348 ‒ Women’s sexual health, menopause, and hormone replacement therapy (HRT)

100% of people are heavily impacted by what we just discussed. They misinterpreted the data so drastically and scared everybody with so much fear that you actually have an entire generation that has forgotten how to prescribe hormone therapy. When you took estrogen and progesterine or estrogen alone, you had a decreased risk of colon cancer. You had decreased risk of fractures, like significant decrease of fractures, decrease of diabetes. We saw a decrease in overall mortality, a decrease in cancer specific mortality. The reality is this is half the population. This is not niche medicine. If a penis shriveled

up at age 52, we'd probably have a vaccine sponsored by Fizer, right? This is this is they created Viagra, they would create this this vaccine. No one even tells. I love that analogy. There are two hormones we've talked a lot about, but there's a third that we haven't yet talked about. Doesn't get enough attention in women, and of course, that's testosterone. I I don't know who said who decided that men get testosterone and women have estrogen. Like, we have both of the hormones. We love to gaslight women and say, "Well, if you have your period,

your hormones are normal." And the reality is is that's not true. I know there are people in the Medicare system who are going to be interested to understand that. If everybody in Medicare eligibility used vaginal estrogen, we would save Medicare between 6 and 22 billion dollar a year. They're going to their doctor for cultures. They're in the ICU with sepsis. Um, this is a huge economic and mortality problem that we are dealing with and no one cares. We just got done saying that that study didn't show that. So, why is that box labeling still there?

We're killing women by trying to protect them. Hey everyone, welcome to the Drive podcast. I'm your host, Peter [Music] Aia. Rachel, thank you so much for making the trip out to Austin. I have been looking forward to this episode for a while, and I am uh willing to go on record uh predicting that this will be a very popular episode given the nature of our uh of our discussion. I am so thrilled to be here. I have been nervous for quite a long time, but I'm super happy to be here. Um, I almost don't know

where to begin. Um, but it might not be a bad idea to just give people a little bit of a sense of your background. You are a urologist by training. Um, and maybe help us understand how your training in urology led you to what you're doing today because most urologists uh wouldn't be doing exactly what you're doing. When we think of urology, we think about, you know, prostates, we think about kidneys, we think about bladders. Yes. But what you forget, Peter, is that urologists are ultimately the quality of life doctors. We deal with urination problems

and we deal with sexual medicine, right? No one cares about erections and orgasm and libido quite the way that a urologist cares about. And when we're board certified, actually, it's not a gender thing. We're not penis doctors only, right? We are board certified to take care of everybody's uh genital and urinary tracts. And so what the unfortunately society has led us to know a lot more about the men's sexual health and men's genitals than female genitals. And so my background um I trained in urology really because I was interested in women's health but I also

was interested in sexual health, sexual medicine. And um I didn't like delivering babies. I didn't like OBGYn. I I it just didn't fit well with my personality. And what I love about urology is that we can see everybody and we can really dive deep on quality of life issues and and the magic of urology is also that you really can you get to know your patients. It's not like you know when you did surgery you take out someone's appendix and you never see them again. Maybe you do one posttop visit. Urologists have deep relationships. We're

both surgeons but we actually care about the medical side of these quality of life issues. And so as I was going through medical school, I really realized that talking about sexual health, quality of life issues, that was fun for me. I was good at that. And in medicine, you kind of gravitate towards what is easy, not what is hard. Um, and so it's just been a joy. Um, and really I've been working to further the field of urology to make us better at taking care of women. And so really I do a lot of educating

and teaching uh to my colleagues about how we really need to care about the whole you like everybody. I really mostly want to talk about it from a female standpoint today truthfully because I think this is where there's just a der of great information out there and where I think there's an abundance of garbage information out there. So while I appreciate that your breadth of knowledge will cover both sexes, um you'll probably notice kind of a bias in what I want to talk about uh visav women specifically. So let's let's start with perhaps the the

biggest and most obvious uh difference between men and women. Um and that is from an endocrine perspective. Women go through this period called menopause which is a rather sudden and abrupt loss of their sex hormones. Um and that's you know to be contrasted with the way men's sex hormones kind of decline over time a little more slowly. So um I again the listeners of this podcast are highly areriodite and they won't need like the lengthy uh dissertation but just give us a quick overview of what the heck is happening in menopause. Why is it happening?

Um and and and and then we can get into maybe what what some of the symptoms are before women might really notice them. Yeah. Well, you know, I certainly did my research and I am not a car person, but I know you are a Formula 1 guy and I got a a very interesting email last week that said, "Dr. Ruben, my wife is seeing your practice and she her libido is now like an F1 Formula 1 race car and I'm like a 1988 Honda Civic. What can you do for me? And I think that really

my analogy I really like to look at is sort of the gas tank analogy. This idea that men as they age, you know, sometimes we see a decrease in their gas tank. They're feeling low. They're feeling down. They've got erectile dysfunction, low libido. Whereas women in the age at age 52, their gas tank is empty. Right? This is a castration event. We don't have many castration events in men's health. And so menopause is sort of a your gas tank is officially empty. There's not much in the tank. Perry menopause is this time where it's very

erratic. The gas tank is over full and then it goes to empty really quickly without warning. And so I like that analogy because I think it's helpful when we're talking to women about the reason you don't feel like yourself is because there's just no gas in the tank. So, we see the ovaries are no longer producing estrogen, progesterone, and testosterone the way that they were during your reproductive years. I love that analogy. I've never heard it before, but it absolutely replicates what of course we see clinically, which is in perry menopause. Why do we sometimes

when we're measuring a woman's labs, say every 3 months, see periods where estradiol is through the roof, FSH and LH are low and 3 months later it's completely flipped. And of course, with it go symptoms. So, can you explain why there's this, you know, if if we have kind of hormones running like this during premenopause, they're like this during menopause, but it's this transition is nothing like linear. It looks kind of like the stock market actually. It goes up, it goes down, and even it's not even just checking it every 3 months. If you check

it every 10 days, you're going to see a fluctuation. I'm obsessed with looking at the menstrual cycle. I'm obsessed with talking about numbers here because it is so fascinating and we are not taught to think this way and so I have a lot of curiosity about it. So, for example, when you're in your, let's call it healthy reproductive years, and by the way, nobody is the book, right? We think of the you talk a lot about continuous glucose monitors. I would love continuous hormone uh sex hormone monitors and and unfortunately, I know there'd be a

lot of unintended consequences and bad things that would come of it. But I'd be very interested because the book says our low, so if you have your period that you're bleeding, that's day one. Your low is not zero, right? In fact, it's probably somewhere 40 50 is probably what the low should be of estradile and that's you know pograms per milliliter um as opposed to testosterone which we do nanogs per deciliter as you know. So so probably let's say 50 is your low. Then you go to ovulate and that's in your midcycle and usually it's

about 150 let's sayish maybe it's 200 300 whatever it is pregnancy your level is 3,000 or higher right is very high and so if you're in your normal reproductive cycle you go from 50 to 150 so let's use the gas tank analogy you're at a quarter tank at 50 and you go to 3/4 tank at 150 then down to a quarter tank you can drive wherever you want to go you know during that time what happens in perry menopause cause and it is this chaos and erratic sort of fluctuation where your body is just wanting

more hormone than it has. Your brain, your FSH is telling your eggs to do more than they can. Sometimes they overshoot. So now you are overflowing gas. We've seen estrog I had a lady come in, you know, her but her day one her estrogen was 200 and her day 10 her estrogen was 900. Right? So, this is this wild fluctuation in pmenopause. And and what I'd like to do now just is make sure that anybody listening who wants a more nuanced overview of this, we're going to link to a video that I made a couple

of years ago where I walk through the ovulatory cycle and I draw the graph of estrogen, progesterone, FSH, and LH according to the nomenclature you're using by days. But let's also have you do an explanation now of the role of FSH and LH on the brain because you've already referred to that and what the feedback cycle looks like with estrogen. I just want to make sure people are are following the physiology you're describing and that video is so fantastic. We actually were talking about it before doing this podcast about that video and I said, you

know, if you asked most OBGYNS to draw the menstrual cycle, many of them wouldn't be able to do so. It's incredibly complicated and it's so confusing and and we think our doctors know everything and unfortunately they don't. And so what happens is estrogen, you know, um again, you have your period, your lining of your uterus is shedding, your estrogen is kind of at its all-time low. And and again, just to make the obvious statement, it's because most of the time when a woman ovulates, she does not get pregnant, right? Let's talk about in this non-preg

state, right? you didn't make a baby. You're shedding the lining. Your estrogen's about 50, let's say, to make it easy. Now, it's starting to go up up up up and you're developing this follicle, right? So, this egg is developing. And then as your, you know, the LH is sort of your brain's uh sort of marker of of okay, it's time to ovulate. So, that's when you pee on a stick and you're trying to check if you're ovulating, it's checking your LH levels. And so, you're going to see this increase in LH. That happens. Again, everyone's

a little bit different, but it happens kind of mid cycle, day 10 to 14, you know, somewhere along the again, urologist, not gynecologist. And so, you get this LH surge. The egg pops out and it is the shell of the egg that creates the progesterone surge. So, you actually don't make any progesterone really in that first half of your cycle. And then after ovulation, we call the second half the ludial phase, which just means, you know, sort of that's when progesterone is around. And so you get this surge of progesterone when there is no fertilization

that that shell of the egg sort of evaporates and then you lose your progesterone and it is that withdrawal of progesterone that causes the uterine lining to shed. Now again this is very confusing for people because hormones through that time your estro your progesterone goes from very very low to after you ovulate very very high. Um and it's that cycle every month. Now estrogen again goes from 50 to 150 back down to 50. That's what the book says. I don't know about you, but my patients are not all on the book, right? They're sort of

Yeah. A lot of my patients don't read the book about what their physiology is supposed to do. It's very disappointing. I agree completely. And so, we're super interested in this is is really trying because we we care about how people are feeling, right? And so, everyone, you know, I'll say I may say this a lot during our conversation is there's the book answer, there's the Instagram answer, and then my answer sort of somewhere in the middle, right? is how we sort of talk about it and understand it. And so I again I think um I

think the numbers are helpful for people to see. When you're pregnant, your estrogen's 3,000. When you're sort of regularly ovulating, it's 50 to 150. Perry menopause it could be zero. It could be a thousand and down to zero in 2 seconds. So let's talk about why. So why is it that in pmenopause um the fluctuations in estradiol level are so dramatic? I think it has to do with the fact that you have a limited number of eggs. You're sort of getting to that end of your, you know, sort of bucket of eggs that you're born

with and sort of, and that's again controversial on the internet. Um, and then so, so your body is really trying to do what it has always done and it's just having trouble. It's having trouble recruiting the egg, ovulating. You don't ovulate every time. Sometimes you ovulate twice, you know, or push out two eggs sort of in this permenopause cycle. So we can sometimes see really elev like high elevations which can come with symptoms and that's the challenge of pmenopause is sometimes you have symptoms because you're too low sometimes you have symptoms because you're too high

and sometimes it's that fluctuation like again we'll go to the car model you're driving 100 miles an hour on on on the highway and you go to empty gas tank immediately that is not good for a car that is inflammation that is irritation that is a lot of you know that is a lot of pmenopause symptoms and so maybe to extend the anal allergy. Part of the reason why a woman during this period of time can experience these enormous surges of estradiol is if you think that there's say uh you know a kink in the

gas line and you really really want to squeeze the the the lever to get as much gasoline as you can in the car. Sometimes you overshoot and just you get a whole bunch extra in there because again you're you're there's there's volatility in the in the follicle release. I knew you would like this analogy. Yeah. No, I love it. You're welcome. Um the one other thing I want to talk about um because it's going to come up later when we get to HRT is um do do you buy the argument which is I the argument

I have found most appealing as to why women have varying degrees of sensitivity to the dramatic reduction in progesterone that they experience in the last quarter of the cycle once the lining sheds. So we talked about how of course during the ludial phase we're building up you know progesterone levels are rising we're building up the endometrial lining in preparation for uh pregnancy again most of the times that's not going to happen lining sheds progesterone crashes this is what's referred to as you know obviously PMS and some women are somewhat unfased by that you know and

other women that's a big deal and so the question is is this about central receptors of progesterone and varying degrees of sensitivity. I think it's a really important question and we see this clinically all the time, right? In that if if you give somebody say micronized progesterone or a synthetic progesterine say in birth control, you will see a wide variety of reactions to these different medications. And so I would say it has to probably do with the GABA receptor, right, and the metabolites of progesterone and how the body, you know, how the receptors uh in

the brain sort of use these uh molecules. And so I think we just don't know enough about I you know I tell my patients all the time. I wish oh my gosh we have so much work to do in women's health. We have so much research we need done. This is why I come on this uh platform not because I want to be on this platform but I need smart people to be listening to this to ask the research questions and to do this research because clinically we see this all the time. You give you

know somebody and I will put put up that menstrual cycle uh with my patients and say when do you start to have symptoms? Are you having symptoms when your estrogen is falling? Are you having symptoms when your progesterone is falling? And can we sort of hack the system to help you feel better? And how are you going to respond to it? Because when we give someone micronized progesterone, I would say a third of the patients love it and guzzle it like it's candy and they're the happiest people in the world. Helps their sleep. It reduces

anxiety. Oh my god. Changes their life. Oh, it's absolutely life-changing. A third of the patients are like, I don't really notice. It doesn't bother me. I've got no, you know, it's fine. Like if you tell me I need to take it off, you tell me I need to take it to protect my uterus. no problem. And then you've got a third of patients who are very sensitive, right? The progester and even within that third, it is extreme. I mean, we see progesterone allergies where people have horrible reactions to uh it makes me too sleepy. It

makes me feel bloated. I don't like this. And so, I don't as a as a clinician and an interested researcher like I don't know exactly enough to be able to spot who those people are ahead of time. We've established now what's happening. We've established that during the period of pmenopause, the one consistent thing that's happening is inconsistency. At some point, we we get to the place where the consistency returns, but now it's a new norm. And that new norm is you don't make estrogen, you don't make progesterone. The signal from your pituitary FSH and LH

begin monotonically rising, rising, rising. Um, and so, you know, if you were to do the blood work of a woman in her 60s who had never been placed on HRT, you would see a very high FSH, a very high LH, usually above the lab's cutoff for measurements. It's, you know, and then estradile and progesterone non-existent. Um, let's talk about all the reasons why that woman that I just described in her 60s who is now 10 years out of any hormones, what are the risks to her physical health, uh, mental health, emotional health, the the the

whole picture of her health, cognitive health, everything. What is what is what is she worse off for at that uh, at that period of time? So I think this is a really important question in the sense of what is the risk of taking hormone therapy in that patient and what is the risk of not taking hormone therapy in that patient. And so I think it's super interesting because we love talking about the risks of medication but we don't spend a lot of time talking about the risks of not taking medication. So if we think about

that woman as she gets older um she certainly will have the microbiome and genital and urinary changes of not having hormones. So as a urologist this is the actually one of the things that one of the couple things that will kill her right as the you lose hormones in the genitals which are very hormone sensitive the bladder is very hormone sensitive you change the microbiome you increase you decrease the acidity of the tissue the bad bacteria grow your risk of urinary tract infections increase drastically. So she may get recurrent urinary tract infections or pelvic pain.

she may develop osteoporosis, right? Which we know more people die of hip fractures about the same die of hip fractures as die of breast cancer. So the risk of not taking hormone therapy when you get a hip fracture as all of your listeners know you're you're going back to the life that you lived is very challenging, right? Or you die. Um, and so there's also the risk of we know dementia and Alzheimer's much higher in women and we can argue the data and I don't think we actually have good data about you know whether hormones

are you know when to start them and and if they're actually protective and how they're protective but we also know that heart disease is the number one killer of women and we know that things get worse as you get older. So I think there are significant risks to that person and from the mental health perspective I think there's no question that we see worsening of me. Now, I will say perry menopause from what I understand of the data is actually worse on mental health and can actually level out a little bit once there's less erratic

hormones. But again, an empty gas tank is still an empty gas tank. And so, we see a lot of challenges, you know, sort of in this time period. We talked about obviously the risk of dementia, we talked about the risk of osteoporosis, cardiovascular disease, um colon cancer, right? All of these are risks that are pretty clearly going up in the absence of hormones. Um, so do you want to talk about the history of HRT? I mean, you know, it was a largely normal practice uh in the 1960s. They, you know, certainly had some fits and

starts, right? They initially were just replacing estrogen. Um, figured out pretty quickly, i.e. within a few years that if you only gave a woman estrogen, you were going to run the risk of endometrial cancer going up because the endometrial lining just continued to get bigger and bigger and bigger and you eventually developed hyperplasia, which presumably became metiplasia and ultimately cancer. We figured out pretty quickly how to combat that. If you just oppose the estrogen with progesterone, you keep the endometrial lining in check. And this largely became the um uh the standard of care through the

1980s uh and into the 1990s. And this was largely validated by epidemiologic uh observations which showed that women who took hormones did significantly better. Now, people who listen to this podcast are well aware of how critical I am of epidemiology. And it's certainly very easy to make the case that in the 1980s, women who were taking hormones had a healthy user bias, right? These are women that probably had better access to health care. They were probably more health consscious, and as a result, they were probably doing many more things to improve the quality of their

health. So, the NIH did something that I think made a lot of sense. it was the right thing to do which was they said look we can't rely on this epidemiology we need to do a randomized control trial and they did it through something called the women's health initiative which had two two components a nutritional component uh that was asking a question about low-fat diets and then um a component that was looking at the HRT so um would you like to pick up the story as to how the study was designed maybe talk about some

of the the the potential pitfalls of it and and ultimately how the results of that have been misunderstood and misinterpreted for so long. The fact that this story hasn't been made into a Hollywood uh biopic mega drama, I don't know, right? This is a big deal. A billion dollars of our resources went into doing this study. And there are many things that we learned that were helpful and useful and this huge set of data that we're still using today to extrapolate information from. And there was a lot of good that came from it. But there

was a lot of misinformation and just really bad marketing or really effective marketing you could argue because what is so wild, Peter, is that when this study came out um and they did a press conference, okay, before the study was published, they did a press conference. Have you ever seen the NIH do a press conference that Matt Lowour talked about or that was made on you, you know, like Good Morning America? Like they did a press conference. I remember I was in medical school at the time. Like I remember sort of you know this happening

and they said okay this we had to stop the study early. It is increasing the risk of breast cancer and increasing the rate of risk of blood clots and cardiovascular disease and we have to stop the study and everybody this there's different statistics out there but people will say about 40% maybe of women were on hormone therapy at the time. Overnight it went it crashed to nothing. You're talking billions of dollars of an industry went to nothing. And the the people who were prescribing the hormone therapy were like, "This doesn't make any sense. I I

do this I've been doing this for 20 years, 30 years. I don't have a clinic full of people who are dying of blood clots or heart attacks or who get breast cancer. Like this is not my clinic. Whose clinic is this?" And then over the years, you know, then they published the paper and and as we talked about, you know, before we did this podcast is that they misinterpreted the data so drastically and scared everybody so with so much fear that you actually have an entire generation that has forgotten how to prescribe hormone therapy. And

this is where the nightmare that we're living in today because now we realize that the data was misinterpreted. So if we talk about and again and the WHI was one medication, one dose, that's it. And it was a sort of birth control pill style kind of hormone therapy. So a synthetic estrogen and uh uh progesterine, it was not sort of the what we call, you know, more um and we can talk about the marketing term bio identical, but the FDA approved products that we use today like estradiol and progesterone. They're different medications that we use

today. And so you're talking one medication, one dose, and we are still practicing fear-based medicine 30 years later, whatever it is, saying like like like we don't practice any other medicine like this. We're like, well, there was one study about surgery 30 years ago, and that's the way we practice medicine, right? We evolve, we learn new things. So, what did it show? Let's talk about the good. When you took estrogen and progesterine or estrogen alone, you had a decreased risk of colon cancer. You had decreased risk of fractures, like significant decrease of fractures. Decrease of

diabetes. Okay, that seems like a good those seem like all good things. This is in the hormones we don't even really prescribe anymore, right? We saw a decrease in overall mortality, a decrease in cancer specific mortality. Um, and then when you looked at the cardiovascular data over time, and again, I'm a urologist. I'm not a heart expert, but you saw there was actually no difference, right? It actually wasn't so scary. Now, as you get older, we know birth control pills can cause blood clots. So, we do worry about giving a birth control pill to grandma

because you can increase blood clots, right? That's true. I agree with that. When it comes to breast cancer, the most fascinating data that didn't make the press conference, women who were on the estrogen alone, so they didn't have a uterus, so they didn't need the progesterine therapy, had a decreased risk of getting and dying from breast cancer, right? And that didn't make the news. Estrogen was never this co even in that study that put the box labeling on all the products. It's not true, right? So then when you looked at the estrogen and the progesterine

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

because of a bad misinterpretation of statistics. So Rachel, I don't know how good you are at sensing a person's blood pressure from across the room, but if you were able to sort of project your your your vision into my corateed artery. I see it bulging. Yeah. You you'd notice that my my blood pressure is up. It I'm probably at 180 over 120 right now. Um, first off, I think that was a remarkable, succinct summation of the WHI. I'm only going to repeat a few things be, not because I didn't think you did a great job.

You did, but because sometimes hearing it twice, highlights the egregiousness of this study. Shout it from every rooftop you can find. Um, and truthfully, I have friends, female friends, and I have patients who to this day are paranoid about hormones. And I just I I want to offer yet another uh opportunity for them to to sort of understand what's going on. So, this was a study that had, you know, two parallel arms, right? one where women without a uterus were just randomized to either the synthetic uh or ecquin based estrogen versus a placebo and then

one where if you had a uterus you got MPA a synthetic progesterone and the estrogen as you pointed out the um elephant in the room here was the one finding that got all of the attention was that in the women with uterus group if you got the synthetic progesterine and estrogen, you had an increase in your incidence of breast cancer. It turned out it didn't actually lead to any change in mortality from breast cancer, but there was an increase in the incidence. Now, um the number is really scary if it's given in relative terms. It

was a 24% increase in the incidence. Incidence for the listener meaning getting breast cancer, right? So, you had a 24% higher chance of getting breast cancer if you took the um two hormones. On the surface, that sounds devastating. But again, as people who listen to this podcast know, we always need to think in terms of absolute risk. And relative risk doesn't mean that much if you don't understand absolute risk. So, if I said to you, Rachel, um, I have a treatment for you that is going to fix a hundred problems, but it increases your risk

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

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

from teaching at the largest internal medicine conference, ACP, the American College of Physicians. And you're talking more than 20,000 internal medicine physicians. I was asked, what a wonderful thing. I was asked to give a course on female sexual dysfunction and it was wonderful. I talked a lot about menopause. There was no other menopause content at this course. There was no courses how to prescribe given everything you've done, my colleagues and myself have done to bring it into sort of just popularity. patients are coming in asking questions and there wasn't even a course to learn. I

can't say that's true for GLP-1s or any of these lipid lowering agents or all of the things that you've been pushing. The problem is you now have a you have a brain drain, I think, because the doctors who prescribed hormone therapy either retired or died, right? And there was no one they taught ahead of them. Now, I was very lucky. We had very good mentorship and incredible experience, but we are now trying to make up for lost time to train people how to write prescriptions. So, it's not enough to say, "Hey, the WHI was misinterpreted

and we've done a bad thing for women." People don't know how to do this and it's not a small like it's it's a huge problem. And the reality is this is half the population. This is not niche medicine. the fact that menopause medicine is the tiniest little uh room of a of subset of gynecology, which it should not be under gynecology, right? This is whole body medicine, and yet nobody seems to care. Yeah. It's really interesting to hear you say that because you're you're highlighting something that's as dramatic and potentially more dramatic than the thing

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

the number of women who were deprived of HRT because of the WHI and calculate the excess mortality that was achieved through that injustice through hip fractures, cardiovascular disease. Like we just went through the entire list, right? Like so calculate the number of lives that were lost, the amount of disability that was incurred because to your point, even if you don't die from a hip fracture, 50% of survivors never regain the same level of function. Um, and I didn't even know how to quantify all of the sexual side effects that women unnecessarily endured, all of the

vasa motor side effects that they unnecessarily endured. Didn't even try to quantify that because I don't know how to. But, you know, that's the thing that I focus on. And again, it's personal to someone my age because my mother and my mother-in-law are in that category, right? Like they're the ones that got absolutely screwed by this system. Um, you're highlighting something equally and potential equally catastrophic with potentially a greater impact, which is we failed to train a generation of doctors to do anything about it. And if that's not reversed, the problem doesn't get much better.

Yeah. Yeah, I mean the data is very clear on this, right? Less than 6% of internal medicine OB/GYN or family practice doctors get even an hour of menopause education in their training. Do you remember learning about menopause in your medical school? Zero. I didn't learn one minute of it. And so here's I did learn that hormones were bad. Oh yeah, you learn. Right. So So there's this this So so because you are taught hormones are dangerous or the bodybuilders take the hormones, the snake oil salesman take the hormones, right? like we don't talk about this

in real medicine, right? So, you actually have everyone says it's not my it's not my industry. It's not my thing. I went to this internal medicine conference, you know, yesterday and all the internal medicine doctors were saying, but this isn't this isn't my field. Like, I don't feel comfortable. Right? An endocrinologist was standing there saying, I don't feel comfortable doing this. I said, you're a hormone doctor. Like, that is what you do. It is so embarrassing. I've been asked to speak at multiple academic centers to teach on hormone therapy. And every time I'm like, is

this real life? I am a urologist teaching hormone doctors about how to prescribe hormone therapy. And it is real life. And this is why I'm so loud about it because we have to change this. We have to change this on a big level because I need the ICU doctors and the pulmonologists and the card and the you know the heart doctors and all the doctors to know that menopause affects their organs, right? Colon cancer. Why aren't why aren't GI doctors talking to women that estrogen prevents colon cancer? Why are we checking Dexas at 65? Like

why are rheatologists not prescribing hormone therapy? I found out recently that psychiatrists, because I do a lot of teaching about how to prescribe hormone therapy. A few of us are very passionate about it. And I was like, "Sit with me. I will teach you how to write the prescriptions. I've had psychiatrists tell me their malpractice insurance will not cover them if they prescribe hormone therapy." And I said, "Wait a minute. You prescribe postpartum depression drugs, which are progesterinebased, right? You do reproductive psychiatry, which means birth control is a part of what you do. And you're

being told you're not allowed to prescribe hormone therapy when hormone therapy is one of the greatest anti-depressants in the history of of medicine. It is insanity. We're living in a nightmare. Yeah. So, let's talk a little bit about how we go about doing things. Um so there are two hormones we've talked a lot about but there's a third that we haven't yet talked about that is um very linked to these two hormones uh doesn't get enough attention in women and of course that's testosterone. So uh before we get into how one should think about replacing

hormones, can you talk about the relationship um of testosterone to to women's sexual health and what's happening to testosterone levels during this transition from perry to menopause because of course this I want to bring this into the HRT discussion. So it's super interesting and I'm very passionate about this topic and so I think it comes from this idea that I do uh testosterone for men all the time, right? I'm very confident. I love prescribing testosterone for men's sexual health for um uh and actually very interestingly enough when we prescribe testosterone for men remember their gas

tank doesn't get empty it gets low right it's off label right we are doing off label testosterone therapy in men unless they have kleinfelters or some you know significant medical problem like we're doing off label testosterone for men and it's very understood it's talked about the FDA just three weeks ago removed the labeling on testosterone therapy saying it no longer is a cardiovascular disease risk. So that's great news, right? So the the thing about women in testosterone is it's actually not a menopause thing. Testosterone is an age related decline. So in your 30s, you're starting

to drop your testosterone. And testosterone I I don't know who said who decided that men get testosterone and women have estrogen. Like we both have all of the hor like we we have both of the hormones. Sorry to interrupt. You probably heard me make this point before because you alluded to it a few minutes ago. We measure testosterone in nanograms per deciliter. We measure estradiol in pograms per milliliter. If you normalize those to the same level, women are shocked to learn that they have 10 times the amount of testosterone in their body that they do

estradile at peak estradile. We way more, right? And I love sharing that. Right? When you put everything in the same units, we are testosterone driven beings. Both of us, right? Are testosterone driven beings. And so it's a you know again a and and we don't teach this to OBGYNS. No OBGYn knows some do but but very few know about the role of testosterone in women's health. And so we love to gaslight women and say well if you have your period your hormones are normal. It drives me insane. This women are told this all day every

day is well you you can't possibly have a hormone problem because you're getting your period regularly. And the reality is is that's not true. Why? Because if no one talk that that curve that curve we were just talking about testosterone is nowhere on that curve. And so we know there's a peak of testosterone around ovulation right that is nature's way of saying let's make a baby. We know that. We know that your libido goes up around ovulation because your testosterone goes up. And so there is this age related decline in testosterone. And here's another big

problem. We give women birth control pills all the time. How does birth control work? By the way, birth control is highdosese hormone therapy. We love hormone therapy and birth control, but as soon as you become menopause, everybody's afraid of hormone therapy. It makes no sense. So birth control is high dose, I would argue, you know, sort of the hormone therapy we're talking about in the WHI that is more synthetic that has side effects that have issues like that. So birth control turns off your ovaries and it adds back ethinal estradile and a synthetic progesterine. It

doesn't add back testosterone. So, we are botching testosterone for women sort of for along the life cycle to be honest. But if you take someone who's never been on birth control, their testosterone starts to drop in their 30s. So, what are they complaining about? It's not just a libido thing. We know their testosterone receptors all throughout the genitals and the urinary tract. So, we see women have an increased risk of UTI. We see an increased risk of pain with intercourse or pelvic pain conditions. We see uh there are some studies that indicate potentially depression and

anxiety can increase because we do think there's a testosterone uh effects on the brain. But we have global consensus and I don't know if you've read the news lately Peter but like we don't agree on too much as a globe but there is global consensus that testosterone in women works for low libido and so specifically the data is on postmenopausal women. That's where the global consensus is but there is data in pmenopause and much smaller studies on uh before that. So, but the the consensus is it works, but everyone has emotions about testosterone. I don't

know. I didn't think testosterone was a feeling, but apparently it is a feeling for people because people hate talking about it. And again, nobody taught you how to prescribe it. So, people are and there's no FDA approved product for women except in Australia, it's approved by their their governing body. And so, you have a lost art of knowing how to give people back testosterone when they are symptomatic. And I think this is an area where women sometimes are also a bit concerned about what happens if I take testosterone because testosterone understandably has conjures up images

of all sorts of things from large muscles, you know, big mustaches, uh lots of, you know, other things. So, so how do you talk to women about this? um we we enjoy having these discussions and um and also acknowledging side effects, right? Like the most common side effect we see in women is acne, right? And and I I don't think I've ever gotten to the point where I've seen any of the really dramatic side effects. Um but I do tell women, I say, "Look, there's a decent chance if you were shaving your legs every 5

days, you're going to be shaving them every 3 days. That that's that's a chance. If you were kind of susceptible to acne growing up, you might get a little bit more of it and we'll have to back off. Um, how do you how do you talk about the risks of testosterone therapy? I love talking about this and I'm actually grateful for celebrities because just in the news in the past few weeks, Halib Berry says she's on testosterone. Kate Winslett says she's on testosterone therapy and I they look pretty amazing to me and they don't look

androgenized at all. And so I actually want to do this study. It's it's something my research team's working on is I think I have more patients who never start testosterone therapy because of the fear of side effects than actually stop testosterone therapy because of the side effects. That's my sort of observation in doing a lot of this. Now when we talk about side effects I tell them think about a horny teenager. They have these great libidos but they have some oily skin, acne, you know. Um but that's when you get really high with your doses.

We really don't see it clinically. Yes. Could you I tell them to put the I I I use FDA approved testosterone for men just at doses kind of onetenth the dose in a way. They rub it on their leg because if they do get hair on their leg, people are used to having hair on their leg and so they shave it, they wax it, they laser it, whatever it is that they do with hair with leg hair. Um I don't have that many patients stop for acne, oily skin. Um again, I think there's that fear

when you get really high in the dose. So I'm not a pellet promoter or user because you get super physiologic levels and I can't take it out if you get a pellet put in. And so if you have deepening voice or clitoromegaly or you know a hair issues these are the challenges with some of these super physiologic levels. But when we're using sort of um reasonably dosed uh level like um uh topicals, we really see magic happen. And and I can't tell you when we get estrogen and progesterone right for our patients, it is by

adding that third piece, that testosterone, because your ovary does three, it probably does more than three things, but at this point, estrogen, progesterone, and testosterone. When we add that testosterone piece, I it's wild. All the the patients come back and they say to me, "Wow, I feel like me again." It's wild, right? That's the piece. Wow, I didn't realize how badly I felt. Wow, that was the missing piece. I hear it over and over and over again. And I can't not want that for all women, right? I can't not want to give them that as

an option on the menu. Let's just finish the swing on on testosterone. Do you prefer then to rely on the topical version of which would be like an androgel type product um and just dose it at a much smaller dose. Yeah, that's typically how we do it and how our guidelines sort of look at it. So iswish, the International Society for the Study of Women's Sexual Health, fabulous organization. You can find any doctor to help you with menopause and sexual health by going to their website. They came out with a really lovely sort of how-to

practice guideline that they took from the global consensus. And they do recommend using sort of that FDA approved testosterone for men and using it at appropriately uh doses for females. So um I like Testum, which is sort of the 1% generic testosterone gel. I brought I'll show it to you. I brought it for you to to show you. It's a it's a fivemill tube of gel. Our male patients would use the whole tube of gel, rub it on their chest every day. I have very few men who do that by the way. They injections, orals,

those are much better. Um, and so I tell my patients, use a blob or 0.5 mls. So they can put it in a syringe if they want to and dose out that 5 mls. They take a blob, they rub it on their calf every day. Um, and so um, just don't use the whole tube should last you about a week or 10 days. That's kind of it's an ish, right? like it's it's not an exact precision science, but the patients can figure this out. It's not that challenging. And I I will say this and I

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

Oh my gosh, I initiated sex. Wow, that orgasm was easier to have." Right? It's these are the things that patients notice. I also get patients telling me their stress incontinence is slightly improved. Why? because the urethra has testosterone receptors in it. We know that for all genders. Um, and this these are the kinds of things my patients will report, but I think it I don't know. What do you think? I think it takes a while. H, it's an interesting question. Um, I I I mean, I definitely agree that that's true for some people. That said,

I've also seen people who within weeks report feeling better. Now the challenge here of course is the only way you could understand this is through blinding right we just don't know how significant the placebo effect is um and and therefore it's hard for me to to discount or know we do we do because we have studies on testosterone which show Oh sorry I mean within my observation I hear you um I want to ask you another question about nodesto so netesto for the listener is a nasal formulation it's an FDA approved formulation um we've In

theory, it seems like a great idea. In practice, it has not really panned out just based on its messiness. It's a it's a gel, a nasal gel. Um, we've had women use it vaginally, you know, nasally. Like, what's your experience been with it? So, it's gotten harder and harder to find uh these days. And so, I think similarly, we've been interested in it and people have played with it before. This idea, can you do, you know, one squirt into your Nobody likes to squirt things in their nose, it turns out. And so it's a challenge.

Now I also any of these topical testosterone formulations, a lot of them have alcohol in them. So I don't recommend putting them on your genitals directly. Um but I do think it needs to be studied for this. You know, it's it's challenging finding the formulation of testosterone that is low enough like from the male side because we have lots of formulations for men that is low enough to kind of give an appropriate dose. Why isn't a female formulation being made? Buckle up, buttercup. So here we go. We had a billion dollars that was put into

it. A billion dollars in a five-year study that was done at the FDA and it showed it was safe. It showed that it was effective. It showed that it was fine. It wasn't that Here's the the the TLDDR on testosterone is it's not that serious, right? We want it to be serious. Again, not a feeling. We want it to be like all about aggression. It's not a it's not a feeling. Like it truly isn't. Um and so they did five years of study. A billion dollars went into it and the FDA came back and they

said, "Oo, women have breast tissue, so we're going to need five more years of data and another billion dollar study and every company was like, I'm out." Right. The benchmark was different for women. Men, six months. And this was a real goalpost move. Yeah. They just keep moving the goalpost everywhere. They move the damn goalpost. Okay. I talked about the labeling on testosterone being removed that it doesn't worsen cardiovascular disease. Why? because they did the Traverse study that your listeners know about that proved it. The box labeling on estrogen products which says that estrogen causes

stroke, blood clots, heart attacks, probable dementia, like we just got done saying that that study didn't show that. So why is that box labeling still there? We're killing women by trying to protect them. Why do you think this is happening? If you if you if you try to steal man the case for the other side, where where are they in their thinking on this? I think medicine has a humility problem uh and a um a deeply ability to say, "Hey, we we didn't know what we didn't know back then. We're learning and we're adjusting." They

don't like to say, "I don't know." They don't like to say to evolve in their thinking. And for some reason, women's health comes with so much bias and it is the amount of money that goes into women's health research is like worse than it was 10 years ago, right? like like but is this a paternalistic I mean I hate to put sort of sociology on top of this but what like again when I I as you know I've spoken with one of the PIs from the WHI and I think she is by far the most

honest broker of that group and I don't have good things to say about that group. I really don't. Um but I also can't even wrap my head around their thinking. Like I can't steal man their case. I wake up in the morning, I'm like, how is this real life? Like, we met, okay, I'll give you an example. We met with the chief before the administration changed. We met with the um the I think it was the the chief medical officer of the FDA, we met with someone high up at the FDA. It was a room

full of permenopausal women. I was like, "Yeah, we got this. It's a room full of permenopausal women." And we presented our case about vaginal hormones, um, which is basically micro doing hormones, and they prevent UTI by more than half. when you use vaginal hormones, you treat the genital urinary s uh syndrome of menopause. And we said to them, we said, "Your labeling, this should not have the same labeling of all estrogen products. You should remove the labeling." And they said, "Well, we're really going to need industry to come at us to remove the labeling." I

said, "You didn't need industry to put the box on. Why do you need industry to remove the box?" But we no longer have industry in this field in any significant way because the WHI destroyed that industry. So we have a huge problem where you actually don't have any money to women's health. I think Fizer completely fired their women's health division saying yeah we're going to look at allergy now. Uh you have entire department we we did a study once on pelvic pain uh and we were looking at bachelinam toxin and pelvic pain and I was

on the call where they said we have a new CEO now and women's health is no longer a priority. Like I heard those words. So we do have a paternalistic problem. We It's true. And unfortunately, it's not getting any better. I usually do not subscribe to to theories like that. I usually find myself thinking there are alternative explanations and we're just pointing to the most sensational ones. But it gets hard to dismiss an argument as follows, right? which is if the tables were turned and the WHI was really the you know MHI right the men's

health initiative and it produced equally idiotic results would we be in the same place we are today or would men have said oh hell no to the traverse trial right there were two bad studies that were done horrible studies that made no sense that showed testosterone had some dangers so they the FDA threw that box labeling on said oh my gosh within minutes. They created the traverse trial. It got done in five years and within minutes when it was finished and it got published in the New England Journal of Medicine, the box was removed. And

by the way, the traverse trial is not even a great trial. Like I've been so critical of the traverse tile. Amen. Right. I I think you could have come to the same conclusion of the traverse tile if you knew how to read all of the data before it. I actually don't think the traverse trial added much. But anyway, that's the point. Totally. Because you could look at data. Oh, there was an increased fractures from the Oh, testosterone causes fractures. That makes no sense. We know that's not true. We know testosterone helps bone mineral density. And

so, you can make the same arguments of how you look at these studies, how these studies are designed, the flaws of them. You're going to do a study for 5 years. Why are you giving people gels? You know, is that the right thing? So, why are we looking why do we care what the people of the Women's Health Initiative said 20 years ago? Why is that even news, right? And why can't it die? And because you don't have enough people like you standing up, you don't have the internal medicine doctors standing up and saying this

is wrong because they're not teaching it, right? You don't have the OBGYn saying this is wrong because they're delivering babies and women are dying in childirth. Women's health, like menopause health in particular, is important to nobody, right? And when it's nobody's problem, nobody takes ownership of it. Yeah. I mean, I do believe this is going to change. And and I don't know who said this, but it's it's a it's a great quote that said uh funeral by funeral science makes progress. And so, you know, that's not a that's not a that's not a great explanation

for what's about to happen temporarily because, you know, it's going to be a while before everybody who held that belief, you know, in their in their in their soul is is no longer around. Um, but it it does give me hope that um a new generation of of women will come along and take ownership over their health. Um, and and and and look, I've seen a change in 10 years. I mean, 10 years ago when I was prescribing hormones to women, you c you cannot believe the fights I would have with their other doctors. And

I don't mean like, you know, we weren't fist fighting, but they were scolding me like, "How dare you?" you you know, and they but but but it came with an arrogance of a a lack of willingness to even look at the data now, which I found ironic, right? It's like, if if you want to scold me, you better know as much as me and hopefully more. But the this this this sort of arrogance of I'm going to scold you but I know nothing and I'm not actually willing to have a discussion with you because I'd

be like great let's let's turn to figure two in the JAMAMA paper and let's look at this and look at the appendix and look at the supplemental data like are you seeing the same thing I'm seeing? Can we at least agree on the facts? No, we can't. And it's so fascinating because I would never I would never tell my I do sexual medicine so I look at the whole patient. I look at everything and I would never say to them, "Hey, you're you have to stop this beta blocker right now because it's causing your erectile

dysfunction, right? I would never tell a patient that though the beta blocker may be worsening his erectile dysfunction, but I would never say stop this medicine. It's kill it's it's hurting you." Right? I would talk to their doctor. I would have a conversation. But there's something about hormones that doctors who know nothing feel very confident in saying, "You can't be on this. you must stop this without even having that curiosity of, huh, I wonder if the person who prescribed it actually knew what they were talking about. And it is it is everywhere, right? We see

this all the time. Now, let's talk about the flip side because the unfortunate nature of everything we've just described is you create a fringe movement. And unfortunately, I've seen a lot of dock on a box hormone practices that are, I believe, putting women at risk and I believe are doing bad things to women in the name of doing good. And I don't believe that these are inherently bad individuals. I think they are I think they're ill-informed. I think they're just not that bright. Um, and and maybe some of them are just actually charlatans and they're

seeing an enormous opportunity here. Um, as a general rule, I tell patients, be very, very suspicious of a doctor that is selling you hormones. Be incredibly suspicious of any physician who has their own compounding pharmacy within the practice and is giving you compounded formulations and also making money on it. talk a little bit about the I don't want to call it the dark side, but just kind of the fringe side of this world. So, I would argue that people care about their pain points. People want to feel better. People will go to anyone who tells

them, "Here's, you know, there's a whole supplement aisle at CVS that makes all these wild claims that we're going to help you with everything." And the reality is is I just got done saying your gynecologist and your internal medicine doctors are going to in that 10-minute visit tell you that you don't need this. This is not going to help you. And so enter the fringe people, the snake oil salesmen, the people who are doing um wildly inappropriate things. That doesn't mean the hormones themselves are bad. It just means we have a marketing problem here. If

we're not doing it and helping people, people are, you know, they hear their friend did it, they hear their their neighbor did it, and they said, "I want what she's having." Right? This is why we call ourselves the menopausi. This is why we teach so loudly is because we're trying to bring it back into medicine and evidence-based medicine and say you can actually do this quite reasonably. In fact, there are many FDA approved products that work, you know, much better, that are more regulated, that are totally safe. You know, here's what they are. they should

be covered by your insurance, you know, and giving them that knowledge because the problem is is when no one is speak right, it's too quiet. No one is giving people answers. No one's even looking at the questions. So then the fringe people take over and are unfortunately doing very inappropriate thing. You know what? We see this with men's health, too, right? As a urologist, we see shot clinics and all these wild PRP clinics and and and testosterone pellet clinics and compounded pellets and all of these things because my colleagues, we are not doing enough to

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

it right and that is true for hormones for everybody because they just talked about this the last menopause meeting less than 4% of women are on hormone therapy right now less than 4% that's worse than 4% of elig of women who would theoretically be require less than 4% that's worse That's worse than 10 years ago. That's worse than 10 years ago. It is so bad out there. I need So I I did the same calculations you did when I was on my Uber on the way over. I said, "How many women are over 40?" It

was something like 84 million according to AI, right? And I said, "Okay, how and there about 3,000 people on the Menopause Society website. That doesn't mean everybody knows what they're doing or that they all do the same thing, but divide 84 million by 3,000. It's a big number. And we can't see patient panels of 27,000 people. Like that does not the math doesn't math there. So we need people to step up and write the So who should be writing estrogen prescriptions? Who? Every doctor who sees a woman of that age. Every doctor who sees a

woman of that age. And so who actually does? Nobody. Let's talk a little bit about the playbook. I want to tell you how we do it. And um I don't I'm not saying we do it right because I don't think there's a right way to do it, but I mostly want to hear how you do it because I bet you're way better than than we are. [Music] Um maybe we take a step back and explain. We've already alluded to it twice, but I just want to make sure um people are understanding this. If a woman

has a uterus, you have to protect that endometrial lining. So, even if she's in the camp of women who don't notice being on progesterone, you have to be on progesterone. Um, we'll come back to IUDs and progesterone coded devices and things like that. Nel, let's just talk about the way you get progesterone. So, the progesterone is the easiest of the lot here, right? Um, is there any reason when giving oral progesterone to use anything other than micronized FDA approved progesterone orally? What's lovely is we need a toolbox because not everybody responds to the same thing.

I love micronized progesterone. I think it's a fabulous product. Um so yes, I think it's is my go-to first line. Sometimes we need to put it vaginally instead of orally to help with some of those sedating side effects. So um you can avoid sort of going to the brain if you put it vaginally. Um and so we do find that cuts down a bit. But you're going to start orally. I typically start orally. You're going to start at 100 milligrams depending on your dose of estrogen. Um, I typically start with a 100 milligrams. Some people

say if you're going higher with your estrogen, you may need to do 200 milligrams of progesterone. That data is not very clear. And so, and there's really two ways to give progesterone. You could do it every single day, right? So, typically 100 milligrams every day. And then some people, and a lot of data shows if you do it cycllically, like 200 milligrams, you know, 12 to 14 days out of the month is another way to do it. Both are fine. But uh when we see many patients right they they feel better doing it 100 every

day because it can help with sleep and anxiety reduction. And do we believe that a h 100red systemically is sufficient to oppose estrogen. I think that's the way um I think there is not enough data there and we need more. I think if patients bleed it's a nice tell that maybe they need more progesterone. I think there's some interesting that I've learned that some people say if you take it with fat or you take it with something to eat it absorbs better because m you know progesterone is not absorbed very well which is why we

always had synthetic progesterines you know in the first place and so we're still learning sort of the capabilities of micronized progesterone but according to most menopause specialists out there they typically will use 100 milligrams every day or 200 milligrams 12 to 14 days of the month. So the only thing that we do I would say different there is while we start women at 50 to 100 we will generally take them to 200 if tolerated and if not keep them where they are at 100. But we find women who are in that 1/3 to 1/ half

group who are very positively uh selected towards progesterone. They feel fantastic at 200. The most notable improvement is sleep. So would you agree with that? That's the thing that most women are just over the moon with how well they sleep. It is. It's so fun to get hair gets thicker. Um, and mood improves. And then of Now, so now let's talk about the other subset of women. Um, and this is a real subset. No question. Um, it's I would say in our population it's it's about 10 to 20% for whom if you bring progesterone in

the room, something goes wrong. Mhm. their mood really changes. Now, it can in some cases become depressive, but more commonly what they tell me is, and I'm quoting them, this is not me saying it, I become a raging And I'm worried I might kill my husband. So, for those women, we think progesterone is a bad idea. And we then use a progesterone coded IUD. So, are you doing that or are you using a suppository at that point? Yeah, you can do either, right? You can say, "Hey, try taking this vaginally and see if that goes

away, right? See if you're no longer feeling anger or bloated or, you know, have um irritability." Um, and so vaginally can be an option. We love uh perestin coded IUDs, right? They're great in pmenopause. Why? Cuz people think that you just kind of like lightly like dance into menopause. It is like bloody murder hell scene, right? Like it can be terrible. You can bleed the whole month. You can bleed heavy. You can bleed when you're least expecting it. So, the IUD is very nice because it will stop bleeding. And so, you throw an estrogen patch

on and some testosterone and that's your a really great pmenopause uh plan. Now, you can still take and you get birth control, which is very important, right? And so, um you can add micronized progesterone to the patient who gets good sleep even if they have an IUD. That doesn't add danger. We love that, right? So, we love IUDs for this population. There's another there's and then there's the synthetic progesterines which you can use as well. I've seen people do things like um slind which is a birth control a proesterin only birth control pill add a

patch and testosterone to that as well. Now again synthetic progesterines sometimes can have mood side effects as well. So they're not completely benign for all people. Um there's another uh uh I don't know if you've used this at all in your practice. Uh it's called duet. Have you heard of this? Yes. So, it's just a um it's an oral estrogen, but it also has what's called basodoxifene, which protects the uterus, but is not a progesterone based medicine. I wish they were separate. I wish we could just give basodoxifene alone, any pharmaceutical oral estrogen if you

don't have to. Now, it's again, oral estrogen is not evil. Um, you know, I'm a sex doctor and we know that to transermal is a little better for sexual function. So, that's again why I'm a big fan of trans dermal products as well. But that's kind of another option for progesterone. Uh people get uh hysterctomies for lots of reasons. We've had patients do that who really don't tolerate progesterone and then you can just use estrogen only. Are you referring women who are on what potentially might be a low dose of progesterone to their gyn for

endometrial ultrasounds on some regular interval just to look for hyperplasia or anything like that? So, we really don't like to look for things. Um, the nice thing about endometrial cancer, from what I understand, again, I'm putting my urology hat on. I am not a gynecologist, it bleeds. So, if you Now, if you bleed, um, then if you bleed and you just started a new hormone therapy, it's probably okay. Now, for me, I like to know if there's any structural things going on. Do you have a polip? Do you have a fibroid? Is your lining super

thick? You know, if you're in pmenopause, you still should be bleeding, right? So, it's that challenge. I don't go looking for things that aren't uh bleeding because I don't necessarily want to find things. Um and so so no, at this point there's not necessarily a reason for routine surveillance because if your lining is say 6 millime and you're not bleeding, um are you really going to put that woman through a biopsy and through a hysteroscopy and and those have significant you know pain and and problems that go with that as well? Anything else you want

to say about progesterone? I think we covered a lot of progesterone. No, I think Do you start it concominantly with the estrogen? Do you like to start one before the other? I like to start one before the other in general because I like to people to know what's doing what. Agree. This because you know when you just give when when someone comes to see you and says give it all to me. It's always a disaster every time. It's a one time it worked well for me but it's pretty much a disaster. So, I like to

stack it. So, as we can and again, you're not going to cause and endometrial cancer in in three months of using just estrogen. I mean, you're talking something that takes years and years and years to develop and even that data is not that clear-cut. So, I'm not worried about me causing a uterine cancer. Now, often, again, we'll start with the estrogen because I feel sometimes you'll start with progesterone if sleep is the major issue, but I find like the vasom motor symptoms are so um it's such a big deal to get rid of those. So,

I do like often starting with estrogen and then slowly adding in the other ones. Yep. That So, I'm I'm really happy to hear we're we're following your playbook already. So, yes, we almost always start with estradile. Um, and we muck around for a while till we get it right. And that's why I saved it for last, by the way, because it's the hardest in my opinion, in my experience, to get right. Then we fiddle with um progesterone and then testosterone if they're not already on it. But to your point, some women are coming into pmenopause

already on testosterone. Okay, let's talk about estradiol. [Music] Um, there are two other estrogens. Estradiol is E2, but there's estrone E1 and there's estriol E3. Now, the FDA only has a battery of approved products around the second estrogen, which is the dominant estrogen. There's no FDA approved product for estrone. Um, and there's no FDA approved product for estriol, but there are plenty of compounded uh, opportunities around that. In fact, the most common of them is referred to as biestrogen, which is an 8020 mix of estriol and estradiol. Um, what is your take on why that

product exists? Do you view that as a reaction to the WHI? I mean, how do you think about it? Yeah, I think as you said it right there, I think that what happened happened is the women's health initiative happened and hormone therapy all went into the to the alley. It went to the alley and I think one of the ways that these alley do back alley doctors did it was saying, "Oh, we're using the safer version. We're using this compound and we're going to make it 8020 and we're going to use the more safer option."

And by the way, I haven't seen that data. Uh, you know, and there is no data on biased in in large trials that's going to really tell me what it does. And so, and we're going to just use this. Um, and that's what got people through for a while. And I don't actually blame those people. If they had no alternative, right? If I were in the middle of the desert and I had the options and I was having horrible symptoms and I had the options of nothing or a biased cream, like I'd probably slather the

bias cream on me. But we don't have we're not in you know where we are now we have lots of options. We have FDA approved options and they're covered by insurance most of the time. So I tend I don't prescribe it because I haven't needed to. Now if I have a patient who comes into me and they're feeling great and they have no problems. Do I have to change them? Well I'll say well do you want to save some money? Like we could change you to a different formulation. That's an option. Sometimes I'll even check

if say they're having symptoms. We'll check their levels. And I don't know if you find this, but their estradile level is essentially zero. It's less than five. And I'm saying, listen, I think you're just using fancy lotion. I think you're paying a lot of money to put nice lotion on you. And I don't know that it's protecting your bones. And if we're using this to protect your bones or to stop your hot flashes or to help with your sexual health, maybe we use the formulations that are a little bit better studied and that, you know,

I know are absorbing in your body because I can prove it. So that's my What's your take on that? We don't use it at all. Um I have used it occasionally in the past, probably about 10 years ago. Um largely in women who were terrified of HRT. And to your point, it was viewed as look, if you buy the argument, and this is a biochemical argument. There's no there's no human data that that that demonstrate what I'm about to assert. But if you and and again I say this because one can look at a whole

bunch of biochemical charts and tables and talk themselves into anything being true. But there's there are biochemical arguments to be made that estrone and in particular one of the metabolites of estrone and I think it's four hydroxyestone is the the is the is the estrogen that is driving breast cancer. So in an estrogen sensitive breast cancer, given that you have so many estrogens, is it more likely that one is responsible than another? And and so the answer is, oh, you know, some of the data suggest it's for hydroxyestone. Well, estriol has no biochemical path to

even get there. In other words, the there there are no series of enzymes that can convert estriol into four hydroxyestone. And um of course there are uh pathways that will turn estriol weekly into estradiol. So maybe you get a little bit more. So anyway, all this is a long-winded way of saying, you know, no no no no reason at all from an evidence perspective to use it. Uh we don't use it, have not used it in a decade. Uh but that that was my halfbaked argument in certain situations. And in fact, I I did use

it once in a woman who um had breast cancer. Um was adamant that she needed hormones symptomatically. She really seemed to um wanted it very badly. And I felt that this was a reasonable compromise. For what it's worth, she got insanely better on the biest. So how much of that was from the estriol? How much of that was from the estradiol? I have no idea. When I teach this and I I do a lot of teaching of physicians holding their hands saying you can do this, you can write these prescriptions and one of the things

that I just keep coming back to is the sentence, what are you afraid of? Right? And I love that because when someone says, "Well, can I do it in this patient?" Well, what are you afraid of? Can I use this product? What are you afraid of? And it forces, I think, in menopause medicine, the reason we're all struggling is we're not yet at an algorithm or a playbook, as you say, that it's a one-sizefits-all. What's so sexy about this field is we actually have to use our brains. We have to use our brains. We have

to talk to people. We have to get to know what's bothering them. And we have to do the right tools for them, which may be different in each person. And so then it becomes you have to also understand what are your patients afraid of, right? Because that is the only thing that matters is what you're we take risks all the time. I took a risk taking a car to get here, right? We take risks. I if you ever drink alcohol, you are taking a risk, right? We all take these calculated risks and we all have

different calculations. And so I love to push people of well if you were to use this. So so patient comes in unbiased. Uh is that safe? Well, what are you afraid of? Am I afraid I'm going to hurt this patient? I don't think I'm going to hurt them necessarily, but I don't know what's in that compound. I don't know if the top of the bottle is the same as the bottom of the bottle. I don't know if it's good for her bones. I don't know if it's absorbing in the way that it should be. But

I do have studies on FDA approved estradiol, right? And and then it becomes what am I afraid of with the with the patients? Well, what are you afraid of about the estradile? You afraid of cancer? Because you know that in the Women's Health Initiative, people who used estrogen had a decreased risk of getting and dying from breast cancer. Our patients don't know this, right? Yeah. And you you mentioned this earlier. I think this is one of the biggest limitations of you know how I talk about this thing medicine 2.0 which is very few people are

conditioned to ask the question what is the risk of not acting. Uh you know we we we we have a reasonable idea of what is the risk of doing X what is the risk of doing Y although in this particular example we seem to get that you know patently wrong. But the what's the risk of not doing something is um is is very significant. So um let's talk about all of the different ways in which a woman can get estradiol through an approved tested chemically sound means. Yeah. So um a little bit of nomenclature here

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

treat the genital and urinary symptoms of menopause. And those are pretty much safe. No, I'm going to say it. They are safe for every human on earth including your 99year-old mother-in-law in the nursing home who is potentially could die of a urinary tract infection. So this is kind of the two separate areas. And I think the question you're asking me is let's talk about systemic. Let's start with systemic. I and we can let's come back to that as we talk about geno genital urinary because I got a lot to say about that one. So systemic

estrogen has a toolbox, right? We have patches, we have gels, we have rings, uh, which go vaginally, um, we have oral estradile, right? Um, we have, um, those are the big ones. There are injections. That's kind of an old school way that I kind of use sometimes, injections of estradile, valorate, or cipionate. Um, and so each one has pros and cons. Um, and it's nice to have the toolbox because not every uh product works for every patient. And the key is is getting it right for that patient because you need something that they're going to

do and that they're going to do it for a long time because these are not things that you just, you know, do for a weekend. Uh, let's start with the oral. So, we have an oral formulated estrogen. Um, we don't use it that much. I'm trying to think. used to use it a bit more than than we did now. Honestly, sometimes I would use it for women who were we were struggling to get the dose right on something else and I just needed something to get them through the weekend and it was like, "Okay, just

I want you to just take a milligram of of of this estradile tablet tonight while we readjust your cream or your patch or whatever." When are you using oral estradile? So, I don't use it much. Um, but that's not to say that it is there isn't useful. I think it is actually very useful and I think it's underused. Right? For example, people are used to taking birth control pills. They're used to taking pills. They like pills. Um, you doing for a a healthy person uh uh with no major risk factors of cardiovascular issues, taking an

oral estrogen really is not going to increase your risk of blood clots or heart attacks or anything like that at any significant worrisome level. It's no more increase in risk of blood clot than a birth control pill. Less. It's less. Yeah. So given the ubiquity with which women are on birth control pills, we're we tend to blow this out of proportion. Yeah. So what is your what is your advice to or what is your patient selection criteria on that? In other words, who are the women that you would say I don't want you on oral?

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

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

oral hormone product. Does that make is that helpful? Um, now I want to paint this because this is actually an area where I would love to see research. Uh I was speaking at a Harvard testosterone course with Abe Morgan Tyler uh and Moira who you've had on the show and and I was speaking about women's testosterone use and um the speaker who got up there um to talk about uh transgender hormone therapy talked about sublingual estrogen. He kept referring to sublingual estrogen. And I got up to the micro I ran to the microphone. I said,

"What are you talking about? I've never heard of sublingual estrogen. There's no product. Who what are you saying?" And he says, "Oh, you just take an oral estrogen tablet and you put it under your tongue like a tic-tac and you let it dissolve and it doesn't go through the liver and it works fabulously to increasing blood levels." And I said, "Oh my god, this is this sounds amazing." And it doesn't drive up SHBG presumably because it doesn't go through the liver, which actually if you think about it logically, I love logic here because we don't

have a lot of data, we love logic. I said, "Well, if you take an estrogen ring and put it in the v a high dose estrogen ring and you put it in the vagina, same thing. You absorb estrogen vaginally, so what's the difference there?" Right? A sublingual estradiile. So, I think it's fascinating. I don't have many patients on it, but I would love to see data sort of look in that direction because it's cheap. Oral estrogen is cheap. Uh you get lots of doses. You can dose it. You know, does that mean you can get

away with a lower dose? You can get away with a lower dose. Absolutely. You must, right? Because of that first pass effect. Mh. So how do you dose it then? So I again I don't have patients on this and I haven't seen any studies on this but I I think Could you ask this guy? Yeah, absolutely. What did he how does he dose? So I think they typically again transgender uh hormone therapy uses much higher doses. So my guess is one or two milligrams B is probably what they do. If I were playing with it,

I would probably be nervous and I'd probably do 0.5, you know, and I check levels and I do twice a day. Again, this is not what I do in my clinic, but just as we think through what are you afraid of, right? What are you afraid of with this? It's pretty fascinating stuff. Okay. Um, let's talk about the paniply of topical ways you can do this. Creams, patches, what are the challenges of using these things? How do they limit women's activity levels? I mean, I used to have this whole talk I would give women about

what I thought was the best way to maximize the absorption of the cream and what I wanted them to do before they put it on. And I wanted them to have a shower and I wanted them to exfoliate their inner thigh and I just had this whole like routine that was probably so elaborate that it it decreased compliance cuz like it's not that serious. It's not that it's not that serious Peter talk about it. No, but it is true, right? For men in testosterone like we a we often find the topicals do not some they

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

twice weekly patches are much better tolerated and my patients like them better. What's nice about patches is you have a wide variety of doses that you can play around with. Um, and so I always when I start patients on hormones, I typically choose like a medium to medium low version because if you go too high initially, they get breast tenderness and they get really annoyed with you and then you have to backtrack. So I always like kind of titrate up a little bit as we need to. So patches are nice, but for some people they

don't stick well. For some people they uh don't absorb well. For some people they feel that they kind of drop off. If you change it twice a week they feel like they're getting a little lower. We also notice women who use the sauna who are very very athletic and exercising like crazy. You just have an adherence physically an adherence problem. Yeah. And there are people who are allergic to the adhesives, right? We see that as well. So that's so some people are patch, you know, they love patches. Again, you have to have a menu. If

you're going to a doctor and they give you one type of hormone therapy and that's the only type, please run. Right? They need to know the menu because you are not a, you know, it's not a one-sizefits-all, right? So there's gels and there are number of different gels. There's gels like the brand name is Diva Gel goes on your thigh. There's Estrogel which goes on your arm. There's Eva Mist which is a spray sort of an aerosolized spray that goes on your arm. Um gels can be really nice because it's every day. Um so it's

dosing every day. Um the challenge is sometimes they take a little bit to dry. So if you're a busy person and you want to rub something on, you want to run out of there. Um uh I find gels um not everybody wants to do something every day. So again, it's you got to get to know the people of like what do you what do you what do you like to do? What's your routine? Um you have to get it into their routine. And sometimes you got to work up to it. And sometimes I have patients,

right? They'll they'll use patches. Uh but when the summertime hits and it's hot and muggy, they'll switch to the ring, right? Or they'll switch to a gel. Like they'll they'll kind of What's the case for not just using the ring all the time? So I love the ring. So, there's there's two types of ring. Now, this is important. Yeah, it's really important because your pharmacist sometimes messes this up. Uh, so there are two FDA approved rings. Now, a ring, just like a birth control ring, you set it and forget it. You put it in the

vagina, the vagina does not feel it like a tampon, you don't feel it, and it just stays in for 3 months at a time and it's sitting right up against the cervix. Yeah. It's not like a diaphragm where you have to place it or or a menstrual cup or anything like that. You just kind of push it in there and it just settles in and finds a place. By the way, if you have penetrative sex, most people don't take it out. They don't feel it. Like there, nobody's bothered by this thing. So, this ring goes

in there, stays in for about three months. Now, there is a fem ring, which is a high dose ring, which means if you have a uterus, you need progesterone to protect the uterus, and it comes in two doses, 0.05 and 0.1. Then there's an E-ring, which is a 2 mgram like localized estrogen ring. That is you do not need progesterone if you have a uterus because it's just treating the genital urinary syndrome of menopause. So it's not treating your hot flashes. It's not protecting your bones. It's not going to help your night sweats but it's

going to prevent UTI. It's important that you know the difference because the pharmacist sometimes won't and he'll give you the wrong ring which could be catastrophic if they think they have a systemic ring but they have a a local ring. So the ring is lovely and it's just dose is the only difference between the two, right? Yeah, they look a little different. But yes, the reason one is one is a high dose and one is a low dose, but it's you change them at the same frequency. Yeah, both three months. Okay. I thought you changed

the east ring more more frequently, but good to know. Both three months. Now, there's a company right now studying a product um and I'm no I'm not at all affiliated, but it is a one-mon ring that has both estrogen and progesterone in it, which is very interesting, and I'm curious to see where the research goes with that. It's a one-mon ring. So, so the issue with the ring, I love the ring. Now there are women who you you show them and they're like I am not putting anything in my v like no I don't want

that. There are women who've used rings for birth control. They love the idea. I will tell you and we've been hoping to publish on this clinically. Again I don't know about you but my patients don't listen to the book. They don't read the book and they don't follow the FDA curves but my patients it peters out like it literally stops working that last month. Everyone's a little different but I have patients where that last month they are dragging their hot flashes. Why not just swap it every 2 months? So, it's expensive. So, a lot of

times insurance doesn't cover the ring. It's about $180 cash price when you use an online pharmacy called Transition. And so, um, it's expensive. Sometimes they'll slap a patch on or a gel at the time to sort of overlap. So, they'll change it early or they'll add a different therapy or they'll stop using the ring altogether. It is like perfect for like two months and then it kind of and and we'll check levels again. There's the book answer, the Instagram answer, and the Dr. Rubin answer. Um, this is where checking levels is actually helpful. I would

love to to, you know, I'm sure there are a couple of my patients that would actually volunteer to do this where we just do twice a week levels for 3 months while they're on a product, while they're on a ring and just watch the It's incredible, right? Cuz you will see it, you'll check it, you'll have a 0.1 ring in and you should expect estrogen levels of 60, 70, something like that. And you'll see an estrogen level of like 13 and you'll be like, "Oh my god, this is not working." Right? and they'll complain of

hot flashes, night sweats, you know, sort of their symptoms will come back. And so we see a lot of ring issues with sort of dosing for that purpose. And then another problem is if you have any kind of prolapse. So as you as people have babies, every things can kind of prolapse and so uh people can the ring can fall out during bowel movements, other things like that if there's not enough uh space in there. So I had a a an ultramarathon r that can get expensive. It gets expensive. So I had this ultramar this

is this is where checking levels is beautiful. marathon runner comes to me, you know, she loves her ring. She's doing great. She messages me, "Oh my god, I I feel awful. Something's not right. I'm just like, I don't feel like myself again." I said, "Oh, you know, where are you in your ring? You know, where are you in the cycle of your ring?" We talk about it. I said, "Let's just check a level. See what's happening." "Sure, estrogen was undetectable." I said, "Okay, we need to change this ring." And she messaged me, "I can't find

it. She can't find the ring. It's not there." She probably had a a bowel movement, didn't it? Fell out. She didn't notice. and then her her sort of levels dropped. So, it's where that detective work kind of helps you kind of figure out what's going on with your patient. So, the ring is not perfect for everybody, but I love the ring. You know, if you're in pmenopause and you have an IUD, a ring, you put a little testosterone, you know, every morning, you know, it's amaz like it's really a set it and forget it sort

of. You get vaginal estrogen, systemic estrogen, you get your progesterine from the IUD, you add a little topical testosterone, low, very low maintenance and maintenance solution. Yeah. And not that expensive like you can do it relatively inexpensively. Two things I want to talk about on the lab front. We've talked a lot about labs. Um, so not sure if you share our our view on this. We are really fistidious about using LCMS for estradile. We do not want to use the Eliza based assays at all. Are you pretty meticulous about that or do you find that

you're just happy checking any estradile? I typically get the sensitive estradile level. Yeah, that's what we give for everybody and same with the the testosterone as well. So, so let's maybe make that a PSA for people both physicians who are out there and patients. We have seen that if you do not use the uh the LCMS assay right which is the very sensitive the liquid chromatography assays the results can be meaningless and I mean truly meaningless and the reason is that the ELISA based assays are so susceptible to interference from other molecules and um there

are some really known obvious supplements that completely obscure the findings. So, biotin which is in a lot of things will I mean render uh a nonLCMS test uh irrelevant. Um but I think there are other things that we're just not fully aware of. So, you know, it is worth splurging and paying the extra maybe it's5 or $10. It would be the cash price difference on that test. But absolutely make sure when testosterone and estradiol are being measured, if you're the physician, you actually have to go through the hoops and make sure you're ordering the LCMS

test. And if you're a patient, you should be asking for it. So, we're going to get a lot of hate. Uh just so you know, we get a lot of hat there's a lot of um there's a lot of disagreements uh when it comes to hormone therapy, how to properly do hormone therapy, how to check for hormone therapy. one of the places and it's funny because I truly believe and for anyone who's going to say mean things about me on the internet from this podcast I truly believe that actually most of us agree on like

98% of this like truly we want women feeling better many of most of us believe the data that hormones the benefits outweigh the risk um and so I think 98% we agree there's the 2% where there is uh disagreement and part of it is also in the what we don't know yet right like the the unknown and the curiosity and sort things and lab testing is one of those issues. The book says never check labs. If your doctor checks labs, they are really doing something wrong. You should only care about symptoms. And then you have

sort of the fringe that are doing all saliva based testing every minute. Check labs. Do you know all these expensive labs which I do not agree with. Again, the Instagram answer, the book answer, the Dr. Rubin answer of sort of there are reasons to check labs and I do find labs um similar to you. My curiosity with labs is so fascinating when you can capture this permenopausal fluctuations and show the patient the reason you feel so terrible is because your estrogen was a thousand and now it's zero and that hurts. Now do I need numbers

to to to to know that that's what's happening. It actually helps patients quite a lot for them to look at this and see the data. Um what is your take on that? because it is a very controversial I'm actually surprised but this is you have to understand I don't spend any time paying attention to the buffoons in the periphery on this topic so I you know I I don't like the term even I I don't I don't like the whole terminology around functional medicine I don't buy into the idea that you need to be spending

an inordinate amount of money on esoteric nonvalidated labs um Again, I I think you can you can go to LabCore, you can go to Quest, you can go like any clea approved lab that knows how to do an assay correctly is all you need. Um, our view and what we tell patients is the symptoms are the most important things, but the numbers help direct my thinking. This is how we manage thyroid. this is how we manage sex hormones, you know, and and and to be clear like there's again I you you know there's a caricature

of the Dunning Krueger curve that I just find so helpful, right? So for the folks who aren't familiar on the X-axis you have experience, right? And on the y ais you have confidence. And in the in the sort of character version of the representation of this curve, you initially have a huge spike which then falls into a valley and then a slow rise. And of course the huge spike is referred to as the peak of Mount Stupid followed by the valley of despair and the slope of enlightenment. And it's just important for people to understand

that when you are on Instagram and YouTube, disproportionately you are seeing people at the peak of Mount Stupid, which is to say they have very low experience, insanely high confidence. And these are the ones that are telling you that TSH, I'm making this up as one example, TSH must be between 0.4 and 1.9. And if it is any bit above 1.9, you have hypothyroidism and you need to be on armor thyroid or naturid or whatever. And and and it's sort of like no, none of that is correct. Okay? And you just have to take care

of enough patients for enough years to get humbled enough to know that whatever you think you know with rigidity is probably wrong. You've seen all my gray hair that I've grown. It's true, right? And and I find you know what's so again that humility of medicine is I have made a c I am famous and my patients love me because I spend a lot of my day saying we don't actually know this is a datafree zone. Here's what I think. Here's how we're going to use logic. Here's the tools in our toolbox. But there is

that ability to really know the data so well to truly understand there's a lot we need to figure out. And that's why I have a research group and that's why we're trying to answer these questions because we have more questions than we have answers. Um, but I also need to get my patients feeling as good as possible. And that is it's addicting to be honest. Yeah. So here's what we do. We we we focus relentlessly on the symptoms and we care what the estradile level is. We also think the FSH is a very helpful marker.

So if a if a woman's FSH is 78 and her estradiol is 40, I'm inclined to believe she needs more estrogen, especially if she's saying I think I feel a bit better. I'm just not sure. Like to me that says I'm going to go more. And by the way, with the labs being where they are, I'm more inclined to push a little bit. But again, nothing tells me I've given her too much estrogen more than her saying her breasts hurt. like and that's the advantage of doing it with these short-term estrogens because I can pull

it back really quickly. So, I don't know if that answers your question, but I I would consider myself an essentialist on labs, kind of a minimalist essentialist, uh but but neither not an absolutist in either direction. And I love that. And I think it's so re it's such a reasonable and logical like the logic there. It makes so much sense to me. So, we're totally in line with that. Um, and that's why again it's very confusing for our patients on social media because they want the exact answer, right? And you're not going to find your

exact answer from one doctor on social media, right? Oh my gosh, you said that I have to use an estrogen gel, but I use a patch. Should I switch to a gel? And it's not, again, it's not that serious. There is a menu if it's working for you and you feel like you're getting what you need. Um, now it's good to get educated and learn about all the different options so that you can see what's right for you, but I think expecting that one doctor gives you all the answers is not going to happen. So,

anything else you want to say about systemic therapy before we go and talk about local therapy in the context of genital urinary symptoms of menopause? Yeah, I think we haven't spent a lot of time really talking about the symptoms of menopause, right? What are we treating? Why do people have why do people need systemic therapy? And I think, you know, I'm often saying that menopause has the worst PR campaign in the history of the universe. Why? Because we think it's for old people and we think it's just hot flashes. And we think hot flashes go

away. There's actually not enough education. Like we can argue about E1, E2, and E3. But the reality is doctors don't even know the symptoms of menopause. Patients don't even know the symptoms of menopause. Right? The person who was doing my makeup this morning, she's like, I just feel awful. I feel like an old person. I'm not sleeping. I'm not fun anymore. I can't drink. I can't, you know, my joints are achy. And I said, "Welcome to you need hormone therapy, right?" Like, I'm always teaching no matter who I'm, whether it's a cab driver, a hair

stylist, I'm always teaching. But this idea of of of you have hormone receptors throughout your whole body. It is a whole body experience. So, yes, there's hot flashes and night sweats. And by the way, hot flashes are not just a nuisance. that is a neurologic vasculogenic probably event, right? The the worse your hot flash is, the worse your risk of cardiovascular issues and things like that. Um, joint pain is a huge one. I never thought as a urologist I would treat so much joint pain. Uh, never in a million years did I think I cared

about joint pain and yet patients come in all the time and say, "Oh my god, I don't get out of bed feeling old. I don't feel creaky. Um, my joints recover again after I exercise." And again, empty gas tank inflammation. when you uh I think hormones are um nature's uh joint fluid if you will. So so almost like brake fluid, right? Go back to the car analogy. I love we are going to milk the heck out of this. I love it. Right. So So it's really cool. So your eyes need lubrication, your ears need wax,

your vagina needs lubrication, your joints actually need lubrication. And so think of horny teenager, you've got oils, oily skin. So So hormones create these oils, vaginal lubrication, oil for your skin. There are androgen receptors in your eyeballs, right? In these myobbian glands. So, so I think of hormones like fluid. So, as you lose the hormones or the hormones go too high or too low, it dries everything out. And so, you get joint pain, you get frozen shoulder, you get planter fasciitis, and now it was recently published on by our my colleague Vonda Wright, the muscularkeeletal

syndrome of menopause. Right? This idea that so many women in their 40s and 50s everything starts to break down. It's because the gas tank is empty and that inflammation increases. It's such a simple an it's such a simple analogy. So what are the symptoms? You've get muscularkeletal symptoms, sleep issues, mood issues, um uh bleeding changes, um obviously low libido, orgasm problems, arousal problems, pain with sex increases like crazy. Um I sent you a list here. What am I missing? You've got a you've got a list there. Uh irritability, very common one. Um I think the

one that I was going to ask you about is brain fog and depression. Um this is one where I think this is a I think this is a very unique one because it's one that gets easily dismissed as something unrelated. Say say more about those. It's it's one of the most common symptoms and all women start going to doctors in their 40s. like like doctors, you're I know you're listening and you get so many people and every day you say, "Oh, it's probably hormonal." But you're not giving them the solution. You're just telling them it's

not cancer. So the neurologists are seeing all these patients to rule out um you know a cognitive decline or all these other issues, but really it's that brain fog because your brain is filled with estrogen receptors. I This is crazy research. Okay, I don't know if you've had Lisa Mossone on, but here's this researcher from Cornell, neuroscience researcher, who says, "Hey, I want to study Alzheimer's. I want to do this. This is just in the last couple years." And she goes to her lab manager and says, "Okay, what's the assay for estradiol in the brain?

I need to look at estradiol receptors in the brain." And the people at Cornell was like, "That doesn't exist." She's like, "What do you mean that doesn't exist?" She's like, "How can we not look at estrogen receptors in the brain?" So she gets um Maria Shrivever to give her a giant amount of money who gives her a huge amount of money. So she now develops this assay. This is only within the last couple of years. She just published in nature very early findings that what would you expect? Right? Your body is efficient. It's not going

to do things it doesn't need to do. So the hypothesis was that as menopause gets later and later the estrogen receptors in your brain are going to downregulate. Why have receptors around when there's no estrogen to feed the brain? What did she find? the exact opposite, right? That actually even up to 65. She stopped looking past 65 cuz she's like, "There's no way that's going to matter, the increase in receptor density the older you get and it correlates to brain fog and irritability, you know, sort of correlates to all these symptoms." My reading of that

was estrogen is so important in the brain that it has to upregulate the receptors as the estrogen level goes down and down and down. In other words, it's a lot like the way the brain is treated for glucose. The body will if you if you are fasting, the muscles will within days become completely insulin resistant. It's their way of saying every molecule of glucose that that liver spits out better not go into the muscle. It better go to the brain. And so you look like you have diabetes in an effort to save glucose for the

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

they're empty. It is. This is why we see ADHD pop up in pmenopause. All these women are saying, "I have now new diagnosed ADHD. It's real." Why? Because your brain is is having a panic attack because it's just trying to figure out some stability here. Which is why actually in empty gas tanks, so in menopause when you are totally empty, the brain fog gets better, right? Because there's still the volatility of hormone volatile anymore. But if we just all I'm saying is just add some estrogen, right? to just keep the receptors happy. The other one

that we didn't talk about was the urinary symptoms. So both urinary incontinents and then the higher prevalence of UTI. You've alluded to it a little bit, but just maybe finish the swing on that. Okay. So this is my favorite topic in the history of topics. Uh because we used to call this problem initially it was called scenile vagina. That was the initial uh yes there was a papers written on the scenile vagina. Then it got up to I don't even understand what that means. an old vagina I suppose but the then it got changed to

vulvo vaginal atrophy or atrophic vaginitis that was the terminology that was used up until 24 before that it was seen vagina totally missed that check the history books very fascinating so vulvaginal atrophy was sort of the common name of this of okay as you get older the vagina atrophies it shrivels up it shrinks up you know again if a penis shriveled up at age 52 we'd probably have a vaccine sponsored by fizer right this is this is they created Viagra, they would create this this vaccine. No one even tells. I love that analogy. So, you're

saying if by the time a man became 50, his penis became a shriveled up useless organ. You you you you're saying that the medical system would have probably done something about this. What do you think? Right. Like, tell me what you think. You might be on to something, Rachel. I I I I know what I'm talking about. So, this is Right. So, so, so this is the thing we just told, we just called it Volvo vaginal atrophy and we said, "Well, if you have pain with sex or a little vaginal dryness, here's some moisturizers. Here's

some lubricants. Here you go. If you're really bothered, really bothered, you got to be really bothered." Then there's this thing called vaginal estrogen that we could give you. Now, here's the crazy part of this is it's not just a little vaginal dryness. The vagina and the bladder need hormones, right? Babies don't have hormones and that's why you see it's red, it's irritated, they're these small little labia manora. Diaper cream was invented, right, to because it looks so painful. Then hormones, they pee their diapers all the time. The genitals morph and change with hormones, right? Puberty

happens and you have a change of the genital and urinary system. And um and so what happens is as you lose hormones, it goes in reverse. And so it changes the microbiome. uh the the hormones keep the tissue acidic. It grows the healthy lactobacilli. It is uh the vagina is supposed to be acidic. It's supposed to be able to fight infection. And without proper hormones, you lose that ability to fight infection. So you see urinary frequency, urinary urgency, vaginal dryness, increase in leakage, increase in urgent continents, and recurrent urinary tract infections which can and do

kill people. Okay, we've known this since the '9s in the New England Journal of Medicine. Actually, this was on estriol. They looked you could reduce the risk of urinary tract infections by well over 50%. We have known this all along and yet and that was with topical estriol. Yeah. Interesting. Yeah. I was not aware of that. And yet there is no FDA approved estriol formulation despite that fact. Yeah. Correct. I think it's available in Europe. Um so we so the name got changed in 2014. Okay. 2014, a bunch of people got in a room and

they said, "You know what? This bulb vaginal atrophy thing, that's kind of a bad name because it doesn't describe what's really happening to people." So, they changed the name to Genito urinary syndrome of menopause, GSM. Now, there was one urologist, my mentor, was in the room and they almost didn't put the word urinary in it. And he fought and he yelled and he screamed, "This is the power of one person to be able to change the whole world." And they said, "Okay, we'll listen to you. We'll put the word urinary in it." And I'm so

glad they did because the urinary problems are the things that kill people, right? People are dying of urinary tract infection. In fact, a large amount of money goes to Medicare expenditures when it comes to urinary tract infections. And we published last year that if Medicare patients used vaginal estrogen, which is safe for everybody, and $13 a tube, we would save Medicare between 6 and 22 billion dollar a year. Billions. Just say that again please because I know there are people that are in the Medicare system who are going to be interested to understand that. Okay.

So when you when you do a lowd dose local vaginal estrogen or DHEA product you can reduce your risk of urinary tract infections by more than half. They are safe to use if you've had a history of blood clots, breast cancer, whatever medical problem you can come at me. I can tell you that it's safe. Okay. It will not only help with lubrication, help with pain with sex, uh uh help with urinary frequency, urgency, leakage, but it will reduce your risk of urinary tract infections by more than half. It's also inexpensive and covered by your

insurance. If everybody in Medicare eligibility used vaginal estrogen, we would save Medicare between 6 and 22 billion dollar a year. And in my opinion, that is a conservative estimate because of how many patients are getting urinary tract infections. They're going to their doctor for cultures. They're in the ICU with sepsis. Um, this is a huge economic morbid and mortality problem that we are dealing with and no one cares. I mean, again, I always try to come up with the steel man and say, is it that they don't care or is it that they're unaware or

is it that they feel that it just needs to fall on the shoulders of somebody other than themselves? So, I think we have a marketing problem. I I truly believe this is a marketing problem because let me tell you, but how Okay, let me push back. Not because I don't agree with you, but I'm just gonna put put my my hat on that says the opposite, right? So maybe I am too attuned to this, but I feel like there is nothing more talked about right now. I mean, look at what Halib Berry is doing. Look

what Oprah is doing. Look what Gwennneth is doing. I mean, there are so many very powerful, very influential women that are talking about this. Why is is this not in the zeitgeist right now? It's getting better, but again, they don't know how to write the prescriptions. Okay. So, let me tell you, you're saying there's not enough physicians talking about this that if it really comes down to prescript it's not over the counter. If you can't get the prescription or if you don't go to your doctor saying that you need it. Uh we had an Instagram

reel just yesterday that the patient said, "I sent my my friend went to her doctor, said she was having pain with sex, asked for vaginal estrogen, and her gynecologist said, and I quote, "You need to think of other ways uh to to change your relationship from now on. It's not in the cards for you. What does that mean?" Meaning you can't have sex anymore, right? And the fact is, it's not about sex. It's about urinary tract infections. Wait a minute. Wait a minute. This is impossible for me to fathom. A woman went to her gynecologist

and said, "I'm having pain with intercourse." Yeah. This woman, any idea how old this woman is? In her 60s. Okay. And the gynecologist said, "Didn't didn't didn't you think this gynecologist doesn't know about estrogen?" Honestly, I don't know anymore. It's incredible. Right. So, so, okay. So, we could argue Viagra 1998, Viagra comes out. Viagra changed the world. Billions of dollars. What is Viagra? It is a PD5 inhibitor. It relaxes smooth muscles of the penis, increased blood flow, gives you a rigid erection. So, it helps with arousal for men. Okay? If you take it micro dose,

low doses, it can also help with BPH or urinary problems. Right? We love Viagra. We love Seialis. Wish it was in the water. We should study it in women. Um, this is the problem though because I did in medical school. Oh, I'm going to talk about that. But, but I will argue we have had Viagra for women long before we've had Viagra for men. And we've known about it since the 1970s. And Viagra for women is vaginal hormones. What do vaginal hormones do? They relax the tissue. They increase arousal. They increase lubrication. They increase orgasm.

They help with urinary symptoms. So they do everything Viagra does. And they prevent urinary tract infections. Viagra doesn't do that. So you're talking about better than Viagra. It's inexpensive. Now it didn't used to be. So when I got out of my training, a tube of Estrace was $500. now because of people like Mark Cuban and Good RX and I've I've talked to Mark Cuban on my DMs and Twitter and he knows more about vaginal estrogen than 90% of doctors. But this idea of of it's not expensive. A tube of estrogen is $13, right? And you're

saying that the reason that this price has come down is I I know Mark is a very hardliner against the PBMs. Did Did Mark basically take a sledgehammer to that? Yeah. Yeah. They changed they changed the game. And so it's incredible. Oh my gosh. It's incredible. And he understands this. He he literally understands the nuances of why vaginal estrogen is so important. I can't get doctors to do that. I think he's he's incredible. And so so so we have a marketing problem. We have a product that is better than Viagra for women. It's been around

longer than Viagra. It's inexpensive. It's inexpensive. What are we missing? What? It's marketing. We're not telling the patients. We're not telling the doctors. And we have a box labeling that says this product causes stroke, heart attacks, blood clots, probable dementia, breast cancer, and needs to be taken with progesterone. Not one of those statements is true. Not one. Okay. So, we went to the FDA and says, "You got to remove the box. This is not you're you're killing people." And the FDA said, "Nah, we're going to leave the box on. This is a nightmare." Right? So,

so can I can I just tell a very personal story? I promise it won't take long. So, I was just spent, my mother just died in November. We spent six months in the ICU in Houston, Texas. Six months. My mother, nobody would should be in an ICU for six months. It was absolutely gut-wrenching, horrible time for me. My mother had been on vaginal estrogen because, you know, of course, I'm going to want her to prevent UTI uh for many, many years. You know, she's a 70-year-old woman, many years. So, she gets into the hospital, has

a transplant, has a catheter, uh uh and isn't doing well, is on ECMO, and very sick for a very long time. And I said to the doctors, I said, "I know this isn't the most important thing in the world, but I'd like to restart her vaginal hormones because having a catheter, being in an ICU, and being immuno compromised, my mother's risks of a urinary tract infection are incred incredibly high. And a urinary tract infection is going to kill this woman. So, I would like to restart her vaginal estrogen." And because menopause medicine is a tiny

little field in a tiny little corner, they looked at me like I was an insane person. They said, "What do you mean? you can't this is this is like your mother's very sick right now. I said I know my mother's very sick right now and this is one thing I can control. I sort of did a do you know who I am because I'm on the guidelines committee for GSM for the American Neurologic Association. So for the transplant team I had to write up a whole I wrote up a whole SBAR of like here's why

it's important. Here's the research. Here's all the literature. Here's the citations. And they said but but it'll increase her risk of blood clots. I said no it won't. Vaginal hormones don't increase your risk of blood clots. you're talking to my it's like a hydrocortisone cream but compared to a solumedrol right those were very different things so then they went to the ICU team they said no we can't give this to her to increase her risk of blood clots had to convince them then the pharmacy they finally got them to write the prescription I had to

teach them how to write the prescription pharmacy wouldn't dispense it why it increases the risk of blood clots it says so right on the box so I had to call and yell right I'm trying to run a practice in Washington DC my brother and father are trying to advocate with me because they know that this This is they also follow me on social media. They know this is important. Finally, the pharmacy dispenses the tube of estrays. There's no applicator. The nurses don't know how to give it. I had to show them and teach them how

to give my mother who was on ECMO and you know ultimately passed not from a UTI, thank goodness, but but had to show them how to dispense. I had to do all this being one of the leading educators on this topic. What does everybody else do? And guess what? The teams changed every week. We had to do this every week and to teach them why this was important and how to do this. Vaginal hormones should not be gynecology. It should not be a small subset of menopause medicine. We could save Medicare between 6 and 22

billion dollars a year. If people understood this, if the box labeling weren't on there, I mean, I I I it is so personal at this point and yet it is it is it's it's a it's horrible. Well, I'm I'm very sorry to hear that that story both at the personal level, but also at the at the the sort of meta level of of what is implied. Um, I want to clarify one thing, Rachel. Um, if a woman is on a high enough systemic dose of estradiol, does she also need later in life local estrogen? Maybe

even not later in life. So, we find that systemic hormones are not often enough to help with the genital and urinary symptoms. And most doctors don't know this. And you're not, again, what are you afraid of? You're not adding any systemic risk. It doesn't increase if your estrogen level 70 on your patch and you add a vaginal estrogen, her estrogen level is going to stay 70. You're not going to get that systemic absorption, but you are going to reduce your UTI rate significantly. Has that study been done? Um, it it's a great question. um super

interesting study. It's a very much expert opinion and and and when the guidelines come out in the next couple weeks or actually when this think of how think of how easy it would be to do a study where you took a a group of women that were all at systemic target of estradiol and you randomize them to a placebo vaginal cream versus an estradile vaginal cream. You could follow these women for a year if they were in a susceptible enough population and you would get a very clear answer as to whether or not you're getting

additional UTI protection. And if the answer to that is yes, just imagine the implications there. At that point, it becomes malpractice. You're definitely and and you are you're getting more UT. We know and we just published a study that DHEA does the same thing. It reduces the risk of UTI by more than half. Why is DHEA doing it? So DHA is a fascinating uh so they've looked at a lot of oral you probably know this data better than I do oral DHEA the data is all over the place right because your adrenals are pumping out

a lot of DHEA so but when you put DHEA vaginally it is this the idea is that your vaginal enzymes convert it into both estrogen and androgens and what's so fascinating is we know that the vagina the vulvarvestibule the clitoris the bladder have androgen receptors so us using just estrogen in this tissue may be missing the whole point. We probably we do have patients that benefit from having an androgen in the tissue as well. And the only FDA approved product we have is um intraosa which is vaginal dha. Now it's often hard to get for

patients. Um if I could get it for everybody I I would. It's fabulous because the tissue needs it needs androgens. Um so it's it's um the data is very good. It's just we've just started using it so I don't have a lot of experience with it. It's gonna change. So there is some data, not a lot, but there's data that shows someone with urgency um you give them vaginal estrogen, switch them to DHEA, it'll it'll help those people who still have urgency. Do you think it gives you the same UTI protection? We we published on

this. So we just published in the menopause journal that it it shows the same decreased risk of UTI by more than half. So that was a very proud publication that we just put out. Um and so um we use it frequently. What's nice about the product, it's a nightly product. It's DHEA and palm oil. So, it's very moisturizing, very lubricating. And my mentor Owen Goldstein published that actually it also helps the tissue called the vulvarvestibule. Do you know what the vulvar vestibule is? Well, I know what the vulva is and I know what a vestibule

is, but I I don't think I know what the vulvar vestibule is. It's okay. So, I'm obsessed with homalologues. Homologues are sort of this idea of how one part, you know, I'll give you an example. The penis and the clitoris are exactly the same thing. Yes. Sorry. No, that's right. They're homologues of each other, right? The head of the penis and the head of the clitoris homalologues. The um urethra, right? They're so so it's what part of the body in one is the same in the other. So the homalologue, okay, of of the labia, sorry,

of the scrotal skin is the labia majora. Okay, you're with me. the prepuse or the hood, right? They every every the clitoris and the penis both have a prepuse or a hood to it. Um the So, okay. So, there's a line that goes down a penis that goes down the the penis and the scrotum. Do you remember what that's called? Median raf. Uh yeah, you got it. Rafé. Yeah. Okay. So, the median rafé is the line that goes down the penis and the scrotum. Straight line right in the middle. What's the homalue in the vulva?

I just learned this. Oh, well, it must be the vestibial. No. No, I don't know. Close. labia manora. Okay, so it's skin. It's ectoerm, right? So it is skin, right? And we're split open. So if you take the median rafé and you split it, right? That's your labia manora, which very hormone sensitive. I'm I'm I'm I am very po I'm not on Tik Tok, but I am trending on Tik Tok because I talk about the labia manura shrinking and disappearing in menopause and the internet has broken because of it. Um so the labia minor is

very hormone sensitive tissue that we do not study and we know almost nothing about but it resorbs in menopause inside the labia minor. So if we cut into the median rafé in a man and we do this when we put in penal implants or we do urethral surgeries we get to the male urethra. So Peter your outside of your cheek is skin right the inside of your cheek is different tissue right do you agree? One's more sensitive one's thicker. So the um the skin of the of the median rafé is very different than the skin

of the tube of your urethra. You agree? For sure. So if you split open the labia minora, you get to the urethra and that is the vulvar vestibule. So the tissue that surrounds the urethra in a woman that goes all the way around and I will show you nerdy anatomical diagrams when we're done here because I need you to know this. That is the female urethra. It's called the vulvarvestibule. It is made up of endoderm. So we think of the cervix as a transition point. But the most important transition point that affects sexual health in

a woman is when you go from ectoerm of the labia minora to endoderm of the vulvar vestibule and then past the himman is misoderm. Okay. It's fascinating anatomy. Why is this important? Super compressed. It's super but it's so important because if you push with a Q-tip on the labium minora they'll have no pain. If you push them on their vulvar vestibule, they'll say that's my UTI. That's my interstatial cyitis. That's the pain that I have with sex. It is rich in hormone receptors. It is. So, this is why 50% of women go off their endocrine

therapy for breast cancer because they have urinary symptoms, pelvic pain symptoms, and it is all sourced in a body part that no one taught you in medical school. And I I did that on purpose because I knew you wouldn't know it because no one is taught how to examine it. they put a speculum in and they bypass it completely and they are missing the problem. So my uh back to the DHEA this tissue is has estrogen and testosterone receptors in it. So sometimes estrogen is not enough to help this vulvar vestibule tissue and so DHEA

there's some data there's one paper to suggest that DHEA is enough and this is the one time that I will compound a product for a woman otherwise I use FDA approved products in my practice and I compound basically the amount of estrogen and estrogen top vaginal topical cream the 0.01% 01% and I will use a topical testosterone.1% different than the 1% we talked about for libido but a 0.1% they rub it topically on this vulvarvestibule you cure pain with sex you help these UTI symptoms interstitial cyitis goes away in so many patients it's miraculous sorry

tell me again.1% tea and what was the percent 001% estradiol and we typically use like a a versa basease or a methyl cellul in that no but I would love to see that studied, right? I would love to see And what's the base? Um, it can be usually a methyl cellulose or a versa basease. There's a base called Elage that a lot of people are using right now. Again, I am not a compounding junkie in any way. This is a miraculous compound that gives like literally will if you have a patient who's on vaginal estrogen,

systemic estrogen, systemic testosterone, they say, "Peter, I still have pain with sex. It still kind of hurts." It's always the vestibule and the pelvic. This is super interesting. Isn't it fun? Um, there are three other questions that I want to ask you going back to hormones postmenopause. Um, and these are I'm saving the three most contentious questions for for last on this topic. Question one, I buy your argument, this is someone's posing this question to, not me. I buy your argument that hormones are safe, but I am now 56 years old. I finished menopause at

49. Isn't it too late to do anything about it? Yeah. So, we have this idea in menopause medicine called the timing hypothesis or the window idea, right? So, the question of the timing hypothesis is what are you afraid of? What are we worried about? We're worried about blood clots. We're we don't want to hurt people. We're worried about cancer. We're worried about blood clots. We're worried about heart disease. But the question is is does the hormone therapy that we use apply to the data that we have? and I would argue it doesn't. And so there

is a level of we don't know what we don't know. Um but even the timing hypothesis using Premro which was the medicine used in the WHI is under question. So Susan Susan Davis from Australia just wrote a big paper questioning the timing hypothesis and say actually when you look at the data really closely even it doesn't really hold muster. We shouldn't really be forcing people to like say you cannot start hormone therapy after 60. So I think this is where shared decision- making really comes into play of what are we treating? What are we trying?

Do you care about your bones? Do you care about your sexual health? Do you care about you know sort of your mental health? And do you want to see if hormone therapy helps with these things? Now hormone therapy is indicated for three reasons. Vasom motor symptoms, hot flashes, night sweats, that sort of thing. Prevention of osteoporosis, which to me is a green light. So anyone should be offered hormone therapy because who wouldn't want to prevent osteoporosis and the thing I just talked about a lot is the genital and urinary syndrome of menopause. So anybody of

any age and I'm talking even pmenopause and premenopause vaginal estrogen or DHEA is safe and really helpful to prevent UTI and should be used absolutely everywhere throughout life throughout life. Um okay now I'm going to ask another uh question that is the extension of that question but I think your logic is going to hold the same which is the hedging strategy which says not only use as little as possible for as short a duration as possible says you really need to stop this after 10 years right I mean so even if you were lucky enough

to catch a woman through perry menopause and you know you got her on hormones by the age of 49 Now that she's 69, you got to stop it, right? Definitely not. So that's really the the there is no data to suggest stopping it. In fact, stopping it, all of your bone gains go away. They all go away quickly. By the way, that was the argument put forth to me with one of the authors of the WHI, who is by far the most willing to concede that mistakes were made, right? which was, okay, yes, I will

concede that the estradiol is doing amazing things for the woman's bones, but remember, they're going to go away when you stop the hormones as though that was a necessary thing to do. So, keep them on, right? And again, this idea of if hormones if you if it's not broke, don't fix it. By taking a woman off of hormone therapy, you actually potentially could be disrupting any plaques that are there. You could be causing vasopospas. Like, there are all these things that could happen. And so it we really don't want to take women off their hormone

therapy unless there is a reason to. And the only reason I honestly see is if a woman has an active cancer that you are going to target hormones as a target for your treatment of cancer. That's not to say the hormones cause the cancer, but we have a target sometimes because all body parts have hormone receptors and we have used hormones as a target for our breast cancer therapies and some other cancer therapies. Is that helpful? Does that does that make sense? Yes. And it actually dovetales perfectly into my third critical situation, which is how

do we manage hormones in women who are at risk of breast cancer from a familial standpoint who uh have been diagnosed with DCIS, which is not cancer, but increases the risk of cancer. So that's kind of a subset of the first group. And then in women who actually have breast cancer or have a history of treated breast cancer. So I would imagine you see women that fit into all three or four of those buckets. How do you handle it? Yeah. So first we take a long time at my clinic and we get to know each

other and we really try to dive into the data and say what do we know? What do we not know? And I always tell people you can't take hormone therapy because Rachel Rubin tells you to take hormone therapy. You have to do your own research. figure out what you you know what you're interested and so I have a lot of colleagues who are are talking about this. You had a blooming uh on your show and he has a great book called estrogen matters. He's an oncologist who's questioning a lot of this research. We have amazing

colleagues of mine like Kurin Men who is a gynecologist who had breast cancer as a young person in her 20s and now takes hormone therapy and talks a lot about hormone therapy and teaches courses on hormone therapy and breast cancer. So I am always learning about well what data. So I don't like fear. I don't like telling women they can't do things with their body. I like understanding well what are we afraid of? And so when it comes to the BA patients if you do surgical menopause on someone and they don't have cancer and you

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

patient population. And again, the question is if you're allowed to get pregnant, are you allowed to take hormone therapy? And that's really the push back that we give some people. And I think there's a lot of data that we need here. But we need to be asking these questions. I'm a urologist. Testo. When I came out of my training, it was testosterone fuels prostate cancer. Now 10 years later, it's you have prostate cancer. Sure, we can give you testosterone. No problem. If you have metastatic disease, we target testosterone. So, we're going to use castration level

androgen blockers. But that doesn't mean if you have localized disease that you can't have testosterone therapy. So, we think of testosterone and prostate cancer as a saturation model concept. And I actually think we need to be using that model potentially when it comes to breast cancer and have more logic and understanding and less fear. Um, it's marketing. All prostate cancer is testosterone sensitive prostate cancer. But we don't cut off testicles for the fear that an abnormal cell will happen in a prostate. All a lot of breast cancer is estrogen uh uh receptive breast. Not all

of it, right? But some of it is. That doesn't mean that estrogen causes cancer. Is that helpful? Like I think it's a it's insanely helpful. And of course it echoes exactly what Ted Schaefer said when we spoke about this after discussing the traverse trial which was I think to me the most telling thing that Ted said was look if I have a man who's got a Gleon 3 plus three means he has prostate cancer and we are going to follow this and if it becomes a 3+4 he's we're going to actually have to take this

thing out. Um we'd put him on TRT if he needed it. And his argument was exactly your argument on the pregnancy side, which is the reason we would happily give him TRT is let's just assume he's a man replete with testosterone. Would we castrate him during that period of time of observation? Of course not. So why would I not give him testosterone if he needs it, even though he actually has prostate cancer? And this is again where that patriarchal divide happens is we're willing to take those risks and focus on quality of life when it

comes to men's health. We castrate women with the mere thought that they may develop an abnormal cell in their body and completely ignore their quality of life and all of those things that go with it. And that women are more than breast tissue. They are so much more than their cancer risk. And we have to understand and actually have these reasonable conversations with women. And and what I say is your oncologist is not in charge of you. They don't tell you. They give you advice. They are so it's like a pit crew. Let's go back

to our car model. You have a pit crew, but you get to decide who's on your pit crew and who fits into your pit crew, but it can't be just one doctor. You may need someone to talk about your sexual health. You may need someone to talk about your menopause hormones. You may need a bone doctor. You may need a, you know, a heart doctor. So, you need to collect your pit crew. But with one doctor says, "No, you can't do this with your body." I don't like that termin. I don't think it's fair anymore.

And when you give women information about how their bodies work, they make great decisions for themselves. They can look at the menu and say, "Listen, I'm most worried about Alzheimer's and I've looked at the data and this is what I choose to do." Or, "Hey, I'm more worried about osteoporosis. Listen, my grandma died." No, sorry. My grandma broke a bunch of ribs, right? She had Alzheimer's and osteoporosis and my grandpa hugged her and she broke a bunch of ribs. like that's not how I want to age, right? So, what do I care about? I don't

want to get osteoporosis. I don't want to get dementia. And I've seen all the literature. Hormone therapy sounds pretty good to me, right? Like, and that's really the key. I think there's a lot of people on social media maybe negative about hormone therapy, but if you look, they are on hormone therapy themselves. They will say they have an estrogen patch on. Well, I'm sorry. I don't I because I don't pay any attention to social media. There are people out there saying they're they're anti-HRT, but they use HRT. So I don't what's their argument? What are

they talking about? This idea that we are overselling HRT, that not every woman needs HRT, and I'm not suggesting every woman needs HRT, but I want every woman to be offered the menu, right? I want them to know what they are like like uh just like I want people to know how to exercise and lift weights and eat healthy. Here's the menu. If you choose to smoke and drink and do drugs, that is your choice. But I want you to know that the menu exists. Does that make sense? Sure. um what do women need to

be aware of? So not every woman can come and see you, right? Not every woman has access to a doctor who has the breadth of knowledge that a select few do in this space. So a how can women find practitioners near them and what do they need to be aware of? what are the exploitative practices out there that that they need to be uh mindful of and not get duped into sort of sub you know either dangerous therapies or you know just uh you know overly extractive therapies. I think there's danger on both sides. There's

danger going to the doctor for 10 minutes and saying oh that's not safe. You don't want to do this. Right? And there's dangers of going to the very expensive pellet clinic that is going to overdose you and charge you lots and lots of money. So you need I like um being somewhere in the middle and getting a few opinions here, right? So this is where opinions can be uh following the a bunch of people on Instagram. Don't just follow one people, follow a bunch of people. If you like books, there's tons of books now on

menopause, right? There are What are some of your favorites? So I mean you've got um Mary Cla Haver has the most popular book called The New Menopause. Heather Hirs has a great book called Pick Your Menopause Type. Um there's been a a a hot and bothered as journalist wrote a great book on perry menopause. Uh Jansancy Dunn. Um Tams Infidolist wrote a book um about menopause who's also a reporter. So you're getting a Estrogen Matters is a great book, right? A really great book. So this is there's a lot of books now, thank goodness. Um

you know there's one called the Menopause Manifesto. There's great books on menopause. There's also podcasts now. There's great podcasts out there. There's great um Oprah just did a special on uh uh uh you know there's there's documentaries on PBS now. So menopause is having a movement. So you can't have this excuse anymore of oh my doctor doesn't do this. Go find a different doctor. There are tele medicine companies. And what's a what's the website you refer to? Menopause.org is the menopause society website. That doesn't guarantee you have someone who knows everything but menopause.org means somebody

took a test and put some effort into saying I care about menopause. I um I'm on that website. But iswish iss.org is the women's sexual health society. So people who we care about menopause and sexual health. So that's a great place to find a provider. So those are two websites that can help you find someone. Again, you have to advocate for yourself because no one will do that other than you. And so I think the more you educate yourself, the more you can find the right people in your pit crew who are going to fill

that gas tank and get you to where you want to go. Do you feel that there are too many women that are still getting their hormone therapy in the in the sort of dark alley with with sort of highly sus individuals? And if so, what would be what would be a clue that you're in that camp? Because there's nobody that's in that camp that knows it, right? So, what what who are what are the I want I want a woman who's watching this who's not getting great medical care but thinks she is to maybe get

a a bit of a hint as to what that might look like. I think this is a a problem. When your doctor only has one type of med when your doctor says no, you can't have anything, that's suspect. If your doctor says you can only have this really expensive product that has to be uh uh uh inserted into your butt uh four times a year and you have to pay me thousands of dollars, that's extremely suspect. Compounded by me. If they say you have to pay lots of money for this special compounded product that's safer

and more effective, I call red flag on that situation. If you have to give very expensive saliva testing labs and they're making you pay a lot of money, very suspect. Again, that doesn't mean you can't do it. If it's working for you and you're happy, you have body autonomy, you do what you want, but know that there's red flags there. Um, I think the pellet industry, we I have a big problem. We have an FDA approved pellet for men. Okay? It can be FDA approved. I am not upset with a pellet as a concept. If

the pellet companies cared about women, do the studies. Go through the FDA. Show me it's safe. If you believe it's billion-dollar industry, if you believe that it's the greatest thing in the world, show me so that I have that so that I can start using it because I'm going to because the FDA is a pretty good compounding pharmacy. So, do the work. Go. I have my beef with the FDA. Hello, you need to take that box labeling off estrogen products, especially vaginal estrogen. But if the pellet companies deeply cared about women, which they say they

do, do the work that everyone takes advantage of women. All the supplement companies, all of these, they take advantage by promising these things to women, but they don't do the work of science. So that's what I ask is is just do the work. Rachel, as expected, this was this was a fantastic discussion and I think it adds to what we're trying to do in this podcast, which is really um have nuanced and deep discussions about important topics. You know, not every podcast I do gets to impact that many people. Um some of them impact nobody.

They're just really esoteric, but they're they they they fit into my curiosity window. Um but but this is this is kind of a topic that really impacts almost 100% of the population because 50% of the population is who we just talked about but the other 50% of the population would be hardpressed to say that they don't care about at least one person in that other group. So again there 100% of people are are heavily impacted by what we just discussed. Can I say one thing real quick is that I'm a I'm also a men's health

doctor and I lecture my urology colleagues and I say and you talk about longevity and here are the things you can do for longevity. I think you're missing one point and that is that men who are divorced, single or widowed have horrible health outcomes. Horrible. Whether you look at mental health, prostate cancer, cancer outcomes, horrible. They die sooner. So if you want longevity, if you want to keep living, how do you you have to keep people partnered. And when do people get divorced? Between 40 and 60. That is the age of pmenopause and menopause. Menopause

is killing men. It is killing men because it changes their marriages and it leads to divorce which leads to death. So I I I give this lecture of if if men's health doctors, if doctors truly cared about keeping men alive, they would do menopause medicine because that is the most one of the most important ways to keep men alive. So that's my other argument for you to focus on this and really make change here. And I'm just I can't thank you enough for this platform um because it is everybody's problem. Rachel, thank you very much

for the work you're doing and thanks for coming today. Thanks for having me. [Music]