The Peter Attia Drive - #348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT) | Rachel Rubin, M.D.

Episode Date: May 12, 2025

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Rachel Rubin is a board-certified urologist and one of the nation's foremost experts in sexual health. In this episode, she shares her deep expertise on the often-overlooked topic of women’s sexual health, exploring why this area remains so neglected in traditional medicine and highlighting the critical differences in how men and women experience hormonal decline with age. Rachel explains the physiology of the menstrual cycle, the complex hormonal shifts of perimenopause, and the wide-reaching health risks associated with menopause, including osteoporosis, cardiovascular disease, dementia, and recurrent urinary tract infections. She also breaks down the controversy surrounding hormone replacement therapy (HRT), particularly the damaging legacy of the Women’s Health Initiative study, and provides guidance on the safe and personalized use of estrogen, progesterone, and testosterone in women. With particular emphasis on local vaginal hormone therapy—a safe, effective, and underused treatment—Rachel offers insights that have the potential to transform quality of life for countless women. We discuss: Rachel’s training in urology and passion for sexual medicine and women’s health [3:00]; Hormonal changes during ovulation, perimenopause, and menopause: why they occur and how they impact women’s health and quality of life [5:30]; Why women have such varied responses to the sharp drop in progesterone during the luteal phase and after menopause, and the differing responses to progesterone supplementation [14:45]; The physical and cognitive health risks for postmenopausal women who are not on hormone therapy [17:45]; The history of hormone replacement therapy (HRT), and how misinterpretation of the Women’s Health Initiative study led to abandonment of HRT [20:15]; The medical system’s failure to train doctors in hormone therapy after the WHI study and its lasting impact on menopause care [29:30]; The underappreciated role of testosterone in women’s sexual health, and the systemic and regulatory barriers preventing its broader use in female healthcare [35:00]; The bias against HRT—how institutional resistance is preventing meaningful progress in women’s health [46:30]; How the medical system’s neglect of menopause care has opened the door for unregulated and potentially harmful hormone clinics to take advantage of underserved women [53:30]; The HRT playbook for women part 1: progesterone [57:15]; The HRT playbook for women part 2: estradiol [1:05:00]; Oral formulated estrogen for systemic administration: risks and benefits [1:13:15]; Topical and vaginal estrogen delivery options: benefits and limitations, and how to personalize treatment for each patient [1:17:15]; How to navigate hormone lab testing without getting misled [1:24:15]; The wide-ranging symptoms of menopause—joint pain, brain fog, mood issues, and more [1:31:45]; The evolution of medical terminology and the underrecognized importance of local estrogen therapy for urinary and vaginal health in menopausal women [1:37:45]; The benefits of vaginal estrogen (or DHEA) for preventing UTIs, improving sexual health, and more [1:41:00]; The use of DHEA and testosterone in treating hormone-sensitive genital tissues, and an explanation of what often causes women pain [1:50:15]; Is it too late to start HRT after menopause? [1:56:15]; Should women stop hormone therapy after 10 years? [1:58:15]; How to manage hormone therapy in women with BRCA mutations, DCIS (ductal carcinoma in situ), or a history of breast cancer [2:00:00]; How women can identify good menopause care providers and avoid harmful hormone therapy practices, and why menopause medicine is critical for both women and men [2:06:00]; and More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, and we've established a great team of analysts to make this happen. It is extremely important to me to provide all of this content without relying on paid ads. To do this, our work is made entirely possible by our members, and in return, we offer exclusive member-only content and benefits above and beyond what is available for free.

If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to PeterAtiyaMD.com forward slash subscribe. My guest this week is Dr. Rachel Rubin. Rachel is a board certified urologist and one of the nation's leading experts in sexual health. She is among a select group of physicians with fellowship training in sexual health for both men and women, bringing a rare and deeply informed perspective to her clinical work.

In our conversation today, we focus on women's sexual health. We discuss why sexual medicine, particularly for women, remains so neglected in traditional healthcare. The critical difference in how men and women experience hormone decline with age, the physiology of the menstrual cycle, including the role of estrogen, progesterone, FSH,

and LH and Y perimenopause is characterized by extreme hormone fluctuations. The risks of menopause beyond just symptoms like hot flashes, including the risk of osteoporosis, cardiovascular disease, dementia, and recurrent UTIs. The long standing controversy around HRT and how a single study, the Women's Health Initiative study, led to decades

of fear-based medicine and an entire generation of women, by my calculation more than 20 million, deprived of the benefits of HRT. How to use estrogen, progesterone, and testosterone therapy for women, including dosing, delivery method such as oral, transdermal, vaginal, and why personalized care is essential. The overlooked role of testosterone in women's health, both before and after menopause. The benefits of local vaginal hormonal therapy, a safe, inexpensive, and underutilized treatment

that prevents urinary tract infections, improves sexual function, and dramatically enhances quality of life in post-menopausal women. This is a podcast in which I learned a lot, even though I like to think I know quite a bit about this already, but Rachel's expertise here is second to none, and I was feverishly taking notes

throughout and obviously can't wait to implement many of the things I learned into my own clinical practice. So without further delay, please enjoy my conversation with Dr. Rachel Rubin. Hey! Without further delay, please enjoy my conversation with Dr. Rachel Rubin. Rachel, thank you so much for making the trip out to Austin. I have been looking forward to this episode for a while and I'm willing to go on record predicting that this will be a very popular episode given the nature of our discussion.

I am so thrilled to be here. I have been nervous for quite a long time, but I'm super happy to be here. I almost don't know where to begin, but it might not be a bad idea to just give people a little bit of a sense of your background. You are a urologist by training and maybe help us understand how your training in urology led you to what you're doing today because most urologists wouldn't be doing exactly what you're doing. When we think of urology, we think about prostates, we think about kidneys, we think about bladders.

Yes, but what you forget, Peter, is that urologists are ultimately the quality of life doctors. We deal with urination problems and we deal with sexual medicine, right? No one cares about erections and orgasm and libido quite the way that a urologist cares about. And when we're board certified, actually it's not a gender thing. We're not penis doctors only. We're board certified to take care of everybody's

genital and urinary tracts. Unfortunately, society has led us to know a lot more about the men's sexual health and men's genitals than female genitals. And so my background, I trained in urology really because I was interested in women's health but I also was interested in sexual health, sexual medicine. And I didn't like delivering babies. I didn't like OB-GYN.

It just didn't fit well with my personality. And what I love about urology is that we can see everybody and we can really dive deep on quality of life issues. And the magic of urology is also that you really get to know your patients. It's not like when you did surgery, you take out someone's appendix and you never see them again. Maybe you do one post-op visit.

Urologists have deep relationships. We're both surgeons, but we actually care about the medical side of these quality of life issues. And so as I was going through medical school, I really realized that talking about sexual health, quality of life issues, that was fun for me. I was good at that. And in medicine, you gravitate towards what is easy,

not what is hard. And so it's just been a joy. And really I've been working to further the field of urology to make us better at taking care of women. And so really I do a lot of educating and teaching to my colleagues about how we really need to care about the whole, like everybody. Yeah, and I really mostly want to talk about it

from a female standpoint today, truthfully, because I think this is where there's just a dearth of great information out there, where I think there's an abundance of garbage information out there. So while I appreciate that your breadth of knowledge will cover both sexes, you'll probably notice kind of a bias in what I want to talk about vis-a-vis women specifically. So let's start with perhaps the biggest and most obvious difference between men and women. And that is from an endocrine perspective, women go through this

period called menopause, which is a rather sudden and abrupt loss of their sex hormones. And that's to be contrasted with the way men's sex hormones decline over time a little more slowly. So again, the listeners of this podcast are highly erudite and they won't need the lengthy dissertation, but just give us a quick overview of what the heck is happening in menopause. Why is it happening? And then we can get into maybe what some of the symptoms are before women might really notice them.

I certainly did my research and I am not a car person, but I know you are a Formula One guy. And I got a very interesting email last week that said, Dr. Rubin, my wife is seeing your practice. Her libido is now like an F1 Formula One race car and I'm like a 1988 Honda Civic. What can you do for me? My analogy I really like to look at is sort of the gas tank analogy. This idea that men as they age sometimes we see a decrease in their gas

tank. They're feeling low, they're feeling down, they've got erectile dysfunction, low libido. Whereas women at age 52, their gas tank is empty. This is a castration event. We don't have many castration events in men's health. And so menopause is sort of a, your gas tank is officially empty. There's not much in the tank. Perimenopause is this time where it's very erratic. The gas tank is over full and then it goes to empty really quickly without warning. And so I like that analogy because I think it's very erratic. The gas tank is over full and then it goes to empty really quickly without warning. And so I like that analogy because I think it's helpful when we're talking to women about the reason you don't feel like yourself is because there's

just no gas in the tank. So we see the ovaries are no longer producing estrogen, progesterone, and testosterone the way that they were during your reproductive years. I love that analogy. I've never heard it before, but it absolutely replicates what, of course, we see clinically, which is in perimenopause, why do we sometimes, when we're measuring a woman's labs, say, every three months, see periods where estradiol is through the roof, FSH and LH are low, and three months later, it's completely flipped,

and of course, with it go symptoms. So can you explain why there's this, if we have hormones running like this during premenopause, they're like this during menopause, but this transition is nothing linear. It looks kind of like the stock market, actually. It goes up, it goes down, and it's not even just checking it every three months. If you check it every 10 days, you're going to see a fluctuation. I'm obsessed with looking at the menstrual cycle. I'm obsessed with talking about numbers here because it is so fascinating and we are not

taught to think this way. So I have a lot of curiosity about it. So for example, when you're in your, let's call it healthy reproductive years, and by the way Nobody is the book you talk a lot about continuous glucose monitors I would love continuous sex hormone monitors and unfortunately I know there'd be a lot of unintended consequences and bad things that would come of it But I'd be very interested because the book says are low So if you have your period that you're bleeding that's day, your low is not zero. In fact, it's probably somewhere 40, 50

is probably what the low should be of estradiol, and that's picograms per milliliter, as opposed to testosterone, which we do nanograms per deciliter, as you know. So let's say 50 is your low. Then you go at ovulate, and that's in your mid-cycle, and usually it's about 150. Let's say ish, maybe it's 200, 300, whatever it is.

Pregnancy, your level is 3,000 or higher, right? It's very high. And so if you're in your normal reproductive cycle, you go from 50 to 150. So let's use the gas tank analogy. You're at a quarter tank at 50, and you go to three quarters tank at 150, then down to a quarter tank.

You can drive wherever you want to go during that time. What happens in perimenopause, and it is this chaos and erratic fluctuation where your body is just wanting more hormone than it has. Your brain, your FSH is telling your eggs to do more than they can. Sometimes they overshoot. So now you are overflowing gas. I had a lady come in, her day one, her estrogen was 200,

and her day 10, her estrogen was 900. So this is this wild fluctuation in perimenopause. And what I'd like to do now is make sure that anybody listening who wants a more nuanced overview of this, we're gonna link to a video that I made a couple of years ago where I walk through the ovulatory cycle and I draw the graph of estrogen, progesterone, FSH and LH according to the nomenclature you're

using by days. But let's also have you do an explanation now of the role of FSH and LH on the brain because you've already referred to that and what the feedback cycle looks like with estrogen. I just want to make sure people are following the physiology you're describing. And that video is so fantastic. We actually were talking about it before doing this podcast about that video. And I said, you know, if you asked most OB-GYNs to draw the menstrual cycle, many of them wouldn't be able to do so. It's incredibly complicated and it's so confusing.

And we think our doctors know everything and unfortunately they don't. And so what happens is estrogen, you have your period, your lining of your uterus is shedding, your estrogen is kind of at its all-time low. And again, just to make the obvious statement, it's because most of the time when a woman ovulates, she does not get pregnant. Right, in this non-pregnancy state. You didn't make a baby, you're shedding the lining, your estrogen's about 50, let's say, to make it easy. Now it's starting to go up, up, up, up, up, and you're developing this follicle.

So this egg is developing, and then the LH is sort of your brain's marker of, okay, it's time to ovulate. So that's when you pee on a stick and you're trying to check if you're ovulating, it's checking your LH levels. And so you're gonna see this increase in LH that happens, again, everyone's a little bit different,

but it happens kind of mid cycle, day 10 to 14, somewhere along the, again, urologist, not gynecologist. And so you get this LH surge, the egg pops out, and it is the shell of the egg that creates the progesterone surge. So you actually don't make any progesterone really in that first half of your cycle. And then after ovulation, we call the second half

the luteal phase, which just means that's when progesterone is around. And so you get this surge of progesterone when there is no fertilization, that shell of the egg evaporates, and then you lose your progesterone, and it is that withdrawal of progesterone that causes the uterine lining to shed.

Now again, this is very confusing for people because hormones through that time, your progesterone goes from very, very low to after you ovulate, very, very high, and it's that cycle every month. Now estrogen again goes from 50 to 150, back down to 50. That's what the book says. I don't know about you,

but my patients are not all on the book. Yeah, a lot of my patients don't read the book about what their physiology is supposed to do. It's very disappointing. I agree completely. And so we're super interested in this. We care about how people are feeling. I may say this a lot during our conversation is there's the book answer, there's the Instagram

answer, and then my answer is somewhere in the middle. It's how we sort of talk about it and understand it. Again, I think the numbers are helpful for people to see. When you're pregnant, your estrogen's 3,000. When you're regularly ovulating, it's 50 to 150. Perimenopause, it could be zero, it could be 1,000, and down to zero in two seconds flat. So let's talk about why.

So why is it that in perimenopause, the fluctuations in estradiol level are so dramatic? I think it has to do with the fact that you have a limited number of eggs. You're sort of getting to that end of your bucket of eggs that you're born with. That's, again, controversial on the internet. So your body is really trying to do what it has always done,

and it's just having trouble. It's having trouble recruiting the egg, ovulating. You don't ovulate every time. Sometimes you ovulate twice, push out two eggs in this perimenopause cycle. So we can sometimes see really high elevations which can come with symptoms. And that's the challenge of perimenopause is sometimes you have symptoms because you're too low. Sometimes you have symptoms because you're too high.

And sometimes it's that fluctuation, like again, we'll go to the car model. You're driving 100 miles an hour on the highway and you go to empty gas tank immediately. That is not good for a car. That is inflammation, that is irritation, that is a lot of perimenopause symptoms. So maybe to extend the analogy, part of the reason

why a woman during this period of time can experience these enormous surges of estradiol is if you think that there's, say, a kink in the gas line and you really, really want to squeeze the lever to get as much gasoline as you can in the car, sometimes you overshoot and just, you get a whole bunch extra in there because there's volatility in the follicle release.

I knew you would like this analogy. Yeah, no, I love it. The one other thing I want to talk about, because it's going to come up later when we get to HRT, is do you buy the argument, which is the argument I have found most appealing, as to why women have varying degrees of sensitivity to the dramatic reduction in progesterone that they experience in the last quarter of the cycle once the lining sheds? So we talked about how, of course, during the luteal phase we're building up,

progesterone levels are rising, we're building up the endometrial lining in preparation for pregnancy. Most of the times that's not going to happen. Lining sheds, progesterone crashes. This is what's referred to as PMS. And some women are somewhat unfazed by that. And other women, that's a big deal.

And so the question is, is this about central receptors of progesterone and varying degrees of sensitivity? I think it's a really important question and we see this clinically all the time. If you give somebody say micronized progesterone or a synthetic progestin, say in birth control, you will see a wide variety of reactions to these different medications. And so I would say it has to probably do with the GABA receptor in the metabolites of progesterone and how the receptors in the brain use these molecules. And so I think we just don't know enough. You know, I tell my patients all the time, I wish, oh my gosh, we have

so much work to do in women's health. We have so much research we need done. This is why I come on this platform, not because I want to be on this platform, but I need smart people to be listening to this, to ask the research questions and to do this research. Because clinically, we see this all the time. I will put up that menstrual cycle with my patients and say, when do you start to have symptoms? Are you having symptoms when your estrogen is falling? Are you having symptoms when your progesterone is falling? And can we hack this system to help you feel better? And how are you gonna respond to it?

Because when we give someone micronized progesterone, I would say a third of the patients love it and guzzle it like it's candy, and they're the happiest people in the world, helps their sleep, reduces anxiety. Oh my God, changes their life. It's absolutely life changing. A third of the patients are like,

I don't really notice, it doesn't bother me, it's fine. But if you tell me I need to take it, I'll take it. If you tell me I need to take it to protect my uterus, no problem. And then you've got a third of patients who are very sensitive. And even within that third, it is extreme. I mean, we see progesterone allergies

where people have horrible reactions to, it makes me too sleepy, it makes me feel bloated, I don't like this. And so I don't, as a clinician and an interested researcher, like I don't know exactly enough to be able to spot who those people are ahead of time. Okay. So we've established now what's happening. We've established that during the period of perimenopause, the one consistent thing that's

happening is inconsistency. At some point, we get to the place where the consistency returns, but now it's a new norm. And that new norm is you don't make estrogen, you don't make progesterone. The signal from your pituitary, FSH and LH, begin monotonically rising, rising, rising. And so if you were to do the blood work of a woman in her 60s who had never been placed on HRT, you would see a very high FSH, a very high LH, usually above the labs cutoff for measurements, and then estradiol and progesterone non-existent. Let's talk about all the reasons why that woman that I just described in her 60s, who is now 10 years out of any hormones,

what are the risks to her physical health, mental health, emotional health, the whole picture of her health, cognitive health, everything? What is she worse off for at that period of time? So I think this is a really important question in the sense of what is the risk of taking hormone therapy in that patient,

and what is the risk of not taking hormone therapy in that patient? Yeah is the risk of not taking hormone therapy in that patient. Yeah, and that's why I want to start with this. And so I think it's super interesting because we love talking about the risks of medication but we don't spend a lot of time talking about the risks of not taking medication. So if we think about that woman as she gets older,

she certainly will have the microbiome and genital and urinary changes of not having hormones. So as a urologist, this is actually one of the couple things that will kill her. As you lose hormones in the genitals, which are very hormone sensitive, the bladder's very hormone sensitive, you change the microbiome,

you decrease the acidity of the tissue, the bad bacteria grow, your risk of urinary tract infections increase drastically. So she may get recurrent urinary tract infections or pelvic pain. She may develop osteoporosis Which we know more people die of hip fractures about the same with dive hip fractures as dive breast cancer So the risk of not taking hormone therapy when you get a hip fracture as all of your listeners know

Going back to the life that you lived is very challenging or you die There's also the risk of dementia and Alzheimer's much higher in women and we can argue the data and I don't think we actually have good data about whether hormones, when to start them and if they're actually protective and how they're protective. But we also know that heart disease is the number one killer of women and we know that things get worse as you get older. So I think there are significant risks to that person and from the mental health perspective, I think there's no question that we see worsening. Now, I will say perimenopause,

from what I understand of the data, is actually worse on mental health and can actually level out a little bit once there's less erratic hormones. But again, an empty gas tank is still an empty gas tank. And so we see a lot of challenges in this time period. We talked about, obviously, the risk of dementia. We talked about the risk of osteoporosis, cardiovascular disease, colon cancer. All of these are risks that are pretty clearly going up in the absence of hormones.

So do you want to talk about the history of HRT? I mean, it was a largely normal practice in the 1960s. They certainly had some fits and starts. They initially were just replacing estrogen, figured out pretty quickly, i.e. within a few years that if you only gave a woman estrogen, you were going to run the risk of endometrial cancer going up because the endometrial lining just continued to get bigger and bigger and bigger and you eventually developed hyperplasia, which presumably became metaplasia and ultimately cancer. They figured out pretty quickly how to combat that if you just oppose the estrogen with

progesterone, keep the endometrial lining in check. And this largely became the standard of care through the 1980s and into the 1990s. And this was largely validated by epidemiologic observations, which showed that women who took hormones did significantly better. Now, people who listen to this podcast are well aware of how critical I am of epidemiology. And it's certainly very easy to make the case that in the 1980s, women who were taking hormones had a healthy user bias. These are women that probably had better access to healthcare. They were probably more health conscious.

And as a result, they were probably doing many more things to improve the quality of their health. So the NIH did something that I think made a lot of sense. It was the right thing to do, which was they said, look, we can't rely on this epidemiology. We need to do a randomized control trial. And they did it through something called the Women's Health Initiative, which had two components, a nutritional component that was asking a question about low-fat diets and then a component that was looking at the HRT.

So would you like to pick up the story as to how the study was designed, maybe talk about some of the potential pitfalls of it, and ultimately how the results of that have been misunderstood and misinterpreted for so long? Dr. Kinn-Karpen The fact that this story hasn't been made into a Hollywood biopic mega drama, I don't know. This is a big deal. A billion dollars of our resources went into doing this study. And there are many things that we learned that were helpful and useful and this huge set of data that we're still using today to extrapolate information from and there was a lot of good that came from it. But there was a lot of misinformation and just really

bad marketing or really effective marketing, you could argue, because what is so wild, Peter is that when this study came out, they did a press conference before the study was published. They did a press conference. Have you ever seen, they did a press conference. Before the study was published, they did a press conference. Have you ever seen the NIH do a press conference that Matt Lauer talked about or that was made it on Good Morning America? They did a press conference. I remember, I was in medical school at the time.

I remember this happening. And they said, OK, we had to stop the study early. It is increasing the risk of breast cancer and increasing the risk of blood clots and cardiovascular disease and we have to stop the study. There's different statistics out there, but people will say about 40% maybe of women were on hormone therapy at the time. Overnight, it crashed to nothing. You're talking billions of dollars of an industry went to nothing. And the people who are prescribing the hormone therapy

were like, this doesn't make any sense. I do this, I've been doing this for 20 years, 30 years. I don't have a clinic full of people who are dying of blood clots or heart attacks or who get breast cancer. Like this is not my clinic, whose clinic is this? Then they published the paper. And as we talked about before we did this podcast

is that they misinterpreted the data so drastically and scared everybody with so much fear that you actually have an entire generation that has forgotten how to prescribe hormone therapy. And this is the nightmare that we're living in today because now we realize that the data was misinterpreted. So that WHI was one medication, one dose. That's it. And it was a sort of birth control pill style kind of hormone therapy. So a synthetic estrogen and progestin. It was not the, what we call more,

and we can talk about the marketing term bioidentical, but the FDA approved products that we use today, like Estradil and progesterone, they're different medications that we use today. And so you're talking one medication, one dose, and we're still practicing fear-based medicine 30 years later, whatever it is, saying like, we don't practice any other medicine like this.

We're like, well, there was one study about surgery 30 years ago, and that's the way we practice medicine. We evolve, we learn new things. So what did it show? Let's talk about the good. When you took estrogen and progestin or estrogen alone, you had a decreased risk of colon cancer. You had decreased risk of fractures, like significant decrease of fractures. Decrease of diabetes, okay, that seems like a good, those seem like all good things.

This is in the hormones we don't even really prescribe anymore. We saw a decrease in overall mortality, a decrease in cancer-specific mortality. And then when you looked at the cardiovascular data over time, and again, I'm a urologist, I'm not a heart expert, but you saw there was actually no difference. It actually wasn't so scary. Now, as you get older,

we know birth control pills can cause blood clots, so we do worry about giving a birth control pill to grandma because you can increase blood clots. That's true, I agree with that. When it comes to breast cancer, the most fascinating data that didn't make the press conference, women who are on the estrogen alone,

so they didn't have a uterus, so they didn't need the progestin therapy, had a decreased risk of getting and dying from breast cancer. And it didn't make the news. Even in that study that put the box labeling on all the products, it's not true. So then when you looked at the estrogen in the progestin groups,

there was a fear that there was an increased risk of incidence but not mortality from breast cancer. And even when you look at that data, there is questioning of the fact that the placebo group actually was more protected by breast cancer because many of them had been on hormones in the past. And when you use a correct placebo group, the lines actually go together. And so you're more of a statistics nerd than I am. But the reality is there was no difference. And so we scared an entire generation of people

away from hormones because of a bad misinterpretation of statistics. So, Rachel, I don't know how good you are at sensing a person's blood pressure from across the room. But if you were able to sort of project your vision into my carotid artery. I see it bulging. Yeah, you'd notice that my blood pressure is up.

I'm probably at 180 over 120 right now. First off, I think that was a remarkable succinct summation of the WHI. I'm only going to repeat a few things, not because I didn't think you did a great job, you did, but because sometimes hearing it twice highlights the egregiousness of this study. Shout it from every rooftop you can find. Truthfully, I have friends, female friends, and I have patients who to this day are paranoid about hormones, and I just want to offer yet another opportunity for them to

sort of understand what's going on. So this was a study that had two parallel arms, one where women without a uterus were just randomized to either the synthetic or equine based estrogen versus a placebo. And then one where if you had a uterus, you got MPA, a synthetic progesterone, and the estrogen. As you pointed out, the elephant in the room here, the one finding that got all of the attention was that in the women with uterus group, if you got the synthetic progestin and estrogen, you had an increase in your incidence of breast cancer. It turned out it didn't actually lead to any change

in mortality from breast cancer, but there was an increase in the incidence. The number is really scary if it's given in relative terms. It was a 24% increase in the incidence. Incidence for the listener meaning getting breast cancer. You had a 24% higher chance of getting breast cancer if you took the two hormones. On the surface, that sounds devastating, but again, as people who listen to this podcast know, we always need to think in terms of absolute risk.

And relative risk doesn't mean that much if you don't understand absolute risk. So if I said to you, Rachel, I have a treatment for you that is going to fix a hundred problems, but it increases your risk by 100% of getting hit by an asteroid, would you take the medicine or not? Well, you'd have to know what your base level risk of getting hit by an asteroid is. And given that it's almost zero, doubling it doesn't mean anything. So the absolute risk increase for these women was 0.1%. So to put that in less technical terms, it meant even if you believe the results of that study and you've offered a great explanation for why the actual results should be questioned, but even if you take them at face value, for

every 1,000 women who were put on HRT, an additional one got breast cancer, though she didn't die from it, at any increased rate to the women who didn't get the hormone. This to me, and I'd like you to push back on this, although I'm worried you won't be able to because you share my bias. This is the greatest injustice imposed by the modern medical system in our lifetime. You are not going to get pushback from me on that. This is a disaster. I just got back yesterday from teaching at the largest internal medicine conference, ACP, the American College of Physicians, and you're talking

more than 20,000 internal medicine physicians. What a wonderful thing. I was asked to give a course on female sexual dysfunction and it was wonderful. I talked a lot about menopause. There was no other menopause content at this course. There was no courses, how to prescribe, given everything you've done, my colleagues and myself have done to bring it into just popularity. Patients are coming in asking questions and there wasn't even a course to learn. I can't say that's true for GLP-1s or any of these lipid lowering agents or all of the things that you've been pushing. The problem is you now have a brain drain, I think, because the doctors who prescribed hormone therapy

either retired or died, and there was no one they taught ahead of them. Now, I was very lucky. I had very good mentorship and incredible experience, but we are now trying to make up for lost time to train people how to write prescriptions. So it's not enough to say, hey, the WHI was misinterpreted and we've done a bad thing for people don't know how to do this.

It's a huge problem. And the reality is this is half the population. This is not niche medicine. The fact that menopause medicine is the tiniest little room of subset of gynecology, which it should not be under gynecology. This is whole body medicine, and yet nobody seems to care. Yeah, it's really interesting to hear you say that because you're highlighting something that's as dramatic and potentially more dramatic than the thing I've tended to focus on.

I've focused more so maybe I just take for granted that I got lucky and I had amazing mentors and they taught me how to do this stuff. But it's also the nature of my personality to just be endlessly curious and show up in somebody's clinic for two weeks and do this. I've tended to focus on the lost generation of women. So I had my analysts do this analysis two years ago, and I don't remember the exact numbers, but the analysis was calculate for me or estimate for me the number of women who were deprived of HRT because of the WHI and calculate the excess mortality that was

achieved through that injustice through hip fractures, cardiovascular disease. We just went through the entire list. Calculate the number of lives that were lost, the amount of disability that was incurred because to your point, even if you don't die from a hip fracture, 50% of survivors never regain the same level of function. And I didn't even know how to quantify all of the sexual side effects that women unnecessarily endured, all of the Vesa Motor side effects that they unnecessarily endured. Didn't even try to quantify that because I don't know how to.

But that's the thing that I focus on. And again, it's personal to someone my age because my mother and my mother-in-law are in that category. They're the ones that got absolutely screwed by this system. You're highlighting something equally catastrophic with potentially a greater impact, which is we failed to train a generation of doctors

to do anything about it. And if that's not reversed, the problem doesn't get much better. Yeah. I mean, the data is very clear on this. Less than 6% of internal medicine, OB-GYN, or family practice doctors get even an hour of menopause education in their training.

Do you remember learning about menopause in your medical school? Zero. Zero. Not one minute. I didn't learn one minute of it. I did learn that hormones were bad. Oh, yeah, you learned.

So because you are taught hormones are dangerous, or the bodybuilders take the hormones, the snake oil salesmen take the hormones, we don't talk about this in real medicine. Everyone says, it's not my industry, it's not my thing. I went to this internal medicine conference yesterday, and all the internal medicine doctors were saying, but this isn't my field.

I don't feel comfortable, right? An endocrinologist was standing there saying, I don't feel comfortable doing this. I said, you're a hormone doctor. That is what you do. It is so embarrassing. I've been asked to speak at multiple academic centers to teach on hormone therapy.

And every time I'm like, is this real life? I am a urologist teaching hormone doctors about how to prescribe hormone therapy. And it is real life. And this is why I'm so loud about it because we have to change this. We have to change this on a big level because I need the ICU doctors and the pulmonologist and the heart doctors and all the doctors to know that menopause affects their organs.

Colon cancer. Why aren't GI doctors talking to women that estrogen prevents colon cancer? Why are we checking DEXAs at 65? Why are rheumatologists not prescribing hormone therapy? I found out recently that psychiatrists, because I do a lot of teaching about how to prescribe hormone therapy. A few of us are very passionate about it.

And I was like, sit with me. I will teach you how to write the prescriptions. I've had psychiatrists tell me their malpractice insurance will not cover them if they prescribe hormone therapy. And I said, wait a minute, you prescribe postpartum depression drugs, which are progestin-based. You do reproductive psychiatry, which means birth control is a part of what you do, and you're being told you're not allowed to prescribe hormone therapy? When hormone therapy is one of the greatest antidepressants in the history of medicine,

it is insanity. We're living in a nightmare. Adam Benz Let's talk a little bit about how we go about doing things. So there are two hormones we've talked a lot about, but there's a third that we haven't yet talked about that is very linked to these two hormones, doesn't get enough attention in women, and of course that's testosterone. So before we get into how one should think about replacing hormones, can you talk about the relationship of testosterone to women's sexual health and what's happening to testosterone levels during this transition from peri to menopause because of course I want to bring this into the HRT discussion.

Super interesting and I'm very passionate about this topic. And so I think it comes from this idea that I do testosterone for men all the time. I'm very confident, I love prescribing testosterone for men's sexual health. And actually, very interestingly enough, when we prescribe testosterone for men, remember their gas tank doesn't get empty, it gets low, it's off-label.

We are doing off-label testosterone therapy in men. Unless they have Kleinfelters or some significant medical problem, we're doing off-label testosterone for men. And unless they have Kleinfelters or some significant medical problem, we're doing off-label testosterone for men, and it's very understood, it's talked about. The FDA just three weeks ago removed the labeling on testosterone therapy, saying it no longer is a cardiovascular disease risk.

So that's great news. So the thing about women and testosterone is it's actually not a menopause thing. Testosterone is an age-related decline. So in your 30s, you're starting to drop your testosterone. And testosterone, I don't know who decided that men get testosterone and women have estrogen. Like we both have both of the hormones.

You've probably heard me make this point before because you alluded to it a few minutes ago. We measure testosterone in nanograms per deciliter. We measure estradiol in picograms per milliliter. If you normalize those to the same level, women are shocked to learn that they have 10 times the amount of testosterone in their body that they do estradiol at peak estradiol. Way more. And I love sharing that when you put everything in the same units, we are testosterone

driven beings. Both of us, right, are testosterone driven beings. We don't teach this to OB GYNs. No OB GYN knows some do, but very few know about the role of testosterone in women's health. And so we love to gaslight women and say, well, if you have your period, your hormones are normal. Drives me insane. Women are told this all day every day is, well, you can't possibly have a hormone problem because you're getting your period regularly. And the reality is, is that's not true. Why? That curve, that curve we were just talking about testosterone is nowhere on that curve. And so we know there's a peak of testosterone around ovulation. That is nature's way of saying, let's make a baby. We know that. We know that your libido goes up around ovulation because that is nature's way of saying, let's make a baby. We know that, we know that your libido goes up

around ovulation because your testosterone goes up. And so there is this age-related decline in testosterone. And here's another big problem. We give women birth control pills all the time. How does birth control work? By the way, birth control is high dose hormone therapy. We love hormone therapy and birth control, but as soon as you become menopause, everybody's

afraid of hormone therapy. It makes no sense. So birth control is high dose. I would argue the hormone therapy we're talking about, the WHI, that is more synthetic, that has side effects, that have issues like that. So birth control turns off your ovaries and it adds back a final estradiol and a synthetic progestin. It doesn't add back testosterone.

So we are botching testosterone for women along the life cycle to be honest, but if you take someone who's never been on birth control, their testosterone starts to drop in their 30s. So what are they complaining about? It's not just a libido thing. We know their testosterone receptors all throughout the genitals and the urinary tract. So we see women have an increased risk of UTIs. We see an increased risk of pain with intercourse or pelvic pain conditions.

We see there are some studies that indicate potentially depression and anxiety can increase because we do think there's a testosterone effects on the brain. But we have global consensus and I don't know if you've read the news lately, Peter, but we don't agree on too much as a globe. But there is global consensus that testosterone in women works for low libido. And so specifically the data is on postmenopausal women, that's where the global consensus is, but there is data in perimenopause and much smaller studies before that.

The consensus is it works, but everyone has emotions about testosterone. I didn't think testosterone was a feeling, but apparently it is a feeling for people because people hate talking about it. And again, nobody taught you how to prescribe it and there's no FDA approved product for women except in Australia, it's approved by their governing body. And so you have a lost art of knowing

how to give people back testosterone when they are symptomatic. I think this is an area where women sometimes are also a bit concerned about what happens if I take testosterone, because testosterone, understandably, conjures up images of all sorts of things from large muscles, big mustaches, lots of other things. So how do you talk to women about this?

We enjoy having these discussions and also acknowledging side effects. The most common side effect we see in women is acne. I don't think I've ever gotten to the point where I've seen any of the really dramatic side effects, but I do tell women, I say, look, there's a decent chance if you were shaving your legs every five days, you're gonna be shaving them every three days.

That's a chance. If you were kind of susceptible to acne growing up, you might get a little bit more of it and we'll have to back off. How do you talk about the risks of testosterone therapy? I love talking about this, and I'm actually grateful for celebrities because just in the news in the past few weeks,

Halle Berry says she's on testosterone, Kate Winslet says she's on testosterone therapy. They look pretty amazing to me and they don't look androgenized at all. And so I actually wanna do this study. It's something my research team's working on is I think I have more patients who never start testosterone therapy

because of the fear of side effects than actually stop testosterone therapy because of the side effects. That's my observation in doing a lot of this. Now, when we talk about side effects, I tell them, think about a lot of this. Now when we talk about side effects, I tell them, think about a horny teenager. They have these great libidos, but they have some oily skin, acne, but that's when you get really high with your doses. We really don't see it clinically. Yes, I use FDA approved testosterone for men, just a doses, one-tenth a dose in a way. They rub it on

their leg because if they do get hair on their leg, people are used to having hair on their leg. And so they shave it, they wax it, they laser it, whatever it is that they do with leg hair. I don't have that many patients stop for acne, oily skin. I think there's that fear when you get really high in the dose. So I'm not a pellet promoter or user because you get super physiologic levels and I can't take it out if you get a pellet put in. And so if you have deepening voice or clitoromegaly, hair issues, these are the challenges

with some of these super physiologic levels. But when we're using reasonably dosed topicals, we really see magic happen. And I can't tell you, when we get estrogen and progesterone right for our patients, it is by adding that third piece, that testosterone, because your ovary does, probably does more than three things, but at this point, estrogen, progest third piece, that testosterone, because your ovary probably does more than three things,

but at this point, estrogen, progesterone, and testosterone, when we add that testosterone piece, it's wild. All the patients come back and they say to me, wow, I feel like me again. It's wild. That's the piece, wow, I didn't realize how badly I felt. Wow, that was the missing piece. I hear it over and over and over again.

I can't not want that for all women. I can't not want to give them that as an option on the menu. So let's just finish the swing on testosterone. Do you prefer then to rely on the topical version of which would be like an androgel type product and just dose it at a much smaller dose? Yeah, that's typically how we do it and how our guidelines look at it. So ISWISH, the International Society for the Study of Women's Sexual Health, fabulous organization. You can find any doctor to help you with menopause and sexual health by going to their website. They came out with a really lovely how to practice guideline that they took from the

global consensus. And they do recommend using that FDA approved testosterone for men and using it at appropriately doses for females. So I like Testim which is sort of the 1% generic testosterone gel. I'll show it to you. I brought it for you to show you. It's a 5 milliliter tube of gel. Our male patients would use the whole tube of gel, rub it on their chest every day. I have very few men who do that by the way. Injections, orals, those are much better. And so I tell my patients, use a blob or 0.5 mL so they can put it in a syringe if they want to

and dose out that 0.5 mLs. They take a blob, they rub it on their calf every day. And so just don't use, the whole tube should last you about a week or 10 days. It's an ish. It's not an exact precision science, but the patients can figure this out. It's not that challenging. It's not an exact precision science but the patients can figure this out. It's not that challenging. I will say this and I think

I have colleagues who disagree with me on this and I would love to know your experience. I think testosterone, I think for men too but that's my bias, it takes a while to kick in. I will tell patients you need to do this regularly and I think it's gonna be three, four, even five months before you're going to really wake up and say, wow, this is working. Oh my gosh, someone just walked across the street and I did a cartoon style head turn when my eyes popped out of my head. Oh my gosh, I initiated sex.

Wow, that orgasm was easier to have. These are the things that patients notice. I also get patients telling me their stress incontinence is slightly improved. Why? Because the urethra has testosterone receptors in it. We know that for all genders. These are the kinds of things my patients will report. I don't know. What do you think? I think it takes a while. Hmm. That's an interesting question.

I mean, I definitely agree that that's true for some people. That said, I've also seen people who, within weeks, report feeling better. Now, the challenge here, of course, is the only way you could understand this is through blinding. We just don't know how significant the placebo effect is and therefore it's hard for me to discount or know. We have studies on testosterone which show... Oh sorry, I mean within my observation. Got it.

I see. I hear you. Yes. I want to ask you another question about Natesto. So Natesto for the listener is a nasal formulation. It's an FDA approved formulation. In theory, it seems like a great idea. In practice, it has not really panned out just based on its messiness.

It's a gel, a nasal gel. We've had women use it vaginally, nasally. What's your experience been with it? It's getting harder and harder to find these days. And so I think similarly, we've been interested in it, and people have played with it before. This idea, can you do one squirt into your, nobody likes to squirt things in their nose, it turns out.

It's a challenge. Now, any of these topical testosterone formulations, a lot of them have alcohol in them, so I don't recommend putting them on your genitals directly. But I do think it needs to be studied. It's challenging finding the formulation of testosterone that is low enough, like from the male side, because we have lots of formulations for men,

that is low enough to kind of give an appropriate dose. Why isn't a female formulation being made? Buckle up, buttercup. So here we go. We had a billion dollars that was put into it, a billion dollars in a five- year study that was done at the FDA and it showed it was safe, it showed that it was effective, it showed that it was, the TLDR on testosterone

is it's not that serious. We want it to be serious, again, not a feeling. We want it to be like all about aggression, it's not a feeling, it truly isn't. So they did five years of study, a billion dollars went into it and the FDA came back and they said, oh, women have breast tissue, so we're gonna need five more years of data

and another billion dollar study, and every company was like, I'm out. The benchmark was different for women. Men, six months. And this was a real goalpost move. Yeah, they just keep moving the goalpost. Everywhere they move, the damn goalpost. Okay, I talked about the labeling on testosterone being removed that it doesn't worsen cardiovascular

disease. Why? Because they did the Traverse study that your listeners know about that proved it. The box labeling on estrogen products, which says that estrogen causes stroke, blood clots, heart attacks, probable dementia, we just got done saying that that study didn't show that. So why is that box labeling still there? We're killing women by trying to protect them.

Why do you think this is happening? If you try to steel man the case for the other side, where are they in their thinking on this? I think medicine has a humility problem and a deeply ability to say, hey, we didn't know what we didn't know back then. We're learning and we're adjusting. They don't like to say I don't know. They don't like to evolve in their thinking. And for some reason, women's health comes with so much bias. The amount of money that goes into women's health research

is worse than it was 10 years ago. But is this a paternalistic, I mean, I hate to put sociology on top of this. As you know, I've spoken with one of the PIs from the WHO and I think she is by far the most honest broker of that group. And I don't have good things to say about that group. I really don't. But I also can't even wrap my head around their thinking. Like I can't steel man their case. I wake up in the morning and I'm like, how is this real life? Okay, I'll give you an

example. We met with the chief before the administration changed. We met with the, I think it was the chief medical officer of the FDA. We met with someone high up at the FDA. It was a room full of perimenopausal women. I was like, yeah, we got this. It's a room full of perimenopausal women. I was like, yeah, we got this. It's a room full of perimenopausal women. And we presented our case about vaginal hormones, which is basically microdosing hormones. And they prevent UTIs by more than half. When you use vaginal hormones, you treat the genitourinary syndrome of menopause. And we said to them, we said, you're labeling, this should not have the same labeling of all estrogen products. You should remove the labeling." And they said, well, we're really going to need industry to come at us to remove

the labeling. I said, you didn't need industry to put the box on. Why do you need industry to remove the box? We no longer have industry in this field in any significant way because the WHO destroyed that industry. So we have a huge problem where you actually don't have any money to women's health. I think Pfizer completely fired their women's health division saying, yeah, we're going to look at allergy now. You have entire departments. We did a study once on pelvic pain. We were looking at botulinum toxin and pelvic pain. And I was on the call where they said, oh, we have a new CEO now and women's health is no longer a priority. Like I heard those words. So we do have a

paternalistic problem. It's true. And unfortunately, it's not getting any better. I usually do not subscribe to theories like that. I usually find myself thinking there are alternative explanations and we're just pointing to the most sensational ones, but it gets hard to dismiss an argument as follows, which is if the tables were turned and the WHI was really the MHI, the Men's Health Initiative, and it produced equally idiotic results, would we be in the same place we are today or would men have said, oh, hell no. The Traverse Trial, right? Yeah. There were two bad studies that were done, horrible studies that made no sense, that showed testosterone had some dangers. The FDA threw that box labeling on, said, oh my gosh,

within minutes they created the Traverse Trial. It got done in five years. And within minutes when it was finished and it got published in the New England Journal of Medicine, the box was removed. And by the way, the Traverse Trial is not even a great trial. I've been so critical of the Traverse Trial. I think you could have come to the same conclusion of the Traverse Trial if you knew how to read all of the data before it. I actually don't think the Traverse Trial added much. But anyway. Totally. Look at data.

Oh, there was an increase fractures from the... Oh, testosterone causes fractures. That makes no sense. We know that's not true. We know testosterone helps bone mineral density. And so you can make the same arguments of how you look at these studies, how these studies are designed, the flaws of them.

You're gonna do a study for five years. Why are you giving people gels? Is that the right thing? So why do we care what the people of the Women's Health Initiative said 20 years ago? Why is that even news and why can't it die? And because you don't have enough people like you standing up, you don't have the internal medicine doctors standing up and saying this is wrong because they're not teaching it.

You don't have the OB-GYN saying this is wrong because they're delivering babies and women are dying in childbirth. Women's health, menopause health in particular, is important to nobody. When it's nobody's problem, nobody takes ownership of it. I mean, I do believe this is going to change. And I don't know who said this, but it's a great quote that said, funeral by funeral science makes progress. That's not a great explanation for what's about to happen temporally, because it's going to be a while before everybody who held that belief in their soul is no longer around. But it does give me hope that a new generation of women will come along and

take ownership over their health. And look, I've seen a change in 10 years. 10 years ago, when I was prescribing hormones to women, you cannot believe the fights I would have with their other doctors. And I don't mean like we weren't fist fighting, but they were scolding me like, how dare you? But it came with an arrogance, a lack of willingness to even look at the data, which I found ironic. If you want to scold me, you better know as much as me and hopefully more.

But this arrogance of I'm going to scold you, but I know nothing, and I'm not actually willing to have a discussion with you. Because I'd be like, great. Turn to figure two in the JAMA paper and let's look at this. And look at the appendix and look at the supplemental data. Like, are you seeing the same thing I'm seeing? Can we at least agree on the facts? No, we can't. And it's so fascinating because I would never... I do sexual medicine, so I look at the whole patient.

I look at everything. And I would never say to them, hey, you have to stop this beta blocker right now because it's causing your erectile dysfunction. And I would never tell a patient that, though the beta blocker may be worsening his erectile dysfunction, but I would never say stop this medicine, it's hurting you. I would talk to their doctor, I would have a conversation, but there's something about hormones that doctors who know nothing feel very confident in saying, you can't be on this, you must stop this without even having that curiosity of, huh, I wonder if the person who prescribed it actually knew what they were talking about.

And it is everywhere. We see this all the time. Now, let's talk about the flip side, because the unfortunate nature of everything we've just described is you create a fringe movement. And unfortunately, I've seen a lot of dock-on-a-box hormone practices that are, I believe, putting women at risk and I believe are doing bad things to women in the name of doing good. And I don't believe that these are inherently bad individuals.

I think they're ill-informed. I think they're just not that bright. And maybe some of them are just actually charlatans, and they're seeing an enormous opportunity here. As a general rule, I tell patients, be very, very suspicious of a doctor that is selling you hormones. Be incredibly suspicious of any physician who has their own compounding pharmacy within the practice

and is giving you compounded formulations and also making money on it. Talk a little bit about, I don't wanna call it the dark side, but just the fringe side of this world. So I would argue that people care about their pain points. People wanna feel better. People will go to anyone who tells them,

there's a whole supplement aisle at CVS that makes all these wildish claims that we're going to help you with everything. And the reality is, is I just got done saying your gynecologist and your internal medicine doctors are going to, in that 10 minute visit, tell you that you don't need this. This is not going to help you.

And so enter the fringe people, the snake oil salesmen, the people who are doing wildly inappropriate things. That doesn't mean the hormones themselves are bad. It just means we have a marketing problem here. If we're not doing it and helping people, they hear their friend did it, they hear their neighbor did it, and they said, I want what she's having.

This is why we call ourselves the menopause. This is why we teach so loudly, is because we're trying to bring it back into medicine and evidence-based medicine and say, you can actually do this quite reasonably. In fact, there are many FDA approved products that work much better, that are more regulated, that are totally safe.

Here's what they are. They should be covered by your insurance and giving them that knowledge because the problem is, is it's too quiet. No one is giving people answers. No one's even looking at the questions. So then the fringe people take over and are unfortunately doing very inappropriate things.

You know what? Men's health too. As a urologist, we see shot clinics and all these wild PRP clinics and testosterone pellet clinics and compounded pellets and all of these things because my colleagues, we are not doing enough to take care of men's sexual health.

And so these clinics exist to prey on those patients who deeply want to connect and get their answers, which is why my colleagues and I are even loud about it for everybody. Yeah, the number of online testosterone clinics is mind boggling. And a lot of them are prescribing, I think, second tier drugs. And you know what I say? I say, you know, with these things is the people who need it are not being offered it, and the people who don't need it are abusing it.

And that is true for hormones for everybody. I talked about this at the last menopause meeting, less than 4% of women are on hormone therapy right now. Less than 4%. 4% of women who would theoretically be required. Less than 4%. Wow. That's worse%. That's worse. That's worse than I would have guessed.

It's worse than 10 years ago. It is so bad out there. I did the same calculations you did when I was on my Uber on the way over. I said, how many women are over 40? It was something like 84 million according to AI. And there are about 3,000 people on the menopause society website.

That doesn't mean everybody knows what they're doing or that they all do the same thing, but divide 84 million by 3,000, it's a big number and we can't see patient panels of 27,000 people. The math doesn't math there. So we need people to step up, so who should be writing estrogen prescriptions, who? Every doctor who sees a woman of that age.

Every doctor who sees a woman of that age, and so who actually does? Nobody. Yeah. Let's talk a little bit about the playbook. I wanna tell you how we do it. I'm not saying we do it right, cause I don't think there's a right way to do it,

but I mostly wanna hear how you do it, cause I bet you're way better than we are. Maybe we take a step back and explain. We've already alluded to it twice, but I just wanna make sure people are understanding this. If a woman has a uterus, you have to protect that endometrial lining. So even if she's in the camp of women who don't notice being on progesterone, you have to be on progesterone.

We'll come back to IUDs and progesterone-coated devices and things like that. Maybe let's just talk about the way you give progesterone. So the progesterone is the easiest of the lot. Is there any reason when giving oral progesterone to use anything other than micronized FDA-approved progesterone orally? Dr. Kinnick What's lovely is we need a toolbox because not everybody responds to the same thing. I love micronized progesterone. I think it's a fabulous product.

It's my go-to first line. Sometimes we need to put it vaginally instead of orally to help with some of those sedating side effects. So you can avoid going to the brain if you put it vaginally. And so we do find that cuts down. But you're going to start orally. I typically start orally. You're going to start at 100 milligrams, 50 milligrams? Depending on your dose of estrogen, I typically start with 100 milligrams. Some people say if you're going higher with your estrogen, you may need to do 200 milligrams of progesterone.

That data is not very clear. And there's really do 200 milligrams of progesterone. That data's not very clear. And there's really two ways to give progesterone. You could do it every single day, so typically 100 milligrams every day. And then some people, and a lot of data shows if you do it cyclically, like 200 milligrams, 12 to 14 days out of the month is another way to do it. Both are fine.

When we see many patients, they feel better doing it 100 every day, because it can help with sleep and anxiety reduction. Do we believe that 100 systemically is sufficient to oppose estrogen? I think there is not enough data there and we need more. I think if patients bleed, it's a nice tell that maybe they need more progesterone. I think there's some interesting that I've learned that some people say if you take it with fat or you take it with something to eat, it absorbs better because progesterone is not absorbed very well, which is why we always had synthetic progestins in the first

place. And so we're still learning the capabilities of micronized progesterone. But according to most menopause specialists out there, they typically will use 100 milligrams every day or 200 milligrams 12 to 14 days of the month. So the only thing that we do, I would say, different there, is while we start women at 50 to 100, we will generally take them to 200 if tolerated, and if not, keep them where they are at 100. But we find women who are in that 1 third to 1 half group

who are very positively selected towards progesterone, they feel fantastic at 200. The most notable improvement is sleep. So would you agree with that? Totally agree. Most women are just over the moon with how well they sleep. They love you forever. It is so fun to get to see.

Hair gets thicker and mood improves. So now let's talk about the other subset of women. I mean, this is a real subset. No question. It's, I would say in our population, it's about 10 to 20% for whom, if you bring progesterone in the room, something goes wrong.

Their mood really changes. Now, it can, in some cases, become depressive, but more commonly what they tell me is, and I'm quoting them, this is not me saying it, I become a raging bitch. I'm quoting them, this is not me saying it, I become a raging bitch. I'm worried I might kill my husband. So for those women, we think progesterone is a bad idea.

And we then use a progesterone-coated IUD. So are you doing that or are you using a suppository at that point? You can do either. You can say, hey, try taking this vaginally and see if that goes away. See if you're no longer feeling anger or bloated or have irritability. And so vaginally can be an option. We love perjustin-coated IUDs. They're great in perimenopause.

Why? Because people think that you just lightly dance into menopause. It is like bloody murder hell scene. It can be terrible. You can bleed the whole month. You can bleed heavy. You can bleed when you're least expecting it. So the IUD is very nice because it will stop bleeding.

And so you throw an estrogen patch on and some testosterone and that's a really great perimenopause plan. Now you can still take- And you get birth control. And you get birth control, which is very important. You can add micronized progesterone to the patient who gets good sleep even if they have an IUD. That doesn't add danger. We love that. So we love IUDs for this population. There's another synthetic progestins which you

can use as well. I've seen people do things like slend which is a birth control, a progestin only birth control pill, add a patch and testosterone to that as well. Now again, synthetic progestins sometimes can have mood side effects as well. So, they're not completely benign for all people. There's another, I don't know if you've used this at all in your practice, it's called Duave. Have you heard of this? Yes. It's an oral estrogen, but it also has what's called basodoxaphen, which protects the uterus but is not a progesterone-based medicine. I wish they were separate. I wish we could just give basodoxaphenolone,

any pharmaceutical reps, so that you don't have to use oral estrogen if you don't have to. Oral estrogen is not evil. I'm a sex doctor and we know that transdermal's a little better for sexual function, so that's again why I'm a big fan of transdermal products as well.

But that's kind of another option. People get hysterectomies for lots of reasons. We've had patients do that who really don't tolerate progesterone and then you can just use estrogen only. Are you referring women who are on what potentially might be a low dose of progesterone to their GYN for endometrial ultrasounds on some regular interval just to look for hyperplasia or anything like that?

We really don't like to look for things. The nice thing about endometrial cancer, from what I understand, again, I'm putting my urology hat on, I am not a gynecologist, it bleeds. Now if you bleed, then if you bleed and you just started a new hormone therapy, it's probably okay. Now for me, I like to know if there's any structural things going on. Do you have a polyp? Do you have a fibroid?

Is your lining super thick? If you're in perimenopause, you still should be bleeding. So it's that challenge. I don't go looking for things that aren't bleeding because I don't necessarily want to find things. So no, at this point, there's not necessarily a reason for routine surveillance because if your lining is say six millimeters and you're not bleeding, are you really going to put that woman through a biopsy and through a hysteroscopy and those have significant pain and problems that go with that as well. Okay.

Anything else you wanna say about progesterone? Do you start it concomitantly with the estrogen? Do you like to start one before the other? I like to start one before the other in general because I like people to know what's doing what. I agree. When someone comes to see you, says give it all to me. It's always a disaster.

Every time, it's one time it worked well for me, but it's pretty much a disaster. So I like to stack it. And again, you're not going to cause endometrial cancer in three months of using just estrogen. I mean, you're talking something that takes years and years and years to develop and even that data is not that clear cut. So I'm not worried about me causing a uterine cancer. Now often we'll start with the estrogen. Sometimes we'll start with progesterone

if sleep is the major issue, but I find the vasomotor symptoms, it's such a big deal to get rid of those. So I do like often starting with estrogen and then slowly adding in the other ones. I'm really happy to hear. We're following your playbook already. So yes, we almost always

start with estradiol and we muck around for a while till we get it right. That's why I saved it for last by the way, because it's the hardest in my opinion and my experience to get right. Then we fiddle with progesterone and then testosterone if they're not already on it. But to your point, some women are coming into perimenopause already on testosterone. Okay, let's talk about estradiol. There are two other estrogens. Estradiol is E2, but there's estrone, E1, and there's estriol, E3.

Now, the FDA only has a battery of approved products around the second estrogen, which is the dominant estrogen. There's no FDA approved product for Estrone and there's no FDA approved product for Estriol, but there are plenty of compounded opportunities around that. In fact, the most common of them is referred to as BiEst, biestrogen, which is an 80-20 mix of Estriol and Estradiol. What is your take on why that product exists? Do you view that as a reaction to the WHI?

I mean, how do you think about it? You said it right there. I think that what happened is the Women's Health Initiative happened and hormone therapy all went into the underground. Went to the alley. It went to the alley. Yeah. And I think one of the ways that these back alley doctors did

it was saying, oh, we're using the safer version. We're using this compound, and we're going to make it 80-20, and we're going to use the more safer option. By the way, I haven't seen that data. And there is no data on biased enlarged trials that's going to really tell me what it does. And we're going to just use this. And that's what got people through for a while. And I don't actually blame those people if they

had no alternative. If I were in the middle of the desert and I had the options and I was having horrible symptoms and I had the options of nothing or a biased cream, I'd probably slather the biased cream on me. Where we are now, we have lots of options. We have FDA approved options and they're covered by insurance most of the time. So I don't prescribe it because I haven't needed to. Now, if I have a patient who comes into me and they're feeling great and they have no problems, do I have to change them? Well, I'll say, well, do you want to save some money? Like we could change you to a different formulation. That's an option. Sometimes I'll even check if, say, they're having symptoms, we'll check their levels. And I don't know if you find this but their estradiol level is

essentially zero, it's less than five and I'm saying listen I think you're just using fancy lotion. I think you're paying a lot of money to put nice lotion on you and I don't know that it's protecting your bones and if we're using this to protect your bones or to stop your hot flashes or to help with your sexual health maybe we use the formulations that are a little bit better studied and that I know are absorbing in your body because I can prove it.

And what's your take on that? We don't use it at all. I have used it occasionally in the past, probably about 10 years ago, largely in women who were terrified of HRT. And to your point, it was viewed as, look, if you buy the argument, and this is a biochemical argument,

there's no human data that demonstrate what I'm about to assert. And again, I say this because one can look at a whole bunch of biochemical charts and tables and talk themselves into anything being true. But there are biochemical charts and tables and talk themselves into anything being true. But there are biochemical arguments to be made that estrone, and in particular one of the metabolites of estrone, and I think it's 4-hydroxyestrone, is the estrogen that is

driving breast cancer. So in an estrogen-sensitive breast cancer, given that you have so many estrogens, is it more likely that one is responsible than another? And so the answer is, oh, you know, some of the data suggests it's 4-hydroxyestrone. Well, estriol has no biochemical path to even get there. In other words, there are no series of enzymes that can convert estriol into 4-hydroxyestrone. And of course, there are pathways that will turn Estriol weekly into Estradiol. So maybe you get a little bit more. So whenever... There's a long-winded way of saying no reason at all from an evidence perspective to use it.

We don't use it, have not used it in a decade, but that was my half-baked argument in certain situations. And in fact, I did use it once in a woman who had breast cancer, was adamant that she needed hormones. Symptomatically, she really seemed to, wanted it very badly, and I felt that this was a reasonable compromise. For what it's worth, she got insanely better on the biassed. How much of that was from the estriol? How much of that was from the estrriol? How much of that was from the estradiol?

I have no idea. When I teach this and I do a lot of teaching of physicians holding their hands saying, you can do this, you can write these prescriptions. And one of the things that I just keep coming back to is the sentence, what are you afraid of? And I love that because when someone says, well, can I do it in this patient?

Well, what are you afraid of? Can I patient? Well, what are you afraid of? Can I use this product? What are you afraid of? And it forces, I think in menopause medicine, the reason we're all struggling is we're not yet at an algorithm or a playbook, as you say, that it's a one size fits all. What's so sexy about this field is we actually

have to use our brains. We have to use our brains. We have to talk to people. We have to get to know what's bothering them, and we have to do the right tools for them, which may be different in each person, because you have to also understand what are your patients afraid of,

because that is the only thing that matters. We take risks all the time. I took a risk taking a car to get here. We take risks. If you ever drink alcohol, you are taking a risk. We all take these calculated risks and we all have different calculations. And so I love to push people of, well, if you were to use this, so patient comes in on biased, is that safe? Well, what

are you afraid of? Am I afraid I'm going to hurt this patient? I don't think I'm going to hurt them necessarily, but I don't know what's in that compound. I don't know if the top of the bottle is the same as the bottom of the bottle. I don't know if it's good for her bones. I don't know if it's absorbing in the way that it should be, but I do have studies on FDA-approved estradiol. And then it becomes, what am I afraid of with the patients? Well, what are you afraid of about the estradiol? Are you afraid of cancer? Because you know that in the Women's Health Initiative, people who used estrogen had a decreased risk of getting and dying from breast cancer. Our patients don't know this.

Yeah. And you mentioned this earlier. I think this is one of the biggest limitations of how I talk about this thing, Medicine 2.0, which is very few people are conditioned to ask the question, what is the risk of not acting? We have a reasonable idea of what is the risk of doing X, what is the risk of doing Y, although in this particular example, we seem to get that patently wrong. But what's the risk of not doing something is very significant. So let's talk about all of the different ways in which a woman can get estradiol through an approved, tested, chemically sound means. A little bit of nomenclature here. There is systemic estrogen.

So when we're talking about hormone therapy, whether you call it hormone replacement therapy, the new way we talk about it is menopause hormone therapy, or if you wanna just say hormone therapy is totally fine, we're talking about hormones for your whole body. Estrogen for your hot flashes, for your bone protection, for your skin, hair, and nails, that's estrogen, that's systemic estrogen. But there's this whole other topic which I hope we talk about later because it's my favorite

one, which is local vaginal hormones which are to treat the genital and urinary symptoms of menopause and those are pretty much safe, no no, I'm gonna say it, they are safe for every human on Earth, including your 99-year-old mother-in-law in the nursing home who potentially could die of a urinary tract infection. So this is kind of the two separate areas, and I think the question you're asking me is, let's talk about systemic estrogen.

Let's start with systemic. Let's come back to that as we talk about genitourinary syndrome. Because I got a lot to say about that one. So systemic estrogen has a toolbox. We have patches, we have gels, we have rings which go vaginally, we have oral estradiol. Those are the big ones. There are injections that's kind of an old school way that I use sometimes, injections

of estradiol valerate or sipionate. And so each one has pros and cons, and it's nice to have the toolbox because not every product works for every patient. And the key is, is getting it right for that patient because you need something that they're going to do and that they're gonna do it for a long time. Because these are not things that you just do for a weekend.

Let's start with the oral. So we have an oral formulated estrogen. We don't use it that much. I'm trying to think. Used to use it a bit more than we did now. Honestly, sometimes I would use it for women who we were struggling to get the dose right on something else, and I just needed something to get them through the weekend. And it was like, okay, I want you to just take a milligram of this estradiol tablet tonight

while we readjust your cream or your patch or whatever. When are you using oral estradiol? I don't use it much, but that's not to say that it isn't useful. I think it is actually very useful and I think it's underused. For example, people are used to taking birth control pills. They're used to taking pills. They like pills. Doing for a healthy person with no major risk factors of cardiovascular issues, taking an oral estrogen really is not going to increase your risk of blood clots or heart attacks or anything like that at any significant worrisome level. It's no more increase in risk of blood clot than a birth control pill.

Less. It's less. Yeah. So given the ubiquity with which women are on birth control pills, we tend to blow this high proportion. Yeah. So what is your patient selection criteria on that? In other words, who are the women that you would say, I don't want you on oral? Is this just factor V laden?

Is this women who are obese? Where do you say, ah, the risk is a little too high? I tend to always start transdermal. And again, this is my sex doctor hat, because we learned from this study called the KEEPS trial where they looked at oral estrogen versus transdermal estrogen and it's a fascinating trial but in that trial they found that yes, there's a slight increase of blood clots with oral estrogen but sexual function is better in

transdermal and that's because of what happens to sex hormone binding globulin. So when you take oral estrogen, we talk a lot about first-pass metabolism through the liver, it goes through the liver, the liver, lots of things go through the liver when you take medications. In this one in particular, it can pump out more clotting proteins, so if you're at any risk of blood clots, just like birth control pills, if you're a smoker, if you are overweight, if you have a genetic predisposition to blood clots, we're not going to use an oral hormone product.

Now I want to paint this because this is actually an area where I would love to see research. I was speaking at a Harvard testosterone course with Abe Morgan, Tyler and Mochera who you've had on the show and I was speaking about women's testosterone use. And the speaker who got up there to talk about transgender hormone therapy talked about sublingual estrogen. He kept referring to sublingual estrogen. And I ran to the microphone, I said,

what are you talking about? I've never heard of sublingual estrogen. There's no product. What are you saying? And he says, oh, you just take an oral estrogen tablet and you put it under your tongue like a tic tac and you let it dissolve and it doesn't go through the liver

and it works fabulously to increasing blood levels. And I said, oh my God, this sounds amazing. And it doesn't drive up SHBG presumably? Presumably, cause it doesn't go through the liver. Which actually, if you think about it logically, I love logic here, cause we don't have a lot of days, we love logic. Is it, well, if you take an estrogen ring,

a high dose estrogen ring and you put it in the vagina same thing you absorb estrogen vaginally what's the difference there right a sublingual estradiol so I think it's fascinating I don't have many patients on it but I would love to see data look in that direction because it's cheap oral estrogen is cheap you get lots of doses you can dose it does that mean you can get away with a lower dose you can get away with a lower dose? You can get away with a lower dose, absolutely. You must, right? Yeah.

Because of that first pass effect. So how do you dose it? Again, I don't have patients on this, and I haven't seen any studies on this. Did you ask this guy? Yeah, absolutely. How does he dose it? Again, transgender hormone therapy

uses much higher doses. So my guess is one or two milligrams BID is probably what they do. If I were playing with it, I would probably be nervous and I'd probably do 0.5 check levels and I'd do twice a day. Again, this is not what I do in my clinic, but just as we think through, what are you afraid of? What are you afraid of with this?

It's pretty fascinating stuff. Okay, let's talk about the panoply of topical ways you can do this, creams, patches. What are the challenges of using these things, how do they limit women's activity levels. I mean, I used to have this whole talk I would give women about what I thought was the best way to maximize the absorption of the cream

and what I wanted them to do before they put it on and I wanted them to have a shower and I wanted them to exfoliate their inner thigh and I just had this whole routine that was probably so elaborate that it decreased compliance because like... It's not that serious. All right, talk to me about it. But it is true for men in testosterone, we often find the topicals do not, some they

absorb beautifully and you get these beautiful levels and they feel great and then you do have a population that just doesn't absorb well through the skin and unfortunately we don't know who those people are. I always tell patients, here's the menu and we're gonna tinker. We have to tinker to get it right for you because you're not like anybody. And so patches, a lot of people have heard of patches.

They like patches, they make twice weekly patches, and they make once weekly patches. I find the twice weekly patches are much better tolerated and my patients like them better. What's nice about patches is you have a wide variety of doses that you can play around with. When I start patients on hormones, I typically choose like a medium to medium low version because if you go too high initially, they get breast tenderness and they get really

annoyed with you and then you have to backtrack. So I always like titrate up a little bit as we need to. So patches are nice, but for some people they don't stick well. For some people they don't absorb well. For some people they feel that they kind of drop off. If you change it twice a week, they feel like they're getting a little lower. We also notice women who use the sauna, who are very, very athletic and exercising like crazy, you just have an adherence, physically an adherence problem.

Yeah, and there are people who are allergic to the adhesives. We see that as well. So some people, they love patches. Again, you have to have a menu. If you're going to a doctor and they give you one type of hormone therapy and that's the only type, please run. They need to know the menu because it's not

a one size fits all. So there's gels, and there are a number of different gels. There's gels like the brand name is DiviGel goes on your thigh. There's Estregel, which goes on your arm. There's gels like the brand name is Diva Gel goes on your thigh. There's Estra Gel which goes on your arm. There's Eva Mist which is a spray, sort of an aerosolized spray that goes on your arm. Gels can be really nice because it's every day. So it's dosing every day. The challenge is sometimes they take a little bit to dry.

So if you're a busy person and you want to rub something on and you want to run out of there, I find gels not everybody wants to do something every day. You got to get to know the people. What do you like to do? What's your routine? You have to get it into their routine. And sometimes you got to work up to it. And sometimes I have patients, they'll use patches. But when the summertime hits and it's hot and muggy, they'll switch to the ring or they'll switch to a gel. What's the case for not just using the ring all the time? Oh, so I love the ring. There's two types of ring.

Now this is important because your pharmacist sometimes messes this up. So there are two FDA approved rings. Now a ring, just like a birth control ring, you set it and forget it. You put it in the vagina, the vagina does not feel it like a tampon, you don't feel it, and it just stays in for three months at a time.

And it's sitting right up against the cervix? You just kinda push it in there, and it just settles in and finds a place. By the way, if you have penetrative sex, most people don't take it out, they don't feel it. Nobody's bothered by this thing. So this ring goes in there, stays in for about three months. Now there is a fem ring, which is a high dose ring,

which means if you have a uterus, you need progesterone to protect the uterus, And it comes in two doses,.05 and.1. Then there's an E-string, which is a two milligram localized estrogen ring. You do not need progesterone if you have a uterus because it's just treating the genitourinary syndrome of menopause. So it's not treating your hot flashes, it's not protecting your bones, it's not gonna help your night sweats, but it's gonna prevent UTIs. It's important that you know the difference because the pharmacist sometimes won't

and he'll give you the wrong ring, which could be catastrophic if they think they have a systemic ring, but they have a local ring. And it's just dose is the only difference between the two. Yeah, they look a little different. Yeah, yeah, yeah. The reason one is systemic is-

It's a high dose and one is a low dose. But it's the same, you change them at the same frequency? Yeah, both three months. Okay. I thought you changed the East ring more frequently, but good to know. No, both three months. Now there's a company right now studying a product. I'm not at all affiliated, but it is a one month ring that has both estrogen and progesterone in it, which is very interesting. And I'm curious to see where the research goes with that. It's a one month ring. So the issue with the ring, I love the ring. Now there are women who you show them

and they're like, no, I don't want that. There are women who've used rings for birth control. They love the idea. I will tell you, and we've been hoping to publish on this clinically, again, I don't know about you, but my patients don't listen to the book. They don't read the book

and they don't follow the FDA curves, but my patients, it peters out. It literally stops working that last month. How long? Everyone's a little different, but I have patients where the FDA curves, but my patients, it peters out. It literally stops working that last month. How long? Everyone's a little different, but I have patients where that last month they are dragging. Their hot flashes come back. So why not just swap it every two months?

It's expensive. So a lot of times insurance doesn't cover the ring. It's about $180 cash price when you use an online pharmacy called Transition. It's expensive. Sometimes they'll slap a patch on or a gel at the time to sort of overlap. So they'll change it early, or they'll add a different therapy, Sometimes they'll slap a patch on or a gel at the time to sort of overlap. So they'll change it early or they'll add a different therapy or they'll stop using

the ring altogether. It is perfect for like two months and we'll check levels. Again, there's the book answer, the Instagram answer and the Dr. Rubin answer. This is where checking levels is actually helpful. I'm sure there are a couple of my patients that would actually volunteer to do this where we just do twice a week levels for three months while they're on a product, while they're on a ring, and just watch the curve. Oh my God, it's incredible.

Because you will see it, you'll check it, you have a 0.1 ring in and you should expect estrogen levels of 60, 70, something like that, and you'll see an estrogen level of 13. And you'll be like, oh my God, this is not working, right? And they'll complain of hot flashes, night sweats, their symptoms will come back. And so we see a lot of ring issues with dosing for that purpose.

And then another problem is if you have any kind of prolapse. So as people have babies, things can kind of prolapse. And so the ring can fall out during bowel movements, other things like that, if there's not enough space in there. So I had an ultra marathon runner. That can get expensive. It gets expensive. This is where checking levels is beautiful.

Marathon runner comes to me. She loves her ring. She's doing great. She messages me, oh my God, I feel awful. Something's not right. I don't feel like myself again. I said, oh, where are you in your ring? Where are you in the cycle of your ring?

We talk about it. I said, let's just check a level, see what's happening. Sure, estrogen was undetectable. I said, okay, we need to change this ring. And she messaged me, I can't find it. She can't find the ring. It's not there. She probably had a bowel movement.

It fell out. She didn't notice. And then her levels dropped. So it's where that detective work helps you kind of figure out what's going on with your patients. So the ring is not perfect for everybody, but I love the ring. If you're in perimenopause and you have an IUD, a ring, you put a little testosterone every morning,

it's really a set it and forget it. If you get vaginal estrogen, systemic estrogen, you get your progestin from the IUD, you add a little topical testosterone. Very low maintenance and complete solution. Yeah, and not expensive. Like you can do it relatively inexpensively. Two things I wanna talk about on the lab front.

We've talked a lot about labs. So not sure if you share our view on this. We are really fastidious about using LCMS for estradiol. We do not want to use the ELISA-based assays at all. Are you pretty meticulous about that, or do you find that you're just happy checking any estradiol? I typically get the sensitive estradiol level. Yeah, that's what we get for everybody.

And same with the testosterone as well. So let's maybe make that a PSA for people, both physicians who are out there and patients. We have seen that if you do not use the LCMS assay, which is the very sensitive, the liquid chromatography assays, the results can be meaningless. And I mean truly meaningless. The reason is that the ELISA-based assays are so susceptible to interference from other

molecules. There are some really known obvious supplements that completely obscure the findings. Biotin, which is in a lot of things, will render a non-LCMS test irrelevant. But I think there are other things that we're just not fully aware of. So it is worth splurging and paying the extra, maybe it's five or $10, it would be the cash price difference on that test. But absolutely make sure when testosterone and estradiol are being measured, if you're the physician, you actually have to go through the hoops

and make sure you're ordering the LCMS test. And if you're a patient, you actually have to go through the hoops and make sure you're ordering the LCMS test. And if you're a patient, you should be asking for it. So we're going to get a lot of hate. There's a lot of disagreements when it comes to hormone therapy, how to properly do hormone therapy, how to check for hormone therapy. And one of the places, and it's funny because I truly believe, and for anyone who's going to say mean things about me on the internet from this podcast, I truly believe that actually most of us agree on like 98% of this. Truly we want women feeling better. Most of us believe the data that hormones, the benefits outweigh the risk. And so I think 98% we agree.

There's the 2% where there is disagreement and part of it is also in the what we don't know yet, the unknown and the curiosity and sort of things and lab testing is one of those issues. The book says never check labs. If your doctor checks labs they are really doing something wrong. You should only care about symptoms. And then you have sort of the fringe that are doing all saliva-based testing, every-minute check labs, do all these expensive labs which I do not agree with. Again, the Instagram answer, the book answer, the Dr. Rubin answer of sort of there are

reasons to check labs and I do find labs similar to you. My curiosity with labs is so fascinating. When you can capture this perimenopausal fluctuations and show the patient the reason you feel so terrible is because your estrogen was a thousand and now it's zero and that hurts. Now do I need numbers to know that that's what's happening? It actually helps patients quite a lot for them to look at this and see the data. What is your take on that? I'm actually surprised, but you have to understand I don't spend any time paying attention to

the buffoons in the periphery on this topic. I don't like the whole terminology around functional medicine. I don't buy into the idea that you need to be spending an inordinate amount of money on esoteric, non-validated labs. You can go to LabCorp, you can go to Quest, you can go like any CLIA approved lab that knows how to do an assay correctly is all you need. Our view and what we tell patients is the symptoms are the most important things, but

the numbers help direct my thinking. This is how we manage thyroid, this is how we manage sex hormones. And to be clear, there's a caricature of the Dunning-Kruger curve that I just find so helpful. So for the folks who aren't familiar, on the x-axis, you have experience. And on the y-axis, you have confidence. In the sort of character version of the representation of this curve, you initially have a huge spike,

which then falls into a valley and then a slow rise. Of course, the huge spike is referred to as the peak of Mount Stupid, followed by the Valley of Despair and the Slope of Enlightenment. It's just important for people to understand that when you are on Instagram and YouTube, disproportionately you are seeing people at the peak of Mount Stupid, which is to say they have very low experience, insanely high confidence. And these are the ones that are telling you that TSH, I'm making this up as one example, TSH must be between 0.4 and 1.9.

And if it is any bit above 1.9, you have hypothyroidism, and you need to be on armor thyroid or natrathroid or whatever. And it's sort of like, no, none of that is correct. And you just have to take care of enough patients for enough years to get humbled enough to know that whatever you think you know with rigidity is probably wrong.

You've seen all my gray hair that I've grown. It's true. I find, again, that humility of medicine is, I am famous and my patients love me because I spend a lot of my day saying, we don't actually know. This is a data-free zone. Here's what I think.

Here's how we're gonna use logic. Here's the tools in our toolbox. But there is that ability to really know the data so well, to truly understand. There's a lot we need to figure out. And that's why I have a research group. And that's why we're trying to answer these questions, because we have more questions than we have answers. But I also need to get my patients feeling as good as possible.

And that is addicting, to be honest. Yeah. So here's what we do. We focus relentlessly on the symptoms. And we care what the estradiol level is. We also think the FSH is a very helpful marker. So if a woman's FSH is 78 and her estradiol is 40, I'm inclined to believe she needs more estrogen, especially if she's saying, I think I feel a bit better, I'm just not sure.

Like to me that says, I'm gonna go more. And by the way, with the labs being where they are, I'm more inclined to push a little bit. But again, nothing tells me I've given her too much estrogen more than her saying her breasts hurt. And that's the advantage of doing it with these short term estrogens, because I can pull it back really quickly.

So I don't know if that answers your question but I would consider myself an essentialist on labs, kind of a minimalist essentialist but not an absolutist in either direction. I love that and I think it's such a reasonable and logical the logic there it makes so much sense to me so we're totally in line with that and that's why again it's very confusing for our patients on social media because they want the exact answer and you're not gonna find your exact answer from one doctor on social media. Oh my gosh you said that I have to use an estrogen gel but I use a patch. Should I switch to a gel? Again it's not that serious. There

is a menu if it's working for you and you feel like you're getting what you need. Now it's good to get educated and learn about all the different options so that you can see what's right for you. But I think expecting that one doctor gives you all the answers is not going to happen. Anything else you want to say about systemic therapy before we go and talk about local therapy in the context of genitourinary symptoms of menopause? We haven't spent a lot of time really talking about the symptoms of menopause.

What are we treating? Why do people need systemic therapy? I'm often saying that menopause has the worst PR campaign in the history of the universe. Why? Because we think it's for old people, and we think it's just hot flashes. And we think hot flashes go away.

There's actually not enough education. We can argue about E1, E2, and E3, but the reality is doctors don't even know the symptoms of menopause. Patients don't even know the symptoms of menopause. The person who was doing my makeup this morning, she's like, I just feel awful. I feel like an old person.

I'm not sleeping. I'm not fun anymore. I can't drink. Joints are achy. And as a welcome to you need hormone therapy. I'm always teaching no matter who I'm not fun anymore. I can't drink. Joints are achy. And as a welcome to you need hormone therapy. I'm always teaching no matter who I'm with. Whether it's a cab driver, a hairstylist, I'm always teaching. But this idea of you have hormone receptors throughout your whole body.

It is a whole body experience. So yes, there's hot flashes and night sweats. And by the way, hot flashes are not just a nuisance. That is a neurologic, vasculogenic probably event. The worse your hot flash is, the worse your risk of cardiovascular issues and things like that. Joint pain is a huge one. I never thought as a urologist I would treat so much joint pain.

Never in a million years did I think I cared about joint pain and yet patients come in all the time and say, oh my God, I don't get out of bed feeling old. I don't feel creaky. My joints recover again after I exercise. Again, empty gas tank inflammation. I think hormones are nature's joint fluid, if you will. So almost like brake fluid. Go back to the car analogy.

We are gonna milk the heck out of this and I love it. So it's really cool. So your eyes need lubrication, your ears need wax, your vagina needs lubrication. Your joints actually need lubrication. And so need wax, your vagina needs lubrication, your joints actually need lubrication. And so think of horny teenager, you've got oils, oily skin. So hormones create these oils, vaginal lubrication, oil for your skin. There are androgen receptors in your eyeballs, right, in these myobian glands. So I think of hormones like fluid. So as you lose the hormones or the hormones go too high

or too low, it dries everything out. And so you get joint pain, you get frozen shoulder, you get plantar fasciitis. And now it was recently published on by my colleague, Vonda Wright, the musculoskeletal syndrome of menopause. This idea that so many women in their 40s and 50s, everything starts to break down,

it's because the gas tank is empty and that inflammation increases. It's such a simple analogy. So what are the symptoms? You've get musculoskeletal symptoms, sleep issues, mood issues, bleeding changes, obviously low libido, orgasm problems, arousal problems, pain with sex increases like crazy.

I sent you a list here. What am I missing? You've got a list there. Dave Korsunsky Irritability, very common one. One that I was going to ask you about is brain fog and depression. This is one where I think this is a very unique one because it's one that gets easily dismissed as something unrelated. Say more about those.

Dr. Julie Korsunsky It's one of the most common symptoms. All women start going to doctors in their 40s. Like doctors, I know you're listening and you get so many people and every day you say, oh it's probably hormonal but you're not giving them the solution. You're just telling them it's not cancer. So the neurologists are seeing all these patients to rule out cognitive decline or all these other issues but really it's that brain fog because your brain is filled with estrogen receptors. This is crazy research.

Okay, I don't know if you've had Lisa Musconi on, but here's this researcher from Cornell, neuroscience researcher who says, hey, I want to study Alzheimer's. I want to do this. This is just in the last couple years. And she goes to her lab manager and says, okay, what's the assay for estradiol in the brain? I need to look at estradiol receptors in the brain. And the people at Cornell was like, that doesn't exist. She's like, what do you mean that doesn't exist? She's like, how can we not look at

estrogen receptors in the brain? So she gets Maria Shriver to give her a giant amount of money who gives her a huge amount of money. So she now develops this assay. This is only within the last couple of years. She just published in Nature very early findings. What would you expect? Your body is efficient. It's not gonna do things it doesn't need to do. So the hypothesis was that as menopause gets later and later, the estrogen receptors in your brain

are going to down-regulate. Why have receptors around when there's no estrogen to feed the brain? What did she find? The exact opposite. That actually, even up to 65, she stopped looking past 65 because she's like, there's no way that's gonna matter. The increase in receptor density, the older you get,

and it correlates to brain fog, correlates to all these symptoms. My reading of that was estrogen is so important in the brain that it has to upregulate the receptors as the estrogen level goes down and down and down. Every morsel. In other words, it's a lot like the way the brain is treated for glucose.

The body will, if you are fasting, the muscles will within days become completely insulin resistant. It's their way of saying every molecule of glucose that that liver spits out better not go into the muscle, it better go to the brain. And so you look like you have diabetes in an effort to save glucose for the brain. And I think that's what's happening with estrogen.

And could you argue that weight gain in menopause is evolutionary so that you make more estrone or whatever, right? That then goes to the brain because it wants every morsel that it can get. So this idea of hormones matter for the brain deeply. This is very important. This is fascinating research, but you're going to see a lot of, again, think of a receptor as perimenopause is happening. The receptors are full.

Now they're empty. Then they're full. Now they're empty. Now they're half full. Now they're empty. This is why we see ADHD pop up in perimenopause. All these women are saying, I have now new diagnosed ADHD, it's real.

Why? Because your brain is having a panic attack because it's just trying to figure out some stability here, which is why actually in empty gas tanks, so in menopause where you are totally empty, the brain fog gets better. The volatility of hormone gets less, yeah. But if we just, all I'm saying is just add some estrogen to just keep the receptors happy.

The other one that we didn't talk about was the urinary symptoms. So both urinary incontinence and then the higher prevalence of UTIs. You've alluded to it a little bit, but just maybe finish the swing on that. Okay. So this is my favorite topic in the history of topics, because we used to call this problem, initially it was called senile vagina. That was the initial, yes, there was papers written on the senile vagina.

I don't even understand what that means. An old vagina, I suppose, but then it got changed to vulvovaginal atrophy or atrophic vaginitis. That was the terminology that was used. I'm familiar with that term. Up until 24, before that it was senile vagina. I totally missed that. Check the history books.

They're very fascinating. So vulvovaginal atrophy was sort of the common name of this. Of, OK, as you get older, the vagina atrophies. It shrivels up. It shrinks up. Again, if a penis shriveled up at age 52, we'd probably have a vaccine sponsored by Pfizer. They created Viagra.

They would create this vaccine. I love that analogy. So you're saying if by the time a man became 50, his penis became a shriveled up useless organ, you're saying that the medical system would have probably done something about this? What do you think, right? Tell me what you think.

You might be onto something, Rachel. This is the thing. We just called it vulvovaginal atrophy. And we said, well, if you have pain with sex or a little vaginal dryness here's some moisturizers here's some lubricants here you go if you're really bothered really bothered you gotta be really bothered then there's this thing called vaginal estrogen that we could give you. Now here's the crazy part of this it's not just a little vaginal dryness. The vagina and the bladder need

hormones. Babies don't have hormones and that's why you see it's red, it's irritated, they're these small little labia minora. Diaper cream was invented because it looks so painful. They pee their diapers all the time. The genitals morph and change with hormones. Puberty happens and you have a change of the genital and urinary system. What happens is as you lose hormones, it goes in reverse. It changes the microbiome. The hormones keep the tissue acidic. It grows the healthy lactobacilli. It is the vagina is supposed to be acidic, it's supposed to be able to fight infection and without proper hormones, you lose that ability to fight infection.

So you see urinary frequency, urinary urgency, vaginal dryness, increase in leakage, increase in urgent continence, and recurrent urinary tract infections, which can and do kill people. We've known this since the 90s in the New England Journal of Medicine. Actually this was on Estriol. They looked, you could reduce the risk of urinary tract infections by well over 50%. We have known this all along. And that was with topical Estriol. Yeah. Interesting.

Yeah. I was not aware of that. And yet there is no FDA approved Estriol formulation despite that fact? Yeah. Correct. I think it's available in Europe. So the name got changed in 2014.

2014, a bunch of people got in a room, and they said, you know what, this vulvovaginal atrophy thing, that's kind of a bad name because it doesn't describe what's really happening to people. So they changed the name to Genitourinary Syndrome of Menopause, GSM. Now there was one urologist, my mentor was in the room, and they almost didn't put the word urinary in it.

And he fought and he yelled and he screamed, this is the power of one person to be able to change the whole world. And they said, okay, we'll listen to you, we'll put the word urinary in it. And I'm so glad they did because the urinary problems are the things that kill people. People are dying of urinary tract infection.

In fact, a large amount of money goes to Medicare expenditures when it comes to urinary tract infections. And we published last year that if Medicare patients use vaginal estrogen, which is safe for everybody, and $13 a tube, we would save Medicare between six and $22 billion a year, billion. Just say that again, please, because I know there are people that are in the Medicare system

who are gonna be interested to understand that. When you do a low-dose local vaginal estrogen or DHEA product, you can reduce your risk of urinary tract infections by more than half. They are safe to use if you've had a history of blood clots, breast cancer, whatever medical problem you can come at me I can tell you that it's safe. It will not only help with lubrication, help with pain with sex, help with urinary frequency, urgency, leakage, but it will reduce your risk of urinary

tract infections by more than half. It's also inexpensive and covered by your insurance. If everybody in Medicare eligibility used vaginal estrogen we would save Medicare between six and twenty two billion dollars a year and in my opinion that is a conservative estimate because of how many patients are getting urinary tract infections. They're going to their doctor for cultures. They're in the ICU with sepsis. This is a huge economic morbid and mortality problem that we are dealing with and no one cares.

I mean, again, I always try to come up with the steel man and say, is it that they don't care or is it that they're unaware or is it that they feel That it just needs to fall on the shoulders of somebody other than themselves. I think we have a marketing problem I truly believe this is a marketing problem. Okay, let me push back Not because I don't agree with you, but I'm just gonna put my hat on that says the opposite So maybe I am too attuned to this, but I feel like there is nothing more talked about right now. I mean, look at what Halle Berry is doing.

Look what Oprah is doing. Look what Gwyneth is doing. I mean, there are so many very powerful, very influential women that are talking about this. Is this not in the zeitgeist right now? It's getting better. But again, they don't know how to write the prescriptions. So you're saying there's not enough physicians talking about this? Yeah. If it really comes down to prescriptions.

If you can't get them, it's not over the counter. If you can't get the prescription, or if you don't go to your doctor saying that you need it, we had an Instagram reel just yesterday that the patient said, my friend went to her doctor, said she was having pain with sex, asked for vaginal estrogen and her gynecologist said, and I quote, you need to think of other ways to change your relationship from now on. It's not in the cards for you. What does that mean?

Meaning you can't have sex anymore. You can't have sex anymore. And the fact is it's not about sex, it's about urinary tract infections. Wait a minute, wait a minute. This is impossible for me to fathom. A woman went to her gynecologist and said, I'm having pain with intercourse. Any idea how old this woman is? In her 60s. OK.

And you think this gynecologist doesn't know about estrogen? Honestly, I don't know anymore. It's incredible. So we could argue Viagra. 1998, Viagra comes out. Viagra changed the world. Billions of dollars. What is Viagra? It is Viagra comes out. Viagra changed the world, billions of dollars. What is Viagra?

It is a PD-5 inhibitor. It relaxes smooth muscles of the penis, increased blood flow, gives you a rigid erection. So it helps with arousal for men, OK? If you take it microdose, low doses, it can also help with BPH or urinary problems. We love Viagra. We love Cialis.

Wish it was in the water. We should study it in women. I did in medical school. Oh, I'm gonna talk about that. But I will argue, we've had Viagra for women long before. We've had Viagra for men, and we've known about it since the 1970s, and Viagra for women is vaginal hormones. What do vaginal hormones do?

They relax the tissue, they increase arousal, they increase lubrication, they increase orgasm, they help with urinary symptoms, so they do everything Viagra does and they prevent urinary tract infections. Viagra doesn't do that. So you're talking about better than Viagra. It's inexpensive. Now, it didn't used to be.

So when I got out of my training, a tube of Estrace was $500. Now because of people like Mark Cuban and GoodRx, and I've talked to Mark Cuban on my DMs and Twitter and he knows more about vaginal estrogen than 90% of doctors, but this idea of it's not expensive, a tube of estrogen is $13. And you're saying that the reason that this price has come down is I know Mark is a very hard liner

against the PBMs. Did Mark basically take a sledgehammer to that? Yeah, yeah, they changed the game. Awesome. And so it's incredible, oh my gosh, it's incredible. And he understands this. He literally understands the nuances. Awesome. And so it's incredible. Oh my gosh, it's incredible. And he understands this. He literally understands the nuances of why vaginal estrogen is so important. I can't get doctors to do that.

I think he's incredible. So we have a marketing problem. We have a product that is better than Viagra for women. It's been around longer than Viagra. It's inexpensive. What are we missing? It's marketing. We're not telling the patients.

We're not telling the doctors. And we have a box labeling that says this product causes stroke, we're not telling the doctors, and we have a box labeling that says this product causes stroke, heart attacks, blood clots, probable dementia, breast cancer, and needs to be taken with progesterone. Not one of those statements is true. Not one. Okay, so we went to the FDA and says, you gotta remove the box. You're killing people.

And the FDA said, nah, we're gonna leave the box on. This is a nightmare. Can I just tell a very personal story? I promise it won't take long. My mother just died in November. We spent six months in the ICU in Houston, Texas. Six months my mother, nobody should be in an ICU for six months. It was absolutely gut-wrenching, horrible time for me. My mother had been on vaginal estrogen because I want her to prevent UTIs for many, many years. You know, she's a 70s for many, many years. She's a 70-year-old woman, many years. So she gets into the hospital, has a transplant,

has a catheter, and isn't doing well. Is on ECMO and very sick for a very long time. And I said to the doctors, I said, I know this isn't the most important thing in the world, but I'd like to restart her vaginal hormones because having a catheter, being in an ICU, and being immunocompromised, my mother's risks of a urinary tract infection are incredibly high,

and a urinary tract infection is going to kill this woman. So I would like to restart her vaginal estrogen. And because menopause medicine is a tiny little field in a tiny little corner, they looked at me like I was an insane person. They said, what do you mean? Your mother's very sick right now. I said, I know my mother's very sick right now,

and this is one thing I can control. I sort of did a do you know who I said, what do you mean? Your mother's very sick right now. I said, I know my mother's very sick right now and this is one thing I can control. I sort of did a do you know who I am because I'm on the guidelines committee for GSM for the American Urologic Association. So for the transplant team I had to write up a whole s-bar of like here's why it's important, here's the research, here's all the literature, here's the citations and they said but it'll increase her risk of blood clots. I said no it won't. Vaginal hormones don't increase your risk of blood clots. It said, no, it won't. Vaginal hormones don't increase your risk of blood clots. It's like hydrocortisone cream compared to a Solu-Medrol.

Those are very different things. So then they went to the ICU team. They said, no, we can't give this to her to increase her risk of blood clots. Had to convince them. Then the pharmacy, they finally got them to write the prescription. I had to teach them how to write the prescription.

Pharmacy wouldn't dispense it. Why? It increases the risk of blood clots. It says so right on the box. So I had to call and yell, right? I'm trying to run a practice in Washington DC. My brother and father are trying to advocate with me because they know they also follow me on social media. They know this is important. Finally, the pharmacy dispenses the tube of estrous. There's no applicator. The nurses don't know how to give it. I had to show them and teach them how to give my mother, who is on ECMO and ultimately passed,

not from a UTI, thank goodness, but had to show them how to dispense. I had to do all this being one of the leading educators on this topic. What does everybody else do? And guess what? The teams changed every week. We had to do this every week and to teach them why this was important and how to do this. Vaginal hormones should not be gynecology.

It should not be a small subset of menopause medicine. We could save Medicare between six and $22 billion a year if people understood this, if the box labeling weren't on there. I mean, it is so personal at this point, and yet it is horrible. Well, I'm very sorry to hear that story, both at the personal level, but also at the meta level

of what is implied. I want to clarify one thing, Rachel. If a woman is on a high enough systemic dose of estradiol, does she also need later in life local estrogen? Maybe even not later in life. So we find that systemic hormones are not often enough to help with the genital and urinary symptoms. Most doctors don't know this.

Again, what are you afraid of? You're not adding any systemic risk. It doesn't increase. If your estrogen level's 70 on your patch and you add a vaginal estrogen, her estrogen level's gonna stay 70. You're not gonna get that systemic absorption, but you are gonna reduce your UTI rate significantly. Has that study been done?

That would be a super interesting study. Think of how easy it would be to do a study where you took a group of women that were all at systemic target of estradiol and you randomized them to a placebo vaginal cream versus an estradiol, and you randomize them to a placebo vaginal cream versus an estradiol vaginal cream, you could follow these women for a year if they were in a susceptible enough population, and you would get a very clear answer as to whether or not you're getting additional UTI protection.

And if the answer to that is yes, just imagine the implications there. At that point, it becomes malpractice. We just published a study that DHEA does the same thing. It reduces the risk of UTIs by more than half. Why is DHEA doing it? So they've looked at a lot of oral. You probably know this data better than I do. Oral DHEA, the data's all over the place,

because your adrenals are pumping out a lot of DHEA. But when you put DHEA vaginally, the idea is that your vaginal enzymes convert it into both estrogen and androgens. And what's so fascinating is we know that the vagina, the vulvar vestibule, the clitoris, the bladder have androgen receptors. So us using just estrogen in this tissue may be missing the whole point. We do have patients that benefit from having an androgen in the tissue as well. And the only FDA approved product we have is IntraRosa, which is vaginal DHEA.

Now it's often hard to get for patients. If I could get it for everybody, I would. It's fabulous because the tissue needs androgens. The data is very good. We've just started using it, so I don't have a lot of experience with it. So there is some data, not a lot, but there's data that shows someone with urgency,

give them vaginal estrogen, switch them to DHEA. It'll help those people who still have urgency. Do you think it gives you the same UTI protection? We published on this. So we just published in the Menopause Journal that it shows the same decreased risk of UTIs by more than half. So that was a very proud publication that we just put out. We use it frequently. What's nice about the product, it's a nightly product. It's DHEA and palm oil, so it's very moisturizing, very lubricating. And my mentor, Erwin Goldstein, published that actually it also helps the tissue called the vulvar vestibule.

Do you know what the vulvar vestibule is? Well, I know what the vulva is, and I know what a vestibule is. I don't think I know what the vulvar vestibule is. So I'm obsessed with homologues. Homologues are sort of this idea of, I'll give you an example, the penis and the clitoris are exactly the same thing. Yes, yes, sorry. No, no, no, that's okay.

They're homologues of each other, right? The head of the penis and the head of the clitoris, homologues. So it's what part of the body in one is the same in the other. So the homologue of the scrotal skin is the labia majora. Majora, yeah. Okay, you're with me? The prepuce or the hood, the clitoris and the penis both have a prepuce or a hood to it.

So there's a line that goes down a penis that goes down the penis and the scrotum. Do you remember what that's called? Median raff. Yeah, you got it, raffae. Yeah. Okay, so the median raffae is the line that goes down the penis and the scrotum,

straight line right in the middle. What's the homolog in the vulva? I just learned this. Oh, well it must be the vestibule. No. No, I don't know. Close, labia minora. Okay. So it's skin, it's ectoderm.

So it is skin and we're split open. So if you take the median raffae and you split it, that's your labia minora, which very hormone sensitive. I'm not on TikTok, but I am trending on TikTok because I talk about the labia minora shrinking and disappearing in menopause and the internet has broken because of it. So the labia minora is very hormone sensitive tissue

that we do not study and we know almost nothing about, but it resorbs in menopause. Inside the labia minora, so if we cut into the median raffae in a man, and we do this when we put in penile implants or we do urethral surgeries, we get to the male urethra. So Peter, your outside of your cheek is skin, the inside of your cheek is different tissue. One's more sensitive, one's thicker. So the skin of the median raffae is very

different than the skin of the tube of your urethra. You agree? For sure. So if you split open the labia minora, you get to the urethra, and that is the vulvar vestibule. So the tissue that surrounds the urethra in a woman that goes all the way around, and I will show you nerdy anatomical diagrams when we're done here, because I need you to know this,

that is the female urethra. It's called the vulvar vestibule. It is made up of endoderm So we think of the cervix as a transition point But the most important transition point that affects sexual health in a woman is when you go from ectoderm of the labia minora To endoderm of the vulvar vestibule and then past the hymen is mesoderm. It's fascinating anatomy Why is this important? Super compressed. It's so important because if you push with a Q-tip on the labia minora, they'll have no pain. If you push them on their vulvar vestibule, they'll say, that's my UTI,

that's my interstitial cystitis, that's the pain that I have with sex. It is rich in hormone receptors. This is why 50% of women go off their endocrine therapy for breast cancer, because they have urinary symptoms, pelvic pain symptoms, and it is all sourced in a body part that no one taught you in medical school and I did that on purpose because I knew you wouldn't know it because no one has taught how to examine it. They put a speculum in and they bypass it completely and they are missing the problem. Back to the DHEA, this tissue has estrogen and testosterone receptors in it. So sometimes estrogen is not enough to help this vulvar vestibule tissue. And so DHEA,

there's some data, there's one paper to suggest that DHEA is enough. And this is the one time that I will compound a product for a woman. Otherwise, I use FDA approved products in my practice and I compound basically the amount of estrogen and estrogen vaginal topical cream, the.01% and I will use a topical testosterone.1%, different than the 1% we talked about for libido, but a.1%, they rub it topically on this vulvar vestibule, you cure pain with sex, you help these UTI symptoms,

interstitial cystitis goes away in so many patients. It's miraculous. Sorry, tell me again, 0.1% T? And what was the percent DHA? 0.01% estradiol, and we typically use a versabase or a methylcellulose base. And no DHA in that? No, but I would love to see that studied.

And what's the base? It can be usually a methylcellulose or a versabase. There's a base called Elage that a lot of people are using right now. Again, I am not a compounding junkie in any way. This is a miraculous compound that literally will, if you have a patient who's on vaginal estrogen, systemic estrogen, systemic testosterone,

and they say, Peter, I still have pain with sex. It still kinda hurts. It's always the vestibule. This is super interesting. Isn't it fun? There are three other questions that I wanna ask you going back to hormones post-menopause. I'm saving the three most contentious questions for last on this topic.

Question one, someone's posing this question to you, not me. I buy your argument that hormones are safe, but I am now 56 years old. I finished menopause at 49. Isn't it too late to do anything about it? So we have this idea in menopause medicine called the timing hypothesis. Or the window idea, right? The window or the timing hypothesis.

So the question of the timing hypothesis is what are you afraid of? What are we worried about? We're worried about blood clots. We don't want to hurt people. We're worried about cancer. We're worried about blood clots. We're worried about heart disease.

But the question is, is does the hormone therapy that we use apply to the data that we have? And I would argue it doesn't. And so there is a level of we don't know what we don't know. But even the timing hypothesis using PremPro, which was the medicine used in the WHI, is under question. So Susan Davis from Australia just wrote a big paper questioning the timing hypothesis and say, actually, when you look at the data really closely doesn't really hold muster. We shouldn't

really be forcing people to say you cannot start hormone therapy after 60. So I think this is where shared decision making really comes into play of what are we treating? Do you care about your bones? Do you care about your sexual health? Do you care about your mental health? And do you want to see if hormone therapy helps with these things? Now hormone therapy is indicated for three reasons. Vasomotor symptoms, hot flashes, night sweats, that sort of thing. Prevention of osteoporosis, which to me is a green light, so anyone should be offered hormone therapy because who wouldn't want to prevent osteoporosis?

And the thing I just talked about a lot is the genitone urinary syndrome of menopause. So anybody of any age, and I'm talking even perimenopause and premenopause, vaginal estrogen or DHEA is safe and really helpful to prevent UTIs and should be used absolutely everywhere. Throughout life. Throughout life. Okay. Now I'm going to ask another question that is the extension life. Okay, now I'm gonna ask another question that is the extension of that question,

but I think your logic is gonna hold the same, which is the hedging strategy, which says not only use as little as possible for as short a duration as possible, says you really need to stop this after 10 years. So even if you were lucky enough to catch a woman through perimenopause, you got her on hormones

by the age of 49, now that she's 69, you gotta stop it, right? Definitely not. So that's really, there is no data to suggest stopping it. In fact, stopping it, all of your bone gains go away. They all go away quickly. By the way, that was the argument put forth to me with one of the authors of the WHI,

who is by far the most willing to concede that mistakes were made, which was, okay, yes, I will concede that the estradiol is doing amazing things for the woman's bones, but remember, they're gonna go away when you stop the hormones, as though that was a necessary thing to do. So keep them on.

Again, this idea of if it's not broke, don't fix it. By taking a woman off of hormone therapy, you actually potentially could be disrupting any plaques that are there. You could be causing vasospasm. Like there are all these things that could happen. We really don't want to take women off their hormone therapy unless there is a reason to. And the only reason I honestly see is if a woman has an active cancer that you are going to target hormones

as a target for your treatment of cancer. That's not to say the hormones cause the cancer, but we have a target sometimes because all body parts have hormone receptors and we have used hormones as a target for our breast cancer therapies and some other cancer therapies. Is that helpful?

Does that make sense? Yes, and it actually dovetails perfectly into my third critical situation, which is how do we manage hormones in women who are at risk of breast cancer from a familial standpoint, who have been diagnosed with DCIS, which is not cancer, but increases the risk of cancer. So that's kind of a subset of the first group. And then in women who actually have breast cancer or have a history of treated breast cancer.

So I would imagine you see women that fit into all four of those buckets. How do you handle it? So first, we take a long time at my clinic, and we get to know each other. And we really try to dive into the data and say, what do we know? What do we not know? And I always tell people, you can't take hormone therapy because Rachel Rubin

tells you to take hormone therapy. You have to do your own research, figure out what you're interested in. And so I have a lot of colleagues who are talking about this. You had Avram Bluming on your show and he has a great book called Estrogen Matters. He's an oncologist who's questioning a lot of this research. We have amazing colleagues of mine like Corinne Men, who is a gynecologist who had breast cancer as a young person in her 20s, and now takes hormone therapy and talks a lot about hormone therapy

and teaches courses on hormone therapy and breast cancer. So I am always learning. So I don't like fear. I don't like telling women they can't do things with their body. I like understanding, well, what are we afraid of? So when it comes to the BRCA patients, if you do surgical menopause on someone and they don't have cancer and you do not give them back hormone

therapy, you are trading one problem for another. You may give them extra life from a breast cancer perspective but you are shortening their life from a bone health and a cardiovascular disease perspective. That is very clear. So the other problem is the DCIS. If you are not going to give someone endocrine therapy of any kind and they're done, they have surgery, they're done, there is no reason why they can't take hormone therapy. And then when it comes to active breast cancer, there is a lot of emerging questioning in this patient population.

And again, the question is, if you're allowed to get pregnant, are you allowed allowed to take hormone therapy and that's really the pushback that we give some people and I think there's a lot of data that we need here but we need to be asking these questions. I'm a urologist. When I came out of my training it was testosterone fuels prostate cancer. Now ten years later it's you have prostate cancer sure we can give you testosterone no problem. If you have metastatic disease, we target testosterone, so we're going to use castration level androgen blockers. But that doesn't mean if you have localized disease that you can't have testosterone therapy. So we think of testosterone and prostate cancer as a saturation model concept.

And I actually think we need to be using that model potentially when it comes to breast cancer and have more logic and understanding and less fear. It's marketing. All prostate cancer is testosterone-sensitive prostate cancer. But we don't cut off testicles for the fear that an abnormal cell will happen in a prostate.

A lot of breast cancer is estrogen-receptive breast cancer. Not all of it, but some of it is. That-receptive breast cancer. Not all of it, right? But some of it is. That doesn't mean estrogen causes cancer. It's insanely helpful. And of course, it echoes exactly what Ted Schaeffer said when we spoke about this after discussing the Traverse trial, which was, I think, to me the most telling thing that Ted

said was, look, if I have a man who's got a Gleason 3 plus 3, means he has prostate cancer and we are going to follow this, and if it becomes a 3 plus 4, we're gonna actually have to take this thing out. We'd put him on TRT if he needed it. And his argument was exactly your argument on the pregnancy side, which is the reason we would happily give him TRT is, let's just assume he's a man replete with testosterone. Would we castrate him during that period of time of observation?

Of course not. So why would I not give him testosterone if he needs it, even though he actually has prostate cancer? And this is again where that patriarchal divide happens is we're willing to take those risks and focus on quality of life when it comes to men's health. We castrate women with the mere thought that they may develop an abnormal cell in their body and completely ignore their quality of life and all of those things that go with it. And women are more than breast tissue.

They are so much more than their cancer risk. And we have to understand and actually have these reasonable conversations with women. And what I say is your oncologist is not in charge of you. They give you advice. It's like a pit crew. Let's go back to our car model. You have a pit crew, but you get to decide who's on your pit crew and who fits into your pit crew.

But it can't be just one doctor. You may need someone to talk about your sexual health. You may need someone to talk about your menopause hormones. You may need a bone doctor. You may need a heart doctor. So you need to collect your pit crew, but with one doctor says, no, you can't do this with your body.

I don't like that terminal. I don't think it's fair anymore. And when you give women information about how their bodies work, they make great decisions for themselves. They can look at the menu and say, listen, I'm most worried about Alzheimer's and I've looked at the data and this is what I choose to do.

Or hey, I'm more worried about osteoporosis. Listen, my grandma broke a bunch of ribs. She had Alzheimer's and osteoporosis and my grandpa hugged her and she broke a bunch of ribs. That's not how I want to age. So what do I care about? I don't want to get osteoporosis. I don't want to get dementia.

And I've seen all the literature, hormoneormone therapy sounds pretty good to me. And that's really the key. I think there's a lot of people on social media maybe negative about hormone therapy. But if you look, they are on hormone therapy themselves. They will say they have an estrogen patch on. Because I don't pay any attention to social media, there are people out there saying they're anti-HRT,

but they use HRT. What's their argument? What are they talking about? This idea that we are overselling HRT, that not every woman needs HRT, but they... Use HRT. What's their argument? What are they talking about? This idea that we are overselling HRT, that not every woman needs HRT. And I'm not suggesting every woman needs HRT. But I want every woman to be offered the menu. I want them to know what they are. Just like I want people to know how to exercise and lift weights and eat healthy.

Here's the menu. If you choose to smoke and drink and do drugs, that is your choice, but I want you to know that the menu exists. 06. What do women need to be aware of? Not every woman can come and see you. Not every woman has access to a doctor who has the breadth of knowledge that a select few do in this space.

So A, how can women find practitioners near them? And what do they need to be aware of? What are the exploitative practices out there that they need to be mindful of and not get duped into either dangerous therapies or overly extractive therapies? I think there's danger on both sides. There's danger going to the doctor for 10 minutes and saying, oh, that's not safe. You don't want to do this. And there's danger on both sides. There's danger going to the doctor for 10 minutes and saying, oh, that's not safe. You don't want to do this. And there's dangers of going to the very expensive pellet clinic that is going to overdose you and charge you lots and lots of money.

So I like being somewhere in the middle and getting a few opinions here. So this is where opinions can be a bunch of people on Instagram. Don't just follow one people, follow a bunch of people. If you like books, there's tons of books now on menopause. What are some of your favorites? You've got Mary Claire Haver is the most popular book called The New Menopause. Heather Hirsch has a great book called Pick Your Menopause Type. There's been a hot and bothered as journalists wrote a great book on Perry Menopause, Jancy

Dunn, Tamsyn Fadal just wrote a book about menopause who's also a reporter. Estrogen Matters is a great book, a really great book. There's a lot of books now, thank goodness. There's one called The Menopause Manifesto. There's great books on menopause. There's also podcasts now. There's great podcasts out there. Oprah just did a special.

There's documentaries on PBS now. So menopause is having a movement. So you can't have this excuse anymore of, oh, my doctor doesn't do this. Go find a different doctor. There are telemedicine companies. And what's the website? So menopause.org is the Menopause Society website.

That doesn't guarantee you have someone who knows everything. But menopause.org means somebody took a test and put some effort into saying, I care about menopause. I'm on that website. But iswishisswsh.org is the Women's Sexual Health Society. So people who we care about menopause and sexual health. So, that's a great place to find a provider. So, those are two websites that can help you find someone.

Again, you have to advocate for yourself because no one will do that other than you. And so, I think the more you educate yourself, the more you can find the right people in your pit crew who are gonna fill that gas tank and get you to where you wanna go. Do you feel that there are too many women that are still getting their hormone therapy in the dark alley with highly sus individuals?

And if so, what would be a clue that you're in that camp? Because there's nobody that's in that camp that knows it. I want a woman who's watching this, who's not getting great medical care, but thinks she is to maybe get a bit of a hint as to what that might look like. I think this is a problem. When your doctor says, no, you can't have anything, that's suspect. If your doctor says you can only have this really expensive product that has to be inserted

into your butt four times a year and you have to pay me thousands of dollars, that's extremely suspect. If they say you have to pay lots of money for this special compounded product that's safer and more effective, I call red flag on that situation. If you have to give very expensive saliva testing labs and they're making you pay a lot of money, very suspect. Again, that doesn't mean you can't do it. If it's working for you and you're happy, you have body autonomy. You do what you want, but know that there's red flags there. I think the pellet industry, I have a big problem.

We have an FDA approved pellet for men. It can be FDA approved. I am not upset with a pellet as a concept. If the pellet companies cared about women, do the studies, go through the FDA, show me it's safe. It's billion dollar industry. If you believe that it's the greatest thing in the world, show me so that I can start using it

because the FDA is a pretty good compounding pharmacy. So do the work, I have my beef with the FDA, hello, you need to take that box labeling off estrogen products, especially vaginal estrogen. But if the pellet companies deeply cared about women, which they say they do, do the work. Everyone takes advantage of women, all the supplement companies, they take advantage by promising these things to women, which they say they do, do the work. Everyone takes advantage of women. All the supplement companies, they take advantage

by promising these things to women, but they don't do the work of science. So that's what I ask, is just do the work. Rachel, as expected, this was a fantastic discussion, and I think it adds to what we're trying to do in this podcast, which is really have nuanced and deep discussions about important topics. Not every podcast I do gets to impact that many people. Some of them impact nobody. They're just really esoteric, but they fit into my curiosity window. But this is kind

of a topic that really impacts almost 100% of the population because 50% of the population, because 50% of the population is who we just talked about. But the other 50% of the population would be hard pressed to say that they don't care about at least one person in that other group. So 100% of people are heavily impacted by what we just discussed. Can I say one thing real quick? I'm also a men's health doctor,

and I lecture my urology colleagues. And I say, and you talk about longevity, and here are the things you can do for longevity, I think you're missing one point. And that is that men who are divorced, single, or widowed have horrible health outcomes, horrible. Whether you look at mental health, prostate cancer,

cancer outcomes, horrible. They die sooner. So if you want longevity, if you wanna keep living, you have to keep people partnered. And when do people get divorced? Between 40 and 60. That is the age of perimenopause and menopause. Menopause is killing men.

It is killing men because it changes their marriages and it leads to divorce, which leads to death. I give this lecture, if men's health doctors, if doctors truly cared about keeping men alive, they would do menopause medicine, because that is one of the most important ways to keep men alive. So that's my other argument for you,

to focus on this and really make change here. And I just can't thank you enough for this platform, because it is everybody's problem. Rachel, thank you very much for the work you're doing and thanks for coming today. Thanks for having me. Thank you for listening to this week's episode of The Drive. Head over to peteratiamd.com forward slash show notes if you want to dig deeper into this episode.

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