195. Menopause Hormone Therapy: What the WHI Got Wrong and What the FDA Finally Fixed | Lauren Spivack, MD

the prime time for benefits from hormone replacement therapy, namely estrogen, which is prior to the age of 60 and within 10 years of menopause. Some ADHD symptoms, a lot of that can improve with hormone replacement therapy because we know estrogen affects the brain. What's important to note is that women spend about one third to one half of their lives in this menopause time period. So it's a huge part of the lifespan. Welcome to Medicine Redefined. I'm Dr. Altamasharaja, and I'm Dr. Darshan. Let's put the help back in the healthcare. Today, Dr. Lawrence Spivak joins us to talk about why menopause, a condition that affects every woman for a third to half of our life, has been so poorly understood and under treated by the medical system. Dr. Spivak is a board certified OBGYN who trained at Sydney Kimmel Medical College Jefferson, served as chief resident at Cooper University Hospital and completed a fellowship in minimally invasive gynecological surgery at the University of Rochester, where she worked in one of the country's largest pelvic pain referral centers. She's a menopause society certified practitioner and a member of the ISS-WSH and the International Pelvic Pain Society. And she now treats patients across the spectrum of pelvic pain, sexual medicine, and menopause in South Jersey and through the evidence-based telehealth platform alloy. In this episode, we dig into the Women's Health Initiative, the study that scared an entire generation of women off hormone therapy based on a misinterpreted breast cancer signal that never reached statistical significance. We talk about the FDA's November 2025 decision to remove the black box warning from estrogen products and what the, quote, window of opportunity actually means. And why the formulation you choose matters more than most providers realize. We also get into the Musculoskeletal Center of Menopause, formerly named in 2024 and the role of testosterone in women. Why compounded pellets can be dangerous and where the menopause conversation risks overcorrecting into sensationalized claims? Let's get into it. If you're a high performer who wants a clear plan for longevity, performance, and staying active with fewer setbacks, I'm now seeing patients through my telemedicine practice who are finding health and performance. I'm opening a limited number of founding member spots at refininghealthrx.com. All right, let's jump in. Dr. Lawrence B. Vack, welcome to the show. Thank you so much, thanks for having me. I'm super excited for this conversation, particularly because it happens every time, every now and then, where the media and everything that's kind of forefront in people's minds is a topic that we can talk about and actually put out there for people to get educated on, especially because there are people on both sides of the aisle from political lens and can become really, really polarizing. So before we do that, before we talk about menopause on a hormonal therapy and or just hormone replacement therapy, as people understand it, I wanna get a little bit of a background on you. So what is it important about you that the learner should know would be aware of in terms of your background and how you got to where you are tonight? Yeah, thanks. So a little bit of a security path for me. So I am an OBGYN trained physician. And while I was doing my training, I decided since I was more interested in gynecology and operating that I wanted to actually complete a fellowship. So I did an additional fellowship called a minimally invasive gynecery fellowship, which was in Rochester, New York at the University of Rochester, which unbeknownst to me had a very big pelvic pain center that was a large part of the training in terms of the minimally invasive gynecery because a lot of what we were seeing was not only endometriosis, but all sorts of other things that are non-operative that cause pelvic pain. So I found myself doing fellowship with a large at a large academic setting with a huge referral center for they had a specific pelvic pain center. So at the time, I really didn't know a lot about how to treat pelvic pain and it's sort of the dreaded chief complaint for gynecologists that people come in with very commonly because we don't have enough time to treat it and it can be very complex if you don't know how to treat it. So it was upon being there that I really got the tools to learn how to treat pelvic pain and went from really disliking it to having a real passion for it, which happened to also coincide with my own struggles with chronic pain, back pain and neck pain where I really started to personally have this understanding of the impact of pain in one's life. So as I became really interested in pelvic pain and certainly developed the surgical skills from an endometriosis standpoint, I came back to New Jersey and really wanted to focus on pelvic pain. And in doing so, also began to see a lot of patients, menopausal patients who were having pelvic pain from the standpoint of painful intercourse, vulvar pain, any number of things that overlapped with what I was seeing. And during ObuGYN residency, there was a huge dearth of training on menopause, basically little to none. I had maybe one lecture on menopause and so that were trained very well in obstetrics, basic GYN, no training in menopause. So I came out as an attending and sort of avoided asking menopause questions because I didn't know how to treat it. And then I realized how much it was overlapping with my pelvic pain and how much I actually wanted to learn about it. And so I then sought to really learn about menopause from the standpoint of conferences that I was going to training that I received as a menopause practitioner. And it has now become a huge part of my practice and something that I'm very passionate about. So that's kind of how I got to the menopause part of things. And at the same time, it's obviously exploding right now in the media and in general with various things that have happened but women really taking it into their own to become advocates for the stage of life which for so long has kind of been brushed aside or people have been told to deal with it. I think one of the other things I would say is that in a lot of the patients I deal with, pelvic pain wise, there's a lot of gas lighting these patients have come in, hold nothing is wrong. And so the same thing has happened with menopause and perimenopause where either they're just told to deal with it or you're still having a period, you're fine and women are really suffering. And so to be able to have the skills to help and educate women has become that part of my practice has really become very important to me. Yeah, things like you're just getting older. This is the aging process. Exactly, yeah. Yeah, it's tough because pain is a universal thing. And the reality is there is some truth to the fact that as we get wiser in our years, I like to tell my patients that things do break down. We have a little bit wear and tear. There's some cumulative trauma, there is some damage. But oftentimes there is something under the hood that can be looked at. And I think just as a word of use gas lighting, I don't know where I heard this recently. So you have two things going against them, right? So one, women have been neglected in just medicine, respect to research and the resources that are allocated towards studying the issues that are unique to them. And then also the aging population, seniors. That's another thing. And so they got the double whammy on that regard, right? You mentioned that give me a sense of what's the average age range of the person that you're dealing with? Because I know the folks that we work together with, like it could be as young as 16 year old, 17 years old. Yes. So really since we're talking and it could go from endometriosis and that's we're talking about could be starting in teenage years in 18. And then from a menopausal standpoint or women that are having things going on, I'm seeing people up into their 80s and with sort of newer onset, not simple to treat what will maybe get into later genital urinary syndrome of menopause, but coming in with a lot of vaginal pain, urinary recurrent UTIs. And those are these older women in their 70s or 80s that have been suffering for a long time. And there are also other skin conditions that can affect the vulsa that tend to be something in older women. And a lot of people just, you know, it's been itching, it's been burning, I've just been dealing with it. And then at some point they do get to me either through an annual or a referral. So I really see a whole age range. Certainly with this menopaus population, it's, you know, averages 40s to early 60s. Yeah. You had mentioned something interesting which hadn't occurred to me. You said that despite going through residency and if fellowship, you did not feel prepared to treat this population in this pathology, if I can even call it that in particular, who, what residency would prepare you? Is that an endocrinology thing that somebody would be more prepared to do that? Well, I think that's part of the issue in general. And you'll see at least on social media with a lot of these what they call sort of like menopause warriors or this whole team with menopause practitioners that are talking about how actually so many providers need to be educated because it does fall on OBGYNs. But it also is orthopedic in nature. It can be dermatologic, it can be cardiology, internal medicine because there's 25 plus symptoms of menopause, very menopause. But primarily, I mean, OBGYN should absolutely, we're taking care of women or people with wolves across the lifespan. That is something from a gynecology standpoint that's a huge thing we should be educated on. And because of all of the scare behind hormonal replacement therapy, the WHOI study, which I know we'll get into, we really didn't, it was really passed over. I had the one lecture I remember receiving in residency was from an attending, it was all based on the WHOI data. And a lot of kind of scare tactics where people really weren't prescribing or very few and far between. I didn't understand everything that happened in menopause. I had no idea of the different options of medications. It was very overwhelming when I did go out into practice and realize I had so many women coming to me just that they're annual having various issues that were all consistent with menopause. And I was not sure how to help them. This is four years ago and now I'm obviously much more equipped. But it took a lot of hours and a lot of colleagues and a lot of conferences to really get that training. And that's not a unique story amongst people who are now specializing in menopause in terms of how they gained that expertise because it's not an art training. Hopefully more so now. But yeah. The lost generation as they've been named, these folks you were talking about. So let's get right into it, right? So you used a couple of terms, right? We've talked about menopause, perimenopause. There's postmenopause. Can you clarify what each of those means? Maybe we could put some time lines on when expectations are, of course, nobody's bodies don't reach textbooks. I like to say. And so people are going to approach you different timelines. But give us a little highlight on that. Yeah. So perimenopause. So menopause in general, I guess we'll start with menopause. That is the single point in time after a woman has stopped having a period for 12 months. And so that can only be sort of retrospectively understood. So then we go, and the average age of menopause is to be at least in the United States 51 to 52. But then when you read worldwide, it's more like 48. But it ranges from late 40s to mid 50s that it's going on. Perimenopause is the time period leading up to that final menstrual period. And that is a time where women can have significant symptoms because there's a hormonal rollercoaster of sorts. And that time period can be 10 years. So these are women showing up in their late 30s and in their 40s, still potentially having, well, not potentially, having menstrual periods regularly or maybe starting to skip months here and there, but with significant symptoms. Postmenopause is really everything after that I haven't had a period for 12 months. And I think what's important to note is that women spend about one third to one half of their lives in this menopause time period. So it's a huge part of the lifespan that women are having this sort of different hormonal milieu. Yeah. So you mentioned the WHO, right? So the Women's Health Initiative depends on who you follow, who you listen to, could be the greatest debacle in science. Yeah. The worst executed study, the worstly conducted randomized control trial. Or if you talk to some people, so actually, the study was quite good. It's the interpretation and the execution afterwards from the data that is where the ball was dropped. Where, what camper you in or where do you fold? Yeah. It's interesting because sort of in preparation for talking to I reviewed the WHO and some of the other literature and it's always been something. I feel like it's finally starting to become more clear to me, but it's very confusing because it depends who you read and what you think. So I think that the issue is the absolute misinterpretation of the data and the generalizations that were drawn about hormone replacement therapy based off of a population that is not the population that we actually treat. So the, I don't know if we want to get more into a huge... Let's do it. Yeah, let's tell people exactly what the study was and how it is executed. So the Women's Health Initiative was a large, the largest double-blind randomized controlled trial that followed 161,000 people that from about 40 different medical centers that the WHO started. The Women were recruited between 1993 and 1998 with an average follow-up of about 5.2 years. So the WHO was aiming to look at estrogen only versus estrogen progesterone therapy with the primary outcome being is there any reduction in actually coronary heart disease and that was non-fatal MI or just any coronary heart disease with a secondary or a primary adverse outcome of invasive breast cancer. They were also looking at incidents of stroke, PE, uterine cancer, colorectal cancer, hip fracture and death. The study was prematurely stopped in 2002 because the report came out that there was a very increased risk of breast cancer in the estrogen and progesterone R. The estrogen arm did continue. So that is where the, and because that was, that came out basically hit all the headlines and overnight about 80% of people who were getting hormone replacement therapy had stopped. And so all of these women who were getting treatment stopped because it was now hormone replacement therapy or now menopausal monotherapy causes breast cancer. Retrospectively, there's been a lot of reinterpretation of the data. So I mean, a couple of the things that happened is when they talked about this risk, they talked about it as a relative risk as a percent change rather than an absolute change. So they said there was a 26% increased risk of breast cancer which would certainly make someone think, wow, I should stop. But then if you go into absolute numbers that was an increase of eight additional cases. So it went from 38 per 10,000 person years, from 30, not on estrogen and progesterone to 38. So we're increasing eight in 10,000, which is a rare event and can be similar comparatively to drinking an alcohol drink a day, being physically inactive, being overweight. So the way that it was written and interpreted that was one of the problems. The other problem was that the group, the placebo group who didn't receive anything was actually in looking back at it did not have, it wasn't that the group taking HRT had a higher rate of breast cancer and looking back at it, the placebo group actually had an unusually lower risk of breast cancer potentially because many of them had been on hormones in the past. And so when those people who had the lower rate were removed from the comparison, there was no longer any difference in breast cancer rates between the hormone replacement group and the control group. And I've seen these nice graphs where that difference just disappears. So that's part of just the data that was not, how it was interpreted incorrectly. Also, the average age of women in this study was 63 years, significantly older than who we recommend receiving hormone replacement therapy. And it was, they said, the WHOI said it was a relatively healthy population, but in fact, it was not a truly representative healthy population. There was actually 35% were overweight, 34% were obese, 50% were current or past cigarette smokers, and then you add on this median age of 63. So all of this, you cannot generalize these results to the entire population. So when there was a reanalysis of women age 50 to 59, they ended up finding lower all cause mortality, lower coronary artery disease, and no increased risk of breast cancer in this estrogen and progesterone arm, or in the estrogen only arm. And then subsequently the estrogen and progesterone arm, there have been, that is, is it actually the type of progesterone that may have caused what was the slight increased risk? But in general, they've really, the WHOI, has walked back all of their claims, really with the exception of this breast cancer risk, depending on who you talk to. And that actual thought has just been pervasive amongst providers who still think, hormone replacement therapy, equals increased breast cancer risk. When we really know that is not the case. Why haven't they walked back the breast cancer piece of it? Well, I mean, there's an entire book about it. I think some of it is just who the principal investigators were, what, I mean, one or two of the people who just won't, just kind of, I think they want the belief so much to be that breast cancer risk is increased, that there are, they sort of massage the data to the point that they just won't. I got you. And also, the other thing that I would say that was brought to my attention just as another thing is that in the study, when they talk about this 26% increase, they say, quote, the 26% increase in breast cancer incidents among the HR2 group, compared with the placebo C group, almost reached nominal statistical significance. Meaning it did not reach statistical significance and it could have been spurious. But as one of the PI people said, because breast cancer is so serious an event, we set the bar load of monitor for it. We pre-specify that the change in cancer rates did not have to be that large to warrant stopping the trial. The trial was stopped at the first clear indication of increased risk. This is one of the people who will not sort of back tread. So this is kind of the, you know, sticking their head in the sand type thing. Yeah. There's a lot of people suffered. So what's, what's really interesting is I think so we're, let's state this, right? So we're recording earlier in December. I think it was last month or the month before the FDA came out and just took off the black box warning of all of these. Was it was the last month in November? Yeah, it was November 10th. Yeah. So they had a whole press conference and everything like that. Now I was a little too young. I guess they in back in 2002, you said they abruptly stopped it. Yes. My understanding is from listening and reading that they actually made a big deal out of it. They put a press conference there like we have to stop this ultimately. You and I are not too foreign. I don't think so. You were probably a young girl as well. Yeah, I don't remember not at all. I'm curious though. Have you had conversations with other women in your life? Maybe your mom and other relatives. And if they were on menopause hormone therapy and at that point had stopped, is this somebody you've had conversations with people close to you? I would say not so much close to me because my mom was a situation where she was a breast cancer survivor. That's mean that was ever offered to her. However, I have had patients who talked to me about their mother, for example, who was on it. It was stopped or patients coming in and they're very much being dissuaded by their mothers who were of that generation who heard that news who absolutely never touch it because of this breast cancer risk. But yeah, in terms of it's definitely, I think a lot of the generation like our parents, but I didn't have anyone close to me that was sort of had these medications removed suddenly overnight. I'm wondering if we can talk a little bit about the age and how that's relevant. So you mentioned the average age in the United States around 51, 48 if we consider the parts of the world. The average age in the study was 63. What is the downside of actually starting MHT at somebody in their mid 60s? Because I'm even thinking about the people that lost generation, so to speak, right? So maybe this is these women who maybe 10 years ago were hitting that 48 to 52. And now they're gonna be in their early to mid, maybe even late 60s. My understanding is that estrogen has a particular role when it's when those arteries are lined with some plaque versus not can you talk a little bit about that? Yeah, so that was part of the issue with that WHI study was the age, which was 63. And so what has been elucidated since that point in many studies is this sort of window of opportunity, the prime time for benefits from hormone replacement therapy, namely estrogen, which is prior to the age of 60 and within 10 years of menopause. And that is because in that time period, there is decrease in cardiovascular risk, increase in symptom relief, decrease in any ad specifically like heart attack, stroke, blood clot, whereas over 10 years from menopause greater than 60, you have higher baseline vascular disease in general, increase in atherosclerosis, and so increase risk of coronary heart disease and stroke when you add estrogen later, as although estrogen can have, like you were saying protective effects early in menopause when the arteries are still elastic, they can improve endothelial function, be favorable for lipids. Once the plaque is established, which could be many years after menopause, estrogen actually may destabilize those plaques and increase the risk of stroke. And so that's where that greater than 10 year, greater than 60. And then from a brain health standpoint, although estrogen earlier on may be neuroprotective and there's more and more work being done into that, late initiation may confer no benefit in the WHI, talked about an increased risk of dementia, which is also something that can very much be debated in terms of how they defined it. But those are sort of the reasons in terms of the stroke coronary heart disease risk. Yeah, I love it. Thank you for that. All right, so let's get into recognition. You had mentioned earlier on that 25 symptoms or so, maybe probably even more, right? But it's spending multiple specialties. And one of the challenges in medicine is that we practice in silos, right? So your OB at this point, you're doing primarily GYN public and you get a little niche. I've got my think here, I'm doing a lot of non-surgical musculoskeletal medicine. But really, the body doesn't operate that way, right? It doesn't recognize that I need to go see GYN, I need to go see the human or sports guy or I need to see somebody else. And so you're gonna have a disease process and you're gonna have the symptoms that you're gonna have. And the patients are gonna have the complaints that they have. So what are some of the common things that practitioners should be able to recognize? And maybe we can just for simplicity, bucket that into different areas. You had mentioned orthopedics as well. What do you think it makes sense to start? Well, I think talking about kind of the way that it does van a lot of different specialties because there are the classic hot flashes, night sweats, other symptoms of vaginal, dryness and urinary symptoms, which are sort of more classically, I guess recognized by GYN. But then there are significant cardiac type things where women will start to experience a lot of palpitations, heart racing. And so many people, once they come to me, they've already had a full workout with cardiology, worn a halter monitor, done all the things. When really, if we sort of had talked to them about everything, we would say, actually, this is like perimenopause, menopause, then we have a lot of people, there's an inner ear itching is like a tremendous symptoms. Itching in general, like scalp itching, but the inner ear, it's just, you know, will drive people crazy. And so many people have seen ENT for that and have been getting different treatments to try to figure that out. Then we have frozen shoulder and various musculoskeletal syndromes that happen in menopause. Joint pain people have had rheumatologic workups and a lot of that increase in muscular and joint pain is also menopause related. So for me, I go through and kind of ask these 25 symptoms and it doesn't have to be my specialty for someone to say, yeah, I have horrible joint pain, like I can't my knee, you know, and for me to recognize that, not that I'm the only one that's going to solve it because there's, of course, pathologies, but a lot of that in seeing these patterns and knowing these are entities that they fall into that category. And then I have a lot of referrals from psychiatrists as well, mental health providers because there's a tremendous uptick and mood-related issues, some really significant anxiety, new onset anxiety, panic, worsening depression, and so astute mental health practitioners are also sending, realizing the time period in women's lives and that some of that, instead of being put on an SSRI or some anti-anxiety medication, actually the women need hormonal medications and that resolves a lot of the mood issues. So that answers it, but it's such a wide array of symptoms. The H&G is interesting. I've never heard that before. Is that the mechanism, is that the estrogen of withdrawal, is it progesterone, is it both? It's estrogen-related. I mean, also like tinnitus is another one, dry eye, it's just the, and I don't know, in the inner ear specifically, estrogen receptors and that sort of thing, but whatever it is, low levels of estrogen, also just dry skin, but itchy skin can be a really intense thing. And often, I mean, it's the inner ear thing and people have no idea, and then I say it and they're like, oh my God, and then the itching and the ears go as long as you start. But it is a low estrogen symptom. The orthopedic stuff, so the term has now actually been categorized as the MSM. So it must go as a center of menopause. And I first heard about this. I'm kind of ashamed that I didn't ever learn about this as somebody who prowess themselves to really understand that this system and pain in general, but it makes a lot of sense, right? And we don't learn about how, as you highlighted, the estrogen receptors all over the body. So we have it in collagen, right? So estrogen stimulates collagen production. So as we're getting a little bit older, your tendons, your ligaments, so they'll lose elasticity, become dry, brittle. Synnovial fluid is another important one. So joints as you brought up and synnovial fluid is going to bathe all of our joints and over time, if you're going to get less of that, you're going to have less nourishment to that joint. People have pain. Inflammation in general. Inflammation is just an interesting term because people will just throw that around without it really meaning anything. But from a, from estrogen is a potent end to inflammatory. So it's progesterone. But when it leaves, you know, inflammatory cytokines like TNF alpha are, are wrapped up and they cause the systemic case. So I think it's, that's the mechanism for those who are interested and from those my colleagues listening. And then the other thing is, I think I might have texted you about this where I have had conversations all of us who treat chronic pain for all of our patients when they get pregnant, their pain gets better. And that's just the case. And I went down this rabbit hole deep down and like, what is it? It has to be a role in progesterone because that's the primary one. It's really all of the hormones, progesterone earlier on and then estrogen as well. And yeah, came to learn that progesterone has a little bit of a GABA like effect. So has that volume effect, right? Aside from the anti-inflammatory stuff that we had talked about. And if you, I have like a muscle relaxer, nature's muscle relaxer, overall everything is going to feel a little bit better and you're going to be a bit more relaxed. So it's interesting. Worked with a guy on the inpatient side who, you know, I covered from time to time and he has an outpatient practice. And he's, yeah, I put everybody on a microgesterone. Right, I was going to say this is micronized progesterone. This is because of the, yeah, one of the metabolites, the, I think, pregnant alone, that is the metabolite that has the GABA effects. And so that's the progesterone we use for hormone replacement therapy. And taken in the evening, it has that mild-sendative effect. Help was, helps with sleep. And so, yeah. And right, never knew that until I started doing core of the menopause therapy in terms of why that is because there's all sorts of other types of progesterone that doesn't happen for. Yeah. And one of the other challenges I think we were talking about the aging population is you have so many people as they have these somewhat vague, they have multiple issues. And I don't know if this is a system-based issue where you have specialists and subspecialists. So today I had a patient come to me who I had referred this patient for knee pain to one of my colleagues and came back and said, me, that doctor just does the back. And this is an interventional spine but also musculoskeletal training doctor. But now they're only doing the back. And you know, you have some of the older docs who will give a shit and say like, oh yeah, eventually somebody just only does the right shoulder and then the left shoulder and like, I take care of everything. And that's frustrating for patients because when somebody comes in and they have patient pain in their shoulder and their knee and stuff and then all of a sudden you're like, oh, you got fibromyalgia. And especially challenging for women. And again, that's kind of what I was thinking about as well. And so I want to caution though to myself but also my colleagues is like, then maybe we'll come back at the end and make a steel man for the case for the opposite side is like there aren't, as you mentioned, true pathologies, right? So if there is true underlying arthritis, it might not be a hormone. So it might be something also not. The challenge is when things are really superimposed. I guess my question for you would be, is how do you tease out, right? Like how do you tease out when you need to refer to me for something like this versus when you're like, I really do think it's a hormone problem. Yeah. Well, first of all, I would say coming back to you or saying you were barricaded and know about this musculoskeletal syndrome of menopause, that only got named in 2024. I mean, the orthopedist, Dr. Vonda Wright. Funderate, yeah. So it's not, you know, and yes, it's very common but these things are known but now being named. I would say so in terms of what I refer to you. So sometimes people have had, they've already been to a rheumatologist, they've been worked up for something autoimmune in terms of what pains they're having. If it's specifically localized to a hip, a knee, a shoulder, so we know frozen shoulder happens more in menopausal patients, it doesn't mean that I'm gonna give you hormones and all that's just gonna go away. But you know, sometimes if it's this like, I just wake up in the morning and everything hurts or like I just, I feel like I'm 80 years old all of the sudden. Sometimes it doesn't take that long to start hormone replacement therapy and see how things are gonna feel. So it's six weeks. So I always see patients back usually around three months time and depending some of them, the joint pain is gone. I mean, they feel so good. All their symptoms are improved. But for people who certain things persist or I have a sense that they should see someone to really get the back looked at or the hip, I'm absolutely, I know that the prevalence of that is gonna be more so in this older population for all the reasons you've set, wear and tear age and then all the things that happen from a muscular skeletal standpoint with lower levels of estrogen. So I think it's kind of looking at the complete picture. And for me, I'd always rather have more of a team around and console you and see what you think because it's not where I don't wanna be practicing in a stylus. So I really wanna understand all the other things that could be going on contributing to pain. Yeah, and then hopefully those different specialists are actually communicating and say, hey, I actually don't think this is the primary reason. I think you're hunch onto it, do what it is. But you do it. And you and I do this all the time. That's kind of one of my favorite things as well. Hey, do you think it's this? And you know, we're kind of just playing with these ideas, is this going on? Should they be seeing a third person? Should we be tagging somebody else? And it's collaborative like I think it should be. So I'll give us both a pad on the back on that one. Let's talk about different formulations. Cause I think this is also important, right? And so I think people need to understand, and there's this really awesome piece I read on the Guardian, which actually was a response to the FDA announcement. Actually, maybe can you just tell the listeners what the FDA announcement that they were referencing earlier? What was it that it talked about? So, you know, Senator Kennedy was on there. Marty McCarry was the head of the FDA came and talked about that. What was that all about and why is that relevant here? So essentially as a result of this WHOI study and this claim about increased risk of breast cancer, there were FDA black box warnings put on all hormone replacement therapy products, including vaginal estrogen, which we know doesn't cause breast cancer. Basically, alerting women in big letters to increase in cardiovascular risk of cardiovascular disease, breast cancer, probable dementia, with estrogen-containing products. And so this has been a huge thing just in terms of and the fight by a lot of the people who are fighting for menopause, that this information, which is inaccurate and also much more nuance, should be removed. So essentially, what was trying to be done was just to get the label off of the vaginal estrogen, because that is a local topical cream where it's completely bogus to think that, or not bogus. But we know that there's no increased risk of breast cancer in the topical estrogen cream. The other, you know, all these other scare tactics, women are actually harming some women who would be prescribed something, pick up the medication, see these huge warnings, who's going to want to take something that's increasing their breast cancer risk, or dementia risk, or increase. And when many of those things have been disproven. So the label has now been revised, whereby that black box warning is being removed, actually from all estrogen-containing products. And there's now going to be age and timing recommendations about that taken within 10 years, less than 60. And then my understanding that it is that it will be up to the individual formulations to sort of talk about on their own product, the risks. So oral versus a transdermal. But that sort of big warning that the FDA had done from this data that has now been, you know, understood to not be the true data has now been removed. So it was a really big for many, not that it's changing how any of us who practice menopausal practicing, but more so for the public and also for patients to feel safer about what's generally regarded as a very safe treatment. Absolutely, and make sure life is easy because now when you're having the conversation, they're open to the conversation. They don't have a barrier and a wall put up, like at least the patients and mom if they're in the room with them. We've talked about that in the WHO, it was all oral, right? Everything was systemic, both risk-resistant. It was oral, so they were using conjugated, we equine estrogen, which is not, you know, it is still used, but we use what is now considered body identical or bioidentical, so extra-file. And then it was using the Medroxyprogesterone, which is a different type of progesterone than the Prometrium that we typically use now as in sort of the revisiting of the study, some of the issue was thought potentially to be due to the formulation of progesterone. So Prometrium, which is the micronized progesterone and is body identical is the preferred progesterone to be used with menopausal hormonal therapy due to its safety. Yeah, and I want to make sure that I've been interested because you've used to term bioidentical and people will hear this and micronize and that's the same thing, right? Differentness, right? Well, bioidentical was kind of used amongst, really, as like a marketing ploy when people were getting things like pellets, the medications that we have that our FDA approved are bioidentical, but because they're not, you know, they are the correct term is now body identical because it's the same molecular property, but it's not, that's kind of what's being used. I'm trying to say that as that's what the people, is that compounded or no? It is not compounded. It's awesome. The sort of all the big menopausal bodies recommend against compounding because it's not regulated and the FDA, we have these good safe products and the compounding ends up coming from pharmacies where the medications are, is that, I mean, many of them could be totally fine, but you can't exactly, no one is kind of coming in and saying, this is exactly what you're saying. This is at this correct dose and then pellet therapy is sort of its whole other thing that people are doing. You shouldn't need to be paying an arm and a leg for something that insurance covers is also feeling. Are there insurances that don't cover? Most insurance, I mean, there's some form of hormonal placement therapy that you can get covered either through insurance or through cost plus that Mark Cuban's online pharmacy. There's a lot of basic hormone replacement therapy that's super affordable, so there are ways to do it if your insurance doesn't cover it. You don't have insurance, but the compounded in the pellets, none of that's covered by insurance. So people are paying hundreds of dollars for that when they could be using something that they could pay for with insurance. Interesting. So I wanna start local and then maybe we'll come back to systemic with respect to dosing and formulations, right? So you've talked about the vaginal estrogen. Talk a little bit more about symptoms that the patients will experience in the signs where you're gonna make that decision. And then what other, are there any other roles for the local estrogen or the vaginal, or the only one? Well, so there is, there are now and more and more products actually estrogen for the face. And those are all, there's nothing prescription at this time, these are all compounded because of the properties that we know that estrogen can do to the skin. So there's a lot of people using estrogen-based skin products. However, from a prescription standpoint, sorry, topical would be the vaginal estrogen cream. It also comes as a tablet and you can also, there's also a ring that you can insert as well. But it's all doing the same thing. So it's treating something that in medical terms is called the genital urinary syndrome of menopause, which are a constellation of symptoms that happen with low levels of estrogen where you that affect both the bladder and the vagina and the vulva. So patients can complain of vaginal burning, vulvar burning, irritation, itching, pain during any kind of intercourse or anything penetrative. A lot of urinary symptoms, frequent UTIs, urgency frequency, waking up in the middle of the night. Sometimes these are the most bothersome symptoms and they're so easily treated with topical estrogen in a cream. And there's actually evidence about it preventing UTIs and we know in older women, UTIs can really be a cause of significant morbidity and mortality. So I often see a lot of people coming in, they've had recurrent UTIs or we almost use it as like a preventive type thing because there's so many benefits and there's basically no one that can't take it. It's that safe in terms of its use and works really well. How often do they have to apply it? You said primarily symptoms maybe a nighttime but it's twice a week. Oh, okay. So there's a medication which if someone is using a patch from a hormone replacement standpoint, there are patches that are also changed twice weekly. There's some that are changed once weekly but what I will advise is if you're using the patch, change it twice weekly and use your vaginal estrogen cream those same days that you change the patch. So to start, sometimes there's a teaching of low sort of a loading dose where you do it every night or every other night for two weeks and then go to your maintenance twice weekly. The reason for that, again, it's just kind of the teaching, like how we were taught but also just to take effect more quickly. So that is sort of, I give that as a choice but it's not a necessary thing. Yeah, do they have a topical ointment or a cream? Like I know for testosterone replacement therapy, they actually have a cream that sometimes women will use to rub in, do they have anything like that for it? Yeah, so for menopause hormonal therapy, that include there's an oral formulation, which is a pill that I was telling you about. Then there's a gel, so that's probably similar to the testosterone that you're talking about that comes in doses and individual use packets. And so that's just rubbed onto the skin once a day and then there's a spray as well that is sprayed onto the skin and you can self adjust from one to three sprays and that's another route. And so those last three are considered transdermal or through the skin and then the first one is the oral. For the transdermal, is your preference the patch? My preference is the patch because that is just what insurance ends up covering a lot of the time and it's just very, it's nice and it's easy. You sort of put it on, said it and forget it type thing and it tends to be very well tolerated in terms of maintaining steady states. We'll tend to do really quite well on it. Some people like to do something every day and like the gel, some people like the spray where they can self adjust especially if you're kind of doing a little something perimenopause related where you may need more in one part of the cycle than the other. You could do the first half of the cycle or two sprays in the first half, one kind of adjusted as needed and what your symptoms are. But the patch is just, it's very nice and simple and people know how to use it and we can adjust dosing pretty easily all of them. But that one is probably the most, when I most commonly prescribe and then the pill would be the other thing that I prescribe. I would think with the gel and maybe even the spray, there might be some concern that it could rub off onto kids if you have them, family, other people like that. Is that something you caution people about as well? Yeah, so it's supposed to, you're supposed to let it dry and not put anything else on it for an hour. And so for some people that can be prohibitive, I mean the transference is gonna be so minimal. The gel, their alcohol base, so they dry really quite quickly and I like it's not transferring. But if that is a concern, I'd say use it at night before you go to bed and then there is not gonna be any issue with that. Okay, awesome. When you're having the conversation for the patient, let's say they've seen the updated press conference by Marty McCury and they're coming in and you have a patient coming in, maybe they're 53 years old, they're complaining with some of these symptoms, maybe got some joint stuff, some of the GSM that you've talked about. And you say, hey, let's try this. What are the risks that you're still cautioning, giving them some caution about, 10 year, 20 year, talking me through that conversation what that looks like? So I basically talk to them about the benefits of estrogen in terms of kind of what their symptoms are and why estrogen will help them. And then in terms of the formulations, it's really oral versus transdermal. And so when people have a certain history, so the oral, there may be a slightly increased risk of blood clot with the oral formulation because it's going through the liver and first pass metabolism. And so there was recently something I saw a really great graphic sort of showing the relative rate of blood clot. So with estrogen and tablet, it's very low with a birth control pill, it's higher than what I'm talking about, but still very low. And with pregnancy, it's far higher. And all the time I'm not worrying about blood clot and everyone, many people killed. So from a relative standpoint, it's incredibly low. Like we can still give, well, so the reasons that we wouldn't do that would be for example, someone who is a smoker. They can still get hormone replacement therapy, but we're gonna want them to do the transdermal route because we don't want anyone with migraine with aura. Those people, they can still get it, but because of that theoretical increased risk, those people can't take migraine with or can't take birth control pills because increased risk of stroke. So same thing, we're gonna move them to the transdermal category, maybe high cholesterol, any sort of risk factors for atherosclerotic disease or coronary heart disease. But for the most part, it's generally very safe. But if someone wants the absolute safest where that risk of blood clot completely goes away to whatever one's baseline is, then that would be the transdermal option. So the patch, the gel, the spray. In terms of ability to tolerate, it's really just, it's all the same actual medication. It's getting metabolized slightly differently and some people just tolerate one more than the other. Estrogen by mouth does metabolize into a couple of other types of estrogen in the body. So sometimes that, you know, people do better with that versus through the skin. Some people have better steadier states with the patch. For example, that's being changed every three days. So I really kind of give them the options. We tailor it to what someone wants. It's not a one-size-fits-all. So sometimes we try a couple of different options or change doses. And then if a woman has a uterus, she does need to take that progesterone. The micronized progesterone is typically what I will start with because of the safety profile surrounding the micronized progesterone. And that is typically taken at night. And we can adjust that dose because there are increasing sleep and mood benefits if you increase the dose. Some people can have progesterone intolerance and not feel well, either with bloating GI side effects, headaches, you know, that sort of thing. And in that situation, we can certainly switch to another type of progesterone, be it what was used in the women's health initiative, which is totally fine and other North Indra. And there's some other options that are still okay that they're fine. But typically we'll start with something systemic estrogen progesterone if they have a uterus. And then if they're having GSM symptoms, often the systemic therapy can take care of that. But for many women, they do need an additional localized targeted approach to really get at that tissue. And so many people want that because it just can be a real game changer because there's a lot of sexual function changes that happen. And so increasing blood flow and lubrication and getting that tissue healthier with the cream can really make a big difference for people and their comfort. How often is the oral estrogen pill dose? Does that daily here? Yeah. Okay. They're all able to be dosed from a very low dose, to sort of, you know, whatever the highest doses, which is frequently, it almost always lower than what you would have in a birth control pill. So people think, you know, in terms of understanding it, estrogen in a birth control pill, which we do use, and there's a role for impairing menopause, that's synthetic, and it does tend to be higher doses than these much lower doses that we're using in hormone replacement therapy. And I kind of explain it, want someone, a mentor of mine, talked about kind of a gas tank being empty and sort of talking about estrogen. If you sort of are on, you know, you're used to being at a quarter to a half a tank and that's where you feel good, we're not trying to get you to three quarters of a tank. We're trying to, where you're on empty to like getting up to a quarter or a half just so that the hot flushes go like the symptoms get better. We're not trying to pump you with some crazy high dose of estrogen. That's not happening at all. Yeah. I lost my chair. For a second, give me a sense of numbers. Are we talking micrograms, milligrams? Like what's the starting dose for the transdermal and maybe even the oral just for the estrogen? Yeah, so the oral is in milligrams. Milligrams, okay. Starting dose is usually one milligram. Okay. And then the patch dose is typically in micrograms. So point zero five is usually the starting dose. And so the, because point zero five micrograms and the patch is equivalent to one milligram for the pill. Gotcha. And then the spray and the gel are a little bit, like it's a little bit different in terms of that. But for most people, I will start them. If they're coming in their 50s, sort of a standard fair person, either one milligram oral or point zero five patch, unless they say I'd really like to start very low. So point zero to five is the lowest you can go with the patch. And the pill you can also go to point five, which would be that equivalent. And those are also maybe lower doses. Someone is coming in their early 60s. There's still a candidate in many ways, but we're wanting to make sure, because there's sort of out of that window, potentially, that we do the lowest dose for them, you know, to get rid of symptoms. That's, that would be a reason I wouldn't start them at the point zero five per se. And what about the micronesse progesterone? What's micronesse progesterone is in milligrams. So the standard dose for uterine protection is 100 milligrams. Okay. Haley, it doesn't come any lower than 100 unless you get it compounded. And then if you do choose to take it in a cyclic fashion, which would be 12 to 14 days of the month, that is 200 milligrams. You would take for 12 to 14 days of the month. Many of them do end up just taking 200 milligrams or even sometimes 300 milligrams daily, because it can help a lot with mood and sleep. And sometimes if there is any kind of breakthrough bleeding from the hormone therapy itself, the progesterone helps to stabilize the lining. So we may increase it in that regard. But 100 is that is the dose. The floor. So I'm thinking about women in perimenopause. So somebody maybe they have last menstrual cycle was six or seven months ago, but they're having a lot of the symptoms that we're talking about. I would think that if we started HRT on them, we would probably send them into menopause, right? Cause their body would much like else stop producing that from that negative feedback system. How do you think through that? How do you talk through that with them is, okay, we're gonna do this and then you're gonna do this indefinitely cause you probably can't stop for. So actually, so the, if we are putting someone on hormones and their perimenopausal, we are not going to be putting them into menopause. Okay. So really if you are perimenopausal, presumably, you're still cycling, your ovaries are getting quieter, but you're still making estrogen. You're still making progesterone, maybe not at the levels that you were, but you're having symptoms. And so what we're doing in that regard is basically adding to what your body is already making. That sort of gas tank thing. So if you're like, used to being at a half a tank and now you're sort of always at a quarter of a tank because of perimenopause, we're just kind of boosting you up. So you're still, your cycles are still happening whereby like versus birth control pill, that those doses are high enough, that basically kind of takes over. Your ovary stops is not kind of ovulating and doing and seeing those hormones are doing the thing. So it's really almost, it's like additive. So women will still continue to bleed regularly or have their irregular bleeding. So one of the big things in perimenopause can be heavier periods, erratic bleeding. And so hormone replacement therapy isn't great for treatment of that because it's not really doing much with the bleeding. So that's where sometimes we talk about other things like an IUD. So sometimes, you know, we will start it and have to adjust doses because there are such fluctuating levels of hormones in perimenopause, which could be more difficult to treat. You're not like at a low, low, you're sort of high to low, but some of the ideas you're kind of reducing those high to low swings and some of that can be part of the mood-related symptoms. So they will often still, you know, I do many perimenopausal patients, you're still getting regular periods or they're weird, you know, every three or four months and they're on hormone replacement therapy. So it sounds like the doses low enough for the negative feedback to the pituitary is not going to shut it off. Correct. Right. Gotcha. Cool. Yeah. I want to come back to the breast cancer piece for a second. I think one of the things that we have some, actually a lot of clarity on is the fact that, you know, if you have certain genes, if you have some predisposition in your family, particularly the bracket mutations, your family, your personal risk of breast cancer is very, very high. And so how do you have the discussion with the patient who have a very strong, robust family as your breast cancer? Maybe they've got some bracket carriers in there. And for those who don't know this, the RCA is the gene and any type of mutation into that, increases your risk of breast cancer. I don't know what exactly, but by what percentage maybe you can tell us about that, but how are you having that conversation with those patients? Yeah. So I think that some of the sort of misconceptions around breast cancer and hormone replacement therapy is that if you have a family history, a strong family history that you're not a candidate for. And so that is not true. So people who come in and may have a strong family history, it doesn't mean that they're not candidates for hormone replacement. It doesn't, it's not going to increase the risk above what someone's risk is for the most part. However, if someone has a pretty significant history of breast cancer and their family and ovarian cancer, it would, I would potentially talk to them about it being making sense to potentially get tested for some sort of genetic mutation. Because then that might be something that a bracket carrier might want to do something about whether it is an uvarectomy removal, the ovaries, whether it's a prophylactic mastectomy, genetic counseling, potentially talking about medications that can help. But it's not something that if you have a bracket in the absence of any kind of breast cancer, you still can take hormone replacement therapy. So many people would say, no, you can't, but there's nothing in the actual guidelines that says that you are not able to. If you have a personal history of breast cancer, that is something that we tend to not. But even so, there are many circumstances from a quality of life standpoint and working together with an oncologist where that may end up being the most beneficial thing for a woman to do. And that's a really gray area in terms of, does it will it or will it not increase any risk? But quality of life standpoint, many people, if they're that miserable and other things have failed, they may say I want that. But for genetic carriers, that is something that is not, you can still have that. And there is something that I don't think I have it. I might have to look, but it's, I think if you are bracket positive and you have an euphrectomy, you have your ovaries removed, you're, and you take hormone replacement therapy, you actually have a lower risk of breast cancer. So there's things that are almost a little bit counterintuitive that, again, in my learning of this entire world, there's a lot of data and there's a lot of stuff and misconceptions. So, you know, they're, excuse me if I'm sort of still, I'm not talking out of turn, but there's certain data that I more recently have been learning where I was like, oh, okay, that's an interesting one. So it's not like it's off the table for those patients. But genetics can be something that is very important for one to know for themselves and management as well as for their family. No, I mean, no, I appreciate it. The fact that you're so informed is somewhat impressive to me. I mean, as you talked about, I think that, you know, I used to term loss generation, but I think the physicians in our generation, we just weren't taught. And people will talk a lot about that. I said, you know, this, like you said, you know, we hear a graduate from a residency training. 2018. Yeah. So there are a couple of years ahead of me. And, you know, I think that probably our attendings of the time was like, no, this is what the status is. And we're not going to discuss this as you talked about. Not to mention, you know, you're doing the OB and GYN two specialties in one. And that's a different conversation for a different day, probably. But I want to talk about when men of causal hormone therapy would not be the right thing. So we've highlighted a couple of cases, right? So you talked about patient migraines with aura where that might be contraindicated. Other patients may be a relative contraindication and an absolute contraindication. But where would other strategies be more impactful? You know, I'm actually thinking about this. And I don't know if this was mismanaged. But, you know, when my mom started menopause and stuff and she was started an SSRI, actually. And that was probably because she had some of those symptoms where we're mood related, some of the hot flashes and stuff. And interestingly, you know, I was uninformed at that time. And now we're going to have a different conversation for sure. But I'm thinking about what other approaches you can take to manage some of these symptoms. Because that's the thing that's most obtrusive to somebody's quality of life. So I would say one thing to correct. And I might have misspoke. So migraines with aura is not a contraindication to hormone replacement therapy. We would not do your oral formulation patch would be fine. Migraine with aura, we don't like to do with people with birth control pill because of that. That's right. You did say that. That's my bad. No, it's fine. I just wanted to make sure that. So in terms of like absolutes for contraindication for hormone replacement therapy, we had someone with a history of a part attack. Any history of blood clot, be it a DVT, you know, blood clot in the leg or PE. If it's provoked, that's a different story. And often you can do transdermal for them. But DVT or PE, unexplained vaginal bleeding, like you need to get that take. We have to figure that out before we start on something, history of breast cancer. There are of course nuances for many of those. But those are kind of the things where the risk is, in many cases, outweighs that benefit. So in terms of other options, so your mom may have been started on SSRI, she may have been started on PAXAL or Paroxetine because that is an FDA-approved non-hormonal treatment for hot flashes in women. So PAXAL is one of them. We also off label, we use a fixer, which is another anti-depressant. Gabapentin is another medication that can help with hot flashes. And something when I was reviewing things this weekend, I think I read Gabapentin in PAXAL will help in about 60% of people from a hot flash standpoint. So when it works, it's great if they can't take something hormonal. There is a newer non-hormonal medicine called Vioza or Filuzinont, I think is how you say it. I might have said that wrong. That's within the last couple of years, that's a non-hormonal treatment for hot flashes that is sort of like, it may work. It may not, one of the side effects listed is hot flashes, which is kind of crazy. So you have those options for hot flashes in terms of the vaginal or the general urinary symptoms. You can really almost always do the vaginal estrogen. There's some other types of formulations. We might use something called DHEA, can be placed vaginally. Sometimes for the mood, anxiety, for those symptoms, you may want or need an SSRI or some kind of anti-depressant or anti-anxiety if you can't take hormones or if there's an additional issue. And then there are various things that we can do for sexual dysfunction as well. Medications, but some of those, they're for pre-manipausal women. So it can be, some of this can be a little bit challenging territory and we really do this like biopsychosocial model really kind of addressing all the different parts of the equation. I want to pull that thread a little bit more. So as you know, the name of the podcast is Medicine Redefined. And I think the thing's in medicine that we didn't do a good job getting education on certainly not our generation is the role of exercise, the role of the importance of sleep, how does nutrition play into that? And so is that something that's part of the equation when you're having a conversation? I know at least my reading of MSM and you brought up Dr. Von der Wright, she is a very strong advocate for the importance of resistance training, right? And we talked about this at length multiple times that exercises in medicine. You have to dose it accordingly. And so when we're talking about building those muscles around the joints to take the stress off the joints to improve your pain. We're talking about building those tendons and ligaments and loading their property. That's a conversation I'm having with every single person that walks into almost every single person. But tell me a little bit about what that looks like for you. Yeah, so I think that component, I think with perimenopause and menopause, some of the things that are most upsetting to patients are lack of sleep or interrupted sleep, weight gain, and then inability to sort of lose weight or too much pain such that they can't exercise. And so really the talk is about kind of, okay, when we improve sleep, it's going to improve so many other things for you in terms of like from metabolic standpoint, from an energy standpoint, from a hot flat, all of these things. And then adding also helping to be able to get some of the muscle and joint pain to be improved, whether that is with medication, but exercise and weight bearing exercise, they do talk about a lot. The barrier for many people is that either they've gained a lot of weight and it's really uncomfortable, it hurts them, they are so exhausted, they don't have the energy to do that. And so kind of getting them to be in a better mood and energy place and kind of like back to the basics in terms of let's get your sleep better, then to be able, then many women are able to start walking again. And the whole strength training that really has taken off and I'm a big proponent of that myself and the importance of it. So I do try to talk about the importance of that because there are certain, you know, programmed targeted towards menopause, so women that can be really helpful in that transition and kind of the understanding that it's not necessarily about looking so muscular, but having that strength and the stability to support your bones and to have strong muscles, you know, some of these providers, Mary Claire Haver is a big menopause person. You know, she has a lot of supplements that she talks about and a particular diet. I'm not as sort of in on those supplements. I think it's totally fine. You know, creatine is a big thing that's happening right now. I feel like I haven't done enough research to sort of say, yay or nay. We just had a podcast about it. You should listen to it. Well, I'll have to listen to it. Yeah, because I love that sort of, you know, very holistic approach. I'm not just, you know, needing to give you only medicine. I think there's so many things that go into it. And so I'm definitely big on that as well. Yeah, love that. Yeah, I'll have to check out what's beside it. That name sounds familiar to me. I think I've heard her talk at least on a diary of CEO, but I need to check out the supplements. You, as you're talking about sleep, I was thinking about what we had spoken earlier about the micronized progesterone. I apologize if I already asked this, but is there ever a role for just the progesterone in the insulation talking about that? So that often, because perimenopause can be difficult to treat, especially because people are still having periods or, you know, it's just a little bit harder with these hormonal fluctuations. Sometimes some of the big things going on are mood, sleep interruption, anxiety. And so it can be really nice just, especially if you're kind of like, all right, let's start with something. Bird control pill is absolutely something that can be very helpful in certain circumstances, but many people can't or don't want to take that. So the prometrium taken at night can be very helpful because it may help with some hot flashes, I mean, or night sweats, not tremendously so, but more so to get people sleeping again, also with the progesterone and how that can affect mood, you know, those levels, if you're not audulating regularly, you're not producing those levels of progesterone kind of bumping that up, especially even second half of the cycle, when you might be feeling worse, that can be very helpful from a mood standpoint, so we can kind of experiment with doing it every night or just doing it for half of the cycle, but sometimes that can be a really nice sort of entree into starting and seeing how that feels. Yeah. You know, I just realized that we didn't talk about testosterone and I think we've talked about this before, at least on this show that even though we spent a lot of time and when we think about women, we're thinking about estrogen progesterone as I mean, hormones, testosterone is actually the most abundant hormone in the body and with respect to absolute metrics. And so what can you tell us about the role of testosterone? Is there a role in supplementation and replacement in this case? Why is that important here? Yeah, I mean, I prescribed testosterone with some regularity. I think there's a lot of debate right now about testosterone. There's some, you know, people in the menopause community who are very pro testosterone, because the indication for it right now, the paper written, you know, the dosing is about low libido and postmenopausal women. And that, you know, I didn't, as one of the other main complaints people come in with, it's that, you know, their libido has totally tanked. There's, you know, and they're very upset it's affecting them, their relationship, their sense itself. So sometimes that is about getting, you know, the estrogen is also very important, but testosterone can be sort of a icing on the cake type thing often once we kind of get hormones. The sort of estrogen progesterone in a good place, people are still having pretty significant low libido issues. Testosterone can be very helpful to add and there is a role for that. We sort of have to, since there is no, in this country prescription dose for women, we basically use the same medication that men are taking and the, you know, little gel that I will have women use, man would use one full tube a day and a woman is gonna use one tenth of that. So a little pea-sized amount that shall rub on her, you know, one, you know, her thigh or her butt, something like that once a day. And, you know, we do check testosterone levels and liver function and monitor. And for some people, it makes a tremendous difference. And then the other thing that it can help with, it does tend to, you see differences in cognition and brain fog, there can be some, you know, increase in muscle mass and strength and mood. So just the same things it helps with men, you know, there are people talking about these other benefits for testosterone. However, right now the indication for it is low libido and postmenopausal women. Do I also use an impairment appausal women? Yes, because I'm also using hormone replacement therapy and them and they're suffering from some of those same things. I think, you know, there will be more and more, I guess, with testosterone coming up, especially as people are being more vocal proponents of it. So I think that there's a role for it for sure. What's the average time that you'll give just the estrogen and progesterone building blocks so to speak, to get that dialed in and you're like, okay, I feel like we're in good place. Now is the time to add testosterone. Months, years, what are we talking about? I usually say about three months because I have patients start whatever dose that we've just guided, they're going to start on. Get in touch with me in six weeks to kind of let me know how they're feeling. We adjust that dose and then I, usually they come back at three months. And if we make any other dose adjustments, I really want to make sure that is we're good on that because often libido gets better. The vaginal estrogen can do a lot from the standpoint of sensation and lubrication and help with sort of that standpoint. At that point, three-ish months once were stabilized, that is when some, many people are coming to ask me because they're seeing it talked about, written about, but sometimes I will offer that up. For some people, it works amazingly. For some people, it doesn't work. And so that's, I mean, that's the case sort of with everything, but I want their hot flashes. I want everything else optimized because so many other things in terms of low libido, that is not, it's not in isolation. It's so many things sleep. And you know, a ton of different parts that go into sort of how your mind is thinking about and wanting sex. So not, I'm not making them wait and wait, but I do want to do the other sort of more traditional things that I am excited about using testosterone. I've been using them for the last several years on patients. I'm interested in monitoring. You brought that up, you know, it's primarily symptom-based, right? These symptoms that we're treating, it's all symptom-based. It's how they're feeling. It's a purely clinical diagnosis in that sense. Whereas supposed to TRT, this was replacement therapy, even when somebody comes in, they'll have those symptoms and maybe some of the signs that you had talked about, we will get baseline levels. We'll check twice. We'll make sure they have to have a level that would be, suggest that, you know, they would have hypokinatism. We could talk about why that's happening and then we'll potentially treat it. And I will recheck in about six weeks, eight weeks. Of course, the most important thing is how are you feeling? Those things that we had talked about are we making improvements? And then to the thing that you had talked about with a gas tank, you know, I really love that analogy. Like we want to get that person back to kind of where they've always been, ideally, if we've had levels and we know that between 400 and 600 kind of diagrams are just a leader. If that's, they've done well, we want to get them back to that. We don't want to get that person up to 1,000. That's not going to be helpful. Is that the case in terms of monitoring something you'll look at, you'll make the diagnosis that this person is, you know, having these symptoms of menopause. And do you check a baseline and then check afterwards? Yeah. So in terms of this kind of, you know, this is also that I've kind of been learning by colleagues and reading papers because no one in my practice is doing it, maybe a little bit through me. But the guideline at least is to check a baseline, to also check liver function. It's, you know, the, what we're seeing at is total testosterone, but depending on who you listen to, some people are also checking free testosterone. Some people are also then doing a sex hormone binding glibulin to then calculate the amount of available testosterone. I think what I've kind of come to is that it seems like total testosterone is what we're, what I should be looking at. And then, you know, the range really is trying to get it like 40 to 70, potentially. So people who are coming to me that have had pellet therapy, they are frequently in testosterone, having testosterone levels in the 100s, 200s, such large clitoris, they have lost hair, they maybe have voice changes. That is not a safe way to do testosterone. That's not what I'm trying to do. You know, those people may have incredibly high libido, but they feel terrible. They feel ragy, they don't, you know, they don't like the way they feel and their, their hair is falling out and they have hair growth in other areas. So I'm monitoring, and I usually don't like you, even if someone has sort of a normal testosterone level, whom I just say that that was always their normal. So it's more about kind of what is their baseline and making sure that they're absorbing it, you know, that we don't need to change that or I don't have to say, hey, instead of making it two last 10 days, let's make it last seven because your levels are still pretty low. And then yeah, we'll usually monitor it six weeks and then usually I do three months and then six months and then kind of like, what about the estrogen and progesterone? You're checking that too. So there's actually not any indication for checking estrogen or progesterone. So estrogen, like in, in all of the guidelines, you treat based off of symptoms. So I know if you're coming in and you're menopausal, your estrogen levels are gonna be less than 50. Like I just know that it doesn't need to, I don't need to do any lab work. Your progesterone levels are gonna be very low. If you're in parimenopause, it's gonna mean even less to me because you may be going back and forth good enough 50 all the way up to 500. So it's not gonna tell me anything, but there are specific instances where you may, where you are checking, for example, if you're increasing the estrogen dose and someone is not responding because there are what are called poor responders, you know, the estrogen in a patch formulation. So maybe you have to change from a patch to a pill. So to kind of see what levels there are. And then there are certain menopause practitioners who are doing more boutique medicine who do say that there are certain levels for bone health and bone protection, like 40 to 70, for example, for estrogen levels. So they may be checking based off of the fact that they're trying to make sure a person has adequate levels for bone protection. That's sort of a little bit out of the guidelines in a most standard way I'm not checking because it's not telling me anything. It's really are your symptoms better. Something is weird or someone's not responding that way that I think they should, you know, we may check. And sometimes if someone is, for example, has had a hysterectomy so we don't know whether they've been a year without a period. Again, I can treat them regardless of what their levels are, but some women do like to know. Like I want my hormone levels checked and if that's something that is important to them, I will, I'll say it's not going to make a difference in what I'm doing, but we can certainly do that. And it may be conclusive for menopause or it may be like, yeah, sounds looks like you're impairing menopause, but it doesn't matter, I'll treat you the same. Makes sense. I think before we close, I think it's important for us to play devil's advocate and look at the other side. As you've mentioned, I think you called them menopause warriors. They're a lot out there. And there are, there's no shortage of people who will, you know, bash the WHI night for valid reasons. Like you highlighted a lot of the flaws in the study. Although I did listen to a really great podcast. It was the Dr. Mike podcast. I don't know if you know him, the checkup and he had Dr. Jen Gunther on there. And she had talked about some of the things with the WHI study. For instance, like people will say the horse urine, right? The estrogen drive from that. It's like, I don't know this. To be true, and I haven't actually looked at it. She said at that point, that was the most commonly used formulation that people had. And so they used what they, the information they had and they tried to do the best of it. It's the interpretation where I think the ball was really dropped. But this piece that was really interesting, I'll center to you. And I want to kind of read a little excerpt to you where Dr. Marty McCarrie, so this piece is in the Guardian. Marty McCarrie says there may be no other medication in the modern era that can improve the health outcomes of women on a population level than hormone replacement therapy. And he calls it life changing, even like saving treatment. Senator Kennedy had said, hormone therapy was extending the lives for women as much as 10 years. And then another person here and says, today we have the opportunity to add up to a decade of healthy years to the life of every woman that you love, or at least Jackson here. And the reality is a lot of the, I guess not the proponents, the opponents of this will say, well, actually there's, we don't have a lot of great evidence that it really just all caused mortality, all the things by as much as what they're saying. Certainly not a decade. We don't have the data to say that. As we've touched on time and time again, this is a symptom-based thing. And I mean, listen, both of us, I think the primary thing that we're trying to improve the quality of life thing, that's pretty much all my job. I'm not doing anything life-saving in my job. And so it's not to dismiss, that's not important. But to make these bold claims that it's gonna add a year or 10 years of your life, I think that can be really problematic. But we're talking about headlights, right? That's what catches headlines. And you've talked about these boutique clinics, these people. And I think my suspicion is, in fact, the more the suspicion I can almost wager, that a lot of these telehealth clinics, this metapause industrial complex is gonna pop up more and more. These TRT clinics, peptide clinics are popping up even more. Moments can be really tricky. And so I guess what I want to learn from you a little bit, see where your head's at in terms of, where do you see this explosion of telehealth metapause platforms? And what concerns you about it, if anything? Yeah, so first thing I'd say in terms of that, what you were reading is that I think some of the nuance in there is the fact that estrogen and hormone replacement therapy can reduce risk of cardiovascular disease. And heart disease is like the leading killer of women. And so the, of course, some sort of metapausal hormonal therapy may reduce risk of those sorts of deaths up to 50%. So prevention of osteoporosis, and we know that hip fractures are a huge reason for mortality. So estrogen preventing hip fractures is also, you know, you have to be on it for a longer period of time. That's also another way that people may improve their lifespan. But I think yeah, making these very broad claims, it is sort of some misinformation. It's like the pendulum is sort of swinging in the other way. I think there are tremendous number of benefits from hormone replacement therapy. But yes, those numbers of 10 years, yeah, we don't have those numbers. We do know that there are many benefits. I would say from like the telemedicine standpoint, I mean, to be, to be, you know, very transparent, I do work for a telemedicine company called Alloy and they practice all evidence-based medicine and they're doing, you know, menopause medicine, skin care, sexual health. They just added on some weight management. So I think that, and it is the practitioners, I think they're now up to 27 physicians. And these are all people who are menopause certified. These are some of the top people like in the field that, you know, are some of my colleagues that I get to ask questions to. And I at least see from what we're prescribing because we're only prescribing FDA-approved type things, the patch, the pill, the gel, paxle, versus some of these others, which may be doing things like progesterone in a cream form, which we know it doesn't really get absorbed well. That may not be enough or things that don't have enough evidence yet like DHA. So I think the issue is that there is a need, there's a market because people are reading this stuff. And then there are a lot of deserts in the country where people do not have access to someone who they can go face-to-face with and give them their care and give them good information. And so that's why I think many people are turning to these telehealth type situation. So I think the onus is also on providers to become educated and to be able to provide that to their patients. So patients aren't needing to, one, you know, pay a lot out of pocketware, they may have insurance that could cover it, and two, find someone locally who might be able to help them. You know, I think everything you have to kind of look at with caution and what are the products, who's prescribing them, and so that's why I was very discriminating in working for this company in terms of highly respect what they're doing, how they're doing it, the patients they're helping, the message which is all evidence-based, there's nothing that's being done that isn't outside of the exact guidelines that I follow in my office. Yeah, is estrogen controlled? Estrogen is not controlled. Many, well, progesterone is not either, just testosterone. So many people are coming onto these platforms asking for testosterone, and that is not something that alloy provides. It's a controlled substance for a variety of reasons. It's not FDA approved yet. So that is not sure. I don't know of any other companies where people are able to get testosterone, but I mean, obviously lots of people can get accomplished, but you can get what you want from somewhere, but it's about safety. So coming back to some of those warriors, right? So I'm not going to pick on Gwyneth Paltrow. Everybody picks on her. So I think I heard about Halle Berry. I remember Mel Robinson listening to her podcast, you know, talking about her brain fog in cognitive symptoms, and I think she's a lawyer. Having been so sharp for a majority of her life, and then now all of a sudden struggling to do some basic things for her. And I'm just wondering, do you think generally that is a helpful part of the conversation for folks such as yourself who are trying to do this, quote unquote, in an evidence-based fashion, who are trying to add nuance to the conversation rather than just say, study is all bad. Everybody needs this. This is going to fix all your symptoms. Where do you land on that? Well, I mean, I think the brain fog, those sorts of cognitive changes are very real and very distressing. And you have these high functioning people who start to not be able to find words and can't remember things. And they think, you know, many people in menopause think that there you have Alzheimer's. Like it becomes that scary. And a lot of that stuff and the attention, you know, in attention sort of some ADHD symptoms. A lot of that can improve with hormone replacement therapy because we know estrogen affects the brain. And there's more and more studies being done on the cognitive benefits and potentially prevention of dementia. I mean, they're not things that are being said super loudly, but those are part of, you know, use and some prevention. So I think that at least some of the, when I say menopause warriors, I'm sort of talking about actual like medical providers that are passionate about this, getting out their own social media, disseminating, you know, information. Because they're own sort of, I'm big on testosterone, I'm big on vaginal estrogen, you know, whatever the thing is, but I do, well, I lost my train of thought. Oh, I think that the thing that's important and I heard one physician talk about this is that when she has patients coming to her, she's not ever saying, I'm going to make you feel 100% better. But she's aiming to get 70 to 80% improvement. And so I think that sort of expectation setting for such a sort of a magic, everything's going to be better. But I will say that I have people come in and they literally, they're just like, I feel so much better. I feel like myself again, this was, I can't believe I felt this bad for this long. So it can be just absolutely an incredible thing for certain people that are really suffering. But, you know, not everything is appropriate for everyone and not everything will always work exactly the same. And so I think there's, you know, being able to understand the nuance and figure out if things aren't working, what else to do or other places to look. But, you know, there will be frequently, there's improvement, not someone's going to feel like they're 25. But we can get people to feel, you know, often a lot better if they're appropriate candidates. Do you see any over treatment or do you have any concerns about inappropriate MHTUs here at all? Or do you think is it that we're just, we're still catching up? I think, I'm not sure if I can really speak too much more than I guess myself per se. I mean, in terms of inappropriateness, I think it's the lack of use. So people who are coming to me, who have gone to two or three gynecologists or their gynecologists, they've seen forever, has been dismissive. So it's kind of that lack of understanding this part of the life cycle and how to help a person and what are the very real symptoms going on. I would say some of the treatment that I feel can sometimes be slightly dangerous or negative would be some of the pellets because I do feel like people are getting very high levels of testosterone, also not the way that it works, these sort of being, you know, having these pellets put in, having these peaks, ebbs and flows of their hormone levels. So they feel great and then they start having hot flashes again and just not being sort of educated on the evidence, what the options are. So that's where I see it being like, that really makes me upset. Sort of there's this market of people, they vulnerable people who need help and that's the only place that they go. But by and large, I feel like, you know, I've had, you know, maybe someone who is doing their very best as a primary care provider and may start something that I see the patient and I think that might not be the safest thing to do for X, Y and Z reason, but might I have done that five years ago? I mean, yeah, I was, you know, I was not good menopause provider before I learned all this. So it is a learning process and I think you have to develop the people around you to help learn how to prescribe and ask the right questions because there is so much nuance to it and a lot of misinformation that has gotten propagated over the course of these last, you know, 25 years. For sure, and our hope is conversations like this helps people get educated, you know, I think, I don't know where I heard this, but the reality is that no person is not going to be untouched by the struggles of menopause, right? Whether you're, if you're a woman, you're gonna probably experience it at some point. Definitely experience at some point. If you're a male, you probably have a woman in their life who is going to experience it at some point. I mentioned, I've already done that. And, you know, my wife at some point, I'm sure it's gonna go through this. So it's good to be armed with knowledge and pick this up earlier on so you can intervene for better quality of life, which is probably the most important thing at least to us that we care about. Absolutely. Lauren, if you could, you know, like I said, just the underuse is what you highlighted, maybe the inappropriate use, right? So over the next five years, if you could change two or three things in our healthcare system with approach to menopause, what would they be? So I think it would be more specialties armed to prescribe hormone replacement therapy. So you were asking, who's job is it? And I think that making it so that it's not, doesn't just fall on the gynecologist, but that there's someone can go see their primary care doctor and that person might recognize it, prescribe it or an endocrinologist or a urologist, or even, you know, a psychiatrist, which sometimes they will. So kind of having a wider swath of people that have the knowledge and the understanding, because it's also not rocket science to prescribe it once you sort of, you know, do it enough and you can do the low risk and then kind of build up your confidence. So that would be one thing. It's just a wider breadth of people taking care of menopause. I would say, what else would I want to say? More training. So more training at the residency level. And I think the only way to really get people like internal medicine doctors and other primary care, you know, people to know about is to actually learn about it. Because it, like you said, it will affect every single person. So it's going to, it's going to be something that many people, residents in training are going to come across someone who's having, you know, some of what's going on is their menopause-related symptoms. But I think widening that education from a residency training standpoint actually some sort of a curriculum or even in starting in medical school. I mean, do you, I don't remember learning it, barely anything about menopause in medical school. This is a huge, you know, lack. Like that's a huge thing that's missing from our medical school education. And then I would say, I mean, I think right now I'm finding that there's a particular who I think she's Italian, her name is Lisa Moscone. And she's doing some really amazing research looking at brains and hormone replacement therapy and the role of estrogen. And so I'm really looking forward to sort of the information that comes out as it relates to cognition and brain health and dementia as it relates to estrogen and or estrogen deficiency. Cause I think at least since I've heard her talk, she's doing some really interesting work. I love it. Amazing. Lauren, is there anything that you think that we didn't cover that is worth talking about? And I think we got through. I had some notes here. I think we got through so much. Good. I'm glad. Yeah. And yeah, I know that we didn't even get too much into this BVX special. But my hopefully you're going to join us in a future where we can talk about another important thing, something that you and I have closely been working our last couple of years together. So the last question that we'd like to ask everybody, we practice in this system in the States where it's getting people better after they've already endured something and illness, a sick care system, we say. And so what we're interested in is practicing healthcare. And so the question is, how do we put the health back in healthcare? And it's from a menopause standpoint almost. Where do you want to go? Well, I think that at least from my standpoint, I am catching women often in time periods, for example, like their annual where nothing is actually wrong. They are not sick with anything. That's part of why what I really like about gynecology and obstetrics. There wasn't always about an illness, but that is actually a time where I've been taking the opportunity to talk about things like, you're at an age where perimenopause might be happening. Where menopause is starting. I want to just talk to you about some of the things that may be starting to happen so that you will become aware of them or even bringing someone back just to educate more. And I'm really big on giving people books to read, different people that are reputable on social media, just the tools to really be empowered and understand their own bodies to then be able to make the decisions before a thing happens that they're then dealing with three, six months, three years, five years down the line. So I think it's a lot about, for me, the education and validating. And yeah, that's what I would just, yeah. Yeah, I'm just thinking, I don't really have any preventative annual visits piece of this. They don't come to me for that. Yeah. They come to me with problems. Right, so that's where I have that. And even, I mean, menopause, they're coming in, but then it may be an opportunity to talk about, you know, some people at that point say, yeah, I mean, I'm 55, like I shouldn't, I don't really want to have sex anymore. You know, they just normalize various things. That's really the opportunity as someone who's interested in sexual medicine or pelvic pain to say, you don't have to feel that way. We can talk about this and I think just opening that door up and having a safe space and talking about, you know, like you said, as opposed to sort of the sickness part of it and what kinds of things that we can continue to expect from a health standpoint and, you know, is what's important with my patients. I love it. Lauren, thank you so much. Thank you so much. It was great to chat. Likewise, until next time. Okay. Thanks for listening to the other episode of Medicine Redefined. If you enjoyed this episode, please be sure to check out some of the additional resources in the show notes. Please also check out our social media platforms where you can find more content like this. You can follow us on Instagram, Twitter and TikTok at Med Redefined. We also want to thank our team for the production of this podcast, specifically Ethan Jewel video, Harita Yapuri on social media, Zanablegmani on research and Syrah Khan for newsletter. 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