Your Lifestyle Is Your Medicine
“Your Life Style Is Your Medicine” is a podcast that focuses on how a person's lifestyle can be the key to health and happiness. Routed in the principles of lifestyle medicine, Ed Paget, osteopath, and exercise scientist, interviews area-specific experts on how lifestyle impacts well-being, focusing on purpose, physical activity, nutrition, sleep, and stress, which could lead to a longer, happier life. Edward now runs immersive lifestyle medicine retreats, with the purpose of helping others take back control of their lives to live longer and healthier.
Your Lifestyle Is Your Medicine
Podcast Episode 64: Understanding Menopause
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Menopause gets treated like a vague “phase,” but one detail changes how you think about everything: menopause is literally one day, marked after 12 months with no period. The harder stretch for many women is perimenopause, when ovulation becomes unreliable and hormones fluctuate in ways that can disrupt sleep, mood, focus, weight, and relationships long before anyone says the word “menopause.” That confusion fuels bad advice and delayed care, so we wanted a plain-English reset.
I’m joined by Katie Lomas, a nurse practitioner who specializes in women’s health and hormone replacement therapy (HRT). Together we tackle the myths that keep coming up in clinics and group chats: whether you can use HRT in perimenopause, what’s actually happening with bone density loss and osteoporosis risk, and why “no hot flashes” doesn’t mean “no problem.” We also unpack the lingering fear around breast cancer risk and the Women’s Health Initiative, including the difference between relative risk and absolute risk, plus why the type of hormones and the delivery route matter.
We get practical about options and personalization: transdermal estrogen (patches and gels), oral estrogen, micronized progesterone for uterine protection, and the often-missing conversation about testosterone as a human hormone that can influence motivation, cognition, mood, libido, and muscle. Katie also explains why vaginal estrogen is an underused tool for GSM (genitourinary syndrome of menopause), dryness, pain, and recurrent UTIs, and why shared decision-making should start with your goals for health span, not just a prescription.
If this helped you sort truth from noise, subscribe, share it with a friend who needs it, and leave a review so more women can find evidence-based menopause care.
Menopause Starts With A Surprise
SPEAKER_01So menopause is literally one day. It's marked by one year of no periods. And that one day, so that 12 months of not ever you're having a period. Congratulations. Now your ovaries have failed and you're not making any more. We don't really know when we're going to go into menopause. There's no test out there that says to us, like says, your ovaries are going to fail now.
SPEAKER_00Welcome to the Your Lifestyle is your medicine podcast, where we do deep dives in topics of mind, body, and spirit. So these conversations, you'll hear practical advice and effective strategies to improve your health and ultimately add health span to your lifespan. I'm Ed Paget. I'm an osteopath and excise physiologist with a special interest in longevity. Now in the clinic I work in, we hold weekly meetings where we get a guest speaker to come in and educate us on their specific domain. Now recently we had the pleasure of hosting today's guest, Katie Lomas. Now she's a menopause expert who managed to articulate and educate us on women on what women are going through without losing me personally in all the complex details of hormonal cycles and different medications. And her way of explaining things was so simple that I just simply had to get her on this podcast and share her knowledge with you on this very important topic.
Meet The Menopause Nurse Practitioner
SPEAKER_00So okay, welcome to the show.
SPEAKER_01Thank you. It's an absolute pleasure to be here. Thanks for having me.
SPEAKER_00I always like to start these episodes with the guests explaining a little bit about who they are so that our listeners understand where we're going to go on this journey and who is the expert in front of me.
SPEAKER_01So I'm a nurse practitioner. I work with women specializing in women's health and specifically hormone replacement therapy.
SPEAKER_00Perfect. Can you just tell us a little bit about the difference between a like a nurse that someone might be familiar with and a nurse practitioner? Are they two different things?
SPEAKER_01They are two different things. So a nurse practitioner has advanced training, I have a master's training level. We practice similarly as a general, like as a GP. So we can prescribe, we can diagnose. Our background is nursing, though. So you would have started off as a nurse and worked as a nurse and then worked towards becoming a nurse practitioner.
SPEAKER_00Perfect.
Perimenopause Vs Menopause Defined
SPEAKER_00Okay. And you so your specialism is really perimenopause and menopause. And one of the million dollar questions is the definition of those two terms. But I think we should start there so we can ground this conversation. Let's start with perimenopause. What is that?
SPEAKER_01So perimenopause is a time where you how I explain it to my patients is your ovaries are reaching a critical stage where you have you're not able to um, you don't have as many eggs anymore. So you're not going to be ovulating as often. So your hormones really start to fluctuate. So it's a it's a time, and I've heard this quite a bit, and I think people can relate to this feeling is a hormonal chaos, just this up and down, up and down, up and down, where your hormones are they're they're not being reliable anymore. Not reliable anymore. And it's and it's about a seven to 10 year period for women. So this is this is not a short period in in time, and this affects every single woman who, every single one is going to go through perimenopause, and they'll experience it very differently. So uh some women will experience it very differently. So it's it's a challenging time, very challenging time.
SPEAKER_00All right. And then what is menopause then? And can you contrast those two things?
SPEAKER_01So menopause is literally one day. It's marked by one year of no periods, and that one day, so that 12 months, the not ever you're having a period. Congratulations, now your ovaries have failed and you're not making any more eggs. That is menopause. So the the idea of like menopause, perimenopause, the how we kind of use the vocabulary, it it's all fluctuate, like look, fluctuation of hormones in the beginning, up and down, up and down, up and down, and then really getting to a place where you have little to no hormones or just very kind of more stable. So a lot of women will actually experience a lot worse symptoms in perimenopause than they will in even menopause because of this up and down, up and down, up and down. And this idea that women can't have hormone replacement therapy in perimenopause and they have to wait for their organs to actually fail is very outdated.
SPEAKER_00Okay, let's explore that a little bit because I was talking to clients, friends, and some family about uh this podcast doing my research, and they all had differences of opinion about things. And it seems to me that there's so many myths out there. And so I want to set the record straight with you right here, right now, on perimenopause and menopause. Not sure I'm the right man to do it, but you are the right woman to do it. Okay, so I didn't know this that in perimenopause, you could be having HRT. In fact, is it it's better, you just said, to have HRT.
Why HRT Can Start Earlier
SPEAKER_01Yeah. Well, if like just think about it from like a logical point of view, right? So your hormones are going up and down, up and down, up and down. Two years before you hit menopause, and we don't okay, first let's back up a minute here. So we don't really know when you're going to when we're gonna go into menopause.
SPEAKER_00When you say lose bone mass, is it there there's a peak bone mass loss at that time, or is it just this is the beginning of your bone loss that happens throughout the rest of your life?
SPEAKER_01So women will lose uh the two years before menopause, they'll start to lose their bone mass. It's gonna depend on genetics a little bit, it's gonna depend on lifestyle, which I'm sure you know your muscle mass, exercise, diet, all of those things contribute to this. But when you don't have estrogen anymore, so estrogen acts as a mediator between the two types of cells that build up bone and break down bone. When you don't have estrogen in the amount that you used to have it circulating around anymore, because the two years before menopause, that's when where estrogen really starts to drop. So if we back up and talk about perimenopause and talk about hormones and how and kind of the where the first hormones that really start to lower in perimenopause is progesterone. So that's the first one that starts to go down. So then testosterone, then estrogen. Estrogen, your body's always trying to make estrogen. It's always trying to do funny things to make estrogen. And I'm sure we'll talk about that because like with weight loss or weight gain and everything, right? So if you if you back up and you think about so progesterone's lowering, testosterone's lowering, estrogen is the last one that really starts to take a dive at those last two years. So that's when we start to see more symptoms like hot flashes, we start to see um brain fog even, and then the bone loss. And so for again, for a lot of women, we're not doing DEXA scans, we're not measuring because it's not part of um the schedule because you're you're you're too young. But I see I see women in their early 50s that have low bone mass already that have not been on our HRT during menopause, um, for you know, for multiple reasons. But the the HRT is definitely part of that story.
SPEAKER_00So this might be a myth then. Uh I was under the impression that there was like a period of time for those two years that you lose a lot of bone mass and then it sort of stables out a bit as you get older, but that's not true.
SPEAKER_01It doesn't stable, it doesn't stabilize unless you were exercising. You were you know that so there are things that you can do to increase bone mass. So so I don't want women to think that if they're not on HRT, they're going to lose all their bone mass, because not every woman does that. So there are other things that help increase your bone density, exercise, plyometrics being a big part of it, right? Which I'm sure you know you probably know a lot about. Um, so like having that jarring motion on the bones is really important. So just because you don't have estrogen doesn't mean you're gonna lose all your bones, but it increases women's um the chances that they're gonna get osteoporosis, osteopenia, so low bone mass. Uh and and we see that more in women as you age. So more women as they're older that are not on HRT are going to have hip fractures, larger, you know, hip fractures. And of those women, a lot of them were then going to lose their mobility and not gain their mobility after having those incidences. So it's a very it's preventive, like preventative.
SPEAKER_00Okay, so that's that's interesting. You gave us a clue there that there's some research that suggests that women who don't have HRT have an increased likelihood of hip fracture and all the complications that are associated with that.
SPEAKER_01Yeah, that's it's very well documented.
SPEAKER_00All right. Well, let me throw out another myth there uh and see if it's true or false.
Breast Cancer Fear And WHI
SPEAKER_00Some people think that if they take HRT for an extended period of time, it's going to increase their risk of breast cancer. True or false?
SPEAKER_01Yes, it's false. So that's that is a question that I get quite a bit for women that come in and the concern that they have around HRT. So well, and we'll just I'll take you back to kind of maybe where that started from. So prior to um, so so women, first of all, women have been on HRT since the 70s. So they, you know, and so and it was well known that being on HRT, replacing estrogen in particular, helped women have less chance of cardiovascular disease, all these different different ailments. And so there is a study that was in the early late 19 or uh 1990s, early 2000s called the Women's Health Initiative. So that study looked that's like good study, bad study, but um it what it did is it looked at hormone replacement therapy for women. We can, that's a whole podcast of the women's health initiative study. But in a nutshell, it looked at hormone replacement therapy in women, um two groups of women. So one group that had uh their uterus, so they were receiving estrogen and progesterone, but they were receiving a synthetic estrogen and a synthetic progesterone. So um conjugated equinestrogen and um a synthetic progesterone. And then the group that did not have their uterus and were only receiving the conjugated equinestrogen. So they that study looked at probably flawed in a lot of ways. So it what it did is it looked at older women that um, so they selected for older women mostly that have were not symptomatic with with um with menopause symptoms because and the reason for that is because they also had a placebo group. And so if you had symptomatic women that you were giving placebo, they're gonna know that they were taking placebo if they were having hot flashes and having so they took this group of women that didn't have a lot of that they didn't have any symptoms, they they did that. Older group of women because they wanted to study disease, and so that's a very expensive thing to study in younger women. So they took these these women who were far past, probably about 10 years past even um menopause. So they so studying older women. So older women have a higher risk of breast cancer to begin with. Um, and then they put them on the synthetic estrogen and progesterone and they followed them. And so what came out of that is a few of the researchers went to the went to the media and said that, you know, they stopped the study five years in. It was supposed to be a seven, 10-year study, saying that breast cancer, um, that estrogen causes breast cancer. So what what it was is they were talking about a relative risk. So they weren't talking about absolute risk. So they've re-examined that study now, and they've said that actually when you look at relative risk, absolute risk, the absolute risk is is 0.15%. Like it's it's very, very low. So you have a higher risk of getting breast cancer if you're a smoker. You have a higher risk of getting breast cancer if you're obese. So the the absolute the absolute risk is quite low. Very, quite low. The other piece is that you have a much higher risk of getting cardiovascular disease if you don't have estrogen. Estrogen is a vasodilator, it it helps promote blood flow, right? So yeah, there's there's so many, so many things about that study. But what the I think the big thing about that study is it just kind of let the genie out of the box to for a lot or the Pandora's box open to for a lot of women. So when I speak to a lot of women, they don't know why they think that, but they think that. And then they'll get on breast, they'll get on HRT and somebody says it causes breast cancer, and they're and they're very scared of that. They're very worried about that. So that is a conversation that I end up having a lot with patients. So they're like, where did this come from? Where did this information come from? And then actually, back to that whole the study, they actually found that that group that didn't have a uterus that were just was just on conjugated equine estrogen had a lower risk of breast cancer. So what they really think is probably maybe it was the synthetic progestin that maybe increased that absolute risk a little bit. So um, so you know, that study, there's some really good things about that study, about other things that came out, but that piece was just a flawed interpretation of really what happened. And so what ended up happening is a lot of women got yanked off of their hormone replacement therapy. And consequently, a lot of women now have missed, you know, missed their that window of starting hormone replacement therapy, and they're angry. They're very angry. I see them on a daily basis, very angry, and um and they and they want to know, you know, what they can do now.
The 10 Year Window Explained
SPEAKER_00You you mentioned something interesting there that there's a window. Um, so this might be another myth, but something that I've heard is that after menopause, if you go 10 years without taking HRT, then starting HRT after 10 years is not worth it or it doesn't do anything. True or false? Okay.
SPEAKER_01So false. Yeah, false. So, you know, I think the other piece is that HRT it's a huge tent. Hormones is it's a tent. People think of HRT maybe as just estrogen, but it's not. There's you know, there's other hormones that are part of that. So it I think, you know, it really this is a conversation that I have with women. It's a it's a risk versus benefit conversation. So what we do know is that, you know, starting hormone replacement therapy within 10 years of that last period is um is is ideal in terms of like especially with estrogen, because estrogen can be a little pro pro-inflammatory after that period of time because your body hasn't seen it for a bit, because it acts as a vasodilator. If you do have maybe some plaque that's there building because of lifestyle, because of you know, all these different things, that maybe it increases your risk of cardiovascular um event in that first two to three years. So that's a risk factor. But again, every woman deserves a conversation. Like, what what's your blood pressure? What's your blood sugar? How active are you? Do you have like have you do you have plaque? Do you have a history of family disease? So are you having debilitating symptoms of brain fog that is you're not, you know, joint pain, brain fog, shoulder. Um oh my gosh. No, I'm having brain fog. So soda pain. No, joint joint pain, um, joint pain, frozen shoulder, right? So frozen shoulder. Um so uh so a lot of women, they just they feel like they've missed that window. And it and it really what it is is a is a conversation around risk versus benefit. So do I start women after that 10-year period? Yes, I do. Do I not start women on estrogen after that 10 period, 10-year period? Yes, I do. It depends on their goals also. So that's a conversation I have with women around what are your goals? Um, you know, what are your risk factors, all like all of these different things. So kind of back up, you know, can they have progesterone? Can they have testosterone? You know, there's other other hormones are part of that conversation to you.
SPEAKER_00And this is obviously a very individualized approach. But most people, especially here in the UK and in Canada as well, their doctor is gonna say, okay, here's here's here's your HRT, you know, come back and see me in whatever a year. You're asking a patient's goals. I mean, who does that? I mean, you do obviously. But what what difference does that make? And why should a woman going to see their doctor perhaps even mention their goals?
SPEAKER_01I I think again, like this is this conversation around um health promotion and disease prevention, right? So hormones make healthy cells be healthy. So if you're like I like this idea, like this this kind of emerging idea of health span rather than just lifespan. So do you want to be, you know, in your 70s, 80s, living vibrantly, hike like for you know, hiking a mountain? Like what, like be very specific. I asked them, really be specific about what your goals are. What do you see yourself in five years, 10 years, 15 years, 20 years? What do you see yourself doing? What do you want to be doing? Like, how active do you want to be? How sharp do you want to be? What do you want to be doing your? I'd have a woman say, I'm gonna do my PhD when I'm 80. I'm like, great, awesome. Let's let's work on that. That's great. You know, so you know, the so then you can really work with it's it's more to me, it's more than just giving out a prescription for hormones. It's a a lifestyle prescription. It is, you know, talking about diet, it's talking about exercise, like all of that comes into play. Talking about, you know, um, you know, mental health and your nervous system and how to regulate all these things. So it is like a huge, it's a huge umbrella.
SPEAKER_00Yeah, it is.
HRT Is Not Just Hot Flashes
SPEAKER_00Okay. So let's let's go back to some of these myths. Um, I was chatting to again some of my clients and patients, and they said, Well, no, I don't need HRT because I haven't got any hot flushes. So is HRT just for hot flushes?
SPEAKER_01So, no, it's not just for hot flashes. Um, so a lot of people think that, or they think that they have to suffer a certain amount before they're allowed to have HRT. That drives me insane. It absolutely drives me insane. Um, so there's a lot of things metabolically that are going on that you can't see, right? So going back to what I said about hormones make healthy cells be healthy, right? So you have receptors all over your body for hormones. So what you know, hot flashes are associated with low estrogen, um, especially like in the in an area in your brain that regulates your temperature, your thermal regulation, right? So some women will experience hot flashes, some women, and there's a degree of that. There's a degree of like maybe my body temperature just feels a little bit warmer. Maybe I used to wear a sweater everywhere and now I'm wearing like a tank top, right? So there's there's that that to literally sweating in front of you, dripping, dripping wet, right? So sometimes some of these like subtle, there's subtle changes that they will experience and they just don't feel like they're suffering enough. Well, I can handle it, right? So, but they that what they don't understand is kind of what's happening on a cellular level, what's happening under their metabolism, what's happening, their glucose regulation, like all of those other things that are impacted by having low hormones. So, so hot flashes, while they are a symptom, they're not the thing, if that makes sense.
SPEAKER_00Yeah, and I understand it that the thing, as you've mentioned, is uh the increased risk of heart disease, uh, increased risk of osteoporosis, increased risk of dementia, uh increased risk of um what am I missing? Am I missing there's there's three big ones right there. Is there a there's a fourth or a fourth?
SPEAKER_01Yeah, three well there, I mean there's so many, there's so many different things that like right. So they're finding that it's associated with, but specifically for women, heart disease, lung fracture, uh it's your your endocrine, like your ability to metabolize glucose and everything, which which has a down regulating effect on on a lot of different things, right? So that's one of the reasons that people come to see me a lot, is uh especially in perimenopause, is weight gain. That's like one of the big things weight gain, anxiety, mood, you know, that sort of thing.
SPEAKER_00All right. Well, this is this is good. This brings me to my next myth. I heard that HRT causes weight gain.
SPEAKER_01I love that. I love that too. So I have a I have a lot of women who are like, I can't take progesterone because it's going, it's going to make me gain weight. So uh a side effect of progesterone can be water retention. So you might feel like, so I think we should back up a little bit and talk about weight, maybe a little bit, because in that that the perimenopause menopause um time, one of the things that women do present, one of the one of the probably the things that I deal with on a regular daily basis is they come in to see me because of weight gain. They're like, I'm doing everything that I used to do, I'm eating the same way I used to eat, and I'm just I'm gaining this, I'm gaining this weight. And they can't get it off. So they they exercise more and they eat less, and it's not working. And and and in fairness, a lot of them have even gone to their physicians, and that's what they've been told is to exercise more and eat less. And it's really insulting because some of these women, when I track, when I go through their diet with them and track, they're literally eating 800, 1000 calories a day, like they're starving themselves and gaining weight. So, you know, so they're they're very focused on like a number on the scale. But I like to tell them like that number on the scale represents your bone mass, your muscle mass, your your water, you're retaining water, like all of that piece. So progesterone, when you first start taking it for some women that can have some side effect of water retention, a little bit of weight gain, that usually subsides. And sometimes it's a dose really it's a dose related issue, also. Um, but and then also estrogen. If your estrogen is too high, also that can contribute to that. But that's the that piece of, you know, I guess the art of hormone replacement therapies. Um And this is where a lot of women are missing in that piece, is that they're not being monitored. And one dose is not for, you know, the dose for me is not gonna be the same as the dose for someone else, right? Because, you know, there's so many things that we, you know, that we can't measure how women uptake their hormones, like what how many receptors they have, how sensitive their receptors are, that the pharma, the the how drugs are metabolized in in our bodies, right?
SPEAKER_00So hopefully that was a bit of a roundabout way to answer it, but we've got this potential weight gain that's happening around perimenopause anyway, and then we have a potential weight gain if the hormones aren't dosed correctly. So, how does a woman find out whether or not they're taking the right dosage? What can they ask their doctor or you, or what tests they can they do?
Dosing, Labs, And Delivery Options
SPEAKER_01So that's also a really great question because I actually see a lot of women because they're requesting laboratory tests for their hormones, and you know, they go to their their doctor and their then their doctor doesn't want to do them for them. So, which is, I mean, I don't have a problem giving women the test for like labs. So, how how I do it is I look at their symptoms, but they're having side effects and their laboratory values. So because that it does, it's a piece of the puzzle. So I do like to look at laboratory values. I think that it's not the whole piece. So I it's it's a bit tricky. Like it really literally is all of those things. Because if you're just looking at a laboratory value, that alone isn't necessarily going to give you all the information either. So, because a lot of women will be like, what number am I striving for? Like they're they're very goal-oriented. They're like, What if I have to get to, right? And I'm like, well, there's a range, but how do you feel? Are you having any side effects? And what are your lab values? So if I have a woman who's like sleeping great, she says, so say she's in menopause, so she has not had her period. She's sleeping great, she's feeling relaxed, she's not experiencing anxiety anymore, she feels like more like herself, and we have her in a certain dose progesterone, but her laboratory value looks a little suboptimal. I'm not necessarily going to increase that dose. She's feeling great, but I am going to monitor her. I and I think that is maybe one of the things that um is a bit lacking is that just that lack of kind of following women through this journey and regularly. So, and and also how you, you know, what you eat, your stress, your exercise, all of that's gonna affect your hormones.
SPEAKER_00And then with the dosaging, it's there's different applications. So we got pills, we got patches, we got creams. Do they make a difference? Is there an optimal way or is it different for every individual?
SPEAKER_01Transdermal application means that patch, a gel that applies transdermally to your skin and in a dose that is high enough that it is absorbed in your whole body. So systemical, systemic absorption. Um, so patches do not increase your baseline risk for blood clot because of the way that they're absorbed. They don't have to be oral, yeah.
SPEAKER_00Oh, just wondering though, uh blood the blood clots. So that's to do with this the slight inflammatory effect of estrogen.
SPEAKER_01Uh one thing to consider when you're giving hormone replacement therapy to anyone to answer your question about transdermal, oral creams, all these different applications, is you really want to get a sense of what their baseline risks for certain things are. So with estrogen in particular, we worry about potential blood clot risk. So some women will have a genetic predisposition to potentially cause blood clots. So blood clots are like something that uh may cause a stroke or heart attack, right? It releases and blocks that blood flow. So one of the questions I'll ask a lot of women is like, you know, do you have factor five ligin, which is one of the genetic risk factors. And some women know that they do because they've already had a blood clot when they were younger, an unprovoked blood clot. So that means they were doing nothing, they got a blood clot. A provoked blood clot is something like you broke a leg, you were laying in bed for six months, and you've got a blood clot. That's a different story. That's you were inactive, you were like there's that's a different story. So transdermal doesn't increase your risk above your baseline, whatever your baseline is. So very safe for even women who have factor fibin. I would never give somebody like that oral estrogen. But I do give some women oral estrogen because that's up their preferred. They're like, I'm not gonna put this on, I'm not gonna put it on every day. I'm gonna take a pill, I'm gonna do that. So it has to work for the woman. So this is the other thing to just say that you only do one form for everyone. It just doesn't work, right? So I use oral, I use transdermals, more transdermals probably than oral for sure. Um, and then I use I use a lot of bioidental hormones. So that's another term that you might hear a lot. Like, what is bioidentical hormones? It's just really what your body already recognizes and sees. So it's it's estradiol, which is what your body has. It's not conjugated equine estrogen, which comes from pregnant horse urine that has lots of different types of estrogens that your your body doesn't even recognize or see. So, same thing with a synthetic progestin. That is like, again, you don't have receptors for a synthetic progestin. It acts some like it's it's actually more powerful, more potent, but progesterone, which is what your body already sees, right? So back to estrogen. So you have the transdermals, you've got oral, and then you also have vaginal estrogen. Then you have vaginal estrogen. So vaginal estrogen, I like to think about it as like face cream for your vagina. Okay, this is what I say to women, face cream for your vagina. So, because a lot of women, or even they'll even go to a pharmacist and I prescribe them a topical, you know, a patch maybe, or the gel. And then I also prescribe them vaginal estrogen, and then their pharmacist says, Oh, you're on you can't touch, you can't take both, which is that's not true. So vaginal estrogen is low-dose estrogen. So it only acts like on that tissue, so only on the vaginal tissue. So I use it a lot for women with some that have vaginal dryness, GSM, so genital urinary symptom of menopause. It's a thing 50 to 80 percent, it's a huge range, but we'll experience some sort of symptoms of GSM, which can be dryness, pain with you know, inner course, just pain, period. It can be um lack of uh the ability to orgasm, uh you know, uh your frequent urinary tract infections, like there's this like multiple things. But so vaginal estrogen, very, very helpful. If if you do, if you do nothing, if you do no hormone replacement therapy, every woman I feel like should be on some sort of vaginal estrogen. And a lot of women that it's very, very safe. Women who are who have breast cancer or going through breast cancer treatment can be on vaginal estrogen. So it is it's very safe, it's not systemically absorbed, and I just I think everybody should be on it.
SPEAKER_00Sounds like most people, that never came up in any of my research for this for this uh topic. That never came up, and it sounds like most people will be benefiting from that.
SPEAKER_01Oh, they absolutely most women will be benefiting from that to some ex to some extent. So I like to start with a cream usually, but there's other things called, like there's something called vagifam, there's tablets that you can get, there's suppositories that you can get, there's different things that you can use. So again, it has to work with what the your the lifestyle of that woman and what she and and also what she maybe needs. They have your women have estrogen and testosterone receptors on their vagina. So as you get older and you lose those hormones, that tissue becomes thin. It doesn't get the blood flow there as well as it did. So that's why you know orgasm is more difficult, the tissue becomes more frible. The other thing that changes is the pH of the vagina. So it becomes more basic. So now you have this area that this this you have this system that was designed to kind of stop infection with this acidic environment. It's like I think of it as like um a moat around a castle. Like that the acidity of your vagina, that's like the moat, stop anything from getting in. So now that moat's dried up. Like that's a horrible term, but it's really that's what a lot of women will say. It's just dried up. So it's uh now they can't now now you're getting these recurrent urinary tract infections after urinary tract infections, and that is dangerous. That is that can kill women, it kills older women. Like I'd love to go into nursing homes with just vaginal estrogen for everybody. I really enjoy it.
SPEAKER_00Yes, what about progesterone? Because people put the patches
Progesterone Benefits And Intolerance
SPEAKER_00and they put them on one side and then the other side and they alternate their places where they put them on their body.
SPEAKER_01Yeah. So patches are for a patches, there's a weak patch, like so a patch that you change every week. There's a patch that you change twice a week. You can put them, um, I like to tell women, like, put it around your abdomen, kind of on your hips. A lot of women like to find that they'll like they say that they feel like it gets better absorption if they put it on their hips, just where there's some fat that it can absorb. Um, so that's and you would change it based on the schedule, like what you're using. So women who have a uterus need progesterone also. So what's available for women, um, what's FDA proof for women is something called permetrium. So it's micronized progesterone. It comes in like a little round little ball, and you take it at night before you go to bed, helps you relax, helps you sleep, helps that that GABA. So progesterone is like a it does help stabilize mood for a lot of women. But there is something, there is, there is a thing where women have an intolerance to progesterone. And so I see that probably in about a third of women that I work with. So a third of women will love progesterone. A third of women will be like, eh, I don't know. I don't really notice that much difference, but I know I have to take it to protect my uterus because what progesterone does is it acts as a it balances estrogen. So it balances estrogen so that it estrogen causes the uterine lining to increase, and progesterone stops that from happening as much, right? So, and that's why women in perimenopause start to have a lot of heavy bleeding when their progesterone goes down, because estrogen is on its own, causing that increased blood like um tissue development in the uterus. So progesterone helps you feel relaxed, helps you feel calm, helps you deal with things that you know, just your your daily stress, how you feel. But sleep in particular. So third of women love it, third of women are like, eh, I'd have to take it from my uterus. I don't think it really helps me with my sleep or anything like that. And then a third of women will have some type of side effects for it. So, which range from mild, to which we talked about a little bit with the bloating, maybe a little bit of maybe even diarrhea, nausea, um, some mood. It's even a little bit of mood where it's it actually acts opposite of the relaxation type thing, where it actually makes them feel a little bit anxious to absolutely crazy. So they're like, I I could not take estrogen at all. I felt like I was just not even myself. I was I was crazy. So, or not estrogen, progesterone, pardon me. So they'll have that type of side effect. And so of that group of a third that maybe have some sort of reaction to or or you know, negative um side effect to the progesterone. Sometimes it's dose related, sometimes it's a route related, sometimes it's um, we just need to change that. We have to compound it into a smaller dose, maybe longer acting instead of the immediate release. So there's a lot of different factors for it. But progesterone is for a lot of women, that is their desert island hormone. Like they are like, I will go to my grave with my my progesterone in my hand. So I actually have this one lady who's this older lady who I see who she um she's in her 90s, and so she outlived her doctor that was prescribing hormone therapy for her. And so she got this new doctor who she calls him a young whipper snipper, who is like he's in his 60s. He wouldn't prescribe her hormones, and so she came to see me and she um she said, I told him that he could wrestle it from my cold dead hands. So I I actually think for her, like, I mean, she's not even on like bioidentical, she's on like conjugated equine estrogen, she's on front, she's she's not even on like the the stuff that you know that you would be taking more now. But I mean, she is in her 90s, she lives alone, she's you know, ambulated, she does not have osteoporosis, she's sharp as a tool, sharp as a I don't know, yeah, sharp as a tool. Um, and so I'm like, I actually think it would be detrimental to stop her from her hormone therapy at this point. So I'm like, yes, no, you do not have a problem. I will prescribe your hormones. That's fine. Um so I think that's like a really great like to look at that and like going back to that conversation we had about, you know, health span, right? So like that's what I want to be like when I'm if I if I'm lucky enough to be that old, I want to be like, I want to be like her, right?
SPEAKER_00So and you you bring up a good point then. So is there any duration that people should be on HRT, or can it just go to the rest of their lives?
SPEAKER_01Yeah, so I I I get that question a lot too, because there's this idea that shortest period, short like shortest period and the smallest dose possible, right? The lowest dose hospital. And that and that's not there's no evidence actually that supports that. So actually, even in the Metaplaus society, you look at that, there's no no guideline that you can only be on hormone replacement therapy for five years or you know, 10 years, or you have to be taken off of it. So for like I want women to be on it all the like forever, if that is what works for them. If that's what they want, if that's what works for them, and that is in their, you know, part of their plan, part of their goals, part of like how things are working for them, and it's working well for them, then great. So I want it to be affordable and I want it to be in a route that is going to work for them, right? So that's why we're kind of talking about all these different ways that you can take hormone replacement therapy. It has to it has to work for the person who's taking it and it has to be affordable.
SPEAKER_00And
Testosterone For Mood, Drive, And Focus
SPEAKER_00well, also that brings me to the last hormone as well, uh, testosterone. Because many women that I've spoken to are not prescribed testosterone and they're wondering whether they should be, and then they hear, you know, their work colleague took it and now she can manage meetings again with 20 people and remember everyone's names and you know, be be on point like they used to be in their 30s. Um tell me about testosterone.
SPEAKER_01So I I like talking about testosterone. I mean, I like talking about all these hormones you know, but testosterone is a hormone that it's it's so controversial. I don't know why. I really don't know why. So I get people who come in and say, well, testosterone is a men's hormone, like that's that's for men. And testosterone is a human hormone, first of all. Let's start with that is a human hormone. Women actually have, like to put it in context, women, if if the way we measure hormones are all in different units. So it's kind of a little confusing when a woman looks at her numbers and sees like estrogen as being this really high number and testosterone being this low number. But when you if you put them all in the same units, we have more testosterone. We just have 10 times less than men do.
SPEAKER_00That's so I did not know that. Hang on, let me just summarize that, see if I got it right. So the the most abundant hormone in the female body is testosterone. That's right. How interesting.
unknownYeah.
SPEAKER_00Okay, so why aren't they? So women, yeah. Why don't they give them out of their HRT?
SPEAKER_01Yeah, so it should be part of the HRT for a lot of women. So a lot of women will continue. The thing with testosterone is that it's made in the ovaries for sure, right? So it's made in the ovaries, but it's also made a little bit maybe in the adrenal glands, it's also made in and organs, so it's made in other areas. So your testosterone will drop in perimenopause and menopause for sure, but for a lot of women, they can maintain like their testosterone levels, not to the extent that they were before perimenopause and menopause, but they will maintain them a little bit. So um I think that's maybe part of the conversation, like of why maybe women have not been replaced um earlier. But, you know, for for women, testosterone is for a lot of women, it's it's like a it's the hormone that kind of puts it, puts everything together. And they feel like, you know, I felt a little bit better with progesterone, I felt, yeah, even a little bit better with the estrogen. But man, when I started taking testosterone with everything, I felt like me again. So, and that is something that um, you know, I don't know that you can put a value on that. It's when women don't feel like themselves, would they feel like that, like they'll come in? That's a thing that they'll say to me is that I just I don't feel like me. I feel like a shell of me. And so I find that a lot of women, you know, they'll be offered SSRIs because they're said that they're depressed. And I mean, and some women do need some SSRIs. I am not saying, I'm not trying to make anyone feel bad that they, you know, should have tried testosterone or anything like that first. So SSRIs can be very helpful, but I don't think it's the it should be the go-to when we know in perimenopause that our hormones are shifting and dropping. We know in menopause that our hormones are shifting. So, you know, with common things being common, let's treat some of these common things before we throw all these other medications that have real side effects and sexual side effects. Like the SSRIs have sexual like side effects, where now you're you're definitely don't want to have sex with your partner, which is that can be very distressing for women and their relationships. Very, very distressing. Where they're like, I don't know what's changed. I I love my husband, I you know, or my partner. I think they're attractive. I all these things. I just I just I can't. I just don't want, I just cannot. And then and it becomes a real challenge in the relationship. And then you mention, you know, professionally, they're at work and you know, they're they're high achievement, you know, high performers, and all of a sudden they they're they can't find words that they were looking for, they can't focus, they're they're not able to to you know do what they were able to do before, or again, they're they're putting on weight, they're going to the gym, they can't put on any muscle. Like so you think about testosterone as a you know, muscle only, but it is testosterone is a mood hormone. So it affects the affects the brain. And to kind of to think, you know, that it only acts this in this little wee part of the brain that it acts as libido is is like it's absurd, right? So it it acts on everything, so it helps with like drive, motivation. So all of those things are like a down, like a trickle effect. Like you get better, you know, your your clarity, your thinking, your drive, all those things improve with testosterone. So that that is a really, really common that I see a lot of women who may already be on some progesterone and um estrogen, and that was working well for them, but now they just again they're just not really feeling like themselves. They don't have any drive. Maybe they used to go to the gym all the time, and now they can't even get it out the door to go to the gym, and then and they liked it. They're like, I I like doing these things. I just I just don't feel like I like anything anymore. Like they feel flat, they feel very flat. So it can be very, very, very helpful for them. Um, the crazy part though is that you know, in North America anyway, we don't have an FDA-approved testosterone for women. So, and the only way that the only approved um treatment that using testosterone for women is hypoactive sexual disorder, which is just is crazy. So the only reason, so I'll I'll just back up and tell you. So really the only reason I can treat a woman with testosterone in North, like in Canada I hear is if she has low sex drive. Okay. So that's so it's used off label to treat the brain, the mood, the all those other things. But sex drive is a mood. It's a it's a libido is a mood, right? So this is like testosterone affects your mood, it affects your your ability to like feel like yourself. So and we don't have that, we don't have an FDA approved testosterone form of testosterone. So it's I think it's really, really a shame. So then I have to either compound it for women as a cream that they apply. So we were kind of talking about like the different ways of putting on hormones, right? So testosterone comes, I can compound it as a cream, they can apply it to their leg, you know, their arm. Um, I get a lot of women to actually use it on their vulva, their clitoris, because it can help with orgasm. So if that's something we're working with, or even if they've got really severe GSM, so that genital urinary symptom menopause, I will use some testosterone sometimes um vaginally, also for that. And it can be very beneficial. Um, the other way we can use testosterone is we can get um uh a male's version. So I actually I brought a little show and tell for you to see. So this is called testum. So it's the it's a men's testosterone, it's approved for men. So one tube is 50 milligrams. So for women, you would literally like, and this is Very scientific, and so some women have problems with this. But so for men, they would use this entire dose and apply to their testicles every day. The whole tube, the whole tube. The whole tube, the whole tube every day. So for women, you would apply about a P size amount because this is gonna last me, well, whoever 10 days, P size amount, and then rub it on, you know, arm, outer leg, something like that. So you do that every day. So um, and then we monitor your levels because we want to make sure with testosterone that you're not being like that you're not super physiologic, that you're in range. Some women will feel better at a little bit of a higher range, but again, we go back to that whole, what are your symptoms? How are you feeling? And your love values. Okay. Um, another way of giving testosterone in um Canada would be injections. So again, taking a men's product and only taking a tenth of that dose and then injecting that. And then I'm sure people have heard about pellets. We I'm not a big pellet proponent because those are really high doses, and women will often feel amazing or horrible because they'll have a lot of side effects because they're really, really high doses. Um, and then and then they'll crash with it. So, I mean, I'm not I'm not like anti-anti-pellet, but I would say that you need to, for me, you need to be on hormone, like on testosterone for a period of time. We need to really see what your dose is before that. Maybe that would be a route that you would explore, but it is uh less less common. So I would say the most common way to give testosterone here in Canada would either be to use like something like the testone or andergel, which is men's product, or compound the cream.
SPEAKER_00Okay, so if you were to test the a blood test, do you have to justify that blood test testing testosterone for a uh patient and they have to say I've got low libido, like do you have to quit to um justify that test, or do you just test across the panel anyway, the whole panel?
SPEAKER_01Nobody has to justify anything for me. I I test every patient hormone. So I don't make people sit there and lie, and you know, and and I look I I hate that that you know, if that women will have to go into like a doctor and lie that they potentially lie that they have like low libido because they want to get their testosterone levels tested or anything. So I test everybody's hormone levels it because I do think that it can be extremely validating to women to see. Um, but I'd like to kind of tell people like, you know, hormone levels are definitely are gonna change. Like you can test my hormones four times today and they're gonna be a little four times different. Like they're like different four times, right? So I'd like to tell women, like, again, what are your symptoms? How do you feel? What are your lab values? But I like to tell them that like lab values are kind of like watching a preview to a movie. So sometimes you watch that preview and you know the whole movie, like you've got the whole thing. I don't even watch it. I got the best parts. Other times you're like, I have no idea what this movie is about. I gotta watch another preview. So it can be it can be very helpful to continue to like to trend. So not just on hormones, but on like the metabolic markers, like your A1C, like right. So we haven't even really we haven't even touched on any of that. But like that is huge. Or like, so what is happening metabolically to these women as they're as their hormones are starting to drop? Because we were talking about hormones make healthy cells be healthy, right?
SPEAKER_00Right. So yeah, it's it's a whole it's a whole thing. Yeah, I understand. Uh I'm just thinking about all my clients and patients who have not been offered testosterone, and you know, some of them say, I like you said, I don't feel like myself or a lot of my patients in Calgary are very um they're executive women, and yet they're struggling maintaining that high performance that they once had, and they feel like they are on HRT, but they're they're still not getting it. And I wonder whether the testosterone is the missing piece. And so I'm just trying to think how would they approach this with their doctor?
SPEAKER_01You know, certainly having that conversation with your your primary care provider is a great place
Finding The Right Provider And Wrap
SPEAKER_01to start. Like, how much do you know about hormone replacement therapy would be a really good like place to start? And a lot of you know, physicians they don't have a lot of training. Physicians, nurse practitioners don't have a lot of training in hormone replacement therapy. So I like to say to people, like, don't, you know, ideally, yes, you would be able to get this type of therapy from your primary care provider, but you may not. And so you may have to seek somebody who specializes in this area so that you can have an informed conversation with them, talk about risk and benefits, and then have like a trial of therapy, like a with through a shared decision-making model, have like a trial of therapy around that medication. But I like, I mean, I have a lot of women who have come in and said, My doctor is very against testosterone, or my nurse very against testosterone, and they do not want me to have it. And so, like, I think that just goes back to probably just not really understanding everything that testosterone does and how it's evolved. Because one of the things that I hear a lot of is we don't have enough research, we don't have enough research. There's a lot of research actually on testosterone, a lot of usage research on giving high levels of testosterone to trans men. And we know that that does not increase their you know risk of cardiovascular disease. It does not in like increase mortality, like any of that stuff. So we've been giving high doses of testosterone to trans men for over 50 years. So there is a lot of research on testosterone. It's just maybe not double, you know, you know, double blind control, you know, studies. But you know, if you're gonna be waiting for some of that research, you're gonna be waiting a very long time to maybe feel a lot better.
SPEAKER_00So and maybe what we're seeing here is that sort of the that uh older patriarchal approach to medicine where, you know, this is a male hormone, we're not even gonna factor it into the clinical trials for women.
SPEAKER_01Well, women haven't been studied, uh, like there was not there was no mandate to study women until the 19 mid-1990s. So a lot of research has not been done on women. Women are really under research, our whole. So even the the all the research on statins is all done on men. So it's it's very interesting. And and women are not little men, we're very different. We're very different, and specifically our hormones, right?
SPEAKER_00Exactly. So I asked this question a while back and I was like, okay, is this just sexism? And uh the doctor, the doctor asked it, he said, Well, well, no, he said that it's women have a cycle, and so it will affect the way the drugs interact, so we don't get clear answers uh from the clinical clinical trials. And I said to him, I said, Well, hang on, but you you take the answers from the clinical trials on whatever college age males and you give those drugs to women. That doesn't make any sense.
SPEAKER_01No, it doesn't make any sense. Well, and I mean, like these other like you know, studies are they're very they're great if the but even like going back to what you said, it's like so you're studying something like the women's health initiative. So you wanted to study hormone replacement therapy in women going through menopause, but then you took a bunch of women that were like well past menopause that were that also they controlled for being quite ill. Like they wanted women that were that had diabetes, that were overweight, that smoked because they wanted to study like the death like piece of, you know. So it yeah, like so. I think going back what you say is really important when you do have this research that comes out is really important to actually look at it. Is that actually even studied in the patient population that I'm wanting to treat? Like, is that even reflect that? Right? So, anyway, we can go on and on about that too.
SPEAKER_00But it seems to me like you you you're like uh an orchestra conductor in this beautiful symphony of the different hormones and how they all interact, plus the person's life, plus their goals, plus their symptoms, plus their nutrition, plus their lifestyle. And you bring it all together in this really wonderful, holistic way. And I and I commend you for that.
SPEAKER_01Oh, thank you. I I love I love what I do. I love seeing women every day. I love I love interacting with them and seeing them be the best versions of themselves because to me, like when you treat women, you treat the whole family because they go home and they are, you know, they're the best versions of themselves, but then trickle down to everything. And so I absolutely love that. It's just very rewarding for me.
SPEAKER_00Perfect. Well, thanks very much for joining me in this myth-busting episode of Peri and menopause. But if people wanted to find out a little bit more about you, I know you just started um your own business. Can you tell us where that is and what you do there?
SPEAKER_01So I I have a business in um Calgary, Alberta. It's called Empowered Women's Health. And um, you could find me online. Um, I treat women, I treat women in perimenopause and menopause pri primarily, but I also I also treat a lot of women with just some hormone imbalances. So PMDD, um, PCOS, which has recently been um renamed. Right. So very exciting. I'm I'm super excited about that. So yeah, so it is a metabolic condition. So I'm like, I love it, I love it. So it's like this is just like a really great um area to um to be practicing medicine in and to be able to contribute and and to help women. So I'm happy to see people, you know, look me up, give me a call.
SPEAKER_00All right. Well, thank you very much, and you have a great rest of your day.
SPEAKER_01Thank you very much. I really appreciate you having me on Ed.
SPEAKER_00Thank you for joining me in my conversation with Kate. I hope you enjoy this podcast. And if you're an Apple, I'd love it if you could leave a comment and maybe even a five star review, because that's how the show gets boosted. And remember, if you want my help directly, you can email me, ed at edpaget.com, or visit my website, edpaget.com, and yeah, you will find out a little bit how you can make your lifestyle easier for your medicine.