The Business of Orthobiologics Podcast

Orthobiologics: What If Hormones Were The Missing Variable? | Conversations in Regen Episode 15

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Could hormones be the missing variable in orthobiologic treatments for musculoskeletal pain and healing? Find out more here, Visit my Website : https://pxllnk.co/AD/BOBsite

In this enlightening discussion, Dr. Ariana DeMers, the Queen of Business Orthobiologics, and Dr. Matthew Hernandez, an expert in hormone replacement therapy (HRT), explores the critical link between hormone therapy and orthobiologics. Hormones play a significant role in inflammation and joint pain, yet they’re often overlooked in regenerative medicine practices. This video dives deep into how hormone-related joint pain can be effectively addressed when combined with orthobiologics and the latest advancements in hormone therapy.

Dr. DeMers, a passionate advocate for the integration of orthobiologics in patient care, teams up with Dr. Hernandez. Together, they share their experience on how integrating hormone therapy with orthobiologics can optimize patient outcomes. Learn about the science behind hormones and inflammation, how hormone therapy can enhance the regenerative response, and why it should be considered a key component in musculoskeletal care.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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SPEAKER_01

We know that the risk of cancer, the risk of cardiovascular disease, all of those are non-existent or very mild risks at the end of the day.

SPEAKER_00

We have failed an entire generation of women.

SPEAKER_01

The FDA had done a disservice with the Women's Health Initiative and really scaring women out of hormone therapy.

SPEAKER_00

You don't want to do hormones because you're gonna get breast cancer and you're gonna get DBTs and you're gonna like die. But what they didn't take into account is health. Hello everybody. So glad you're here and you're joining us to with conversations in regenerative medicine, exploring frontiers in PRP, BMC, MFAT, and controversial topics as well as cutting-edge insights for the future of interventional orthobiologics. I'm so happy everybody is here. For those of you who do not know me, I'm Dr. Ariana Demers. I'm board-certified, fellowship trained, sports medicine, orthopedic surgeon, and regenerative medicine aficionado. I am a SAD offer, educator and trainer in orthobiologics and ultrasound, and I have a regenerative medicine business, cash-based orthobiologics business in rural Northern California, a town of 20,000. So people always say you don't understand, your patients have the means. So I'm gonna tell you, I live in a quite rural environment and have had a lot of success with orthobiologics. And most importantly, I am passionate about helping other physicians incorporate orthobiologics in their practice seamlessly. So for those of you who are expecting Dr. Josh Jacter, fortunately or unfortunately, he had an emergency. But Dr. Matthew Hernandez has been so kind to join us, and he is the best in the business. When it comes to regenerative medicine and integrative care, he I thought of no one else. So I just want to introduce you to Dr. Matthew Hernandez. He is uh owner of a co-owner and physician at Ethos Integrative Medicine, a medical clinic that is specializing in regenerative medicine and hormone therapy, geared towards helping active individuals live the life they love. He also is a business consultant, elevating doctors in private pay medical models. He is an adjunct professor at the Southworth College of Naturopathic Medicine and a host of the Ethos Athletes Podcast. So definitely a shining star and top doctor. So I am so glad that he was able to join us on very short notice. I'm so thankful to you, Matt. I'm really happy you're here. So glad you could join us. So for everybody that has joined us thus far, I really appreciate you taking time out of your day to put a little bit of extra information in that thought process in regenerative medicine, and honestly, talk a little bit more about maybe some controversial topics that we don't necessarily get in the mainstream research, mainstream conversations. So the other piece of this is that this is basically a fireside chat between friends, and we'll get some questions and answer sessions, and we'll be able to gain some actionable insights and implement things in your practice immediately. So you can get your burning questions answered today, and I just wanted to kind of give you an overview of what we're talking about here. So my belief is that orthobiologic treatments will be first-line treatment for musculoskeletal care in the next five years. The train is leaving the station. And so if you are not actively offering these treatments to your patients, you've got to get on the train, right? This will be the standard. Here's the problem is so many of us are looking to integrate orthobiologics successfully, but it's hard, right? Maybe we know that orthobiologics is the best treatment for our patients, but how do we do it successfully? And maybe you've tried some things, but maybe you say, gosh, I don't know the science. Maybe I don't know the technique, cash-based business, marketing sales. And maybe you've just thought I'm not good at business. But it's not our fault. We did not learn this in school. And so some of you maybe are struggling with how to be successful and capitalize on this $4 billion ⁇ biologics market. So maybe you're just thinking, gosh, I deserve more time with my patients. I deserve more time with my family doing the things I love, right? So if you could please, please just it put in the chat what the thing is that you're struggling most with. And so maybe we can help you in this session today. So the question is, is how to win, right? While we're talking about the science today, we also need to consider how we talk about this with our patients. So we all win, patients and doctors, right? And to that end, you need a system. Now, we're not gonna go over this entire system today, but we are gonna get a little bit further down this journey to be wildly successful in your orthobiologics practice. So you need a system. And we're gonna talk a little bit about that knowledge today. So, Matt, let's get down to business. And my friend, we have questions, right? There's been so much activity around hormone replacement therapy and arthritis and teninopathy. So, my first question is to begin, can you share what kind of led you down into the intersection of hormone replacement therapy and orthobiologics? And then maybe ultimately what has pushed you to kind of speak more publicly about the role or lack thereof in women's health with you know this hormones being taken off that black box, you know, the black box has been removed from estrogen. Can you just kind of talk a little bit about how you got to where you are today?

SPEAKER_01

Yeah, absolutely. So, for first off, thank you for having me and you know, pleasure to meet everyone. So, the really when we started, and I'll say we a lot because I I co-owned the practice with my my wife as well, also a physician. So, when we started our practice, a lot of our background already came in having training in HRT and being able to utilize that. And then you know, we we started learning about orthobiologics in school and and then you know, more specialty training after the fact. And really, like when when we sat down, we we were thinking about okay, what how do we want to help people, and what do we think is the best route to go and really optimize these treatments when you know when you're looking at at how hormones play into not only healing but with pain perception, all these different things, it it really makes sense to to combine the two together at the end of the day. And so this has been you know, we just hit our 10-year mark in our practice two weeks ago, and we've gone and and have always combined these two things just because it made sense for us to really optimize not only the patient, but to get give them the best possible treatments when we're looking at orthobiologics. And then when it comes to talking about the FDA's role in women's health, this for women's health specifically, this is my wife's domain. I I do I do men's hormones, but I can at least speak to what I hear her say and and the bit that I know from her. And really the FDA you know has had done a disservice with the women's health initiative and really scaring women out of hormone therapy. And you see that even I don't want to deviate too much, but you see it even with men and and men being scared out of hormone therapy because of cardiovascular disease, prostate cancer, all that kind of stuff. Women have the same fears, and you know, the it's just more it was just more more publicly on display if for women's health, which uh you know was ultimately a disservice to them, knowing that the women's health initiative didn't have great statistics. The population group that they used was an older population than what would normally be used in this case. The type of hormones that they were using is not what's typically used in HRT, or not at all at what is used was used in HRT. So a lot of different things on that part. So I'm I'm really glad to have seen some of the reversal of that information and from that standpoint. And the more in more access to information we have, the more individuals, and like from a patient perspective, are being educated. And I mean, patients come in, you know, at least the ones that we work with come in extremely educated on on options that exist for them. And I really like the trend that's going. When we started 10 years ago, we were like the what we did was not as popular, and it's only become more popular throughout the 10 years. And so I'm I really love the direction it's all going.

SPEAKER_00

Yeah, absolutely. So where do you feel like both medical societies and the FDA? We clearly we have failed in an entire generation of women. We have set them up for failure in so at so many levels. And I think the silent actor in this is musculoskeletal health or poor musculoskeletal health. Right. Not only from tanninopathy, but from arthritis. Everyone thinks it's an osteoporosis problem, but that's like the end result. If you start sooner, really, this is all plays a part. So when you talk about your patients coming in educated, where do you think that? Because clearly the FDA is not educating, and clearly the main medical societies are not educating our patients well on HRT. So they've clearly failed, right? So, where do you recommend and see the best well-informed guidance coming from?

SPEAKER_01

Yeah, it's a great question. One of the things that's really difficult for patients on the consumer side is because this market has only gotten more popular, with popularity also comes bad players into the area, too, right? So you get social media influencers trying to make a buck, and some, you know, some of the stuff that they say is accurate, some of it's not accurate. You have the same thing from podcasts, you have the same thing from YouTube. So there's a lot of noise in the area, right?

SPEAKER_00

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SPEAKER_01

And you know what the way we really position ourselves is is we go and talk to talk to patients about okay, you're gonna you're gonna hear a lot of information, not only from all the different forms of media you can consume, but even from your doctors that may be more conservative on treatment, not opt for HRT or not recommend it. And really our job is to kind of cut through the noise and make it individualistic for you. So like what makes sense for you as a person, not like a blanket statement, right? And and that's where having our having experience and an understanding of what like if we stick with women, what's wrong with the women's health initiative and those types of things is gonna be really important. And so the best I I have yet to find anyone in what do you call it in in the research that I've done or the conferences I've attended or the podcast that I've listened to where I take their word as gospel, right? And so you you kind of take bit pieces of information from what you believe makes sense based on your training, on your experience, all that kind of stuff, and and you put that together, and ultimately you position yourself as someone who can help patients cut through the noise with that information. And so they can you know patients can go and listen to all the podcasts, listen, like you know, educate themselves, all that kind of stuff, but there still is the what do you call it? There there is a variable or a factor that plays in where the doctor says everything's gonna be okay, or this is you know, this is ultimately what I think is best for you. Like there's still power in that, right? And so it's really just educating ourselves on that piece. Uh yeah.

SPEAKER_00

So more acting as a guide and an educator, and maybe some of that is reassurance. Um, because what I find, and I'm sure you you find the same thing, is that this whole generation it's been fear-based. And so it's like, oh no, you don't want to do hormones because you're gonna get breast cancer, you're gonna get DBTs, and you're gonna like die. And but what they didn't take into account is health.

SPEAKER_01

Right.

SPEAKER_00

And so we haven't, we haven't done anything to enhance women's health for the last 20 plus years regarding hormone replacement therapy. So I I just, you know, I have some, you know, friends and colleagues who I think do a nice job. I think that Peter Atian and you know, others have really tried, even Deb Matthews, she's done a really great job and trying to clarify why how did we get here, right? How did we get here all the way here 20 something years ago and now trying to work out of this really dangerous position that we find ourselves in where we've really have done worse for our patients because we've recommended against HRT for women. I was sharing with you earlier that women's hormone levels drop off significantly earlier than men's hormone levels, right? And the shocking thing that I've found is that the levels of arthritis rise precipitously at the same time when women's hormones are declining, and that's quite a bit earlier than men's arthrite levels rise for this same problem, right? And so not only do we have an earlier presentation and we have a higher level of arthritis, but it's reversible, right? So with hormone therapy, we can actually avoid these arthritic conditions, the this early onset of these arthritic conditions. How do we rectify that in our mind that we've not only condemned women to more higher levels of osteoporosis, fracture, but tendinopathy, arthritis, all of the things that go along, you know, accelerated aging. How do we rectify that in our brain? When patients talk to you and say, What do you mean I could have been on HRT? What do you tell them? Sorry, we screwed up, we didn't know.

SPEAKER_01

Yeah, yeah. I mean, it's difficult to have that conversation when someone's coming to you, you have this solution for them that should have been offered to them, you know, 10 years ago or whatever it is. And there's instances where they'll sit in front of us and say, Well, you know, you know, I I I was told by you know doctor down the street that, you know, in in traditional system that I wasn't a candidate for that, or you know, I was scared out of it because of XYZ. And it's like, okay, you know, I get it, but at the end of the day, you know, if when we look at the research behind it, we know that the risk of cancer, the risk of cardiovascular disease, all of those are non-existent or very mild risks at the end of the day. And when we're looking at your health as a whole and how do we keep you healthy as long as possible, we know that when we're looking at muscle mass and muscle strength and all those things, like bone density, all those, those those are you know the big big factors into how your overall health as you age and hormones play a direct role on that. So do we get scared from weighing this risk of that may not happen, or if we have lower levels of sex hormones and all those different things that we know will cause not muscle wasting necessarily, but but muscle weakness and and trouble building strength and all that stuff, you know, which which direction do you want to go with and when when you're picking that? And so it becomes when you go and think of it like you know, from that standpoint, it becomes a lot easier for people to understand, oh, this actually makes sense for me to be on. And it's unfortunate that they didn't get you know the timing of it right necessarily if if they were if they were scared out of it, but there is a point where you know they can still likely be on it at the end of the day, and so you just have to go and modify it for them.

SPEAKER_00

Right. Absolutely. Well, you know, I always love these conversations because I learned so much, and you know, I always love everybody's perspectives, but we have more questions for you. So, how do you explain this modern hormone replacement therapy safety to patients who are fearful because of these headlines, these scare tactics, these misstated statistics, really, um, and misstated risk factors? How do you really maybe become that guide? Because I tell you what, these these women have been hearing this message for 20 years. How is it that we can cut through the noise in one visit and really be like, oh, okay, sure, no problem. I'll start HRT tomorrow. You know, yeah, what what do we use or what do we talk about that's so clear that it was will actually help understand a why it happened and b that it's misplaced fear?

SPEAKER_01

Yeah, it's a great question. When we talk to patients in our office, it's really knowing the history of of how it came to be, right? And so when we're looking at again, women we'll stick with women's hormones, going and talking about okay, you you saw these headlines or you were told this by this doctor, whatever it is. What this doctor, we tend to go and ask questions on if they got their information from a doctor, we tend to ask questions to kind of gauge what that doctor's knowledge is. And so one thing would be if they were recommended hormone therapy and the hormone, you know, when we asked what was the hormone therapy you were recommending, it was birth control, it's like, okay, that's that doctor's clearly like not practicing HRT, that kind of stuff, right? They're clearly working off outdated information. And so then we can go and say when we're looking at at what this doctor's going off of, and that's a bad mouth of the doctor or anything like that, it's just not their specialty at the end of the day. But when we're looking off of this information, they're going off of women's health initiative. With women's health initiative, this is what's wrong with it. We know that their candidate choice was was older women that wouldn't necessarily be the ideal demographic for being on HRT in the first place. We know they use these particular hormones that are not HRT hormones, they use progestines and stuff like that instead of actual progesterone. The stats that that they gave on cardiac risk and cancer risk, this is why we know that even like blood clots, for instance, we we know that you can give transdermal estrogen, it has no increased risk for blood clots, but it does increase or it does help with overall quality of life and stuff like that, right? And so it it and and regulate a lot of those symptoms. And so when you start what in our experience, we when we start and and and talk about the history, the different bullet points of what was wrong with it, at that point, patients have already most at least the ones that come to us have done a lot of like reading on their own and have heard the same thing. So the fact that we're saying the same is reassuring for them. And then we go and talk about okay, again, that that risk versus benefit ratio here of are we scared of this X percent chance? You know, I'll go with men because I know those stats a bit better. Like with men and TRT, two percent chance that they'll develop a DBT by from having an elevated testosterone with hemoglobin and nematocrit being high. So if if what you know it's two percent, and if you get a dbt, yes, it's gonna be a pain, and that's like the worst. Worst case scenario that can happen here. But if we manage that really well and we don't overdose you, we pick the form of hormones that's good for you. We're doing quarterly visits to make it to check blood work, doing those things, checking all the different risk factors that you may have. The benefit, you know, you keep there's a 2% chance you'll get a DBT, but then the benefit is that you get more energy, you get stronger, you recover faster, you know, like all these different things that that come with that. So most individuals do not mind taking that small risk if they know that it's going to be monitored really well. And that's our our our thing is that we we see people every quarter. Like there's no, it's not negotiable. If you they don't want to do it, they don't work with us. So, and and every quarter is important because that's how we that's how we keep them safe at the end of the day and make sure that we we keep those levels, you know, balanced and and we're checking all the different risk factors, making sure nothing's going wrong.

SPEAKER_00

Yeah, so I think you know, what you've touched on is patient education, figuring, but also reassurance that this is not a flyby night clinic, that they're just not buying them online. And you know, you said something really important, which is that you monitor them every three months and it's non-negotiable. Right. Um, and so for me, I think that's one that's one thing that I think as a regenerative medicines specialist is it maybe it maybe is not doing hormone replacement therapy. That's one way to vet a practitioner who does a really good job with hormone replacement therapy. The person who took the online weekend course and doesn't do any follow-up labs, doesn't see them every quarter, doesn't measure, doesn't check other concomitant disease states, probably is not the practitioner to partner with. And so what would you say if you're if you're recommending, you know, what are the top things that you're like, okay, these are legit great practices for hormone replacement therapy physicians. So that if I don't want to do that, but I'm looking for someone to partner with, what are the what how do you find or how do you vet those physicians?

SPEAKER_01

Yeah, great, great question. So I think what I've done in the past is how often are they seeing people? So quarterly visits is is our standard, right? The most that I'll go is if a patient has been with us for like three years, then at that point, like we know that they're balanced and everything's going at this point. If if they've been with us for three years typically, I'll move it to to instead of every 12 weeks, we'll do every 16 weeks, so three times a year. But that's the most I'm willing to go. I'm not willing to do six weeks, six months, because something can happen in six months. So the frequency is gonna be really important from that standpoint. I think one of the most important things, and I I think the you know, people on this call can relate to it because like yourself, you're orthopedic surgeon trained and you do regen, right? And so there's for us and hormones, we're agnostic to the type of hormone that's given. So we don't just do pellets, we don't just do injections, we don't just do creams or patches or whatever. Like we we literally do not care what form we use, it's whatever's right for that individual. And I think that's really important because a lot of uh I see Margaret had also mentioned in the comment, a lot of these HRT clinics that just do pellets and stuff like that. I mean, I get it from a business standpoint, it's streamlined, it's nice, it's profitable, that kind of stuff. But you're doing spreadsheet medicine, and that's what you're trained in at that point, where you go input the patient's age, input their labs, and then the pellet company who has obviously no bias on how much you should be giving at that point. They're the ones dictating what how much pellets you're giving them. And you know, there's obviously conflict there. So those are two big ones like the frequency, how agnostic they are from that standpoint with with the different types of treatment. I would say, yeah, I would say those are the big two at the at the end of the day. Like that'll help you weed out people pretty quick from my standpoint and how we set up our business. This is harder for people to see from the outside, but a lot, and you know, not to knock people at the end of the day, but you know, this is just our opinion. A lot of hormone clinics go and they offer low pricing to see the doctor, and and the reason they do that is because they make their money selling product, right? And so they make their money, they make their money selling peptides, selling hormones and all that stuff. When we started our practice, we didn't feel like that was ethical. We didn't want our doctors to be incentivized by that, and so we charge a higher amount of money, or we we charge a we're on the higher end of the spectrum for our time, but it's because we don't make money off of the medication that that we recommend. And so we can go and do that ethically, not feel guilty about that. Would we make more money like the other way? Probably, but you know, that I I wouldn't be able to sleep at night either. So that's you know, it it is what it is.

SPEAKER_00

Those those are really good kind of rules of thumb for vetting whether, you know, the doc down the street who is doing HRT maybe is the person to partner with if you're not looking to do it yourself. Yeah. You know, great, awesome. We still have more questions. I'm sure you're uh expecting that.

SPEAKER_01

Absolutely.

SPEAKER_00

Can you kind of talk about how hormones influence musculoskeletal pain, healing, the regenerative response, and maybe the biggest gaps that you've seen in physician training and understanding? I think as we go along, this is kind of new territory in thinking about the relationship between the hormones and muscoskeletal care. I will tell you, as an orthopedic surgeon, you know, 15 years ago, I sure as heck did not learn about that. The only thing that we used hormones for was like an oh, by the way, you have osteoporosis and one treatment might be estrogen, but it's not recommended. That was the the whole thing. And then when you talk about risk, when we talk as orthopedic surgeons about risk of osteoporosis, even if you have a hip fracture, you have a 25% chance of dying within the year of hip fracture. So it's not nothing, right? So if we were to be able to prescribe HRT to avoid osteoporosis, we're actually decreasing your risk factor of hip fracture and subsequent death by a significant amount. So how where do you see these biggest gaps? And I mean, I know where I'm coming from, I'm like, what? Pain? Knee pain and hormones? What are you talking about, right? But where do you think the biggest gaps are or the most helpful kind of knowledge bombs that maybe you can help us with today that has been kind of a game changer in your regenerative clinic?

SPEAKER_01

Yeah, for sure. So so I think that the biggest gaps are in medicine, and this is for all healthcare providers, regardless of what healthcare provider you see, from a surgeon to a physical therapist to a chiro to a massage therapist, like does not matter what the healthcare provider is. Like literally that we're all trained this way. We're all trained to have a solution that is or look for problems that we have the single solution to, right? So if it's a I I use this example with patients where if they have knee pain, they see a massage therapist, they have quad tightness, they see a chiropractor, their pelvis is misaligned, they see a physical therapist, their hip is weak, they see an orthopedic surgeon, they have arthritis, right? And it could all be true to some degree, but at the end of the day, there's the it's likely a component of all of them. But the when when we're looking at at healthcare providers, that tends to be the biggest gap in knowledge, is is we focus on the things that we know how to do and we ignore everything else. And so when we're looking at at hormones, when I look at at a patient in front of me, some of the things that I'm paying attention to. So I can think of an individual that I saw a year ago. So we've been working with him for actually probably a year and a half now. So older guy had arthritis in both of his knees, confirmed on X-ray, all that fun stuff, had some back pain as well that went that was with that, was having trouble moving around, going from seated to standing, was you know, was an avid pickleball player that slowed down quite a bit because of the pain. He's in his 60s, and pain in general, you know, on average was probably like a six to seven out of ten at its worst, maybe a five on average or so. And so he's sitting in front of me. He was referred to me from a physical therapist that I work with, and he was referred for regen, like at the end of the day. Like he was there for injections, he wanted PRP and all that stuff. And so I'm talking to him, and he's saying, Yeah, I have pain, you know, in this knee, in this knee, in my back, in my wrist, all this stuff. And so it's common for us as orthobiologic individuals to go and be like, let's inject it all, let's go. And you go and do that. When I was listening to him, though, I started asking a little bit more systemic questions. What does his energy look like? What does libido look like? All those different things. Well, found out that he had low testosterone, and or I had a hunch that he did. So we ran it. Sure enough, he did. His testosterone was in the like 250 or something like that. And I said, you know, hey, at the end of the day, I you know, could I go and inject you? Yes. Like I could inject now, and you'll probably get some relief realistically. But at the we I want to go and get your body in a position where it can heal at its absolute best, and being able to use these, you know, these injections and PRP at the fullest capacity. And so we know that sex hormones have a play a role in pain perception, right? And so testosterone and estrogen play a role in that. And so I told him, I was like, let's get your testosterone up first, see how you do. If my expectation, and I didn't say this out loud, but my expectation was that his pain would probably go down to a three, three out of ten from five. And like just with that alone, just because there was a lot of stuff going on that my that that made me feel that way. And so sure enough, we increased his testosterone, got him into the 900 range, and he started feeling better. And so his pain went down, he was able to move, he wasn't as stiff when he was working out, he wasn't as sore after the fact, all that kind of stuff. He still had pain though, like he still has arthritis, all that stuff. But we got him in a better position overall to go and do our treatments, and and as a result, we were able to resolve it, I feel like a lot faster with fewer injections than than if we had just chased it with injections itself. And so, I mean, we we know, like I said, sex hormones play a role with pain perception. We know that growth hormone, IgF1, testosterone are anabolic, right? And what are we doing with these regenerative medicine treatments? We're trying to rebuild collagen, we're trying to change pain signals, and so to ignore hormones with that, I don't want to go and say it's doing a disservice, but I think we're missing the mark if we're not paying attention to that. And so there's ways that we can optimize these treatments to obviously be the best, right? And so we do that not only for the biologics, where we're trying to get what's the best platelet count, what's the best way to get so many stem cells, like all these different things, right? So, what how do you improve the environment of the body that you're injecting at the end of the day?

SPEAKER_00

Absolutely. Yeah, thanks so much for sharing that because I think you're so right. As musculoskeletal practitioners, you see what you know, and you're like, oh my gosh, I can totally help that. But I think if you're not trained or haven't had exposure to the fact that sex hormones, estrogen, testosterone, and other peptides and hormones can really help with musculoskeletal pain, with recovery, with tissue regeneration and recovery and repair. It's so hard to understand because clearly I didn't learn this in school. And clearly I'm it's it it feels uncomfortable to learn things from popular media, right? You're like, what is this? Estrogen pain syndrome, and then you start like going down the rabbit hole, you're like, oh my goodness, apparently this is a real thing, right? And how did I have to learn about it from social media? This seems like a problem. But fair enough. I think as our as we get trained, we are so siloed in the way that we train. Don't miss out. Please subscribe to our newsletter now to stay ahead of the world of orthobiologics. You can find the link below. Additionally, if you're ready to start this journey with me in my orthobiologics masterclass, come join us. You know, another example of our silo training that I always use is prolotherapy. You know, as an orthopedic surgeon, A, I never got trained in prol therapy, B, I had no idea it was. C, when I found out what it was, I was like, oh my gosh, that's voodoo medicine. And then B, when I use it all the time, and I'm like, pissed that I never got trained in how to do this. And what and then how is it that I've been doing injections for so long and I've never used this really important tool? So I feel like hormones replacement therapy is a really viable, important tool in the toolbox for muscoskeletal care and regenerative medicine. And so, where do you see, you know, this like where do you start? And I think this is our next question, right? For clinicians who want to update their hormone replacement therapy approach in a safe and ethical way. Like, where do you start? Where do you go? Like, uh because it gets up pretty daunting pretty quickly. And I think the first response is like, oh, good God. You mean I'm not testing that, I'm not doing that. Like, I don't know the first thing about this. But also all doctors that went to school learned the things. And as I go along and in this regenerative medicine and lifestyle medicine vein of my practice, it becomes very clear that we all can just doctor our patients, right? And and the patient in front of us is not one thing, it's not just a knee arthritis, it's not just uh, you know, uh hormone deficiency, it's not just a thyroid, you know, deficiency. This is a whole person with multiple contributing factors to all of the experience and the things that are that they bring to the table. And pain is one of them. Pain is why patients come to seek our opinion and our help. So if you are doing orthobiologics in your practice and you're like, huh, I have been following the news, I have been following some really big players in the field that are talking, uh Kelly Kasperson, Peter Tia about the musculoskeletal component of HRT. Where do you start? Can you take a weekend course and like at least consider that it might be part of the puzzle?

SPEAKER_01

Yeah, great question. So when it comes to hormones, it's like you mentioned, it it can be complicated and it could be a little daunting. My caveat to that will be I think that for a lot of the people on this call, again, making the assumption that most people are orthopedic trained. I am not orthopedic trained. I do orthobiologics and I do hormones, but I like I'm not a trained surgeon. So when it comes to surgical outcomes for a knee issue compared to regen and like how to weigh at the pros and cons of each side, I can't speak to that's why I always call Ariana to figure that out. I I think that I'm at a bigger disadvantage from that perspective than y'all would be from a hormone piece. So I I say that because as daunting as hormones can be, you know, I I think it's possible to be able to have a solid understanding. Maybe it's not something you want to do at the end of the day, but you it I think it's possible to have a solid understanding of how these things connect and how it ties into regen. And so when when I'm looking at education and how to do this, so some of the things that we use from a training standpoint to train our team outside of our experience is gonna be you can use podcasts like ATA, Huberman, you know, the individuals like that. Ben Greenfield's probably a little bit more on the on the edge with some stuff, but in general, you know, it's good to hear those different opinions from that standpoint. So those podcasts, I think, do a fairly solid job at introducing it. I wouldn't go with everything they say, just like I've said earlier, there's not one person I found that take their word as gospel. There's a great book, or so let me back up. Great conference would be A4M, which I'm sure many of you are aware of. So A4M is a solid conference. They you know they have again some some trainings on there. One of their doctors that speaks at A4M, it's I forget how you say his name, but Theory Hearthgo or something like that. He's a he's solid. He has a book. If you're gonna get one resource, I'd probably get this one. He has a book called The Hormone Handbook, and I think there's a second edition. That one that one does does really well. And what I like about that book is it not only tells you it it breaks down every hormone, signs, symptoms, how to troubleshoot, or how to dose, how to troubleshoot the dosing, all those different things. And that that one I think is a great place to start from an understanding perspective because you can just understand one hormone at a time. That being said, one of the biggest things that I think is really important is just like Ariana said, the person sitting in front of you isn't just a knee, it's not just a shoulder. The person sitting in front of you is not just testosterone, it's not just estrogen. Like hormones are a symphony, they're all interconnected. One of the things that we see in our practice is someone, both men and women will have this problem where they came in from another hormone clinic, they have low libido, the hormone clinic just kept jacking up their testosterone. Testosterone is not the only hormone that controls libido, like cortisol plays an impact, estrogen plays an impact. So you have to know how to balance all those, and you have to know how to balance them for that person specifically, because again, I could have 10 different guys in front of me, and not all of them are gonna be an optimal testosterone of 800. Some of them, their optimal might be 600, others might be 1200. And so you you need to learn how to balance those. But I think those are those are pretty solid starting points. There is a book, and I I actually Amy mentioned it in the comment. I was gonna bring this up, Amy, so thanks for pointing that one out. When we talked about how do you educate patients on HRT and to help them understand, overcome fears, all that stuff. There's a book called Blind Spots by Marty Marcari. Phenomenal book. Like if you want to understand how medicine ended up the way it is, read any of his stuff. It's a phenomenal book. But I mean, he has blind spots, he has the price we pay. There's a few books that he's written, but Blind Spots specifically goes over certain headlines that have happened in medicine. So, like antibiotic use, HRT, eggs being bad or eggs causing cholesterol issues. And in each chapter, he breaks down the history of how that came to be and then why it's wrong. And so if you go and look at the HRT chapter on that book, that'll give you a lot of the information you need for being able to have a conversation with patients without diving into hours of research.

SPEAKER_00

Awesome. Awesome. Yeah, I wanted to also mention uh, you know, Donna White's BHRT Academy can get you started.

SPEAKER_01

Oh, yeah, she's awesome. Yeah, yeah. She's great.

SPEAKER_00

That's where I got started. So and I'm an orthopedic surgeon, so it we can be taught. But you know, the other thing that I think that patients and maybe physicians don't realize is that we all have all of the hormones, right? Women and men. They're just in different ratios. And so men have estrogen too, right? Women have testosterone too. So we're not all so different. And it is quite critical in our health and well-being. And you know, we don't want to just avoid disease, but we want to promote health, right? And I think those are very two very different perspectives, and and so thank. You so much for you know providing a little different perspective from a regenerative therapy expert who also has phenomenal training in hormone replacement therapy. So the question is what's the next step, right? We got the knowledge. Thank you so much for that knowledge, drop. That's awesome. I really appreciate it. So our practice launch system also provides you knowledge and expertise on how to attract the right patients, how to create a cash-based business, how to have high-converting consults for patients that just say yes, and obviously putting it all together. So I think that if you want the fast track, right, we can you can come see me in Clearwater for join me for hands-on workshops and labs, especially in the business of orthobiologics and some hands-on training. But ultimately, I have a little quiz for you that may help you kind of clarify what help you need. And then we're gonna go to QA with Matt, and we can ask all of our burning questions. So this is a QR code. I'd love everybody to scan this QR code to see what your next step should be in your orthobiologics practice, right? What your workflow looks like, legal freedoms, your time freedom, and really where you are on your PRP clinic. So go ahead and just scan the QR code real quick. We can always go back, but we're gonna go to our QA session right now. And so I'll leave this up. This is Dr. Matthew Hernandez. This is his expertise ethos Integrative Medicine, Dr. Matt Hernandez on IG, Ethos Athletes Podcast or on his podcast. But what I wanted to ask is please, if you're having questions for Matt, Dr. Matthew Hernandez, please put them in the chat. And if you have a question, the chances that everybody else has that same question. So please help everybody out and type the question in the chat. Or maybe even just uh, hey, I'm really struggling with this, or are you telling me I actually have to test for hormones? I I just do PRP in knees. Is this like legit? And and then maybe we can chat a little bit about that. Margaret, thank you so much for putting this. Yes, we do have this Western medicine handicap, right? Where our lab values are are an issue and how we have nutrition in our food uh has changed significantly as we've gone along. And we're living longer. And so people used to die at age 60. So losing your hormones at, you know, between 40 and 50 and 60 didn't really matter if you were dead, right? So now that we have significantly longer lives, it really does matter. Just like we we've talked about this uh concept of health span. What we're trying to do is is prolong health. And I think HRT is a really important piece to delay that onset of arthritis, improve the ability for the body to continue to be able to heal itself. So these these books are all awesome recommendations. There's some questions on are there any regulations with which one might want need to comply if they're doing HRT?

SPEAKER_01

Any regulations?

SPEAKER_00

Yeah, so like I think there's a lot of fear in physicians who don't do HRT. Like, how do they cross their T's and dot their I's? Can they just go ahead and start prescribing TRT? Or can they just go ahead and like call it good and do it as good as those online dock in a box, or maybe not dock in a box to prescribe a DATA and progesterone and an estrogen patch? Like, is how good is that, or how not good is that? Is is that like a place to start? I really don't I don't have the answer for those, but I I would love your opinion from a risk perspective. What is the, you know, what are the worries? What are the risks and what should we be from a regulation standpoint, what should we be considering?

SPEAKER_01

Yeah, uh great question. So I mean, at at the end of the day, the regulation state to state, I have no idea. Here in Arizona, you know, it's we can prescribe a bunch of different types of hormones and stuff. I know one popular one that people ask about quite a bit is like growth hormone. That's one that I do not touch personally because I feel it's so heavily regulated. Like I don't want any anyone knocking on my door at the end of the day. I'll use peptides instead for that to increase pulsing of growth hormone, and that tends to work well for us. But outside of that, I mean your standard consent forms and stuff like that. I would still, even though we know risk of DBT, of cancer, of cardiovascular disease, all those are low, I would still put that on the consent form at the end of the day because it doesn't matter what we think and what research says, it's like legal, medical will always take forever to go and change their opinions, and so you're still gonna be held by that standard. And so I would definitely pay attention to those. And then yeah, really looking at at different at different risk factors, and my our philosophy at our practice is we tend to be really conservative when we dose. So a lot of clinics that I know that exist over here will start on very aggressive dosing, and that aggressive dosing is usually where you end up having trouble. So in men, it's either their testosterone's gonna convert to estrogen quite a bit, and then you know, that's gonna cause an impact, or their hemoglobin hematocrit over 90 days will jump up, that's gonna start causing blood pressure issues and put them at risk for DBT. So, so really understanding or you know, go going and paying attention to more conservative dosing, knowing the different forms, all that stuff. Those are the things that we do to protect ourselves. And that's worked for us for the last 10 years, you know, knock on wood. So, yeah, I I would definitely pay attention to those things and really understand multiple forms. And the that hormone handbook that I mentioned, he goes over different forms for for treatment, and so you can use that as a guideline for your stuff.

SPEAKER_00

Yeah, so I have a couple of questions. You know, I don't do injectable testosterone, and I'm not sure. Is there more restrictions on prescribing injection injectable testosterone? Is there a registry? I think there is, right?

SPEAKER_01

Yeah, so so a great question. So testosterone it is is uh you know a controlled substance at the end of the day. So you need DEA. Most pharmacies will check how often is this person getting testosterone, and that that's in all forms. So that that's gonna be, yeah, regardless if it's cream, troche, any of that stuff, it it's all it's all heavily regulated. So in that one, it's you you want to go and and make sure that you're you're not and pharmacies will somewhat regulate this for you, but you you want to go and make sure that you're not over-prescribing it at the end of the day. So even a patient that I have who I do, he's been with me for like six years. So we we do a follow-up every four months, and I saw him at month 14 instead of or sorry, week 14 instead of week 16, and I called in a prescription to like refill it, and the pharmacy called us back to be like, hey, are you sure you want to do an early refill on this? And say, Oh yeah, it was two weeks early. Okay, yeah, that's fair. But you know, I wasn't in trouble or anything like that, but it is that tightly regulated, and growth hormones even more so than that. So something to pay attention to from that standpoint.

SPEAKER_00

I will share with you a tale of caution, but just like talk to your pharmacies. Pharmacists are in our world of orthopedics, pharmacists are like the bane of our existence. But in the world of hormone replacement therapy and compounding pharmacies, they can be a lifesaver. And here I'll give you an example. So I had a patient who was using a topical compounding cream, and there was a practitioner who, you know, they just missed the decimal point, but that's a major issue when it comes to dosing. And so she was getting a hundred times the normal dose of testosterone in her cream. Now, she really liked the libido piece, but she now had anxiety, her hair was falling out on her head, and she was giving hair other places, right? And so when I looked, I was like, I don't think this is the proper dose. And you know, my husband is an OBGYN and I said, Hey, look at this dose. And he was like, Oh my. And so we shifted her to a female dose of testosterone, not a male dose of testosterone. And, you know, so just be really like the your pharmacists are can be really good at guiding you to proper dosing and you know, all of those things as well. I do have a question. There's you know, is there an age when it's too late to provide HRT to patients?

SPEAKER_01

Great question. So I will speak from the men's side because that is the side that I know. I'm women, I'm pretty sure there is a point where you can't do it anymore, but I'm not I'm not 100% on that one. From men, I I haven't seen a limit on that. There's more precautions, like as the older they get, if you're dealing with like BPH and stuff like that, you obviously don't want to make that worse. But again, you can do conservative dosing and still be fine. I mean, I I have the oldest guy I have on on testosterone, he's on a cream, so he's on an injection where it's like crazy high, but he is on a cream, he's 86, so you know it's yeah, no, no issue. He's been on it for four or five years now, so yeah, so still no issue.

SPEAKER_00

Yeah, so I always joke that you know, if men's hormone testosterone dropped at the same precipitous rate as women go through menopause, there would be like in a national emergency, right?

SPEAKER_01

Yeah, for sure.

SPEAKER_00

So just putting that into perspective. I will also tell you my patients who are reliably on hormone therapy, my women who are on hormone replacement therapy and have been for years, when you compare them to their peers, they are significantly younger looking. Their tissues are significantly more robust. And so this is a game changer for your patients. You know, if if our I know we've gone over time, but if our audience here is like, gosh, I wonder what it would take to just set up a bare bones HRT clinic, what does that look like? Is this a massive investment? Is it, you know, can you start pretty just simply just testing some patients and saying, hey, why don't we start with the bare basics and see where we go? Like, how do how does that look?

SPEAKER_01

Yeah, that's a great question. No, investment is not the biggest investment's gonna be in the education for it. That's literally it. Because um, you don't have to hold inventory from a business perspective, right? Like you you literally just use compounding pharmacies or you know, whatever I would say, compounding pharmacies, they're more knowledgeable when it comes to this stuff. You have to be able to do blood work, but again, you can send people to lab core, you don't even need that in-house if you if it's not needed. And so, yeah, it it really is going and starting if if I had a pro tip, and you know, I hesitate to say this because I don't know how people will take it, but whatever. Men are easier with hormones than women, like with women, you're chasing a moving target, and I I say that because when we do our doctor's meetings here at our office to see like patient progress, our two docs who do women's hormones when I was like, you know, our patients hitting the winds that we're looking for, stuff like that, the target's always moving. Whereas guys, it's like energy, yeah, done, awesome. Like, perfect, let's move on to the next thing. And so if if you want an easy place to start that is a little bit more forgiving, I would start with guys because it's good, it is easier at the end of the day. And even when you know Alex, my wife, when she hears me do men's hormone consults, and she's had to cover for me a few times, and she's like, Oh my god, that is so much easier than doing women's consults. Um, and so that's you know, that's my two cents on that. You can potentially start with guys on that part, just because you're really looking at testosterone, estrogen, a CBC, a CMP, PSA, those are the very base slabs that you need, and then you can build from there. And then I know women, you have to obviously factor in like cycle timing and all that kind of stuff, or yeah, like the timing of cycle and everything like that. But going and learning the basic testing and learning the different forms of that you can give. So, like with men, when we're looking at when I work with men and I want to increase their testosterone, I know the options that I have available are gonna be you could do clomophene, you could do Kaisotrex, you could do testosterone injection, testosterone cream, or pellet, which is pretty rare for guys to want to do anyway. Those are the four ways we can increase testosterone, and those I laid them out from most conservative to most aggressive, and so you can learn how to do those and be able to do that part. And I I think there was a question about like hair loss and and HRT and men. I have had some guys who were on injectable testosterone, they were starting to have hair thinning, hair loss. I switched them over to Kaisotrex, which is a short has a short half-life and it's a pill. Their hair loss went away, like it stopped. And so you can change forms, and that that can also make a difference for people.

SPEAKER_00

Awesome, awesome. Let's see here. One new oh, oh, how concerned must be be about HRT interacting with patients' medications?

SPEAKER_01

Like great question. Should we stress out?

SPEAKER_00

Like, we doesn't humans have hormones, right?

SPEAKER_01

There's definitely not a lot of interactions. I mean, so maybe some small ones, but like you're gonna hurt someone putting like screwing up their blood pressure medication than you will their hormones. So yeah, there's not much big interactions to worry about too much.

SPEAKER_00

Awesome. Okay, thank you so much. Well, everybody, thanks so much for staying over time. I really appreciate it. Matt, thanks so much for dropping your knowledge bombs, and hopefully, we'll see you in two weeks. We're gonna be talking about how we really start on the front end of orthobiologic care, priming and improving the human before we draw blood so that we can improve the outcomes on the back end. So, this is gonna be pre injection optimization of orthobiologics in two weeks. So, hope to see you then. Have a great rest of your night.