ou’re giving your female patients testosterone. I am. Why are you giving them testosterone? There is no Wow.

0:05 Not all men suffer from low testosterone. All women will go through menopause. From 1999 to 2020, menopause

0:15 hormone therapy dropped almost 30%. So the women’s health initiative did more damage towomen’s health and hormones

0:21 than any other single study in the history. When someone is in menopause, should

0:28 they wait? I hear a lot of people say, “Well, I want to wait.” Wait for what? These things don’t get better.

0:34 I see a lot of providers putting patients on estrogen cream. We don’t recommend it.

0:39 Every female listening to this podcast needs to be taking notes and considering this no matter where they are in
their

0:45 life cycle. All women should have vaginal estrogen. And when they are entering menopause,

0:50 vaginal estrogen with also testosterone will prevent vaginal atrophy.

0:57 Women are not nearly as studied as they should be. It’s embarrassing. It’s actually embarrassing how little we know

1:03 about women in relation to the science of this stuff. We cannot stop menopause or menopause, but we can get ahead
of

1:09 it. Just for the ladies out there listening, we’re never going to treat menopause. It’s happening.

1:19 [Music] Gabrielle, want to talk about estrogen.

1:24 What are the most common kind of signs and symptoms that a woman is low on estrogen? Number one, you won’t believe
this and

1:30 this might be very surprising, but when a woman is going through menopause, one of the first signs she will be
getting

1:36 hot flashes. You’ve heard about hot flashes. Maybe you’ve even seen it. Have

1:41 you ever seen a hot flash? I have not. Uh, you know, we live in Texas. It was

1:47 very hot here. But before moving to Texas, I was in New York and nobody was walking around with little those

1:52 handheld fans. Have you ever seen that? I know that. Yeah, the handheld fans. Yes. A sure sign and symptom that a

1:59 woman is going through menopause. Okay. Yeah. No, not not funny but true. Um, one of the most common signs or even

2:08 symptoms that a woman is low in estrogen, hot flashes, also joint pain,

2:13 believe it or not, frozen shoulder. Frozen shoulder. Yes. And I learned this from uh Joselyn,

2:18 Dr. Joselyn, who she’s an orthopedic surgeon who was recently on the show. And I didn’trealize that when women are

2:25 going through musculoskeletal pain, it’s not just overtraining. Go figure.

2:31 Then why aren’t more women on estrogen? Well, I’ve got actually some numbers

2:37 here for you. Are you ready for this? I am. Okay. From 1999

2:42 to 2020, menopause hormone therapy dropped almost

2:48 30%. Why? Why is that? From the Women’s Health Initiative. So, it was 26.9% down to 4.7%.

2:56 Holy smokes. Yes. So, the women’s health initiative did more damage to women’s health and

3:01 hormones than probably any other single study in the history. You thought

3:06 castrating men? Yes. because you thought castrating men was bad. The Women’s Health Initiative

3:12 left 20 years of women from being treated for menopause. Meaning, you ask

3:19 me what the signs and symptoms are. Hot flashes, brain fog, mood, poor sleep,

3:26 all of these things can be contributed to low estrogen, not to mention change in the lipid profile.

3:32 a woman’s life who is going through symptoms of menopause is again it is so

3:39 challenging and I’ve seen it and it it really affects their lives. Could you explain for the audiencethe

3:44 the women’s health initiative that was looking at the relationship between estrogen and cancer if I remember
correctly? Yeah, women’s health initiative did a

3:51 number of things and the thing about the women’s health initiative is it used

3:57 premodile which is what we now use. So, Premro and

4:02 then it used a synthetic progesterone. They found that it increased the risk of

4:08 cancer and it was for example, I’m looking at this here, a higher risk of

4:14 um thromboembolism, stroke and breast cancer. When that happened, they created a mass

4:22 hysteria and it really turned people away. Everybody So, so the baby got thrown out with the bath water.
everything got

4:27 thrown out which I think is devastating because we’re seeing rates of

4:32 osteoporosis and dementia Alzheimer’s dementia in at

4:37 rates we haven’t seen before and it could have been prevented the average

4:43 age of enrollment by the way for the women’s health initiative was 63 that’s 12 years past normal menopause a
woman

4:48 typically begins menopause and menopause is a big termit’s around

4:54 menopause a woman could have these symptoms for 10 years. Wow.

4:59 Yeah. Really, really bad. But the thing is is that the Women’s Health Initiative

5:06 equated this Prem Pro and synthetic progesterone.

5:11 with hormone replacement therapy and it really turned people away. So, just to be clear for the audience,

5:17 they should not use that as a reference point. No, it dropped hormone replacement or

5:23 menopause replacement therapy by 60%. It left millions of women undertreated.

5:29 So, now that the audience has been educated and we’re looking at this, what are some of the options? What are some

5:34 of the delivery options for a woman who’s considering going on estrogen? Well, first of all, you don’t do
estrogen alone. You go to your provider,

5:42 you get total estrogen, estradiol, progesterone, you get FSH and LH.

5:48 Typically, those numbers will increase. They’ll become high when you are in menopause. And around menopause,

5:54 they’ll be all over the place. Testosterone. Testost erone. Yeah. Free testosterone and sex hormone

6:00 binding globbulin. All of which are important. These hormones are so important for women, not just for brain

6:08 and bone and heart health and of course lab values, but also vaginal estrogen.

6:14 One of the things that I hear all the time in my clinic and strong medical is that sex becomes painful or women
are

6:19 getting more UTI. And then to top it off, they also can’t train and are

6:25 gaining weight. Wow. Yeah. It’s interesting. Not all men will

6:31 suffer from low testosterone. All women will go through menopause. And yet from

6:38 based on the statistics, a smaller percentage of them is going to get treated than men despite the fact that

6:44 every woman listening to this podcast is either going to experience this or experiencing this now or it’s only a

6:51 matter of time. Yes, you would definitely go if you are a woman, you will definitely go through menopause. And
now we’re seeing a

6:57 resurgence of the conversation around menopause, which is so important in menopause because there’s a lot of

7:04 myths out there and especially with the delivery system for fertility

7:10 and for pregnancy. So if a woman doesn’t want to become pregnant whenshe’s

7:15 young, she’s typically put on birth control. Yes, birth control will increase sex hormone

7:21 binding globbulin, which think about it, hormones are like kids. We have kids, both of us.

7:26 We do. Uh we do. And they can’t go anywhere alone. Same with hormones. Hormones

7:32 don’t go anywhere alone. But when you increase sex hormone binding globulin, you make free hormones less
available.

7:39 Which means from a young age, if women go on birth control, then she will

7:44 likely require, for example, testosterone to have a higher dose of

7:50 testosterone than she would normally to get the same result. Wow. I I don’t think that’s discussed a

7:55 lot. No. Yes. Um what is definitely not discussed is that birth control while important that

8:02 when you are taking an oral agent, it can affect the microbiome. Actually, we

8:07 worked on a study with the legendary I’ll roll my eyes Andy Galpin Kristen Holmes. We just uh recently

8:14 published a study on that. But I saw that. Yeah. It affects the microbiome. Also will irreversibly increase sex

8:22 hormone binding globulin. And again, someone will say, well, isn’t preventing pregnancy important? Yes, but there
are

8:27 other ways to do it, like an IUD, which is the merina, a non hormonal IUD. If a

8:32 woman is entering menopause and is starting to get increased

8:38 bleeding, an IUD can be very helpful if she doesn’t want to take the pill, which personally I don’t recommend,
but again,

8:44 you have to look at your blood work. No, that’s that’s great. Hormone replacement therapy isn’t an option for

8:49 somebody. Are there are there any natural treatments that uh women for menopause? For menopause, HRT-AMA- The
Truth About Hormones.docx

8:55 we’re never going to treat menopause. It’s happening. Uh you’re never going to stop it. And I was

9:02 recently at this amazing event. Um I went to a place called Newtopia, which

9:07 actually I came over to your house to practice this talk and it was this talk about conscious consumerism. One of
the

9:15 things that I kept seeing was take this for hormone balancing, this food for hormone balancing. That’s the wrong

9:22 message. Hormones being quote balanced. What What does that even mean? The

9:27 outcome that we’re looking for probably in younger women is fertility. Polycystic ovarian syndrome is the

9:33 number one cause of female infertility, which in a large part is related to the health of skeletal muscle. No
amount of

9:41 supplements is going to fix that, but a good diet and training regimen will

9:46 help. Which again, I know that we’re talking about menopause and hormone

9:51 replacement therapy. Estrogen and progesterone and testosterone are not used to treat body composition for

9:59 menopause, which people will say, I’m going through menopause. My body is is changing.

10:05 Estrogen should never be given alone. It should always be given with progesterone.Progesterone protects the

10:12 uterus and the endometrium. Delivery systems for estrogen. Someone

10:17 listening to this, our number one delivery system that we like in the clinic is an estrogen patch. Now, we live
in Texas.

10:23 Yes. Which means it’s hot. And if you are swimming a lot and going in the sauna, you might find it not great for
you.

10:32 Then then what do you do? Yeah. So if if you’re using an estradi patch, what’s what’s you mentioned one mistake
you

10:38 HRT-AMA- The Truth About Hormones.docx avoid swimming a lot. A great question. Actually, I called Dr. Rachel
Rubin. I don’t know if you know Dr. Rachel Rubin. I do think she listens

10:45 to this podcast. Rachel, I’m looking forward to seeing you at the North American Sexual Medicine meeting,

10:52 but she said she’ll use injections. And if someone cannot tolerate a patch, then

11:00 potentially an estrogen injection. I think that it’s a little volatile for people, but

11:07 estrogen patch is the number one way to go. People ask me all the time what kind of protein powder I use. And in
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12:29 and use the code drlion for 20% off. So for the uh injections, how do you do

12:35 that? Is that subcutaneous or intramuscular? You can do all hormone subq

12:40 and you could even mix it with your testosterone. Whoa, whoa, whoa. And also guys, we’re not giving medical
advice, but we get so many questions on

12:47 hormone replacement therapy or menopause replacement therapy. And because of all the myths out there, I thought
we could

12:54 break down a little bit what we do in clinical practice. No, but I I want to go back to that and

12:59 and you know, pump the brakes. You just said testosterone in terms of hormone replacement therapy

13:06 when we’re talking about the female patient. Yeah, you’re giving your female patients testosterone. I am. Why
are you giving them testosterone?

13:12 I don’t want to say it’s because it helps their husbands feel happier. I’m just kidding. I’m totally kidding,
guys.

13:17 Um, testosterone is really important for women and it’s important for sex drive.

13:23 It’s important for muscle mass. There is no FDA approved testosterone

13:29 for women. Even though we can treat hypothyroidism

13:34 with thyroid hormone, we can treat menopause with estrogen estradiol,

13:41 but there is no FDA approved testosterone per women. Do you think there’s just

13:47 such a like a stigma with testosterone in women or just lack of understanding? All of it. I was shocked when I
started

13:53 treating women with testosterone. I was shocked at how little data is out there.

13:59 And actually, we’re working on a study at Baylor on um safety profiles to really help move the needle for people,

14:05 but in the US, it is not prescribed nearly as much as it

14:10 should be. There is no FDA approved indication. People typically give testosterone off

14:18 label for hyposexual desire disorder. Is that is that the only reason? I mean,

14:24 not if you’re in my clinic, but that is really one of the indications which is

14:30 unbelievable to me. Yeah, that that seems a little sexist, right? In terms of that’s that’s the

14:36 only reason people are prescribing it to a female. Well, the uh off label indication, but HRT-AMA- The Truth
About Hormones.docx

14:42 when you think about it, testosterone is important not just for men, but also for women.

14:49 And there are testosterone receptors everywhere. One of the things that I always hear for from women is that

14:55 they’re afraid to go on testosterone because they’re afraid of losing their hair, getting acne,voice changes,
that

15:01 their clitoris will grow. If you are being treated by a physician who is

15:06 tracking your blood and you are given appropriate doses, not super physiological doses, you should not have

15:14 a problem. And then for their labs, are there any values that hard and fast? Are

15:20 you just looking at the holistic patient kind of profile every time or are there their numbers that you know
kind of like

15:25 the males have the 300 ngs per deciliter, what does the female have? Typ and that’s a really challenging

15:31 question because we don’t have great data for women. The typical dosing strategy is onetenth amale dose.

15:37 Okay. If a man gets 100 milligrams of testosterone, a woman should get 10, which that would beon

15:44 the highend for us. The best delivery system for testosterone in my opinion is

15:50 a subq weekly or bi-weekly injection, which they could do also with their estrogen if they don’twant to do the

15:56 estradile patch. So, it’s all at once. They could. And you’re probably thinking, um, what would you start with?

16:03 Yeah. Are you wondering what you would start with? I am wondering what you start with. I would typically start a
woman on testosterone before. If she is younger

16:11 and she has not gone through menopause and looking at her labs, she has low libido. Why is libido important to

16:19 treat? Mental health. There’s a lot of other factors land Gabrielle.

16:24 HRT-AMA- The Truth About Hormones.docx I know just setting you up and that that is also hilarious. Um, think
about this.

16:30 The relationships, having a good relationship with your spouse is everything. It means everything. You’re

16:35 not going to be able to live well if you are constantly at odds with your spouse. Now, I’ve been a

16:42 doctor for well over a decade. There is two things or there are two things that

16:48 people that couples fight about. Money and sex. I can’t help someone’s financial

16:54 situation, but I definitely can help their sex life. Okay? And it is a couple’s responsibility, a

16:59 couple’s disease. Then I want to say disease, but um hyposexual desire disorder would be it has to last for at

17:06 least 6 months and um it’s not just a fluctuating libido and it’s not just in

17:12 her head and oftentimes it has to do with hormonal changes. Wow. No, that that’s great and I’m sure

17:18 um very helpful for a lot of the listeners. What about so when the a female goes on testosterone, are there

17:24 any like body composition changes? Are there any other things? cuz you you mentioned some of the masculizing uh

17:30 effects of testosterone. What what can a female who wasn’t on testosterone expect once she goes on testosterone?

17:36 What I have seen is that women’s muscle mass can increase if they’re training. You’ll also see her recovery is better.

17:42 For a woman going on testosterone, I think it’s really important to manage expectations. When women come into our

17:48 clinic and they say, “I’m going through menopause. My body composition has totally changed.” when they start

17:56 estrogen, progesterone, and testo sterone, we typically don’t see a change in body

18:02 composition if that’s all you’re doing, which and I can’t give you an answer as to why, but as opposed to say a
male, we

18:08 HRT-AMA- The Truth About Hormones.docx were talking about that other study you put a man on testosterone goes
up, muscle goes up,

18:13 but also the dose is so much different. The dose is onetenth a male dose

18:20 when she is training and her diet is together. We do not necessarily see a negative

18:28 change in body composition through menopause. And that’s probably one of the most commonthings that women will

18:34 say, “I’m going through menopause. Let’s take away hot flashes.” Hot flashes, brain fog, thosetwo, listen, we
hear

18:42 that all the time. But also, women really struggle with body composition changes around this time. And the
question is, is it related to

18:49 hormones? Probably. But once you replace those hormones and her symptoms are better, if

18:55 she is not training, eating well, and drinking less, we won’t necessarily see

19:02 changes in body comp. Yeah. So, you got to do it. But I mean, it makes sense because, right, like estrogen is
going to affect insulin

19:07 sensitivity. So, less estrogen, less insulin sensitive. So, I mean, it it would make sense that you improve that,

19:13 you can improve body composition. I I know we’re talking about menopause, but

parmenopause, like is there like
19:19 fertility? Like what’s what’s that look like? if the woman still wants to conceive. Are you guys planning on having more kids?

19:24 No, we are not. Um, this is a great question. A woman who is going through menopause, which

19:31 menopause is that time around menopause can happen that can last 10 years. The

19:37 average age of menopause is around 50, which is so disappointing. It’s happening. And I do think just for the

19:44 ladies out there listening, we have to accept it. And it it kind of sucks

19:49 because with lower estrogen, our skin changes, our joints change, our hair

19:54 changes. And how can we stop that from happening? Well, we cannot stop

20:00 HRT-AMA- The Truth About Hormones.docx menopause or permenopause, but we can get ahead of it. What do I mean by
getting ahead of it? If a woman is

20:06 having symptoms, but still menrating, let’s say her periods are terrible and

20:11 she’s not sleeping, we would start with progesterone first for sleep. micronized

20:16 progesterone and that is given orally. I see a lot of providers putting

20:22 patients on estrogen cream. We don’t recommend it. We recommend micronized progesterone.

20:29 The absorption is better. Also, uh functions as a GABA aagonist, helps

20:34 people sleep. There is also progesterone troies. And I’m going to give you another tip. Postpartum. Some women
that

20:41 go through really bad postpartum depression, sometimes providers will give say just a shot of

20:48 progesterone, 200 milligram shot and that can help with postpartum depression. Wow. And the the cream is that
just an

20:54 absorption just a Yeah. And also the metabolism cream is interesting. It’s really tough for

21:00 people. Now the delivery mechanisms for hormones, let’s think about what they are. Injectable,topical, and oral.

21:09 injectable. There’s a lot of es and flows because you inject it. There’s a

21:15 peak in a trough. Topically, you have less

21:20 ability to control the delivery system. Here’s why. And I’m saying delivery

21:26 system, that’s not the right word. For example, an estrogen patch. And I’ve used estrogen patches. I switched
from

21:34 the vial dot to generic. And I looked at my numbers and my numbers didn’t change. It was because my skin was not

21:40 compatible with that patch versus a Vivevel Dot. And again, I have no

21:45 relationship to these companies. The skin quality and the kind of skin you

21:50 have makes sense. Plays a role. Yeah. Thicker skin or, you know, for whatever reason. You mentioned those
HRT-AMA- The Truth About Hormones.docx

21:56 other delivery methods when we were talking a little bit about testosterone. What about uh the nasal? Is there a

22:02 nasal estrogen? There is. I do not use a nasal estrogen. What a great question. Why not? I don’t know. I I don’t know because the

22:09 patch works so well. I don’t recommend estrogen cream because think about it, the patch exists. Have you ever
seen

22:16 estrogen patch? I don’t think I’ve ever seen one in person. No. The patch has the designated amount as

22:23 opposed to the cream. The cream is it’s totally messy. You might do two pumps and maybe you got this time you
got a

22:29 bigger pump than I can see that. But the absorpti on for estrogen cream,

22:34 I’m not a fan. What I love estrogen cream for and I think all women should have vaginal estrogen and when they
are
22:42 entering perry menopause vaginal estrogen with also testosterone and even DHEA in

22:50 the cream will prevent vaginal atrophy and protect people from UTI.

22:56 Wow. Is that compounded um that combination or or is there a product out

23:02 there that already does that? We typically use compounded. But every woman listening to this who is going

23:09 through menopause or someone who is suffering from UTI. Number one, do not get constipated.

23:16 Constipation increases your risk of a UTI. Believe it or not, it it affects the anatomy. And number two, estrogen

23:24 cream is really good for the flora. Wow. For the vaginal flora. Yeah. Didn’t know that. Thanks to one of the

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26:17 we talked about with with males, are are there any supplements or anything like

26:22 that that are out there for um estrogen production or things that you put females on that you’d recommend?

26:28 DHEAS is one of the agents that we use. Okay. believe it or not, because I kind

26:33 of poo pooed any kind of oral hormone balancing, but DHEA definitely

26:39 can be used and we use anywhere from five to 10 milligrams depending, you

26:45 could even go to 20. Sometimes women will get some acne from it, but there is

26:50 potential evidence for it to be supportive DHE use in women. Also, we

26:55 were talking about hyposexual desire disorder and the genital urinary symptoms of menopause. There is an FDA

27:02 approved vaginal DHA insert which it’s 6.5 milligrams and it is called intraosa

27:10 and it’s indicated for post-menopausal women with painful sex and vulvo vaginal

27:18 atrophy. the DHEA versus just the estrogen because my understanding the DHEA it can go to

27:24 estrogen or testosterone. So is that just kind of given the body um for lack

27:30 of better word like the substrate to produce what it needs to produce in the ratio that’s needed. But also keep
in mind if a woman is in

27:36 menopause DHA is separate and that’s one of the the blood markers that we HRT-AMA- The Truth About Hormones.docx

27:41 measure. I don’t know if I mentioned that earlier. We do measure DHEA. DHEA can beimportant for inflammation as

27:47 well. Wow. If a woman is on estrogen, progesterone, testosterone, and you

27:52 measure her DHA and it’s low, definitely supplement it. But I also want to be clear in terms of expectation,

27:59 a woman who is in menopause isn’t going to take DHEA and all of a sudden feel

28:05 better as if she is on a menopause replacement therapy. DHEA is always used in conjunction.It’s

28:13 never like a monotherapy. It can be. Okay. It can be when you’re young, but again

28:18 define young. That’s right. That’s such a good tricky question here. Um, when you are young

28:25 and you are making hormones, you have a lot of flexibility. As you get into menopause,

28:32 you’ll see that sometimes cycles become irregular. You will see sleep gets

28:38 disturbed. But if you measure your blood work, the blood work, you might go to the doctor and the doctor might
say

28:44 you’re fine. And you go, you know what, doc, I’m just having brain fog. I’m not feeling well. And you have to be
able to

28:50 treat symptoms. And one of the ways that we and there’s various ways to measure, you know, you can do it very

28:56 complicated. There are month tests. Can you imagine testing urine or blood

29:03 levels for a month to see what your markers are? That’s not fun. Um, not fun. But I think that figuring

29:09 out how you feel as a woman and understanding that there is a cyclical

29:14 nature and starting I think progesterone which is protective uterine protective

29:21 can be very helpful. And our starting dose for women again we use a micronized progesterone. It could be 100 to
200

29:29 HRT-AMA- The Truth About Hormones.docxmilligrams. Women with endometriosis seem to respond really well with
micronized progesterone. And it’s a it’s

29:36 a great place to start. very safe. Again, right now we have a landscape of

29:42 coming out of being afraid for the last 20 years. Yes. And and so in that same vein, I

29:47 have a a female friend who went to their physician and asked about these things

29:53 and we’re immediately shut down. immediately shut you’re fine. Everything’s with the normative value.

29:59 So I want to ask you, you know, how do you recommend that patient who maybe went out and asked their provider
about

30:05 these things we’re talking about and they get shut down immediately to tactically push back and then is there a

30:10 point or cut off point you would recommend they go find a new provider? Probably immediately.

30:15 Okay. I mean because part of being a physician and you know this you see you

30:21 don’t see patients but you have clients you know as a a ranger and dietician and

30:26 you know taking care of high performance individuals it’s a team sport. If someone is coming in and saying hey
I’m

30:32 going to give you an example. Are you ready for this? Yes. I know a patient. She’s postmenopausal

30:38 and she missed the quote window of opportunity for menopause treatment.

30:43 There is information out there that once you are 10 years past menopause that you

30:48 cannot be treated with hormones. Well, think about all the women that missed. That that doesn’t seem right.

30:53 Right. Part of it was the increase in coagulability with an oral agent. There

30:59 was concerns about blood clots, strokes, but we have to recognize that number one, women are not nearly as
studied as

31:06 they should be. It’s embarrassing. Yes. when you go back and you look, it’s it’s actually embarrassing how
little we kno HRT-AMA- The Truth About Hormones.docx

31:13 about women in relation to the science of this stuff. And number two, there is

31:20 a lot of information that’s taking a long time to get out. For example, oral say oral birth control might
increase

31:27 coagulability, which is the clotting in your blood. But there’s very little evidence that an estrogen patch
because

31:34 of the delivery method increases coagulability or again people are concerned about uh

31:40 DVT. So back to the story, this woman um who’s postmenopausal said, “I chew a lot of nicotinegum.” And the
provider said,
31:48 “Well, we’re not going to put you on estrogen because of it.” But the reality is we have tore-educate and
understand

31:56 that is I appreciate the safety of that but we have to recognize that the

32:01 information out there is not the same. It’s not just about estradile. It’s also

32:07 about the delivery mechanism from a safety standpoint. Estrogen especially delivered in a patch is very very
safe.

32:14 So with that and kind of back to that case a woman goes into the physician she’s experiencing this. What should
she

32:21 say? I mean, is there kind of a a for lack of a better word, a script or or words she should say and then you’re

32:26 saying if that physician immediately like shuts you down and they’re like, you know what, you’re you’re you’re

32:31 fine. You’re not in a disease state. Yeah. Um go you would you would say immediately go and look and try to find
another

32:37 provider. I would there’s two ways to looking at preventative care

32:44 and medicine. Again, there’s probably a lot more than two ways, but there is the

32:49 physician that is going to treat you for a cold, treat you for things. You’re coming in, you’re sick, I’m
treating

32:54 you. Yeah. And then there are the physicians that are thinking long term. For example, we HRT-AMA- The Truth
About Hormones.docx

33:01 know men opause is coming. Hot flashes are real. It’s not just hot flashes. It’s osteoporosis. If someone falls
and

33:09 breaks a hip, it’s not just I have brain fog now. We’re talking about Alzheimer’s later.

33:14 If you treat these things early with velocity, then your chances of living a

33:22 long healthy life and one that is enjoyable increases as opposed to, you

33:28 know what, you’re not there yet. Your FSH and LH are not

33:34 really high. Your estrogen is not zero. Why would you wait? No, that that makes perfect sense.And

33:40 so is there a a a resource or kind of a place for women interested in this what

33:47 we’re talking about to find these more forwardthinking preventative physicians that are out there?

33:53 Um well we we treat it in our clinic strong medical but also you can look at

34:00 there’s various organizations of physicians that are trained in menopause treatment. Again, there’s the Endocrine

34:07 Society, ACOG, NAMS, NAMS. I don’t know who came up with all these uh acronyms,

34:14 but yes, and I will say that people will go to non hormonal medications. If

34:20 someone says, “Well, you know what? I’m having hot flashes.” Someone might say, “Okay, well,let’s put you on an
SSRI.”

34:26 Well, or I’m depressed. Let’s put you on SSRI. as opposed to just like with men, if a

34:34 man is depressed, well, we check his testosterone or we should be. We should do the same forwomen for sure.

34:40 Wow. I didn’t even think about that. So, that that is really um a great point to highlight is some of these
psychological

34:48 issues that we that we may see that we’re going to psychotropics could actually be fixed viatotally hormone

34:54 therapy. Totally. And the other thing is the next question is um when someone is in

35:00 menopause, should they wait? I hear a lot of people say, “Well, I just I I want to wait.

35:05 Wait for what?” And I and I don’t mean to be negative. Not getting better, but these things don’t get better. You

35:11 are not I mean, could you suffer and go through hot flashes? Totally could do that. Will your brain fog
stabilize?

35:18 Maybe. The next question is, how are we also going to protect your bone? Do you need to train? Yes. Could you
just take

35:25 hormones and be better? No. You have to have these lifestyle factors in place. But the conversation needs to
change a

35:32 bit in the way that certain things are not going to get better. You are going to have less estrogen. You will
have

35:41 typically less progesterone. Your testosterone may go down. These are not

35:47 things that through a flower or an herbal tincture or psychotherapy is

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36:55 your first order. That’s thisisneed.com. This is really

37:01 exciting and eye opening because basically every female listening to this

37:07 podcast needs to be taking notes and considering this no matter where they are in their their life cycle, right?
Um

37:13 whether it’s preemptive or they’re already experiencing this and need to get treatment right away. Yes. Yes. And
estrogen therapy is very

37:20 safe. Uh, it is approved MHT, so menopause hormone therapy considerably

37:27 lowers a risk of hip fractures. That’s huge. Hip fractures,

37:33 which can be a death sentence. I mean, people don’t understand a hip fracture when you’re 70 can be fatal.

37:38 Yes. Yes. Cardiovascular protection. Again, it’s not the only treatment,

37:44 right? We can’t say, “Well, I’m going to give you estrogen and it’s going to prevent your cardiovascular
disease.” No, but

37:49 it’s going to rage HCL probably lower triglycerides and also transdermal estrogen micronized

37:56 progesterone and then the merina it does not appear to increase the risk of DVT

38:02 which again that has really one of the thrombosis which is one of the reasons why people uh have really

38:08 turned away from it. Transdermal estrogen micronized progesterone also it appears to be

38:14 favorable in blood pressure. Wow. where that’s something that we didn’t talk about. Testosterone can

38:20 increase blood pressure. That is again something that we didn’t mention. But I

38:25 also looked up some numbers and recent reports indicate that only 1.8% of women

38:31 over 40 are using hormone therapy for menopause. Even though 100% of women go through menopause,

38:37 HRT-AMA- The Truth About Hormones.docx there is like 98.2% of the population out there that needs to be on it who are not getting it.

38:42 And it becomes a really important conversation. estrogen and progesterone, people are much more open to it now
and

38:50 that’s FDA approved, but testoster one is not. I just want to put that out there. I I think that that is
fascinating and

38:57 important to understand. Yes. No, especially given all the benefits that you just highlighted. Um

39:03 why why wouldn’t it be FDA approved? And I I wonder if that’s coming with enough people using it off label,
right? Or

39:09 this this surge. And then the other thing is imaging. And we didn’t really talk about this. There

39:15 is also a lot of information out there where people are afraid to get mammograms at 40. You should.

39:22 There is no reason why you wouldn’t go and get a mamogram. People are afraid of

39:28 radiation. And I would say, listen, you’ve got to put these screening pieces in place. But what about the woman
that

39:35 cannot use hormone replacement therapy? Yeah. What does she do? Well, this is where a real conversation comes in
with

39:42 both the oncologist and the menopause expert because not all cancers or breast

39:50 cancers or uterine cancers, whatever kind of cancer, necessarily would exclude you from taking hormone

39:57 replacement therapy. Now, when you take a look at men, there are men that have prostate cancer

40:05 that are treated with testosterone. Yeah, that’s that’s and they do better. You have to It’s not

40:12 throwing out the baby with the bathwater. Yeah. Separating for taking each each of those instances separately
and looking

40:18 at it. No, I mean, this is all great information and I and I think for that female looking to, you know, consider

40:25 hormone replacement therapy or have that conversation, you’ve laid out a great roadmap into how they should
approach HRT-AMA- The Truth About Hormones.docx

40:30 that. And then most importantly, if their physician is not willing to have that conversation with them to find a

40:36 new physician. I agree with that. Let’s talk about how often um individuals should get blood

40:41 work. Yes. And listen, depending on where you are in your cycle, you can take it on day

40:47 21, etc. But let’s think about how often a woman should be getting her blood work

40:53 who is going through menopause treatment or even menopause. at baseline four to

40:58 six weeks after she begins a therapy and then I would do it again another three

41:04 to four months to make sure that she’s regulated. Do we regulate based on blood work numbers? Not necessarily.
She

41:12 should have symptom control of vasom motor symptoms. She should be sleeping better. She should be feeling better

41:18 from a mood perspective. And also we want to see again this isn’t direct

41:24 trea tment but if her cholesterol numbers really tank during menopause which is

41:31 what we see menopause menopause we should see some improvement in that if she’s being treated and then of course

41:37 it’s not always hormones you have to look at thyroid as well meaning it’s not always sex hormones you have to
look at

41:45 everything so you so a thyroid panel would be part of always that always is going to go with it.

41:51 Let’s talk about how a woman can take testosterone. How can a woman A woman can take besides the mix and the
Okay,

41:57 how a woman can take testosterone. A woman can take intraasal testosterone. All right.

42:03 A woman can take testosterone gel or cream. Very messy. She can also take

42:11 testosterone intermuscular in her shoulder, but she can also take

42:16 it subq. I imagine that the cases are kind of similar like the male and and

42:22 HRT-AMA- The Truth About Hormones.docx that you’re going to see more of the peaks and troughs intramuscular or
or no. Yeah, it depends on if a woman is and I

42:28 think that eventually women will be able to take it orally through the lymphatic

42:33 system which would be so Kaiser is used for males but I do think that eventually they will beusing it for women.
Women

42:41 do the best clinically that I have seen with sub-cutaneous doses of testosterone. And we start anywhere from 5
milligrams

42:50 a week. It should be typically one tenth of the dose of a male. 5 milligrams is

42:57 often too low for women to feel better with libido. Upwards of 10 milligrams a

43:03 week seems to be a sweet spot for women. When we’re talking about this, just to to clarify, would you ever would

43:10 testosterone just be the only therapy you would do or is this always in conjunction with Actually, sometimes.
Oh, wow.

43:15 Sometimes it depends on the woman. Some women you put on estrogen, they don’t feel great. Progesterone is great

43:22 for sleep and some women do great on progesterone, but nearly all the women that I have treated do very well on a

43:30 lowd dose testosterone therapy. That’s surprising. I I think because what percentage I don’t know if we have

43:37 that of like women who are I mean we talked very low the low percentage of women taking estrogen what what
percentage probably are taking

43:43 testosterone even below that so we talked a lot about estrogen replacement therapy hormone replacement therapy

43:48 these females what are some of the risks associated or are there any what’s that saying there’s no free lunch

43:54 I mean there might be but when it comes to hormone replacement therapy and

43:59 listen everything everything has a risk and we have to balance the risks and

44:05 benefits whether it’s tzepide uh ompic all of the agents everything HRT-AMA- The Truth About Hormones.docx

44:10 has a risk estrogen progesterone testosterone the risk isn’t the same for

44:15 everybody would I say that it is of benefit I would say yes but it’s

44:23 definitely casebyase basis can there be an increased risk in breast cancer or

44:28 uterine cancer depending depends on your genetics with your lifestyle, with these agents,

44:36 a good provider is going to sit down and go through everything with you so that you can make an informed
decision. Um,

44:43 but we can mitigate certain risks that we know. So, for example, if we know

44:48 that an oral agent is going to increase the risk of a coagulopathy or some kind

44:55 of clotting, then we would use transdermal instead of oral. Gotcha. So looking at not only the

45:01 substance but also the administration, the route of delivery, all like that. And then getting auterine
ultrasound,

45:07 getting a mammogram routinely, getting a pronovo or a full body MRI scan, also

45:14 doing the early detection cancer screenings. There are all things that we can do because ultimately the idea is

45:21 how do we live as better sher humans. That is awesome, right? Yes. I love it. Again, hopefully this

45:28 was valuable and helpful for people in understanding what kind of blood to get,

45:34 how the deliveries are done, why it’s important, and again, this is just the beginning of the conversation.

45:40 Yes. Thank you so much, Nick. No, thank you.