Insights from the Couch - Real Talk for Women at Midlife

Ep.62: Perimenopause and Menopause: What You Need to Know with Dr. Kelly Casperson

• Colette Fehr, Laura Bowman • Season 5 • Episode 62

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We're thrilled to bring you this powerful and myth-busting conversation with Dr. Kelly Casperson, a board-certified urologist, author of You Are Not Broken, and host of the top-rated podcast of the same name. If you’ve ever felt confused, dismissed, or flat-out frustrated by the information (or lack thereof) around perimenopause and menopause, this episode is for you. Dr. Casperson breaks down the science with clarity and humor, helping us all better understand what’s really going on with our hormones—and why we don’t have to just "tough it out." We cover everything from early symptoms like brain fog and poor sleep to the misunderstood role of hormones like estrogen and testosterone. We also talk about how we as women can become better advocates for our health in a system that often leaves us behind. 

 

Episode Highlights: 

 [4:38] - Debunking the myth that menopause only happens in your 50s—and how "average" doesn't mean "too young."
 [7:16] - Brain fog, sleep issues, and the importance of estrogen and testosterone for your mental clarity.
 [16:50] - The real story behind testosterone—what it does, why it's not “just for libido,” and how women actually produce more of it than estrogen.
 [21:33] - Pros, cons, and controversies of pellets vs. transdermal testosterone and how to advocate for safe, effective treatment.
 [29:00] - Why age-based hormone treatment guidelines are outdated and how to start thinking preventively about your health.
 [34:30] - Breast cancer survivors and hormones: navigating a complex and often misinformed landscape.
 [38:59] - Common myths around risk and how to challenge medical gatekeeping with knowledge and confidence.
 [42:44] - The fallout from the 2002 Women’s Health Initiative study and how misinformation persists decades later.
 [44:08] - Where to actually find a menopause-savvy provider who knows the full menu of treatment options.

 

Links & Resources:

 

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Laura Bowman:

Sarah, hello everybody. Welcome back to insights from the couch. We are so excited because we have Dr Kelly Casperson joining us today, a urologist, podcast host and author who's on a mission to transform the conversation around sex and intimacy, especially for women at midlife and beyond. She is the host of the top rated podcast, you are not broken, where she dives into the science mindset and practical tools that help women reclaim pleasure and confidence in their bodies. Dr Casperson is also the author of the groundbreaking book, you are not broken. Stop shoulding all over your sex life, which has helped 1000s of women better understand their sexual health and rewrite the outdated narratives we've all been fed. Her work is empowering, evidence based refreshingly real. We are so excited to have her here with us today. Yay, yay. Thanks for having me. Thanks for being here. Our community was so pumped that you were coming.

Kelly Casperson:

Oh, that's awesome. Yes,

Colette Fehr:

yeah, we've got so many questions, and it is such an honor to have you. You're such a wealth of knowledge, and you are so inspiring and empowering just your approach and your creativity and your humor and your knowledge. So let's dive right into the heart of it. Thank you. Yes,

Unknown:

you are you are seen. You are seeing. You are seen.

Colette Fehr:

So we want to dive right in and start by giving a little bit of a definition to perimenopause, because, as you've said, this is perimenopause is finally having the moment that maybe menopause had a couple of years ago, and people are just tuning into the fact that we don't have to wait till everything falls apart to start addressing it. So can you give our audience a little insight into what perimenopause really is, what some of the early symptoms are, that kind of thing?

Kelly Casperson:

Yeah, happy to because you're right, like menopause is now I, at least in my bubble, it's happening. And 2025, 2026 the books are starting to come out about perimenopause. So that's the it's like the the younger stepsisters like me too. Don't forget, I'm down here. But it's interesting, because I think what Gen X did for menopause, because the oldest Gen X is turning 60 this year or next year. That's crazy, I know. Like, I'll pause for our heads to explode about that one, right? Like, what, what Gen X did for menopause. Now the millennials are doing even like, you know, to outdo the Gen X's for perimenopause. Of like, we understand what pregnancy is about. We understand what puberty is about. We go through significant hormone changes in our lives, often multiple times before we get to this stage. And to call it midlife is actually like a massive blessing, right? Average age longevity for women in America now is 82 to 84 so to call it midlife is like incredibly inspirational and awesome. Of like, this isn't done. This is just a change that, like puberty, like having a baby, we need to understand what our body is doing. So it's a very empowering time to be like, hey, things are going to change, and women are. Women do very well with information. You know, one of the one of my stereotypes, is people are like, you're just, you just want everybody on hormones, and I'm like, No, hormones? I'm like, No, I want everybody to have the information, then they can make the right decision for them with that information. Yeah, and like that, I always say, spoiler alert, most people want to be on hormones then, because you but you have to undo everything that society told you about what menopause is and what hormones are, and if they're dangerous, you have to, like, you have to give people info so they can make the right decisions. So menopause is a stupid definition. It was created centuries ago when we didn't have we couldn't measure hormones, and we couldn't measure what ovaries did, and we it basically was like a year after no natural periods, because that was easily measurable in the world and but what that is, is it's a symptom of what's actually happening, which is a profound hormone change, right? So today to say, oh, women stop having periods, as if that's the big thing, instead of, well, periods stop because of profound low hormones, which is actually the thing, right? So average age in America of menopause 51 people use that statistic to usually tell people that they're too young for X, Y and Z. I see that all the time you're too young for X, Y and Z. It's like, well, actually, average means 50% of people go through menopause before 51

Colette Fehr:

wow, really, 50% of people go through menopause before

Kelly Casperson:

51 Yeah, that's what average age of menopause is. 51 means, right? Well,

Colette Fehr:

Math has never been my spouse. Thank you for clarifying that, right? But that does blow my mind, because you do. I have thought of it as, oh, if you're not in your 50s, it's probably not going to happen yet. But that's not true.

Kelly Casperson:

47 normal, 48 normal, four. Six normal like, that's all within one standard deviation of 51 when you start getting below 40, we're talking before 45 is early menopause. Before 40 is called premature menopause, meaning, like it gets more rare that it happens young. But certainly anybody who's in the menopause and perimenopause world, like, there are 18 year olds whose ovaries stop working. There are women in their 20s who ovaries stop working for no apparent reason, or is there no they haven't fully figured all of it out yet. But just like, Hey, your thyroid stopped working, your pancreas stopped working, right? She had diabetes, diabetes in children, your pancreas stopped working when you were seven, right? So it's like, you know, most pancreas is take you through your life, but some don't. So it just what I see a lot, though, this is what I see with women. They're either told they're too young or then they're told they're too old, and either way, it's kind of in his dismissal, like, so you don't get treatment, right? It's like you're too young before menopause to get anything, and then you're post menopause, you're too old to get anything. And I'm like, oh my god, like, go to the doctor on that one specific day, so you actually get treated. But so perimenopause just means surrounding menopause, right? The scientists will kind of push that past the year of no periods, but in in the real world, it's really the years leading up to menopause. It's a clinical diagnosis. What that means is, I can't X ray you. I can't ultrasound you. I can't do a lab test and tell you you're in perimenopause. Western people like black and white. We like things on paper. And so, you know, I had a woman come and she's like, but am I in perimenopause? And I'm like, and she kept repeating it, but am I in perimenopause? Right? And I'm like, What do you mean by asking that question, right? And what she meant was, can I get help? Can I be treated,

Laura Bowman:

right? What are those signs and symptoms that are? I mean, I've I'm 47 I'll be 48 in September. I've never had a hot flash, but, like, my brain feels like a piece of Swiss cheese half the time. Yeah, I can't, like, think of like, I can't pull a thought out of my head, and I feel like I have what I just forgot, the other symptom I have, but definitely brain. There's

Kelly Casperson:

something else there. Maybe it's memory. I don't remember

Laura Bowman:

what is, but I'm telling you that's like, sort of the key symptom for

Kelly Casperson:

me right now, the problem with hot flashes is that's the stereotype. Yes, right? So when you don't fit the stereotype, you get dismissed because you're like atypical. But 7070, to 80% of people will have hot flashes, not always in perimenopause, sometimes post menopause, and that means a good 20% of people don't have hot flashes. That's good news. Hot flashes are actually associated with dementia and cardiovascular disease. They're not benign. So the fact that you don't have them, like probably a good thing, right? But I can't remember anything. Can't remember, but at least I'm not having hot flashes. So perimenopause, again, clinical diagnosis, which means a good doctor is going to rule out other things. How's your thyroid, how's your insulin, how's your blood pressure? Like, they're gonna look at everything. But what you see a lot is women will come back and they'll be like, they told me, everything was fine. They didn't find anything wrong with me. It's like, great. That means it's perimenopause, right? Because you didn't have some other huge abnormality come back. Wonderful. It's not cancer, it's perimenopause. So in medicine, we have a saying, common things are common. And when you hear hoof beats, think horses, not zebras, right? And so we don't want to say everything is perimenopause, because you're allowed to have other issues at any age. But you rule out the other issues and you say, good news, we didn't find a brain tumor. Your brain fog your word finding ability that is a sign of of perimenopause. So hormones that are ovaries make testosterone and estrogen work in the brain. These are neuro hormones, neuro chemicals, whatever we want to call them. The biggest damage we did was say, well, two things. Number one, men. Men make testosterone, women make estrogen. That's oversimplified, and it's a little true, but not fully true. Men need estradiol, women need testosterone. We all have different combinations. And then the other thing we did is we called them sex hormones. That's a problem, because we dismiss sex. Sex is extra. Sex is not you don't need it for life. Our species isn't going to die off if you stop having babies. Having babies, right? So calling them sex hormones diminishes what they actually do in your body, which is, they make your brain function incredibly important, right? So, very common in perimenopause to have this brain fog, brain some people will call it cognitive fatigue, right? It's just like, Oh man, I'm fried, uh, lower energy. I just hit a wall at 3pm uh, sleep issues, super big. Start kicking in and perimenopause. And again, the the misnomer, or what I see a lot of, is when women go in to get help, people ask about their periods. That's great. Let's learn about your periods. But having a period. Doesn't dismiss you from being treated. You can have low hormones and still have enough occasionally to bleed from your uterus. In addition, a third of women in America don't have periods, IUDs, hysterectomies, uterine ablation, ablation, yeah. So, so your periods meaningless because you don't have one, right? And then the women who have periods get dismissed because you're like, but you're still having periods, so you're fine. Your hormones are fine because you're having periods. No. Periods are not magical by any means. So the true perimenopause experts, if I was to see you and I ruled out all the other things, I'd be like, let's see what your estrogen is doing. Let's see what your testosterone is doing. And women will say, I feel like myself again. And they've actually started to study this, this, n, f, L, M, not feeling like myself, which in medicine is a very it's very vague. Like, how do I measure Laura not feeling like herself, right? Like, is there a test? How do you How do I know how you felt two years ago? So it's not something in medicine that we can test, but it's incredibly common. About 60% of women in perimenopause say I don't feel like myself.

Colette Fehr:

Wow. Okay, I love this term. This sounds very therapy aligned, actually, because I do think it's something I can see why it's hard to define, but I do think it's powerful. If you don't quite feel like yourself. That's a terrible feeling, right? What's a terrible feeling? Women say I feel like I've lost myself, or I'm losing myself, and so in you, correct me if this is wrong, because I read about this in the New York Times, but in terms of why the hormone thing got dropped for a while, what I read in this article was that this study came out until 2002 hormones were given regularly. Then this study came out that showed a small increase in the risk of breast cancer. And so then all of a sudden, it became taboo that people maybe misinterpreted the results. I'm not even sure if I'm reflecting that back correctly. But then all of a sudden, nobody was doing hormones anymore. And now the thought leaders in the field, even though many doctors aren't properly trained, not necessarily through fault of their own, the thought leaders in the perimenopause and menopause space are saying, you know, with education for many people, hormones really are better, and they're better earlier than we might think, and perhaps not just if you're symptomatic, because I didn't really have any symptoms, and theoretically it looks like I might be through menopause, and I really didn't even know it was happening.

Kelly Casperson:

Yeah, I'd say you've got that all perfect, and my job here is done. Okay, well, signing off.

Colette Fehr:

No, but I mean, so that is, that is along the right lines. But, yeah, but help our audience understand then, why are hormones potentially so important now for so many people, even in perimenopause, because you talk a lot about being proactive rather than reactive.

Kelly Casperson:

Yeah. So hormones, again, they work everywhere in our body, ears. It's called the frozen shoulder. Is called the 51 year old shoulder, for a reason, right? That's when it shows up. What else happens? Average age 51 right? So, joints, muscles, bones, brain, eyes, dental, health, certainly the pelvis, your clitoris, blood flow goes up when I give you testosterone, right? Lubrication, the ability to orgasm, decreased risk of diabetes, decreased risk of of depression. We've got randomized, placebo, controlled trials and perimenopause, that if you start a woman on estrogen versus placebo, in one year, she'll be less depressed than her placebo. People, oh, my god, same thing with same thing with diabetes. Like they're small studies, but they're there. And I'm like, Dude, if a if a blockbuster drug came out and could decrease the risk of diabetes by 30% they'd have they would buy all the Super Bowl ads. Yep, right, but it's like, these are generic, old medications. They're not making people a ton of money, and it is what it is. So you actually have to be educated to know about it. So what do? What are hormones good for? They're everywhere in our body. Hormones prevent disease. Hormones are pretty bad at treating disease, right? So what does that mean? It means in the medical paradigm, how many women come to me and say, My doctor said, Come back when I'm more sick.

Colette Fehr:

That's what happens. That's what happened to me. That's exactly what happened to me. My doctor was like, at 50, he was like, I don't think you're through menopause yet. He's like, but we won't really know unless we check your hormones. So when you turn 51 we'll check. And I had to say, you know, I'd rather check now. We checked I still had some estrogen and testosterone. And he was like, you're fine at 51 he said, let's test again. And I had no estrogen and no testosterone,

Kelly Casperson:

right? Not why did, why did we wait for you to fall off the cliff first, right?

Colette Fehr:

And now I did a bone scan, and my bone density was not good, yeah, yeah.

Kelly Casperson:

So

Laura Bowman:

with the timing, like, I don't understand the timing, like, where is the ideal intervention spot? So

Kelly Casperson:

as far. Preventing disease the earlier you start on hormones. In this in the menopause transition, which is a more accurate term than, like, the day of a year of no periods, right? It's like, dude, Clay, you're 50 years old, like you're clearly in perimenopause, like just by age definition alone, like you wouldn't have periods, but like, you're just in perimenopause. So some things to think about. Your biggest rate of bone loss is in the two years prior to your periods ending. So I missed it look. How do you know when your periods are going to end? Nobody knows that, right? So I really think if we have this conversation, 10 years from now, we are going to see more and more people being treated in perimenopause. I'm in perimenopause. I'm on all of the things. And here's the other thing that's interesting, when you said, like, I didn't have any symptoms. Have any

Colette Fehr:

symptoms, I believe you, or maybe I did, and I didn't know,

Kelly Casperson:

but often you put people on hormones and they're like, Oh my God, my sleep is so much better. I had no idea that, right? So that is, it's not that I don't believe people when they don't have symptoms, but it's also like, Hey, give yourself a little bit of hormones and see what's better. I read a woman. I just read a woman. She was her sleep was horrible. And she had an aura ring so she could actually be like, my aura ring says my sleep sucks. And I knew that anyways, so we put her on just a very low dose estrogen patch. She came back and she's like, Oh my God, it's actually recording deep sleep and REM sleep. And I'm like, I have a goofy question. I'm like, Are you dreaming? And she's like, I'm dreaming, and she wasn't dreaming before. Yeah,

Laura Bowman:

that's so interesting. I don't think I dream as much,

Colette Fehr:

no, and I have to say I because I am on an estrogen patch now and progesterone. And I do, I have been noticed. I've never been a good sleeper, so it's been hard for me to notice, but I have been having dreams more, and I would not have even thought that had to do with that. So let me while we're here, let me ask you this, what about testosterone? Is that only if you want to have increased libido, or is that really important for other things

Kelly Casperson:

too? Yeah, it's my it's my favorite topic, because I, like, I started this advocacy with female sexual education, basically, and then came into menopause, when people were like, Yeah, but you know, what happens to your sex life with menopause? And I'm like, I don't. So then I peeled back the onions on all of that. And so just think about it this way, ovaries make testosterone, right? So we got to dig back. Just because testosterone was discovered in rooster testicles doesn't mean that it doesn't exist in women. Women make four times the amount of testosterone than estrogen. The only way you get estrogen in your body naturally is by converting it via testosterone, right? So you have to educate women about their bodies first, because otherwise I'm this crazy doctor who's like, I think testosterone is awesome. And then you're like, why do you want to turn me into a man? Like, right? You've got too many preconceived notions of what testosterone is. So ovaries make testosterone. You make the most testosterone in your 20s, and you basically get a linear decline after that. There's no cliff that testosterone falls off with menopause. So perimenopause, a lot of people have very low testosterone, and I guarantee you had they actually checked your testosterone years prior, it would probably be low. But, and that's got its own host of things. It's actually lab values are not perfectly accurate, because our testosterone is so much lower than a man's, and lab values were designed to check men's testosterone. So labs aren't perfect, but by and large, you're you're losing testosterone production after your 20s, and there's no big cliff that happens when your periods stop. So again, testosterone, like in any gender, testosterone is vague, lethargy, maybe not sleeping. I'm working on at the gym and not seeing any gains. I just can't hold on to muscle mass. Mood, the get up and go. I just want to get things done. The mental clarity. I feel like maths harder now.

Laura Bowman:

Okay, so I feel like I need testosterone.

Kelly Casperson:

Yeah? Now, Laura needs design. I think I do too, yeah. So we have multiple issues with testosterone. Number one is just the gender bias of it's for male bodies, and we don't have an FDA approved product yet, but I tell you this, it is coming right now. You have to use a compounded product, or you have to micro dose a male product, both of those not covered by insurance, because insurance uses the FDA approval to justify paying for things so many, many barriers. Again, physicians didn't get educated on testosterone. The other big barrier is a lot of recent research, we've been giving women testosterone since 1948 there's a paper published in 1948 that said, at this point, we feel like we have enough data and safety to say that testosterone is essential and useful in women 1948 Wow. So we've been really dragging our heels on this. But recent data is for libido. Where is libido in the body, the brain, brain, the brain tying back in testosterone is a neurochemical in men. Low testosterone levels are associated with depression and dementia in women, and the studies are starting to come out. Louise Newsome just published an amazing study out of the UK that already had. Them in on estrogen and progesterone. They were already on those hormones. They came in, they did not adjust those doses, and they started them on testosterone, significant improvements in mood, decrease in depression, increases in energy and like, there's just more and more data, but we are never going to get like, a randomized, placebo, controlled trial that's spanning 20 years, that's saying this is going to prevent dementia. We're it's not going to happen, yeah, but we know that when brains function better, they do better, right? And testosterone does that. And people are like, it's only good for libido. And you're like, okay, but where's the, where's the square centimeter of the libido box in your brain, right? Libido is complex, body image, relationship, energy, status, right? While you're sleeping, right? Like, how, how much dopamine Are you making? Guess what helps make dopamine, testosterone and estrogen, right? So it's so yes, testosterone is helpful for libido, not everybody in all libido, but hormone responsive libido, but the narrow mindedness is when people say it's only for libido, it's like, yeah, it's not how the brain works.

Colette Fehr:

See, I'm so glad to hear you say that, because I haven't understood and I've heard horror stories from people. I've heard people saying, the pellets are great, the pellets are terrible. You know, if you do testosterone, you're gonna grow like, black hair. You're gonna grow a beard,

Kelly Casperson:

not the black hair. Yeah,

Colette Fehr:

I'm just like, so afraid. What's the best way to do testosterone currently? Are the pellets bad? Like, what? What's your take on that?

Kelly Casperson:

There are current international guidelines. And we always joke the international world doesn't agree on much, but they do agree on testosterone. So we have international guidelines. It's free online. Of dosing testosterone for women is priority for libido again, because I think it's incredibly paternalistic to be like you can have something your ovary naturally makes and you ran out of because you live too long if you want to sleep with somebody. And we have four, it's super messed up. But we have four countries currently that has a female dose testosterone cream. And that's Australia, New Zealand, UK and South Africa. Interesting. It's called androfem. They have it. It's a lovely product. And in Australia, Australia tends I love them. I have the biggest Australian audience because they get my sense of humor. But it's very paternalistic, and literally, women are denied testosterone at the doctor's office because they are single. Ooh,

Unknown:

stop, yeah, wow, that is so bad. It's

Kelly Casperson:

super messed up. Yeah? So, so, going back to what you're saying, the international guidelines say transdermal is the best way to start. It's very physiologic. It's one day at a time. You just put it on. It's very easy. I tend to compound because I think micro dosing the male product is a little bit clunkier, but it's a great way. They're cheap. I can get my compounded testosterone for like 65 bucks for three months. Same if you dose the male dose, it lasts a very long time. It's very cheap. You test levels six to eight weeks afterwards, make sure you're absorbing, see how you're feeling. Libido can take a while. Libido can take a good four to six months to kind of kick back in all the time you're like, reading my book and seeing the psychotherapist to figure out your relationship and how you were socialized with sex and like all the other libido issues, right? There's not ever just testosterone, but where do pellets come in our because our FDA has failed to give us a female product, and because mainstream medicine has failed to treat female hormone deficiency appropriately, women are suffering and they want answers, fair enough. Yeah. What do they do? They go outside of medicine to the people who only do pellets? Why do they only do pellets? Because that's probably all they were trained on. And pellets make them a lot of money. Yeah, I don't get any money by prescribing a compounded testosterone product, but if I did pellets in my office, that's hundreds of dollars. So there is a financial motivation towards pellets. And pellets tend to be, first of all, it's like a little piece of bird seed just implanted, kind of upper buttock, usually three to four times a year. So you'll get a super high high, and then it'll wear out. It tends to be a big steroid high. Women are like, I love it, and then it wore off and I like, they kind of chase that high and they can't get it again. Yeah. So it's not good. But some people need high doses of testosterone to feel good. Those people do incredibly well with pellets. All right. So what's the best way to not get the people super, super high, but to treat the ones who need it higher, right? Start transdermal. Okay, your way up. Okay. Then the like, the pellet gurus will say, like, and how I joke is, I'm like, You got to earn your pellet. And they're like, What do you mean by that? And I'm like, Just do physiologic, low dose transdermal testosterone first. Yeah, that makes sense. See if you like, it be like, and then it's the women who are like, I think I want to try a little bit more and do it slowly. Yeah, right. So the body doesn't care so much. Out the level as the rate of change and shocking the body. It just like, thyroid, postpartum, yeah, you know, extreme weight loss, anything that's a big shock to the body. It shocks the hair follicles, and the hair hates it, right? The hair is like, I can't handle all this massive change that you're doing. So it's not so much that it's a certain testosterone level or testosterone itself that can cause hair loss. It's the dramatic change of, I have no testosterone, and I threw in a pellet and I got up to 350 which is a man's level overnight. Hair hates that. Yeah. So it's like, be kind to the hair. Be kind to the body. Go slowly. Side effects of testosterone are masculinization. If I push you high enough you'll start to masculinize, which could mean, you know, frontal hair loss, more growth in the facial hair, but it's very, very rare at female dose testosterone.

Colette Fehr:

Okay, okay, okay. It is rare at female dose testosterone. So you're saying, like, I have an appointment with MIDI. Is that how you say it? MIDI? MIDI, okay? And because I did not feel like I had a good experience in my doctor's office on multiple accounts, including I felt pushed onto pellets, yep, and it felt very financially motivated. I can't speak for what that doctor's thinking, but it didn't feel good to me, not to mention the whole way my perimenopause menopause experience has been handled. So if I'm not on testosterone now, then that could be a good thing to talk about, starting with a transdermal product that is at a female dose level. And potentially, you know, I'm about to turn 52 Laura, being younger, even she could potentially benefit from testosterone, even if she's not in menopause or post menopause yet,

Kelly Casperson:

yeah. And I'll just reiterate so it's clear for the listeners of like, menopause means no periods for one year. It means nothing about anything else, anything can be on hormones or not be on hormones. I mean, it does mean like, Hey, you're not going to get pregnant now. Like, if you haven't had natural periods for your your rate of pregnancies, like that. Pregnancy is like nil. But besides that, there is testosterone doesn't fall off a cliff at menopause. So I think we're going to see more and more perimenopause women. And the perimenopause experts will be like, dude, testosterone is low in a lot of perimenopause women. And there, there isn't a period. Is a very arbitrary cut off for if you can be on these medications or not.

Laura Bowman:

Okay, so let me go back because I'm, you know, I'm trying to piece this together for clients and myself. So what is the time, what in a perfect world a woman would begin to get supplemental estrogen and progesterone at like, what point in the journey is in your mind?

Kelly Casperson:

I mean, it's, it is individualized, okay? It really is like, you know, and where I think the menopause gurus will get in trouble so we don't do it is like, everybody needs this. Everybody needs this. And an age like saying, like, 48 right? Like you, you've been to your high school class reunion. Not all 45 year olds look the same like, some are looking like very, very well preserved, and some are looking like they've, we don't know how much longer they're going to last. What I mean by that is like to say there's an age, yeah, it's like saying your your last period is meaningful. It's not accurate, right? And so it's really like, do you have symptoms? Okay, you don't have symptoms. Are you an a healthy person who wants to make the decision to be on hormones for preventative health, right? And the screening for, like, going back to the bones, screening for osteoporosis in this country is abysmal. It's age 65 unless there's risk factors, that's not screening, that's diagnosing osteoporosis. Yeah, I thought that was bad. And then I went to Australia, and they're like, Yeah, we start at 70. Oh, my God, right. So every woman that comes to see me in my clinic gets a DEXA. Dexas are cheap, not like just cash. DEXA is 80 bucks in my town. At what age do you start that? Whenever you want. I start. I start

Colette Fehr:

everywhere than now, because I just got one, and that was the first it was ever mentioned to me. And I already had some, not terrible, but some bone loss, and I had no idea that I could have been paying attention to this much sooner. Yeah, so it sounds to me like you're saying, hey, there's no it is individual, but start educating yourself and being proactive now, because you could potentially be in perimenopause much earlier, potentially than people have thought you could be there in your 30s, in your mid to late 30s, right? It's possible and go in, you're going to have to probably be the person who goes and says, Hey, can we especially if you're not symptomatic. Hey, can we test my hormones and see what's going on? Get a baseline. We really have to advocate for ourselves much more than we have been. Yeah.

Kelly Casperson:

I mean, if I got to do, like, some sort of universal, this is what I wish sort of thing like, at age 40, you're going to get a discussion that, Hey, you. Yeah, maybe you're aware or not, but like, we're going to be out living our ovaries. And what that means is we get to make the decision of if we want to replace those hormones or not, right? So it's like, get the education to know that it's coming. Because so many women, they're like, I'm anxious, I'm depressed, I'm not sleeping, they I'm on like, four other medications for this. Now, do you think this could just be perimenopause? Like, that's what's happening. Now, I want to shift that to be like, Hey, we're running out of ovaries at some point, and we'd like to make it to 84 so that's 40 years with no hormone productions that help our brain, help our bones, help our muscle, help our mood, help our genitals, life, half half of your life. And remember when you're frail with diseases at 76 that's not the time to start hormones. Now the granted, the boomers are pissed. Average age of the boomers was early 50s in 2002 when the Women's Health Initiative came out. This is an entire generation of women who were not given an option, yeah. So they're pissed. And the the the current myth, just to address them, is the current myth is, if it's more than 10 years post menopause, you can't be on hormones. That's not can't, is

Laura Bowman:

that can't because I have a client right now who went through early menopause. She's now for my age, 47 she's been postmenopausal for 10 years. She has

Kelly Casperson:

helped me. She's been on hormones. She just found out that,

Laura Bowman:

like, hormones would have helped her. She's got some cardiac issues. She's like, please ask her, Can I start

Kelly Casperson:

this is, this is life and death, just to be, just to be dramatic, for a hot second early menopause, so early, certainly earlier than 40 definitely think in 45 early menopause associated with significant increased risk of death, heart disease, heart attack, dementia, like it is no joke, and to the to the point of like, I want to use the word malpractice very carefully, but we have written standard guidelines that say hormones should be given till natural age of menopause. So all these women should be on hormones to at least age 5051 and then they then we get to choose, right? So remember, hormones are a choice after natural menopause, but we have strong guidelines that women should be offered hormones up to natural age of menopause, and the women who aren't, it's heartbreaking. We have the data. It is bad for your health to not have hormones. Could she start at this age? Likely, yeah. And would that help her? Yeah? Likely, yeah. I mean, your question earlier of like, I don't have any symptoms, should I start is like, can you feel dementia? Can you feel

Laura Bowman:

heart? Oh, I feel like I can. Yeah, you're like, me,

Kelly Casperson:

yes. So you do have

Colette Fehr:

symptoms, but you can have a lot happening that you can't you can't feel Yeah,

Kelly Casperson:

the medicine needs to switch the conversation to prevention of disease, maintenance of function, which is very different than come back when you're sick, and we'll see what we have for you.

Colette Fehr:

Yes, prevention of disease. And actually, one of our audience members wanted us to ask you that question that you know, after 10 years or so, there supposedly aren't any benefits to treatments. That's what she had heard. But you're saying that's not so.

Kelly Casperson:

Dude with multiple studies of like women in their 70s, you throw a low dose estrogen patch on and their bones improve, like hormones will always help your bones. Okay, will you get the if there is any dementia prevention, it is starting the hormones Young. Why? Because hormones prevent disease. Hormones don't treat disease. So if a 73 year old comes in and she's like, Can I start our hormones? Or will it help my help my dementia risk? No, the study, the studies, don't show that, but it'll help your bones. Yeah, right. So important, heart risk, dementia, brain risk, early menopause. What do they mean by early menopause, within 10 years of your last natural period? But that doesn't mean there aren't benefits for older people starting and then remember, genital hormones, or what we call local vaginal hormones. You can start that at any age. Start your start your demented aunt with recurrent UTIs, who's 91 she can start on vaginal estrogen. Incredibly important, any age. Can start that. So when people say, when people say, hormones like this big umbrella term, yeah, I'm like, there is nothing more irritating to me, because I'm like, Are you vaginal hormones, testosterone? You can start testosterone at any age. Oral microns, progesterone, you start that at any age. So like when people say, I can't take hormones, that usually means you don't know enough about all the options there are in regards to hormones.

Colette Fehr:

That's an excellent point. And I want to ask you another question from our audience about that that's sort of playing off of this. So for women who have had breast cancer, and I know everybody's probably different, but she says, okay, most people just put breast cancer patients to the side as at risk. This is not the full picture. Where do we go? Who do we see for clinically accurate information, and are there studies? What does somebody who has had breast cancer or. Has breast cancer do to begin to unravel what's right for them?

Kelly Casperson:

Great question. Currently in America, 4 million breast cancer survivors. Wow. Massive population, massive suffering. There was just a paper published literally this week looking at it was basically a 1700 breast cancer survivors polling them about hormones and sexual health, and it is abysmal. Like, I know it's bad because I'm in this world and reading that paper, I did some Instagram reels on it yesterday. I'm like, It's really bad. Wow, it's super bad. So you gotta back up, and you gotta be like, remember, this is the best way to do it. Food doesn't cause monsters fair enough, but monsters eat food. Okay, so if you have breast cancer, get rid of the freaking food, right? That's hormones. Okay, so that is a treatment for many, not all, breast cancers, but many breast cancers, it's not that the food caused monsters. It's that monsters eat food. Okay, right? And you, you have to clarify that, because what we do, what they've done is they've they've used breast cancer you can look at markers on if there's estrogen progesterone, markers on breast cancer cells, and so they'll call it estrogen positive. Progesterone positive. The Lay population has taken that, probably because the oncologists haven't done a good job of explaining it. They've taken it to say those hormones caused that cancer. No prostate cancer is testosterone positive. If you stain to prostate cancer cells, and we don't go around saying, I have testosterone positive prostate cancer, and testosterone caused my prostate cancer. It didn't. It just stains for it, right? So the first thing you have to do in this population is you have to educate them and be like hormones are food, but food doesn't cause monsters. More and more and more people who are experts are saying, listen, breast cancer is a tricky beast. It does stupid things like, it comes back eight years later. It comes back 10 years later, right? But what's the number one killer of a woman who's been cured of breast cancer heart disease? Yeah, really. Right. And so these women are like, I care about my bones, I care about my brain, I care about my sex life, and I'm not getting any treatment. It is an individualized risk benefit conversation, right? Nobody is ever gonna say we're fine. Now just give all the breast cancer survivors hormones. Nobody's ever gonna say that, except for vaginal estrogen. Vaginal estrogen is very low dose skincare for down there, pretty much every, nearly all, I will say that breast cancer survivors can be on vaginal estrogen, and we know they're horrifically under treated. So that is low hanging fruit again. If a breast cancer survivor says I was told I can never be on hormones, I'm like, there's a whole bunch of different hormones, and testosterone seems to be breast protective, interesting. So why we're not doing more research on that is mind boggling to me. So to answer the question, read the book estrogen matters, by Dr Avram blooming and Carol tavris. It's a brilliant book. It breaks down all the data for you, and then you have to see a menopause specialist who understands this data. Dr Corinne men is an amazing advocate to follow on Instagram. You should have her on her podcast. She's an OB GYN, who is a survivor herself, who knows the data like nobody else, and is a huge advocate. So I know multiple breast cancer survivors who are on hormones. I take care of breast cancer survivors on hormones. I want educated women. I want women to understand I can't ever say your breast cancer is not going to come back, but to the best of our knowledge, hormones aren't going to make it come back. More

Laura Bowman:

To that end, Kelly, like is there? Are there people that just like, full stop. Can't do hormones because I'll just be transparent my dog, I've had preeclampsia with all three of my babies, my my OB, GYN was like, basically, like you, you're not going to do hormones like your your blood pressure, stroke risk is high. Like, this isn't for you. Is that

Kelly Casperson:

true? Does testosterone increase stroke and breast cancer risk? I don't know. No. Does vaginal estrogen increase your stroke and breast cancer risk? No, does transdermal estrogen increase your breast cancer and stroke risk? No,

Laura Bowman:

when you say, is that patch? Like a patch? Patch? What I have? I have the patch. Yeah,

Kelly Casperson:

that's the most common way to get estrogen. So this is what I advise, and this it you have to deliver it well, because you never want to insult somebody by this. What is the actual risk? Show me, right? What's the actual risk? Where is the where is the statement that says I can't take hormones? Show me Hey, no, say Yeah. Say that nicely. It might be nice if you have already an established relationship with somebody, right? But this, like the risk is too high, is very paternalistic, and it is meant to shut down discussion. Yeah, you can very accurately say what is the risk? And this is my body. I should be able to make an informed decision on if that risk is right for me or not. I. Every single medication has risks. Life has risks,

Unknown:

right, right? It's cost benefit, yes.

Kelly Casperson:

So you need to, you need to understand what your risk is so that you can make your best decision. Now we know transdermal estradiol does not increase the risk of stroke or blood clots, so when they say that that's too high of a risk for you, you'd be like,

Unknown:

huh, based on what. Tell me it based on what,

Kelly Casperson:

based on what. And let's remember, in the 1990s 40% of women in America were on hormones. Now 5% of women in America are on hormones,

Colette Fehr:

right? So it's like, whole study thing. I mentioned

Kelly Casperson:

it's a whole study thing. So what happened? We have two decades of clinicians who did not get trained in hormones after the 2002 Women's Health Initiative, which in it's wrong. It's inaccurate. Said estrogen increases breast cancer risk. That's not what that study shows. That study, this is what I love to tell people. That study is free online, 2002 JAMA article, Women's Health Initiative. It's free online, everybody can read it. So

Colette Fehr:

this is just the game of telephone, like, how does this happen?

Kelly Casperson:

So remember, in 2002 we didn't have the internet very much, right? So they, they did this billion dollar study, they said, We're going to stop this study the progestin, estradiol. Remember, these are oral synthetic medications we no longer use, right? So people will also argue like it's kind of irrelevant there, but the Women's Health Initiative did tell us some useful things, so we won't throw out the whole baby with the bathwater, but it's medications we no longer use. The medications we use now are much safer, but they said we're going to stop this one arm because it looks like breast cancer risk might be higher, and we want to stop it. What they actually found out was that in the estrogen alone arm, so these are women without uteruses, so you can they didn't have to take the synthetic oral progestin. Get a 30% decreased risk of breast cancer by taking estrogen. That didn't make the news. So what happened? They said, We're going to go to the media. And the other people in the group said, but you haven't published the study yet, so you're going to go to the media, and nobody can read the study now, back in 2002 journals came in the mail, right? So the news blew up and said, estrogen study halted. Billion dollar study halted because estrogen causes breast cancer. The doctors sat around having to wait a whole week to get in their mail the actual study so they could read it, because he couldn't read it online, right? And the damage. And in that conversation in that room, they said, if you go to the media and you say estrogen causes cancer, the genie will be out of the bottle, and we'll never be able to put the genie back in the bottle. And they did it anyways, and 20 some years later, we're still trying to put the damn genie back in the bottle.

Unknown:

Wow. That is just terrifying.

Kelly Casperson:

It's a it's egregious. It's egregious. I mean, it is. I would say, you know, one of the best ways to control women is to keep them afraid. Yeah, right. And Laura to speak to you, if, like, if somebody's like, Hey, your risk is too great. It's like, No, you're allowed to be like, What is my risk? Yeah, what exactly is my risk? And I should be able to make that decision. I mean, let's talk. Let's talk. Let's, you know, talk about medicine for a second. I we will put you under anesthesia to make your breasts bigger,

Unknown:

which has risk, tons of risk, right? That's not gonna

Kelly Casperson:

make you live any longer, but it's gonna, it might improve your body image. That's great. We we allow it, right? But you're like, I'm allowed to make, I'm an adult, I'm allowed to make decisions about what I want to do with my body. This bodily autonomy.

Colette Fehr:

So let me ask you before we have to wrap up here, because we could certainly keep you here all day and never run out of questions. But where does is there anywhere any resources you can share for where someone can find somebody who actually knows what they're doing? Because I get asked that question all the time, do you have a good menopause doctor? Do you have a good resource? Yeah, so do you have any suggestions?

Kelly Casperson:

I mean, the best thing is so say, you know, for the therapists who are listening and people who take care of midlife women, is like, find the people in your town that do good medicine. What do I mean by that, people who sell pellets and don't do any other type of hormone. To me, I'm like, that's a one trick pony. That's one option to like, most menopause experts will be like, we've got oral, we've got transdermal, we've got vaginal, we've got blah, blah, blah, we've got, like, it should be a menu. So that's one sign to know if, if that person's doing good work or not. The menopause society, menopause.org It's a pretty low bar. Not everybody who's even menopause certified knows about hormones or to stop, especially testosterone. So I would say that's a pretty low bar. The one I really like is ish wish.org It's the International Society for the. Study of women's sexual health. Why do I like ishwish? Because those are people who care that sex med is medicine. So they're comfortable with desire, they're comfortable with pelvic issues. They understand the role of hormones in sexual health, so they tend to be pretty knowledgeable with testosterone as well. So it's weird. It's a weird like sex Health niche place, but by and large, I'm like, nationwide, that's probably one of the best places to go for find a provider. The online ones are great. Like you said, MIDI alloy ever now, genev for vaginal estrogen. Interlude. So there's more and more online, because it's like, if you go to a clinic that says, I do hormones. Yeah, that's a way more fruitful conversation than like, you paid for parking, you took off work, you paid your copay. And they're like, Oh, the risks are too high, right? And then you're like, what are the risks? And they're like, I don't know. Nobody actually knew enough to ever ask me that before, so I don't actually right.

Laura Bowman:

Does insurance cover any of this? Yes.

Kelly Casperson:

Okay, yeah. FDA approved hormones have been around for a long time. The asterisk on that is testosterone because we don't have an FDA approved testosterone. The other problem with the telemed companies and testosterone is testosterone because of the doping athletes of the 1980s I can't make this up. Testosterone is a schedule two medication by the DEA. What that means is even companies that have multiple state licenses, people don't understand how physicians are licensed, but physicians need a DEA in every state that they have a medical license if they want to do scheduled medications. Scheduled medications means like ketamine, codeine and one hormone that our body naturally makes is on that list because of the doping sporting scandals of the 80s. Congress passed the 1990 doping anti doping act. Wow. Now there is some movement to say for female dose testosterone that should be deregulated to increase access. Let me tell you. Me giving a woman the testosterone back that she had when she was 35 is not going to make her win gold and pole vaulting, isn't it? That's not gonna unless she was already that close, you know? So it's it is another barrier for women is the fact that we don't have an FDA approved product for testosterone, so that limits insurance coverage and then the DEA restrictions. But

Colette Fehr:

you can get transdermal testosterone, even though it's not right, like you can get the kind that you can the lotion, or the ointment that you can put on,

Kelly Casperson:

you can either compound a cream, or you can use a male product and use 1/10 of the dose.

Colette Fehr:

So this is so much good information and so much to think about. It is crazy how much people don't know or understand. And it's our health and our longevity and our quality of life that's at stake?

Kelly Casperson:

Yeah. I mean, here's a takeaway that people don't often think of. So remember the 1990s 40% of women are on hormones. Women's Health Initiative happened a good amount, a decent amount of women who were on hormones didn't stop, right? Their doctors were like, We know that studies bullshit. We know that our women do well, but sure, we'll keep you on hormones. Those women are now 84 years old, approximately, right? Talk to them, because what they say is, they say, these are women who've been on hormones for 30 years. Here we are like, Oh, what's this new thing? Right? It's like, this is not new. It's just we forgot how good it was these women in their 80s who've been on hormones ever since menopause, they say, you will pry this out of my cold, dead hands.

Laura Bowman:

There's no stopping point, like there's no natural

Colette Fehr:

and they're feeling the benefits of it, so they don't want

Unknown:

to stop right

Kelly Casperson:

there. They're feeling the benefits of it, but they're also seeing the people around them age differently, and I think that's why the millennials and Gen X are doing this differently, because we're taking because we're taking care of those people, and we're like, what if it's possible that frailty is not the only option? Exactly. There are more hospitalizations in America every year for hip fracture than stroke and heart attack combined. The elderly women are forgotten silent voices. That's where the suffering is. And in order to not be that statistic, you've got to think about your 80 year old self when you're

Unknown:

50. Yes, good point. Oh, a we're thinking about, damn, this has

Colette Fehr:

been amazing. Amazing. It, you know what? Thank God we're we're so lucky to be at this time when at least people are paying attention to this. And I think a big takeaway for our audience is go out there, get educated, advocate for yourself, and don't think it's too early to look into this. Yeah, right. It's better to start now and find out what's right for you.

Kelly Casperson:

In perimenopause, I see all the time. I'm told I'm too young. I'm told I'm too young. Their suffering gets dismissed. And we know the rate of depression skyrockets and perimenopause. The rate of anxiety skyrockets and perimenopause, women are increasing their alcohol use and their drug use to I see enough self treat untreated perimenopause and menopause. Exactly. The women are not. Okay, and it's, you know, when you're feeling crappy, it's really hard to advocate for yourself, really

Laura Bowman:

hard. And they trick their own brain. They're like, this isn't, you know, I'm fine. It's the whole like, I'll get through this. Like, you know, I can exercise away, or something, diet. That's

Kelly Casperson:

the other myth, right? That there's a like, there's an over it. It's like, No, honey, your hormones are low forever, right? Yeah, there's no, like, I'll get through it, but you get through it till what your your ovaries aren't coming

Colette Fehr:

back, right? And this is vital to our organs, not just symptoms. Obviously, it's vital if you have symptoms too, but that we need hormones for health. They

Kelly Casperson:

help our mitochondria. They help our glial cells. Like, I often think, because I read a lot of basic science paper, right? I often think, like, the basic science researchers are like, What the f are you guys doing? Like, how much more data on how hormones work, the help cells do you need?

Colette Fehr:

Yeah. So it really shows you the psychology of group think and how, once something becomes installed our perceptions, it can be very difficult to override and re narrate that even when the data doesn't support what we think 100%

Kelly Casperson:

I mean, we've got so much data on that, right? You like, you challenge somebody's ideas and they double down on it. Well, you

Colette Fehr:

are going to help so many people, just even with this conversation today. So thank you so much. And I know both Laura and me are benefiting from this. And so

Laura Bowman:

totally I can ask you, like, 50 questions. I bet you get cornered at like, a cocktail party all the time.

Kelly Casperson:

It's pretty fun. I mean, it just it always speaks to like, this is a big this is 50% of the population,

Colette Fehr:

right, right? Right? And we matter. We matter. We matter

Kelly Casperson:

matter. I mean, let alone, you know, what percentage of divorces happen in midlife,

Colette Fehr:

right? Oh, I can speak to that from what I see in my office.

Kelly Casperson:

Oh, yeah. Like, you know, I have divorced lawyer friends who are like, untreated menopause is a big, big issue, absolutely, and I never say that to blame the woman, I say that to say we must know what's going on so we can make the right decisions and advocate for ourselves

Colette Fehr:

exactly and that it has widespread effects, widespread effects what we might think so before you go tell our audience how they can find you and about your book and all that good stuff,

Kelly Casperson:

thank you. Thanks for having me. So I hang out on Instagram at Kelly Casperson. MD, my website's Kelly Casperson md.com, the first book is you are not broken. The podcast is called you are not broken. And then the second book is coming out September 2025, and it's called menopause moment.

Colette Fehr:

Wonderful. Thank you so thank you so much. Thanks for having this pleasure. Having you. Yes, thank you. Thank you. Applause.