Perimenopause and Menopause: New Approach to Management

Perimenopause and menopause can feel confusing, overwhelming, and full of conflicting advice. In this educational webinar, Theodore Friedman, MD, PhD explains a modern, evidence-based approach to understanding and managing menopause.

You’ll learn what is actually happening hormonally, how menopause is diagnosed, what labs are useful (and which are not), and how lifestyle, nutrition, and hormone therapy can be used safely and effectively.

Whether you're experiencing symptoms now, approaching menopause, or trying to understand treatment options, this webinar provides clear guidance rooted in endocrinology and clinical experience.

Topics Covered in This Webinar:

What are the most common symptoms of menopause?

How menopause connects to other endocrine conditions (thyroid, adrenal, metabolic health)

How menopause is diagnosed — beyond just age and symptoms

What laboratory testing is helpful for evaluation and follow-up

The role of lifestyle interventions in menopause treatment

Estrogen therapy: Is it safe or dangerous?

Understanding bioidentical hormones vs. traditional hormone therapy

Is there a menopause-specific diet?

Evidence-based supplements that may help with symptoms

Note:
This content is educational and not a substitute for medical advice. Consult your clinician for personalized care.

Visit https://www.goodhormonehealth.com to view Dr. Friedman's other health topics and make an appointment.

Transcript

SPEAKER_01 0:04

So today's topic is titled Menopause New and Not So New Approach to Management. I did give a webinar on menopause about 10 years ago, and it looks like some things are similar and some things have changed a lot. And I'll try to emphasize some of the changes. Today's our my wife and I's 28th anniversary. This is from our trip to Belize. The outline of today's talk is what are the symptoms of menopause? How does menopause relate to other inner conditions? How is menopause diagnosed? What labs are needed to diagnose and follow menopause? How can lifestyle changes be used to treat menopause? Is estrogen safe or dangerous? What are biodentical hormones? What supplements can be used for menopause? And is there a menopause diet? The female reproductive system is outlined here. You have the ovaries, you have the fallopine tubes, you have the uterus, and then you have the vagina. There's a cycle of estrogen, progesterone, testosterone that's pretty clear-cut. In the follicular phase, which is when I recommend you getting hormones, you have low levels of estrogen, testosterone, and progesterone. And mid-cycle, you get a peak of estrogen. And you can see the testosterone rises a little bit, but not too much. So in general, you can measure testosterone any time of the month. And then in the second half of the cycle, you have a rise in your progesterone. That's the luteal phase. And you have also a rise in your estrogen. So you can see the flattest part of the curve is on day three. Um, this looks at the um the um levels of estradiol and progesterone with age. Per pre-menopause, you have um high levels of estrogen and progesterone. In the menopause transition, the ages 35 to 50. You still get spikes of estrogen and little spikes in progesterone, but it declines um uh between age 35 and 55 or so, 53. Postmenopausal, you have low levels of estradiol and progesterone. Menopause is a cessation of menses for one year. Most women experience menopause between ages 40 to 58 years of age with a median age of 52 years. Batches associated with early menopause include body lower body weight, menstrual length, uh, not having uh children, doli parity, smoking, never use of oral contraceptives, lower socioeconomic class, and race or ethnicity. Higher body weight is associated with later onset of menopause. Some women who go through menopause have no symptoms at all, but most experience some symptoms often beginning several years before their last period. Perimenopause may be worse than menopause. Uh, why so many doctors fail with menopausal care? Symptoms are under-reported and under-treated. Many doctors don't even ask patients about their menopausal status. 2% of people receive no treatment advice. 23% felt dismissed. Rarely do physicians discuss menopause unless the patient brings it up first. Studies of primary care physicians and gynecologists found that the discussion of menopause is initiated by the patient 91% of the time. It's a high percentage. And that the most challenging aspect of treating these patients were due to confusion and controversials in treatment options, which we'll try to clarify today. 65% of women felt unprepared for their menopausal experience. We call this the menopausal transition, unprepared, dismissed, and suffering. I think this woman is a great example of this. The symptoms are often worse than expected. There's fear, confusion, and vulnerability. Unanswered questions uh happen frequently, and the patient's often dismissed. Definitely I want to be different than that. Um the symptoms include uh about 6% of patients, not too many, no or little symptoms. Mild symptoms is 25%, moderate symptoms is 47%, and 41% of patients have severe symptoms. That's a pretty high percentage. Um, in premenopause, the symptoms are 19.7, perimenopause are 46.5, and postmenopause is 85.3. So most women going through menopause have symptoms, many of it quite severe. In addition to fatigue, other common overlapping symptoms that include that can contribute to the feeling of exhaustion include joint and muscle aches, sleep problems, 86% of people have sleep problems, and hot flashes, 83.5%. Now, this shows the years around the final menstrual period when the patient stops having their periods. You can see one of the first things is cognitive symptoms. Um, you can see then sexual and urogenal alterations start low but then go up. Depressive symptoms sort of peak around the time of the last period. The um the sexual and urogenal alterations happen a little bit usually later in the menopause. Sleep disturbances are quite common, happen sort of around menopause. And depressive symptoms also are quite common, usually around the, you know, between one year before the final period and the final period. So these are a huge number of percentage of patients that have these symptoms that, again, are mostly dismissed or not adequately treated. Uh, this is what happens to hormones. In early menopause, the estradiol is relatively unchanged. The first thing that happens is the FSH, folliclion stimuli normal, goes up. You have cardiovascular risk factors include the carotid insulomedial thickness increases. You have vascular remodeling, and you have worsening endothelial function, so you're getting more through things related to clots. There hasn't been many studies in early menopause, um, but in general, the early menopause things start happening right away. You can see the weight happening in late menopause, the estradiol goes down, AMH goes down, FSH goes up, body composition gets worse, body fat expands, so the fat mass expands, and the muscle mass, which is really important, your fat fee or lean mass decreases. Your energy expenditure goes down, so you're not burning as many calories. That's why you gain one of the reasons why you gain weight. You don't oxidize fat, and you have um you can have a decreased energy intake, but uh uh not always the case. Um, so all these can lead to this weight gain. You can see the picture of this woman has gained a lot of weight from early menopause to late menopause. Your cardiovascular risk factors increase even more. You have dyslipidemia, uh, worsening your cholesterol profile, the carotid dental needle thickness, um, the aorta gets worse, vascular remodeling, endophilic function gets worse, your cardiac health gets worse, you have increased sleep disturbances, which we'll talk about extensively. That can lead to problems with your hormones, problems with insulin resistance, to all these late menopause. And then in post-menopause, your estradiol drops, um, and it's usually for two years after your last period, and then stabilizes, your FSH goes up, fatty composition continues to get worse, your fat mass increases, your abdominal fat gets worse, your fat pre-mass gets worse, your sleep, your uh sleep and energy and resting energy expenditure, physical physical activity energy expenditure all go down, fat oxidation goes worse. So all these things contributed to waking and feeling bad, uh, a lot of your symptoms. Your cholesterol continues to go up, your insulin resistance goes up, you get glucose intolerance. Some people can get prediabetes and diabetes, and your sleep disturbances get worse. Now, the terms I see used are both hot flashes and hot fleshes. Uh, hot flashes are used in the United States. Hot fleshes are used in Europe. The medical term is vasomotor symptoms. I think most people like the term hot flashes. Up to 80% of uh Caucasian menopausal women experience hot flashes. High fluoresces vary with race and ethnicity, with African-American white women reporting more hot flashes, and Chinese and Japanese-American women reporting fewer hot flashes, and perimenopausal women do have a high rate of hot flashes. Hot flashes can be bothersome to women, they can adversely affect quality of life. Treatment of hot flashes, therefore, can improve quality of life, may improve sleep and mood. And don't I think that the key takeaway points hot flashes lead to poor sleep? Well, you don't sleep well, you feel fatigue, you gain weight, your some of your hormones like cortisol and leptin go up. So all these things are some of the detrimental issues of hot flashes, why they should be treated. And this is certainly a woman's health issue. The most common symptoms would be some of these things we talked about, the metaposogenic cessation of menses for 12 consecutive months. The symptoms, hot flashes, are hot fletches, night sweats, insomnia is very common, palpitations, depression, anxiety, memory loss, change in cognition, vaginal dryness, vaginal thinning, uh, urinary dysfunction, uh, change to sexual response and sex drive, apnea, hair loss, and irregular bleeding. I want to really place this emphasis, the connection between poor sleep and menopause. Menopause leads to poor sleep, and poor sleep leads to worsening symptoms of menopause. People that sleep poorly, often from menopause, who sleep less than seven hours a night, are more likely to be overweight, have diabetes, and metabolic syndrome. Both the quality and the quantity of sleep matter. So if you're waking up a lot at night because you're having hot flashes, both your quality and your quantity is going to be worse. People can track this on their iPhone, for example. But the quality is you want to go into deep sleep, and this is very uh significantly affected in menopause. And the menopause leading to poor sleep leads to fatigue, waking, insulin resistance, diabetes, and obesity. And the poor sleep itself leads to worse than any menopause symptoms. So again, it's a vicious cycle. Poor sleep leads to menopause, menopause leads to poor sleep. The hot flash physiology is not completely understood, even though I gave this talk 10 years ago. I don't think there's been much improvement on it. Um, there's not a direct correlation between estradiol levels and hot flashes. In general, the with the drop of the estrogen level, withdrawal of estrogen is necessary for induction hot flashes. It's a narrowing of the thermal hypothalamic thermoregulator set point or thermoneutral zone. I'll show this on the next slide. So this means people sweat easier and shiver easier. So you have a narrowing of that temperature. Thus, a small increase in core body temperature results in heat dissipation response experiences a hot flash. This is this sweating thrust. You have this thermoregulatory zone. And um, you have a thermonutral zone where in normal asymptomatic women, pre-menopausal women, it's kind of wide, so they're not either sweating or shivering. With hot flashes, this zone narrows. So people start sweating more and shivering more. And therefore, you can often feel hot, but also some people feel cold all the time. So this is one of the important issues of hot flashes and seems to be related to this physiology. So estrogen withdrawal can lead to increased norepinephrine. You feel like you get a little bit of like adrenaline rush. This is a very important metabolite. MHPG is the primary brain metabolite of metinephrine that seems to go down. Um, increased activation of alpha adenergic receptors, reduction of thermoregulatory zone, autonomic reactions to cool the body are affected, and you get hot flashes. Okay, so what kind of tests do I recommend doing? Um the first one is I recommend while a woman is still having periods, to get a day three FSH and estradiol. And basically an LH is not terribly helpful, but the FSH, when it starts going up, is consistent with perimenopause. An FSH between 15 to 30 is consistent with perimenopause, and greater than 30 is consistent with menopause. An estradiol level less than 40 on day three recycle is consistent with perimenopause, and less than 20 is consistent with menopause. Very important, and we'll talk about this a little bit more. The hormone called SHBG, sex hormonal binding global, binds to estradiol. So if you have a high SHBG, your estradiol will look higher. If you have a low SHBG, your estradiol will look lower. So the results vary a lot with patients. Uh, these may be repeated often and interpreted in the context of the patient. Um, what are the different hormones like in different conditions? In menopause, the testosterone is low, the estradiol is low, the LH is high, the FSH is high. And hypopertuitarism, the testosterone is low, estradiol is low, LH is low, FSH is low. And in PCOS, the testosterone is high, estradiol varies, LH is usually high, FSH varies. Cushions, it varies a lot. So I didn't put that up as a row, but in general, in cushions, you might have lower testosterone, lower estradiol, sort of normal LH and FSH. So both hypopertuidism and menopause have lower estradiol. So a patient that has hypoperturidism and menopause, their estradiolis could be especially even lower and might not might even be especially more symptomatic. In general, as I mentioned, in menopause, the LH and FSH go up, but in hypoputuriism, they go down. So you may not have an elevated of LH and FSH in if you have both of these conditions. PCOS, a common condition, I gave my webinar about it last time. We're getting a product called Symmetra coming on board pretty soon to treat it. And it usually lessens in menopause, but a lot of times it doesn't go away. And then you have this high LH to FSH ratio in PCOS. There's a hormone called antimalarian hormone AMH. It's a very important test. I think it's underutilized. It predicts egg quality and menopause. In a study of 35 to 39-year-old pre-menopausal women, the mean mean time of menopause was 9.94 if your AMH was low, and 13 if your AMH was higher. So general higher level of AMH has been a positive correlation with natural fertility in women aged 30 to 45. No, this is only statistically. If some patient has a low AMH, it doesn't guarantee that they're going to have trouble conceiving, but it's uh it's an indication. I measure this hormone frequently. I think it's quite helpful. This can be measured any time of the day and any time of the cycle. Now, testosterone declines with age. This is pretty dramatic here. So you like the look at this figure on the left. This is total testosterone level of age, sort of peaks around uh you know 18 to 20. And you know, by 50 or 60, that's about a fifth of the level of the peak. Um, and by 16, 70, it really declines. So you do have this decline in testosterone, which I think is quite significant. The next slide on the right looks at testosterone in males and females. Um, the testosterone is also peaks around for males, you know, peaks in the 20s and 30s and 40s, declines a little bit with age, but the testosterone in females especially declines um with age. The estradiol is also quite high during reproductive areas around time and drops uh post-menopausal. So testosterone, I think, is a forgotten hormone. Many of my patients go on it, they like it a lot. Um, symptoms of low testosterone in women include decreased muscle sprint, osteoporosis, libido changes, a low mood, fatigue, uh thinning hair, baldness, anxiety, depression, vaginal dryness, and cognitive change. So a lot of symptoms that my patients have. Testosterone has roles of enhancing libido, promoting muscle development, stimulating red blood cell creation, increasing skin collagen production, promoting reproductive health, encouraging bone growth. So it really does a lot of things. Um it helps the brain with spatial memory, it helps uh prevent estrogen proliferation in the breasts, increases uh muscle and bone formation and mass, it helps uh prevent anemia, um, it influences uh functions related to reproduction and helps with skin collagen content, which is very good. Um, but what happens if you take too much uh testosterone? High testosterone is associated with symptoms of PCOS, the same things we talked about last uh next webinar. Acne, uh loss of hair on your head, breast swelling is rare, allergic reaction, super rare, headaches change in libido. Sometimes your libido gets better, uh, voice changes and extrafacial hair are the more common ones. Less common ones are quite rare: blurred vision, blood collapse, fluid retention. So I want to emphasize the difference between bioavailable, free, and total testosterone. The bio of testosterone is what in general what I often measure. Um, the testosterone is usually 20 to 80 nanograms per deciliter. Most of it is SHBG bound, so sex organ binding a lot of bindings to about 60%. Um, the album bound is 35 to 40 percent, and the free is that 2%. So there's not that many free testosterones around, especially women. So I don't think the assay is that great for low levels unless you do by equilibrium dialysis. Um, and uh there's a direct assay, there's a calculated assay for free. In general, I like the BioVel testosterone. It's readily available at the labs. It measures free and albumin-bound biologically active testosterone, and it's accurate, it's reliable pretty for the most part. I like a level between, say, um, three and seven is optimal. The SHBG, as I mentioned, is very important. In general, low SHBG is associated with insulin resistance, diabetes, and obesity, and I would consider that bad. High SHBG in general is good. But if you're at if your SHBG is high, your total estrogen testosterone and your total estradiol, SHBG binds to both testosterone and estradiol. So the total can look high, but in actuality, it could be the free or the bioavail, it could be normal. So measuring total testosterone alone, I think is very misleading. I never really recommend doing that. Uh the free testosterone is often low, inaccurate at low levels. So I usually recommend, at least in concert, the total plus the bioavailable testosterone. And I like a level between three and seven for the biovel testosterone in women. Okay, I'm gonna talk about the Women's Health Initiative study. This is a very important controversial uh finding. Um, observational studies. So these were studies that looked at women on estrogen, they had lower rates of heart disease. There's confounders, the women that were on estrogen went to their doctors more, they're probably higher educated. So it was originally thought that estrogen had beneficial effects on the heart disease. When I was doing my endocrinology fellowship with BMI, Gordon Cutler taught me that estrogen therapy for postmenopausal women, they saved a million lives. It was quite dramatic. So along came this woman's health initiative. It was a large prospective clinical trial of post-menopausal women. They were trying to look at heart disease. So instead of looking at women that are 50, you would expect for a menopausal study, they looked at women with the average age of 63. The drug at that time used was called premarin. It conjugated equine estrogen, it means it comes from horse urine, which something that I think when people think about it, they wonder why we ever use that. And then there's also estrogen plus progesterone called Prempro. If you had a uterus, if you didn't have a uterus, you just got premarin. And the question was could it prevent chronic conditions such as heart disease and dementia? The estrogen with the progesterone porcelain trial ended early. Again, this was about 2002, due to increased risk of breast cancer. Again, this was premarin, uh, women in their 60s. There are increased risk of blood clots, stroke, heart disease among women who received this treatment. The estrogen alone arm and women with hysterectomies show no detrimental effects and a possible decrease in coronary artery disease when women by age 50 to 59 were analyzed. There's a lot of sub-analysis of this afterwards. And I think in general, the conclusions were like that. That women around the menopausal age, the estrogen may have been beneficial only when it's gone into the later era and does it look more detrimental. And again, only this is relevant for premarin. The benefits of hormone replacement therapy in the women's health initiative include uh prevention of osteoporotic fractures, colorectal cancer, and the effect on dementia was unclear. And these findings were only applicable to women taking premarin and provera. Oral estrogens, such as what's given here, oral premarin and provera, another one called estrace, affects liver proteins, leads to clotting. Some of the effects may have been because it's called first pass effect. When you take oral estrogens, it goes to the liver. When you take estrogens by patches or gels or creams, it seems much safer. So since that study came out, um, the use of premarin and provera plummeted, while the use of creams, gels, and patches has risen. Many women, after hearing these contexts often taken out of contact and sensationalized, sought safer treatment, rectangle hormones, or stopped them completely. Many doctors stopped giving hormone replaces call together, letting patients just struggle with their symptoms. A reanalysis of the data looking at 8,000 women, a lot of women in their 50s who were rolling the study, and found that unlike their older counterparts, this group face no increased risk of heart disease during the study period. So is estrogen safe or dangerous? I think that's the struggle. We're worried about, you know, do no harm. Um, I think some people were worried about breast cancer. When you think about it, breast cancer takes 20 years to develop. So it's unlikely that a woman got breast cancer at 55 imposed on post-menopausal estrogen for five years. The estrogen was probably playing a role. Um, but that was a concern. And um and um there's been a change. Um, so I got this article, the free press. I really like to read that. Um, it's called Estrogen's Back. It has this woman uh on the left side before estrogen and the right side after. Um the quotes Dr. Jessica Navarro beside estrogen for hot flashes. More women are using it as a facial cream, beauty products for vagal dryness, such as pain on intercourse, and vulgar atrophy. I use it every night and I feel like my skin is more hydrated, less red, my fine lines have softened. Estrogen is the key to aging wealth. And there's a growing uh number of providers, doctors, that are pushing estrogens now. And I think that's uh they some of the emphasis has changed. So I want to show this YouTube video here of um um the head of the FDA, um, Dr. Makari.

SPEAKER_00 21:27

Want to put that machine in its proper context and let people know that there are tremendous long-term health benefits. In fact, you say hormone report on during a a sort of pile on uh bandwagon of American women going through perimenopause or menopause. So we're removing the black box warning from many of the estrogen products. That warning was put in a sort of pile on uh bandwagon thinking. It was a group think in 2002, 2003, that women really should not be taking these projects. Products because of the risks. We now have a more nuanced understanding, and we want to put that fear machine in its proper context and let people know that there are tremendous long-term health benefits.

SPEAKER_04 22:12

In fact, you say hormone replacement therapy can be a breakthrough for women.

SPEAKER_00 22:16

Yeah, arguably, with the exception of vaccines or antibiotics, there's no medication that can improve the health of women on a population level more than hormone replacement therapy. For example, it reduces the risk of fatal heart attacks significantly, up to 25 to 50 percent. Well, that's the number one cause of death in women. It reduces cognitive decline. It may prevent Alzheimer's. In one study, reduced the risk by 35%. And it improves bone strength and prevents osteoporosis, which is a common cause of a cascade of events later in an older woman's life after a say a fall or an accident. Fractures lead to immobility and ultimately could lead to a woman's demise. So there's tremendous long-term health benefits, not to mention the short-term benefits of alleviating the symptoms of menopause.

SPEAKER_04 23:06

What does this announcement mean for the tens of millions of American women going through perimenopause or okay?

SPEAKER_01 23:14

So I think that's quite impressive. Um is estrogen. Can people see my screen again? Yes, you can see it. Okay. Estrogen safe or dangerous. Marty Mlocky says it's an American tragedy. I do think it's one of the biggest mistakes in modern medicine. Marty Merlockey uh told the 50 to 70 million women over the last 23 years have been dying. Incredible life-changing, life-save benefits hormone replacement therapy because of the dogma. And you could see the link in the uh CBS news. Um, so the US FDA removed the black box warning on many hormone therapy drugs used for menopause and perimenopause about two months ago. A major turnaround is like it encouraged more women to seek treatment. And in fact, since the FDA lifted the black box warning about to again about two months ago, prescriptions for hormone replacement therapy have increased 86%, leading to shortages of estrogen patches. I have patients that are saying you can't get the patches. I'll talk about some different alternatives for patches, but I think this is a life's life-changing change. Um, and I thank Dr. Malaki for his insight into this, Dr. McGow. Uh, the treatment for uh hot flashes is primarily estrogen therapy. Estrogen therapy has a greater than 80% efficacy in relieving visomato symptoms, so it's quite effective. Prior to the women's health initiative, estrogen therapy was widely advocated on the publication of the WHI. There was a marked decrease in estrogen use due to perceived risks with uh estrogen. In general, you want to avoid oral estrogens and birth control pills. Both of those lower IgF1. In general, most of my hypopituitary patients are on growth hormone. I would say oral estrogens is the one contraindication, one drug people on growth hormone should not take. Um, for some people, it's okay, it's not an issue. But many of my patients do um do worse on oral estrogens. Um, there's a common birth control pill called northendrin or slins. Um, I think it might be a little bit better, but it's um gynecology is using that uh quite um frequently. And it also lowers IGF1, it lowers bivalve testosterone, which could be good if you have PCOS, but in some of my hypopit patients, we don't we talked about how important the testosterone is. You don't want to lower it. Um, it also can lead to blood clots and waking. Um so in general, I would say a woman over 40 should probably not be on birth control pills. Uh maybe a younger woman, it's ideal. Uh Vival dot is my go-to estrogen patch. It's a small patch, it's twice a week, it usually is covered by insurance. The chlimera is a larger patch given weekly. Other patches include the dotti patch. Dotty patch is uh becoming popular. Patients that can't get a vital patch can go to a dotty patch, they're basically interchangeable. Um, there's a one called a Minivel, there's one called a LoRa, there's one called Menostar. Sometimes they fall off and need to be tapered on.

SPEAKER_03 26:06

Sorry, Dr. Freeman, the other, yeah, that's better.

SPEAKER_01 26:09

Okay. Um and there's combi patches um called estrogen plus progesterone. I like oral progesterone. I don't like estrogen progesterone patch. So I usually give people oral, um transdermal estrogen plus oral progesterone. Um compounded creams are another option, we'll talk about them. And in general, um, I think there's more of an emphasis on giving people, even with their uterus removed progesterone. Progesterone has a lot of benefits. Um, and I think there's more of a movement to give everybody progesterone, even if they don't have a uterus. The estrogen, I like that one also 0.06%. So it's a topical gel. Usually start with one pump a day given on the inner arms. Sometimes the insurance cover is a little bit harder with it, but it's an excellent product. Um, I like to measure your estradiol levels. I aim for an estradiol level between 50 and 100 micrograms per mil. If the patients are still having mesh disease, it should be done on day three of their cycle. If no amencase, it can be done in any during the cycle. Estrogen is balanced to SHBG. Uh so I recommend getting an SHBG. You usually want to get an estradiol, it's part of this the bivalve testosterone sort of package. And um, the high SHBG could mean a total total estradiol high, but the free cannot be normal. And you can measure free estradiol. I often do that uh in my patients. Progesterol replacing. Women with uterus need progesterone. Um, if you give estrogen without progesterone, you can get an endometrial buildup, and that could lead to endometrial cancer. Um, I usually give uh biodentical progesterone, it's called um prometium, or just how it's called progesterone is the generic. I don't like the synthetic provera. The provera is madroxy progesterone, it's not biodential. Um and I like to, I often work with gynecology colleagues to get a transvaginal ultrasound. Um the thickness of the estrogen, uh, the endometrial thickness on vaginal transvaginal uh estrogen, transvaginal ultrasound should be less than five millimeters. If it's more than that, sometimes they need higher dose of progesterone or lower doses of estrogen. Progesterone helps with hot flashes as well as estrogen and also helps with sleep. Progesterone rarely leads to fatigue, occasionally can lead to a little bit of swelling, bloating, waking. Usually doesn't, but I usually have people take the progesterone at night. Um, if you give it at night um continuously, like 200 milligrams, you don't get uh a period usually. If you give it for part of your cycle, such as 10 days, for example, the menses will occur a few days after the progesterone stop. I usually give people a choice. Uh women less than 45, I usually encourage them to have a period, but some of them don't want a period. While greater than 45, I usually have them not take a period. Prometrium is progesterone, it's biodentical. Again, I usually give the 100 to 200 milligram dose if no period is desired, and 200 milligrams for 10 days a month if period is desired. And you can give progesterone to somebody without a uterus, you just don't have to. Somebody's having side effects that you can give it just frequently or infrequently, you can give it every three to months. Just make sure you monitor that urine lining. So progesterone uh replacement is crucial. Um, in patients without a cycle, I start patients on days 15 to 25 of the calendar month because people aren't having a period. And then I move it to 15 to 25 of the menstrual cycle. I usually give um a compound, I often can give uh compounded progesterone creams, but they're not, they're a little bit less absorbed. Some people like them quite well, but I usually like the promet tumor progesterone pill. Don't recommend Provera. And I usually don't monitor progesterone levels, but occasionally I do. Now, testosterone is a crucial hormone. It's the underrepresented uh under-appreciated hormone. I usually give it in women with symptoms of low testosterone, low libido, weak, low muscle strength. I uh people that should have a bioavailable testosterone less than two, especially women with hypopituitarism, menopausal women frequently have low testosterone levels. I like a compound like gel, usually 1.25 milligrams per mil or 2.5 milligrams per mil. I get it from University of Compound and Pharmacy. There are male preparations that are cheaper, but it usually gives you a high level. It's very hard. You have to give it just a teeny bit of it to get it to work. So I like the uh the topical better. The pellets I definitely recommend avoiding. They give sky-high levels after the shot, after the pellet, you know, probably higher than my level and lowered before the next pellet every three or six months. It's definitely non-physiological. And I use for physiology in general. I like to have the um biovoltosterone level between two and seven, um, you know, sort of again, what a normal woman should have. Side effects uh include facial hair, acne, hair loss or under on your head. And most patients really like the testosterone, many as a game changer. What are some other treatments for hot flashes? The pharmacological alternatives include um SSRIs like um surchaline prozac, SNRIs like effects or gabapentine. These have about 60% reduction in hot flashes. Um, but I don't think they work as well as estrogen, and they have more side effects usually. Um, some recent studies have found that gabapentine is one of the key drugs that leads to higher rates of Alzheimer's disease. Um gives you fatigue, trouble, sleep, uh, makes you tired, um, weight gain. Um, so I usually don't do these alternative drugs. I would rather put just put somebody on um on estrogen and progesterone. Um, and then the other option is supplements, which we'll talk in a second. Meditation and deep breathing is another option. While it may not stop hot flash entirely, it can seem to reduce the bother, the intensity and anxiety associated with them by calming the nervous system. You could do a cooling breath called Sitali Anayama, curl your tongue into a tube or your lips or part of your lips if you can't. Inhale deeply, feel the cool air entering your body, close your mouth and exhale slowly through your nose. The stop method used this method um uh for 10 seconds in or the panic loop, slow down, take a deep breath, observe the sensations warm in my in my sorry missed cut off a little bit. Um, but uh that the stop method is an idea, is a good idea also. What are biodentical hormones? And this is a controversial area. Biodential hormones are defined as compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body. They have been promoted as safe and more effective alternatives to traditional hormone therapy, often by people outside of the mainstream medical therapy. And then any hormone can be made biodentical. The term is often used to describe formulations containing estrogen, progesterone, and androgens, um, often from natural sources or from uh synthetic sources, but the natural, the one the body makes. Um, so they can be made by extracting desode diosogen from plants, usually these high-yield soy or Mexican yams, and it's structurally similar to steroids. It must be changed into progesterone, which is then a precursor, used as a precursor to make biodential hormones such as androgens and estrogens. These isomolecular hormones are identical to those found women and therefore purported to be better tolerated and more appropriate to treat menopausal symptoms. And this was especially important, I think, when there was the premarin, which is very non-biodential. Now that we have estradiol creams and gels, that's also biodential. That's a little less of an issue now. Uh Suzanne Summers, who I like very much, um, wrote a couple of books called uh The Sexy Ears, discovered the hormone connection, the secret to fabulous sex, great health, and vitality. But you know, she tried to solve, make a uh make some money off of this also. She had a couple of books. Um she had a company and did a lot of um um food lines, fitness products. Unfortunately, she died at the age of 73 of breast cancer in 2023. According to the its advocates, uh, the um the bioidentical estrogens are more or more what the body makes. There's three biodential estrogens, estrile, estrone, and estradiol, and which estriol is the most, but it's very weak. Estrone is probably detrimental, so usually don't give that, but estradiol is what the body mainly makes compared with premarin, which has several other synthetic estrogens, which are not biodential. Estriol appears to antagonize the proliferate effects of estrone and estradiol, while it doesn't, uh has less tendency to stimulate endometrial proliferation. Estrone may have detrimental effects on the breast, and it's not recommended. Natural progesterone has benefits over synthetic ones, as I mentioned before. I like progress like progesterone over progestins, which are provera or madroxy progesterone. Natural progesterone affords the same project protection against endometrial cancer, synthetic progesterone, but doesn't interfere with the body's ability to protect against heart disease. So the mainstream uh organizations, uh, college of gynecologists were against biodental compounded biodentical. Um, and then there were some issues that the FDA was compounding on these. But in general, um, I use some biodental compounded estrogens, but I think with the really excellent availability of things like a viable dot patch and estrogel, there's not as much need for these as there was before. So I use biodenttical estrogen, estradiol and progesterone, what the body makes. I often get it from you know prescriptions, but sometimes common compounding pharmacies. I especially like the viable dot pad and oral progesterone, which are biodentical, but not compounded. What can a patient do to balance their hormones or improve menopausal symptoms? So we're uh trying to get back to what their patient can do. So some of these are common sense things, some of these are part of my talk on lifestyle medicine. Um, I'm really interested in having patients do what they can to do. So eat high fiber whole foods, move, sleep better, stress management, and the supplements we'll talk about. Now, as I mentioned earlier, there's a lot of detrimental hormone changes associated with the menopause, decreased muscle mass, lower resting energy expenditure. You're you got but you're down about your you burn about 300 calories a day less than you did before menopause. So just to break it, please get yourself. So your um waking is common. Body weight in menopause is recommended to um correspond with your energy intake according to your body composition. Basically, I don't recommend people to like fast, but in general, people should try to lose weight if they're able to, if they uh can, and um eat eat healthy foods. Salt consumption should be liminized. And I'm really a big fan of a vegetable diet. I have my vegetable revolution on my website, and try to eat three to four servings of vegetables and one to two servings of fruits per day. This will help you with menopause as well as your overall health. So you shouldn't eat well below your basal metabolic rate. It has a risk of low energy availability and may worsen menopause. So you should avoid starvation diets. But in general, I like people to eat a little less, try to lose weight, try to drop that weight one to two pounds per week, maximize fat loss, minimize, preserve lean muscle mass, try to do weight training if you can, um, and then always do lifestyle changes. This should be long-term effects and not a short, quick diet. Um, the American College of Lifestyle Medicine advocates the six pillars of health. Pillar number one is good for both life and health, as well as menopause. So I took this from the American College of Lifestyle Medicine. It's a whole food plant-based diet. Whole foods mean single ingredients, foods, unprocessed or minimally processed foods as they exist in nature. So you can see that on the lower right there, the carrots and papayas and mangoes and zucchini and things like that. Single ingredient as they exist in nature foods. Plant-based means that most of your calories should come from fruit, vegetables, whole brains, and legumes. Legumes are quite beneficial for menopausal symptoms, also. So most of your foods should come from these types of foods. A whole food plant-based diet leads to weight reduction, reduce visceral fat, the fat around your organs, and decrease some of the uh symptoms of depression and fatigue, things like that. So I recommend for a menopausal diet, soy products are good. Foods, especially berries, have a lot of antioxidants in them. Vegetables, leafy greens, whole grains, beans, nuts, and legumes. Plant-based foods rich in calcium. I don't think people should get calcium from external sources, but from your plant-based foods. Fish has some controversy with the plastics in it, but in general, I recommend fish for menopausal issues and unsaturated fats in moderation can be added. So someone else's idea of a menopausal diet. Tomatoes have antioxidants in them, eggs are a good source of vitamin D. Um, vitamin D tofu has fine soy. Soy is better is beneficial. I'll show that on the next slide. Radishes could be helpful, greens are helpful, fed cheese can be helpful, and seeds such as um chia seeds are also have a lot of nutrition that are helpful for menopause. Fruits to avoiding menopause, red and processed meat. Um, studies have found those are the most detrimental. Sodium-containing foods, and I love this picture of the, and I showed this to my patients at power obesity, ultra-processed foods versus processed, minerally processed. Corn is minerally processed. It grows on the ground, grows in the Central Valley. Canned corn is a little bit processed, it's still pretty much corn. Doritos has a little bit of corn in it, but not too much. It's mostly preservative, chemicals, additives, flavoring salt, sugar. So you want to avoid those ultra-processed foods. Um, it leads to uh worsen physical function cognition and also menopausal issues. Fruits and veggies have phytonutrients. These are very important to help you with menopausal symptoms. Um, when you eat a whole food, especially a lot of different colors in the foods, increases the bioavailaby. Um, you get a lot of these phytonutrients, which helps uh make sure that you don't have symptoms of menopause, and fiber is crucial. Soy has isoflavins in it, it's associated with reduced inflammatory bacteria associated with heart disease, risk reduction. There's some evidence for improving heart flashes. The isoflavins and soy foods help balance hormone levels and have some estrogenic activity. Try to eat it as a food and not as a supplement. Fermented foods are also quite effective. Misu, tempeh, pickles, yogurt, kimchi. They support gut health, cardiovascular help, and potential help with mood and benefits related to menopause. Good sleep hygiene. We talked about at the beginning. Sleep is leads to poor sleep leads to menopausal issues, menopause leads to poor sleep. It's important to try to go to bed at the same time at night. Don't eat before you go to bed, get enough sleeping for at least uh seven to eight hours, try to be get restorative sleep, and try to don't stay up real late at night and have a normal circadian rhythm. Stress management is crucial. Some people like taking baths, spending time with uh bath salts, candles, a day's spocks, connect with your spiritual sources are always good things to help with your um menopausal issues. Supplements. Okay, supplements are key. My favorite one, I never want to go to supplement in general, is vitamin E. Really works well for hot flashes. Other ones are curcumin, magnesium, flaxseed oil, even primrose oil, and B vitamins. There was a study of 51 patients. There was some issue that this there's a question about the study, but I think it's been proven. Um, other studies have shown it also. There was a different when they gave either placebo or vitamin E. Um, the people in the vitamin E had lower high flash scores. The frequency was less, it was highly significant, and it's recommended for vitamin E for treatment of high flashes. I like vitamin E. Sometimes I even give it with estrogen. Little side effects. Um, it's an antioxidant, which means it helps uh uh prevent oxidation to tissues. It also is helpful for fatty liver disease. Uh turmeric is the whole root, the rhizosome of the curcule curcuma lunga plant, while curcumin is the active ingredient compound in it. Uh, think of the turmeric as like the orange and your curcum as the vitamin C. So you try to get these into your diet. Curcumin also reduces eye flashes as anti-anxiety, antioxidant, anti-inflammatory. Magnesium can help reduce symptoms of menopause. We usually have people taking a diet, like magnesium glyconine, helps with insomnia, tissue dryness, mood swings, anxiety irritability, and water retention. So it's a good supplement to take if you're having menopausal issues. Blackseed oil, um, you can grind it up. They have a substance called lignins in it. Um, they're important modulators of hormone metabolism. These can be quite helpful for high flashes. Even E. Primrose oil has gamma-linolinic acid, an essential fatty acid that helps with prostaglandin synthesis and helps modulate, moderate menopausal symptoms. Black currant also is also quite helpful. B vitamins, B6, B12, and B9, folate are essential for managing common menopausal symptoms like mood swings, fatigue, cognitive decline. They support neurotransmitter reduction, energy metabolism, compound brain fog, which is associated with hormone shifts. So I think taking a multivitamin that has these in or taking these especially are good ideas. Okay, so I think we uh did a pretty good job here. Um please um look at my website, Good Hormone Health. Uh this will be posted in um a couple days, also on Facebook, on a YouTube channel, on my podcast channel. If you have any questions, you can email us and we can go into questions now.

SPEAKER_03 43:09

Awesome. Thank you, Dr. Freeman. I can start on Facebook. Okay. Um Danielle asked, or she said, Dr. Freeman, maybe you'll get to this, but can you talk about how BLA might affect onset on symptoms?

SPEAKER_01 43:26

Um so when you have a BLA, you're missing your uh cortisol, uh mineral cortiscoid, futrical cortisone, DHEA, which is uh also an antigen. Um and you're usually taking cortisol, sometimes too much cortisol that can affect your estrogen. So in general, you know, I think if you're properly replaced after a BLA, you should have the same menopausal issues as a regular person. If you're improperly replaced, you may have more issues.

SPEAKER_03 43:54

Um we have another question. What about instant sweating right out of the shower? Sweating profusely. Just blow drying your hair.

SPEAKER_01 44:01

So I think that sounds like you're having nanopausal issues. You need to either go on estrogen or go up on your estrogen or consider progesterone.

unknown 44:09

Okay.

SPEAKER_03 44:10

Hell yes. I thought that the later analysis showed that the older women that had negative outcomes were associated with a longer gap for treatment.

unknown 44:19

Right.

SPEAKER_01 44:20

So most of them didn't get treatment until well into their 60s. I think the newer analysis says if you treat a woman around 50, it's usually beneficial.

SPEAKER_03 44:28

For those of us that are panhypopituitary and need to do a blood draw, if we have had vaginal estrogen added Monday, Wednesday, Friday to help with a variety of symptoms, including interstitial. Yeah. Do we need to do anything specific for timing of lab/slash vaginal estrogen that is inconsistently taken?

SPEAKER_01 44:55

You know, I think if you still take it three days a week, it's probably going to be fairly consistent. One issue I do see, especially with testosterone, sometimes with estrogen, is people put it on their inner arms near their anticubital vein, and then they get the blood draw and it's sky high. So make sure that if you do put it on your arm, don't get a blood draw at that time. You know, I think if you take estrogen every other day, um, it's probably not going to be that different from one day to the next day.

SPEAKER_03 45:21

Sherry asks, what about 10 years postmenopause? Weight gain, hair loss, weak muscles, fatigue, lack of sleep, pituitary adenema present, but testing negative for ACTH, ETC.

SPEAKER_01 45:35

You know, it sounds also like menopause. Menopause can happen right after your last period, it's going to happen up to 10 years afterwards. So, you know, I think you should look into um menopausal issues and um maybe go on treatments.

SPEAKER_03 45:47

Okay, Cheryl asks, empty cella and menopause question mark.

SPEAKER_01 45:52

Um it makes it worse. So people with women with hypopituitarism, they have lower estrogen to begin with, including empty cella. And therefore, when you get menopausal, you get uh more symptoms than uh otherwise. And maybe need a higher dose of your replacement.

SPEAKER_03 46:08

Okay, Amy says, happy anniversary, Dr. Friedman.

SPEAKER_01 46:10

Thank you.

SPEAKER_03 46:11

Question one, is there a connection between premature ovarian failure and low cortisol? And if yes, can you explain why? My menstrual cycles began stopping before and after being suspected of adrenal insufficiency.

SPEAKER_01 46:26

So both premature ovarian failure and addison disease are autoimmune diseases. They often can run together, although you know, certainly not most of the time, not always, but sometimes they can run together. And you can get, you know, autoimmune attack on your ovaries, autoimmune attack on your adrenals, and you can get both of them. And I would say both of them need to be properly treated with um, you know, your cortisol and fluctuation for your adosins, and with your um estrogen and uh progesterone and testosterone for your um um menopausal issues, and people with addiscens also are missing some testosterone from the adrenals. So your testosterone in women, um, more of it is made, you know, maybe 60% or so made from the uh ovaries, but a prepared proportion of it is also made from the adrenals. So if you have addisons, then you usually may need more uh testosterone.

SPEAKER_03 47:15

Well question two MTA is supposed to be lower cortisol, however, I was prescribed this another time. My menstrual cycle stopped again, and it was helping my energy, memory, muscles, and digestion, but uh never a hundred percent on a daily basis. Times I was quite ill with low cortisol symptoms, and labs were reading that glucocorticoid steroid in the MPA and then prescribed over FDA recommended amount of oral estradol. The MPA only lasted so long and eventually the MPA quit working. Why would MPA do this?

SPEAKER_01 47:50

So MPA is hydroxy progesterone. I don't recommend that. I would recommend sticking with biodentical progesterone, um, and I don't recommend oral estrogens.

unknown 47:59

Okay.

SPEAKER_03 48:01

Lolly asks, until how many years after menopause can you start estrogen slash testosterone, ETC?

SPEAKER_02 48:08

Okay, that's a good question. I was gonna have a slide on that.

SPEAKER_01 48:10

Um, you know, I think when the WHI came out and there was this backlash, um, I think, and you know, the WHI being women in their 60s, I think most doctors, maybe even including me, felt you give it to her 10 years till you're 60. But then you have people in their 60s that are benefiting from it. You know, they stop it, they get hot flashes still. It still has the benefits of cardiovascular benefits, um, for instance, the hot flashes. Um, so um, you know, sometimes they give it in the 70s, and I have some people on this call probably that might be in their 70s, they're still taking estrogen and testosterone. So I think it varies. Um, you might want to give the dose a little less as you get older. Um, but I think if you're having um menopausal issues and you're in your 60s, you could consider going on it.

SPEAKER_03 48:53

You know, as as a congenit as a congenital pan-hypertuitaryism, 48-year-old woman, when would I decrease my current estrogen and progesterone?

SPEAKER_01 49:03

Yeah, so I think that was the sort of the same question as last time. Um I would usually keep people on their estrogen and progesterone until they're 60 and then sort of reassess. Um, it's some people you want to keep it in their 60s.

SPEAKER_03 49:21

Okay. When should women begin being tested for perimenopause?

SPEAKER_01 49:27

I think when your periods start becoming irregular or you start having symptoms. Um and you know, I'd recommend start with a day three FSH and estradiol level.

SPEAKER_03 49:40

Jen asks, many of my friends have been prescribed progesterone only, but I was prescribed both estradiol and progesterone. Why would one be prescribed uh over the other one?

SPEAKER_01 49:53

Um, you know, I think in general, estrogen is probably more beneficial for menopausal issues than progesterone. Um so I usually give both. Um there's a certain exception. People don't tolerate estrogen, didn't tolerate estrogen as well. They had side effects on it, they wanted to go on progesterone. Um so you know, I think it has to be individualized. But most patients I put on both estrogen and progesterone.

SPEAKER_03 50:15

Shana asks, where should we apply the topical testosterone?

SPEAKER_01 50:19

I put it on your inner arm and then sort of rub them together like this. Um, but make sure you don't have it there when you have your um when you have your blood draw.

SPEAKER_03 50:28

Okay, Jana asks, it seems to be unclear how progesterone could be replaced. Did you recommend taking progesterone on days 15 to 20 per night? Many doctors are recommending not taking every night of the month. What are your thoughts on cycling bio?

SPEAKER_01 50:43

Right, right. So right. So if you take it days 15 to 25 of your month, you'll likely have a period. If you want to have a period, if you're less 45, I usually recommend it having a period. If you take it continuously, you probably won't have a period. And for the people that don't want to have a period, I recommend it continuously, like every day of the month, either 100 or 200 micrograms. And usually recommend it in bedtime, 100 or 200 milligrams.

SPEAKER_03 51:08

What are your thoughts on compounding time release progesterone from university compounding?

SPEAKER_01 51:13

Um, you know, I usually give the progesterone um oil, progest project probetrium or progesterone. I think it works pretty well. Some people I put on creams. Um, I don't particularly use a time release one. The other thing is some people have peanut allergies. Most of the conventional progesterone and probicium are made with peanut oil. So some of the people with peanut oil, peanut allergies, I might uh switch to uh compound.

SPEAKER_03 51:42

How do you handle symptoms of both hyperthyroidism and menopause? They both exhibit the same symptoms.

SPEAKER_01 51:49

Yeah, good point. I was gonna put a slide in that also. So they're very similar symptoms. Um treat them both, get their treat their hyperthyroidism.

SPEAKER_03 51:58

I'm almost 52 and maybe starting to experience symptoms, but so far they have been minimal. I think night sweats, extreme fatigue, not sure about other stuff like dizziness and vertigo. Till have mostly regular menstrual cycles. Does it make sense to start treating how to be proactive, or should I wait until experiencing symptoms?

SPEAKER_02 52:17

I think it depends on how bad your symptoms are.

SPEAKER_01 52:19

You know, you said night sweats and extreme fatigue. It doesn't sound too mild to me. Um it sounds like you're uh having a lot of symptoms. Um I think the sleep is the crucial thing. If you're having trouble sleeping, I think I would start um the estrogen. And as I mentioned, the supplements, especially vitamin E, might be a good choice to start if you don't want to go on estrogen. Okay, one more question, and we'll um tonight.

SPEAKER_03 52:39

Debbie asked, Does estradiol vaginal cream is that useful for vaginal dryness?

SPEAKER_02 52:46

Yes, absolutely.

SPEAKER_01 52:47

The advantage of the vaginal estradiol is advantage and disadvantage. It's not systemic, so it helps vaginal dryness, but it doesn't get into your systemic level, so it's not gonna really help you with hot flashes.

SPEAKER_03 52:59

Do you recommend another medication?

SPEAKER_02 53:03

Um, the vaginal if you I think you should just take estrogen if you're having hot flashes. That will help your vaginal dryness also.

SPEAKER_03 53:09

Okay. How much vitamin E should one take?

SPEAKER_02 53:14

400 units.

SPEAKER_03 53:15

Okay, and then one more question. Is there a benefit to take estrogen if you don't have any symptoms?

SPEAKER_01 53:21

That's a good question, also. So, you know, I think if you're having concerns about osteoporosis, for example, you might want to take it if you have like early menopause and you have thin bones on either your bone density or urine cellopeptide. I might take it, but I think in general, we try to be treat um people with uh symptoms.

SPEAKER_03 53:40

Awesome. Well, if anyone has any more questions or want to see Dr. Freeman, please visit go to home and health.com.