Breaking the Silence: Redefining Menopausal Care for Women with Obesity with Dr. Komal Patil-Sisodia

Menopause and the years leading up to it - perimenopause, are periods of significant change in a woman’s body. Working as a physician, I’ve seen firsthand how these hormonal changes can affect women, especially those struggling with weight.

Unfortunately, if you're in the obesity category and considering hormone replacement therapy (HRT), it’s easy to feel overwhelmed by the lack of clear guidance and support. The crucial link between weight management, menopause, and HRT often gets overlooked, leaving many women at risk and unsure about their options for treatment.

In this episode, I am joined by Dr. Komal Patil-Sisodia, who is triple board-certified in endocrinology, obesity medicine, and internal medicine and passionate about improving metabolic health in the community. Together, we discuss the significant physiological changes women experience during perimenopause and menopause, the benefits of HRT in improving insulin resistance and blood sugar control, and the intricate relationship between menopause, obesity, and heart health.


References

What Is Metabolic Syndrome?

You Are Not Broken Podcast by Kelly Casperson MD

menopause.org

Reset/Recharge Podcast with Dr. Komal Patil-Sisodia

Audio Stamps

01:20 - Dr. Komal shares her background in endocrinology and how obtaining her obesity medicine board certification has helped her practice.

11:48 - We find out about the importance of being proactive when it comes to starting conversations around hormone replacement therapy (HRT) with a knowledgeable physician.

17:48 - Dr. Rentea and Dr. Komal emphasize the importance of seeking out healthcare providers who are knowledgeable and up-to-date about HRT and menopause management, and suggest questions to ask.

21:19 - We explore the benefits of HRT, such as improving insulin resistance and blood sugar control.

29:00 - We learn how menopause, obesity, and heart health are interconnected and Dr. Komal recommends safer HRT options to manage these health concerns effectively.

Quotes

“We are complex human beings. And what we know now and what we know through research may change five years from now. It's always important to be looking at the latest data and evolving your thought patterns as you move forward.” - Dr. Patil-Sisodia

“You have to fix what you can about your environment as much as possible. And then at some point, your genetics will kick in and that's no fault of your own. That is literally what is encoded in your body. And at that point, if you've done all of the lifestyle things, it's okay to ask for help.” - Dr. Patil-Sisodia

“As a medical community, for a long time we haven't shown women grace and we haven't shown patients who are struggling with obesity grace.” - Dr. Patil-Sisodia

“Hormone replacement therapy should be available to all women, even those who are struggling with obesity.” - Dr. Patil-Sisodia

All of the information on this podcast is for general informational purposes only. Please talk to your physician and medical team about what is right for you. No medical advice is being on this podcast.

If you live in Indiana or Illinois and want to work with doctor Matthea Rentea, you can find out more on www.RenteaClinic.com

Transcript

0:28

Welcome back to another super amazing episode of the podcast. And I want to tell you something. I have been wanting to have this physician on for the longest time ever. We have finally connected. And this episode is going to be for you today. If you are struggling with weight management, maybe you're in that overweight obesity category, and you are in the age of maybe paramenopause menopause and hormone replacement therapies coming up, and maybe you're hearing that you're increased risk and you're struggling with getting treatment. There is going to be a lot of stuff we're going to talk about today that is not talked about at all. It is such a gap. It's you losing years of your life over this. I want to start out with introducing Dr. Patil Sisodia. Did I say your name right? Yes, you did. Okay, because I keep referring to you as a first name basis having known you. You know, Dr. Matea, I'm going to call you Matea at some point, and so apologies for that. No, it's great. Can you start out just introducing yourself and about your background, endocrinology, just kind of all of that. So they know who, who, who's talking. Sure. Absolutely. My name is Komal Patil Sisodia. I am an endocrinologist and, in 2020, I decided to sit for my obesity medicine board certification as well, because I just saw this. Huge amount of overlap between what I was trying to do for my patients with diabetes thyroid and then Watching them struggle with metabolic ramifications like being overweight or obese. So that was a pretty easy decision I also have an amazing partner who has built an incredible weight management practice within art like adjacent to our endocrine group. And so it was also to help her cover call, but I ended up learning a ton in the process. And it's just, I, I've been so grateful for the perspective that it's given me when I, when I've been, meeting with my patients. So, Oh, and, and the way that I met you, I just want to tell our listeners. So I was at a Dr. Allie Novitsky conference this past year and One of our other physician colleagues that knows both of us, but we didn't know each other said, you know, you need to know her. And so we sat at a meal and we were talking and I was like, okay, I love everything you're saying. You need to come on the podcast. Was that kind of weird for me to be like, hey, I don't even know who you are. And I'm like, okay. It's, it's so funny that you say that because I felt the same way sitting with you, right? I, this idea for this podcast has, my podcast has been percolating in my brain for like two years now. Right. And it was really being at that conference and actually sitting and talking with you where I was like, Oh my gosh, I think I need to do this. And you, you were such a great source of information and motivation for me. And you were like, Please do this. So I, I have to give a lot of credit to you and to Dr. Ali Novitsky, who I've also worked with since, gosh, I want to say 2019. I feel so wrapped up in support from this amazing physician community that we've built over the last, five, six, seven years. So I thank you. I have to say, I can't wait for your podcast. By the time that you guys hear this, I think it'll be out, but just listen to me when I say that the way in which she's going to talk about things, this is probably, spoiler alert, going to be one of the best episodes we've had. So one of the things when we were talking is that we were talking about kind of gaps in weight care. So a lot of the time, what I experienced, I'm sure you see the same. I actually just unfortunately experienced this with a patient this morning that whenever someone is overweight, so we could say either suffering with overweight or obesity, A lot, everything in their life gets blamed on weight and they don't actually get further evaluation or appropriate care that a similar counterpart at a different weight would experience if their weight set point was lower. And unfortunately, we know that this is true, I have chills right now, like we know it's true. We know it's rampant. And that's constantly something that I'm sort of really advocating for my patients. Hey, why isn't this happening? Why isn't that happening? This evaluation, that evaluation. And we kind of talked a little bit more about perimenopause and menopause, and I don't think a lot of people understand the metabolic changes, how it actually impacts our health. Can you talk a little bit about what, when actually do women experience this and what is actually happening physiologically? And then we can maybe talk more about kind of treatments and things. Absolutely. So this has been a big passion point for me because a lot of women will end up in my office asking, like they go and talk to their primary care doctors and we've just had for like the last 20 years. Nobody is willing to talk about this since the Women's Health Initiative hormone therapy trials were published and while That study was really well intended. It had this ripple effect because of the poor study design and the fact that they were testing high dose hormones in older women, instead of starting at a younger age, we saw all of these increased risk things like cardiovascular disease and invasive breast cancer, get blamed on hormones when it actually is just the natural history of aging and women. Right? So what I like to explain to my patients is that when you hit. You're mid thirties, right? And sometimes for some women, it starts even a little earlier, like sometimes shortly after 30, our reproductive hormones start to decline. It is a natural thing that our estrogen levels will start to decline over time. And what happens if you think about it purely from a mother nature biology perspective is we are not contributing to the gene pool. So, you know. biology is trying to exit us. That's a horrible way of saying it. But all of the different metabolic changes that happen start happening around that time, right? So women will increase their, their fat mass. And the interesting thing about this was that when you have increased adipose tissue, you actually get increased estrogen production from the adipose tissue. So it's almost like a survival mechanism. The body is so cool that way. And the other thing that happens is we have a harder time holding onto our muscle mass, right? So, you know, from being an obesity medicine specialist, that when you lose muscle mass and you're gaining fat mass, your metabolism takes a nosedive, right? So if you're already struggling with being overweight or struggling with obesity, you're, you're going to have a harder time when you hit that period in your life, right? And it's because that shift in hormones. And so that will start somewhere around 35 or 40. And. Your hormone levels will kind of bottom out somewhere between 50 and 55 for some women. It's as late as 60 and You see this continued shift and decline in metabolism, which you know for years we we denied that to people which I think Was part of that Years ago I And that's where you have to tell people, look, you're going to listen today. What I say, don't go back five years because that's invalid at this point. Right. So sorry not to interrupt, but that that's incredible to me. Yeah. No. And I think you and I have a very similar, style when it comes to our patients. I will always tell my patients, you know, we know a Fraction of what our creator created in us. Whether you believe that's God, mother nature, whatever. Right? But we are complex human beings. And what we know now and what we know now through research may change five years from now. And that is, it's always important to be looking at the latest data and evolving your thought patterns as you move forward. And that. That I think is, is something that we, to your point, we don't really do for our patients who are struggling with being overweight or struggling with obesity, which are medical conditions. You know, and I think unfortunately, with society and social media and what we're seeing on television. We push a very certain body type on people, and then anybody who falls outside of that parameter, we don't give them the grace of saying, Hey, you, you have a medical condition that we need to treat. And that to me is the most heartbreaking, right? So now you layer on top of it, perimenopause and menopause, and it's another hormonal shift in somebody who's already struggling. And it's like a recipe for disaster, in my opinion. Yes. They get blamed even more, to be honest, like bring in a food log. I don't believe you. Right. It's more, more and more blame and shame. Definitely. So can you explain the one thing that I don't know that people, cause you had this really cool link that you explained to me. Can you explain how, when the hormone levels are going down, kind of what does that do to cholesterol levels or heart health? Like kind of what's the link there just that people can know full circle on that. Absolutely. So we will start to see blood pressure rise. We'll start to see cholesterol levels go up, even if you've previously had stone cold, normal cholesterol levels, and then because you're putting on more, abdominal fat, which tends to be visceral fat, which is where it packs around your internal organs and creates insulin resistance. We also see blood sugar start to rise and diabetes get worse. I had this amazing patient. Moved away. So I don't, I don't see them anymore, but when they hit menopause, very well controlled type one diabetes, when they hit menopause, the sugars went bonkers. And she was like, she was telling me, I am exercising. I am eating right. I am using my pump. I am using my sensor. I'm doing all the things. Why are my sugars going bananas? And we kind of talked through it. She wasn't sleeping well at night. She was having hot flashes. She was having all of these things happen. All of that has an impact on your metabolic health, right? And to me, that's the best example that I can put forward. And then also I tell people, you know, you're given a hand of cards, that is your genetics. And your genetics are, it's what you have. So you have to fix what you can about your environment as much as possible. And then at some point, your genetics will kick in and that's to no fault of your own. That is literally, what is encoded in your body. And at that point, you know, if you've done all of the lifestyle things, it's okay to ask for help. That's why we have science. That's why we have all of these things to help people. Right. And so beautiful. I love how you describe that, people somehow think it's like a character flaw. It's like, you've taken this as far as you can go and perfection is not required to when people think, no, I need to be more perfect. I think the healthy counterpart that was never given that genetic can, they're not perfect. So why, why would we expect that of someone else. Exactly, exactly. So we don't show ourselves grace, right? And unfortunately, as a medical community for a long time, we haven't shown women grace and we haven't shown patients who are struggling with obesity grace. And so it's really that intersection here that I, I'm interested in talking about today because I hope that we're able to provide women with good information and, and get them having these conversations with their healthcare providers. Do you know one thing that you, you of course said a million things here, but just to highlight, I think this was what shocked me when I talked to you. I understood, like, I've, I always remember rooting in medical school until menopause is 50 to 55. And okay, some women might start earlier, but I don't think I really understood that as early as 35, because I know I've had these patients too. So when you were talking about the blood pressure going up, the blood sugar, your cholesterol levels, right? Basically, for people that are not in medicine, we have something called metabolic syndrome, and it's these different criteria that we look at. You have three of five. I'll put it in the show notes down below in case you want to look at it. But the point is you're describing that people develop metabolic syndrome and people, I guess it's just fascinating to me that at such an early age. So one question I wanted to kind of get into is I know that there's hormone replacement therapy and I want to talk about that more, but I think one question that, that always, or something that I learned that shocked me is like, I think people think that they need to have total cessation of their periods, be totally postmenopausal for this to apply. So can you talk about when do you even start to have this conversation with a physician that knows what they're talking about? Yeah. So I will, I am, Full disclosure here, I've been practicing for 15 years, and I will say that until I started to go through this, I felt like I didn't have answers for my patients. And a lot of it stems from that study and the fact that we just kind of turned off our brains when it came to hormone replacement, right? But if you go back and you look at data, there are studies that show estrogen will increase your HDL. It will improve your insulin resistance. It will decrease your triglycerides. It will do all of these things, right? Obviously, there can be some risks to it, like increased risk of blood clots and, you know, in patients who have breast cancer or uterine or endometrial cancer that may not be available in a systemic form. There are studies showing that women with breast cancer can have vaginal estrogen and, but we just don't talk about when we can start, right? Because I think for a long time, it was just assumed you struggle through it. And then when you're done. You can take hormones for five years, but then you have to stop and it just doesn't seem because we as women, we go through more hormonal shifts in one month than most of our male counterparts do in their lifetime. Right. And I say most because there are, you know, there is a steady decrease in testosterone and for our, There are patients who really struggle with prostate cancer and have to be put on like androgen deprivation therapy and they know what it feels like to go through this, right? But the decline is so gradual that I am now starting like any 40 plus year old woman who walks into my office has been getting this talk now since last fall. And now I think I'm going to extend it to a lower age because we have to be empowered with this information, right? It is, It is crucial to our well being and women, you know, have to show up at home, for self care, in the workplace, for friends. Like, you know, there's so many things you're trying to balance and juggle and if you're not feeling great, you're just not going to be able to do those things. And then I think that further plays into how all of these things get worse. I think that, you start, have to start having that conversation in your mid 30s that this is approaching, right? And everybody likes to be like an ostrich, like, oh my gosh, I don't want to think about it. What are you talking about? I'm going to be young forever, right? Oh, totally. Yeah. And And then all of a sudden you're like, Oh, I'm not sleeping as well, or Oh, I'm starting to get sweaty at night, or Oh, gosh, we make jokes about it too, right? Like how many memes on social media did you see with like people talking about how they sat down to wrap presents for Christmas and they couldn't get back up? Right? Yeah, I mean, All of these things are signs that, our bodies are aging and then it's, it's up to us to have that conversation about when is the appropriate time for us to have these conversations and, and start on very low dose hormone. You can start. a very low dose patch of estrogen, and then you need to give some sort of protective progesterone if there, if there's a uterus, right? And, for women who have had a hysterectomy, they don't necessarily need to do that. And the hard thing, you know, I'll have women come into my office, say, I need you to measure my hormones, right? My hormones are off. Well, with all the fluctuations we go through in a month, there's no stagnant point at any point that if I check your estrogen, it's going to be a true indication. of a true level if you're still menstruating, right? I'm glad you bring this up though, because people will be like, well, the doctor said it was normal. And knowing what you're talking about, I am actually encouraging people to see the right specialists. When I'm hearing the sleep problems, all the different things that go along with kind of perimenopause and menopausal symptoms, they don't realize that those syndromes are associated with it. They just think it's random stuff that's developing. And that's kind of what I'm hoping to, explore in my podcast once it gets rolling, is how we from head to toe go through all of these metabolic changes and how are, how is it related to this period in your life? Right. So I think finding somebody who can have a conversation with you, who is open to this, it becomes very important. And earlier, I want to say. Last fall or maybe earlier this year, Lancet published a series on, menopause and perimenopause. And I was a little disturbed because they made a statement that, you know, over treating symptoms can lead to over medicalization of menopause. And I totally disagree with that. We've been under medicalized for two decades, right? Yes. And maybe it's better if we, if we think about that. So I mean, do you know the comments that I hear? And I don't know, I'm sure you get these two in the office that, and I'm not meaning to throw male doctors under the bus, but literally one that's just seared in my brain is where the doctor said, well, that's just how it is. You just have to suck it up these years. Like you just, yeah, you're just gonna have night sweats. You're going to be mood irritable, sleep affected. I mean, I could go on and on. And it's like, no, you do not need to have. painful intercourse and be hating your life and all these things happening, your blood pressure going up, your cholesterol. I mean, no, that's, that's, that's optional if we want it to be optional. Well, we treat all of the other things that have gone wrong because of our evolution and all the science that's come through. We're living longer, right? So. 2, 3, 4 generations ago, people weren't living as long as they are now. Right. And to sit here at 44 and stare down another 40 to 50 years and think, oh God, is this the best it's gonna get? Right. Oh no, that's not a very uplifting thought. Right? So, I think it's important to have that conversation, because quality of life matters. I don't wanna live another 50 years if it's gonna suck. What? Let me ask you because I feel like everyone that I ever talked to that knows what's going on here has done additional training, has attended different things, what can someone ask their doctor to even figure out? I mean, is it something where you say, hey, are you familiar with hormone replacement therapy? Like, what do you even ask? Because I think that this landscape has changed radically in the past few years. And if you weren't following along, you're not going to be hip to it. Yeah, I think that, there are people who are changing their perspective on it, like menopause. org is the North American Menopause Society. I think that's also important. It is on, on that website, right? And then we have amazing physicians who are out there, mostly in the OB GYN space, who are talking about all of these things and really pushing for, women to have these conversations. So generally gynecologists, I was really excited to hear that at my organization there were two PCPs who were actively talking to their patients about this. Like one had just come back from a course, another one, I was chatting with some of my friends in my neighborhood and she, she sees one of the PCPs that are our organization. She was saying, I have never had a doctor tell me that I'm going to be at risk for X, Y, and Z, based on my medical history and the fact that I'm like 40 plus now. Yep. Yep. Right? But it takes, I love you said this in the beginning with, with really looking at the data and then being willing to evolve your thought patterns and also as a physician, you're prescribing patterns. So when this first came out years ago, when they had new information, new guidelines, I remember Kelly Casperson, who's a urologist, if you guys don't follow her, she's great. She had the podcast. We're not broken. And, and yours is going to be that same type of podcast. It's gonna be amazing. And I literally only hope to aspire to that. So I had known her through other coaching circles and known her for a while. And I literally sent her a DM and I was like, but listen, I'm in primary care. I've heard all these things. I didn't believe it, even though she was telling me and I'm reading the study and I'm reading things. I, it was like, I had fear to change my prescribing practices. And she had the. She had to kind of slap sense into me. And you think about it, it's we, as women have been conditioned to think it is normal to feel crappy after a certain age, right? We as doctors have been conditioned to think that women are supposed to feel crappy after a certain age. And nobody has started to push back on that until just very recently. Right. And I really think it is our generation of physicians that's saying, Hold on a second. This doesn't sound right, right? And it, it actually kind of violates our, our Hippocratic oath at some point to not talk about this, right? Like we, we are very much about not doing any harm. And I think we all got so scared by that study that, you know, we took not doing harm to the extreme where we weren't really doing anything. Completely. And, and I want to say so, and it, I, of course it's going to be our generation because we are only really where women are now a little bit over actually, I think 50 percent of the physicians, even however many 20, 30 years ago. So my mom is, my parents are both physicians. When my mom went to medical school, there was literally three other students. They said, well, one of you is going to get pregnant. One's going to drop out and the other one needs a friend. So if you think about with, they were expecting, two women doctors to come out that year. There's more of us again, everything needs to change, right? We know that women have been left out of research. So, okay. I know I went left a little bit, but coming back, coming back to the plot. So, okay. So the conversation needs to start sooner. You need to have someone that actually is up to date and following these things and then. Let me ask you, when they, when they get on hormone replacement therapy, so do we see then blood pressure improve, cholesterol improve, do we see weight loss? Like what do, what do we, what are we looking for? Are we looking for preventing progression or does it actually reverse things? So that's a good question, and I think that really depends on your genetics to some degree. So that's a little harder to say. There are studies and you know, again, we haven't done enough of this as physicians where once we put people on, hormone replacement, what happens to them, I will tell you with my one patient with diabetes, once she started getting on hormone replacement therapy, her insulin resistance came down and her blood sugars were much easier to control. Amazing. We're still not 100 percent where they were pre menopause, but they, they got about 90 percent of the way there, right? So if we're thinking about prevention and keeping people healthier long term, we have to treat all the things, right? We can't, we can't just kind of pick and choose and say, Oh my gosh, you're working so hard. You're working out, you're doing all the diet things, you know, in terms of making sure that you're, You're eating healthy, you are on medication to treat your obesity, but we're just gonna let this fester in the background. And it's gonna hold you back a little and all these other things you're doing are not going to work as well. That doesn't make sense to me. Right. So I think I, you know, and if you look at the indications for hormone replacement therapy, it's, you know, the very classic, like, are you having horrible debilitating vasomotor symptoms? for vaginal dryness and pain with intercourse. And those are not the only two. Right. There are many other things that happen. Joints get achy, you know, osteoporosis risk goes up. There is actually indication for hormone replacement for osteoporosis management for which I'm really grateful, because that opens up an avenue for, for women to get on it. But honestly, I think we need to be having that conversation sooner. And we need to get comfortable with the concept that trying very low doses of hormones. Makes a difference for, for patients in terms of how they're feeling, right? And if we are able to, based on the data that preexists from, the women's health initiative, there is a great cardiovascular data showing that estrogen is really helpful types of progesterone matter, right? Micronized progesterone is not androgenic. It's, doesn't have as much of an increased, it does not have an increased risk of invasive breast cancer compared to synthetic progestins when they're given systemically. Right. Not everybody can tolerate oral micronized progesterone, but that's where, you know, we need to start talking about, well, how are the IUDs going to be in this landscape as well? Right. Because that gives you localized protection of your uterus. There is a little bit of systemic absorption, but there are different dose IUDs now, there are low, medium, and high dose IUDs that are out there, not sponsored by any of these people, just, bad practice of rattling off brand names. Depending on the dose, it may be more or less useful. Like for example, I have, when I have patients who have PCOS. I have seen them develop more androgenic symptoms when they get a higher dose progesterone IUD and because levonorgestrel is androgenic, right? And for years we told women, no, no, that can't be it. It is definitely it does. And you know, what's funny is this is why people want us to talk about everything on social, but listen to how nuanced this was, what you just said, right? So everybody, you need to meet with a doctor that actually knows what they're talking about, because does the IUD cause a problem or not? Or is it helpful or not? Listen to the different doses. Listen to the different formulations of the oral stuff, like it's not as easy as sometimes people say, Oh, I Googled it. I'm like, okay, amazing. Now let's have a deeper conversation. Absolutely. So for example, micronized progesterone is not androgenic. There's, there was another one that they use in Europe. That's not available here. That's not androgenic. And then there's actually a chart of going from least androgenic to most androgenic. And you don't want to, for example, with somebody who has polycystic ovarian syndrome, where they have a high amount of circulating testosterone, you don't, you may not want to give them a higher androgenicity, or higher androgen, effect progesterone, because it's going to make their symptoms worse. Right. And for anyone who's listening and doesn't know what the word androgen means, think male sex hormone. So I just wanted to kind of throw that out in case they don't know. Yeah. Thank you. I appreciate that. Yeah. So testosterone type effect from the progesterone, right. But then, you know, I I've been listening to some of Dr. Casperson's podcasts and she does, for the longest time, the endocrine society has been very anti testosterone in women. And the way she presents the data, has changed my endocrine mind. And I'm thinking, yes, I learn more about this. Come over to this side. Conversations, right? So then, the question becomes for somebody who is not getting testosterone, then what can we do for them? Or if they have low testosterone, obviously in our patients who have PCOS or polycystic ovarian syndrome, that testosterone is not as much of an issue because they already have higher circulating levels of that. Right. So again, it's a very nuanced murky conversation, but I think really the biggest thing is, is that if we are encouraging. I think it's important to keep in mind, that we are encouraging our colleagues to get more educated on this right if we ourselves are looking into this, we've pledged to being lifelong learners so that we can do right by people. Right? That's the important thing. That's the part that I think healthcare providers need to step up to the plate and make sure that they're getting good quality information. For those of our colleagues who are amazing and are doing this research to make sure that we have new treatment development, and we're tracking all different outcomes for people who are going through different conditions, you know, asking those questions, I think creates that conversation. And my hope is over time, we see more research in women's health that helps us answer those questions better, but, taking the information that we know and applying some. common sense rules and then also having parameters around like, these are the different side effects that you can get from estrogen. Like for my patients that I've started on hormone replacement therapy, I'll have them do very low dose estrogen for a while. We'll see if they do okay with that. And then we'll add the progesterone you give both at the same time, you don't know, like, am I reacting to the estrogen or the progesterone? You have to know. It doesn't have to be for a long time. It can be for a few weeks, right? You're not going to create any murkiness if you do that for a few weeks. And then you have a better idea of when to start or stop something, or explore a different option. But we have to be willing to do that. And then I think also, you know, looking at cholesterol, looking at, how is body composition changing? How are people doing in terms of their weight loss goals and in your clinic specifically, is there blood pressure going down is, there's so many different things, right? And sometimes you have to treat, like, for example, I have a few patients whose cholesterol levels are through the roof. And I can't, in good consciousness, put them on hormone replacement therapy until we get their cholesterol under control. And then we can try something because of the, because we're not sure, if that can sometimes worsen, depending because, with oral estrogen that can actually increase triglycerides. Whereas you don't see that so much with when you give it in a patch formulation, which is transdermal. So it requires understanding what each of these different things does. And it's going to be a big science. We're going to have to put together treatment guidelines for ourselves and algorithms for what's the right way to do this. How do we structure our conversations with patients? I have to tell you, you talking about this, I'm so darn excited. I feel out the hope. I think there's lots of great things that are, that are there. And also just, I can only use the word nuance complex, but how much goes into this? That it's not just, oh, here you are this age. That means this thing. It's like, what's your history? What does this look like? What does that look like? I mean, that is what it's about when someone actually sees you in your totality, right? Just having come off of the eclipse thinking with the word totality, but someone needs to see you. All of it. All of you matters. Not just one thing. And yes, so. And that's the hard thing, right? As we get more information, we as a profession have become more and more sub specialized, right? Yes! There's so much to know that one person can't know it all, and this is where I think as a profession we have to come together. And I love seeing all of these guidelines that come out of Task Force. Forces where it's multidisciplinary because, you know, everybody's contributing to the conversation. And I think that is really the pledge that we make to our patients into our profession when we go into this is how can we pull this information together in a way that we're doing that we're doing the right thing for people. It's really fascinating that you bring that up because I was, I know we won't have time today, so I'm not going to delve into it, but I was going to think, oh, well, and what other lifestyle things do you recommend to your patients? And then I was sitting here and I was like, wait a minute, we're going to focus on this aspect today, because I'm going to assume all of what you just said, I can't even fathom sitting across from you in a visit, being a patient. not like, let's say there's not a medical background and hearing all this and then also doing all the other stuff. Like I, so that's why I do realize, yeah, we all need to work together because I know I will recognize the symptoms in my patient. I will say, please go talk to X, Y, Z for this. I'm thinking it is something I could bring in the clinic, but then I'm like, but But I wouldn't have time to do all the other things, right? So it's like, it's very fascinating, actually, how this all comes together. And, and that's kind of what I'm hoping to break down in my podcast, it's not the same for everybody. We are not genetically built the same, right? So depending on what you see in your history, that may manifest for you after a certain period of time, but. Knowing how that relates to the changes that you're going through and what are the different things that you can do and having experts in those fields, because I'm not a sleep specialist, but I know enough that, you know, sleep is impaired when you hit perimenopause. I'm going to have somebody come on to my podcast and we're going to dig deep into what exactly happens to your sleep cycles, or the different things that you need to do. And so, you know, in terms of getting back to our, our commonality with both, both practicing obesity medicine, I think that it's important for us to look at our patient population. It is just now in the last 10 to 15 years that. Obesity is getting the due that it deserves, right? Yes. And so this is going to be a long process as well, especially since we were set back so many years ago. But I think the more people that are talking about this, the more people that are open to having conversations and asking hard questions, even if you don't know the answers, we're going to get there eventually. We're going to do it. We're going to do it together. So my hope is to create a good repository of information for patients and for providers. And let's let's do this together. I think for our patients who are struggling with being overweight and with obesity, I think it is important to understand that over being overweight or being diagnosed with obesity increases your cardiovascular risk in your lifetime. That is a known thing. That is absolutely a known thing. And so when you layer the fact that going through menopause worsens the underlying metabolic disease and also increases cardiovascular risk, it's like a double whammy, right? And so you can't treat just one, you have to treat both. And I was, I was reading and, I watched a really good, symposium that we talked about earlier, from the international menopause society on, you know, menopause, treating treatment of menopause and obesity. And there were some really, really great, takeaways from there in terms of, you know, basically what we just talked about. Cardiovascular risk goes up, diabetes risk goes up, and menopause is making those changes possible. worse. But then, you know, treating obesity reduces risk of coronary heart disease and diabetes. And then treating menopause improves metabolic factors. So why are we not able to see this as additive? Why does it have to be one and not both? So I thought that that was really empowering to hear like experts from around the world echoing the same thing. Right. And I think Also, for patients who are living in bigger bodies, it's important to understand that there's also an increased risk of thromboembolism that's associated with obesity, right? And that's a known thing as well. And when we worry about hormone replacement, talking to your doctors about hormone replacement, transdermal, Estrogen does not have an increased association with thromboembolism. So if you were my patient coming into my office and you are struggling with being overweight or obese, I would talk to you about transdermal estrogen. I actually like that as a starting point for almost anybody, right? Because you're not swallowing the pills, you're not getting that first pass effect through your liver, which is where I really think a lot of those side effects come from, obviously there are some people who are allergic to adhesives and that's unfortunate because all of the patches are, are stick on, but they come in a variety of doses and you start at the lowest dose and you go, very, very slowly with how you increase that to see where you get the most relief from the symptoms. And once, once you're getting there, you don't necessarily have to, to increase further past that point. And if you look at the way the women's health initiative hormone therapy trials were done, everybody was on the same dose. It was a very high dose. They used a very high dose synthetic progesterone. And then, oh my gosh, the average age of women in that study was 63. And then all of a sudden the conclusion was, oh, bad things happen to women who are on hormones. No, not the lesson. That is not the lesson at all. So I, I think it's important to understand that. There was a great study that looked at, the estrogen, the oral estrogen increases the risk of venous thromboembolism in women with obesity. Transdermal estrogen does not. And then depending on the type of progesterone we use, that risk can go up and down as well. Right? So I wouldn't really love systemic progesterone in women who are struggling with obesity. I would talk probably more and have them go see their gynecologist for an IUD because it is, systemic and then maybe a lower dose one, right? Just to see where we're at, because if you have a uterus, you have to protect it. You cannot take estrogen by itself because that increases your risk of developing endometrial cancer. So, you know, again, very nuanced conversation, but I think, if I were going to sum it up, it's, Hormone replacement therapy should be available to all women, even those who are struggling with obesity. And that, trying to use transdermal preparations is going to probably get you the best bang for your buck without increasing your risk of having a blood clot. Yeah. Oh, this is so good. It's so good. There's going to be so many people, so many women are going to hear this, know a little bit what they're talking about and go find someone that knows how they can help them. I, I, I really hope so. Right. Because I think that, you know, We just, we just have to do better by, by women in medicine period. Right. Yeah. Even, even to our own colleagues, right. We look at the fact that 54 percent of women who are 54 percent of people entering med school are women. Yeah. That's a big part of our profession. Right. Well, we're like, we could go with it to these places. Well, I recently, this was in the past year, I've been seeing that. A lot of new startups are really targeting menopause as far as, products for them and stuff like that. And I'm like, yeah, because they've realized that there's a huge gap in the market. As far as we do want products that support us, we do have the money to spend and it's interesting, right? That almost sometimes I feel like that stuff needs to happen. And then the science needs to evolve a little bit. All of it needs to come together, but It's, I, they gave it some fancy name, which I already forgot, but it was a fascinating episode that I was listening to. I was like, great. Do all the research, do all of it. Yes. We want, we have to have all of the support that's there. Right. And you know, like our insurance companies don't have benefits for women who are going through, you know, periods. So archaic, like not supporting that, not supporting fertility measures. It's just, anyway, I hope that. You know, we'll see over our careers, but the things that you have, weight care be included, fertility, perimenopause, menopause, just all of it, right? Just full supportive care on all of it. So, okay, tell us the name of your podcast. I know we're going to link all this down below, but. Tell us that. Tell us how people can find you locally. Give us a little bit of information. So, the podcast is called Reset Recharge because my entire goal is to reset everybody's understanding around what their metabolic health looks like during this time. And then the recharge part of it is I want to be able to recharge conversations people are having with their healthcare providers, right? If we don't start asking the questions and we don't start educating people, conversations will never happen. What an amazing name. It just literally says it all and it's, oh, it's so good. Okay. And then tell us a little bit again, what is the main kind of what you're talking about on that podcast? I know you've talked about a lot during this, but who should check it out? So I would say anybody who is in that age range and wanting to know more that is noticing. changes in their body. I think, one of my, one of my friends asked me, well, are you going to do an episode for partners on how they can be supportive as, as we go through these changes? And I thought, oh gosh, yeah. Well, I mean, I guess that's an audience as well, right? I honestly hope that people are able to find good information from it. Like I said, we're going to be talking about how metabolic health shifts during this time period. And then also look at all of the different organ systems that are affected, right? Because again, What happens to me is not necessarily going to be what happens to you versus the next person we cross on the street. Right. So I think just getting that baseline understanding of what are all the possible changes. And then, you know, what are challenges that people are seeing, I got a lot of really good questions from, some of my friends and colleagues that I've been running this concept by and that spurred on, you know, several more episodes in my head of, Oh my gosh, I have Let's talk about this. I also want to bring an, an endocrine spin to it as well because you know, like I said, a lot of times there is this, Oh, it has to be my thyroid or it has to be other endocrine thing. And in terms of overlap actually, right? Like they're very, we need to have you back to have like part two on that because I've had different endocrinologists on and we've like. Slowly broached it. But, but it's, it, I, and I feel like every endocrinologist has a little bit of a different view on it. Is that just me? Absolutely. You can put five us, five of us in a room and you'll get five slightly different answers. Yeah. But that's why we call it practice of medicine, right? Yeah, exactly the same. There are guidelines, but we don't do things the same. That doesn't mean any one approach is, is wrong or better than the other. Right. But I think that just giving people a basic understanding of, you know. When you're coming to see me and we check your thyroid test, these are the necessary thyroid tests because unfortunately, I think, you know, because of distrust that people have developed over the years in the health care system, right? We're having to see patients faster. We don't have as much time with them. Those conversations get cut off and that leaves people without answers. There's this distrust that's developed over time, right? And then people will go find online resources and spend it. Thousands. And when I say thousands, I mean thousands of dollars on tests that are not necessarily interpretable or useful or based in science. Right. And it's hard because it's such a vulnerable population. So I can give you want to say the name of these tests because I feel like then you're going to know what it is and you're going to get this test. That means nothing. Right. Exactly. But you know, it's it's when you are right. Paying huge amounts of money for things that have not been proven in science. Like that's such a vulnerable population, right? My goal is to provide people with good quality information that they, you know, then they're not falling to outside sources that are going to potentially take advantage of them in vulnerable situations. So if I can provide good quality information on those things, then keep that conversation going. That's really, that's really my goal. Oh, well, this is gonna be incredible. So we're going to make sure to link all that down below in the show notes. And again, if you're listening to this and you don't know how to get to the show notes on the podcast where you're listening right now, you can always go to rentierclinic. com forward slash blog. And each episode has its own show notes. You can click on it. You can see a bunch more writing. We're gonna have all the links, everything like that. Thank you so much for coming on today. This is life changing for everyone to hear this. Thank you so much for having me today. And like I said, you have been a big inspiration in my, in my first steps towards trying, trying to do this. So hopefully, hopefully it'll continue. Hopefully there'll be a good response, but thank you. Thank you. Thank you so much for everything you've done for me in terms of supporting me and, you know, answering all of my questions about how do I record this? How do I, You know, like all of these basic things that are not so basic, really. It's a, it's a lot of work and I really appreciate your, your time and your mentorship in that way. Thank you so much.