There's ways to make you feel better, whether it's hormone replacement therapy or supplements or lifestyle, like there's not just to suck it up and get through it. There's plenty of options that you could choose to make yourself feel better and not feel like your life is falling apart or that you live in chaos for 10, 15, some people, even 20 years of their life.
Hello and welcome to another episode of Uplift For Her, I am your host, Dr. Mallorie Cracroft, and we are here to talk about all things integrative women's health. Today, we are talking about menopause and perimenopause, and we're very excited, because we get lots of questions. I have Jen here as my guest today. Jennifer Falkner is my nurse practitioner who works here with us at Uplift For Her. So we're super excited you're here. Welcome. Thanks for coming.
Thanks for having me.
We are going to be having really just a conversation back and forth between us talking about menopause. Jennifer sees our menopause patients here, and so we both talk a lot about menopause in a day, and we're excited to share with you the information that we have. So let's dive in. Shall we? Let's do it. Okay. Well, one of the questions that comes up the most, which should just be clear, is, how do I know if I'm in menopause? What is menopause? Will you just clarify some definitions for us?
Yeah, absolutely. So a woman goes through menopause when she goes one year and one day without a period. So Willy menopause is just one day after that. Your post menopausal, anytime before that, that you're having symptoms, is perimenopause as a follow up for that. How does someone know if they're in perimenopause?
We typically know if someone's in menopause based on symptoms. For the most part, there's a couple lab values, but really irregular periods and symptoms, is how we know if someone's in perimenopause. Perimenopause can happen or symptoms can start anywhere from two to 10, or even more than that, really, of symptoms before the age of 51 so some people can start having perimenopausal symptoms in their late 30s, all the way up until menopause. Premature ovarian sufficiency is defined as the last menstrual period before the age of 40. Premature menopause is defined as having your last period before ages 40 and 45.
You can tell Jennifer is studying for her test. She is going to be certified in menopause, and knows all of her definitions. So that's super helpful to know. I think premature menopause is worth bringing up because I think we don't really talk about it that much. It used to be called premature menopause, and now we call it premature ovarian insufficiency, or poi. That's a hard condition, actually, and that's when people get full on hot flashes, cessation of periods, really, their ovaries are shutting down far earlier than they should. So that's a little bit of a different entity all in all of its own. But just to advocate for patients, it's worth bringing up that it gets missed a fair bit, I think, especially if people are on birth control pills for years and then they come off and they don't get a period back. It can take a long time before anyone does their blood work to say, oh gosh, your body looks like it's in menopause. There are some lab values that are really helpful to confirm menopause. In perimenopause, it's a little bit more all over the place. So we'll talk about that, but tell us about the lab tests that can be helpful in menopause. Which tests do you run when you're talking to a patient who you think might be menopausal, she hasn't had periods for, you know, a handful of years?
The most common, I would say, is FSH, which is a follicle stimulating hormone, and this is produced from the brain, and it's shouting to your ovaries to produce more hormones, because your ovaries are going into retirement. So if that's elevated on two occasions, then we can assume that you're in menopause.
Yeah, I agree. Sometimes it can be a little bit vague, but, you know, sometimes it'll be like 30 or, you know, 22 and that's sort of in the moderate zone. If it's like 50, then you are very likely menopausal. So sometimes it's pretty obvious, and I don't necessarily do that testing routinely. I think if a woman comes to me at 51 and she's like, Hey, I haven't had a period in three years, and I have hot flashes and night sweats for me, I can almost tell you with surety that your FSH is going to be really high and your estrogen level from your ovaries is going to be really low, and therefore you're in menopause. So when people say, Well, my doctor didn't do any blood work, I don't always think that's inappropriate, because sometimes you can just tell testosterone, though, is different. I've seen some patients in their mid 30s or late 40s where their testosterone is super, super low. You could call that a perimenopausal symptom or a perimenopausal sign, but I've seen some 50 year old women whose testosterone is perfectly normal. So testosterone, I actually do test because of the estrogen and progesterone, you can I mean the estrogen and the FSH, you can pretty much guess at, but the testosterone can be a little bit all over the map. So in perimenopause, we know that progesterone is sort of one of the first hormones to go. So what would a woman feel like and what symptoms would she experience if her progesterone levels are low?
Signs of progesterone deficiency could be vaginal bleeding, heavy, heavy bleeding, and then also poor sleep, interrupted sleep, poor quality of sleep, some anxiety, and then maybe an overall lack of calmness.
Yeah, yeah. I think that's right. I think sometimes the anxiousness comes up. I think it's really this is a huge point to talk about with progesterone. And then we'll come back to the other hormone changes. Progesterone is the first hormone that I typically see going down, and we actually do see that going down through even the early 30s and mid 30s. It's one of the things that can contribute to fertility issues, is if you don't have really solid, great progesterone levels, it's not always due to perimenopause, but when you start seeing the progesterone levels sag, then you get lots of symptoms like heavy periods and painful periods, like you said, really bad PMS. So as women go through their 30s, and they say, like that week before, the period didn't used to be that bad, and now it's horrendous. That's progesterone, and it gets better when you give them progesterone. So I think it's important to call out that in conventional medicine giving progesterone, bioidentical progesterone is not commonplace. I was training conventional OBGYN and practiced for 10 years, and we really used quite small amounts of bioidentical progesterone. We use synthetic progestins for a lot of things, meaning birth control pills or North End drone or Provera, but we really weren't using much in the way of progesterone, meaning just this is what your body's already making. We use it some in fertility but really not much in other symptoms, and it's super effective, it's cheap, it's FDA approved, it has almost no side effects most of the time. So I really think it's a great tool that we have. It's actually one of my favorite things, because patients love me, you know, you come in with these big problems, and I give them progesterone, they feel so much better. That's a really great tool to know about. So where have you found it helpful to use progesterone in that perimenopausal transition? For the most part, I've
used progesterone with heavy vaginal bleeding, and then also just to help with mood and sleep for the most part. And I think that progesterone is a great place to start, because there's not really a lot of side effects to the micronized progesterone that we like to use. So it's a good place to start. If people aren't feeling, oh, I'm not sure if I want to start hormone therapy and progesterone, it's really safe that we know of in all the data. And then it usually works really well. So it's usually a great place to
start. Yeah, I think that's exactly right. I think a lot of times, and we'll get into this with the safety profile of estrogen. A lot of people worry about estrogen and things like heart attack and stroke and breast cancer, and really, there's never been a study showing any increased risk of breast cancer or anything with progesterone. So it's very, very safe, and you can adjust the dose 100 or 200. It's usually a capsule, and oftentimes it helps so much with sleep. So especially in the late 40s, I would say, when it's really the heavier perimenopause, I'll add it every day and just say, like, hey, take it for sleep every day. And a lot of people feel amazing. How do you dose it when you're doing heavy periods?
So we can do it cyclically. So the last two weeks before your cycle, your luteal phase is when we can do some with some patients, I'll even increase the dose, if they're taking it daily, maybe 100 milligrams. I can go up to 200 milligrams during the luteal phase, during the luteal phase, or we could just only dose it during those last two weeks before the period, just to help give a little extra support that you're not making anymore with your ovaries. Usually this helps women feel a lot better. They sleep better during this time, and also it helps with their bleeding quite a bit, so not bleeding as heavily. Yeah,
PMS too. Yeah. Gets way better with it. Yeah. So progesterone is a really great thing to try. It's and like I said, it's, if you don't like it, just stop it like it's safe to start and then stop. It's just a pretty easy and safe medication. I'm really grateful to have it in my toolbox. So during that perimenopausal transition, like we said, low progesterone leads to trouble sleeping, sometimes anxiety. This is one of the things that I think makes people feel a little crazy. When people say, I have this question on Instagram, how do I not feel crazy and perimenopause. So I don't think people are crazy, but it can feel a little bit crazy when you're like suddenly my brain is working so differently than it was often that's low progesterone, and it's really easy to fix. So tell us about estrogen.
So estrogen, typically, during perimenopause, is all over the place, which is why it's really hard to measure, and why a lot of times in conventional settings, they won't test it, because one day it's really high, one day in the next day it's really low. So it's not wrong not to test it, but we also could, because that's an option for us, specifically on certain days of your ventral cycle, if you're still cycling, your periods get irregular because of the estrogen. And fluctuations, but also with that you're at periods of low estrogen and high estrogen. The low estrogen symptoms you could experience are the typical menopausal symptoms, like hot flashes, night sweats, brain fog, skin changes, joint pain, muscle aches, hair loss, unwanted hair growth, elsewhere on your body, some autoimmune changes, changes in your microbiome, progesterone is pretty specific on what it helps with an estrogen can be anything really I if someone's having a symptom, I feel like we can't rule out that it's not estrogen, because there's estrogen receptors all over our body, and when we don't have it, our body can react in in really interesting ways, in personalized ways as well.
Yeah. Do you have any examples of patients who come in that you're like, oh, man, your estrogen needs some needs some love.
Yes, definitely. So when patients come in and they and they're complaining of the basic symptoms, I think they're pretty aware that they're going through perimenopause, but symptoms of brain fog and memory issues, and it's not, it's not I'm getting lost while I'm driving. It's, oh, I can't remember this person's name. And I used to be really good with names, that's when I get a lot actually, with my patients, is I'm just I'm so checked out of conversations because I'm not remembering things anymore. And that really can be a lack of estrogen.
Yeah, yeah. I think that's important to know, because that can be a little scary, and I think it contributes a lot to that feeling of like, I don't feel like myself. It's hard when you can't function the way that you used to tell us a little bit. One of the things that we see is in perimenopause, actually, the estrogen levels can go up a little bit before they start to go down. And this is something that it's worth pointing out. Menopause and perimenopause are having their day right now on social media and and in the media. And I think that's great. I am, I am a fan of that. And I think the more people know about their own bodies and understanding the transitions that their hormones are going through is is empowering. So I think that's great. But one of the questions I've gotten many times is so media makes it look like everyone needs HRT when they start going through perimenopause. And I think that can be a little bit more nuanced, I don't, I don't think that's necessarily true. How, what is your approach in that perimenopausal transition, when people start having changes, how do you address hormone replacement therapy in that age group?
Typically, I start with saying hormone pace. Hormone Replacement Therapy isn't something that we should start and stop and start and stop. It's kind of something that once we start it, and you're giving your body back these hormones, then we should probably stick with it. So with that, it can be a little bit difficult for some people to want to start taking something without a stop date. So I always give my patients their options. So we have hormone replacement therapy, we have lifestyle and really digging into the lifestyle. And then we have supplements like Vitex and maca. And then
we have also medications that can treat more individual symptoms. We don't have any medications other than hormones that really like treat menopause. You know, mostly hormones are what's treating we call the root cause, right? If the ovaries aren't making hormones, then the root cause is to give you the hormones. But there are some medications that can be used for some of the individual menopause symptoms like low sex drive or hot flashes. Yeah, yeah,
absolutely. And those can be a good option, especially for patients who have contraindications to hormone therapy. So people that should maybe are a little more weary if they had breast cancer in the past, or if they have a history of a clotting disorder or blood clots, then maybe those options would be better for our patients.
So when someone comes in and they say, Okay, I'm, you know, 38 like this patient, or I'm 42 How does that change your approach to hormone replacement therapy? Compared to like a 50 year old who comes in, what I find is oftentimes, their symptoms are different, right? I think that the 50 year olds and the people who start having cessation of periods really are seeing more hot flashes, night sweats, the real clear estrogen deficiency symptoms all the time. How does that differ in that earlier perimenopausal transition? For you,
what I've seen with my patients is really, I think PMS and mood and then irritability, and that's just the estrogen waxing and waning going up and down, and the progesterone going down too, yeah, along with the progesterone. So I think, and I think that really isolates a lot of my patients, because they're like, I feel like I can't be around my family, because I one day, I'm fine, and the next day I'm screaming my head off at them. So I think if they become a little bit more isolated in that sense. So I would say mood and bleeding. Bleeding can be really debilitating, especially heavy bleeding with that lack of progesterone. So
in that early perimenopausal that's where progesterone really is so dreamy, because it boosts that progesterone up, which is helping the symptoms we mentioned earlier. I don't find that a lot of these patients actually need estrogen replacement. And really, I think my approach to hormone replacement therapy is to go slow and to start one thing at a time. I think oftentimes people go to hormone clinics and they're like, Oh, you need hormones. And they just dump on testosterone, estrogen, vaginal estrogen and progesterone all at the same time. Time, but I really think women's symptoms by knowing, understanding the hormones and their effects, you can really get a pretty good idea of what's what their symptoms are due to, and really customize it to them. So I'll tell them, as you're going through this transition, this is going to change. You might start with just progesterone and vaginal estrogen, or maybe progesterone and testosterone and then later add estrogen, or later add vaginal estrogen and then add estrogen last. It's going to be different every time. And once they go through the full transition, when their ovaries really go into retirement, as you said, usually by that point, sometimes then we'll even have to adjust it again and raise that estrogen even a little bit more to make up for what their body was sort of, sort of keeping on board. There one question that I think comes up a bunch is, at least in this integrative space, is the idea of estrogen dominance. And I think it's really interesting, is that something you ever learned about in your training,
my training with you never in my conventional training.
Well, it's funny, because in the conventional world, I think anyone on social media has who follows this sort of integrative health approach will have come across that term estrogen dominance, and they also probably have come across really vehemently opposed conventional medical OB, GYN saying estrogen dominance isn't a thing. There's no such there's no ICD 10 code for estrogen dominance. And I find it interesting, because that's true, estrogen dominance does not have its ICD 10 code, which are codes that we use for billing insurance. But in the conventional medical world, there's no such thing like it's never been identified as a diagnosis, but if you just think about what they're trying to trying to say with it is that the estrogen levels relative to the progesterone levels are stronger. And that's something that we know about because we see it in women who are prone or women who are at higher risk for uterine cancer. They get uterine cancer because they have more estrogen in their body than progesterone. This was also in the early studies on hormone replacement therapy, they started by just giving estrogen, and found that women got cancer that was estrogen dominance. That is an estrogen dominant state when when the estrogenic effects are stronger than the progestogenic effects. And so it's funny to me that it's like totally denied that it's a thing, because it just is a thing. But with regards to what we're talking about in that perimenopausal transition, your FSH is the hormone that comes from your brain, and it talks to your ovaries, like you said. And in perimenopause, that FSH will start to work harder, so it starts yelling at the ovaries, and the ovaries, at first, will respond by spitting out more estrogen. So sometimes those perimenopausal symptoms are actually higher estrogen symptoms, and if you just start throwing estrogen at perimenopausal women, they might feel worse in a lot of cases. So just understanding that in that initial phase of perimenopause, your estrogen levels may be high, but your progesterone levels will still be going down, and that's a very estrogen dominant state, doesn't mean you have to do something specific about it, but just recognizing that people don't feel good when their estrogen is really high in the luteal phase and their progesterone is really low, and then after that, then it goes into menopause, where the estrogen then starts to come down, and the progesterone is low. So I think that's just a helpful thing to consider, because it's, it's pretty confusing. Yeah, I
think it helps give patients an idea of what's going on, rather than my hormones are all over the place. Yes, it's really like a visual thing, like, oh, I have more estrogen than I do progesterone, and that's why I'm having these symptoms. Like, maybe it's not a ICD 10 code, but I think it's helpful for patients to know what's going on in their bodies. Yeah,
I see the same thing with the phrase hormone balance, right? Conventional doctors get so mad about the phrase hormone balance because it's not a thing really like, but it is. I mean, our hormones are supposed to be doing a dance, a rhythmic dance, and they're supposed to be doing it well, and when they do it well, our bodies function really well. And when they don't do it well, then things are don't function really well. And so is it balanced? Like, 5050, no, there's no sort of like, it's not like an equal balance of hormones. But I think, are the hormones in rhythm. Are they? Are they staying in their own routine? And I think for semantics, I call it hormone balance, yeah, because we don't really have a word for it. So I think just saying, like, yeah, your hormones are out of balance. Quote, you know, I'm doing air quotes that our hormones are out of balance. Are they out of balance? No. But are they out of rhythm, out of sync? Yes. So I think it's just semantics, yeah, absolutely Another thing that's really confusing. Talking about hormone replacement therapy and menopause, are the phrases bioidentical and compounded. Tell us. Tell us more about that confusion there and what people are hearing from like their conventional practitioners that may be confusing compared. To what they may be hearing from more holistic practitioners,
the definition of bioidentical hormones are but are hormones that are the same as what your ovaries make? The structure is the same. They're derived from plants, but they're the chemically the same structure as what we what our ovaries have made throughout over our entire life. So the rest of our body is made throughout.
So what's a non bioidentical then
a non bioidentical hormone is something like a progestin, like a synthetic progestin, which is derived more from animal products, and it's actually more similar to testosterone rather than progesterone. So
if you look at it under as a molecular biologist, under organic chemistry, it's a different chemical compound. It's a different molecule altogether. Sometimes you'll see other estrogen products, like conjugated equine estrogen, that's Premarin. Sometimes you'll see estradiol acetate, which is the FEM ring, the vaginal estrogen ring. Those technically are not the exact same molecule, because they have other molecular structures added on. So that's what that means, bioidentical versus non bioidentical. Now this often gets confused with compounded or FDA approved. Explain how that gets confused.
So there are both bioidentical hormones replacement therapy that is FDA approved, but you can also compound bioidentical hormone therapy. So we have options for both. A compound pharmacy is a pharmacy that is not regulated by the FDA, and they're a little bit more of mom and pop kind of shop. They
have an individual pharmacist who's who's taking the powder of the of the estradiol and combining it with the cream to make a lotion.
Yeah, exactly. So we for bioidentical hormone therapy. You can use, you can do both. You can do a compound pharmacy, or you can go through insurance and have it and go do the FDA approved route through a typical pharmacy that that you would use for any other type of medication. Yeah,
I think I hear this come up a lot in in a lot of different areas of I'm in a lot of menopause conversations in my life, and I this, I see it, I hear it. A lot. People say bioidentical is a marketing term, and I disagree, I disagree with that. Bioidentical is not a marketing term. It can be used as a marketing term, but bioidentical refers to the actual chemical structure. So what are you taking? Are you taking conjugated equine estrogen, or are you taking estradiol? Are you taking estradiol acetate? That's not a marketing term, that's just clarity. If it's exactly identical to the compounds that your body produces, then it's bioidentical. So that includes progesterone, that includes estradiol, that includes testosterone. To my knowledge, there's no non bioidentical testosterone. So those are all bioidentical, but compounded is just the delivery system. So is it the kind that you buy in the package from the the pharmaceutical company, or does the pharmacy actually take the powder, make the cream and give it to you? One thing I want to point out is we say that compounding pharmacies are not FDA approved, and that's true. What that means is the FDA has agents inspectors. Sounds, sounds like FBI oversight. It has inspectors that go to the pharmacy, to the pharmaceutical company manufacturing plants, and they make sure that every single dose of medication that comes out is exactly the same, and they give it their stamp of approval. So that's good. That's good. The compounding pharmacy does not have that, but they do still go through rigorous regulations and inspection and oversight. They get audited randomly, like, it's not like they're out there doing their thing without any supervision. They really do have very high quality standards. There are horror stories. So you want to make sure that you're going to a compounding pharmacy that is reputable and that has, you know, good practices. But they pharmacies have their records of their audits, and they can say, this is when we last were inspected, this is how we passed, etc. So there are ways to vet compounding pharmacies. So bioidentical is what we want, I would argue just about always when we're doing hormone replacement therapy, we want bioidentical it's still quite common to go to a gynecologist office and to be offered synthetic progestins that would be things like Provera, medroxyprogesterone or norone. Those are synthetic progestins, and they do not have the same positive effects that we see with progesterone, they do have positive effects in that they're countering estrogen, so they're keeping your uterus safe, which is what, by and large, they're being used for. But they don't offer benefits for sleep, they don't calm anxiety, they don't offer that restoration of self. You know that a lot of people will feel with progesterone, so if you go to your gynecologist and they say, Here, I've given you a prescription for northendrone, or if they say I've given you a prescription and it doesn't say progesterone, it's perfectly fine to say, Would it be okay if I tried progesterone instead? And most of them will say, sure, but there's just not a great reason to jump straight to the progesterone. And they have been linked to increased risk of breast cancer in the Women's Health Initiative study, and there's no benefit. So go with the FDA approved non compounded to start with. I do use compounded prescription sometimes, but I usually try to start with the non compounded FDA approved prescriptions because they're less expensive. And then go with with the compounded if we need to do something special, if we need to adjust the dose, or some people have side effects, and we're using different formulations for that. Another thing that I hear come up a lot is that anyone who offers you compounded hormones is just trying to make more money off of you, and I think that comes because there are some practices that actually sell compounded hormones as they're their own pharmacy. I think when you get pellets that's always dispensed through their own office, and so clinics to I would say most clinics that are dispensing pellets are making additional money off of the testosterone pellets. But compounded medications do not necessarily mean that the practitioner is making a bunch of money off of the patients. I prescribe through a compounding pharmacy, the same as I prescribe through any other pharmacy. I don't make money off of any of it. I say you could have this prescription if you want, and the patient goes and pays the pharmacy. So I think that's another misleading statement that we hear a lot, is that if you're getting compounded, that's your doctor's making money off of you. And that's just ridiculous. Like compounded prescriptions are just from a compounding pharmacy, pros and cons to it, but you should understand what it is, and also understand that bioidentical you could have compounded or not compounded, pros and cons to both, but they're not identical, interchangeable terms bioidentical and compounded. Did I explain that? Or is that confusing? I
think you explained it great. And there are FDA approved bioentical hormones, right as a term that is recognized by major medical bodies, right?
Exactly, exactly. So you can do that. You can get bioidentical FDA approved estradiol, and it's a good thing, usually, in the form of a patch. Is what we recommend. I
think this would be a good segue to talk about the delivery systems of how we give hormone replacement therapy, and specifically what's available and how what we do here at our clinic,
yeah, tell us about that, and recommendations from the North American menopause society, and also where there may be some wiggle room there.
Okay, there are several different ways you can take estradiol specifically so you can take it through a pill, you can take it through a patch, through creams, gels, rings, pellets. The most data has been shown on oral estrogen based on the Women's Health Initiative from 20 years ago. But what we like to do here is transdermal estrogen, which is an estrogen patch that goes it's absorbed through your skin, just because that is the form that gives us the least amount of side effects and also lowest risk. The estrogen patch mitigates the risk of gallbladder disease, and it also mitigates the risk of increasing clotting factors, because we're not getting that first pass effect through the liver when you're ingesting it. Yeah, and
I think that's pretty commonplace now. I think most places you go will not give you an oral estrogen. Not all. I still see patients come to me on oral estrogen, and I don't think it's like, I don't think it's evil. Yeah, you know, I think there are definitely some people who think that oral estrogen has actually some benefits, but I don't think we have the data to support that. I think the data really argue in favor of through the skin estrogen. That's cream, gel patch. I think that's really the way we should be delivering estrogen. If you've already been started on oral estrogen. Do you need to run out to your gynecologist and be like, I need to switch to the patch right now? I think that's debatable. I think that's arguable. I think one way to think about it is if you've been exposed to large amounts of estrogen for a long period of time, and you've never had a clot, like you've had four babies, or you've been on birth control pills, or you've already been on oral estradiol for 10 years, your chances of all of a sudden having a clot because of that are are probably pretty low. But if you're just starting estrogen, I would start with through the skin. And I don't see a great argument to not do that. It's FDA approved. It's inexpensive, like we should really be doing the transdermal estradiol where possible,
yeah, I've had most patients be pretty receptive to that. If they've been started on oral estradiol. We have a conversation about the risks, the benefits of switching to a patch. And everyone that I've seen so far has been willing to switch to the patch just after a little bit more education. Yeah,
we just see better effects with it. Yeah, yeah. Tell us about delivery systems for the others you started on the estrogen. Tell us about progesterone, and then the testosterone and also vaginal estrogen.
So progesterone, we like to give it to capsule. Micronized progesterone, the bioidentical hormone, we just give us a capsule, and it's generally well tolerated. Progestins, there's a couple different formulations, because you could do an IUD, you could do a birth control pill, you could do the next plan on the implantable rod for birth controls also has a progestin in it. So there's several different formulations for progestins, but for micronized progesterone, you could do oral tablet, or you could do a vaginal capsule. And then I've also seen patients have a progesterone cream as well. So.
Yeah, the best data on the safety of countering. So let me back up, when you have estrogen, you need to have progesterone with it, especially for the uterus, because the estrogen on a post like we mentioned earlier, can lead to uterine cancers and other problems. You really want that estrogen and progesterone to be in a dance together. So we never give estrogen on its own, but if someone does have a uterus, then they always, always, always need progesterone with their estrogen. Now, along those lines, the best data that we have for progesterone balancing the estrogen is through either a pill or an IUD. We don't have any data to any great data showing how much of a cream gets absorbed, to say if it's actually appropriate for the amount of estrogen you're on. So if you're in perimenopause, I think the cream can be fine, but when you're taking estrogen, I like the the patch or the IUD. I think it's a good time to talk about the IUD for a second, because I get this question a lot is, I have a Mirena IUD in. I'm 43 you know, I'm getting symptoms of perimenopause. I still need contraception, and I kind of want to think about adding some hormones in, in general, the way that I approach that is to say, Well, number one, contraception, if you get the IUD out, you do have to figure out some sort of contraception, until when no one really knows the answer to that. I think the idea of conceiving spontaneously after 4546 it's pretty low, but we can't say for sure that there's no chance of you conceiving until you're 100% menopausal, meaning you've gone one year and a day without a period. So I think for contraception, i i do like to see some sort of contraception up until somewhere around 50. Now, I do have patients who will say, like, I don't believe I'll get pregnant, and then that's on them. Like, patient empowerment, they can, they can do that. But in general, you do want to be thinking about contraception. So if the IUD has worked really well for you and you've had horrendous periods, is it worth taking out the IUD to then have periods to then mess with your hormone replacement. I think it's a personal choice. One thing that I do see is that the IUD can be responsible for some negative periods or negative side effects. So I get a lot of patients who say, I went to my doctor, they told me there's no chance the IUD can be causing that. And that's just not true. If someone says, I think my IUD is causing this? Then I say, yeah, it could be, because the IUD can actually cause a lot of side effects. It's also a wonderful method of birth control, so we're living in the nuance here. This isn't IUDs are good or bad. They can be really great for some people, and they can cause side effects for some people. But if someone says, I'm thrilled with the IUD, I don't want to take it out. Can I still, you know, have the benefits of hormone therapy, like I'm starting to get some hot flashes, I can't sleep, I'm feeling really anxious or depressed. I've got vaginal dryness. There's no reason why they can't leave the IUD in place until 5052 and do hormone replacement therapy. So that's just a little side side segue in a question that comes up with the IUD
and the IUD can provide some endometrial protection because you're not getting a period, so that lining isn't building up with the IUD, typically, if you're amenorrhea with a if you don't have periods with an IUD in
so and that's why it's so helpful to talk to a menopause expert who can really help you identify what your symptoms are. Trying to tell us, because we have had patients who have the iudn but they have symptoms of estrogen deficiency, but they don't have symptoms of progesterone deficiency, and I still lean towards oral progesterone in that case, because people just feel so much better. And I like the idea of balancing the estrogen in all of the other areas of our body that have progesterone receptors, like our brain and our breasts. But technically, if you have someone who says, Look, I feel fine with my IUD, except I'm getting hot flashes, you could just do estrogen and an IUD. I still like the progesterone oral because I do think people feel better, but, but technically, there are, you know, different ways that you can approach that tell us about testosterone.
Testosterone levels we like to check before we before we start to supplement or give you, give you back some testosterone. And symptoms of low testosterone can be a decreased sex drive, a loss of vitality. Maybe what you're exercising, you just don't feel like you can give it a last extra push. Symptoms like that, where they're a little more vague, I would say. But really, checking your lab values give us a pretty good indication that your testosterone is low. Some people are unreadable low, like less than three, and some people like, maybe I'm 16, but I feel like there's definitely room for improvement. And we know that testosterone dosing, as long as you're within a premenopausal woman's range, it's pretty safe, and as long as you're not being dosed too high, there aren't a ton of side effects with with testosterone replacement therapy, testosterone pellets can't are probably the most common form of testosterone being used right now, least of the what I've seen in practice. And this question comes up a lot. Yeah, it does, and I. Pellets are not my favorite thing, because once they're in, they're in, once they're injected into your skin, you can't get them back. So if you're having symptoms of really high testosterone, which could be acne, some hair changes, unwanted hair growth, mood changes, those you're kind of stuck with that for three months, which is really hard. More sometimes, yeah, more for which is really hard for patients. So that's definitely not the route that I lead people down. I prefer to do a compounded testosterone cream and with some maintenance lab work to make sure that we're not we're not dosing too high, because everyone's different, and some people need different doses to feel better. So really, just regular monitoring going off of symptoms for testosterone. I get this quite a bit for people wanting to know about their testosterone specifically linked to decreased sex drive.
Yeah, I think it's worth pointing out too that this is sort of my approach differs a little bit from some of the mainstream media approach right now. And it goes back to I had a question from Instagram about menopause, and she said, how young is too young for HRT. I'm 38 and my provider put me on HRT. And I think it's a really good question. I think hormones are such a buzz right now that it's really easy to go to kind of some offshoot hormone clinics where they've, maybe haven't been doing it for very long, or they see it as I think a lot of hormone practitioners not to throw anyone under the bus, but to throw someone under the bus. I think some hormone practitioners see it as an easy thing, because you test blood, then you give them hormones, and a lot of times it works. A lot of times they feel better. But I really it is more nuanced than that. And one of the things to think about is, if you're 38 and your hormones are low, why are your hormones low? Is it just perimenopause, or could it be something else going on? One of the things that lowers testosterone, which got me started down this road, one of the things that lowers testosterone is stress, and stress can also lower progesterone. Remember that when we're in a state of chronic fight or flight, the body will feed back and say, maybe it's not a good time to have a baby right now. So it will. It will down regulate reproduction in favor of staying alive, which is generally a good adaptation. But when we're trying to have regular periods, we just want to notice that this could actually be your body trying to tell you something. So I'm not opposed to giving testosterone in that case. I'm not opposed to giving progesterone or estrogen, if that's necessary in that case, but I definitely think it's worth a longer conversation rather than, Hey, your testosterone is low. Take this testosterone for the rest of your life. I think it's worth saying, like, Why would my testosterone be low? We actually don't have enough data on on this type of situation of like, why is someone going through such a crappy perimenopausal transition? Why is this so hard for them? But Susie down the street is just fine going through her perimenopausal transition. Obviously, some of it is genetics, but a lot of it is other things going on in the body, things like cortisol going into play, inflammation going into play, poor stress reduction or lack of sleep going into play, poor exercise, poor food, gut health too. Yeah, exactly. Gut health really plays a strong role in that, and so especially in the earlier perimenopausal transition that late 30s, early 40s, I'm pretty I'm a little slower than some to say, like, Great, let's start your hormone See you in a year, right? Like, I think it's worth saying, can we help your health in other ways if you want to take testosterone in the meantime so you feel better? Great. But you should know that it's not just like, well, the ovaries fail in the late 30s, and your life is going to suck for the rest of your you know? Like, I think it's worth a more nuanced conversation about that.
Yeah. And I also don't think, I think hormone replacement therapy should be individualized. But if we're giving you hormones back and we just and your levels aren't showing it, I don't think it's best to just keep throwing hormones like keep increasing dose, keeping increasing the dose. I don't think that's helpful either, because there is something else probably going on related to your overall health, of why you're not, maybe not taking the more standard doses for women your age. Gosh, that's
such a good point. And I have had many patients come to me who have gone to a pretty hormone centric clinic. And I would say that the older you are, the more those hormone centric clinics. It does get simpler as you get closer to menopause, right? That's a little bit more like, well, you're 50, so yeah, your testosterone might be low and your estrogen progesterone might be low. We fix them. You feel better, but the younger you are and you think you're having perimenopausal symptoms, you're not wrong. It could be, but it doesn't mean that the answer is just to say, like, Well, then let's give them back to you. Like, sometimes we need to say, like, why are they low? And so what I have seen patients come in with is they go to a hormone centric clinic, and they come in on 234, times the dose of of typical hormone replacement. That's not hormone replacement. That's like, that's just like dumping hormones in your system. Why are you not making the hormones to begin with? We. Really be able to treat hormones with physiologic doses, right? There's no woman who needs 800 milligrams of progesterone. I've seen multiple patients come in on that there's that's not even physiologic, like even if you made zero progesterone, that would not be necessary to get you back to an optimal level. So if you're not getting better with hormones, then you need a different approach, not just more and more and more and more. There's a lot of debate about this too, and I think it's because we don't have good data. There is some data around dosing to blood levels, but it's really quite poor data. I think there's also data around dosing to saliva levels, so testing estrogen, progesterone and testosterone in saliva. And I don't I live in the nuance, so I don't think we should say that it's like, all right or all wrong, but we do have to take it in context and say, This is what your blood work says. This is what your symptoms say. Maybe we try this and then see how you respond, and then we adapt. And that's precision medicine. That is personalized medicine, rather than just following protocols and saying, This is how I do it every single time. So I guess just a pitch for how we do things. I
think an important thing to bring up, as well as is, most practitioners are not trained very in depth about menopause and and how to treat perimenopause across all different providers, MDS, pas, NPS, dos, all of them that no one gets that much training on menopause and specifically how to treat them and where to go when maybe someone doesn't fit a perfect little box of, oh, you're having hot flashes. Let's just give you estrogen back. If they're having more symptoms than that, it can be a little bit more difficult.
Yeah, I think that's right. And it's also changing, and the data is ever changing, so it really does require quite, quite a bit of specialization. So I think that's a really good point. I think you mentioned testosterone pellets. We don't really love the pellets, because one thing to emphasize there is it's really easy to overdose pellets, because you're just guessing at a dose. And so when they guess at the dose, they implant it under the skin. That's your dose. That's that's the dose you have now. And if you hate it, then there's no going back on that. And usually it's too high rather than too low. So having too much testosterone can actually cause some, some really undesirable symptoms, like hair loss or acne or hair growth in undesired places. So I think it's pretty important if you are going to do testosterone. I don't do pellets, but I do think that if you're doing testosterone creams, and you've been on now a really steady dose for a while, and you convert that into a pellet, that's the only way that I would consider doing it. I still think that the the nature of release from a pellet still gives you a higher dose at the beginning and then slowly releases little bits over time. So it's still not my favorite. But if I was going to do it, then I would say only if you already know your dose, you've been on it, you've been happy with that dose, and now you've converted it to the pellets. That's the only time I would consider it. And again, that's that's nuanced, right? You're not going to hear that from very many places. I think people are either like, testosterone pellets are great, and, by the way, I make money off of doing them, or you're going to hear from conventional medical doctors who say testosterone pellets are evil, and you should run from any practitioner who says it. So we really want to, like, Get the facts and be in the details as we're talking through this.
One last thing about testosterone too, is some side effects can be irreversible, yeah? So at really high doses, yeah, very high doses. So it's just important to have all the information before you put something into your body that you can't get out. Yeah, yeah. I
think that's right. And, and I but I'm grateful for it, because, man, there are some great success stories of people who really feel like they got their life back. I had a question on Instagram that said advice for women who feel like they're losing themselves in the chaos, and how do I get my vitality and identity back? And that is exactly I mean, almost word for word, what some patients will say when they come back and you've you've balanced, you've gotten them on the proper testosterone dose, you've gotten their estrogen right, you've gotten their progesterone dose. So many people will say, I feel like I got my life back, like I feel like I was a crazy person. And this is not insignificant. I definitely have patients who say, like, I don't know if my husband will stay married to me because I am not myself. I'm yelling all the time. I'm unhappy, I'm miserable, I don't feel good. I never want to have sex. Those are, we shouldn't minimize those things. Like, it makes me really upset when people are like, well, that's no big deal. Like, that's a really massive deal. That's your whole quality of life, that's your whole lifestyle. And if we can make that better, then it's worth knowing that, and it's worth being able to do that. So I think right now, still the only FDA approved diagnosis for some hormone replacement therapy is hypoactive sexual desire disorder, so we'll give you hormones if you have a low sex drive, but not if your mood is so bad that you might divorce your husband, like that's not fair. Why does an insurance company get to decide what's what's worthwhile if there's a Medicaid. Can treat it, then you deserve to have that medication. So just a plug for if you do feel crazy, hormone replacement therapy can make a massive difference. And when I get people that this person mentioned chaos, I do think that the menopausal transition, I call it the the great Revealer, because if you have any bit of anything, some, some borderline cholesterol, some borderline blood pressure, some some iffy mood stuff. You hit menopause. It blows it up. It will take problems that were sort of there before, and can make them really, really obvious. And so it can cause, in addition to the physiologic changes of the body, it can cause this, like what just happened, like everything is falling apart. And in those situations, what I recommend is simplifying the approach by saying, let's get the hormones adjusted. First hormone replacement therapy, compared to functional medicine, is actually pretty easy, so we get that fixed, and we get the hormones leveled out, and then we can see what symptoms are left. When I talk to a woman, she'll come in with 1015, 20, really bother some symptoms, I can't always tell which one is menopause and which one may be more functional medicine or integrative medicine, issues like nutrient deficiencies or hypothyroid or things like that. So we say, let's get the menopause stuff figured out, and then let's see what's left. For some people, nothing will be left. It'll fix them 100% they'll feel like a million bucks. And some people, they'll say, like I'm sleeping a little better, but I still feel terrible. And then we can dive into the other lifestyle and functional medicine approaches, of of supporting the body in other ways, so that sort of, if you feel like your body is falling apart, I would think about starting with hormones, because it really does simplify the approach. I think
also that if you are going to your provider, I've had several patients come in and they say, like, my doctor just said, like, this is the time of life you're in, or, you know, it'll end in a couple of years. I really don't think that's an adequate answer, and you should deserve to. There's ways to make you feel better, whether it's hormone replacement therapy or supplements or lifestyle. Like, there's not just to suck it up and get through it. There's plenty of options that you could choose to make yourself feel better and not feel like your life is falling apart, or that you live in chaos for 1015, some people even 20 years of their life.
Yeah, yeah. Another question that came through on Instagram is, how do I find a doctor that will listen? And that, first of all, just makes me really sad, because, like, that's our training in medicine is to listen. And I do think a big problem is that we're not trained well, and we are pushed by insurance companies and hospital administrators to be very, very, very busy. So just some I like to shield my my colleagues in medicine, because it's a rough gig, like it's, it's, there's some really hard things about it that are pressures outside of us that as as doctors and practitioners, we can't always control, but it, it affects the relationship that we have with our patients. So I want to protect them a little bit and say I think that the training is poor, and I think the time is is low. I don't think we have enough time to really do this appropriately in the conventional medical world, but I also think that it's okay for patients to advocate for themselves, and I think the more empowered they can be to say, these are my symptoms, I think I'd like to try this estrogen patch and this progesterone that's good. Now, obviously the Step Up is to go to a hormone specialist who's going to take the time and see the nuance and make sure you're getting the care you need. But I think absolutely advocate for yourself in terms of finding a doctor who will listen like you were saying. I think it's, I think too often women are told like, well, that's not bad enough. That's not bad enough to warrant hormone replacement therapy. And I think that the data actually argues against that quite a bit, and that hormone replacement therapy is good for health benefits, for for disease prevention. So I think we're going to get there. So don't despair. I think the medical world is going to catch up and they're going to get there and they're going to see like, oh, HRT is actually protected for disease prevention. But right now, I think that women can be gaslit. I think that they can be made to feel dumb or crazy when they have all these symptoms and say, like, well, that's not bad enough for HRT. And I really think that you should be able to have hormone replacement therapy if you want it. I mean, well, it's our job to give you the contraindications, and it's our job to make sure you're doing it safely. But if you're getting that response from a doctor, then I would go to another doctor. And I do think in terms of, like, how do I find someone? I think there's some good resources. I think Dr Mary Claire havers, the pause life with Dr Mary Claire haver. I think that website has a great list of menopause practitioners. I think even a simple Google search, if you Google menopause and doctors, you're more likely to find someone who's advertising themselves as doing hormones, instead of the busy, overbooked doctor who's like, Oh, please don't talk to me about hormones. You know, who's gonna like, dismiss you or throw stuff at you and send you out the door. So it does take some work on your part, and I think that I. In terms of just your regular everyday OBGYN as a regular everyday OBGYN, I will say that some do more reading about it than others. You know, it's not actually part of our core training. You have to kind of do additional North American menopause society training. I think that's getting a little bit better. The American College of Obstetrics and Gynecology is starting to put more training in, but it's pretty scant still, so I think you have to find someone who's really interested in menopause. And unfortunately, that's just a little bit of a crapshoot. So the only thing I can say is keep trying. Go to someone if you don't like it, go to someone else, talk to your friends, create a network of girlfriends, and find the doctor that all the friends are going to the same doctor, and go to that person, because it can be really frustrating. And I would say, don't be too disheartened. There are answers out there, there's help out there, and you can get the help that you need. It just may take a little bit of legwork. Unfortunately, yeah, absolutely. Well, we'll talk again, and maybe next time, we can get into more of the lifestyle and some of the herbs and some of the alternative treatments and even some of the medications outside of hormone replacement therapy that can be really beneficial for the menopausal transition. But I think for today, is there anything else that you feel like you want the megaphone to talk to the group of menopausal women? You see these women all day, every day, and you help these women, and you know what they're coming in with. Is there anything that you want to say to them, yeah, my biggest thing is, first thing, you're not crazy, yeah, and that there's, there's, there's options, there's solutions. We can help you feel better. You should feel better, and you shouldn't feel like you're surviving day to day. There's ways to make you feel better, whether it's and there's many different avenues that we can take. So for my megaphone, yeah, you can feel better. Yeah, I think that's a great megaphone. I will take that well.
Thank you for being here, Jen. If you want to see Jen, tell us how patients can find you.
You can find me on our website, at upliftforher.com, you can book an appointment online. I am doing menopause, perimenopause hormone health visits, and I have some openings available where I can see you pretty quickly, and you can also book by calling an appointment.
Yes, and you also offer discovery calls. So if people aren't sure if this is the route they want to go, they can just sign up for a free discovery call and chat with you for a few minutes. Hopefully they'll see our approach from this episode. So they should have a pretty good idea, but that can be a great option too, to just fill it out there. So thank you for what you do. Jen, it's important that you're, you're in this world, helping these women navigate this because it's a kind of a crazy world when it comes to perimenopause and menopause, and lots of lots of good information, but also lots of confusing information. And we are here to live in nuance, to help find clarity from the polarized views that want to make it seem overly simplified, but also to simplify it when it seems overly complicated. Can we just say like this is, this is what's going to be best for you. So we're happy, happy to be in this work, right? Absolutely. Yeah.
Well, thank you for tuning in. This has been a fun episode to talk about. We hope that you'll join us next week when we're back with another episode, don't forget to like, subscribe and follow. The reviews really help us. So if you can leave us a review, if this is helpful for you, we'd love to get the word out that we are sharing good information and good education for women's health. Women deserve it. They deserve really high quality education, and that's what we're striving to provide. So you can follow us and check us out on podcasts, or you can check us out on YouTube and watch the video. You can see our smiling faces, and we'll see you back next week. Thanks for listening, and come back next time for another episode, and remember this information is for education only and not intended to be medical advice.
