Every woman who lives long enough will go through perimenopause and menopause — but most will do it without the right information, support, or treatment. In this episode of The Dr. Kumar Discovery Podcast, Dr. Ravi Kumar sits down with two menopause experts, Dr. Diana Kumar and Dr. Teresa Walsh, to break down what’s actually happening with hormones, why so many women are misdiagnosed or dismissed, and how modern hormone therapy can safely change a woman’s health and quality of life.

You’ll hear what perimenopause really feels like, why hormone labs are often misleading, how the WHI study derailed treatment for two decades, and how bioidentical estrogen, micronized progesterone, vaginal estrogen, and lifestyle changes can relieve symptoms and protect long-term health.

Episode Highlights

• What perimenopause actually looks like in day-to-day life
• Why labs often come back “normal” even when symptoms are severe
• The difference between perimenopause and menopause
• How estrogen fluctuations — not low absolute numbers — trigger symptoms
• What the Women’s Health Initiative really showed
• Why bioidentical hormones differ from older synthetic formulations
• How estrogen and progesterone therapy are used safely today
• The role of vaginal estrogen for UTIs, dryness, and sexual pain
• Testosterone and DHEA: when they help and when they don’t
• The risks of HRT versus the risks of not treating hormone loss
• When HRT is safe, when to avoid it, and how to find the right clinician
• Why almost all postmenopausal women eventually benefit from vaginal estrogen
• How telemedicine is expanding access to women’s health care

Show Notes

What Perimenopause Really Looks Like

Many women in their late 30s and 40s experience brain fog, anxiety, irritability, sleep disruption, heavy or irregular periods, weight gain, joint pain, palpitations, vaginal dryness, and urinary symptoms — but don’t recognize these as hormonal changes. Symptoms vary widely, which is why perimenopause is often missed until women look back and connect the dots.

Why Labs Often Look “Normal”

During perimenopause, estrogen swings dramatically from high to low. A lab drawn on one day can look perfect, while another day can look drastically different. This is why most menopause specialists diagnose based on symptoms, age, and menstrual patterns rather than labs.

The Difference Between Perimenopause and Menopause

Perimenopause is the volatile transition leading up to menopause. Menopause is the point when ovulation stops and estrogen production drops permanently. Symptoms during menopause tend to be more consistent: hot flashes, sleep changes, cognitive shifts, weight gain, joint pain, vaginal dryness, and long-term changes in bone and cardiometabolic health.

What the WHI Got Wrong

The WHI studied older women, used higher-dose synthetic oral hormones, and stopped early due to an overstated “relative risk.” Absolute risk was very small, and the estrogen-only group actually had lower breast cancer rates. The result was two decades of fear and millions of women left untreated.

Modern Hormone Therapy

Today’s standard is transdermal 17β-estradiol (patch, gel, spray) combined with micronized progesterone for uterine protection. Vaginal estrogen treats dryness, discomfort, painful sex, and recurrent UTIs — and is considered safe for the vast majority of women, including many with complex histories.

Testosterone and DHEA

Testosterone may help some women with low sexual desire, but dosing is imprecise and pellets carry irreversible risks. Vaginal DHEA (Intrarosa) can improve dryness and sexual comfort without systemic effects.

The Risks of Not Treating

Untreated menopause increases the risk of osteoporosis, fractures, cardiovascular disease, insulin resistance, chronic sleep disruption, cognitive decline, and recurrent UTIs. Vaginal estrogen alone reduces UTIs by up to 75 percent.

Who Should Avoid HRT

Current breast cancer, active cancer treatment, recent stroke, heart attack, pulmonary embolism, or major surgery with prolonged immobility are key contraindications. Most other situations require individualized discussion rather than automatic exclusion.

Finding the Right Clinician

If your doctor is uncomfortable prescribing HRT, you can search for a certified menopause specialist through the Menopause Society or contact Dr. Kumar and Dr. Walsh directly through their clinic.

About the Guests

Dr. Teresa Walsh, MD FACOG MSCP
A board-certified OB-GYN and certified menopause specialist with over a decade of experience in surgical and natural menopause, minimally invasive gynecology, and pelvic pain. She is passionate about empowering women through education and compassionate care.

Dr. Diana Kumar, MD FACOG MSCP
A board-certified OB-GYN specializing in menopause care, sexual health, PCOS, and anti-aging. With more than 14 years of experience, she is dedicated to helping women regain their energy, mood, libido, and long-term health.

Connect with the Guests

Website: https://www.findgliss.com/
Instagram (Gliss Wellness): https://www.instagram.com/glisswellness/
Instagram (Gliss Spot): https://www.instagram.com/glissspot/
Their Podcast: https://linktr.ee/glisswellness

Listen on your favorite platform:

Apple Podcasts → https://podcasts.apple.com/us/podcast/the-dr-kumar-discovery/id1808415094
Spotify → https://open.spotify.com/show/3UJhg3Y5jjLP8zO6hbpwfT

Explore more episodes and references:

https://drkumardiscovery.com/podcast/

Transcript

[00:00 –> 00:32] Welcome to the doctor Kumar Discovery podcast. I’m doctor Ravi Kumar. Today’s episode is one I’ve been wanting to bring to you for a long time. I’m sitting down with two extraordinary physicians, doctor Diana Kumar and doctor Theresa Walsh, both obstetrician gynecologists who specialize in women’s health and hormone replacement therapy. I’ve invited them because we’re talking about a topic that affects billions of women, yet remains one of the most underdiagnosed and undertreated issues in modern medicine.

[00:32 –> 01:10] I’m talking about perimenopause and menopause. If you’re a woman or if there’s a woman in your life, I’m not exaggerating when I say this, but this conversation could change your life. So many women suffer with symptoms for years without realizing their problem is connected to a hormonal change. This can sometimes even start in a woman’s late thirties, and even fewer women know that there are safe and effective treatments that can restore energy, mood, sleep, cognitive clarity, metabolic health, sexual health, and overall quality of life. So today, we’re gonna bust this thing wide open.

[01:10 –> 01:52] You’re gonna hear what perimenopause and menopause actually are, why so many women aren’t being diagnosed, why misinformation has gone unchecked for literally two and a half decades, and how modern hormone therapy can be used safely and effectively. We’ll talk through the benefits, the risks, misconceptions, and exactly what a woman can expect by restoring her hormonal balance. After this episode, there should be no more guessing, no more feeling dismissed, no more thinking you just have to tolerate symptoms that are actually completely treatable. So with that said, keep in mind that none of this information can be considered medical advice. All three of us are doctors, but we’re not your doctors.

[01:53 –> 02:07] So take this information, bring it to your physician, and if you need more help, you can contact doctor Diana Kumar and doctor Theresa Walsh, whose information will be in the show notes. So let’s get into it. K. Doctor Kumar and doctor Walsh, thanks for being here on the show today.

[02:07 –> 02:08] Thanks for having us.

[02:08 –> 02:12] Yeah. You should probably tell why we both have the same last name,

[02:12 –> 02:28] doctor Kumar. Okay. So doctor Kumar is not my wife. She’s my sister-in-law. So she’s both doctor Kumar and doctor Walsh are board certified obstetricians and gynecologists, and they practice female hormone optimization, hormone replacement therapy.

[02:28 –> 02:53] Doctor Kumar even looks into longevity medicine. So they’re they’ve got their hands in everything, but they focus on women and women’s health. And I’m super excited to have you guys here today because this is a field that is so underappreciated and undertreated, and that’s women’s hormonal health. And so as a man, we have gradual decline in testosterone through our life. It’s very gradual, and it everyone makes a big deal about it.

[02:53 –> 03:09] If I want hormone replacement therapy, testosterone replacement therapy, I just go get it. Right? But women are unique in that in their middle middle life, their hormones just crash. I mean, they literally go away. It’s almost like a castration event and which no guy could possibly imagine happening to them.

[03:09 –> 03:42] But to women, it happens to every single woman alive who gets to that age. And it’s really not treated for a variety of reasons. And so I’m really excited to hear from you guys, hear how you’re helping women adequately treat this, understand it, and basically bringing attention to it in the medical community. And there’s a couple thing definitions I think we need to get out in front, and I’ll turn this over to you guys. But women go through a period of perimenopause, and that’s before menopause where they have this wild fluctuations and volatility in their hormones, and then they go through menopause.

[03:42 –> 03:54] If you can just tell us what those are, when they happen, what they look like, and because a lot of women, I think they don’t even recognize that they’re in perimenopause or even maybe menopause until they’ve suffered greatly.

[03:54 –> 03:57] Well, Teresa, we need to use some new marketing term castration.

[03:58 –> 04:00] Yeah. I did not even

[04:00 –> 04:05] see that coming. I wouldn’t have called it such a dramatic thing, but it probably is just like dramatic.

[04:05 –> 04:08] I mean, that’s what it is. Right? I mean, they’re losing your hormones.

[04:08 –> 04:20] But yes. Yes. So I would say I always tell my patients that perimenopause is, like, a is a retrospective look. It and I don’t like to call it a disease state because it’s not a disease. It is a natural thing that we all go through.

[04:20 –> 04:43] We use all these marketing terms to make it sound like it’s unnatural or that we have to fix it or as a disease, but it is natural place of being that we transition to for women. And perimenopause, you don’t even know you’re right. You you don’t even know that you’re in it until you’re in it. And then you look back and you’re like, gosh. I I have all these slew of symptoms that don’t match in this whole time I’ve been in it, and I just I feel like I’m losing my mind.

[04:43 –> 04:54] I think those are the common phrases we hear. I’m losing my mind. I’m not something’s not right even though everything all my labs are normal. My husband can’t I’m driving my husband and my children insane. Those are the things.

[04:54 –> 05:15] So I would say that all the symptoms with perimenopause is just so long. It can encompass everything from, like, brain fog, like frozen shoulder, musculoskeletal pain. We’ve heard of what the tongue burning, the ears burning, ringing in the ears. And I’m going down, like, organ base here, but palpitations, anxiety at night. You name it.

[05:15 –> 05:29] Dry skin, dry hair, hair in other places they never had hair loss, irregular periods, heavy periods. I mean, it it it never ends. So it is really all of it can be related for sure. I I I don’t I call it a state of being in it. It’s like a flow.

[05:29 –> 05:39] Because sometimes you think you’re out of it and you’re entering to menopause, and it’s like, surprise. Here’s a period. You’re not in it. You’re still in perimenopause. And then finally, going into menopause.

[05:39 –> 05:46] So what age does that usually happen when women start seeing I know it must vary, but, like, the average age when women go into perimenopause?

[05:46 –> 06:11] Well, average age for menopause is 51, so it’s usually about five to seven years before that. So it really varies depending on the person. And, like, I usually tell patients a good indicator is, like, when your mom went through menopause or your sisters went through menopause or your aunts, so that’s kind of, like, a good indicator of when you’ll do it. And then, like, I think what gets really confusing for perimenopause is that, like, everyone’s different. Right?

[06:11 –> 06:24] So, like, my symptoms are, like, brain fog, and Diana’s are joint pain. Right? So it doesn’t look the same for everyone, which was why it gets, I think, even more confusing. Like, menopause is easy. Like, we can diagnose that in the snap.

[06:24 –> 06:24] Right.

[06:24 –> 06:42] But but I also think age you bring up the point. We’ve seen patients younger and younger. We’re talking about 40, 41, even the late ages of 30, 38, 39. And to really highlight is so different because it’s dependent on what you’ve gone through through life. Hysterectomies, I do think patients see those symptoms earlier.

[06:42 –> 07:10] People who have had lots of children, I do think that they breastfed, had a pregnancy, breast they don’t they don’t even know where they are. And all of a sudden, they are done and then they just crash. So we we kind of hear these things that resonate over and over again, but not necessarily found in a study per per se. Like, people who’ve had chemotherapy at a young age, so they have a earlier like, they age faster for their for their ovaries. People who have done had history of IVF, you’ll see these symptoms start to rise earlier.

[07:10 –> 07:26] There’s no, like, scientific rule or lab that says, yes. I’m in perimenopause, and, yes, I’m in menopause. But we we take we listen to the patients and look at their symptoms in the whole picture. So that’s why it’s not just, like, five, seven, ten years, and it’s not just fifty two. It could be 55.

[07:26 –> 07:29] Saw a patient yesterday. He still has periods of 55.

[07:29 –> 07:37] So biologically, what’s happening in perimenopause? Like, what why why is there this volatility in the hormones in the five to seven years before menopause?

[07:37 –> 08:14] You’re no longer regularly ovulating. So what’s happening is that you’re getting inconsistent signals that is beyond our normal inconsistent signals with, like, our periods. So I usually will tell patients that what is causing symptoms in perimenopause is actually it’s the fluctuations from very high estrogen doses to very low estrogen doses. So this is why I think labs are unhelpful, and most menopause providers no longer check labs as far as part of a sort of workup or indication for getting treatment is because you’re having these swings from high to low. So I can check your hormones today, and they will be stone cold normal.

[08:14 –> 08:37] And they’ll tell you you’re normal, and they will gaslight you. And then if I recheck them in a day or two, they will be totally high or totally low. So this is why it’s not helpful, we shouldn’t base treatment on it. And we shouldn’t check it because it’s just going to make things confusing. If you’re one of those patients that likes having information, like you wear your Oura Ring and you wanna have your labs checked, by all means, we can check them, but it’s not gonna guide our treatment in this case because we know they’re all over the place.

[08:37 –> 08:43] So, again, it’s the swing from highs to lows that are making your symptoms, not necessarily the absolute value.

[08:43 –> 08:55] Okay. So and, doctor Kumar, you had mentioned that, you know, it’s a state of being that all women go into. And does that so if they’re suffering, though, that doesn’t mean they should just deal with it. There are good treatment options for perimenopause. Right?

[08:55 –> 09:04] What you guys practice. Correct? Okay. I hope you’re enjoying the show so far, and the information shared here will make an impact in your life. I need one favor from you.

[09:04 –> 09:20] Please go on Apple Podcasts and rate and review this show if you can. It makes a massive difference in the reach of the podcast, and I’d be so grateful. Also, if you know someone who could benefit from the information we’re sharing here, please share this episode with them. Okay. Let’s get back to it.

[09:20 –> 09:36] Yeah. I I do think that it speaking of longevity and aging, we are gonna age different than our mothers did and our grandmas did. It’s just a different state of of medicine now and how we treat health. But but, yeah, it’s a natural I would say that my mom probably never complained. One, because she’s Asian.

[09:36 –> 09:49] But two, is that, you know, they they just they just assume that that was a normal place of life and they just moved on. Suffered. They did. And then now we don’t have to do that. So, yes, there are really great treatments for many of these things.

[09:49 –> 10:15] And I always add in that HRT is a very big broad word. And we should say I say HRT, menopausal hormone treatment, however you want to call acronym. But these treatments don’t treat everything all the time. So it’s a great way to get some of these symptoms great relief, but it’s not the perfect cure all because I name so many symptoms and there are also multiple other causes for these symptoms. So it’s nice when you see us that we kind of decipher, okay, what what is menopausal?

[10:15 –> 10:26] What are other things? Because everybody has other health conditions that probably correlate to some of their symptoms, and we just gotta treat the body as a whole, not just like, hey. It’s just a hormonal dysfunction.

[10:26 –> 11:04] What’s really interesting to me and what strikes me as, like, very significant in our history is that back in, like, the sixties all the way up to the nineties, there was women were getting hormone replacement therapy. And then in the nineties, the government decided to do a clinical trial. It was called the Women’s Health Initiative. And then in 2002, they stopped that trial early and had a press conference, which, you know, scientists usually don’t have press conferences. But they had a press conference, and they said we had to stop the trial early because hormone replacement therapy, which at the time was this conjugated equine estrogen and this, this different type of progesterone, it’s causing an increased incidence of breast cancer.

[11:04 –> 11:34] And that just scared the world. It scared our country for sure, you know, because the study was done by our country. And then the hormone replacement therapy just completely went away. So my mom, all our mothers, basically, they went through perimenopause and menopause without any treatment. And even today, when I talk to my mom or my mother-in-law, there’s a little bit of fear, you know, in regards to HRT because it left such a lasting imprint on our our society and our minds as far as HRT goes.

[11:34 –> 11:38] So but now here you guys are giving young women and many balls

[11:38 –> 11:39] of away.

[11:39 –> 11:43] HRT. Yeah. So tell me what happened. Like, how did we go from there to here?

[11:43 –> 12:07] Can I also bring up that we still, are in our news, still do these big extrapolating generalized summation? What was the most recent article about, melatonin? And It’s like it’s like we we just we do that all the time. So it’s still ongoing. And back then, it was like in the nineteen sixties, you mentioned this.

[12:07 –> 12:23] If you if you knew that so back then, we had mainly synthetic estrogens. We that’s what we were doing. And the pharmaceutical companies, they knew some of the risk factors. Wyeth, I think, was the biggest producer, knew that it was an increased risk of uterine cancer with them, but they didn’t say anything. They just gave this stuff out, and they would have advertisement.

[12:23 –> 12:49] If you’ve ever seen the advertisement, the man is smiling and the woman is handing him his coffee and said, give them estrogen and your husband will be happy. So it it wasn’t just, like, all great hunky dory, but where where all women got HRT, but they probably felt great because we were giving them synthetic high dose estrogen. And some people did have higher, probably higher breast cancer, uterine cancer, but, you know, it was a low number to treat. So they just continued doing it. And then lot of women were happy.

[12:49 –> 13:06] And then only when the government should have, and it was probably it was the right thing to do, a study to see if there’s a safety profile on these medications. But that study was very flawed. Right? They enrolled women who were who were the average age was 61, 62. So they’re well after perimenopause and menopause.

[13:06 –> 13:49] And then they stopped the study early because they found an increase was of heart disease and breast cancer. But at the time, they were studying synthetic progestins plus synthetic estrogens, and they were giving it at higher doses than we would give now for 60 and above women. And so they they kind of just the New York I was thinking it the New Times, put it on the front page, and then they they just extrapolated that data and just canceled HRT for all women. And that’s what we still do today with and also give drugs that we shouldn’t be giving. So we were history is repeating itself, but that’s that stopped the training of hormone therapy for all residents, medical students for decades to come.

[13:49 –> 14:09] And now we are here where we’re at. And we have pulled data from the WHI for younger populations. We’ve done better studies that show that that’s not always true, that some of these things are different. And I will say that I use this word out like bioidentical synthetic interchangeably or you know, they’re all synthetic. They’re all made by a lab.

[14:09 –> 14:47] Nobody’s going out there and, like, making it from a tree leaf and saying that this is this is natural and biodentical. But what we mean is that back then, they used the Premarin or the conjugated estrogen. So they it’s a combination of multiple estrogens made in a lab, put into a drug, and that didn’t doesn’t mimic the estrogen molecule that you make normally in your body by your ovaries. And now most of the time when we talk about menopause and hormone replacement therapy, we’re talking about the bioidenticals, which means that we’re giving molecules that completely replicate what your ovaries make. And same thing with the progesterone, synthetic progesterone versus those that are not without.

[14:47 –> 14:53] But So they’re so bioidentical hormones are still made in the lab, but they look identical to the hormones that you make in your body.

[14:53 –> 15:10] Yeah. That’s the 17 beta estradiol and then Okay. The estrogen piece, the micronized progesterone. So so if you took it out and drew a picture of it on a carbon chain, it looks exactly like the ones that your ovaries make versus those who are in birth control, for example, are synthetic. They mimic that.

[15:10 –> 15:20] So they can bind to the receptors, but they act differently. And back then, that’s what we used in those studies. And now we’re basically using the bioidentical form. But Okay. You know, people are

[15:20 –> 15:25] using test. WHO used was different than what you guys are giving women, though?

[15:25 –> 15:26] Very different.

[15:26 –> 15:53] Yeah. Okay. So the other thing in that WHO study, and I I was hoping you guys could talk about this, is the the difference between relative risk and absolute risk that they kinda made this whole press conference on. Because they came out and said that hormone replacement therapy causes a twenty six percent relative risk increase in breast cancer. But when you looked at the numbers, it was only an increase in eight out of ten thousand women, which is about a point o eight percent absolute increase.

[15:53 –> 16:00] And, like, why do things like that happen, honestly? Because someone came and told me twenty six percent increase. I’m thinking, oh, that I’m scared.

[16:00 –> 16:10] Right. It’s the same it’s the same if we made those normal those numbers even. Right? If it’s a one in a hundred and you did a study and now you have two in a hundred, you could say it doubled the risk. Right?

[16:10 –> 16:56] But but the the reality is that, you know, if you’re a journalist and even right now, we don’t use we don’t if you’re a social media influencer, what will give you the most clickbait is the numbers you use and how extreme they become. So that’s why if you’re the front page of the New York Times, it behooves you to use those numbers so that you can scare fearmonger what, you know, they believe. But the also, the the big thing on that is that those women are are relatively in that group or relatively unhealthy, and they’re older. So the new data is saying start HRT younger. Start menopausal hormone treatments in perimenopause, not waiting until they’re 65, 60 above, already have cardiac disease, already have hypertension.

[16:56 –> 17:18] So the the data is still relatively the same. It’s just that we don’t start high doses of synthetic HRT for women 65. There are many women who ask us and that’s a complete different conversation and nuance. And they have to understand the risk with it. But just going back to it is that the WHIV pull data from all the younger population, and they it’s there’s benefit to that.

[17:18 –> 17:28] And then when we started doing it for the younger population of 50 55 with bioidentical hormones, the data is better. So that’s why it’s just you can’t So it’s

[17:28 –> 17:48] just generalizing timing. Health Timing and the type of estrogen. The other thing that stood out to me about that WHI is that there was a group of women who had had hysterectomies. They didn’t have uteruses or ovaries, so they were just given estrogen. They weren’t given the progesterone because they didn’t have to suppress the endo endometrium growth.

[17:48 –> 18:09] And those women who just got that estrogen, the same one in the the other study, had a lower risk of breast cancer. So have they replicated that in for further studies? I mean, it I that’s probably an there’s some nuance to that question. But is there is there an increase in risk of breast cancer with the type of hormone therapy that you guys are giving or in women who don’t need to have progesterone?

[18:09 –> 18:56] I think that how I usually explain it is that that study shows that they have with these synthetic hormones in higher doses, it says that those patients did it without progesterone, had lower risk of breast cancer. So that means that in our modern times where we are using bioidentical estrogen in much lower doses and in different formulations than they were using, we know that this is a safer drug and that we have even in our patients that have, like, say, BRCA that are high risk for breast cancer or have a very strong family history without a BRCA thing, these are patients that can safely get estrogen and will decrease their risk. So I feel like if that population that we wouldn’t give these things to now still found a decrease, that says something. I don’t know. That’s usually just it’s reassuring to me.

[18:56 –> 19:12] Give me two snapshots. Give me a snapshot of what a woman looks like when she’s starting to suffer from perimenopause. You know? Maybe, like, a more severe case, like, so the symptoms are more identifiable. And then also give me a case a snapshot of what a woman looks like going through menopause just so our audience knows.

[19:12 –> 19:17] And if people have these symptoms, you know, listeners have these symptoms, they could say, oh, I got that, and that matches what I’m feeling.

[19:17 –> 19:28] Oh, you mean so when my husband calls you and say, hey, Diana’s crazy today, that’s perimenopause? Is that what you’re saying? But what is it what does a picture look like? This is a hard one. Well, perimenopause is easy.

[19:28 –> 19:48] It’s where, like, I forget things that I used to not forget. I remember being in medical school studying like two days before and going, I got this. And now I can read the same article three times and still be like, what what did I just read? So the brain fog is real for us. The other thing is that things you take longer to recover.

[19:48 –> 20:03] I used to work out all the and now I do the same workout, eat the same, and I gain five pounds. I just have to look at something, and the weight doesn’t come off. That’s a I think those are the two big ones we hear about the most. And the last is sleep. I could’ve you know, in residency, we were so tired.

[20:03 –> 20:26] With children, we were so tired. We could sleep anywhere. And then just wanting to stay asleep if our babies didn’t cry or or wake up for for getting kids to school. And now I wake up at 2AM just thinking these are my long list of to do, and I can’t go back to sleep. And that, over time, makes me more and more short-tempered with my family members and Theresa, my business partner.

[20:26 –> 20:32] But, like, that is what a normal day looks like for perimenopause.

[20:33 –> 20:38] What about in perimenopause, what about, like, sexual desire? Does that change in vaginal health?

[20:38 –> 20:53] I think that sexual desire is the most difficult thing that I think we encounter because it’s so multifactorial for women. I think guys wanna have sex. Like, it doesn’t matter. But for women, like, in the back of my mind, I’m thinking, I got clothes to wash. I have to pick up the kids.

[20:53 –> 21:08] I still have to go go groceries. The bed hasn’t been changed. Like, and on top of that, I’m having hot flashes, and I’m gonna sweat. And I’m having some urinary leakage. Like, there’s so much more stuff going not that guys are simple, but, you know, I think that for women, there’s a lot of other things that come into play.

[21:08 –> 21:28] So, typically, once we can kind of fix the big picture stuff, everything else sort of falls into line. Like, when we can get you sleeping again, no one wants to have sex if they’re not sleeping, so we can fix your sleep. If we make it like, your vaginal tissue gets a little bit more sensitive and it gets more irritated. So, like, if we can make sex comfortable, that helps too. So fixing all the little pieces will fix the big picture in general.

[21:28 –> 21:30] So we start with that first.

[21:30 –> 21:37] And and those are things like the, you know, dryness and pain with sex. Those are things that happen during perimenopause, or is it just menopause?

[21:38 –> 21:41] No. I think it starts in perimenopause. Absolutely. Okay.

[21:41 –> 21:57] What we also see postpartum. We forget about that piece. Oh, yes. After they have babies that you know, now we’re having babies later, but 38, 39, they just ignore it because they thought it was normal. And then they don’t say anything for years, But it really starts very, very much earlier than we think.

[21:57 –> 22:10] And then they have recurrent BV, B, yeast, abnormal discharge. It’s just like a slew, a cycle down the drain. And they’re like, what what do I treat first? How do I treat it? And generally, vaginal estrogen is the key piece here, but it treats it very well.

[22:10 –> 22:32] But I’m going to add on there that we just went to the Menopause Society meeting, is this big meeting of all the menopause. And there’s this graph that they showed for libido. And it says it says that the length of time in a relationship versus how much the person desires sex. And and for men, the graph is always the same. It just seems just the same across all for years, like seven years, ten years.

[22:32 –> 23:04] And for women, it’s like a it just goes down, then it never comes back up. So that is just one of the factors is that being in a relationship, being married now in your forties is where you could talk about this midlife factor where you’ve been married, and and and there’s a lot of discussion why divorce rates also rise in your forties. It may correlate. Not that we are blaming everything on marriage and relationship, but it it there’s so many pieces of the puzzle. It’s a very long intake that we do to kind of decipher what can HRT do, what can vaginal estrogen do.

[23:04 –> 23:12] There’s hyaluronic acid. There’s a treatment, all these things, plus depression, anxiety, plus sleep. And then we get to the end, like, is this is this where we’re supposed to be at?

[23:12 –> 23:24] Okay. What about menopause? I mean, that’s I mean, if perimenopause is wild hormones up, you know, on and off, I mean, menopause is basically off. Right? Tell me about, like, the symptoms there, the long term and short term.

[23:24 –> 23:37] Long term symptoms. So short term is very much a transition from perimenopause, but much more constant. So the number one question people will ask is, like, how long do I have to deal with this? And the answer is who knows? So five to ten years sometimes.

[23:37 –> 23:52] Sometimes it’s really short. Sometimes people go through it quickly, but it totally depends on a person, which I feel like doesn’t help anyone, but at least kind of gives you an idea that if it’s really bothering you, go get help. And there is help out there. What I do think helps people is that there’s a diagnosis. Right?

[23:52 –> 24:03] Like, it’s very easy for me to say, like, you’ve gone twelve months without a period. You are officially in menopause. Okay. So that I feel like is helpful for people. Like, people like, I like having a diagnosis.

[24:03 –> 24:08] Like, that’s helpful. And then well, what was the other question? I’m so sorry. Is the What

[24:10 –> 24:29] I really wanna know is I I and I think most women probably already know this, but just so we can say, what does a woman look like in menopause? And I I really wanna know about the bone health, you know, the mental health, the cardiovascular health, the vaginal health, the vasomotor symptoms. Like, woman in menopause comes to you, what do they look like clinically?

[24:29 –> 24:33] All of the above, but worse. Okay. So let me go through this by by by because you

[24:33 –> 24:33] mentioned Or good system, maybe.

[24:33 –> 24:49] Yeah. Depression and anxiety is generally higher in menopause. It’s because all the life things are coming into play. So if they’ve been suffering through perimenopause and now it’s really, really severe, they’re sleeping three to four hours a night, and they have severe anxiety and depression. So that’s been going going on for so many years.

[24:49 –> 25:03] So it rises I’m just gonna average out, like, 52 and above. It’s gonna start to rise. If they had some vaginal dryness who’s using lubrication, now they will know, hey. The lubrication is not enough anymore. I’m using it every time, but I still burn after I have sex.

[25:03 –> 25:17] I still feel like I’m tearing. And so we don’t even have sex that often. It’s just so uncomfortable. So it just the severity does increase. If they were gaining weight, usually, the I see the more weight gain is during the perimenopause phase.

[25:17 –> 25:39] Between 40 to 50, you got your average of 15 to 20 pounds for some patient, and it will start to slow down at the 10 pound mark, but they’re losing muscle mass. They will key the key things they’ll say is I don’t feel as strong as I used to be, and it is noticeable at 50 above versus being in their forties. So then there’s that piece. So they’re they’re still gaining weight, but they also say they’re losing a lot more strength. Cholesterol will start to rise.

[25:39 –> 25:49] A one c, the diabetes screen, will start to rise. We have a lot of patients who use the glucose monitors. They’ll start to say, hey. I think they ate before. I used to go up to like a 120, a 130.

[25:49 –> 26:02] Now I’m steadily above a 140. Significantly different five years ago than it is now. So glucose intolerance rises. Joint pain. So that’s a mix too because the osteoarthritis, other things start to really be there.

[26:03 –> 26:08] But if they were like, had tennis elbow once a year. I play tennis all the time. Golf. Golf shoulder. Whatever.

[26:08 –> 26:21] Now it’s like, can’t play anymore because it’s a constant thing. I see PT. I’ve seen ortho. Help me out because now I can no longer do the things I enjoy in life. And that probably that piece is more after 55.

[26:21 –> 26:28] So Okay. A range so so just everything, but just turned up on the knob of the volume.

[26:28 –> 26:39] Okay. And and what about bone density? Like because that’s a big one. You know, there’s we have all these treatments for bone density, and none of them really work, honestly. I mean, they can slow it down.

[26:40 –> 26:52] You know, may I mean, there might be some vitamin k two studies that show a little bit increase in bone mineral density in the spine. But overall, like, the only thing I think we’ve seen work is keeping a woman’s hormones, like, in a normal level. Correct?

[26:52 –> 27:05] Prevention is key. I have a love Got it. With bone health simply because osteoporosis runs in my family. And most of our patients are Asian Hawaiian ethnicity, so osteoporosis is a big deal. And I would say that prevention is the key here.

[27:05 –> 27:25] If you already have the osteopenia osteoporosis, HRT is not the first line treatment. And you did say, right. There’s the treatments are not that great. So if you can can prevent the disease here, this is the steering of the cruise ship that needs to be steered if it can. So you have to start it before you start losing your bone mass, which really starts earlier than we think.

[27:25 –> 27:39] Does that mean you have to start MHT or hormone replacement therapy earlier? No. That’s not that data is not there yet. But we lay all of our bones and then we get to bone peak bone mass, right, in our twenties. And then after that, it’s just a downhill trend.

[27:39 –> 28:03] As long as you’re still having periods, you probably are still having normal bone cycling where you’re a little bit of bone loss, a little bit of bone building that’s pretty balanced. Once those periods go away, that’s when things kinda go really dysfunctional. So so if waiting until that already happens, it’s a little too late. So I do push for my patients who have really history of osteoporosis in their family that the key is prevention and starting HRT earlier is is a big piece there.

[28:04 –> 28:40] I feel like for longevity medicine, I don’t not necessarily living longer, but living better. Right? Is this is where it’s I think it’s gonna come out with, like, really nice data is that by starting these medications early, especially in patients that have risk factors for osteoporosis, osteopenia, or family histories, starting these estrogens early to kind of, like, keep that bone mass going is really gonna help you live better later. Right? So if you can prevent fractures at an older age, which are catastrophic oftentimes, this is where you’re gonna be able to, like, move around, interact with your grandkids, and sort of, like, live a longer healthier life than you would without it.

[28:40 –> 28:45] And I think this is where we’re gonna see a generational shift from our parents’ generation, And we should.

[28:45 –> 29:01] This is good. I didn’t even add in you know, the big piece is that weightlifting. Right? So I tell all my patients that because it’s not just simply, oh, take the estrogen. Because the estrogen needs weight bearing exercises to lay down calcium and an appropriate scaffold to hold that bone.

[29:01 –> 29:14] And it can still be dysfunctional, which is why we’re still trying to study and make better drugs. But it’s not it’s not perfect. You have to do your part in that. It’s it’s just that. The other question we get a lot is what dose should I be on?

[29:14 –> 29:29] And there’s no defined dose yet. It it’s kind of ranges everywhere. And I do think it matters by ethnicity and by weight and by the person’s health. So so we have to kinda use that. And they you know, we have patients who say, can I just do a DEXA scan every single year?

[29:29 –> 30:00] And if I use if I if I if you already have osteopenia, osteoporosis, you’re using your DEXA scan to scale to range whether your HRT is working, it’s the wrong way to use it because it was preventative. It is not going to it may slow down the loss, but it is not going to cure this disease state. So it kind of said you use it for your own information, but that’s not our goal. Our goal is that how do we keep you from fracturing your hip or your vertebrae, which will give you the worst quality of life the last ten years versus give me the best quality by preventing those falls in the first place.

[30:00 –> 30:17] Okay. I mean, you guys have talked given a very good picture of what a look woman looks like in perimenopause and menopause and, like, all the things that you’re preventing, honestly, by treating in in menopause especially. So what do you how are you guys treating these women? Like, how are you treating a woman in perimenopause and menopause in your practice?

[30:17 –> 30:38] You know, I think that there is a little bit of bias from our practice because by the time patients come to us, they are fed up, they know what they want. So they wanna be on something. So I do think that there’s some probably some steps before that most clinicians are seeing in, like, say, their private practice office. So our patient population tends to be women that wanna be on hormones. And so by the time they get to us, that’s kind of where we’re at.

[30:38 –> 31:06] So I would say most of our patients end up on hormones, but it’s a combination of estrogen with progesterone generally. So the estrogen helps with all of the fun symptoms, hot flashes, joint pains, brain fog. And then the progesterone is to make sure that you don’t get a precancer or cancer in your uterus while you’re on the estrogen. And then we will use the bioidenticals like we talked about, and the vast majority of patients will do great on those. And then the other nice thing about the micronized progesterone, which is bioidentical, did I say it helps with sleep?

[31:06 –> 31:09] And it is the best. It is, like, my favorite pill that I take.

[31:09 –> 31:16] Tell me about that. Like, what happens when when a woman starts taking my is it I assume they take it right before they go to bed. Is that correct?

[31:16 –> 31:22] Yeah. Like, a mind lives on my bedside table, and I it just helps with getting to sleep and staying asleep.

[31:22 –> 31:23] Okay.

[31:23 –> 31:30] We we were at the menopause society meeting, and they said a dozen. And you could just hear this, like, groan in the room saying, like, no one believes that.

[31:30 –> 31:30] Yeah.

[31:30 –> 31:30] Because

[31:31 –> 31:42] And so you’re talking about micronized progesterone. Right? So this is pro bioidentical progesterone that’s just milled into tiny, tiny little pieces, so it’s absorbed well. Correct? Mhmm.

[31:42 –> 31:43] Okay. I don’t know

[31:43 –> 32:04] if that’s the right term, but it is it is put in peanut oil. So it’s it’s, like, formulated in peanut oil. And I will I will throw out that, yes, the menopause society just did a presentation that said that that they found no difference. And I would say that out of doing this for a long time, I don’t see that. But it’s we would have to purposely tell you that’s anecdotal.

[32:04 –> 32:25] But it has to be you know, there’s there’s a lot of early studies that says it increases the GABA receptors. It works on the GABA receptors, which make us more somnolent. The same things that you would see for what trazodone and some of the other medications that work the similar way but without being really sedative. But but I do think it works. It you should we always mention that I tell my patients this.

[32:25 –> 32:52] You just take about an hour for bed, but there’s people who metabolize it way faster and there’s some people who metabolize it a little slower. So if you are taking at nine and you wanna go to bed at ten, but you’re you’re totally out for the night, 09:30, then take it closer to your bedtime. And if you feel no difference and you’re rolling around in bed at eleven, then you should take it earlier because that is different for different people. You can also place it vaginally and rectally. Progesterone has the more side effects, so it gives a little bit of water retention, bloating.

[32:52 –> 33:03] I compare it to being in the first trimester when you’re pregnant. You feel super fatigued and kinda nauseous when you do. It’s very rare side effect, but it does improve. It’s about the change of progesterone, not necessarily the dosing.

[33:03 –> 33:03] Sure.

[33:03 –> 33:15] And that if you wait it out, it will get better, and that most of the patients do great on it. But if it’s still persistent, they can place it vaginally or rectally, which there’s a lot of debate if that’s enough. But but if it

[33:15 –> 33:17] works And if they do that works well for my patients.

[33:17 –> 33:22] And if they do that, they won’t get the the bloating and the nauseous nausea symptoms that you talked about?

[33:22 –> 33:24] Those GI side effects go away. Better.

[33:24 –> 33:28] Okay. Mhmm. So what is the dose of micronized progesterone that you typically give a woman?

[33:28 –> 33:30] About hundred milligrams at night.

[33:30 –> 33:34] And is there any benefit to going higher if you’re not getting benefit from that?

[33:34 –> 33:55] If they say, like there’s certain words that they say to me, oh, my night sweats are worse. My anxiety at night is worse when I go to bed and or it’s improved a little bit, but it has more room. We’ll increase it to two hundred milligrams. And I think perimenopause responds to higher dosage of the two hundred milligram. And when they get to postmenopause, they do better at the one hundred milligram, probably because the GI side effects are more severe.

[33:55 –> 34:02] But that’s just, again, doing practicing this all the time. It’s not like there’s a study that says this is the right and this is the wrong. Just depends on what the patient is feeling.

[34:03 –> 34:07] So let’s go back to estrogen now. How are you dosing estrogen?

[34:07 –> 34:23] It sort of depends on where you are. And I feel like menopause is very easy. Like, it’s just estrogen and progesterone or plus or minus progesterone. The perimenopause is really where it gets a little bit complicated because we’re trying to balance symptoms plus periods. So that gets a little trickier.

[34:23 –> 34:42] So say we are gonna use bioidentical estrogen in perimenopause, you already have a lot of estrogen floating around in spikes. So you’ll have spikes of high estrogen and then drops in estrogen causing really low. So really, we don’t need a high dose. We just need a nice low constant dose to keep you from bottoming out.

[34:42 –> 34:42] Okay.

[34:42 –> 34:58] So the doses in perimenopause may be lower than you would use in menopause. So and, this is all very nuanced, and it sort of depends on how everyone does. So this is where I really think having someone that specializes in this and can kind of play with doses for you really helps.

[34:58 –> 35:00] Okay. So there’s some experimentation there.

[35:00 –> 35:05] We don’t like the word experimentation, but, yes, trial and error. I don’t know. What is a nice way to say that?

[35:05 –> 35:06] Yeah. Yeah.

[35:06 –> 35:07] Trial and error.

[35:07 –> 35:10] But I will I will say that everybody’s different too. Right?

[35:10 –> 35:11] So if

[35:10 –> 35:30] if let’s let’s say Teresa does a a patch of zero point zero five milligrams. Her skin might absorb it more than mine. They just when the FDA regulates it, they just say this is the average that everybody gets. There’s outliers there for sure. So if I’m absorbing a lot more and I get heavy bleeding from it or regular bleeding from it, I need to go down.

[35:30 –> 35:46] People say that all the time where they’re like, my friend’s on this dose. Why am I not on the same dose? Well, your friend is also may not be in the same perimenopausal state at the same age as you, and then your health may be completely different or you might respond to the medication very differently. But I mentioned the patch. There’s the gel.

[35:46 –> 35:56] There’s the ring. There’s the spray. There’s the tablet. There are a bazillion ways to give estrogen out there. The five that I numbered are the kinds that are out there for FDA regulate.

[35:56 –> 36:12] They’re FDA regulated. You can get them at CVS or any of your pharmacies. But in each of those types, there’s also multiple doses. And they each absorb differently across the plane. So if I give you a zero point zero five patch, it does not equal a zero point five milligram gel.

[36:12 –> 36:22] Well, people go crazy about that too where they’re like, I was on this before. I asked you to increase on the gel, you gave me the same. And I’m like, because they are not comparable. It’s different. Matter here.

[36:22 –> 36:30] Yeah. Okay. So let’s talk about the method of administration. So there you mentioned them there’s a transdermal, which is a patch or a cream. Right?

[36:30 –> 36:45] And then there’s there’s intravaginal, which is a is a ring, right, or or an ointment as well or a cream. Tell me all about the different forms of administration, both systemic and local, and why you choose one over the other and why a woman would want one form over the other.

[36:45 –> 37:01] You know, I think that I no. This isn’t what you asked, but I think is important is that, like Diana said, there’s tons of different options out there that are all FDA approved. And I love compounding pharmacies. I think they have their role, and I think I really enjoy them. But this is not the place for a compounding pharmacy.

[37:01 –> 37:29] We have so many doses and options and routes available that we know exactly what you’re getting, that this is not the place to sort of deviate and get some sort of, like, homemade cream from a compounding pharmacy. So that being said, I would recommend an FDA bioidentical. So we have tons of them. And so how they all work well, and they all get absorbed, and we know that. So how I tell patients they can choose one of the many options is that whatever works for your lifestyle.

[37:29 –> 37:46] Like, I am terrible about taking a pill every day. Like, I just cannot do it. So I put on a patch once a week, and I do it every Monday, and that is very easy for me to do. Versus some people don’t wanna wear a patch, and they wanna be on a pill every day because they enjoy taking a pill. Then that is that is what they can be on.

[37:46 –> 37:49] So that’s kind of typically what I do in my counseling.

[37:49 –> 37:53] Okay. And what about pellets and the ring?

[37:53 –> 38:13] I should throw out cost before you move on because that’s a very big thing right now in the current economic state that cost matters here. Compounding drugs are more expensive. And and we wouldn’t use compound only if there’s like an like, it’s really rare. But, like, a patient who’s like a peanut allergy, for example, can’t use progesterone in the way it is created. That’s where you would need to go to do something special.

[38:14 –> 38:29] But but the tablets are the cheapest. We use them less because the tablets have to go through liver bypass. And when you go through the liver, it adds on extra chains to the estrogen and can increase your risk of stroke and heart attack. By relative risk, it’s small. It’s still small.

[38:29 –> 38:38] So we talked about that earlier in the pocket. It’s still small, but it is the cheapest way. You could get this for, like, $3, $4. You know? The patch gets more expensive.

[38:38 –> 38:48] The ring is the most expensive. I usually say by ease of use, you’re going to get more and more expensive. The mist, the spray that you just spray, wait for it to dry. Voila. I’m off the rest of my day.

[38:48 –> 38:57] People love that. It can be up to what? 86 to over a $100 a month. And the ring is, like, 300 to $400 per few months. So it’s

[38:57 –> 38:57] just Wow.

[38:57 –> 39:02] It just Okay. Kinda matters what Yeah. What you can afford.

[39:02 –> 39:08] Okay. Okay. So the simplest seems like the patch. The cheapest is the is the tablet, which

[39:08 –> 39:08] Mhmm.

[39:08 –> 39:11] By the way, the WHO used oral estrogen. Correct?

[39:11 –> 39:12] Correct.

[39:12 –> 39:30] Okay. So and and it sounds like bypassing the liver metabolism lowers your risk of thromboembolic disease, like blood clots, essentially. So Exactly. Okay. And then the the ring is the most expensive, and that’s and that to just be clear, that’s a ring that that the woman places in her vagina and leaves it there and just forgets about it.

[39:30 –> 39:32] Correct? How long does that last for?

[39:32 –> 39:33] Three months.

[39:33 –> 39:34] Three months. Wow. Okay.

[39:34 –> 39:35] It’s so expensive.

[39:35 –> 39:37] And does it dissolve, or do you have to take it out?

[39:37 –> 39:38] Tell no. No. You have to take it out.

[39:38 –> 39:40] It’s like a hard plastic donut.

[39:40 –> 39:40] Okay.

[39:40 –> 39:53] We rarely use it simply. It’s so expensive, but it’s really good for patients who have prolapse. Right? So if you have a prolapse and you’re use a pessary, which are those rings that hold everything up, this is a great way to use that instead or bothersome.

[39:53 –> 39:58] So the ring actually holds the vaginal or the rectal prolapse up?

[39:58 –> 40:02] It’s not meant to, but it’s so big that it it does do so bad.

[40:02 –> 40:04] Okay. Is it uncomfortable?

[40:05 –> 40:08] Mm-mm. No. Because your vagina just sort of stretches.

[40:08 –> 40:13] Okay. Okay. And then you got the spray. You’re saying it’s like a spray that you spray in your body, like a body spray?

[40:13 –> 40:14] Yeah.

[40:14 –> 40:20] And it just it goes transdermal. Okay. And that and that’s very expensive, though, you’re saying? 80 to $90 a month. Yeah.

[40:20 –> 40:21] Yeah. Okay.

[40:21 –> 40:21] With insurance.

[40:21 –> 40:27] With insurance. Okay. Right. Okay. So so that’s so that’s estrogen and progesterone.

[40:27 –> 40:52] What about okay. So here’s another thing I wanna talk about, and it’s not you don’t hear this much talked about with female hormone replacement therapy, but it’s testosterone. Because, you know, testosterone is measured in nanograms per deciliter when you get a lab test. And a man’s testosterone is in the hundreds to thousands, you know, naturally. A woman’s is usually around 20 to 50 nanograms per deciliter.

[40:52 –> 41:18] And then her estrogen, you know, goes anywhere from, you know, 50 to 300 picograms per milliliter depending on where she is in her menstrual cycle. But and we always think, you know, women are estrogen dominant, and testosterone is just kind of like a minor thing. But her testosterone level still, because it’s nanograms per deciliter, it’s still higher than her estrogen. And no one if I if anyone ever asked me before I looked at that and said, hey. Do you think a woman has a higher testosterone than estrogen?

[41:18 –> 41:28] I’d no. But it is. You know, depending on where she is in her cycle, most of the time, the testosterone is higher. So is there any and testosterone is produced in the ovary. Correct?

[41:28 –> 41:28] Mhmm.

[41:28 –> 41:33] So is there any reason to replace testosterone during hormone replacement therapy in a woman?

[41:33 –> 41:44] Okay. So yes. Yes. It’s a pen I call testosterone Pandora’s box because it’s getting its heyday in the news. And as with the news, there’s a lot of there’s so much noise.

[41:44 –> 41:53] Okay. So testosterone is is important. It is the third it’s the one we forget about the most. It is the third piece. I think we simplify.

[41:53 –> 42:14] We tend to simplify things saying that men are testosterone dominant and women are estrogen. We always say these things and that they’re not necessarily true. But the reality is that we slowly decrease our testosterone. It’s not like a cliff dive. It is a very I’m talking like just tiny, tiny and then when you get into your 65 up, do you know it goes back up to normal levels?

[42:14 –> 42:30] Really? There is a going down and a going back up. There’s there’s only so we just went to the conference about testosterone. And then there’s a question of is it is there an importance of why we naturally decrease our testosterone and go up? Is is there some biological significance?

[42:30 –> 42:45] We don’t know. So we just know that because there’s a downward shift, we assume we have to replace it because it is. We assume it’s an issue. But we just don’t know the answer. The only thing that testosterone has shown in studies to improve is the hypoactive sexual disorder.

[42:45 –> 43:02] Meaning that they it’s decreased libido, but also maybe they have the libido but decreased desire or need for that. And it only helps a third of patients. It is not a perfect cure all. Yes. You could use it to they say that increases your energy, helps maintain muscle mass and build muscle.

[43:02 –> 43:25] It’s some play into bone health and cognition, the people who use it. The main stuff that it comes out of is from those testosterone pellet studies, which are paid by the pellet company. You make a lot of money when you give out pellets. There is a financial incentive for the people who give it to you. So anytime there’s financial incentive, you kinda have to question where is the data coming from and done.

[43:25 –> 43:32] Do I believe that these women feel great? Yes. It’s an anabolic steroid. Well, who doesn’t feel good on an anabolic steroid?

[43:32 –> 43:32] Yeah.

[43:32 –> 43:46] Right. So so so you’re right. Think that they it’s hard to maintain that feeling of of of high that they get from it. It also has irreversible side effects. So I always say that I’m happy to give it to you.

[43:46 –> 44:13] If if these are the things, this is the data, informed consent between the two of us. But you have to understand that the male pattern baldness, the lower voice, the growth of your chin and your chest hair, clitoral megalithe, also known as the micropenis, your clitoris gets bigger with the use of testosterone, are irreversible. You’re you you can stop using the testosterone, but your clitoris will still be a micropenis. Your voice will still be deep. The angular structure of your face will still be angular.

[44:13 –> 44:29] And I could give you the estrogen because they assume there’s offset. Like, they would balance each other. That’s not how they work. That it would cure it would treat these side effects because we see the end result of patients who’ve been on years of testosterone pellets and we can’t help them. We tell them, like, we can’t give these high doses.

[44:29 –> 44:42] You you are in such high doses. We can never we don’t have these to give. We can’t give you estrogen to balance your testosterone. It’s not how it works. But there is definitely a place for testosterone for sure, especially as we age and are old.

[44:42 –> 45:09] I think 55 is a great place. People who have really bad big muscle mass loss, like sedentary wheelchair bound, just immobility, you have to kind of it’s a nuanced part where of the conversation where I’m kinda gauging it. I will also say there are no FDA approved products for women that are testosterone. And we are using male products, and we siphon it off and tell them that you have to use droplets to kinda estimate what a female should get.

[45:09 –> 45:12] And you’re talking about, like, the transdermal cream. Right? That’s what you’re

[45:12 –> 45:12] talking about.

[45:12 –> 45:29] Gels I was talking about. They come in a little packets meant for men, and they’re completely dosed for a man to use the whole packet. But we take the packet. We tell you just pretend that you divide it into 10 and that this is what you’re gonna use these three drops a day. It’s not even an exact science, but that’s as close as we can get.

[45:29 –> 45:31] So Very imprecise.

[45:31 –> 45:48] Very imprecise. There’s very little funding in this simply because we, you know, we talked about if a man claims erectile dysfunction or low testosterone, they could sit there and have 20 different things, you know, given to them. But for women, it’s zero. It is zero. No one cares.

[45:48 –> 46:08] That’s one of the discrepancies in medicine. A lot more funding goes towards problems that plague men than towards women. So hopefully that changes as our generations go forward. And I think, you know, what you guys are doing is is making a difference, you know, focusing on women’s health. One more thing I wanna ask you about is DHEA, because DHEA is in the pathway to create testosterone in the body.

[46:08 –> 46:15] So could a woman augment her natural testosterone levels by taking DHEA instead of testosterone?

[46:15 –> 46:18] How I use DHEA is actually vaginally.

[46:18 –> 46:19] Okay.

[46:20 –> 46:49] So it’s the vaginal you put it in your vagina, and then it gets converted into testosterone. It is actually an FDA approved medication called Intrarosa. I don’t remember ever seeing any good data on, like, taking it orally and then having it convert to testosterone. So but there is nice data saying that using it vaginally will convert and will help with some of the vaginal dryness complaints that women experience. And it’s a nice sort of like non estrogen based form.

[46:49 –> 46:53] So patients that don’t wanna take estrogen for whatever reason, they can try this, and it’s a nice option.

[46:53 –> 47:02] It also is compounded in something called the scream cream. We we just so so just to throw that out there, it’s a it’s, you know, it’s it’s added

[47:02 –> 47:04] to Does that mean it amplifies orgasms?

[47:04 –> 47:14] Orgasm. Because it’s a you know, there’s there’s the topical is mixed with the same stuff that’s in Viagra. Right? Because it vasodilates. It causes the blood flow to go to the clitoris.

[47:14 –> 47:38] It opens all the vessels so you have more blood flow. So you get a lot more, you know, sensation and therefore a stronger orgasm. But I will add that, you know, we always assume that more of something is always better. So if you are lacking in something, if we give more of something before it, that you will make more. But those pathways need proteins and cofactors to make testosterone and to make these molecules in between.

[47:38 –> 48:01] If you are lacking in those cofactors, it doesn’t matter how much DHA you take. You assumed it went converted to testosterone, but that same pathway will make some of the estrogens, the estrones, and progesterone. So what if your pathway doesn’t have those and it just converts it to a different hormone? You can get the irregular bleeding. You can get the other things that we just thought was associated with something else.

[48:01 –> 48:04] So it’s very hard to study that and to track that.

[48:04 –> 48:29] Vaginally application is your your preferred method for DHEA. And then that prevents the systemic conversion to other metabolites that you can’t control essentially. Okay. So let’s shift gears a little bit and just talk about, you know, if a woman wants to go on hormone replacement therapy, what are the risks? Because right now, the FDA still has a black box warning on hormone replacement therapy from that WHI study.

[48:29 –> 48:41] You know? Even though the WHI researchers have come back and said, oh, well, we didn’t relay this properly to the public, but we still have this black box warning. So what do you tell your patients before they start hormone replacement?

[48:41 –> 48:58] I will tell people, like, risk of big picture risk are breast cancer. I still mention breast cancer. I’ll say breast cancer, heart attacks, strokes, blood clots. In reality, all of those are very low risk. However, things that I see most common in our practice is gonna be breast tenderness and irregular bleeding.

[48:58 –> 49:24] And so that would be it. And so you have to weigh your decision to start it based on how bad your symptoms are. So if you’re having no symptoms and you have no risk factors for things in your future, like you have no family history of osteoporosis, probably don’t need to start it. But if you have if you’re uncomfortable at all, this is a very low risk treatment option that you can explore. So I do think that the breast cancer gets a little bit more confusing for patients because of the, like, the WHI.

[49:24 –> 49:45] So, typically, my counseling involves just saying, like, if you have a cell that has decided that it’s gonna be breast cancer already, it’s gonna be breast cancer. It is not going to the HRT in itself is not gonna cause breast cancer. It has decided that it wants to be breast cancer at some point and that these hormones will feed it, and that’s why you need a mammogram. And that so we can catch it. But otherwise, you should take the hormones if you’re uncomfortable.

[49:45 –> 49:48] Do you do mammograms before starting HRT?

[49:48 –> 49:55] No. That’s a that’s a recommendation. Right? We can’t make patients do anything, and we shouldn’t. It’s a conversation we say that, hey.

[49:55 –> 50:19] You know, there are even if without a family history, the majority of breast cancers are spontaneous. They come they do not arise from family history. So mammogram is great to have a baseline. They may not agree to there’s like a lot of social media, you know, pressure right now on this mammogram thing and radiation, all these things. But it’s just nice to have a baseline because in the future, if you were to have a mass or something else, they gotta have something to compare it to.

[50:19 –> 50:49] So at least do that. But but that’s just informed you know, we have a a conversation about it, but we don’t require it per se. And I will add on that that the data clearly states that if you use HRT, the thing with breast cancer is that those patients were found at a later stage, which means that the cancer grew faster. It is the estrogen and progesterone are the growth hormone for breast cancer, but it doesn’t actually cause the cell to make that air. This is the cell to tell the cell that I’m gonna continue to grow all the time and become a tumor.

[50:50 –> 50:56] So there’s a defining line there that we have to kind of switch. I think they’re getting rid of the FDA black box one for vaginal estrogen.

[50:56 –> 50:57] For vaginal estrogen?

[50:57 –> 51:12] Yeah. For vaginal estrogen because it’s not systemic. You could use this safely in patients with history of breast cancer, any of the contraindications that you would normally have for taking any systemic hormones, could use vaginal action. So they’re getting rid of that. It’s a slow movement.

[51:12 –> 51:17] That’s step one. And, hopefully, we’ll get off some of the warnings that are in the other medications.

[51:17 –> 51:24] That’s good. So let’s just say a woman has is BRCA positive. Can she still take hormone replacement therapy if she’s suffering?

[51:24 –> 51:25] Yes. Hundred percent. Okay.

[51:26 –> 51:37] And what if she’s had a history? Maybe she had, you know, a history of breast cancer, had a biopsy, it was DCIS, and she’s okay now. Can she go on hormone replacement therapy if she’s suffering?

[51:38 –> 51:49] That is a more nuanced discussion for a specialist. And so I would say, yes. It is an option, but really requires an in-depth conversation that is probably more than this podcast. But, yes. Okay.

[51:49 –> 51:51] There’s a possibility. They have to find the right

[51:52 –> 51:59] But she’s not she’s not immediately excluded. She can have a a conversation with a specialist, and it might be a possibility.

[51:59 –> 52:00] Absolutely.

[52:00 –> 52:00] Okay.

[52:00 –> 52:12] It’s always risk and benefits here. Right? How much are they willing to to take that upon? And then talking to the oncologist. They need to be part of the conversation and kind of just looking at a whole picture here.

[52:12 –> 52:26] Because some you know, there are some who are like, I’m willing to take the risk. I’m not willing to suffer for this. And some’s like, I never ever a 100% don’t wanna go to chemo radiation ever. So if that’s your answer, you know the answer of how much risk you’re willing to take.

[52:26 –> 53:01] Very good. So okay. This is another thing I wanted you I wanted to get you guys to comment on is because we always think about the risks and benefits of a of a drug just like doctor Kumar mentioned. But what about the risks of not being on hormone replacement therapy? Because, you know, I I pulled up a couple studies before we got on, and there was one study that estimated that after the WHO came out in 2002, in the decade following, up to eighteen thousand to ninety thousand women who had had hysterectomies actually died because of the lack of hormone replacement therapy that that they were denied access to.

[53:01 –> 53:26] And then another there was a New England Journal of Medicine study, clinical trial, that showed that hormone replacement therapy cuts UTIs by seventy five percent. Yes. And, you know, I’m a neurosurgeon, but in my practice, I see so much neurological morbidity from UTIs in women, in older women. It’s crazy, you know, how badly and I I mean, it can kill people. And people don’t realize that they think, oh, UTI, you take an antibiotic and treat it.

[53:26 –> 53:36] The amount of morbidity in the l in elderly women is is crazy. So what what do you guys think about, like, the risk of actually not going on HRT in this age group?

[53:36 –> 53:43] Well, we see the risk, so we’re bathing in HRT. Teresa and I have we are so we have baskets of HRT around us. That gives you

[53:43 –> 53:46] your I tell everyone I’m gonna die with my estrogen patch in place.

[53:46 –> 54:18] You know, you mentioned something that’s very hard to study from both a population base and retrospectively because you you fail to also mention the number one cause of of mortality right now is still cardiac disease. And it’s still osteoporosis falls right behind. But how do you how do you say that how do you classify that she died of a stroke simply because of her hip fall that was a year ago or a year and a half ago? The connections have to be made by the people who are doing the study and it’s not it’s hard. So there is a very big ricochet effect from it, but vaginal estrogen is such an easy thing to fix recurrent UTIs.

[54:18 –> 54:46] It is so safe that we’re giving in breast cancer survivors. All women should be on it, especially if they’re we see this often. It depends taking care of your grandmother who is wheelchair bound or not mobile and in a nursing home. They should be using this as prescribed to prevent and keep the atrophy from worsening because they may not be verbal all the time and tell you how much it hurts to wipe or or die from sepsis of a UTI. So that’s just an easy thing.

[54:46 –> 54:51] So did you say all postmenopausal women should be on local on vaginal estrogen?

[54:51 –> 54:53] Did you say that ends up on it?

[54:53 –> 54:54] What’s

[54:54 –> 54:56] that? Everybody should end up on vaginal estrogen.

[54:56 –> 55:10] Okay. That that’s it. That’s because I would say, like, almost none of my elderly female patients are on vaginal estrogen. Because I look through the med list on every one of my patients. I would say almost none of them are, and many of them are wearing the pens.

[55:11 –> 55:24] Well, because this is also part of that grouping. Right? They see the black box warning, and they get scared. Diana and I were trying to figure out one day, like, who cannot be on vaginal estrogen? And we actually can’t think of anyone that can’t be on vaginal estrogen.

[55:24 –> 55:38] I guess if you the only person is like has vaginal cancer that’s like, it’s gone going, you probably not apply some topical thing if you’re going to vaginal cancers and vulvar, you know, getting radiation. Actually, radiation therapy

[55:38 –> 55:39] should be Radiation is probably good one.

[55:39 –> 55:56] It should be positive. But but see, it’s very you’re asking an absolute answer. In medicine, we rarely rarely give absolute answers. But but, yes, there are there are very little if none contraindications to to vaginal estrogen. But you there’s a big key part here.

[55:56 –> 56:09] You have to see a gynecologist. And women stop seeing gynecologists after the cutoff date of no more Pap smear after 65. That’s complete other thing to to discuss about. But after 65, they don’t see us anymore. They only see their PCP.

[56:09 –> 56:27] And that’s not something that’s being conveyed to the PCPs to check off, like, a question. They’re worried about their heart disease. They’re worried about their hypertension and their diabetes. Those PCPs only they have so many things to go through that it’s the forgotten area, and they’re not going to go down that road. So that’s where we come into play, but we don’t see that.

[56:27 –> 56:28] Yeah. Okay.

[56:28 –> 56:39] Well So now the neurosurgeon needs to be giving The key point here to my patient. The key point here is the neurosurgeon sees the majority of patient 70. You need to be giving to us.

[56:39 –> 56:56] I mean, I see so many elderly women come to my office with lumbar stenosis, you know, a tight lumbar spinal canal, and they’re saying and they’re incontinent, and they’re saying, hey. Are we think they’re incontinent because they’re they’ve got pinched nerves in their back. I’m gonna say, well, hey. Why don’t you try some vaginal estrogen first?

[56:56 –> 56:57] Estrogen.

[56:57 –> 57:08] Come back to me. You know? Because a lot of times, they won’t even have leg pain, you know, or they’ll just have some numbness or you know? And and it doesn’t the picture just doesn’t fit. I’m gonna look at that a little bit more closely because if I can

[57:08 –> 57:26] I think that you bring up a nice point, though, right, is that those are the patients that need vaginal estrogen, which you can absolutely anyone could prescribe, I mean, anybody, and send them to the urogynecologist? That’s where they need to be. Like, sometimes it’s a little bit of pelvic physical therapy and and just a little vaginal estrogen, and it’s like magic.

[57:26 –> 57:46] But you did also mention something that those with spine injuries, which is more common than we think because that’s the vertebral fractures are the big things and also the stenosis. Right? Is that they should be seeing pelvic PT. We we forget This is a very big portion of menopause care is that pelvic TP everybody should also see a pelvic physical therapist at some point. They’re like, that’s an easy that’s an easy absolute.

[57:46 –> 58:05] I agree across the board. After your babies and then after in menopause. But they have constipation. Sometimes they also have like, they have to splint because their muscles don’t work correctly and they can’t have a complete bowel what splinting is. Splinting is where you put a finger in the vagina and you hold against the wall to try to push your bowel movement out.

[58:05 –> 58:18] Because you can’t bear down. Your muscle tone is just not there. And then the incontinence. Vaginal estrogen alone is not going to fix the incontinence. That has multi again, multifactorial, but it helps with the skin and the vulvar care.

[58:18 –> 58:18] Yeah.

[58:18 –> 58:35] The the actual care of the skin. There are many other emollients that we could go over, but the reality is pelvic PT will help them take care of that area and maintain what tone they do have and relax the tones that are too stiff so that they can help balance that whole area. That that we we do have a lot of patients who have that.

[58:35 –> 58:43] So these women to have bowel movements, they’re having to basically hold back a rectal prolapse. Is that what they’re doing manually with their fingers?

[58:43 –> 58:47] No. It’s more like a pushing it in, like you’re pushing on a toothpaste tube. So you kinda push on it to help

[58:47 –> 58:49] the pushing the stool out through your vagina.

[58:49 –> 58:50] Through your vagina.

[58:50 –> 58:57] Yeah. Mhmm. And when they do pelvic, PT and intravaginal, estrogen, do they do does that get better?

[58:57 –> 59:25] It may improve some, but it also helps it helps them with the coping. Like, it helps them with different activities that they can to keep that from happening in the first place. It may not because the tone, like you say, if it’s an injury, the tone might never come back or may not go back, but at least it will help strengthen the other muscles that are associated with that function, but help them so they don’t have to reach to the point where they’re splinting every day or all the time. There’s multiple pelvic toy we actually have a podcast coming about that. But yes.

[59:26 –> 59:36] Very good. We’ll link to that in the show notes. Okay. What about this is my next question. So can older women say they’ve, you know, they’ve gone through menopause, they didn’t know it was an option for them.

[59:36 –> 59:44] They just suffered. Now they’re, you know, 70. They’re they’ve got osteoporosis. Can they go on HRT, or is that not an option for them at this point?

[59:44 –> 60:06] I think this is another sort of tricky area. So I’m not gonna say no, but I because I do start it in women that are older, but I wouldn’t start it for osteoporosis treatment. Okay. So there are still women that are in their 60 late sixties and seventies that are still having hot flashes that have never stopped. And those poor people, I will absolutely after some counseling, we I’ve started it.

[60:07 –> 60:20] But just to prevent dementia or to prevent heart attacks or bones at 70 is not a good indication to start. And we know that from the WHI, and those patients that started late and got hormones didn’t do as well.

[60:20 –> 60:29] Right. Right. So when is the ideal time for a woman to start? I mean I mean, is it when she’s in perimenopause and symptomatic? Is it right at menopause, right after?

[60:29 –> 60:31] I mean, when should they start if they’re suffering?

[60:31 –> 60:32] As soon as they start suffering.

[60:32 –> 60:38] Okay. And and as long as they don’t wait too late. Is that what you’re saying? Is is Yes. I mean, when’s the cutoff?

[60:38 –> 60:43] When would you say, hey. Your ten years after menopause is not an option, or it’s it’s higher risk now?

[60:43 –> 60:52] Yeah. We say it’s high risk, but it’s not an absolute no. It just depends. Right? Because this is where the contraindications, which we didn’t go over in detail, but really start to apply.

[60:52 –> 61:05] Like, when we are when we age, we have a higher risk of having had cancer or had cancer. Right? We have a high risk of already having a heart attack or stroke. We have a high risk of going to have a heart attack or stroke. I currently have heart disease, congestive heart failure.

[61:05 –> 61:28] Have uncontrolled hypertension. I am now on diabetes, like insulin therapy for my you know, these these risks now are real and they are true contraindications in some cases. So starting it before you develop them may, you know, somewhat help you prevent them, but but that now you can’t use it because of those disease state. The older we get, the more diseases we acquire.

[61:28 –> 61:38] Yeah. Okay. But if you started it at 50, like you said, Theresa, you can wear it to death, your deathbed Death. That estrogen patch.

[61:38 –> 61:47] There’s no reason to stop it as long as you don’t have right. As long as you don’t have a contraindication that you develop at 80, there’s no reason to stop hormone replacement therapy or menopausal hormone therapy.

[61:48 –> 61:48] Okay.

[61:48 –> 62:07] I think that brings up the two old school things that we were taught and we don’t practice anymore. One is that you have to wait until your periods are done to start age to to start menopause treatment. So you don’t. You can start it while you still have your periods. You can start it when you first have symptoms, whether that’s at 41 versus 45, it’s gonna be different for every single person versus 50.

[62:07 –> 62:22] And that’s the first thing. So we used to wait. We used to say back in residency was like, you gotta wait until they’re done completely one year, no period, and then you can start them with hormone replacement therapy. And then the second is that you had to stop them at some cutoff. That cutoff has never been set.

[62:22 –> 62:32] And menopause society gives you a free rein, really, to say you stop them when there are contraindications or the patient desires to stop. They can continue forever.

[62:32 –> 62:41] So okay. And that those risks so the risks of starting at 70 are not the same as continuing on HRT from 50 through 70. They’re not the same.

[62:41 –> 62:42] Exactly. Okay. Totally different.

[62:42 –> 62:51] Okay. Okay. So what are the the absolute contraindications? I mean, we’ve kind of danced around this, but what I mean, who absolutely cannot get HRT?

[62:51 –> 63:06] Breast cancer. I would say that’s absolute. I would say if you currently have active breast cancer or any cancer Right? Because if you have cancer, you’re such a high risk for clots. Pulmonary embolism and stroke.

[63:06 –> 63:10] And a stroke will definitely that’s that’s the you know, you you die from those.

[63:10 –> 63:11] Yeah.

[63:11 –> 63:28] So I would say current cancer, current getting treatment for cancers, any cancers. And there’s probably a time limit after that because if you’re ongoing you know, it’s not like, oh, I was put in remission one month ago. Can I start HRT? You probably feel like, no. You’re still you’re still in the window, so you can’t do that.

[63:28 –> 63:45] Patients should not start it if they’re immobilized. Like, if they just had recent because I had a patient recently who came in, had knee surgery. He’s gonna be in a cast for six months. Great time to start because when are you more likely to develop a clot? Is it or or back surgery where they’re they’re definitely immobilized in long term.

[63:45 –> 64:00] Current stroke treatment. So this is a nuance here because if you’re on blood thinners, there’s a lot of debate and conversation of that. But if you have recently or currently had a stroke, you just were seen in the ED yesterday, now you wanna stay at HRT, I’d say that’s a hard stop.

[64:00 –> 64:05] Okay. Or any blood clot. Right? A DVT and a PE, recent PE?

[64:05 –> 64:05] DVT.

[64:05 –> 64:09] PE. What about a heart attack if they’ve recently had a stent placed? Okay.

[64:09 –> 64:19] Yeah. The if you’ve had a blood clot on HRT. I’d say that’s an absolute. Yeah. Because that means you’ve proven that you cannot tolerate it.

[64:19 –> 64:21] There we need to give we need to come up with something else.

[64:21 –> 64:47] Right. Right. And I I just wanna, like, mention here too that and and correct me if I’m wrong, but, I mean, we’re putting young women on birth control all the time, which is honestly much higher doses of, like, synthetic estrogens. I mean, these things that we’re talking about are they may be, like, scary, but, I mean, you’re talking about lower much lower dose hormones with a much safer risk profile, but the risks are still there. And, like, people have to know about them.

[64:47 –> 64:49] Right. They’re low, but the risk is there.

[64:49 –> 64:57] They’re they’re there. Okay. Very cool. Okay. So let’s let’s just walk through let’s do two case scenarios.

[64:57 –> 65:09] Okay? I wanted you guys to pretend like this patient just walked into your clinic. Okay? And they’re they they wanna talk to you about what to do. And so with the first one, it’s a 54 year old woman.

[65:09 –> 65:19] She’s got night sweats and recurrent UTIs and brain fog. Okay? She’s otherwise healthy. How would you treat this woman, or how would you counsel her and treat her?

[65:19 –> 65:23] I’m gonna rein her with estrogen and progesterone. Okay. Gonna get it all.

[65:23 –> 65:25] Is this the ideal candidate here?

[65:25 –> 65:39] It’s ideal. Person. Perfect. You know what I it’s really nice about patients like this is that hot flashes, night sweats, they are the best symptoms to treat because they go away so quickly. I usually tell patients seventy two hours, you can start noticing a difference.

[65:39 –> 65:49] Not every time, but of the vast majority. So systemic estrogen, systemic progesterone, and then topical vaginal estrogen. And she’s gonna be a new woman.

[65:49 –> 65:55] Okay. Okay. Great. So, okay, here’s the second patient. This is a 39 year old female.

[65:55 –> 66:09] Okay? And she has just had her third child. She’s having horrible brain fog. She’s having constant knee problems. She feels like her hair is thinning, and she has no energy, and she never wants to have sex.

[66:09 –> 66:15] It’s just not a thing for her anymore. What what would and she comes into your clinic asking, can you help me? What would you do with her?

[66:15 –> 66:17] It would depend if she’s breastfeeding. So assuming

[66:17 –> 66:21] Let’s say she’s done with that. That that’s the baby is a toddler now, let’s say.

[66:21 –> 66:49] Then I think that there are some nice options for depending on again, this is where it gets a little trickier because we’re trying to control periods plus symptoms, but there’s some really nice new birth controls out there that are very similar to your natural estrogen. And so that would be an option that would kind of help with the brain fog in some patients and a lot of the symptoms she’s dealing with or just starting her on menopausal hormone therapy and seeing if that improves everything, knowing that it will not prevent pregnancy. She doesn’t want another one.

[66:49 –> 66:57] So and that’s and that’s an important point I think that we haven’t talked about yet. HRT, even though it’s estrogen and progesterone, does not prevent pregnancy. Correct?

[66:57 –> 67:02] If you’ve been practicing long enough, always we all have one or two patients who got pregnant on HRT.

[67:02 –> 67:03] Okay.

[67:03 –> 67:05] That is that is the key piece that we always try

[67:05 –> 67:06] to tell

[67:06 –> 67:18] our patients. You are not exempt from the pregnancy rule unless you’ve had a vasectomy or a tubal or even some other form of birth control. So that’s very hard to to swallow, I think, sometimes.

[67:18 –> 67:26] Okay. Well, very cool. I I feel like we’ve that was pretty comprehensive. We went through all, I think, most of the questions that a woman would have about HRT.

[67:26 –> 67:29] I hope we’re start sending people to your podcast.

[67:29 –> 67:29] Like, we’re

[67:29 –> 67:32] you have to watch this first, and then we’ll prescribe whatever

[67:32 –> 67:49] you want. You guys are amazing. I mean, you guys have, like, just such a great breadth of knowledge on this, and I I feel like we need to put one of you guys in every clinic because I mean, here’s the thing. Let me let me ask you this. My sister-in-law, she went to her doctor, and she said, I I’m suffering.

[67:49 –> 68:00] I’m I’ve got brain fog, fatigue. I’m just like you know, my hair is not good. Everything is is not going right in my life. I wanna take a look at HRT. And the doctor said, I’m not comfortable with that.

[68:00 –> 68:03] So what how would you counsel someone like that?

[68:03 –> 68:16] To come find us or find another menopause provider. So even if you don’t wanna see us at findlist.com, you can go onto the Menopause Society website, which was formerly known as NAMS, n a m s, which will still bring it up in Google.

[68:16 –> 68:16] Okay.

[68:16 –> 68:23] And just find a local provider near her, and she can find someone that just does this not if not all day, at least has got extra training in it.

[68:23 –> 68:47] I think I think it’s also really hard right now with the world of social media, the news, the current climate, however you wanna say it. There’s so much information out there to kind of see what is real, what isn’t real. It’s so confusing. So it’s nice that we we it it all it’s like, you know, I always say there’s two grains of salt and a lie somewhere in between. And you’ve got to figure out how which ones apply to you, and it doesn’t apply to everyone.

[68:48 –> 69:05] So that whole news flash of, hey, HRT does give you heart attacks. Well, yes, it can. But it doesn’t have to apply to everyone. And so that’s why it’s nice to see someone who kinda does this all day every day. I feel it very hard because we used Theresa and I used to work in those.

[69:05 –> 69:16] We saw 28 to 30 patients a day getting seven and a half minutes, but we also have all these boxes to check. Did you get your pass through? Did you give me a mammogram? Did you get your DEXA scan? Your cholesterol is high.

[69:16 –> 69:33] I need to give you this. It’s just that. And it’s very hard for them to go, okay, I gotta keep up to date on that, but I also get to keep up to date on all the medications to treat your blood pressure. They don’t the new stuff is relatively newer maybe in the last five years. So we’ve really changed our management.

[69:33 –> 69:46] So I think finding the right provider specifically for that is is the best way to go. Okay. I I don’t blame the PCPs at all. We don’t blame the general state. They’ve got lots of they’ve gotta go through all these things.

[69:46 –> 69:56] And they’re making sure that you’re a good candidate because they give us the information. Right? They say this blood pressure is normal, that this person is healthy. I go through the chart and I go, oh, yeah. Yeah.

[69:56 –> 70:06] Yeah. So it makes my conversation much easier. It makes my job a lot easier. But we are slowly training the new generation. It will be fifteen, twenty years just like it was back in the nineties Okay.

[70:06 –> 70:08] To get back on track.

[70:08 –> 70:16] Fifteen to twenty years until we have a large contingent of providers comfortable at providing HRT.

[70:16 –> 70:35] And I will also add that we canceled most of the studies for women for the NIH funding and everything else. So it’ll be another fifty years where we have new data to give. Right? To really there were big studies for brain fog, cognition, dementia. Those those those things have been cut.

[70:35 –> 70:45] We should give, like, you know, a big thing to like, legislation is not giving money to women’s health. So it will be many more years to get new data. We’re working on old data.

[70:45 –> 70:57] Well, that’s disappointing. Honestly, it’s disappointing. But you guys are treating and on the best data, and you’re putting together a lot of empiric evidence, and you’re sharing it at conferences. So, hopefully, that will take us forward, honestly.

[70:57 –> 70:58] Agreed.

[70:58 –> 71:01] Yeah. You guys have a project going on right now. Do you wanna talk about it?

[71:01 –> 71:03] Yeah. Diana, why don’t you take it?

[71:04 –> 71:24] So it’s like, we just launched a vaginal vulvar vaginal clinic. We have, I would say, about fifty percent of our patients have some vaginal symptom and sexual libido, sexual health, the whole thing. And that’s quite the that’s the normal statistic. So we have started a clinic that kind of makes it much more comfortable. You can go in.

[71:24 –> 71:41] You can fill out a form. And then if we need to, we’ll make an appointment. If not, a lot of the stuff can be can be, like, prescribed or discussed through texting and through through the our system. And we prescribe the medication. It arrives to your pharmacy that you’ve listed, and we send it off.

[71:41 –> 72:00] And because there’s a lot of need for urgent care needs right now for for just specifically women’s health, we’ve added an UTI that we talked about vaginitis, STDs. So access is key here because I think The United States is going through a very big women’s health access issue, and we want women to be able to go do it. And so that’s our big project.

[72:00 –> 72:00] How do

[72:00 –> 72:07] they so if someone has a vaginal problem, is that open for them to contact? So how do how would they do it?

[72:07 –> 72:17] Yeah. They would go to our website. It’s ww.findglis.com, and there’s a vaginal health marker. They just click on it, and they fill out the form. And then we respond within six you know, a couple hours.

[72:17 –> 72:35] And we say, if there’s any issues, I’ll call them and say, hey. Can you just tell me again what does this mean for you? Yeah. And then we send the prescription in. It’s going to get easier, because we’re in in a couple weeks, we’re launching a different app so that patients can put their information and take pictures or use video to kinda help us with the diagnosis faster.

[72:35 –> 72:39] Wow. Like, videos and pictures of their vagina.

[72:39 –> 72:46] Yes. Yeah. Surprisingly, for most of our patients, they just when they Zoom chat with us, they just take the phone and bring it all the way down.

[72:46 –> 72:46] Like, this

[72:46 –> 72:49] is the spot that bothers me. Can you look at it? It’s it works

[72:49 –> 72:53] out just fine. Yeah. Can you can you treat and diagnose and treat that way?

[72:54 –> 72:58] Yes. There are many of them. There’s some that may if we need a biopsy, we’ll refer out.

[72:58 –> 72:58] Or if

[72:58 –> 73:14] we think we need a swab, we can order it. And nowadays, the swabs can be mailed to them or, like, there’s new in the urban areas, there’s new cars that drive around with laboratories in the van where they just deliver the swab. They swab or pee in a cup and then put it in and send it off, and we get the results, and we do everything through there.

[73:14 –> 73:39] That’s fantastic. Oftentimes, those problems are embarrassing. Right? I mean, you know, they go you into your clinic, you have to call and make that appointment, you gotta tell them what’s wrong, and you gotta tell the lady up front in in the waiting room, and then you gotta, you know, tell the nurse, and then the doctor comes in for a few minutes, and you don’t know if you’re getting a woman or a man, you know, which doesn’t matter to everyone, but some people does. And I assume that’s the privacy aspect of that is well maintained.

[73:39 –> 73:55] Yep. Right. You know, it’s a we always tell patients that even if you send in a picture, the computer doesn’t say the whole picture. It now recognizes it only saves small key parts. So if you were to download it, all you get is a beige blurred pixelated thing because we we only need a few things to set that diagnosis.

[73:55 –> 74:15] So it’s very helpful. We don’t always have to look at the whole thing. And then the second I I will also add that you had mentioned if there’s, you know, daughters who take care of their elderly mom and they it’s very hard to bring in patients from nursing home, home health, or even home care in. And so they they use we’ve had patients where they like, I’ve been you know, my mom has this thing. She’s complaining.

[74:15 –> 74:27] It hurts. This is what it looks like. Can you help me? Because it’s a very big hassle to get transportation, to get them there, to get them in a strange environment that they may not like or want to be in, and we can help them from afar.

[74:27 –> 74:38] So if people wanna find you, the website is findgliss.com, findgliss.com. I’m gonna put it in the show notes. Is there any other place that people should find you?

[74:38 –> 74:39] We’re on social media.

[74:40 –> 74:41] Instagram?

[74:41 –> 74:46] At Glissspot Glissspot. And Glisswellness. Those are two Instagram pages.

[74:46 –> 74:53] Okay. So I’ll put those in the show notes as well. And is there anything else you guys wanna leave us with, or should we wrap it up there?

[74:53 –> 74:56] No. Thank you so much for having us. This is great. Yeah.

[74:56 –> 74:57] Was awesome.

[74:57 –> 75:21] This was so awesome. And I I I seriously think this is gonna help someone so much, just the the information alone. But the fact that also now they have access to you guys if they need it, you know, it’s just someone who felt like hopeless, you know, they don’t they’re not getting help. And now they got this information. They hear these things that is spoken about so openly by you guys and with so much knowledge.

[75:21 –> 75:25] Think I it’s gonna make a huge difference in at least one person’s life, maybe a lot more.

[75:25 –> 75:27] Thank you so much. Yeah.

[75:27 –> 75:28] Yeah. Thank you.

[75:28 –> 75:36] Okay. Well, cheers, guys. Thank you so much. Okay. So I hope this episode gave you the clarity and the confidence to improve your life or the life of someone you care about.

[75:36 –> 76:03] We recorded this conversation on 11/06/2025. Just a few days later, on November 10, the FDA officially removed the black box warning from hormone replacement therapy. That’s an incredible step forward. And at the same time, it’s impossible to ignore what those two and a half decades of fear and confusion did to women across this country and the world. Millions suffered in silence, and the science was there the whole time.

[76:03 –> 76:37] We talked about that in this episode, but it’s worth saying again, this moment is both encouraging and heartbreaking. We’re finally moving in the right direction, but it took far too long. Alright. On our next episode, we’re shifting gears into one of the most traumatic scientific races in history. This is the story of the polio epidemic and the fear that gripped every American summer, the iron lungs that filled hospital wards, and the two men who set out to stop it, Jonas Salk and Albert Sabin, two brilliant scientists with two very different visions for what a vaccine should be.

[76:37 –> 76:49] Their rivalry shaped the course of modern medicine, and their discoveries changed the world. I think you’re really gonna love this one. So until next time, stay curious, stay skeptical, and stay healthy. Cheers.

References & Resources

The Women’s Health Initiative Randomized Trials and Clinical Practice

Association of Menopausal Hormone Therapy With Breast Cancer Incidence and Mortality During Long-term Follow-up of the Women’s Health Initiative Randomized Clinical Trials

Risks and benefits of hormone therapy: has medical dogma now been overturned?

‘Tis but a scratch: a critical review of the Women’s Health Initiative evidence associating menopausal hormone therapy with the risk of breast cancer

The Women’s Health Initiative could not have detected cardioprotective effects of starting hormone therapy during the menopausal transition

RESPONSE TO LETTER TO EDITOR

A critique of the Women’s Health Initiative hormone therapy study

Sleep disturbance associated with the menopause

Perimenopausal depression: review of recent findings and implications for future research

Systematic review and meta-analysis of the effects of menopause hormone therapy on cognition

Hormonal Agents for the Treatment of Depression Associated with the Menopause

Perimenopause and First-Onset Mood Disorders: A Closer Look

Effects of menopause on temperature regulation

Menopausal hormone therapy for the management of osteoporosis

The Effects of Menopause Hormone Therapy on Lipid Profile in Postmenopausal Women: A Systematic Review and Meta-Analysis

The Role of Estrogen in Insulin Resistance

Estrogen and the Vascular Endothelium: The Unanswered Questions

Genitourinary Syndrome of Menopause: A Narrative Review Focusing on Its Effects on the Sexual Health and Quality of Life of Women

Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management

Recurrent Urinary Tract Infection in Older Outpatient Women

Hormone therapy for sexual function in perimenopausal and postmenopausal women: a systematic review and meta-analysis update

Skin Rejuvenation in Women using Menopausal Hormone Therapy: A Systematic Review and Meta-Analysis

Menopause, skin and common dermatoses. Part 1: hair disorders

The Mortality Toll of Estrogen Avoidance: An Analysis of Excess Deaths Among Hysterectomized Women Aged 50 to 59 Years

Hip fracture in postmenopausal women after cessation of hormone therapy: results from a prospective study in a large health management organization

Hip fracture in postmenopausal women after cessation of hormone therapy: results from a prospective study in a large health management organization

Bayesian Meta-analysis of Hormone Therapy and Mortality in Younger Postmenopausal Women

The Economic Impacts of Menopause in the United States