Transcript for How to Balance Your Hormones: What Your Doctor Isn’t Telling You About Menopause

I am so glad to be here.

Yeah. I want you to feel seen if you're going through the menopause transition. I think so often women are made to feel small and they're not important. And women are uniquely affected by ageism. So you kind of have the double whammy at this time. So I'm hoping that you'll feel that your concerns are valid and they're important. And there are lots of options to do for my health standpoint. And there are many ways to take care of yourself. and I can give you some tools to reframe what's going on with your bodies, you kind of know where you are, and also give you tools to find help if you're struggling.

Yeah, a team menopause. I'm on a two. So I would say that menopause is a normal part of the ovula tricycles that we have. And just like you went through puberty, which might have been challenging and had some symptoms and caused a lot of physical change of the body that menopause is in many ways the same thing. You can think about it as puberty in reverse. It is, you know, not a sign that your body is going to fall apart the next day. It is not some new experience. I know there's a lot of people out there who think that, oh, because women are living longer now. They're just experiencing menopause, but that's not true. The ancient Greeks knew that the average age was about 50, which is about what it is now. And if we erase menopause, then we erase all the grandmothers in history, right? So that it is a normal experience, but normal doesn't have to mean pleasant, right? So just like when you went through puberty, maybe you got acne or maybe you had really heavy regular periods or pregnancy. Also a normal experience, maybe you had terrible nausea and vomiting, maybe you had other complications. So normal things can have complications. And I would say that there are things about menopause that can be very unpleasant for people. There's things that can be very liberating. People who've had terrible painful periods who now don't have them, think it's amazing. People who've had maybe terrible PMS find that the steady, you know, those, the lack of ups and downs of hormones are liberating. And so I would say that if you're suffering, there is often medical treatment for that. And that the best way to know how to make it a more pleasant experience or less owners experience depending on the spectrum you're on is to get informed and have accurate information.

Yeah, well, just like you're, you know, it's a different physiologic process, but you know, you have a winding up, right? So when you go through puberty, you don't start in bang on, have cycles regular, you, they sort of start and stop. They might be heavy. They, you know, have that sort of like flirting with it. If you will, well, you have that same and kind of the last couple of years. You have the starting and stopping with the periods. You have in the winding down of, um, ovulation and so yeah. So they are, they're like bookends, a little bit different, um, you know, it may be like sisters not twins. I don't know.

So menopause, the menopause transition, which is the time leading up to menopause that, you know, you might also think a herd called perimenopause or premenopause, how long's that last? Well, anywhere kind of from sort of forward to 10 years depending, just kind of like puberty, right? Like is big range and how long it can last? Some people seem to have these late growth spurts goes on forever, you know, some people relatively short, kind of the same thing. Oh, wait a minute.

Not really. Certainly, if you develop osteoporosis, you can. But no, otherwise not. And it would be rare to develop osteoporosis in your late 40s or early 50s. That would be a really assigned. You should be something else going on significant. But over time, if you have osteoporosis, you certainly can lose height. And we want to protect that. But yeah, puberty is a many years experience, right? You start to get pubic here, you start to grow, you get breast buds, your body shape changes, you know, you may have mood swings, you may have acne, you sort of this whole experience. And just like puberty might have ended at a different time for different people, some people stopped Growing in grade seven, I was still growing in grade 10, grade 11, right? You have this big range. It's the same thing with the menopause transition. And so I just encourage people to think about it more that way that it is a change. And these changes, you know, don't happen overnight. So it's this physiologic change. And it's related to the decrease in the number of follicles or eggs that can ovulate. And so what happens in response to the decreasing levels of estrogen that are produced, you get other hormonal changes, your brain is trying harder to get the ovaries to ovulate. They can start to get Discoordinated, so you might get one ovulation right on top of each other. So some cycles, you might have higher estrogen levels than normal. Some cycles, you may not have progesterone. Some cycles might be shorter. Some, you might develop estrogen, not get progesterone, but still menstruate. So it's basically hormonal chaos. And so it's people mistakenly think of it as sort of this gradual smooth transition, but it's more like but obviously there's variation. My best friend had regular cycles and then her parents stopped and she had one hot flash. And I'm like, that's kind of the equivalent of showing up as a unicorn. Well, that's showing up in late, the hospital and you're like, oh, I feel a little contractions and you're like nine centimeters in the baby comes out, right? Like there's, you know, there are people who have those experiences and then there's people who have 72 hour laborers, right? So yeah, so it's just wide experience and there are many things that can affect it.

Well, oh gosh, the biggest myth. I would say the biggest myth is that your life is over. That this is the end. Once you age out of being a breeder for lack of a better term, you've lost value, but I would say that You know, many women once the menopause transition is overly described that they have a greater clarity and they feel great and maybe it's not having the hormonal fluctuations. Maybe it's the fact they just don't care anymore because their older it's wisdom with age. I don't know the answer to that. Maybe it's the fact that all of the part of your brain that was tied up with ovulation is now gone because your brain prunes pathways. It doesn't need any more. I mean, I don't know the answer. But I would say that, you know, for some people, it can be very rocky and for some people, it isn't. And for people who it's very rocky, we have treatment.

Yeah, I think education about how your body works is very liberating. So then you don't think that you're uniquely broken or uniquely crazy or something that, you know, what is specific, you know, why is my body behaving this way and no one else is? And you're like, oh, lots of people are behaving this way. Okay, I don't feel so alone. So sometimes just kind of safety or comfort in numbers.

Well, I would say that top recommendation is exercise. I would put that over hormones. Absolutely. But in menopause in particular, how come? Well, exercise touches almost every single domain that is affected by menopause. So if you think that Metapods can start to change the trajectory for risk of osteoporosis and risk of dementia, risk of muscle loss, all of these things. Exercise touches all those domains. So in the Metapods transition, there's an increased risk of depression. Exercise can treat depression. exercise can help protect bone mass. Exercise can help build muscle strength. Build muscle mass. Exercise is great for your heart. It's great for your brain. Basically exercise treats almost everything in menopause except the hot flashes and vaginal dryness. I mean, you know, and we have great medications for those. But so what I'm saying is that, you know, going into menopause without strong foundation and it's not just, you know, cardio resistance training exercise helps with your balance. So you're less likely to fall. I mean, the number one risk factor for breaking a bone is actually falling, right? So, you know, so all of these things can be protected with exercise, but that's not a sexy cell. You know, if you would only ever do one thing for your health, it would be to get your exercise. I mean, and you don't want to play favorites and say what you can only do one thing, but you know, you get what I mean, I'm just trying to emphasize how important exercises and resistance training and building muscle. And I'm always inspired by all these women in their 50, 60s and 70s on Instagram, better like showing like they're flexing their backs or just they're just like cut and I'm just like, oh, yeah. Never too late. Yeah, well, I'm working on it. So yeah, so exercise, eating 25 grams of fiber a day, trying to have more protein, many women don't eat enough protein, and trying to have more plant-based protein in your diet and having more vegetables. I mean, it's not the sexy stuff, but it's the stuff, and then obviously not smoking.

Menopausal hormone therapy, which is what we call it, is giving hormones to treat symptoms of menopause or to prevent complications associated with menopause like osteoporosis.

Yeah, so there's evidence-based FDA approved and then there are scams. I would think that's the best way to sort it out. So many people get hung up on the term bio-identical, which is really a meaningless term, is a medically meaningless term. Whether a hormone is the same or similar to what your body makes doesn't make it safe, I could give you a high amount of epinephrine and cause harm to you, but that's something your body makes, right? So I can give somebody tons of estrogen and give them enemy trial cancer. Whether something similar to what your body makes or not doesn't make it safe, what makes it safe is it studied, is it safe, is it effective, and is it something that can be, we know exactly how much you're getting. So one of the big problems is a lot of people are using compounded medications or pellets, and we don't know what's actually in those things from a, you know, from an actual amount of hormones. If I give you an estrogen patch, I know how much is going to be absorbed. I kid, you know, there's been studies that have been done. I know if you put it on a different body part that's going to affect absorption. So all of this has been done with compounded products. None of that exists. None of it. I don't know how much is getting across your skin. I don't know how much you're ingesting. I don't know how much is being absorbed. You would want to know what you're putting into your body, right? So, so I would say there are FDA approved therapies and there are many good ones out there. So there are, you know, there's estradiol, which is the main hormone that the ovary makes and we have pharmaceutical variations of those. Another big myth is that some hormones are plant-based and, you know, that again is a marketing, is that true? Well, I mean, petroleum plant-based, too, if you want to look at it that way, right? So, yeah, it's plant-based, but it's not. You know, they used a starting chemical found in a plant and converted it into estridile. That doesn't make it any better than if I made Estrodial by assembling it from different molecules. It's the same thing your body can't tell the difference. We just make it from soybeans, which is called semi-synthesis, because it's cheaper than making it by synthesis, which is assembling the molecules itself. So it's a total marketing thing. Plant-based, it means nothing. Nobody's grinding up yams and putting them into pills and giving them to you.

So if you're getting a prescription that doesn't have a package insert with it.

So whenever you get any prescription and this is little folded up book and you unfold and it's like all the risks and benefits and it's like, oh yeah, this big thing. If it doesn't have that, then it's not FDA approved.

So there's this whole sort of loophole for compounded medications. And so they don't have to have that package insert. They don't have to tell you about risks of blood clots or risks of it. They don't have to tell you any of that. So that's a big problem and it makes people think that they're safer because look if I gave you two things. One had a list that said it had a black box warning on it. And the other one didn't. You're gonna automatically think the one that doesn't have the black box warning on is safer. Well, it doesn't have the black box warning because it wasn't required because it's not FDA approved.

You were having the inferior. You were paying more and getting less because we all think when when someone's customizing something for us that we're getting better. We're trustworthy. We believe people. And no menopause society recommends compounded hormones. They're not recommended by the North American, or we now call them that they're now called the menopause society. The national academies for a science medicine and engineering don't recommend compounded hormones. The international menopause society, the British menopause society, none of them recommend compounded hormones. because it takes science and research to know how to get hormones through a skin. It takes science and research to know how to get them from your gut into your bloodstream. When you make hormones, they just get dumped into your bloodstream from your body. You're not eating them. You're not absorbing them. You're not rubbing them on your skin. You didn't evolve to get hormones that way. Now, doesn't matter you that we have modern medicine for reasons. So you know, it doesn't mean you shouldn't take them because we didn't evolve for that. But funny thing, it takes science to figure out how to make these molecules work for us. And so there are several issues with using compounded products. People may be getting more of a hormone than they think they're getting. So you might be getting more estrogen than you need, which could put your risk for endometrial cancer. You might be getting not enough progesterone, which would put your risk for endometrial cancer, or you might not be getting enough estrogen putting at risk for osteoporosis. So you think that you're preventing osteoporosis, but you're not. So this is the analogy I use. Using FDA approved hormones is like going to the gas station that has the gallons on it and you can choose, you know, whichever gas you want. You fill your car and you have a working gas gauge and you're like, I know what's in there and that's important. Going to a getting these compounded formulations or pellets is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you. and let him fill your tank. And oh, he's going to flip that switch off so you don't know how much is in there because you should trust him because he knows that's the difference.

Yeah, I would see. Move away from using bioadentacle and just call them compounded because bioadentacle doesn't mean anything. So bioadentacle is a marketing term used to describe hormones that are plant-based, that are identical to what your body makes. But Estrodial that you get from an FDA approved company, you know, I use an estrogen patch, it's Estrodial. I've got it on right now. The Estrodial in the patch is no different from the Estrodial, the compounding pharmacy is using. They're both buying the raw hormone from the same place. The difference is the pharmaceutical company has studied how to give that Estrodial to you in a reliable dosing manner. The compounding pharmacy has not done that work. They don't have that. And because of that, they're not FDA approved because you have to show to the FDA. And it's expensive. You have to do all those kinds of so they haven't submitted that data. They're just making things up. So you have a precise studied formulation. But the big thing is they're not buying fans to your hormones. All the raw hormone comes from the same one or two plants in the world. It's like me buying Cheerios and putting them in a Cheerio box or putting them in a glass jar with a ribbon around. But did they do the same product? Exactly. Except the delivery mechanism is different. Gotcha. So that's why I tell people, you know Every every estrogen that I would prescribe you from an FDA approved source with the exception of Premran is bio-identical. So everything is just forget that would just forget that word. Okay. Yeah, because the S, so when people use the word bio-identical, it tells me that they think women are dumb.

Yeah. And so, you know, there are The other important thing is when you have an FDA-approved medication, they're batch tested. So what that means is whatever however many one bottle and 50, one bottle and I don't know what it is, is tested to make sure it has what it claims. But when you're mixing up product after product one at a time, there's no batch testing that can be done, right? So the quality, you're talking about a whole different thing in quality control, right? So the only time we ever recommend a compound of product is if there is a true allergy, you know, there's no pharmaceutical option because of a true allergy. And that's where we rely on compounding pharmacies for that situation. So, you know, one example might be pro-metrium, oral progesterone. The brand in the United States is made with peanut oil. So if you have a peanut allergy, you can't take that product. So the options are then to take a different pharmaceutical, or to get progesterone compounded by a compounding pharmacy without peanut oil. That makes sense.

What people need to remember to take away is there's really very few things you need to know about hormones. the two main estrogens that we recommend are either estradial. And if you're stuck on the term bioidentical, that is bioidentical. Now, I'd like people to throw that term away, but sometimes it's hard. So the estradial that I would give you in a patch, or a pill, from a pharmaceutical company, that is bioidentical, right? So you have that. So you want to learn estradial, and then you want to learn tremorin, which is conjugated equine estrogens. And that's only actual natural estrogens because it comes from her seren. So natural means the substance exists in nature and it's being used to unchanged. So they hold they figure out that a horse urine is something that yeah horse urine's got kinds of esterians in it. It's a crazy thing. So those are the two things you need to learn. You need to learn ester dial and you need to learn Perman, which is the trade name for conjugated equine estrogens. And then you need to learn oral or transvaginal or transdermal. So against the skin through the vagina or by mouth guy. And we recommend the number one starting treatment we generally recommend is transdermal estrogile.

So if you were to like, I wouldn't put it here, obviously, but you don't want to stick get to yourself. Yeah, but you only want to put it in the place that the package insert says. Yeah, because it's been studied. They've studied it in different locations that the absorption can change. So if you put it on your belly versus putting it on your thigh or putting on your butt, you might get a different absorption of the amount of estrogen. And you don't want that. You want to know what you're getting.

Yeah. So there's a transvaginal ring that also has estrogen and can be absorbed that way into this into the body. And there's also a ring where the estrogen just stays in the vagina. And if you're having vaginal trinas, you have urinary tract infections. Pain was sex, vaginal estrogen can be very effective for that. And so some people who have no other symptoms of menopause feel great, if you'll find, but they're vaginal dryness, they don't want to take a medication that goes throughout their body. They want to just use a vaginal estrogen. So we have that. That's a great option. When you're using estrogen that goes through your body, About 50% of people will get a good level in their vagina, but some people won't. But from a take home standpoint, there is absorbing through the skin or through the vagina, and there is taking it by mouth. And we believe that absorbing it through the skin has the lower risk of blood clots. So that's why what people need to learn is the first line therapy for menopause is trans-dermal estradiol. You mentioned pellets a couple times, what are those? So pellets are implants that you go to a medical doctor or nurse practitioner and I think maybe even in some places there's naturopath so in certain I don't really know because I'm not really involved with it. Maybe they don't. I'm not sure. And they, they can either have estrogen, they can have estrogen and testosterone, maybe they have other hormones and that really know. And they're made in compounding pharmacies and they're implanted. They're not batch tested. So you don't know how much hormone you're getting. And it's my understanding of it is it's based on a proprietary system. So you get your blood drawn. They follow your hormone levels. And then they decide when you get the next pellet based on that. But we don't recommend hormone levels for giving hormone therapy. It's not based on levels. It's based on symptoms. I don't need to know what your estrogen level is if you're 47 and starting at. I don't even need to know what your estrogen level is when you're 42. I only need to know that if I'm worried that you have premature mental health. So the sort of system is just it's not recommended. There've also been issues with pellets with complications and side effects not being reported to the FDA, which is also another You know, another concern. So we don't actually know how many people have problems versus, you know, pharmaceutical companies when they get adverse events reported. Those are, you know, passed on to the FDA because there's big penalties. My understanding for not doing that. So it's the pellet of delivery mechanism. Yeah. So it's a, it's a, implant that sits in the body, because I don't do it, I don't really know how much about it, because it's not recommended, right? I don't know that much about it. But what it can happen is it can produce very, very high levels of hormones and then it drops off. And in some cases, you can be exposed to the levels of testosterone that we might give someone if they're transitioning, right? So the kind that can cause you to develop and enlarge clitoris, the kind that can cause you to develop these changes from having to high of a testosterone. We don't know when you're using those hormones, then how much progesterone to give you to protect your uterus. So there's all different kinds of issues associated with them and they're very expensive as well. So, you know, they're just not recommended.

No. And if anybody, if you're 45 years or older, you do not need a blood test to get started on Manopausal hormone therapy. You know, if you're 11 and having a gross spurt, no one's like, oh, why are you having a gross spurt? We should check your blood. We would expect you to have a gross spurt at age 11. If you had a gross spurt at age three, that would be different. And that's the same thing for menopause. So if you're 45 or older and you're having hot flashes, you're having vaginal dryness, you're having irregular periods. It's not a mystery. We're expecting it to happen. The average of menopause is 51, right? However, it's happening to you when you're 39. Well, that's different. We need to know, is this an earlier menopause or is this happening for another reason? And so if you're under the age of 45, you need the blood work because you need to make sure that you understand why your periods have stopped. Now, if you just have a lot of flashes, that's a different story. So the blood work is really if you skipped periods. So say you're 42, you haven't had a period in three months. You need to have blood work because we should figure out why that's happened. Yep. But if you're 45 and you're having bad hot flashes and you've had a couple of irregular periods. That's no mystery. You're starting in the menopause transition and right if the average age of onset for the menopause transition is 45. Well, you know what? 50% of people are going to be younger than 45 and 50% of people are going to be older. So yeah, so it has to be putting context. And so that's the internet wants to absolutes. The internet once, test my hormones, don't test my hormones. The internet once, you know, this or that, but medicine is more nuanced than that. And so the only absolute I can say is if you're younger than 45 and you've skipped more than two periods, then you need to have blood work done because we need to know why. Is it an earlier manopause? Is it another condition that's caused your periods to stop? If you're 45 or older, It's not a mystery why you've gone too much without a period. One thing that we didn't talk about is one of the contraindications for starting estrogen is being more than 10 years from your last period or over the age of 60. In general, that is associated with an increased risk of dementia and an increased risk of cardiovascular disease. So we sort of want to avoid starting at what people are older now. It doesn't mean like age 60, if you're 60 years on one day, that's like a hard stop. But I think it's just important for people to understand that there's a kind of a timing. And so if somebody, for example, their last period was 55, we might not cut them off at 60. So there might be a bit of wiggle room there, but in general, we recommend, you know, if people want to start hormones, that is going to be within 10 years under the age of 60. That's kind of the ideal situation and the lowest risk situation.

Well, the Women's Health Initiative was the largest clinical trial I think that's ever been done. It was designed to tell whether hormone therapy, menopausal hormone therapy, was going to actually reduce the risk of heart disease without increasing the risk of breast cancer. And it was also there are other arms that looked at exercise, that looked at calcium, the calcium replacement. So there are quite a few different arms of the limb's health initiative. And the arm with estrogen plus, so when that was permanent, that was used, permanent plus of pregestin. That was stopped early because they reached the threshold of concern about breast cancer. going into the woman's health initiative, we knew that there was a very low risk of breast cancer associated with mental hospital hormone therapy. So this wasn't like a surprise. It was kind of the threshold that was reached. And it was communicated to the public, you know, in a way that is typically not done. You know, usually there aren't press releases. When a study is halted, usually we wait, we get the data, the article is published. So it's peer reviewed and we have all of that. And that didn't happen. And that created this big hoop law where lots of things got taken out of context, lots of things sort of accelerated in ways that were uncontrollable because fear sells. So I don't know how many major news stories were dedicated to the WHO, but it was really out of proportion. And then when when more information came out and when there were more studies that came out, you know that. never gets the same attention. So we know that estrogen plus a progestin is associated with an increased risk of breast cancer. But those aren't the hormones that we typically prescribe now. So that's kind of the difference. We believe that the progestins, which are slightly different molecules on progesterone carry the higher breast cancer risk. It's still acceptable and in the safe range to take. That the hormone progesterone is lower risk. And that if you don't need a progesterone or a progesterone that the risk is the lowest. So I would say to people, you know, if you're taking a trans-dermal estrogen and oral progesterone, which is our standard starting therapy, we believe that the risk of breast cancer is very low. You know, it's not probably zero, but that it is very very low. We believe that if you're taking estrogen alone, that risk is even lower. Some people believe it's zero. Other people believe it may be a little bit higher. So this, and again, it depends how you look at the data. But I would say for the majority of people who are suffering with symptoms related to menopause who have things that hormone therapy can treat, that menopausal hormone therapy appears to be a very, very safe option. And you just have to look at it in context. if you're somebody who is at higher risk for cardiovascular disease, but not super high risk, then transdermal is probably okay, but oral isn't. Because there's a higher risk of blood clots associated with gastro. So you just have to look at what is it going to do for you? So I'm very high risk for osteoporosis. My mother died from osteoporosis. I have quite a high frack score, which is a risk calculator. And so that's the main reason that I'm on menopausal hormone therapy because my risk of osteoporosis is pretty significant. And I'm already kind of, you know, getting closer and closer to osteoporosis of osteopenia. So, and, you know, it's, you know, it's a concern for me from a health standpoint. So, so that's why I'm taking it. And so, you know, people always want us to say, like, zero risk for this end. You know, getting a car has a risk. So I always like to sort of not talk in those kinds of absolutes and say, say, what's the reason you're on it? And what is the risk benefit ratio for you? And for the majority of people, the risk benefit ratio is absolutely going to be in the favor of benefit. But there are some situations where it might not be. So for example, you know, somebody at very high risk for cardiovascular disease, someone who's previously had a blood clot, someone who's had a heart attack. So you have to put it in perspective.

Yeah, and there are calculators that can help you determine your breast cancer risk, right? So I would recommend we, I think we heard it was Olivia Munn who was talking about, I believe that's what was recently talking about. She, you know, had a breast cancer risk assessment, which led to her having MRI, which led to an early diagnosis of a breast cancer. And so there's all kinds of sort of there's several easy tools that we can do to help explain things more in context for you. So if somebody comes to me and and they have something that menopausal hormone therapy can help I do something called an ASCVD score. Calculates your your cardiovascular risk. And, you know, we need your lipids and we need to know your blood sugar and your blood pressure a few other things. And so we can calculate that. I need to see a mammogram and I need to ask you some questions about your breast cancer history risk and that's important because at a certain level when your breast cancer risk is higher based on other factors. There's also a conversation to be had about medications that lower your risk of breast cancer. So there's bigger discussions to have, but so you can do these risk calculators and you say, look, well, I'm somebody who's got hot flashes, menopausal hormone therapy, so gold standard. I've low risk for these other reasons, so there would be no reason not to go on it. But again, everybody weighs risks differently, right? And so, you know, versus you're somebody who you've got a pretty high cardiovascular risk. So can we talk about one of these other treatments for your hot flashes or your somebody who's got a history of breast cancer? So can we talk about one of these other medications for hot flashes?

Well, so are your symptoms improving? So it's really, you know, except for, and how long does it take? Pretty quick. So unless you're someone like me taking it for osteoporosis prevention, because I don't feel any different, right? So, you know, and that's again, a really important reason to take an FDA-approved medications. I wanted to protect my bones. I need to know what I'm absorbing, right? So, so if you have hot flashes, most people say pretty significant improvement within four weeks. You know, depending on how much better people feel, sometimes we might, you know, give an eight week try before switching doses. And it just depends on how people feel on the medications. So yeah, so, you know, usually with something like hot flashes, you know, you're going to see an improvement pretty quickly with depression, usually with then a couple of months as well. And, you know, There are also, so I was like to talk about with menopausal hormone therapy. There are sort of green light indications, meaning these are like the FDA approved solid reasons. Hot flashes, night sweats, gold standard, osteoporosis prevention, FDA approved. And we didn't talk about this, but if you have menopause before the age of 45, we do recommend everybody take hormones regardless of symptoms until at least the average age of menopause. And then at that average age, you can decide if you want to stay on or not like everybody else. What does the average age of menopause? 51. So, but so say you're starting it for, so you've got these green light indications. Great. Everybody believes that the benefits outweigh the risks. as long as you're in the, you know, the right category for that. Then there are sort of more yellow light indications. Things where it hasn't broached where it's recommended in the guidelines, but there's pretty good data to support it. So for example, depression in the menopause transition can be very helpful for that. Many of us would try it if somebody's got a sleep disturbance. Even if they don't think they're waking up with hot flashes, because sometimes people don't wake up, but what it's doing is it's disrupting your sleep architecture, and then you're, so you don't have as much deep sleep. So it might be worth a try to see. Like for example, I still get the occasional hot flash, but even when I was like, I don't wake up, but I'm so hot I wake my partner up. I'm just a super deep sleeper, right? But I've still had disrupted sleep. So you might not realize that. So it might be worth a try to see. The data for joint pain, it's not really that great. I mean, maybe it's gonna help 20% of people enjoying pain, so it wouldn't mean it would be wrong to try. If it doesn't work, you're not gonna keep pushing the dose higher and higher and higher because you're like, oh, well, you know, it was a chance and maybe it's gonna work, maybe it's not. There's some evidence to show that it may reduce your risk of type 2 diabetes. So again, if you're somebody in very, very high risk, that might be a conversation to have. So those are kind of like these yellow light indications. And then, you know, if you have brain fog, so brain fog specifically, there aren't studies to tell us that estrogen treats brain fog. And in fact, people perform better than they think when they have brain fog, so on cognitive testing. So it's kind of the symptom that we don't really understand. So you could certainly have brain fog from depression. Right, you could have brain focus. You're not sleeping well. You could have, you know, so all of these other things could come into play. So so, but if you're only symptom or brain fog, then I might be like, you know, it's less clear you're going to get a benefit from that. And you know, maybe there's a discussion to have about what might be the other factors, but if you've also you know, we've done a depression questionnaire, scoring higher for depression. We'll bring Fox's symptom of depression too, right? So let's get that treated and let's see. And then let's also work on the other foundations, like exercise, needing healthy. Because there is one study that looks at, you know, the healthy things you're supposed to do in counterparts, get your right exercise, eat a, you know, a fiber-rich, healthy diet and not smoke. And I think it was only 8% of women did all three.

What does that mean? I think everybody knows exactly what I mean. But yeah, so there's this edge of a knife, I think, when you're a woman, right? So, you know, we like to women are too hormonal to this to that, but you can also have symptoms related to that. So it's just really important to make sure that because of this history of causing the calling women hysterical, calling them, you know, the mad woman in the attic, all of that kind of stuff, because of that history, I think it's super important to be accurate when we're assigning fault as to what the fault is. So yeah, there was this advice column in the Guardian, and this woman had written in, and I can't remember the specifics now, but herner has been to had a contract or a verbal agreement about how they would be raising their children. And he was clearly not living up to what they'd agreed upon, and he was basically whatever her third child. And I think a lot of women out there know exactly what I'm talking about. Anyway, he was her third child and she wanted to leave him because she was like, like, I don't, I don't want to be a mother to him and this I hear this small lot of women. And she was writing in for advice and because he wasn't vacuuming. I was not even doing any of this stuff. She was basically doing it all. And the answer was maybe it's menopause, maybe you're intolerant because of your hormones. Rightfully. Yeah, maybe she's going hormone therapy. She didn't say she'd having hot flashes. She didn't say she was sleeping poorly at night. She clearly laid out that they had agreed to be equal partners. And here she was now in this relationship where she was doing all the grunt work, all the nasty stuff. And you know, he was out at the pub. Like it was, it was sort of the most obvious, like, pull the plug, get divorced, save yourself run, don't look back, run. And no, maybe it was your hormones, because I know that when I was going through metaphors, I had a shorter temper. So I think it's really important that we are not excusing the bad ways that society treats women. and saying that, oh, if you just took hormones, it would be better, right? Because the answer to being mistreated is not taking hormones. The answer to being mistreated is to be treated correctly. And so I just think that it's really important that we're clear about these things. Now, somebody comes to me and says, oh my god, look, I had the perfect relationship. Oh my husband does everything. And now that I'm not sleeping at night and I'm soaked and sweat all the time, I've got a super short temper. Yeah, your hormones might be having something to do with that. You know, maybe if you actually had a good night's sleep, it would be better. I think most people can agree with that, right? But that wasn't the situation that was being presented. So I just think that, you know, it's really important, especially like in the workplace too, right? You know, that many women in the workplace are treated terribly, especially as they age, there's so many glass ceilings, right? And while it's super important that workplace is accommodate menopause. We also don't want to use that as kind of lip service, so then we can excuse all the bad policies that are keeping women from advancing, right? Oh, look, you know, we're working, we're letting you control the temperature. When really there's also a massive last ceiling. So I just think accuracy and all things.

I would say that's a pretty awful place to be if you don't feel supported and I think whether it's menopause or pregnancy or you've got any other health condition you want the person who loves you to support you. So I would say that That's an awful place to be. And to maybe have a conversation, if you feel safe having that, you know, explaining what's going on. And, you know, maybe saying, hey, here are some things that you could read, so you have a better understanding about where I'm at.

Yeah, if you've got a family member, your mother, your sister, you know, a loved one who is going through a manopause, learn about it. And also think about what you can do around the house to make it easier. You know, I would, you know, everybody needs a little bit of help. In many heterosexual households, women are doing the burden of the labor around the house. There's a study that shows even when our power, it's the same. Women do more of the less fun work, right? I know it doesn't, it's not going to surprise you, it doesn't surprise anybody. So if you take our power well, The man is more likely to be out in the yard playing with the kids, and the woman's more likely doing a laundry. So four hours, four hours, right? So, you know, how can you think about having a more equitable division of labor in your house, right? And how if you have a family member who's struggling, wouldn't you want to carry some extra load to make it easier for them? Like, that's just being a human.

Absolutely. And you know, ask, can I go with you to a doctor's appointment? Can I, you know, can I be your scribe? You know, by the menopause manifesto, you know, my book, you know, think about how you can, how you can do some little things to help, you know, just If you're not someone who's, you look at the chores that you're doing in the house, think of how you can pick up more, think about how you can listen, just sit in the listen as well. You know, not everybody wants an answer. Somehow people just want to talk. You know, there's a great episode of Parks and Rec, where I don't know if you've seen the show, but where Anne is pregnant and her spouse is, I can't remember his name, but is played by Roblo and she's pregnant and she's just very uncomfortable. And she's talking about her aches and pains in this and that. And he just wants to solve everything. Let me get you this. Let me get you this. Let me get you this. And she just wants him to sit and listen. Right. So I think a lot of people just want you to sit and listen to.

Yeah, so the menopause society does have certified, you know, menopause providers. And you can certainly, you know, look for someone who is a certified menopause provider that's not necessarily a guarantee that, you know, that they're going to give you evidence-based care, I understand there's some who also implant pellets, but in general, I think that's a good place to start. If you ask your doctor about menopause and they don't like clam up, if they can have a conversation about it, there's lots of great people who know how to care for menopause who haven't done the test and aren't members of the menopause society, right? The other thing that I recommend people do is you can Google the 2020 North American Manipass Society guidelines for hormone therapy. And you can download it. It will link it in the show notes. It's, you know, it's at PDF now. There's a lot of, you know, semi-interesting things and they're talking about risk, you know, complex studies and things like that. But at the end of every section, they have a kind of a general good plain language summary. And I think that many, many people would find that quite illuminating. You know, to read that and you can even take it with you. So, you know, if you're, or you could read it and say, oh, I'm asking for something and it isn't even mentioned in here. Maybe I'm asking for something that's a little bit out of spec and so I'll ask, you know, do a word search? You know, do what is it control after whatever you have to do? You know, if you've got a specific word, search the document for it and see what shows up in there. So that's a, it's a good place to kind of get some basic information that's evidence-based. They have some information on their website too. And I would just say that for the majority of people who want to try menopausal hormone therapy, a six month to a year tile is as low risk as anything can be. When we look at the risks of breast cancer, if you assume that the studies that show risk are correct, again, we've had the spectrum of some study showing one thing, others showing nothing. There's no risk with a couple of years. Like, like, that risk doesn't accumulate for a while. So if you're really scared, there's essentially, and you're a good candidate, cardiovascularly, trying it for six months is about as low risk a therapy as there can be. And if you try it, you're like, well, this has an improved my quality of life. You know, there's your answer. And if you're on it, you're like, wow, my quality of life has changed a lot, then there's your answer. Because, you know, there's lots of things that haven't been studied. You know, there's, you know, others sort of symptoms like many women talk, but they just don't feel like themselves. Well, we don't have a scoring system for that. I don't know what that means. And you know what, you not feeling like yourself and me not feeling like myself. I mean, too completely different things. We'd be completely different. biological phenomena, but we're using the same words to describe it. So because it's such a low risk thing if you're using the FDA approved therapies and you're in a low cardiovascular risk, there's very little downside for saying, you know, is an appropriate dose improving things. The one word of caution I would give to people is you want to, if you're not improving, to be very careful about dose escalation, right? So if you think about an estrogen patch that has 100 micrograms of estradio, That is about equivalent if you even it out through a whole month to the amount of estrogen you make when you're ovulating. So, if you're needing more than that, I would say, and you're over the age of 45, probably needs to be a bit more reflection, because why would you need on average more estrogen than your body was making? So, you know, so you just want to say, like, if If you're needing more than that, then that might be a time for a reassessment of things. You might be on the right track, but I would say that's a time to reassess.

Well, I want to say that accurate evidence-based information is really the best way through any medical situation. And we don't always have all the answers, and women's health has been underfunded. But having the information that we have is a lot better than just wild guesses, right? So to just keep that in mind, that we do have quite a lot of information that if you're not being heard by your physician, than I know it's hard, and that shouldn't be that way, but get a second opinion. And just be mindful of people that are selling product, because there's a lot of incentivization, that's not even a word as there. It's a lot of incentive. I make sense to me. There's a lot of incentive or there can be bias, right? So you just need to be mindful about that. You know, I get paid the same on salary. I get paid the same weather I talked to somebody about exercise whether I give them hormones. You know, I don't have, you know, any kind of, you know, deal with a specific company. I don't take any money from any pharmaceutical company. You can look me up. So, you know, that bias can come in all different kinds of ways as well. And you know, I just think it's important that if you're on social media and someone's also selling a product to just be really wary of the message. That's all. I just love how you explain this stuff. Thank you. Thank you so much for having me. It's been great.

Okay. Was he new? You were just warming up. It's okay.

Yeah, I just took off a layer of street crime from mine. And now I can, I'm like, oh, wow, my God, I can actually see. It's amazing.

Thank you. Thank you for letting me talk so much.