Perimenopause vs Menopause: The Toll the Change Takes on a Woman's Whole Body

All right, and we're live. Everyone already got some people saying hey, we appreciate it. Um, let's make this a fun active one today. Let's interact with the audience. It's been a while since we've been both back. Uh, so while we're getting going here, why don't you, you know, comment where you're from, if you come from New Hampshire, Maine, or elsewhere. Um, so today's really exciting episode here with uh, the fantastic Dr. Rose. Uh, a couple housekeeping things before we get rolling. None of this is medical advice. This is for uh, education purposes only. If you want some medical advice, welcome to um, become a patient at MedMatrix. You can apply by um, going to medmatrixusa and clicking get started as a patient. Speak with someone from our team. Um, other than that though, just an introduction. My name is Cole Steer from one of the co-founders of MedMatrix. I'm joined here with Dr. Rose, who's an esteemed naturopathic doctor. Dr. Rose, why don't you give a little background on your um, experience with menopause, hormone replacement therapy, and like what got you interested in, um, you know, specializing in menopause and hormonal care in the first place. Yeah, um, so I'm Dr. Sasha Rose. I am a um, naturopathic doctor, uh, also a licensed acupuncturist. I have been practicing for 20 years. Um, I have seen a lot of women in all stages of life over that time. And um, I can't tell you the number of times that I have had women come in to see me who are as young as 35 and as old as 70 and feeling like they're having all sorts of symptoms and there's no explanation and other providers haven't been able to provide much. Um, and so just over time, I just got more and more interested in hormonal balance and the transition uh, that that women go through in those peri-menopausal years and then post-menopausal and how uh, it influences women every everyone differently, but um, you know, for the most part it's going to have an impact one way or another. So, I'm just fascinated by that and I love being able to support women uh, through it. Yeah, that's awesome. All right, so uh, let's start with just kind of like some ground stuff. Like what is like, what is menopause? Cuz it's not just hot flashes, um, it's not just your period going away. It's a lot more than that. So, like, what is actually happening on a cellular level, hormonal level when menopause happens? Yeah, so one thing I do like to kind of lay out is just the terminology, um, cuz we do, um, partly cuz it's easy, we use menopause as kind of the global term for this this these hormonal changes that happen. Um, technically, um, 10 to 15 years, um, before actual menopause is what we call perimenopause. And this is when um, progesterone starts to kind of do a steady decline. Estrogen is usually doing some fluctuations. So, there might be an overall drop in your level of estrogen compared to when you were in your 20s or early 30s, but also there's just these kind of ups and downs that you probably didn't have before. Um, and that again can last 10 to 15 years. Now, that can lead up to there's one day that is menopause and that is literally defined or one moment and that is when a woman has not had a menstrual period for 12 consecutive months. Mhm. So, technically, your you're in perimenopause, menopause is like an event, and then you're post-menopausal. Um, just for kind of some terminology, but basically there's a drop there's a decline in progesterone. Um, testosterone is not technically like a menopausal hormone, that but it does have some impact in that starting even as um, early as your early 20s, late late 20s, early 30s, there's also kind of a steady decline in testosterone. Um, lot like a a loss of um, ovarian hormone signaling and so all of these changes, again, most of that most of the symptoms are going to happen in that kind of perimenopausal time and it affects everything. Um, I mean estrogen alone, there's estrogen receptors in the brain, um, the bones, uh, it affects the the blood vessels and the cardiovascular um, system. So, it really if it's all over the receptors are everywhere and therefore a change in those hormones is going to be felt everywhere. Gotcha. Yeah, I mean you hear a lot about hormones change with your sex hormones change with age, right? Um, I guess again, what's what we're going to do kind of today is like build up context and then kind of just keep building on that and get more specific and more actionable. So, I guess a lot of patients are pretty frustrated with kind of the care they're receiving through conventional medicine when it comes to things like things like menopause. Yeah. Just can you explain [clears throat] like why that is? Like why do some patients feel I mean we hear it all we have some patients say they felt gaslit. Just curious like why? Oh, yeah. Yeah. Yeah, I mean I would say that's not uncommon for for female patients to feel gaslit. Um, so there's really I guess I'll try to say this brief somewhat briefly, but there is like a there is some historical context here. Um, and that is that prior to the 1990s, um, hormone replacement was done fairly often. Um, so estrogen was given, some progesterone was given, and it it was kind of given somewhat frequently. Um, and then there was a um, study called the Women's Health Initiative and basically those the the study was um, abruptly terminated and there was a press conference that happened and it told doctors to take all of your patients off of HRT. There was information put out that it um, increased the risk of breast cancer and it increased the risk of um, cardiovascular disease. We now know that that misin that information was misinterpreted. There's a lot of kind of more details around that, but what what happened is that there's a whole generation of not only women who are not on hormone replacement therapy, but um, a whole generation of physicians and providers who don't know anything about hormone replacement therapy and therefore don't really know that much about menopause in general and it's just not really part of the of the training, part of the language. It's just like it's just part of aging and it's not really studied that much in conventional medical school and uh, up until recently perhaps. And so, there's just this so often times a a person goes to the to the doctor and they feel like something's off, they suspect that it might be hormonal and they're often told, "No, you know, it's all in your head or you're just getting older." or "Here's an antidepressant." or "Here's a referral for therapy." And those can be great things. Those can be really appropriate and you and you know, given the right situation, those are just what's needed, but that whole hormonal component is often overlooked, dismissed, etc. And so people just just like you said, they often will feel gaslit. Yeah, but even I mean I used to talk to a lot of new patients and so we'll do. Um, they talk you know, a lot of doctors will refer them to their OB, right? Yeah. OB, yep. But even then there's still like you go to your OBGYN and they'll say like, "Hey, like here's some birth control that's or um, synthetic patches. Like, can you explain kind of that side of things? Cuz Absolutely. The it's not just like menopause is not just your sex hormones, right? Like it's all there it's a whole body approach. Like what else like what's going on there if you can kind of explain the Yeah, so um, well, I guess to answer that that question, it's it's a whole body thing because there's estrogen receptors, progesterone receptors, testosterone receptors throughout the body. And so, we're talking about the impact of um, I'll just use estrogen in this example, how it, you know, it it impacts brain chemistry, it impacts your gut, it impacts fat metabolism, it impacts bone mineral density. So, it is there is a hormonal basis, but you're right that it cause it it it is multi-systemic as we say. It does estrogen does really impact all parts of a body. Um, I would say in my experience that there are um, some some um, some gynecologists who are well-versed in um, hormone replacement therapy and hormone management. Um, they um, it varies. It just varies in terms of what their perspective is and what their training is and um, there we can get into this later in terms of the therapies, but uh, some of them are prescribing more of the synthetic, which for example, like oral birth control pills. That is synthetic estrogen and and or progesterone. So, Mhm. Um, that was a big part of the issue with the Women's Health Initiative study. It was, exactly. That's what it seems like. I feel like you have to explain that a little bit. They they did this Yeah, yes. They did this huge study and um, they used what's called conjugated equine estrogen, which is synthetic estrogen. And what that means is that it's molecularly similar to our own estrogen, but it's not identical. So when we use the term bioidentical, we we it's yes, it's made in a lab, but it's molecularly identical to our own, which greatly improves the safety profile. The other issue is that when estrogen is given orally, it increases a woman's risk of a blood clot. Um especially for women over 65 who have a high BMI, who are smokers, overweight. Um we for the most part prescribe what we call transdermal bioidentical estrogen. So what that means again, it's bioidentical, which is safer in and of itself, and then when it's done on the skin, so it's topical, like a topical cream, a gel, or a patch, um that has a 0% increase in a blood clot over baseline. So so safer. Got you. So why doesn't I mean cuz here's the golden question I think a lot of people are confused by this. Like why doesn't conventional medicine use bioidentical hormone replacement therapy? But they're like they're still using synthetic hormones, right? The one that's Um no, no. They it's it's all over the map. They some of them some some people are some providers are giving the synthetic, that's what they know, and there are but if a but if a woman is put on a patch, an estradiol patch, that is bioidentical. Um and again, depending on your provider, they're going to be educated in that or not. Now, sometimes what I'm hearing from patients is that a provider is comfortable with maybe an initial prescription of some HRT, but then once kind of the symptoms are not going away or she may or may not be having some side effects, the the provider doesn't doesn't isn't doesn't feel comfortable enough is not skilled enough to manage that that next step. How do we tweak it? How do we adjust the dose? How do we adjust the route of admission? You know, do we change from a gel to a patch? Like that that often there's a limitation in that. And it's honestly, it's it's just people are not have not been taught this in school. So they just don't feel comfortable. Got you. Great explanation. So all right, we've covered some of the ground here of like what is menopause, kind of the conventional backstory with it all. Um let's talk more about kind of like the signs of it. So we know menopause, we'll get more into this as the show goes on, like it's going to affect you greatly physically, right? What about mentally? Like how does menopause affect women mentally? Yeah, yeah. So I think that's a good question because how does So how how you know, mentally, emotionally, you know, what are the signs? What are the symptoms? Again, I think often times the the classic menopausal symptoms are hot flashes and night sweats. And so people will often think and I this is within the medical community, too, not just patients, will think that um you know, if you're not having night sweats, if you're not having hot flashes, then you're just sailing through those that those perimenopausal years. Um I only have a a small percentage of my my female patients who are actually having when they come in, they're not on any hormone replacement therapy, really a relatively small percentage of them are having hot flashes and night sweats. The majority, the vast majority are having um mood changes. That could be anxiety and or depression. Almost always increased irritability. Um what we call brain fog, right? Like that word recall. Um fatigue is a huge one. So and and just overall just like not feeling like themselves. Like that by far, that's the classic picture. As well as this is a physical symptom, but um increased weight gain or difficulty losing weight. So I think that that the mood piece, the mental emotional piece is is huge. Um and what we see when somebody has optimal levels of estrogen, and this is either a woman who is still menstruating and still her ovaries are still producing, you know, optimal levels of estrogen, um or a woman who uh is on hormone some form of hormone replacement therapy and that estrogen is is at the optimal level for her for her body, um what we see is that it boosts serotonin. Um so serotonin and it also boosts dopamine. These are both like feel-good uh neurotransmitters. And when perimenopause happens and there's that drop in the estrogen level, there's subsequently a drop in serotonin and dopamine. Um there's also estrogen has um the ability to kind of through the hypothalamus like regulate cortisol. So what does that mean in real life? That means what I the term I use is stress resilience. Like your ability to just handle life, right? Life is full of big and little stressors. And when you when that drop of estrogen happens, that ability to handle those stressors, um it impacts your cortisol and therefore you're just not dealing with things as well. Um so those are some ways that estrogen in particular um can impact kind of mental health, emotional health. Progesterone um also again, now remember progesterone doesn't do this as much. It doesn't have the up and down fluctuations. It has more of a steady decline, like kind of almost every month your ovaries are going to be making like a little bit less in those perimenopausal years. And then once you hit postmenopause, they're pretty much not making any progesterone at all. Progesterone we consider to be like the calming hormone. So progesterone acts as what we call a GABA agonist, and GABA is another neurotransmitter, which is we call it an anxiety anxiolytic. So it basically reduces anxiety. When your body isn't making progesterone anymore, you're losing that. You're losing that. So you have basically less of that relax, that kind of that calm, that natural relaxation. Okay. Got you. Um and what are like the early signs of perimenopause? Cuz it's it this is something that goes on for a while. It's not just boom, you have it. Like it's sort of Exactly. Like what are these early signs that people start to experience? Yeah. Kind of what I've the early signs of of perimenopause, I would say are maybe some mood changes, maybe um often times maybe a change in sleep. So as I mentioned, estrogen can kind of um let's see, put the brakes on cortis- on some of those cortisol jumps that can happen. When you lose that that the break of of estrogen, what we see in the middle of the night is we see a often times there can be a court like a surge of cortisol between 2:00 and 4:00 a.m. Now, that happens all the time, but it when you're before all this, you've got estrogen that's kind of keeping that in check. And you lose the the brakes of estrogen, and so now you've got this cortisol spike that happens at that time between 2:00 and 4:00 a.m. You also are losing progesterone, which is stimulating GABA, which kind of keeps you in a deeper sleep. So you lose you lose that, and the classic sleep pattern for perimenopausal women is um you know, I used to sleep great, and now, you know, almost every night I, you know, I wake up and I can basically tell you that it's exactly 2:30 in the morning cuz it's the same time every every night. It's it's classic. Um so that often that sleep dysregulation is often one of the first um first signs. And then there will be some of that weight gain. It's often kind of in the abdomen, the midsection. Um And so just overall low energy, like the mood all of the things that I've been mentioning, kind of inability to regulate your mood, like you're just more irritable at you know, often times people will say it's, you know, my partner is just so so much more irritating than he used to be. Now, you know, maybe he is, but [laughter] usually it's it's he might be staying he or she might be staying in the same, but but your your ability to tolerate has changed. Interesting. Um you broke down the way menopause and estrogen affect sleep nicely. How about weight? I know weight is like a really big one. Like how can you explain more specifically how menopause affects weight gain and your metabolism? Yeah, cuz that is often one of you know, for good reason, people women it's upsetting, right? Um So there's a couple different things that can happen with why why the weight. Um One one thing is that estrogen um kind of regulates um energy homeostasis. So, it it it it kind of keeps a regulation on what we'd say like fat metabolism. There's this one just to get a little technical. There is this one um enzyme. Um it's a it's a lipoprotein lipase or LPL that's in a visceral fats, in that abdominal area. Now, estrogen when it's at optimal levels like suppresses this LPL. When you lose that estrogen, when estrogen drops, you get this bump up in LPL. You get this this lipase kind of goes up and becomes more active in that visceral tissue and that kind of gives more you're more just um there's a tendency then towards this central what we call central adiposity or central um fat deposition. And that in and of itself can also increase insulin resistance. And then once insulin resistance is in play, that in and of insulin is a fat building hormone also. And so there's kind of this maybe a little bit of a vicious cycle with that. So, you've got both kind of again estrogen was um suppressing this this one enzyme. Mhm. Uh which is is directly involved in visceral fat, um abdominal fat. And then you've also got estrogen had been kind of um keeping uh this the sensitivity we call it like um insulin sensitivity of the cells in an optimal range. You again have that job of estrogen and then the cells become more resistant to insulin. They're not really taking in insulin as well. Uh which again all of this is in addition to the abdominal in you know, increased abdominal weight. Heart like what we call comorbidities which are associated with that include the insulin resistance. You have increased um risk of things like fatty liver, higher cholesterol, um increased cardiovascular disease partly because of this. So, it's not just it's not just um vanity, right? In the terms of not not liking how it looks. There there's also some uh metabolic risk factors that that increase with that weight gain around the middle. Okay. Um so, let's So, even though like cuz we see a lot of patients like they you know, their whole life it's like they would gain weight and then they kind of do you know, they cut some calories, cut some calories, work out more. Like why does working out actually become less effective and dieting become less effective with menopause? Yeah, I mean I hear that I hear it all the time. Women say, "I'm still working out as much as I always did. I'm watching my calories just as much as I always did. I eat really well and I'm not I haven't changed a thing and I'm gaining weight around the middle." And it's extremely frustrating. Mhm. Um you're basically when you have optimal levels of estrogen, you kind of can have a higher energy expenditure. So, you so you you have a higher resting metabolic rate. You have kind of better even on the level of the mitochondria. Like you things are kind of working efficiently. And you have that drop in estrogen and you inherently have a lower resting metabolic rate. So, you're not really burning through fat the way that you used to. Um and so you're doing again you're doing the same level of activity, but you're not going to get kind of your baseline is shifted and so you're not going to get the same benefits that you did from the same level of exercise. Yeah. All right, that makes sense. Um and what about muscle mass? I know muscle mass is big one cuz you you touched on testosterone a little bit, but let's talk a little bit more. How does menopause affect muscle loss? Yeah, so again in terms of the the hormonal changes involved in menopause, like those I mean that's mostly the you know, estrogen and progesterone. Both estrogen and testosterone impact um muscle mass. So, I'll start with estrogen and then I'll also and then I'll move on to testosterone. Um you lower estrogen, you just have it it basically with low estrogen, you're going to see a loss of muscle mass. You have um kind of lower you're actually unfortunately, you're you're less sensitive to the dietary protein that you're consuming. So, again, here's the woman who's like eating lots of protein and and doing everything that she's supposed to be doing. You're you're not going to get necessarily those same uh metabolic benefits from protein that you if you don't have optimal levels of estrogen. You also um there's well, sometimes it's in it's inadvertent. Sometimes because you're fatigued, because you're not sleep isn't good, you literally don't have the energy to exercise as much. So, sometimes it's a bit of a life like you know, unintentional lifestyle change. Um but because of that that loss of uh support of estrogen, you're going to have um it's going to be harder to to build or to maintain muscle mass. Testosterone as I mentioned earlier doesn't really have like the fluctuations um that estrogen does and it's not like it kind of goes off the cliff that the way estrogen does at menopause, but it is a slow decline, you know, as early as your late 20s, early 30s. That's was probably that you know, that's been going on in kind of a subtle way for a while. And that as well, there's um you know, when you have optimal levels of testosterone are going to help you maintain optimal skeletal muscle mass. Um and that's a you have this kind of steady decline in that and then perimenopause happens and you've got these this drop in estrogen and so it's compounded. So, women will often not notice this until the perimenopausal years or the postmenopausal years even though there's been a subtle shift for you know, a decade. Yeah. Okay. So, that kind of makes me think of like testing, right? I think a lot of patients kind of go more functional because they want more data around their health. Um can you talk a little bit about that because I know like you hear out there some doctors will say if you ask them for hormone testing, they'll say it doesn't matter. Um what like what's your opinion on blood testing for sex hormones and some of the other tests that are out there? Yeah, so I'm a proponent of um blood tests or serum tests for hormones and this is why. I I feel for a couple for a couple different reasons. I like getting a baseline. So, I like when I have when I see a new patient, I like knowing what her levels are just without any you know, she's not in any hormone replacement therapy. I can I can tell right off the bat if this woman is actually postmenopausal or if she's perimenopausal based on um her sex hormones. And that may or may not tweak my recommendations, but I have a baseline. And then if we are going to commence um some kind of HRT program, I it helps me monitor, right? So, it helps me monitor how her body is responding to the hormone replacement therapy, if it's the if it's the you know, an optimal level of progesterone, estrogen, testosterone. And how I do it clinically is I'm mostly going on how she's responding symptom-wise. Uh what she's reporting back to me in terms of how she's feeling. You know, are there um is there an improvement in her energy, uh in in body composition, in her sleep, etc. That's most important, but I like using the blood work to also match with along with that. The you are correct in that um you know, kind of conventionally it is thought that it's not helpful. It's not it's not worth while and that providers are kind of just going on symptoms. I find that we get a more complete and thorough picture with this testing um because it's just it's data. It's more information. It doesn't take the place of listening to the patient. I think we are kind of the pros in actually really listening to the patients, but um it it just gives us a it's it's just more information. It really I mentioned earlier that some clinicians get stuck after that initial prescription of hormone replacement therapy and it isn't always easy the adjusting and the tweaking of the doses and the and the routes of administration, but that's that's part of that's part of what we do and part of that is taking into account those those lab values. Mhm. Okay. Got you. Did I Did I answer the question? Yeah, no. I think you answered that very well. Um we got some questions here about people asking about like what you do about some of the menopause symptoms. We're going to If you guys just hold on in probably about 10, 15 minutes, we're going to start getting into solutions and some patient case studies. Also, if you guys want to um throw comments in as far as like questions go on YouTube or Instagram, where wherever you're coming from, um we're going to do a little bit of Q&A at the end here, so feel free to Right. drop some of those comments and we love interacting with you guys live. So, um yeah, I mean, this is a good segue into kind of like starting to talk about kind of like the functional approach to treating this, I guess. Let's answer some like common misconceptions around hormone replacement therapy. Um or just common questions, I guess, rather. It's like a lot of people say, "Hey, do I have to be on this forever?" What's your kind of response to that? Um no, absolutely not. I mean, in general, I when I can avoid prescribing something that the individual has to be on the rest of their life, I do that. Um it's really we usually take it in kind of 3-month chunks. So, um as I've mentioned, there can often be a little bit of adjusting, trial and error in terms of the type that, you know, they it's this is a this is I say this a lot, this is a customized, personalized medicine. So, it's not like there's one HRT regimen. Like, we really are looking at your lab results, we're listening to you, we're piecing it together. We are also taking into account other things, right? We're taking into account um stress level, nutrition level, um physical fitness, uh nutrient depletion, um all sorts of things. It's not just hormones, right? We're looking at you as the whole person and coming up potentially with an HRT very personalized uh bioidentical HRT program. Um different women have different levels of sensitivity to estrogen, right? So, some women do well on like a higher dose, other women really don't, and we have the tools to to really, again, personalize it. So, um there is a window of time in a woman's life that does if she is put on hormone replacement therapy, it will give her the most benefit in the long term. And that really is kind of the 10 years, I would say, before Remember, menopause is like a moment in time, 12 months of no menstrual period, 10 years kind of on either side of that, I would say, especially the 10 years um you know, after or you know, postmenopausal, there's still this window of time where we see, they know research-wise, we know that if a woman is put on the right types, levels, doses of hormone replacement therapy, we are going to see a reduction in her risk of cardiovascular disease, dementia. We're going to improve her bone mineral density, therefore reducing her risk of osteoporosis and bone fracture. Um and there's even a reduction in risk of several forms of cancer. That's like the optimal window. There the conventional thought is that if a woman is over 65 or 10 years postmenopausal, that it is not safe to put her on HRT. We now know that that is not true, and that it, again, it depends on the person and it depends on how what the what the HRT is. Is it bioidentical? Is the estrogen transdermal versus oral? Et cetera. A woman can still get benefit, um but in an ideal world, a woman does start HRT earlier, and she does not need to stay on it forever. Mhm. Is there an age that's too old? What do you say, I am too old for HRT? No. No. But it's But it's the individual, right? I mean, it's really based on what the what we're look what our goals are and um um and her specific any you know, any just her individual hormonal picture and um what what we're trying to balance with her, but there there really isn't. Mhm. Got you. All right. So, when a patient comes in, uh menopausal patient, um or perimenopause, um what what other key things are you looking at on that lab work that's that's important to cross-reference with? So, what am I looking at on the on the lab work other than her hormone levels? Correct, yeah. Sorry, thanks for specifying. Um I am looking at um levels of inflammation. So, we have a couple markers that um show kind of her baseline level of inflammation. I am looking at micronutrient levels like B12, folate, vitamin D, iron, ferritin, magnesium. Um I am looking at thyroid health, right? So, um thyroid and the sex hormones are intimately connected, and so looking at kind of you know, a lot of women come in and they have a diagnosis of hypothyroidism. Um so, I'm definitely trying to, you know, look at balancing, supporting, making sure the thyroid gland is is as balanced as possible. Um I mentioned cortisol. Uh cortisol levels are also important. Um stress resilience is important. Um so, those are that's not everything that's on on the list, but you know, we have like the liver function tests, so those are going to, you know, potentially tell me if there is any fatty liver, um including non-alcoholic fatty liver, which is the most common. Um the we have a whole cardiac uh function panel. So, what's her baseline, not just her cholesterol levels, but what's her current risk of cardiovascular disease. So, it's pretty Yeah, it's pretty comprehensive, and it it does, again, help me potentially come up with that that really personalized plan for her and helps us together figure out her priorities. Is it reducing her risk of cardiovascular disease? Is it um you know, we want her Is her priority optimal vitamin D so that her calcium absorption is optimal? Is she at you know, she Does she already have osteopenia or osteoporosis? Is that our focus? Mhm. Yeah, that's awesome. Um can menopause then cause other things? I mean, you hear a lot about how like trauma or stress in the body can bring up, you know, things in our genes that aren't necessarily good or other diseases. Um can that happen where you get menopause and then that triggers an autoimmune or so on if that makes sense? Yeah, I think I know I keep kind of going on and on about the benefits of estrogen, but I'm I'm it's kind of just the way it is. They estrogen is um anti-inflammatory. So, in a lot of ways, including kind of the inflammation that's involved in autoimmune conditions, it's putting the brakes on that. It's putting the brakes on inflammation. It's um putting the brakes on um autoimmune processes. Autoimmunity is when part of the immune system is attacking a specific tissue in the body. So, hypothyroidism, for example, um is the part of the immune system is attacking the thyroid gland when it's an autoimmune form of hypothyroidism. Um so, sometimes estrogen has been kind of tamping that down, um and suddenly you lose that, and then there's this flare-up, right? And that, again, it might be kind of the emergence of an autoimmune condition. Um it may not be autoimmune, but it might be joint pain. That's That's one that I forgot to mention. Um joint stiffness, joint pain, definitely not considered you know, historically or in general, people don't really think of joint pain as being a hormonal thing, um but often times that is one of those perimenopausal symptoms. Because you've lost that that you've lost the the anti-inflammatory benefits of estrogen. That's interesting. And how often are these things misdiagnosed or misunderstood by conventional doctors? So, they have joint pain and they get a surgery or they take a painkiller or Right. or they they take an antidepressant. Oh, 99% of the time. I mean, I would say again, it's it's just it's it's not any individual provider's fault necessarily, it's just lack of training, lack of comfort in that in the like menopausal medicine space. Yeah. Understood. Okay, so let's talk let's start talking about like probably why most people here today is just like solutions, like how can you actually um thrive through menopause and so on and so forth. So, like, what is your approach? Like, patient comes in, um like they're menopausal, like, what are some of the things that you start to think of that you're looking at closely? What like walk walk uh myself and the audience through that. So, I spend a fair amount of time, again, um feel like what what are the particular symptoms that this woman is dealing with? We've gone through kind of the you know, the whole litany of what a woman can experience. You know, each person is we're all different, and so again, for some women, it's the sleep and the fatigue. For another woman, it's it you know, maybe it is the hot flashes during the day. Maybe it it can be all over the map, maybe it's the mood. It's So, I really try to listen to her, and you know, one, to get a baseline, and that, again, can help me decide what I'm going to recommend, but it also helps me at those follow-up visits so that I can gauge our success. How is she you know, it's again, it's it's it's somewhat what happens on the blood work, follow-up blood work, but it's largely does she have more energy? Is she sleeping better? Is her joint pain better? If I don't have a baseline of where she started, I'm not going to know if we you know, if we've really improved anything. So, it's a pretty thorough questioning in terms of her concerns, her goals. Um we go through the blood work. Again, it's very comprehensive. Um I do a lot of education around kind of what we're talking about here in terms of what is this hormone mean and how does that hormone impact that hormone and um how could that how why is your you know, your cortisol level how does that relate to the to that thyroid panel, etc. So, there's a fair amount of education. And then we get to what I call kind of the fun or the creative part of the visit, which is again, super personalized, super customized. Um it would be you know, there are some lifestyle often more often than not there's going to be some lifestyle or behavior modifications. Some people feel like there's room for help with nutrition. Other people feel like they've got that covered. They don't really need to go down that road. Um you know, level of physical activity. It's not a one-size-fits-all. I'm not telling every person to go run 3 miles a day. That's personalized as well. What does the person enjoy? What works for them? Um we are looking to maintain and to build skeletal muscle mass. So, we will kind of tweak the exercise regimen to hopefully incorporate that. Um there's almost always some micronutrient supplementation. Um so again, that might be magnesium, iron, vitamin D, B12, etc. There may be some other nutraceutical um supplements that can kind of help her in a natural way. And then there may or may not be a hormone replacement program. Mhm. Okay, what um Okay, and then with hormone replacement therapy, how do you normally what what's your philosophy on dose like or just give me give a obviously we can't give specifics, but like you know, could you kind of explain how you approach hormone replacement therapy when you're prescribing it? Yeah, so um uh you know, most likely I'm going to prescribe um estrogen. There's a couple different forms of estrogen. Estradiol is the strongest estrogen and that's the one that we measure in the blood work. That's the one that most of the research has been done on in terms of um benefits. And so an estrogen prescription may be a patch, it may be a cream, it may be a gel. Um again, it's like a I give women I like to just provide information. I don't like to come at them with a set agenda. I really try to just provide information, educate and and tell them pros and cons and what you know, what I think will work for them. Um if the woman and then there's benefits of progesterone. So, if the woman has not had a hysterectomy, she still has her uterus, we have to put her on progesterone. Um the most effective form is oral progesterone, which is very safe. That is protecting the uterine lining. So, if a woman with a uterus is on what is called unopposed estrogen, so no progesterone, we do run the risk of um a build-up of the uterine lining. It's called hyperplasia and that increases her risk of uterine cancer. But it's a pretty simple fix. Oral progesterone is going to oppose that and um pretty much um you know, zero out that risk. Uh progesterone as I mentioned earlier has its own benefits, largely being calming. Um it's pretty amazing for many women with to help with sleep, to optimize sleep. Um and then depending on um on on what she's looking for there you know, there may or may not be a suggestion for some testosterone therapy. Um testosterone is not yet um FDA approved for women, just to put put that out there. So, um but that you know, that may kind of be part of the treatment plan going forward. Okay, you said something kind of key there, based on what she's looking for. What would Mhm. when would you or when would you not put a lady on testosterone based on her goals? Um part of it is what we see on the blood work, right? Her levels of testosterone on the blood work. Um her goals of um so what is her what is her libido like? What's her her interest in um her sex or sex drive? What is um is she feeling like she's going to the gym and she's there's no muscle definition, there's just she's losing strength. Um and uh what else would she be looking for? To cut the cognitive piece. So, some a little bit of that brain fog, um kind of mental acuity. That can definitely um be if that's feels like that's impaired, that can basically be kind of a sub-optimal level of testosterone. Um testosterone has historically been thought of as like a a male hormone and it really isn't. Um we women have more testosterone receptors than men. And it's it's it's very important to the female body. So, it's kind of you know, has been dismissed, ignored, not thought of as as important and I think there's starting to be more awareness, especially in regards to women's sexual health, but I think it's also just really important in terms of that that physical physical strength, um mo- mobility, maintaining skeletal muscle mass. That's really important. Mhm. So, testosterone is the one that's going to play the biggest role in um your libido as far as sex hormones go. Both both estrogen does as well. Estrogen does as well and then um and testosterone. Uh and then I would also say vaginal estrogen is safe for every woman at any age and you know, there may be vaginal dryness, there may not, but it basically in when estrogen drops in those postmenopausal years, there's you get um you lose some of that health of that vaginal tissue. So again, some women might be feeling pain with intercourse, they might be feeling just um dryness in general and it's a super easy fix with vaginal estrogen. Um it's really safe for any woman of any age. For women who may have a tendency and this happens in for a lot of women in their 70s and 80s, there's a risk of urinary tract infections. Having optimal vaginal estrogen actually prevents urinary tract infections. Um which is kind of a big deal. Mhm. Yeah, totally. Thanks for explaining. Um do you want to talk about um postpartum hormones at all or do you want to do that on a different show? I know you mentioned that in kind of the pre-show. Yeah, um so we I'll touch on it briefly and then I think we can get into it on another podcast. It's just something that I find fascinating, which is there are these um distinct times in a woman's life when it is common for her to have extreme mood changes. So, extreme uh feelings of depression and or anxiety. Those periods are the premenstrual like on a monthly cycle, that PMS week, right? Or for a lot of women it's actually 2 weeks out of the month. Mood is just awful, really depressed, really anxious, really irritable. The another time in a woman's life is immediately postpartum. So, um postpartum depression, postpartum anxiety. Um I have a friend whose daughter gave birth had her with her first baby about 10 days ago and she her mother was telling me it's just extreme and they are just at a loss for what to do. For the like the baby's doing great, but the mom is just not herself. And then the third time in a woman's life is um perimenopause. So, what all what do these three have in common? A a somewhat rapid drop in estrogen. And it's that link. It's that link of serotonin, dopamine, cortisol that we mentioned earlier. Um and people just aren't connecting the dots. Um we're just it's just not out there. That information isn't out there and so I'm hoping to change that. That's awesome. Um so could women postpartum potentially go on um estrogen and that could save them? Yep. For a month. Yep. For some women for some women honestly that might mean a birth control. Like that might be the right thing for her at that time. Um but obviously in in you know, in our medicine, I would prefer more of a bioidentical one that I can really dose appropriately for her. Okay. Yeah, can you briefly explain what is birth control versus what is like hormone replacement therapy? So, oral birth control is um synthetic progesterone or progestin is the synthetic version. Um uh and or estrogen and again, both synthetic meaning molecularly similar, but not identical to our own hormones. Um dosed uh uh obviously dosed at the at the levels that kind of keep a woman from being able to get pregnant. Um and there's additional benefits for a lot of women. Everything from acne to lightening a woman's periods. Um, for some women even that those PMS symptoms. Because what you're doing with an oral birth control is you are giving her body a relatively steady level of those hormones despite her her own natural fluctuations. So it's not entirely different from what we're doing with bioidentical hormone replacement therapy for you know women of all ages. Is that we're trying to give a as your own levels are maybe doing this or this, you know, like so either fluctuating with estrogen or a drop with progesterone, we are trying to at the same time provide a steady stable dose so that you're less sensitive to the your own fluctuations. If that makes sense. Yeah, no, that does make sense. Um, all right, cool. Well, let's do one more question and then we'll do a case study and then we'll do some uh Q&A from the audience. So um, audience if uh yeah, you guys are listening, um, we have some awesome comments going on right now. Uh if you guys could just type out any questions and we'll answer them in just a couple minutes here. That um, it's always so much fun. So yeah, type in your questions and we'll get them answered. Um, we do have a limited amount of time so we're not going to be if if you want to get a question answered, I'd do it right now. Um, we're just going to do it in order they come in. So uh last thing before we go into a case study is um about peptides. Like how do you I know peptides is kind of a big buzz right now. How do you use peptides in conjunction with um helping women with hormonal changes to just enhance results, help them feel more vibrant and healthy. Um, and also why do you like peptides as an option? Yeah, so peptides are um kind of the quick definition is, you know, a peptide is a short protein. It's a sequence of amino acids. Depending on that sequence, we can target different tissues or different parts of the body um in a in a very safe way. The body recognizes the protein, is able to break it down. Um and depending on the peptide, we can target fat metabolism, for example. So there's peptides that are specifically geared towards um that kind of central or visceral um fat. There's other peptides that kind of um mimic the benefits of exercise. So that metabolic rate I was talking about earlier, it can kind of um help boost that. Um, one of my favorite peptides um targets uh connective tissue and reduces inflammation in connective tissue, meaning joint pain, joint stiffness. Um I had somebody here an hour ago who has plantar fasciitis. So the fascia or the connective tissue on the bottom of the foot. Um, it can, you know, help with that. So you know, as you can tell as the listeners can tell, I really like customizing and personalizing and that's partly what I really love about the peptides is that I can really kind of pick and choose. Um, we can what we call we can stack them. It's very safe to do several peptides at a time. Um, you can cycle them. You can take, you know, take some peptides for 3 months and then go off, again very safely. So they can be a really great um part of a comprehensive treatment plan. Mm. And they're very safe, too, right? I mean peptides are They're very safe. Yeah. They're bioidentical, right? Um, they are. So they're they're synthetic, but they just like um hormone replacement therapy, basically your your molecularly identical to our hormones. Peptides are basically mimicking compounds in our own body. They are like often stimulating um you know, the whole a hormonal release that we do normal like growth hormone release that, you know, we do naturally. And they are largely they are safe because the body recognizes them can break them down and eliminate them. So I always say I don't have to monitor your liver or your kidneys when I have you on a peptide because there's no risk of any kind of toxicity. Um, it's not really going to affect any It's not going to affect your red you know, your red blood cells or your white blood cells. It's um we're really [clears throat] we we can kind of be creative and innovative in in how we prescribe them largely because of that high safety profile. Mm. Yeah, and we get them from um, you know, FDA regulated Exactly. online research pharmacies. They're great stuff. So Cora, let's uh let's do a case study. So um, can you give a specific case study of um, you know, one or a couple patients who um kind of more specifically what you did and their timeline and journey would that would be awesome. Yeah, so the first one that comes to mind is a woman who is 52 um and I've been seeing her probably for about 9 months now. Um, and she um she originally came to me with um fatigue some um unwanted weight gain around the middle. Um sleep had changed for her um or it had been kind of poor for a while um but she hadn't really been thinking of it as a hormonal thing until recently. And um she uh what was her what were some of her other symptoms? Um, a little bit of the mood piece, I think and uh definitely some va- like vaginal dryness. So still had a really healthy relationship with her husband, but um had wasn't really interested in intercourse because it was just not comfortable. Um, and that therefore was impacting their their relationship. So um we there was also a a fair amount of work stress for her. So part of our initial plan was some stress management techniques and kind of some setting some boundaries and um she really wasn't doing any consistent exercise. So part of what we did was just kind of come up with a realistic uh plan for her of how she could fit in exercise. On her blood work, I mean it was it I could tell she was not cycling anymore. Her hormones were it was pretty clear that her hormones were not um her own ovaries were not making making um estrogen or progesterone anymore. Um, and so I started her So we did some lifestyle pieces, right? Like the exercise piece and I started her on an initial hormone replacement program um which included some oral progesterone and um uh estrogen cream. And sh- oh, she was having hot flashes, too. The hot flashes were definitely part of what she was coming in for. Um and the next the second time that I saw her, um a lot of the kind of mood pieces had improved. The sleep had improved. Um but and her hot the frequency of her hot flashes had decreased, but she was still having them. So I tweaked the amount of estrogen. Um, I bumped it up a little bit and did some more blood work, etc. I'm always matching the the lab results with how she's feeling. And um at the most recent visit, those hot everything was pretty much improved. Oh, sorry. I had also put her on vaginal estrogen at the fir- at, you know, and so um things are not perfect, but she's not having hot flashes anymore. She's sleeping better. Her intimate relationship with her husband is better because the vaginal tissue is happier. Um and she's still work- I would say she's still working on and we all know this, right? She's working on kind of the stress resilience pieces and and figuring out realistic ways that she can build in exercise. So that's, you know, as it is for many of us, it's kind of a work in progress, but I would say hormonally she's in a better place than when we started. Nice. Awesome. Um, cool. So let's do um some Q&A. So let's go let's scroll up here. So So someone asked what about HRT after 65? I'm 70. Yeah. So I I sort of answered this earlier about um the possibility of women who are over 65 going on hormone replacement therapy. It is the conventional thinking is still that if you are 10 years postmenopausal or um and or over 65 that uh you should not go on HRT. Now again what what does HRT mean? When we are prescribing it, excuse me, when we are prescribing it transdermally, when estrogen is done not orally, but um you know, a patch, a cream, etc. There is 0% increase in a blood clot. That's the primary reason that of this conventional thinking that over a certain age you don't do it because with age a woman's risk of cardiovascular disease, her risk of a stroke or a heart attack statistically goes up with age. So, the thinking is that you're compounding that if you put her on um on estrogen. Again, that probably does that does apply if you're going to give her oral estrogen, especially oral synthetic estrogen. Um you don't see that risk when it's given in this topical or transdermal form. Um and progesterone is safe really at any age. I don't think anybody would argue with that. Um you have to look at the individual. You have to look again at her weight, at her, you know, is she a smoker, um is she sedentary. Obviously, past history of having a heart attack or a stroke, that all kind of it has to be taken into account. Um the the current thinking among the menopause experts is that the benefits will often outweigh the risks for a woman who is over 65. Primarily, we're talking about bone mineral density. And um you know, ideally HRT is given younger, but you still get some benefit. You still get improved um bone mineral density. I did a whole podcast on osteoporosis. So, if you want details on that, you can listen to that one, but um you're you're going to you are going to kind of help that, you know, bone health, bone strength um with with getting that estrogen up. Um and progesterone will often help a woman with sleep, for example, of at any age. So, given an individual's specific metabolic situation, um I would say it's it's no longer uh you know, absolutely not over the age of 65. Awesome. Um you see it on the screen there? I do, yeah. So, the question is, can you speak to joint pain and ligament issues, um specifically foot cramps. Um So, uh yes, as I mentioned, I would say that um joint pain um is not usually thought of as a hormonal thing, right? Like it's not really and there can be so many different reasons for for joint pain. Um or foot cramps or ligament issues. We do know that, as I said earlier, estrogen is anti-inflammatory. And so, when that estrogen level drops, um you are going to potentially have see an increase in inflammation. And that can, you know, is often a big part of joint pain, um ligament issues. The other thing is that specifically with connect connective tissue um as well as skin is that there's um estrogen provides kind of a a like a lubrication and a and a help with elasticity. You lose that estrogen and you can you get kind of more of a um a drying, a um a little bit more of a brittleness in with in connective tissue. And so, that stiffness, that kind of achy can it can often be um not just the not only the joints, but also the surrounding ligaments, the tendons and ligaments around the joints. Awesome. Um what are some strategies you use outside, you know, uh like that you've used to kind of help with I know you see a lot of patients with joint pain. Especially from menopause. Yeah, so if it's appropriate for for a woman, you know, it will often be um uh an an HRT program. And I mentioned um that peptide earlier that I like to use um again for some people for connective tissue inflammation. I'm always looking at diet. I'm always looking at how what's the level of what we call kind of pro-inflammatory foods, processed foods, ultra-processed foods. Um how can we modify that? Um and yeah, and there's, you know, there's there's there's there's several types of peptides um even including some of the GLP-1s that can be anti-inflammatory. So, it it really we we have a pretty big toolbox, which is great. Got you. Um Are some of your patients not functioning because of menopause? That's a great question. Um I'm going to interpret that to mean that are do I have any patients who are not able to go to work, take care of loved ones, um you know, that kind of activities of daily living is what we, you know, kind of the the old technical term. Um I would say, I don't know if I have any of my uh current patients patients, you know, if they're at that level, um how do I say this? Mena the hormonal changes of menopause are most likely contributing to their status of their current status, but there's, you know, always other things going on. And um Cole referred to it earlier, we spoke of it a little bit earlier that sometimes menopause, perimenopausal kind of unmask some underlying autoimmune conditions. Um it will unmask um something called mast cell activation syndrome, which we've also talked about on this podcast before. So, these kind of things that were there before, that were maybe more manageable, that the woman was able to function, and then there's this added insult of the lack of support of of estrogen and progesterone and maybe testosterone, and she can no longer hold it together. Okay, got you. Um hope that answers that question. Um when you were talking about the peptide earlier, were you talking about GLP-1? What's your favorite peptide that you kept saying? Am I allowed to say specific peptides? Yeah. Okay. Um I was referring to one called BPC-157. Um which is um again, probably my favorite peptide in regards to uh joint pain, connective tissue inflammation. Um I find that it is very effective for various types of I'm not going to say uh regardless of the cause, but um various types of arthritis, um different different types of of pain. Um I've just I just continue to use it because I keep getting really positive feedback from people. Mhm. [clears throat] Awesome. Love it. Um you also use GLP-1s quite a bit, correct? Uh yes. I do. And uh for the sake of this question, why do you why do why are you a fan of GLP-1s? I know there's a lot of controversy around them. Um so, uh yeah, I feel like and I know we've, you know, Dr. Renard, uh my esteemed colleague, has done a whole podcast on the GLP-1s. So, I don't want to go into this too much, but um GLP-1s can be really great for um overall metabolic health. So, uh yes, helps with blood sugar and, you know, somebody who's actually diabetic. Yes, helps with weight loss um in a healthy way. Um but I really like I really have come to see that class of medications as um kind of holistic in that they support metabolic health. So, helping with fatty liver, helping lower cholesterol, lower blood sugar, even lower blood pressure a little bit. Um and it they they weren't designed for this. It was an it's an inadvertent finding is that they lower inflammation. Um we are also learning, they don't know how yet, but the GLP-1 medications um impact our brain chemistry. And they are just as they help with what we call food noise, they actually can really help people with substance abuse um disorders, addictions. That's awesome. Cool. Yeah. All right, sweet. Well, that is um the end of this episode. We I actually just did something special for everyone here. So, we, and I know Dr. Rose you appreciate this, is patients who are actually invested in their own health. And we started with 27, 30 people, and we have till still 26 here with us. So, you guys are awesome. Um and because of that, you know, we want to say thank you. Um I just posted a link in the comments that will actually give you $200 off as a new patient. Uh we want to encourage We don't normally discount this much, but, you know, normally we we want patients to invest in their health and their education because those are patients who are going to get better results. You know, this isn't uh the type of health care where it's a magic pill, you know, it's it's it's us working together as a team, and you're working with your provider. So, um yeah, that will be available for another hour just for people who watched the webinar. So, um grab that link, copy and paste it in your browser, um and then you can actually claim that there. Um other than that there, Dr. Rose, why don't you We'll give people few moments to grab that link. Um why don't you leave us with like some final thoughts around um kind of menopause and um just people's approach to their health. Yeah, so nothing is a one-size-fits-all. Nothing is a magic pill. Um it really I feel like um but I do feel like menopause is not kind of the end of the road. I feel like it it it actually can be kind of a time of vitality, and it can be a time one of maybe the best phases of your life when you're kind of receiving the right amount of support. Um And it's just so common that people feel like they're not themselves, etc. You know, that they're aging faster than they should and it's it doesn't really have to be that way. You know, as I think we've outlined in this podcast there's so many ways to kind of support a body, a female body as it goes through these transitions and um it's just I don't know. I just want I just want every woman out there to kind of know that these tools exist and this education and that this and this support exists because um yeah, it's just it's crucial. It's just as you know, it can be women are are sadly so often dismissed and um gaslit when they try to seek help and the more that we can change that the better. That's awesome. Cool. All right, well, thank you everyone. That is it for today's show. Give you a couple more seconds here grab that link it's in the comments just copy and paste it. And yeah, set up a call with someone from our team. Um Thank you, Paula. We appreciate you. Thanks for subscribing. All right. All right, everyone. Good evening. Thanks, Dr. Rose. Appreciate it. Bye, everyone.