogen magically appears. So I want to take a little bit of away that nomenclature. Like, you have to go to a lab to get this stuff. What we mean by body identical is that it is close to the chemical structure as what your ovaries made. And that is going to be estradiol. A human body makes other estrogen-type hormones. So it makes estrone in the

periphery in the brain, mostly in the fat cells, okay? And it is a more pro-inflammatory hormone than estradiol. We also make something called estriol from the placenta for those of us who have pregnancies. That is the main estrogen in pregnancy. Estrone becomes dominant postmenopausal. So you make different types of estrogen. Those are all estrogens. If you have recently googled the sentence, how do you know if your estrogen is from a horse? You may have found yourself trotting through a British Journal of Clinical Pharmacology. The paper is the use of conjugated equine estrogens in hormone replacement therapy still appropriate, which discusses medications like Premarin, which first-time question-asker, really more of a fact-dropper, Lisa, wanted you all to know,

is made from pregnant mares urine, premarin. And yes, they harvest it from farms of confined pregnant horses, and no, it is not necessary these days, as the lab-made estradiol is chemically identical and horse urine free. So no, what you're getting these days, not a lot of horse urine. So thank you to the people in lab coats. And they're all body identical. They're all natural and they're all used in different things. Like I put estriol on my face. I never prescribe estrogen. Never. But I use pretty much for hormone replacement. I'm using estradiol in the vagina or you know, systemically. And then progesterone, there's only one progesterone. It's progesterone. Okay. And then the androgens, we have DHEA plus testosterone are the natural ones. And then

they've synthesized some other ones, but we don't use those. We just use the natural testosterone. Well, methods of administration are fascinating to me. Yeah, very different. Okay, the best way to think of, like, how do you get this in your body? So if we're talking systemic, like, I want to treat my brain, my bones, I want to get it in the blood. You can swallow it or not swallow it. Okay, so we have oral and non-oral. Oral's pill, done. Okay, non-oral. Through the skin, gel, cream, patch, through the vagina, the mucosa, the vaginal rings. Oh. Then we have local, meaning it's not going in the blood.

It's going to stay put. So then we have topical cream for the face. Now, when it comes to facing menopause with your actual face, Mims asked about this. And Leah Rubenstein wrote, oh, an estrogen face cream? Is it magic juicy face cream? What's your estrogen cream on the face? Oh, estriol. Estriol cream.

Where do you get it? So I get it compounded. from a company called Alloy Health, and they do menopause care too. And so they compound it, and I buy it from them. I buy it. They don't give it to me. They gave me the first bottle, and then I, you know, it's ethical. And we have a whole blog about it on our website if you want to go and read. It's the safety studies are linked there. Great. You say, read them to me, because I'm building a sculpture. Okay. I'll give you some lowdowns. Dr. Haver's website says that a recent double-blind placebo-controlled study with 90 participants showed impressive results,

after three months of use, they saw 70% improvement in hydration, 57% improvement in skin texture, improvement in overall skin health was 68%. But it should be noted that a March 26th study in the journal American Academy of Dermatology titled Topical Estrogen Therapy for Aging Skin, Current Evidence and Clinical Considerations, mentioned that off-label use of estrogen cream, like put a dab of your vaginal estrogen cream in your moisturizer and social media amplification of estrogen products for anti-aging are outpacing the strength of available clinical evidence. And they continue that this trend has implications for clinicians who increasingly field questions about access, formulation variability,

and long-term safety. Now, estrogen cream has been proven in some studies to improve the appearance of skin on the body that is not sun exposed, such as once-periodicposed. Such as, once buttocks. So unsun-exposed parts of the body reacted visibly well to it. Sun-exposed areas, such as your damned face, were less responsive, one study found. However, anecdotal reports lately seem to be overwhelmingly glowing. So invest at your own discretion. Many health care providers and estheticians say, just because we don't have more data doesn't mean it's not effective, but again, there needs to be even more data. Many health care providers, and aestheticians say, unless you like spending money to do an at-home trial on yourself,

you can always opt to drink more water, focus on better sleep, improve your diet, you could care less about wrinkles, or you could go for the gold standard topical treatment of retinae or tretinoin to refine your skin texture and cell turnover. I mean, estrogen creams for the face, I'm intrigued. If you want to, go for it. But just know that there are cheaper, proven options, and in the end, it shouldn't matter to anyone but you. So you do you. But yeah, back to ways to get estrogen on or in you.

We have vaginal cream, vaginal ring, vaginal pill. You know, so it gets very nitty-gritty. And that's estrogen. Okay, progesterone is a humongous molecule. Mm-hmm. Doesn't play well. So we have to micronize it. Can't micronize it through the skin.

It doesn't work. Okay, they tried. So we have a lot of synthetic options. Like, we can take Northendron and get it through the skin. That's in a combi patch. So if you want to do progesterone, you have to swallow it. So those of you who are getting compound progesterone cream, really? Your doctor does not understand basic pharmacology. Oh, that sucks. You're not getting endometrial protection. So stop. Go get your oral progesterone. What about testosterone pills? So there is one form. It's mostly available in Australia, maybe undecanoet, so it doesn't affect the liver. The problem with testosterone, some of these oral testosterone is it doesn't play well with the liver. We see cholesterol issues, et cetera. So fortunately, you know, you can do it. Oh, I forgot injections. Those count too. Injections, pills, rings, pellets, la, la, la, you know, we can lots of ways to get it through the skin or through the mucosa with testosterone. So in our clinic, we use either T-stem gel or.

or the andro gel. So yes, to listeners, Cave Lizard, Bobby, and Christina Michaels who asked, are we likely to get an FDA-approved testosterone products specifically for women in the near future in safe appropriate doses? Well, yeah, if you live not in the United States. Here in the U.S., you just get something cobbled from a compounding pharmacy or use andro gel for men off-label, but in much smaller amounts. But as of last year, the UK and Australia both approved something called Androfemm, a specifically for women version of Andro gel.

Andro gel comes in a blue bottle with a silver label. And yeah, Androfem is in a bubblegum pink tube. But in honoring the legacy of women, Androfem contains about one eighth to one tenth the active ingredients, but costs slightly more. It's also messier to apply, and a lot can get wasted in the applicator, but the tube is pink. So if your doctor gives you andro gel, take that extra money, get yourself a few cocktails, maybe Molotov ones. Now, I asked Dr. Christmas what she thought about the tea and HRT, and she echoed those legalities. What about testosterone? So when we use it, it's off-labeled. It is approved, or at least by expert opinion, use for postmenopausal women that have

hypoactive sexual desire disorder. That means you've had decreased libido that is not caused by any other reason, right? There's not relationship to score. There's not vaginal dryness. There's not some underlying medical condition that might be inhibiting sexual desire. And it's lasted for more than six months. And the key is got to be bothersome to the patient, right? So if you have decreased libido, don't have sex drive, but it's not bothersome to you, then it's not really a problem.

So for postmenopausal women with HSDD or female sexual desire disorder, using low dose of topical testosterone, it's about a tenth of the dose that you would use for a man may be helpful. Some of the side effects that you notice for it might be hair growth in places you don't want it in like your face, hair thinning on your head. So places you want it in, it might be hair loss. At lower doses, you really shouldn't notice any cardiovascular things, but, you know, there's limited long-term trial studies, and we do need more data. Hopefully we'll have a female approved option here. Most times when we're using it now, we're either prescribing a male-approved formulation and having women use it at a smaller dose, which gets a little tricky because people can mess it

up. And the risk of messing it up is that they can get super physiologic, high physiologic levels, and there can be side effects that are irreversible that are not desirable for that. So compounding bioidentical options, especially pellets are a no-go. I would not advise people to use that. And many of them are getting sold, you know, false claims to, oh, it's going to be good for your muscles, it's going to give you energy, all these magical benefits. And, you know, initially there's this, you know, euphoric feeling with that first pellet you get. It's why premier athletes sometimes get in trouble for using it, you know, higher doses. But it is a dose-dependent thing. It usually goes down. And then you start giving people higher doses because they want to feel the same way they did

when they first got it. And that's when you start to see some of those adverse side effects that can not only be just displeasing and from a symptom perspective, but also from a health perspective or not desirable either. So yes, if you're using the male marketed stuff, just make sure you're not using too much, or a doctor can't have it compounded or formulated in the right doses for you. Now, on the topic of Boston, let's get to some flim flam. Patron R.G. asked, the loss of labia. Flimflam, this is something I've seen circulating on the interwebs.

Labia Minora receding specifically. Now, this was also on the minds, perhaps other places, too, of TB13, Carrigan Richards, Emily Oxford, Jenna Yu, Kate, McCauley Casey, and Stephanie Magnuson. Minnie, mini, I assume, whisper, said, well, I've heard for some women, they elongate. And Moth asked, what? Do your genitals change in Terribing? Labia Minora 86th, yes or no. Do they just fly away in menopause? They shrink. But you put estrogen on them and they grow back.

We go, hello. So, yeah, they thin. We lose the architecture. We lose the elasticity. And so they can visually look very, very different. I am better at telling a woman's age, if she's not on hormones, by looking at her vulva, than looking at her face. Well, especially nowadays, we have so many things. They will resort. I mean, okay, can you tell me about the importance of topical, local estrogen, for the Vaj.

Vajay, so important. Like you, that's a prescription for the rest of your life because you're so young. Yay. It's hard to get enough penetration from our systemic estrogen. Most of my patients

eventually need some vaginal. So I just put them on it prophylactically. I'm not going to wait until their vagina breaks before I treat it. Yeah. We're just going to give it to him. Bless you.

It is so important. GSM, general urinary syndrome of metapause. I'm talking the urethra, the bladder, the vagina, the vulva, the vestibule, the labia menorah, All of that has estrogen and androgen receptors, okay? And it takes a massive hit when estrogen goes away.

We lose thickness, we lose elasticity, we use the ability to produce mucus. So what used to be normal wear and tear becomes horrific, plus urinary tract infections. The number one treatment for chronic urinary tract infections in a perimenopausal, postmenopausal woman, is vaginal estrogen for prevention. And this is topical vaginal estrogen, which you've got to ask your doctor to add in like a value meal with fries. Not recurrent antibiotics. So any of you who were on recurrent antibiotics. Now, what does birth control pills do? Raise your SHBG, drops your testosterone levels. The vagina and vulva can suffer. So if you're on birth control pills and having chronic UTIs, you need some vaginal estrogen. Holy shit, man. So many people don't know that.

Think of the Eurosepsis in the nursing homes and these women. Oh. We could save so many lives. And then, like, our orthopedic surgery friends who actually pay attention and love women are, like, wait a minute. Everyone is falling because they're delirious from their eurosepsis. Like, vaginal estrogen can save hips, you know, from these falls in these elderly patients. So I'm like, I'm like, I can avoid all this. And we'll talk about other causes of hip fracture in a bit, which may surprise you. But yes, vaginal estrogen is local and it's in addition to other main sources of estrogen for hormone replacement therapy or menopausal hormone therapy. Also, if you're like, why does my puss smell diff? Well, that could also be declining estrogen, which changes the pH balance and it leads to some new, interesting odors. Now, hormone replacement plus vaginal estrogen can help.

with body odors. So yet another reason to explore that. And also news to me, there's a new molecule in town, or I guess it's an old one, two noninol, and a 2001 study out of Japan titled Two Noninol, newly found in human body odor, tends to increase with aging, notes that this is an aldehyde with an unpleasant, greasy and grassy odor commonly detected only in older subjects. 40 years or older, and resulting from oxidized omega-7 fatty acids that form on the skin and then evaporate into air. It can also smell musty or dusty. And unlike sweat, which is water-based, to nonino is oil-based. So regular hygiene may not cut it. You got to scrub, especially the neck, chest, and back area where there's the most of it. May I suggest a long African exfoliating net

or some sort of rough mitt, start of the top of the body, work your way down to the feet, scrub a dub of the back, and no, my fellow white Americans, rubbing soap around with your hands, it's not getting the job done. As for sheets and bedding, smelling fresh, wash at least weekly, use a degreasing or heavy-duty laundry detergent on warm or hot water settings. I know this is not the news you wanted, but it's the information that all of us need. Okay, so from the laundry and back to your sex parts and estrogen therapy. There's vaginal estrogen to really target localized symptoms like dryness and comfort. Now, how is the systemic estrogen administered? asked Tessa Liu for their mom.

Bobby wanted to know about the patch versus the implant. First time question asked her, Gloria looked into the patch, but it was expensive. They wanted to know about pills. So let's talk about the patch, which is this thin, sticky, film anywhere from the size of a big postage stamp to the size of a small cookie, depending on your dosage. And you wear it for about a week straight before changing it out. It's just there. It's saving your sanity and bones while collecting a halo of lint around it. What about when you have an estrogen patch and it looks horrible and leaves a disgusting ring of stickiness around it?

Speaking of experience. Yeah. So you might want to switch the, like, see if there's a different generic that you can get. Okay. But that is a cross-to-bear for a lot of us. Like, I don't have a good trick for that for getting that grungy, nasty. Yeah. Like scrub at it with baby oil, all this stuff. And it's skin cells.

It's just exfoliation. So, like, some people have said, okay, exfoliate there once a week before you put your patch on, like get the dead skin cells off. For me, it's when I get a spray tan. It's like four patches down the road before I can get that sucker to look normal, you know. I know. I'm always like, I wish I could put it somewhere where I couldn't see it, because there's nothing like being like, you want some of this. I, you know, I have to see it because I'll forget I have it. So I have it under, yeah. Oh, my husband, look, I could have, it doesn't take much. He, you know, there's been very, many versions of Mary Claire and he's never turned me down. Yeah, I don't think they're looking at that. He's like, do you have a vagina?

Yeah. Get away. So that just don't worry about it is the best answer. Best answer. Naomi Watts, this tells a really cute story. The first time is she and her husband were like getting intimate. And she had the patch and she snuck. She was so embarrassed because she had early menopause. She snuck off to the bathroom. She's trying to scrub at the thing to get the, she's like dying and he's knocking on the door. Hey, everything okay. So she comes out and she's like, I'm in menopause and I have this patch. And he's like, bring. it. I don't care. The first date I went on with my husband. It wasn't a day, but we met. He was like, let's go get a drink. And I had those jelly boobs on because I was not expecting to meet anyone I would make out with that night. And I remember in my car, like ripping off the jelly boobs just in case. Like, there's all kinds of things that we stick to ourselves despite our age. Yeah. I remember a friend of mine in New Orleans, like throwing hers off the balcony. Like, like, they were like getting hot and heavy. And she, like, snuck out to the balcony. It was, like, throwing her sticky boobs on.

Don't worry about it. Don't worry about it. Okay. So back to sticky estrogen patches versus pills and micronized transdermal androgens and madroxy progesterone acetate versus progesterone pills. I know where you're thinking, do you take them or no? It depends on who you ask and what year it is. Just a heads up. Writing and researching this aside has given me actual nightmares. I've had bad dreams because of it because the information has gone back and forth so much through history and that's led to a lot of fear and misinformation because of that. But you need to know, listeners and patrons, Christine Hurley, Gwendolyn, Faith Stemler, Zander Helms, Jennifer Apria, Caro Young, Bojang, Bugami, Rachel, Sarah Vanderclet and her mom's yeated uterus, Rose McArthurin, Ninja Squirrel, who in their words asked, please address the change. in stance on hormone replacement therapy. Is there new research that has changed the conversation? Boy, howdy, is there. So in a bit, we're going to talk at length on the latest on blood clotting and the fears around that and which hormonal medications pose no extra risk. But Fiona's mom, Emma Porter, Eolfi Holmes, Jennifer Apria, Caitlin Alice, fucking Pez dispenser, Susie Q, Lisa, and in D's words,

any links, increased, decreased risk of things like cancers, etc. So many questions. Okay. So not taking hormone therapy puts you at risk for sleep disturbances, which cause cognitive struggles, harder mood fluctuations, hot flashes, shivering episodes after the hot flashes, joint issues, inflammation, bone fractures, which can prove to be fatal, more later on that, and cardiovascular risks, more later, as well as painful sex and a bunch of other symptoms that we outlined in part one, but you know that because you started there. Now, as for the risks of hormonal therapy, again, we're going to talk about thrombosis and blood clots later. There's good news on that, but let's talk cancer risks. So menopause hormonal therapy has been around since

the early 1940s, but the dosages and the actual formulas have changed a ton. Now, in the 1970s, disco era, studies found an increase in endometrial cancer in patients who were taking estrogen for menopausal symptoms, but we know now, as we mentioned before, that unopposed estrogen, that is without progesterone, is a risk factor in developing muterine cancer. You just ask, my womb, which has been incinerated in a furnace somewhere outside of my body. So, yes, those studies didn't have progesterone. It was unopposed estrogen leading to higher endometrial cancer. Now we know you got to take the prochees. So there's one source of flimflam busted. And then the year 2002, a report came out titled risks and benefits of estrogen plus

progestin and healthy postmenopausal women principal results from the Women's Health Initiative, randomized controlled trial. This threw a real wrench in the info machine. It looked at 16,000 people aged 50 to 79 in the early 1990s receiving horse estrogen and medroxybrogesterone acetate, two medications which are typically not the first choice of modern clinicians. And the hormones were initiated at the average age of 63, so beyond the age of perimenopause symptoms, which have shown to be more distressing than menopause itself. So this, Women's Health Initiative study, the main outcome measures the study reported were coronary heart disease and invasive breast cancer. So after this report came out in 2002 on these treatments that were

available in the early 1990s, the use of hormonal therapy dropped by 50%. Now, fast forward to 26, and let's look at the paper, menopausal hormone therapy and long-term mortality, nationwide register-based cohort study, and that looked at records of nearly 9,000. 900,000 Danish people assigned female at birth and in the end did not find menopausal hormone therapy was associated with increased mortality. So a lot of the fears of hormonal therapy for menopause and perimenopause are based on older studies that used hormonal medications that are not favored these days. But there are some risks though. Like if you've already reached menopause and it's been a decade since menopause, you can have an increase in heart disease. Some studies have

concluded if you start hormone replacement therapy then. And a 2023 study in the journal Breast Care titled Menopausal hormone therapy and the breast notes that hormone replacement therapy can lead to little or no increase in breast cancer risk. If you have already had it, hormone therapy is contraindicated, but if non-hormonal therapies have failed, then you can weigh the risk and the benefits to it. So in all, a lot of studies that report cancer risks came from an era before we knew to pair. estrogen with progesterone for people who still have a uterus. And also, these were trials involving oral and equine estrogen and medroxyprogesterone acetate and HRT started much later. So HRT started earlier, poses much lower risks. And if you have had breast cancer already, it's an individual

decision you can make with your doctor. But yes, that 2026 Danish study is one of the latest, and it found again that menopausal hormone therapy was not associated with increased mortality. So That's great news. How long to stay on it, though? We're going to get there. What does Dr. Christmas think? You know, the reality is this, that if you are under the age of 60, you are within 10 years of the onset of menopause and the vast majority of people, hormone therapy is going to be a safe and highly effective treatment option for managing certain symptoms. In older individuals, meaning individuals over the age of 60 or more than 10 years from the onset of menopause, the risk are actually higher. So when you ask me, how long am I putting you on hormone therapy to be on forever?

Not necessarily. I really want to put you on it when you're most symptomatic, right? And so people are going to be most symptomatic around the onset in those first few years after the final menstrual period. It's why it used to be kind of routine practice to treat somebody for five years. And then we would yank their hormone therapy away. That was, pretty ambiguous. I don't yank it out of anybody's hands. Even if they're 60 or 65, what I'd like to do is just have a conversation about what are the risk and benefits? Do you still need to be on it? Some people do. There's a small percentage of people that will always have their hot flashes. There's about 10% in the population, maybe 15%. And so for those individuals that are older and still

having bothersome hot flashes and night sweats, they may feel like their quality of life is better and they're willing to incur the risk that they might have. I try to get them on the lowest possible dose, and then we have the conversation again every year. And I'm going to knock on my fake wood desk here, though, but, you know, God forbid they were to have a risk factor or develop a breast cancer or something like that, then they all know that I'm going to come off of it then.

And then there are other people that say, you're going to have to pry this from my cold dead hands. And so I don't like to fight, so I don't want to pry it from anybody's hands. As for stopping it, it's really up to you and your doctor, Chicken Hawk and Jennifer Appria. So there is not a set limit on when to stop HRT, but if you don't need it any longer for menopausal symptoms, you can consider discontinuing it and then using vaginal estrogen for localized symptoms.

So yes, the risks in HRT have been found to be much lower for the general population going through paramenopause and menopause, but it also varies demographically. For example, black women are statistically more likely to enter into paraminopause earlier than white people. Their symptoms tend to last longer. And Dr. Christmas found via her 2022 menopause journal study, menopause hormone therapy and complementary alternative medicine, quality of life and racial ethnic differences, the study of women's health across the nation, that some studies have shown black women are given hormone therapy prescriptions for managing their menaceous. symptoms at a lower frequency than white women. As she explained in a UChicago medicine report,

and she continues, some of that may also be due to medical comorbidities, but some of it may also be related to unconscious racial biases, she writes, where physicians don't think that black women's symptoms are serious or uncomfortable. And given the staggering rates of maternal mortality, death and childbirth, for black women in the U.S., which is three times the rate of white patients, which can't be explained by access to care or socioeconomic status. There is a well-documented history of racial biases in healthcare, especially where women's and reproductive care is concerned. And via that 2022 study, she found that most of the non-white women in the study really preferred

integrative complementary alternative medicine or things like lifestyle modifications over prescription therapy for managing their symptoms, and that clinicians should be aware of racial and ethnic differences in treatment preferences when counseling, patients on treatment options for menopausal symptoms to provide the best care, she says. So what could those complementary alternative medicine and lifestyle changes look like? Well, there are some non-hormonal options we're going to talk about in a bit, but there are antidepressants, cognitive behavioral and talk therapy. Those can both help manage emotional regulation. And the Journal of Evidence-Based Alternative Medicine's 2019 report, complementary and alternative medicine for menopause, found that

mind and body practices like meditation and yoga may be a benefit in reducing stress and the bothersomeness, it says, of some menopausal symptoms. Now, what about some herbal remedies? So Black Cohash root, this meta-analysis says that among the studies included, there was no significant difference between the intervention and placebo. But Black Cohash plus St. John's Ward reduced scores on the metapause rating scale by 50% compared to 19% in the placebo. However, St. John's Wart can have contraindications, especially with antidepressants, so do not take that without talking to a pharmacist or a doctor. But as for other herbal remedies, this study listed a bunch. It looked at a lot of data, gave us a lowdown. So, wild yams, more research is needed. Don Quai. Difficult to determine in the two trials due to the use of combined preparations. Maka. More data are needed. Pollin extract. More studies are needed. Evening primrose oil. There is not enough evidence. to support the use of it for menopausal symptoms at this time. Phytoestrogens, more randomized controlled trials are needed.

Vitamin E. Insufficient amount of empirical evidence for menopausal symptoms. There's a saffron extract, which, when administered for 12 weeks, at a dose of 14 milligrams twice a week, was associated with greater improvements in psychological symptoms of menopause, but that study was being funded by a biotech company. And a 2021 study out of India and the Journal of Midlife Health found that Siberian rhubarb, which from what I understand is not actually rhubarb, but it's called that. A compound derived from that

was well tolerated and was found to be efficacious and safe in alleviating menopausal symptoms in Indian paramenopausal women. But in a meta-analysis, yes, more research is needed, and I can tell you, there's going to be less funding for plants and indigenous medicines than there is for proprietary pharma formulas. So what I'm saying is not enough evidence. That doesn't mean that they may not be working, we just haven't spent the money to get the data on it. So for patrons, Kara Young, Minnie Minnie, AOLFI Holmes, Jen, Squirrel, and Kristen, mind-body practices, try those, listen to the Dolorology episode on Pain with Dr. Rachel Zoffness about how physical pain is biological, psychological, and social, which may help. Dr. Zoffness also has a new book called Tell Me Where

It Harts. I should also note that there are over-the-counter formulations just for your intimate parts. and I'm proud to say that one pioneer in this skin care field is none other than my mother-in-law, Christine Mason, who started the company Rosebud Women. It's wonderful. It feels great. It smells great. If you must know, I use it all the time. It's been featured in Vanity Fair and Cosmo and Allure and Vogue, so it's quite legit. Written up and adored all over the world. And I just talked to my brother-in-law, Kyle, also works for Rosebud Woman. And he said, you know what? Use the code ologies if people want. get 15% off. Look at that.

A discount for y'all. So rosebuddwoman.com. These are codologies. Family business. And I'm so proud of my mother-in-law, Christine, for pioneering that field. It's been called La Mare for down there. But don't start taking a bunch of herbs and such without consulting a health care practitioner. Thank you so much.

And if it was as easy as giving everybody a patch and a pill of prometrium, then, you know, I would, first, I could see a lot more patients and I wouldn't run two hours behind in clinic. It's not that easy at all. It's very nuanced. And some people don't respond well to that. Maybe they have skin sensitivity. The patch doesn't stay on. They don't absorb it well through their skin. They need a pill. I mean, there's so many different things. Some people just, they have every side effect that you can get from hormone therapy. If they're going to have some breast tenderness and they might even have a little bloating or breast enlargement being on hormone therapy, especially initially, well, that's going to scare them. That's making your anxiety go through the roof. Let's try one of the newer NK3 receptor, neurokyn B receptor antagonists that work really well.

You know, for some people, that's going to be the option. Let us read from the 2004 book, The Rat Nervous System, third edition. The neurokinen 3 receptor is the tachykinin receptor that binds NKB with the highest affinity among the known tachykinins. Internalization of NK3R in the superoptic nucleus was observed after injection of an NK3 agonist implying receptor activation. And when I read that, I was like, holy shit, bitch, what? So I mozied over to the 2003 article, Neurokine 3 receptor antagonists for menopausal

vasomotor symptoms and appraisal in the journal Cell Reports Medicine, which explained, like a semi-human, that during the menopause transition and in the years following menopause, VMS, those are vasomotor symptoms like cough flashes, affect about 80% of women. And for some, they can be extremely bothersome. of long duration and can negatively impact quality of life, they say. And remember, we talked last week about how that can seriously impact sleep and thus brain fog. And it continues, these symptoms are attributed to the narrowing of the hypothalmic thermoneutral zone triggered by essentially declining estrogen levels. And the central nervous system network activates the NK3R. So a medication

that acts as a neurotokinin-3 receptor antagonist can help you out with that without the estrogen. And that stuff is a daily medication, Fioza, I believe it's called, or Fezolinitant, which is non-hormonal. It's approved in the U.S. and over 40 other countries, it's been approved since 2023. So if you can't be on hormones, those NK3R antagonists could still change your whole life. Some people will say I've got really bad joint pain and I'm not sleeping good. and I have some hot flashes and night sweats and I'm thinking, oh, well, we'll try one of the neurologic agents because they've been shown to help. Some people may have leakage of urine and they have hot flashes and nights sweats. Well, there's a medication that has shown to reduce your hot flashes

and nights sweats by 70%. It's not a hormone. It's a medicine to treat overactive bladder. That might be beneficial for them. Some people need a combination of things, right? I did really well with my hormone therapy. My hot flashes and nights sweats are gone. I might even be sleeping a little bit better, but my mood swings are still horrible, then we need to add an antidepressant to the regimen, too. You know, some people, it's like they'll start to talk and I'll say, oh my gosh, you have a ton of things going on. We need you to see somebody. You've got to talk therapy, right? Sometimes if you're having bad vaginal dryness, we got to deal with that. That's why you don't want to have sex. Your libido's fine. It just hurts. Nobody wants to engage in something that hurts. So it becomes

very nuanced and really understanding, particularly what somebody's going through. through and then we can kind of work backwards from there. And again, there are other non-hormonal vaginal lubricants. There's the antidepressant Symbolta or some SNRIs are prescribed for hormonal symptoms. Gabapentin may work for sleep disturbances. Paroxetine or Paxil can treat hot flashes. So there are some options if you're a breast, uterine, or ovarian cancer survivor, and or concerned about hormonal therapies.

And there are also selective estrogen receptor modulators, which can help menopausal symptoms, and they may help prevent certain types of breast cancer, Dr. Christmas says. But yeah, when it comes to taking estrogen hormonal therapy, if you have a uterus, remember to pair it with progesterone. Or, you know. So, you know, I'm a surgeon, too, so I'm all for just taking the uterus out. But it makes it so much easier. I'm like, it really does. Oh, my goodness. As soon as somebody says they had a hysterectomy, it's like, tell me about it now we're just going to talk about how i'm going to give you estrogen i can give it to you as a vaginal ring i can give it to you as a gel it's a spray as a pills you know we can go on and on and so you know that makes it a little bit easier so as you see there's lots of different formulations it's very nuanced

i tell people to be patient with me i might not get it right the first time but don't don't be discouraged we'll continue to tweak things and change things And sometimes I get real excited about an option. If you don't think it's as nifty as I thought it was, we'll change it. Change it. Some things, sadly, you can't change, like medical menopause, which can happen literally overnight if you've had your ovaries removed, which is like, hey, it's me. Or from cancer treatments like chemo and radiation. So for listeners who ask like Atticus Atlas, Jay, Lindsay Mixer, Melissa Berger, Becca, Anna Ward,

Luzzi Martinez, and potential uterus youanker, McKenzie Frickez, Christine Hurley and Stacey, first-time question asker, who wrote, just return from the gyno, and she's recommending a full hysterectomy. I'm so scared of going straight into menopause. Any info slash experience sharing would put my anxious-minded ease. So again, Stacey had my uterus and ovaries bribed in 2024. I'll link my field trip episode about it in the show notes. But yeah, with ovaries removed, one would experience all of the usual paramenopause and menopausal

symptoms, but harder and faster. And if it happens much earlier than the usual onset age, then you're probably going to need hormonal replacement therapy to make sure that your risks for bone loss and other downstream effects don't crop up. Oh, and maybe regular therapy, regular mental therapy. Dr. B.J. Rimmel at Cedar Sinai writes that with medical menopause, the sudden and dramatic drop in estrogen often triggers more severe symptoms than the gradual decline that happens with natural menopause. And that for younger women entering menopause prematurely, symptoms can be especially distressing. So if you're feeling like you need therapy, I'm there with you. Even just doing this episode makes me want to get back

into therapy right now. But yes, ask about replacing those hormones, if possible. Unless that's not the goal, you may not want to replace those hormones. Trans men and assigned female at birth, non-binary friends, enter the chat if you're not here already. I hope you happen. But Jen McIllivray, Mel Bryan, Karen H, Max G, Dr. Wider, all want to know what's the deal with our paws. How, when, what, why in Dr. Wider's words. A lot of people were curious about this. Zing, Jasper C, Mouse Paxton, Baz Pugmire, Nick Ryder, R. Victor, Ray Press, Matt Thompson, Ricky G, Maddox, all wondering this, Atlas, say them, Aaron Grassie. So the good news is there is research on this and a 2026 paper in the Journal of Obstetrics and Gynecology Canada titled

the non-sistgender experience of menstruation and menopause, acknowledges that while hormone therapy for menopause is widely discussed, it receives insufficient attention in the context of the lived experiences of gender diverse individuals. And it continues that there's no agreed upon menopause definition for trans men or non-binary persons, because those taking testosterone into older age may not experience any physical symptoms of menopause because testosterone typically overrides endogenous estrogen production. So symptoms may be more likely experienced when starting on testosterone. Frequently, it writes, experiencing vaginal atrophy and associated dryness, pain during penetration, and bleeding.

And the paper explains that like menopause, those effects of dropping estrogen can be treated with vaginal estrogen, but there are no studies on how that affects the urinary tract health. Now, if you are trans mask or non-binary, but assigned female at birth, but didn't take testosterone, then, yep, you just get garden variety menopause in your future. And the paper notes that taking estrogen for that may evoke mixed opinions and potentially gender dysphoria. Now, what about trans women, those assigned male at birth? So this paper's got it all, which is why I love it. It notes that as trans women reach the age of traditional menopause, some may choose to continue,

reduce or discontinue their estrogen gender-affirming hormone therapy. And the rationale, it writes, behind dose reduction and cessation is to mitigate the risk of estrogen-related comorbidities with age, like cardiovascular disease or hyperlipidemia. And if that estrogen is discontinued, their symptoms could potentially replicate menopause as the estrogen drops. And the researchers surveyed support groups, and they found that some trans women did expect a hormone reduction. and menopause-like transition in midlife, whereas others expressed in irrelevance of menopause due to their biological differences from cis women. And very lovingly, I like to think, the paper concludes that quality of life is significantly

improved in trans men and women who continue gender-affirming hormonal therapy into old age, even more so than in younger persons, it says. So there you go. And also, if you are listening and you're an LGBTQ scientist, this is why you are so important. in the room and in the field because people who ask these questions get the answers that others need. Now, I wish all of us smooth hormonal transitions no matter which direction we're heading, at which point in life. And we are headed right now for a little sponsor break in this behemoth episode because we have sponsors of the show. And they enable us to donate to not one but three ologists' causes of choice this week.

As we chatted about last week, they're going to go to the Center for Food Equity in Medicine. in honor of Dr. Monica Christmas, to St. Jude's Children's Hospital at the behest of Dr. Marie-Claher and for Dr. Sarah Wukowski, who you'll meet after the break, we're donating to the Menopause Society at menopause.org,

and that is a non-profit, empowering health care professionals by providing them with tools and resources to improve women's health during menopause and beyond. Also, apparently the Menopause Society is headquartered in Cleveland on a street called Sugarin Boulevard. and I can think of no punchline sweeter.

But yes, all of those will be linked in the show notes. You can find out more about them. And thanks to sponsors of ologies who make those donations possible. Okay, in a moment, we'll dig down to your bones. But first, a few of your ears were burning and itching, actually. Tina McIntosh, Jennifer Grogan, Alyssa Van Dyke, bulky Kibbles, J. Fox Club, Jamie, Susan Gare, Alice Rubin, Eileen, and Peter Stofel. Meta Acton, Julia loves fun facts, Aaron Morelli,

Elriv, Diana Teeter, and Ted and Annette Fleming, first-time question askers, they asked, for the love of the flying spaghetti monster, how do I get my ears to stop itching? So from my research, I happen upon the frontiers and allergy paper, itch beyond the skin, mucosal itch, which explained that a lack of estrogen, especially in menopause, can result in itch due to the deterioration in the epithelial barrier of your skin that protects your sensory nerves and that reduces their threshold for activation. So lower estrogen, dry your skin, the dry skin literally gets on your last nerve, causing that itch. So what you can do is you can gently oil it up a little in there, maybe with coconut oil, or Dr. Haver even recommends some estradile cream outside of the ear

canal and on the lobes. Please don't stick anything in your ears for the love of the drum. But Ologies pod friend, Jen Squirrel Alvarez, also offered up that, by the way, Flonase on a Q-Tip helps. Weird, I know, they say. Again, don't sue us for any advice. Now, in part three, we're going to release this a bonus episode. This weekend, we'll have plenty of tips for people going through menopause, perimenopause. It's also for their support teams. So it's for the friends, the fams, the lovers, the coworkers, the Subway Sandwich artists,

everyone in your life who might need tips on how to support you. So that will be part three this weekend. But for now, please enjoy meeting Dr. Sarah Witkowski, who I had the pleasure of chatting with at Smith College on site earlier this year. And first thing I'll have you do is if you wouldn't mind saying your first and last name, so we say it right and the pronouns you use. Sarah Whitkowski, she, her. She's an exercise physiologist who has been researching female specific conditions such as menopause and how it affects the heart and the bones, which is great because Charlton, Magna Casasca, Wendy Miller, and Stacey Pinkwitz wanted to know about this. Stacey asked, what even is menopause?

And will it make my bones explode into a million pieces and my pussy dry? Well, hmm. And from heart to bones, let's talk about bones. Estrogen and bone loss, osteoporosis, osteopenia, menopause, aging. What is causing that weakening of the skeletal system? Yeah, well, it's definitely the decline in the... estrogen. So it's very dramatic. So right around the final menstrual period, two years prior to the final menstrual period, that bone loss starts to come down really dramatically. And so we know it's

going to happen, right? And I think that's the thing to think about. There are people who are at higher risk, right? People who maybe have lower bone density as a start or lighter stature tend to be at a higher risk for osteoporosis later in life, people who are not as physically active. So you may hear the time to really think about your bone health is before you go through menopause. And the tricky part about that is that oftentimes a bone density scan is the first time a woman really gets one is when they're 65. So it's too late. Yeah. So there's a push to try to get more of these measures earlier in people's hands so that they can do something about it, right? And to do things like weight training is a great way to try to mitigate the decline. We know the decline's going to happen in some way.

Can we change that trajectory? If we can flatten that a little bit more, then I think that's a success. You know, for bone density, you need a T score of minus 2.5 to be in the osteoporosis category. So a T score above negative 1 is normal. low negative one indicates bone loss. Why did they make it confusing numerically? I don't know. Everything else sucks. So why not? Now, I've had my little bone scanned and because of my ovarian mishaps, I have mild bone loss. That's called osteopenia. It's in my spine and my pelvis. And I used to be a runner and a hiker for most of my adulthood, which probably has helped. But I definitely need to get my bones up in the green zone out of the yellow before it gets to the red. And you can ask your doctor

about a bone scan. It's good to establish a baseline if you've lived with low estrogen for a while or to start getting them regularly after 65. So maybe, you know, we know we're going to go down. But if we start higher, perhaps we're not going to drop as much or perhaps if we exercise through the perimenopause, we can mitigate sort of what that trajectory change is. But we need better studies. We need more studies that actually track it over time to say, well, if these behavioral, you know, changes can be made early, does it change the trajectory? We don't have the randomized controlled trials to show that yet. Who is studying this? Well, osteologists, and yes, we cover this with an esteemed professor of anthropology and the director of forensic anthropology at Texas State University. This is a guy

who knows the Skellies. He also runs a body farm in a remote region outside of San Marcos, Texas. scholastic reasons. And yes, they do accept submissions if you are a future corpse. But this biological anthropologist, Dr. Daniel Westcott, looks at human long bone biometrics like femurs to determine activity levels and patterns in past human populations, distant ones and close ones. So let's hear a clip from this episode, which will have you jumping for joy or for something. The main thing about like is that by the time you hit your early to mid-20s, you have the best skeleton you're ever going to have in your life. And thereon is actually kind of lose skeleton over your life.

After 25, what we're looking at is break down the skeleton. After 25? That's so depressing. But what really builds skeleton is activity. Really? Obviously, you have to have an adequate diet. as well because you have to have all those components in it but is activity and is that because you're doing little micro fractures or what's making that bone stronger why how is the impact making

you stronger yeah so you're putting bending forces on it and and your bone basically adapts to where to resist fracturing ah so it adds bone in places that you where you have a lot of stress and if you don't have any stress at all, it will either not build it or remove bone from that place. But keep it active. But keep it active. Keep it active. This is so good to know. And then the same thing even with later in life is that, you know, the way you keep from losing bone and becoming osteoproduct and stuff like that, a lot of that has to do with how active you stay. Just a little info on that, according to the National Osteoporosis Foundation.

So two million bones fracture every year in the U.S. because of osteoporosis. That's so many bones. And osteoporosis just means porous bone. So the structure and the bone becomes weaker because it's less dense and it's more porous. So think of like a pumice stone versus granite. So many hormonal factors and inactivity and medications can cause it. But what about slurpy sippy yum yums, which was asked by Emily Burns. What about if you're drinking soda?

Soda can be terrible for your scalp. They can cause osteoprosis, yeah. Can it really? Is it because it's acidic? Yes, the acids in it. Same with lemon water or no? Lemon water is probably worse on your teeth. Oh, Lord, I looked into this.

And yes, soda may be considered bone-hunting juice. Ow, my bones! And some theories are that this is because the phosphoric acid in colas leeches calcium in order to neutralize it from your bones, while other studies suggest it's the caffeine that's going to fudge your bones up real good. But the main moral of the story is that drinking just plain filtered water is great

and that your bones splintering off after 50 is bad. Speaking of, someone asked about flim flam, some myths to bust. Rachel Weiss says, someone once told me that elderly people's hips will randomly break and then they will fall as opposed to the other way around. Is that a myth?

Is that flim flam? Will the bone break and they fall or do they fall in the bone breaks? No, that's true. So typically what happens is that, so a lot of times people will say, you know, I was getting out of my chair and I fell down and broke my hip. In reality, when you are starting to get up, you're putting a lot of forces, your muscles are putting a lot of force on that bone. And so what will happen a lot of times is the femoral neck will break as they're standing up.

Ouch, out. Ouch, out. causing them to fall. Oh, my God. So that's not flim flam. Right. Any other myths about skeletons that you would want to bust? They can't walk around without muscles.

Good point. Heads up. I love sparkling water. And I have weak bones. I'll see you in hell. Just kidding. I'll get it together. So yes, you need bones and we'll address the muscles in a bit. And according to the April 2025 journal of orthopedics paper inquisitively titled, Who Breaks Their Hip? A decade of

traumatic hip fracture data. Up to 96% of folks who fracture a hip are 65 or older. Women are more likely than males to have a hip fracture. And the chances of dying within a year of that fracture are over 30%. So you get a fractured hip, a third of y'all are going to die. Now, it's threefold higher than in the general population, and it included every major cause of death. So it's tough to say which came first, the break of the fall. The study does point out that the elderly tend to fall from beds and chairs. Middle-ageders tend to break a hip from stair falls, and younger people tend to bust them from so-called high force modalities, which I assume is like trying to jump from a roof in a DIY wingsuit or doing kick flips or death drops. But yes, keep them strong in your youth.

And remember that maintaining your bones, it's an act of independence. It is punk to stay strong. Now, back to Dr. Woodkowski. What is it about estrogen and about impact or weight training or I've heard running something that's sort of jostles you. Does it stimulate osteocytes? Does it prevent something that leeches calcium from the bones? Does it stop from producing or does it take away? Yeah. So bone health is a balance between the laying of bone and the gutting away of bone, right?

So it's actually not a stagnant system. We think of our skeleton is stagnant, but it's actually really dynamic. So yeah, weight-bearing exercise and something where you have some impact tends to be the best kind of exercise to help to, number one, build bone, or to try to mitigate it from decline. There have been studies that have taken people who are 65 years old and put them through exercise training where they're doing drop jumps. And they can actually show a little, even in a 65-year-old, they can even show a little bit of an increase. But just think about what the impact of that would be earlier. Yes. It would probably be greater.

We just don't know for sure. But yes, it's the impact factor, right? It's that it's the pounding. So that's an important consideration because you want to think about the kind of exercises that you're putting in. You know, the recommendations currently are at least two days of week of some muscle strengthening exercise. But you could also think about that. Running is an impact sport, you know, or impact activity. there could be other things that are more impactful on the skeleton, but they're also harder to do.

So we have some great suggestions coming up later in this episode, and I also saw a flamenco dancing performance in Spain a few months back, and it featured a woman in her 60s doing some of the fastest footwork and the angriest stomping I have ever witnessed. And with a face that said, don't even try it, Bucco. And in looking up the bone density of flamenco dancers, it's good. I found that during this research, flamencology very much a real word, a real field of study. And so, yeah, I did hunt down a flamancologist and I recorded an episode with a third generation flamenco scholar. So stay tuned for that. Now back to Dr. Haver and why you need to start building a strong body while you're young or even start if you are less young. I really appreciate her candor

about this because it's something that a lot of femme people and mask have struggled with. So our bones and our muscles are constantly turning over, meaning we're chewing up the old stuff and we're laying down new behind. So think of it like Pac-Mans. We have osteoblasts and osteoplasts in our bones, and it is a normal process that up until about 25, we have a net gain of bone,

and then it stabilizes, and then with age, we see it start to decline. So I worry about all these young girls dieting to be thin, and they're not reaching their peak bone mass, and then what are we, you know, now we have an epidemic of a lot of, osteoporosis because we told these kids to diet. Yeah.

Anyway, so I digress. So this process of laying down new bone is highly dependent on estrogen levels in women. And so when we lose estrogen, so the most rapid rate of bone loss begins in perimenopause, three to four years before your period stops. Oh, God. Yeah. And so we're chewing up bone, but we're not laying it down as fast. So by stabilizing that, giving her estrogen, you know, no one studied this yet, like,

how much bone loss can we prevent in perimenopause by getting her on an estrogen patch, low-dose estrogen patch, you know, through that transition. So then, you know, we reach a critical threshold, you know, not everyone with osteoporosis fractures. So 50% of us will, though. 50% of us. Me or you? Who's it going to be? We'll have fractures. It's going to have an osteoporotic fracture before we die. It's going to be me. It's going to be me because I have osteopenia and my goddamn pelvis. Yeah. So I better hit the weights. Yeah. So what can we do? Okay, so we have lots of interventions at work here.

We do have pharmaceuticals. They're kind of fraught with side effects, but we do have some. I don't want to negate them. Okay. Prevention is the best thing here. How do we prevent bone loss? How do we build back? You can build bone at any age. You include it, okay? FDA approved for the prevention of osteoporosis, menopause hormone therapy containing estrogen. Okay? Done. Number two, resistance training. That pull on the muscle and bone, that resistance. So the Liftmore trial was done in Australia, and they took osteopenic, osteoporotic women older, okay? Put them through a series of exercises for, I think, nine months.

And it was like jumping up to a chin up and then dropping. So you have that impact. They were doing squats, lunges, you know, a series of exercises, very reasonable like three times a week. saw great improvements in their bone density just by doing that. Eating enough protein to make sure that you can grow muscle or hang on to your muscle. Number two, making sure you have adequate dietary calcium, not calcium supplements. Calcium supplements have never been shown to decrease the risk of a fracture. All these things add up jumping.

So the way it was explained to me in, you know, the bones have holes in them, right? They're not solid. They have these little cells in them. And so there's fluid in those cells. And so when you jump, you cause, and it has to be eight inches or three times your body weight. So jumping rope, jumping off at eight inch stare, whatever, three times a week for 10 minutes. That works. Wow.

All of that sends a signal to lay down more bone. You have to keep talking to your bones. Hoof. I'm listening. Hang on. We got studies. For example, the 2023 paper, the role of high intensity and high impact exercises in improving bone health in post-menopausal women, a systematic review, which looked at

a multitude of studies about physical activity and bone strength and found that aquatic aerobics use the resistance of the water, and that helps bone and muscle strength. Arobic and step aerobic, multi-directional jumping exercises, those all resulted in a substantial rise in bone mineral density. And across the board, high intensity resistance and impact training was effective at laying down stronger bones. Now, high impact examples might be jumping rope, running, walking briskly, burpees, etc. High intensity resistance training might look like squats with weights and deadlifts and kettlebells. However, they said these exercises were found to be safe and older women, but careful supervision is recommended.

So again, talk to a doctor if you can before taking on a whole new exercise routine. And if you're at a high risk for fracture, start small with light hops and you can even hang on to something stable and hop in place. that helps. Now, while you're jumping through hoops for your health, keep an eye on the vitamin D. Now, according to the 2023 paper, the role of vitamin D in menopausal women's health and the journal Frontiers in Physiology, up to 80% of postmenopausal people are deficient in vitamin D, which is important for mineral metabolism and bone density. Now, vitamin D supplements are recommended by a lot of doctors, but try to get calcium from your diet, like leafy greens and canned fish with soft bones that you're crunching. Dairy, those are all good sources. Now, Dr. Christmas backs this

up saying that being intentional about what you choose to fuel your body with, like a Mediterranean style diet with a lot of veggies, whole grains, omega-3s, olive oil and fish, less meat, less sugar, that is better for your whole body all along. And also, if you're worried about skin, that drink some water, that's worth a lot of dollars because there's just no substitute for eating right and moving your body. I'm sorry, folks, if you don't want to hear that. I know. Okay. When it comes to nutrition and bones, too, do you anticipate seeing any downstream effects from GLP-1s? Yes. Watching the latest award shows, abs of fucking looting. I'm scared to death for these women. Oh, fuck, man. I'm just going to be honest. And look, and parties in the town I live in right now.

I'm just like, what are you doing? And I'm a doctor who prescribes them. But I'm so mean. I'm like, Get on the body scanner. We're measuring your muscle mass. You know, this is non-negotiable. It's a powerful tool. I love them. I love them for my patients. It is changing their lives.

But it's the scariest thing I've seen because the kids are watching and seeing this extreme thinness in these women. Not the men. Yeah. Nope. No. And I live through the grunge era. I live through heroin chic and through the great famine of Lindsay Lohan, 2005. and this is feeling worse.

I just blink and I'm like at what cost to be thin. You know, this is thinness. This is not health. This is not health. I love GLP ones. I love the GLP one. But, you know, it's a tool in your toolkit. So we are counseling heavily on nutrition, on exercise.

We're telling them, don't worry about the scale. We don't care what you weigh. bones and muscles need to weigh a fucking lot. You want to gain weight in your bones and muscles. Let's work on that. Make that your priority. Stop trying to look like a 17-year-old. You know, the male gaze has, like, tricked us into, like, we need to look like we're

prepubescent. I'm like, what the fuck? Like, I'm a woman. I have stretch marks. I have, I'm naturally thin. I get out of thin privilege. But, you know, I don't look 17. I've born children on purpose.

And yes, we have an evolutionary anthropology episode all about how human metabolism works with Professor of Evolutionary Anthropology and Metabolism Researcher Dr. Herman Ponsor. And in a minute, we'll cover how menopause affects cardiovascular health and how to make sure your ticker is sticking well. But we do need an episode on JLPO-1 receptor agonists, which of course do not use if a doctor would not prescribe it. See your actual primary care doc, check in with them to see if it's right for you. For some people, it might be just where the doctor ordered.

And many patrons ask questions addressing body composition, like more adipose tissue, settling in the midsection, and other muscular changes during menopause and paramedopause. Like a guy called Shane, Jill Watt, J.B., Donna and Eric Easton, Donna, Brittany Corrigan, Taylor Clinton, Catherine Aldrich, as well as... Hi, Ali. This is Vanessa Petino from Riverside, California. and I want to start out by saying that I absolutely love your show. My question is, what is the deal with the persistent belly fat or I think it's called visceral

fat that women get when we start menopause? I cannot get rid of this damn thing. I work out every day. I eat healthy. And I'm curious as to the cause. Why does that happen? It's so weird. So let's get your body composition.

How much muscle do you have? How much fat? Where is the fat? So if the fat is intra-abdominal, visceral, okay, that is a biologic marker for risk of cardiovascular disease, diabetes, and stroke. We need to get that down. What do we know works? Higher fiber, higher protein, resistance training, and cardio, stress reduction, prioritizing sleep, community, all of that works together. It is a toolkit and a GOP one if you need it. But that is the last tool in our toolkit. Oh, and hormone therapy. And hormone therapy, of course. Do you have people get like a Dexas scam ahead of time?

So especially if they're high risk. Like if they're coming in and they have low muscle mass, we're going to document that you're sarcopenic so that your bone density will be paid for. But I really encourage patients to let's get that baseline before we start your GLP1, because we need to know what we're working with here. And if you're like many listeners, including Rachel, vegan eater and protein talk, exasperated Evelyn Carlson and first time question ask her Bellboy, whose mom is following the Galveston plan but wondered if it's just another, quote, weird mom diet. I can tell you that the

Galveston diet is specifically geared toward people going through menopause, and it focuses on intermittent fasting with an eight-hour window for eating, low-carb and higher fat foods, and some anti-inflammatory diet strategies. Now, the creator says that inflammation rises, especially with decreasing estrogen levels in perimenopause and menopausal inflammation often hides, they say, behind vague symptoms like fatigue and mood swings and abdominal weight gain. So this eating plan is geared to help with that. And the doctor who designed it is Dr. Marie Claire Haver. So there you go. And a lot of resources for the Galveston diet are free online or we can link her book in the show notes. So you can definitely read up on that because it's geared toward people going through menopause. But again,

Mediterranean diet, also good according to doctors, best doctor to ask is your own. Now, as for protein levels, according to a 2024 Harvard Health article titled Muscle Loss and Protein Needs in Older Adults, Losing muscle as you age has a name. You can call it sarcopenia and it can up your chances of frailty, disability, loss of independence, and even death. So yeah, sarcopenia, we don't like it. So you need to build muscle. Yes, me and possibly you. And if you want to build muscle, you have to lift some heavy stuff or you have to use your body as a weight or you have to resist gravity and physics. And you need protein to build the muscle.

Now, you also need it to help repair tissues to have a good functioning immune system and to keep your skin looking springy. And a 2019 paper low dietary protein intakes and associated dietary patterns and, functional limitations in an aging population. In the journal of nutrition, health, and aging, found that up to 46% of the oldest adults are not meeting protein intake recommendation. And this Harvard Health piece says to aim for 0.5 to 0.75 grams per pound of body weight per day. So a 165 pound adult, it advises needs about 90 to 120 grams of protein per day. And be sure to eat some after a weightlifting workout so your body. has some raw materials with which to get jacked. But no, do not embark on an all-protein diet.

Some doctors advise higher at one gram per pound of body weight, while others say any more than that for people with chronic kidney disease could carry risks. And of course, against your doctor before you start any major dietary changes. Getting blood work, always good for a baseline. But aiming for some protein with every meal will help stabilize your blood sugar can keep you fuller, longer, which keeps you from grabbing some sugar as a snack and is also good for building lean muscle mass. But again, it's not about how you're looking in a body con dress. It's about the whole body and it's what's on the inside that matters, such as your bloody beating heart, which is also a muscle.

Now, Bobby, Megan Pecan, Polymoldroon, and Riley Shea all asked in Riley's words, I've read recently that menopause massively increases risk of heart disease and strokes. Is there any truth to this? And yes, we have episodes on cardiology with Dr. Herman Taylor and on veins and arteries with surgical angiologist Dr. Sheila Blumberg. We have that metabolism episode. But menopause and cardiovascular issues, that is Dr. Witkowski's lifeblood, if you will. My lab and my career has been all about cardiovascular disease risk.

And it has been shown, both by us and others, that this. there is a relationship between the amount of hot flashes, somebody has the objectively measured hot flashes that somebody has, and their risk for cardiovascular disease. Wow. And that really has been what we are trying to understand. And as a physical activity person, a physiologist who works on this stuff, I really wanted to know, well, can physical activity mitigate

that relationship. And with the objective monitoring, we have been able to show that, yes, but in people who are more highly active, they're doing more physical activity that's moderate to vigorous, that relationship goes away compared to those people who are on the lower side of the spectrum. And this is important for our participants to say, look, you are still getting a benefit by doing more moderate to vigorous physical activity for your cardio. cardiovascular health, right? The hot flashes aren't the thing that, you know, people die from, but that people do die from cardiovascular disease. So that's a really important message. And pardon the pun, but does it ever boil your blood that the risk of cardiovascular death in women in

particular is so misunderstood. And so not on a lot of people's radar. I feel like in general, cardiovascular disease is such a killer, but we don't seem to focus on it, especially with women. A lot of times it seems like people who were assigned female at birth were not included in a lot of studies. I think, yes, there's been a big under-representation of women. I think we're starting to turn the ship a little bit on that one. But in terms of cardiovascular disease in general, the awareness, like you're saying, it is the number of killer of women, but most people aren't aware that it is. Yeah. And I think that part of it could be because you don't feel it. It's something that's happening over a long period of time. It's not like a hot flesh, right?

Yeah, yeah. It's the complete opposite of that where you don't have some sort of definitive event that you feel, right? If you have increasing blood pressure, you're like, well, you know, it's going up a little bit. Maybe it's because I'm nervous in the doctor's office. There's a lot of ways to explain things away. And that's why I think trying to get as much early information into the hands of women is important making sure that they are getting their cholesterol checked. You know, they are getting their fasting glucose and their blood pressure checked. And, you know, not sort of taking a reading that is a little bit high and saying, oh, well, maybe I just have white coat hypertension. Or I just, you know, just because I'm nervous. I feel like if you're nervous in the

doctor's office, understandable, but also what about traffic? What about reading the news? What about, you know, finances? There's a lot of things that would make us, maybe that are stress factors on our cardiovascular health, I imagine. Yeah, well, that's a really important point that you make because, you know, menopause and the time of midlife is such an important and vulnerable period because, you know, perhaps the children are still at home and perhaps your parents are aging and perhaps you're trying to manage all the things that you need to and get the groceries and put the, there's so much to be managed and that so much that is stressed. And I think women in general have this outlook to look at other people's health before they look at their own. Yeah. So again, awareness is important.

I love bringing awareness to people. It needs to happen more. So yeah, for sure. I get it. I don't even have kids. I just have a podcast and it is hard to set aside the time and the energy to work out, but we got stuff. So Dr. Wutkowski gives you a plan and advice to get you started in a minute, but McNuckles asked, oh, going into menopause, perimenopause, my cholesterol has gone up. Why? Why? And yes, one 2008 paper titled Menopause, cholesterol, and cardiovascular disease in the U.S. cardiology review notes that more women die from heart disease and stroke than from the next five causes of death combined, including breast cancer. But, Compared with men, women are less likely to be offered interventions, are less likely to be represented in clinical trials, and have a worse prognosis.

Why am I not surprised? But hormonal shifts do impact cholesterol. What do you do? What kind of cholesterol numbers or elevations should people maybe take a second look at if they get their blood work back? That's a really great question. There's some really new data out there suggesting that. and even the American Heart Association right now is saying, you know, when we look at our LDL cholesterol, that's the low-density lipoprotein cholesterol or the bad cholesterol that people like to call it,

instead of having a minimum criteria, they are now saying lower is better. And that's a real different sort of message, right? Because if you're in that green zone, oh, I'm under a certain level, I'm good, you know. But it really is the LDL, the low-density lipoprotein cholesterol that can get into the blood vessel walls and start the process of atherosclerosis. So lower is better. Okay. Cool. On the other hand, when we look at the HDL cholesterol, the high density lipoprotein cholesterol, those are your good cholesterol, what people have said in the past. They're the housekeepers. They're the things that come around. They pull in those LDL particles. They pull in

sort of the bad parts of the cholesterol that you're getting in your diet, and they're taking them back to the liver and processing them. So they're your housekeepers. So you want a lot of them around. But some recent data suggests that the functionality of those HDL particles drops during menopause. So you may have a higher number of those things around a lot more housekeepers on, but they're not doing the job that they used to. So the blood vessels are really sort of the place where we're looking here. And yeah, so they are very responsive to estrogen. It's used to a certain pattern. It's used to fluctuating estrogen.

So we're not 100% sure at this point, but we believe that there is certain remodeling that happens, right? Your blood vessels have to kind of relearn or learn a new normal now. So there's been a lot of news lately on the effects of hormone therapy, primarily estrogen or estrogen and progesterone. So progesterone, if they still have a uterus, they have to have the progestogen. And the question about whether or not that is protective for the cardiovascular system. And the current recommendations still are that from the menopause societies, you know, estrogen is not something to treat cardiovascular disease. So I have an aura ring that just tracks my sleep and things like that. And it keeps mentioning my heart rate variability.

And I'm like, I don't understand what that. means or why it's important. Is that a marker that we should pay attention to? Well, that's a great question. It's getting more press and it's on these devices. So heart rate variability is an interesting outcome measure. And what it is doing is it's looking at the variation between every beat of your heart. So whether or not you feel it, you probably don't. But there are small variations in your heart rate, even if you're just sitting and relaxing, you're not doing very much of anything. And of course, when you get up and move around, there's going to be more variation, right? So the variability between beats is something that is a good thing to have.

It means that your physiology is optimized. You are able to adjust beat by beat, your heart rate is adjusting constantly. To not have that, to have low heart rate variability is a sign that there could be something underlying or something developing. Or it could mean that you're really stressed out. It could mean that you're not sleeping well. It could mean a lot of different things. So in the cardiovascular community, we know that low heart rate variability is kind of a bad sign, right? We don't want low heart rate variability. Luckily, in my world, in the physical activity world, one great thing you can do for your heart rate variability is to exercise. Yeah. And it also improves your sleep quality. And it does, you know, a lot of other things. So yeah, these devices give people

information and you are the second person in just as many weeks to ask me about heart rate variability. And it is an important measure. And again, it's one of these things that we might be able to see on the earlier side. In terms of dramatic happenings, let's quickly address blood clots. Side note, again, we have a whole episode on surgical angiology on veins and arteries, as well as a cardiology and hematology episode on blood. But patrons, Matea Orr, Karen, Haley Rose Jones, and Diana Staracinic Dean asked about hormonal therapy and blood clot risk. And according to a 2025 meta-analysis titled Blood clot risk influenced by hormone therapy administration route and women 50 and over. And remember, this is a 2025 paper. The TLDR from docs nowadays is that

transdermal estrogen, like the patches, the gels, the creams, the rings, etc., does not increase clotting or stroke risk. And that the fears of that have been based on higher dosing, of equine estrogen taken in pill form. Now, when estrogen is dosed orally, what it does is it makes a pit stop in your liver, which then can increase blood clotting factors, and it can lead to, as Dr. Haver wrote on her site, sticky blood. That's when it's in pill form, because again, it hits the liver. Now, the journal Current Opinion in Hematology published a 2010 paper, Risk of Venus thrombosis with oral versus transdermal estrogen therapy among postmenopausal women. And it's summarized it that transdermal estrogens may improve substantially the benefit risk ratio of

postmenopausal hormone therapy and should be considered as a safer option, especially for women at high risk for venous thromboembolism. Now, that was a current opinion in 2010, and it still very much holds that transdermal, meaning not the pill form, being safe is the new standard. But Diana asked, can someone who suffered COVID-induced blood clots even consider HRT? while a 2022 paper in the Journal of Thrombosis and Hemosstasis did note that the management of hormone therapy for people who have had post-COVID clotting illnesses remains unclear. And a 2023 study in the European Journal of Hematology, estrogen-based hormonal therapy and the risk of thrombosis in COVID-19 patients notes that oral estrogen contraceptives and estrogen hormonal therapy are associated

with a significantly increased risk of clotting in COVID-19 patients, especially in older individuals. However, that study again, that was the oral route. So if you've had COVID-19 related blood clots, talk to a doctor, but one who is actually up on recent research. There's new stuff coming out all the time because research can take a while, especially when budgets for it have been recently bulldozed. Now, before my temper flares, once again, let's get some inflammation information. Fans Christensen asked for their mom, who inquired in all caps, all things inflammation. Am I fighting this for the rest of my life? And Marisa Asher's stepmom, Maria wanted to know. Bookbeat, Jay Foxglove, and Jocelyn Vincent all asked about inflammation and joint pain.

And we did cover at length frozen shoulder in part one and how nobody tells you that inflammation can be menopause-related. Now, this was also on the mind of beloved listener. Hi, this is Julie Rose. I am a long time. Does the onset of menopause also affect things like arthritis and joint pain? Because I'm noticing I've got a lot of arthritis pain in my knuckles and in my knees. And I'm wondering what the correlation is there, if anything. Thank you so much. So one of the other main complaints of people who undergo menopause are musculoskeletal complaints, pain, mostly, inflammation. But studies have shown that if we can take somebody who's not exercise training or weight lifting and get them

to weight lifting, their inflammation goes down. So there are many ways through physical activity we can improve the conditions and some of the symptoms around perimenopause. So there are lots of different choices, I think. So that's sort of the thing, right? Physical activity isn't a one-size-fits-all. I think we actually have more flexibility. And I think we need to understand what each person's risk is, what they're coming in with. And then I think that with careful consideration, we could give them the best sort of prescription for what they're exercise. That's my dream, that we could then give them the best prescription based on evidence on what we know to help them navigate the perimenopausal transition. Okay, so we know a lot about the whys, so let's gather some house. And this was on the mind of

Zulika Pevick, Rachel, Haley Rose Jones, wanted to know if weight training should be total body. And Alice Ruben asked, are walking and strength training really the cure all that social media is claiming them to be? How am I supposed to walk? 10K steps, work full time, cook dinner, and keep my house cleaned all at once every single day. I get it and the easy advice from me to me is we do it or we die. We deserve the time it takes to walk and lift some weights in the living room. But I get it. I get it. Now there are plenty of training videos online. There's great ways to go about it. but let's ask Doc Wutkowski what she does. I'm curious, too, you mentioned before we started recording that you live on a farm

with your partner, and you look like you could out, Romney, for sure. Are you lifting bales of hay? Are you out kayaking? Are you a rock climber? I mean, if someone's going to have some advice, I feel like it's good at you. Yeah. My physical activity and my body has changed through time. I used to do a lot more impact.

I was a goalkeeper, so I was. You know, there's a lot of impact. I was more sort of sprinting kind of person. And then as I got older and I got closer to sort of my midlife, I really started to enjoy the running. And I feel like I can do it. I can still do it. I'm going to keep doing it. And part of it is the mental cleansing part of it.

It really, for me, I enjoy it because I get to listen to your podcast while I'm out in the woods running and I get to learn something and, you know, not think about the stressful things in life. or think about my day so that I can organize. It's just for me that is a really important time for me. But I also do strength training exercise at least two days a week. I really, that's how most of us get into my field of exercise physiology is because we like physical activity. Perhaps we played sports. There's something about it that has attracted us. And I think that working with people, I do recognize that most people aren't like me, right?

Most people have a struggle with being physically active. And that's been a great experience for me to sort of learn and think about, well, what kind of science do we need to really show people or to help them understand or to find better prescriptions that they feel like are doable for them and still help them through menopause. That's what motivates me. I think too, culturally, we so pair exercise with aesthetics. And there's something that also probably happens in midlife where you go, fuck you. You know what I mean? Like, I am sick of trying to conform to a certain thing. And I feel like there's not enough emphasis on what we need to do for our mental health

with exercise and activity. And also the inside and that it's not just about bikini. season and such, or revenge bodies. Is there a good way that you feel like you've seen people sort of get into it? Is it like a Zumba class that's fun? Is it something that is meditative, is walking enough if you are going from something sedentary where you're not prioritizing yourself? My advice is that the best physical activity somebody can do is the kind that they're going to stick with. I also believe that there's a lot of power. in group activity. Some people like to be in groups. Other people don't like to be in groups.

But I do see a lot of benefit when people can find others to work out with, hold them accountable, talk about their lives, all at the same time. Right. So I think that those kinds of things are sustainable for people. And I think it can be a very isolating time for women. So I do see a lot of women who come in who are active. And they really like going to the CrossFit gym because there's a community there, right? They really like their running route because, you know, that's their community. And their running group goes and does, you know, 25Ks in a year or whatever. And there's a real big social piece to this for people. But I think in the end, the kind of activity that you're going to stick with is the best kind of activity. I took an early morning walk recently around a

community outdoor track a few weeks ago and in the distance. in a parking lot. I saw a few dozen people doing Zumba. Music was streaming from someone's open trunk. It was beautiful. I almost started crying. Zumba.com, they have a list of such meetups, and it seems incredibly healing. Now, remember, consistency over intensity. You can always work up to things. Tortoise over hair. Pick something you enjoy at a time of day you enjoy doing it. Jarrett, your pod mother, has a term for just starting. He tells himself, Tortoise Sword. Go forth with your efforts brandished. Sustainably is the way.

He made a shirt that says tortoise sword. I will link it in the show notes. Does this help some of those neurochemicals that might be giving you some menopause blues? Well, that's really a great question. So physical activity, people who engage in physical activity around the menopause transitions do benefit. So perimenopause is associated with increases in depression, particularly if you have depression coming into. perimenopause, you have a greater likelihood of a major depressive episode. Low mood is another big complaint for people.

And yes, physical activity can help dopamine, serotonin, these sort of feel-good chemicals that we believe are part of the physical activity. The reward system is there. You feel good once you finished it. And in terms of brain science, I think it makes a lot of sense. And we have evidence in the literature suggesting that it does improve mood. You know, it does decrease depression. If you're already having some mobility challenges, is there anything that you can do from a sitting position that would give you that impact or anything you can do if you're not starting at a baseline of a lot of ability?

Yeah. I think that that's a really great question. And again, I think everybody's situation is going to be different there. You know, what is it they have access to? What is it they can afford? You know, can they not get out of the house? There's physical exercises that you can do without weights, without a fancy gym membership, you know, with nothing, really. And I do a lot of them myself, you know, because I like that idea of body weight exercise. So things like push-ups, burpees, squats, lunges, jumping jacks, jumping rope, etc. Hand weights can go a long way and you can watch one of your programs or listen to a podcast while you do it. Exercise and disability, that is very individual. So if you have balance or mobility concerns, talk to a physical therapist, talk to your doctor first about what's safe for you.

We also have a whole disability sociology episode, and July happens to be Disability Pride Month. So enjoy that one with Dr. Gwen Chambers. We'll link it in the show notes. And if you're needing to get moving more, you can consider trying to do some local errands within walking distance of each other, meet up with a friend for a stroll, take a walk after dinner. You can adopt a rescue pup who will get you outside and around the block a few times a day. You can check online marketplaces or thrift shops for some easy hand weights, abandoned by people who do not yet know how much their bones are begging for it. Starting to lift weights does not mean that you have to wear $200 skin tight leggings in a crop top

and bench press your own weight. And if you're starting from nothing, you can even garden and haul dirt around or grab a few bricks and lift them, but be safe. So, yeah, there are lots of exercises that are sort of friendly for. Maybe you just don't want to be in public because you're fearful of being in public and exercising. Yeah, there are lots of things you can do. Some of our data shows that even people who have more sedentary time have more nighttime

hot flashes. So when we think about a physical activity for that, well, how do we reduce sitting time? That means taking breaks, getting up, you know, if you can, to try to reduce that, having some motion. So, yeah, I think every person could benefit from really, you know, getting to talk to somebody about, like, what are your limitations? What do your likes? What are your dislikes? There's sort of a whole conversation I think needs to happen to try to find the options that are best for people. I feel like if you are looking for research participants, you must have a longer list than you can accommodate as opposed to a lot of other.

other research. People are probably like, please, study me for the benefit of other generations. Yeah, I'll tell you, I mean, that is the biggest thing. We have such a great group of people coming into the lab. They are all willing. They all just say the same thing where, you know, I just want to learn more. I want to help people learn more about this. You know, they appreciate what we're doing. And it's so rewarding. I just really enjoy all the visits. We have to come in early in the morning to get these visits done or on weekends, but it's a pleasure. I really enjoy the work. Is there, you know, last questions I always ask, like, what is the hardest thing about this part of your practice? Dr. Christmas says that business people and lawyers dictating her schedule and how much

care each patient should have is one of the worst things about the work. But also, I mean, menopause in particular has become this monetized entity. It's very commercial. And people are getting information from all over the place. And I get them coming in. And sometimes they're angry because they're all fired up. And so I give people to say, how dare you not give me hormone therapy? It's my God-given right to have hormone therapy. I don't care that I'm 85. I deserve it. And what I say is that you've had a stroke. You have breast cancer and you're 80. I'm being facetious about it right now. But yeah, you know, there's all of these unrealistic claims or that that people have to. And we still stigmatize aging in this country. And a big fear around all of this

is just, you know, not wanting to age. And that's inevitable. Like I really think preaching this age is a gift. There are a lot of people that don't make it this far. And, you know, if you're lucky to live long enough, you're going to go through menopause. If you don't go through menopause, that means you're not here anymore. So, you know, if you think this is horrible, this is terrible, it's awful, then it's going to be. The people that fare the best, when I have to like take a step back and be like, oh, my gosh, how old are you? You look fabulous. The differentiator has not been that they've been on hormone therapy. It's really their outlook.

It's how they take care of their cells, of how active they are. All of it together is important. So this is about how we can age independently. We can thrive. We can be healthy. We can be happy. All the good things. So drink your water.

Stay active. Eat cleaner. If you can, sunscreen. hormones. Dr. Haver's favorite thing is the same, helping people. Like people who feel like something I said did is help somebody somewhere, you know, and I had some of that in clinic, right? Of course I did. But like doing it on such a large scale and like being stopped at the airport and a bathroom. Every time I wash my hands in the bathroom, some sweet soul comes up to me, gets the courage to say hi, and you change my life.

They don't want to bother me, but you just have to know you changed my life. And I'm like, aw, thank you. And then we take a selfie. They're like, does my vulva look okay? You're like, it's funny. Yeah, no, they're not doing that. They're not doing it. Well, hey, so don't flash her your giblets, but do ask generous scholars, gibberish questions. And follow her, check out her book, The New Metapause, and the just released the new perimenopause.

We have links to her social media and website and the show notes. Also follow Dr. Monica Christmas on Instagram at Dr. Monica Christmas. We have her research linked as well in the show. notes. We'll link to Dr. Westcott's Boneyard osteology episode, and you'll also find out more about Smith College's Dr. Sarah Woodkowski linked in the show notes. We have so many studies and resources linked at alleyword.com slash ologies slash menopause. It is a staggering amount of research. Go dig in. And a bonus episode this week will address things such as this question from a listener named Jason. Hi, Allie. My name is Jason.

New York City. I'm actually asking on behalf of a friend whose wife is going through menopause. He is wondering what he can do to support her. He's looked around and around and around and around and has not gotten good advice. Thank you so much. Bye-bye. So yes, support advice. You're going to want to catch that one as well. Now, if you need shorter kid-friendly episodes without me saying pussy so much, you can find them by searching Smollogis, S-M-O-L-G. iES, wherever you get podcasts, those are free and they're shorter and their family-friendly edits. Ologies merch is at Ologiesmerch.com. I'm Allie Ward on Instagram and Blue Sky.

There's only one L and Alley. And we're at Ologies on both. Friend since pre-puberty, Aaron Talbert, admins the Ologies podcast Facebook group. Aveline Malik makes our professional transcripts. Kelly Ardwired as a website. Tending to our biological clocks is scheduling producer Noel Dilworth, the hypothalamus pituitary adrenaline axis,

Susan Hale is our managing director. And the progesterone to my estrogen are the very, very vital editors Jake Chafee and lead editor Mercedes Maitland of Maitland Audio. Also on the editing machine this week is Jared Sleeper of Mind Jam Media, also of my marital relationship. That is your pod mother, and he is good at editing, and it's late. This episode's already a day late because it was much more to write than I thought. Thank you, Jared, for that, and also for weathering my own hormonal storms from early menopause. Look at us. We made it. Nick Thorburn sweated over the theme music and if you stick around until the very, very end, you know, I may burden you with a secret. And this week, it's that last week I confessed to you that I wanted to pick up garbage all over

the neighborhood, but I wasn't ready to be a local character per se in the landscape. And I got so many sweet messages of encouragement from fellow garbage pickers who said, do it. Wear the big hat. walk around with the claw grabber and a bucket and pick up litter. Life is for living. And I'm with you. I decided I'm so thrilled for that as soon as this monster episode is up. And just today, while walking our goblin, like the punchline of some cosmic joke, our street happens to be showered in minuscule paper scraps like a snowfall of shredded documents that spilled from someone's bin It's just shredded paper all over our street. It's like the universe is saying go.

Wear all black and a big hat like you want to. Be the trash witch. So that is tomorrow. Okay, go consult your health care provider. All right. Bye-bye. You should see a doctor. A good doctor.