The Menopause Hour with Winona
Welcome to The Menopause Hour, the podcast where you’ll find the answers to your most pressing menopause questions—the ones you won't get from your OB/GYN. Hosted by Winona’s Chief Medical Officer, Dr. Michael Green, and Medical Director, Dr. Cat Brown, The Menopause Hour is here to empower you with expert insights, tips, and real talk on navigating menopause with confidence and clarity.Brought to you by Winona – menopause care made easy. Join us each episode as we explore the symptoms, solutions, and science of menopause, all while breaking down the stigmas and misconceptions along the way.
The Menopause Hour with Winona
Episode #15 Hormone Truths: Myths, Meds, and the Case for Symptom-Based Care
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In this episode, Dr. Green answers the most common questions surrounding hormone replacement therapy (HRT) and menopause care. He breaks down the importance of symptom-based treatment over lab testing, debunks persistent myths about estrogen, progesterone, and weight gain, and explains how combination creams and vaginal estrogen work. Dr. Green also answers questions about using HRT alongside antidepressants or GLP-1s, the role of IUDs, and common concerns like hair thinning, sleep issues, and libido.
This episode is packed with expert insight for anyone navigating perimenopause, menopause, or surgical menopause.
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Welcome to the Menopause Member, your go-to source for empowering answers to your burning menopause questions, the ones you won't get from your OBGYM. Brent to you by Winona, Menopause Care Made Easy, and hosted by our experts, CMO Dr. Michael Green and Medical Director, Dr. Kat Brown.
SPEAKER_03Hi everyone, and welcome to another Winona Live QA. We're so glad that you're here today. If you haven't been to Winona Live QA, um, these are a lot of fun. If you have been, welcome back. Um, but for those of you who haven't, kind of the way that these work is um, you know, in a moment I'll have Dr. Green kind of introduce himself and give a little bit of a spiel. But essentially, we get to answer all of your questions that you have been wondering about, you have questions about, you kind of just want discussed with you. This is what that time is for. So usually it gets a little bit crazy and a little bit busy. So if you want your question answered, go ahead and put it down in the chat. Um, I recommend to start dropping it there now. I already see some people are typing, it gets a little bit crazy in there. So go ahead and put your question in there. Um, and then we will kind of dive into those in a moment um and we'll get into those. Um just before we start to just want to like let you all know as well. Um, if you haven't heard of the menopause hour, we have a new podcast on Spotify for when I'm featuring Dr. Green and Dr. Kemet. Um, it's a really, really great thing to listen to as well. For if you ever in the car or on a walk and you want kind of to, you know, dive into more questions. It's a great thing to listen to, great resource. Um, we've got some really cool things going on there. Um, and of course, you know, on our website, we also have tons of resources. We have medical, our medical journal and we have articles um about really just every subject you might be wondering about, whether it's, you know, um something that you're experiencing. Um, we recently had one about the power of you know, female friendships and how that can help your health. Um, so really a fun uh thing to dive into over there. Um, but I see that we have a few questions kind of getting put in the chat. So, Dr. Green, I will pass it off to you to give your little introduction and your little spiel, and then we will get into all the questions.
SPEAKER_00Great. So, hi, my name is Mike Green. I am an OBGYN. I actually did a family practice residency first um and found out I didn't really like taking care of sick people. So uh, and I love delivering babies, and people told me I had good surgical hands, and I really fell in love with women's health. So I did a whole second residency and excuse me, became a board certified OG UN, which is pretty much what I spent my career doing. And this last little bit of my career, four or five years, I guess Winona's been around for a little over four, it was probably another year in the planning before that. Um, it's just been a joy um introducing and building Winona and um being able to touch so many women's lives with the treatment that unfortunately uh often is hard to get in the normal brick and mortar practice, and women sort of get marginalized here, which is really a shame. So um, this is like really cool for me that um this has been so successful, but we've been able to help so many people. So really happy about that. Please um type your questions. Um normally Dr. Kat is also here. She's the medical director. I'm the chief medical officer. I'm not sure if I said that. Um, she is actually in Costa Rica filming a menopause-related show. Um, so she's becoming a movie star, or I guess a TV star, I think. So on location in Costa Rica, she was invited to uh to do that. So that's super cool. Um, so I don't think she'll be joining us tonight, um, but she's got a good excuse. Um so we don't type questions like usually then we threaten that Kat and I'll just hang out and chat, but so it'll just be Matty Me. Looks like there's plenty of questions coming in, so that's good. So I kind of want to start off. There was I had a conversation this morning that kind of made me think this is something to good to talk about. So I don't think uh QA goes by where we don't ask, get asked about why we don't do labs at one now. So I want to cover that and then tell a little story. So, first of all, labs are not helpful. Um both the American College of OBGYN uh ACOG and uh Menopause Society, which used to be called NAMS, both have statements saying that labs aren't necessary or even particularly useful for managing menopause symptoms or even diagnosing it for that matter. Really, menopause is something that we do based on symptoms um rather than lab studies. And the problem is the labs vary, like not just day to day, but hour to hour, it could change drastically. So you can check your labs now and it'll say, oh, your estrogen is terribly low, and you check your labs at an hour and say, Oh, it's perfectly normal. And the only thing that's changed is the clock. Um, so it's really not helpful, it's not useful. And in my opinion, it's actually worse than not helpful because the only thing worse than no data is bad data. And when you start making decisions based on bad data, you make bad decisions. Um and it's very tempting when you have data in front of you to use that data, even though you know kind of intellectually that it's not good, it's hard not to use it. So we really do not rely on labs here. Um, and that's really the standard of care, and it's the right way to do it. Doesn't mean that somebody out there isn't going to recommend labs to you. Um, and there's sort of two categories for this. There's sort of your well-meaning doctor um isn't really totally up on the latest, um, and they see, you know, they fill in out their lab slip, and oh, there's estrogen. Okay, I guess I should check that. And then they don't really know what to do with it when it comes back. And they're well-meaning, um, they just don't know better. Um, and that's most of the people. Unfortunately, there's a small percentage that are just trying to make more money because labs are lucrative and people make a lot of money off labs. And so there are unfortunately, you know, uh a few out there in, you know, in the menopause space that do labs basically to pad their income. Um, and that to me is is you know really not right. Um, I know there is a big company that is planning a menopause launch. Um, and I'll be honest with you, I like competition. Um, I've always said this competition makes everybody work a little bit harder and a little bit better, and it's good for patients, and so competition is good. Um, I heard through the grapevine that part of their menopause launch is going to be home labs, which is really disappointing. Um, in fact, I don't want to give away, but um you know, somebody that's running their that program has been on record saying they understand that labs aren't useful. So that tells me that they know better and this is just a way to make more income, and that's not right. Uh at Winona, we want to practice the absolute standard of care best medicine to give you the best outcomes. We also want to do it in the most efficient way because we know that this is basically a cash pay service. We don't want to waste your money. Um, and so you know, there's this medically really good reason not to do labs, but it's also the right thing to do um financially. And in fact, the conversation this morning, someone was saying, Well, gee, are we gonna start doing that? I'm like, no, like, yeah, we can make more money, but it's not right, it's not good medicine, and I'm not gonna practice bad medicine. So that's the lab thing. Somebody's gonna come on late and they're gonna ask me that question anyway. Um, and you guys can all snicker. But anyway, so um that comes up every time I haven't looked at all the questions. I bet there's a question there about labs already, but anyway, so that's kind of my little my little prelude. Um, hopefully we've uh built enough questions to keep you guys interested and and get some knowledge out there. So let's let's hit it.
SPEAKER_03That we do. I was gonna say we got we have a lot of questions already. So we'll we should dive into those. Um, but yeah, thank you, Dr. Green. I think that's a that's a really good, that's a really good word as well. And that's something I've really appreciated about Winona too, is just really like how much they care, you know, for for patients and kind of what that looks like. And um yeah, so I think that that's always great to hear, I think, a doctor saying and putting patients first, I feel like is such a um such a good thing. But kind of to dive into the questions for tonight. Um, our first question is from Angie. Um and Angie says, um, she says, I have had diarrhea for the last week or so about two to three times daily. She says I started Winona combination cream uh on 5-1. Um, and she says I also have dry mouth. Do you have any thoughts on this?
SPEAKER_00Diarrhea is not a typical side effect of these medications, um, it just isn't. Um the caveat would be um some women do have some unscheduled bleeding when we first start the medication. That's fairly common, and that can cause some cramping of the uterus, which can stimulate the colon because the intestines sit right on the uterus. So that's the one time you can sometimes see diarrhea. But if you're not bleeding, um, I don't think it's related. You probably ate something or have a little stomach bug, or there's a million other reasons for diarrhea, is probably not from HRT, even though I understand there's this sort of timing thing that it kind of makes sense. But I just it's not a total thing that we see. The dry mouth is most likely from dehydration from the diarrhea, because that's one of the things that diarrhea does is cause dehydration. So I would guess that they're linked. Um, dry mouth is also not a common side effect of HRT. So um I think you probably got a little bug going or you ate something. Um, but um, I don't know if you traveled recently, but you know, don't drink the water, right? Um, but uh I don't think it's from the hormones.
SPEAKER_03And our next question comes from Julia. Um and Julia says, what's the best way to take progesterone, um, estrogen and testosterone at the same time?
SPEAKER_00So progesterone is for most people, it tends to make them sleepy. And so we typically recommend taking progesterone at night. Um every once in a while you get somebody who gets the opposite effect and uh it's activating instead of sedating. And so if you find that you're taking progesterone at night and you're like bing wide awake, like you just drank a cup of coffee, take it in the morning. Even more rare, but but it does happen. Sometimes progesterone can cause crazy dreams that aren't pleasant. And so if that happens, you take it in the morning and that solves it too. But for the vast majority of people, you want to take progesterone at night. Estrogen, we also typically recommend taking at night, um, again, to help with the sleep benefit, um, because a lot of times hot flashes, night sweats um can interrupt sleep. Um, and so that's another, you know, one sleep issues are very common issues in the menopause transition, and um, a lot of it has to do with you know these night sweats and hot flashes that people get, or from um frequent um you know, getting up to go to the bathroom, and Esther can help with that too. So taking at night tends to help a little bit more with the sleep issues, so you kind of get a little extra out of that. We don't offer testosterone, we offer DHEA, so if that's what we're referring to. For most people, it's not so important when you take the DHEA. And so I tell people to take it when it's easiest to remember. For some people, they find taking DHA in the morning gives them a little boost of energy and can be helpful that way. It's totally acceptable to experiment and see what your body does because everybody is a little bit different. So you could try taking them at different times of the day and see what works best for you. The most important thing is to remember to take it every day, whatever time of day that is. Um, so um, some of it is whatever's going to work best for your routine is also another important thing.
SPEAKER_03And our next question is from Deborah and Deborah says, I just started using the cream. She says, I've only been doing one pump. Is this still going to work? She says, or do I need to do the two pumps? I'm a little bit nervous. People have been telling me that the cancer rate is high with the cream.
SPEAKER_00So I'm, you know, uh, I love to barbecue and cook. In fact, I just got a new gravity smoker, which I'm super excited about. But uh, so I go on these threads, particularly on Reddit, where we share people share recipes and stuff. And it's always funny because someone will say, someone will get a recipe out, and then someone will talk about how they change it, and that recipe is no good. And it's like, well, you didn't try the recipe, right? So you really have to take the medication as prescribed. I would highly recommend using the two pumps the way it's prescribed. Number one, depending on what dose you're on, there can be safety issues with taking one pump instead of two. Um, so there's a reason for all this stuff, and it's really designed for two pumps. Um, so I would highly encourage you to do two pumps. There's really every now and then people have side effects or there's some issue, and we'll tell them, okay, use one pump for a little while, and then we'll go get you back to either two pumps or a lower dose that's you know intended for use. Um, there was something about cancer that you threw in there at the end, right?
SPEAKER_03She said that um people have been telling her the cancer rate is high with the cream.
SPEAKER_00Not from what no, no, they haven't, because it's absolutely not true. So I don't know who those people are, but those people don't know anything about uh hormone cream. Um the risk of cancer with combination HRT. Well, let me back up a bit. What's the goal out of life? I mean, there's lots of goals, but as far as health, you want to live the longest, healthiest life you can. Um, and so eventually we're all gonna die. Uh I hate to say it, but there's like one thing in the world that everybody can agree on, um, and that's that everybody has to die at least once, right? So um, you know, something's gonna get you eventually. The idea is to put that off as long as possible and live as healthy as possible. If you look at women that start hormone replacement therapy that are appropriate candidates for it, and you compare them to women that never use hormone replacement therapy, the women that use HRT live longer, healthier lives than women that don't. So that is your risk of dying from all causes is less with HRT than without it. So that's the big picture. I'm a big picture guy, and to me, that's the most important thing. This is gonna help you live a longer, healthier life, and that's really important. Does that mean it's gonna make you impervious, you know, turn you into a superman? No, you could get hit by a truck tomorrow. Who knows? Okay, hopefully not. Um, there could be an earthquake in the middle of this thing, and you know, but um, but you know, the HRT on average is gonna help you live a longer, healthier life. So that's the important thing to keep in mind. Now, we do know that women that use a combination estrogen progesterone, whether in cream, pill, patch, anything, have a slight increased risk of breast cancer. However, they have a decreased risk of colon cancer, decreased risk of uterine cancer, decreased risk of several other cancers. Uh, so in and most importantly, it decreases your cardiovascular risk, which is your number one risk of dying. So most women die from cardiovascular. That's the most common reason that you're gonna die someday. So if you decrease that risk, it really helps. So there may be a slight increased risk of breast cancer, but it's that is is really overwhelmed by the decreased risk of everything else. So taking, and then here's the other thing there's absolutely no evidence that taking one pump versus two pump is gonna change that risk in any meaningful way. So you might as well use it the way it's gonna work best um and decrease your risk. So going to one pump actually increases your risk of problems and doesn't decrease your risk of problems. So I know that's a big long explanation, but I hope that's helpful.
SPEAKER_03No, that I think that was great, Dr. Green.
SPEAKER_00Um and obviously I talked too much, so sorry. I don't have chat here to like shut me up.
SPEAKER_03I feel like with the questions, though, you know, in-depth is always better, right? I feel like usually. Um, our next question comes from Kathleen. And Kathleen is wondering can you take this product if um if I'm on depression and anxiety medications?
SPEAKER_00Yes. Um, so I can't think of any depression or anxiety medication that would be dangerous to use in addition to the HRT. Um, and in fact, HRT often helps with depression and anxiety. Now, don't just stop your medicines when you start the HRT. But for a lot of patients, after they're on HRT for a while, they can go back to their doctor that's prescribing these medicines and often cut back or stop some of the medicines, which is which is great. So it is um safe to take. I can't, like I said, I can't think of any antidepressant or anxiety medicine that it wouldn't be safe to take with. So yeah, those are are safe. Fortunately, there's very few medicines that aren't safe to use with HRT.
SPEAKER_03Absolutely. And our next question comes from Lisa. Um and Lisa is wondering how do I know if I'm taking the right dose if some of my symptoms are better but others aren't?
SPEAKER_00So my definition of the correct dose is that dose which relieves all your symptoms without causing side effects. Um, so it sounds like you could maybe tweak your dose a little bit. You're getting some relief, but you're not getting flow relief. I'm greedy. I want you to be great, not just good. So um, you know, it depends how long you've been on it. We like to give the medicine, you know, a good three months or at least a good 10, 11 weeks, 12 weeks before we change the dose, because that's how long it takes to really kind of get a good picture of how your body's going to respond. A lot of people get relief from some of the symptoms early on, but some of those other symptoms can take longer. So if you're past that mark, I would message your doctor and talk to him about the symptoms that are better and symptoms that could still use help, and they can help adjust your dose in the right way, depending on which symptoms you are. You know, we tweak it different ways to try to really fine-tune this for you. So when we dose this originally, I have an algorithm I developed over about the first thousand patients. It works really good. Um, and most of the time kind of dials it in, you know, pretty close or just right. It's purposely designed to underdose a little bit. Um, so you know, there's a range, and I'd rather be at the low end than the high end. And the philosophy is that if I'm gonna miss, I'd rather that I relieve some of your symptoms, but not all of your symptoms, rather than cause you a bunch of side effects. So if I overdose you, it's gonna cause problems, and then we've got to kind of get it down. So I'd rather not cause problems. So it's better to sort of ratchet up slowly. So that's how the program is designed. It's designed to get it mostly right, and for most patients, it's it's good from the beginning. But if it's not, then hopefully and most of the time it's just adding on a little bit rather than taking away. But sometimes every now and then somebody's super sensitive to the medicine and we do overdo it a little bit. Um, but that doesn't happen very often.
SPEAKER_03And our next question is from Paula. Um, and Paula says, which part, if any, of the therapy is causing weight gain? She says, and I've been gaining a little bit of a little bit of weight, and can I expect it to go away? She says, I'm about three weeks in and I'm on Zbound, and it's very disheartening, and it's making me want to stop.
SPEAKER_00So three weeks in, it's probably water retention. Um, long term, for most women, these medications make it easier to lose weight. And by the way, there's really emerging data that GLP1 medications such as Z-bound and HRT work synergistically together for weight loss better than either one alone. So you're on a great combination. I wouldn't make any judgments based on the first three weeks of the medicine, um, especially with weight gain. It's probably water retention, which is fairly common and that tends to go away with time, can take a little while. Um, the medications, it's a little frustrating, but it's kind of the way you want it. The side effects kind of happen right away, which is a bummer, and then they tend to go away. The benefits take a while to come on. So, like in your case, you've been on it three weeks, you probably aren't getting that much benefit. Now you've got some weight gain, which is again it's probably temporary in water. It's frustrating because you're all excited, you're oh, I'm gonna feel so much better, and you start the medicine, and like you don't feel better and you're having side effects. That's a drag. But those side effects tend to go away, and then the benefits kick in. It's kind of the way the medications work. So if you hang in there, um, I think you're gonna find that weight to go away. The Z bound also is gonna make the weight fall away. Um, and in the long term, you're gonna find um really good success, would be my prediction. So hang in there, um, it's beliefs coming.
SPEAKER_03And our next question tonight is from Linda. Um and Linda says, Should a woman consider surgery if menopause continues for over several years?
SPEAKER_00We don't do surgery for menopause. Um, so I'm not sure what surgery you're thinking about. Um, but for menopause symptoms, really isn't a surgery that helps. Um, so no, if menopause symptoms are continuing, it means we need to you know start you on HRT if you haven't started yet, or you know, fix your dose so that we can get those symptoms under control. But there really isn't a surgery that's gonna help with that. There's a few exceptions. I I guess let me throw a caveat in there. If your symptom is vaginal prolapse or urinary leaking, there are surgeries that can help with that. And HRT does it's kind of the first line treatment for those things. Um, and for mild to moderate symptoms, it can work quite well. But sometimes it's just so advanced that you do need surgery for those two things. So it depends on which menopause symptom you're um talking about.
SPEAKER_03Absolutely. And our next question is from Sandra. And Sandra's wondering should a woman Women start HRT even before having clear menopause symptoms?
SPEAKER_00Well, the operative word there is clear. So the classic menopause symptoms, the hot flashes and the night sweats and the mood swings, sometimes are a little bit late to the game. And menopause symptoms often start much more subtle. A little bit of brain fog, maybe some sleep disturbances, you're starting to get a little belly you didn't get, things like that that aren't like necessarily totally obvious. And that's a great time to start HRT. And some women never get hot lashes or night sweats or the other classic things, or they develop later. So you don't have to wait until you're like miserable. And so I'm kind of jumping on that word clear, uh, because I think a lot of people miss these subtle signs. We see a lot of patients that have gone to their regular doctor with these more subtle signs, and they're on the younger side, and their doctor doesn't even think about menopause or worse, orders labs and labs are normal. Oh, it can't be that, which again, labs don't help. And that's one of the places where women get marginalized because the labs are normal, even though there are symptoms. Um, and so they put them on other medications, maybe an antidepressant or maybe Adderall or something like that, um, when what they really need is HRT. So a lot of times it's pretty subtle at first, and that's a great time to start the medication.
SPEAKER_03And our next question is from Mariah. Um, and she's wondering, what does DHEA help with? And how do I know if I need it?
SPEAKER_00So DHEA gets broken down um almost immediately, like within 30 minutes of taking it into most into testosterone and estrogen, but it's a testosterone that we're using the DHEA for. Testosterone is a controlled substance in most states, so we can't provide it through our platform. Um, and so DHEA is a nice, it's actually a safer way of doing testosterone anyway, um, because it's not the doses we use, it's not going to overdose you. So it's really used to increase your testosterone a little bit. And at first glance, women are like testosterone, that's the male hormone. Um, and it's true, testosterone is the dominant hormone in men, just like estrogen is a dominant hormone in women, but women do make a little testosterone and it's beneficial. And we know that if you look at women age 20 and you compare to women to age 50, testosterone levels on average are 50% of what they were at age 50 to age 20. And that can be important. And so things that DHEA can benefit would be energy, um, libido, and weight loss. Those are kind of the three big ones that DHA helps with. So if you're having any of those symptoms, DHA may be a nice addition for you.
SPEAKER_03And our next question comes from Bita, and she's wondering, she says, Hi, I just started HRT seven days ago. Why do I feel so emotional for the last two days?
SPEAKER_00So this is kind of what I was talking about earlier with the side effect thing. What happens is it takes about three, maybe four weeks to really get a steady blood level. Um, and so at first, the blood levels of the hormones are climbing until they get to that steady state, and then they level off and they get steady. The body does not like changing hormones. Um, and so in those first few weeks, you've got this sort of rapid increase of estrogen. The body doesn't like that and it responds negatively. And that's where side effects can come in. And those can be a lot of things. It can be emotional, um, it can be um, you know, the water retention, as we talked about earlier. Um, some women actually get an increase in hot flashes and nice spots in the first few weeks because of that sudden rise in estrogen. As those levels steady off and we get to that level we want, we get a nice what we call a steady state where they stay about the same, those side effects tend to disappear. Um, and that's when the benefits come in. So it's not surprising that you have some side effects in the first week or two. Um, but if you can hang in there, they should go away.
SPEAKER_03And our next question is um, she says, My primary doctor refuses to put me on HRT medications as she believes I will develop cancer. Should I be worried for the long-term effects of using HRT? And I know you answered this one a little bit already, Dr. Green, but it is a common one that we get sometimes.
SPEAKER_00No, and I want to take, I want to answer a different part of this question. And you know, the the sort of underlying question is why is my primary doctor telling me this and you're telling me something completely different? Um, which is a totally reasonable question. And it's frustrating when you're dealing with two different, you know, healthcare professionals um and they're telling you opposite things. Um, so like who do I believe? So let me kind of give a little history to explain um part of the problem. So I'm I'm old, I've been doing this for over 30 years. So when I first got out of residency, we were giving hormones to everybody. Like we were starting 80-year-olds on hormones. We thought they were like vitamins that we thought it should be in the water, like everyone should be on HRT. Um, and you know, at the time, the best available data told us that. What happened was in 2003, four, something like that. Anyway, um, a couple years out of practice, um, this women's health initiative study came out. And it was the biggest study ever done on hormone replacement therapy. Unfortunately, they didn't just release the study, they released little excerpts of it and um, you know, the media outlets. And so you got these crazy headlines where people didn't even have the whole study to look at. It was HRT is doctors are killing patients with HRT and all this stuff. Um, and it scared everybody to death. Uh, I remember the day that hit because the phone was ringing off the hook at the office, and all these women were stopping their HRT, and then they were just miserable. It was a mutter. When the study was finally published, and everybody was able to really dig into it. What it really said was, hey, HRT needs to be used properly. It's a medicine, it's not a vitamin. No, we should not be putting this in the water. We need to be careful about who we prescribe it to. But if we prescribe it appropriately, it's really safe and really beneficial. No, you should not be starting an 80-year-old on HRT. Um, and so we learned that. Um, but by that time the damage was done and everybody was just scared to death, and nobody would use HRT after that. That lasted for a long time, 10, 15 years. And so doctors that were in training, what we call residency, were not being trained on HRT because basically it was like, look, you got a lot to learn, and nobody's ever going to use this stuff, so there's no point teaching you how to use it. And so there's sort of this whole generation of doctors that were trained based on this bad information or not trained at all on HRT. Um, and so there's this big hole in knowledge. Fortunately, the pendulum has swung back, and people have done more studies and they've dug deeper into the studies that are out there and realize that, like I said before, HRT is actually really beneficial when prescribed to the appropriate patient. Decreases your risk of overall death, it helps you live longer and healthier. Um, and the cancer issue is really minimal, like teeny increased risk of breast cancer, and that's pretty much it. Um, it decreases other cancers. So um that's why you're getting this different stories from different people. This is what I do for a living. Um, you know, I live and breathe HRT and menopause and perimenopause. Um, and so um, you know, I read everything out there, um, and I'm, you know, about as knowledgeable as I can be about HRT. Your primary doctor takes care of all kinds of stuff, and HRT is one teeny piece of what they do. Look, don't take my advice about your blood pressure medicine or your seizure medicine or anything else, really. Okay, but when it comes to HRT, that's what I do. Um, so I don't want my plumber doing my electrical work and vice versa. Um, and so you know, there is some specialization in medicine. So I hope that's helpful.
SPEAKER_03And our next question tonight comes from Charla. And Charla says, I'm currently on a protocol, progesterone and uh estrogen cream for a year now, plus 25 milligrams DHEA. She says, at first I felt good, boosted mood, libido. After about six months, my anxiety mood and heart palpitations um are unbearable a week before my cycle. She says, My joints hurt and my workouts don't feel as easy anymore. Do I need testosterone? Should I test for thyroid issues? She says, I just want to feel sexy again. I don't have libido anymore. Sad face. She added.
SPEAKER_00Okay, so um it's pretty common and normal for the dose. Dosage needs to change over time because the body's needs change. As you continue to progress through the menopause transition, you often need a little bit more medicine to get the same benefit. I would absolutely message your doctor, um, and we can probably help you by increasing one or more of your medications to help get those results back that you initially had. It sounds like you had really good success at first, and then it sort of stopped working, which tells me there's a pretty good chance that increasing the dose is going to get you back to where you originally were. As far as thyroid goes, you know, every woman should be getting health maintenance. You should be seeing your regular doctor, you know, once or a minimum every other year. Um, once a year is probably better. Um, and part of that is going to be a health blood panel, your blood count, how's your liver, how's your kidneys, check your thyroid. So if you haven't had your thyroid check in a while, that's worth doing, um, as well as other things and making sure that you know your overall health is great. So you still got to get your oil changed and your brakes checked. Um, so don't stop doing that. You need your mammograms and your papomeres and your blood work and a good physical exam every year. Um, that's super important. Um, so don't neglect that. Um, and it may be that there's some adjustments in other areas of your body that could be contributing, but it sounds to me from your history and your story that an adjustment on a dose may be very helpful for you.
SPEAKER_03And our next question is from Aubrey. Um and I'm loving the beginning of this question because she says, I just want to say that I've been on Winona for more than two years. She says, I feel great. She says it probably took me six months before everything was right, and I felt like myself again. I was keeping track of everything. And she says, Winona has a great list of possible symptoms that I found really interesting. She says, I haven't been to one of these in a really long time. But she says, but I recently hit one year since my last period. Does that mean I'm officially post-menopause now?
SPEAKER_00So we arbitrarily define menopause as one year without a period. I say arbitrarily because it really is. Like you got to pick a number, right? Um, and so um, like if you're over 50, that number is one year. Um, although I've seen people go a year, a year and a half, and all of a sudden they get a period again, it can happen. Um, happen to my wife. Um, so you know, it there isn't like okay, you one year and you absolutely can't have, you know, it doesn't really work that way. We kind of pick a number. Um, and one year is a pretty good number. So, yes, by definition, you are now postmenopausal. Does it change anything about your treatment? Not really. Um, it you know, just because you've got a year, we're not gonna change your dose. Again, we're gonna base that on symptoms. Um, it does mean that it's less likely that you're gonna ever have any more bleeding. Um, so if you still got some, you know, emergency box of tampons, it may be safe now to donate those to a shelter, you know, it's what my wife did. Um, you know, and and you know, it means you're probably pretty much out of the woods. Um, but otherwise, it's not, it's it's sort of just an arbitrary definition. It's a line in the sand we have to draw.
SPEAKER_03And our next question um is what symptoms are enough to justify HRT? She says, I am 47 and still have regular cycles, just shorter. But for the last six to eight months, I have vaginal dryness and I can't possibly eat less, but I still can't lose weight. Um, and she says, no hot flashes or insomnia, though. She says, is it still justified? Um, also, how safe is it to take for over 12 or 15 years?
SPEAKER_00So the first part is a judgment call, and ultimately it's your judgment. So it kind of depends, you know, on how bothersome the symptoms are that you're having. Um, and that's really individual. Some women will have the same symptoms, and for one, it's like, yeah, it's no big deal, and for other, it's driving them crazy. So if these are symptoms that's obnoxious or annoying, it may be worth treating. Stuff costs money, so there's an investment. Um, and you know, there's a hassle factor because you have to use it. Um, and so um, those are some things to consider. You know, you don't want the medicine to be worse than the problem, right? So um, if the symptoms are a little annoying and it's worth it to you, spend a little bit of money and do the treatment and you know, remember to do something every day or every couple days or however, you know, whatever you end up being on, then I think that justifies treatment right there. If it's like, yeah, it's there, but it doesn't really bother me. And gee, dealing with medicines seems annoying, then it may not be time yet. Um, so that's a judgment call that uh no one really can make for you but yourself. Um, and um it's you know, you got to kind of count the costs and make sure the benefits are gonna be worth it. Um, the second part was a risk question. I forgot exactly how it was worded. Sorry.
SPEAKER_03Yeah, the second part was she was wondering how safe is it to take for over 12 or 15 years?
SPEAKER_00Yeah, great question. And the answer is that we used to say use the least amount for the shortest amount of time, and that has kind of gone away. And the new thinking really is that for a lot of people, this is good to be on for long periods of time. And there are a lot of women, and I'll tell you what, a lot of female OBGNs in particular that are planning on being on this forever. I know Kat would tell you right now, you can fry those out of my cold dead hands, because I heard her say that on other QA's. So it's safe to take as long as it's helpful. Um, and there's actually some health benefits to being on it long term, particularly the cardiovascular benefits, decreased risk of osteoporosis, decreased risk of certain cancers. So it's now the new thinking is that it's considered safe to be on it as long as it's beneficial for you. And it goes back to the first part of that question. Well, what is beneficial? And everybody has to make that decision for themselves. Like, you know, how much is it helping you and is it worth the hassle factor and the cost of using it? And again, that's a very individual decision.
SPEAKER_03And our next question is from Jana. Um, and Jana says, Hi, Dr. Green. She says, I had an in-person, she says, I had an in-person gyno ask me to go off the transdermal progesterone and start oral instead. She says, I did the oral over nine months, um, but the oral progesterone had a very strong sedative effect on me that never lessened. She says, Could you speak a little bit about the differences in safety and effectiveness in transdermal, oral, or infaginal, bioidentical progesterone?
SPEAKER_00So um progesterone is a large molecule, um, which means that it doesn't penetrate through the skin as well as estrogen does. So transdermal progesterone is tricky. It needs to be done right or it doesn't work. Um, and so that's the key. There's a couple things. Number one, you have to use the right kind of progesterone. Number two, you the dose has to be adequate. Um, and number three, you need a good compounding pharmacy that's doing it right. Those are the three things you need to be able to use transdermal estrogen safely. So, because of that, both ACOG and the Menopause Society have a warning saying that if you're going to rely on transdermal estrogen for protection of the uterus for endometrial protection, you've got to be really careful. And you know what? I completely agree with them. And if I was the person responsible for writing the physician statement, I'd write the exact same statement because they're right. You really do. I can tell you, Winona, we are exceedingly careful. I can't tell you how like anal we are about this, um, because we don't want to hurt anybody. I mean, our number one rule is safety, safety, safety. Um, and we won't do anything that we don't feel is completely safe for patients. Um, because look, if I relieve your hot flashes and I cause you uterine cancer, I haven't done you any favors. So we are number one, we use the correct progesterone, which is more expensive. We use an adequate dose and we're extremely careful about that. Which um, if you're around for, I think it was the first question or the second question where they asked about using one pump of cream, and I said there's some safety issues there. Um, one pump of cream, depending on the cream, with a 5200 or higher cream, one pump does not give you enough progesterone for transdermal use. Um, and so it's okay for the short term, um, but it's not okay for long-term use. So, you know, those are the kind of things that we consider and we make sure that we have an adequate dose in our creams. Um, and number three, we have our own pharmacies. So we have our own, we have two compounding pharmacies, one in Idaho and in Twin Falls, and one in um California. Um, and so we have control over the quality of the QA. I'll be honest with you, if that wasn't the case and we were just using sort of random compounding pharmacies across the country that I didn't have any control over, I wouldn't feel comfortable prescribing this way. But I know we're doing it right. Um, and we've had we've had over 150,000 patients come seeing Winona and we haven't had any problems with their progesterone. So um thank goodness. Okay, but you know, it's because we're really careful about this. So I understand where your gynecologist is coming from. They don't know that, they don't know me, they don't know how we're doing it, and so they're worried for you. And what their advice isn't completely wrong. And if I had a patient come into my office on some cream and I didn't know where it was coming from, I'd be concerned as well. Um, but I can tell you from the other side, since I'm the one supplying it, that our cream has adequate progesterone to protect your uterus. Um, it works. Uh so um ultimately you've got to make a decision whether you know the comfort of following your gynecologist, who you probably have is probably a great gynecologist and you have a great relationship with is worth the extra sedation. Um, or if um you feel comfortable using the cream, um I'm comfortable prescribing this to my family members. Um, so um, but ultimately, you know, you you've got to decide that. But I can tell you that 100% we are very, very careful to make sure that that cream, the progesterone, that cream works. Um, and like I said, we haven't had any problems, so we know that that it is working for our patients.
SPEAKER_03And our next question tonight comes from Krista. Um, and Krista's wondering is it okay to take HRT with hypothyroidism? She says, I had a thyroidctomine in 2022.
SPEAKER_00Yes, absolutely. It does not replace your thyroid medicine. Okay, so you're gonna need thyroid medicine, super important. So don't stop your thyroid medicine because you're on HRT. But the two in combination work work fine. Now, some people think, well, gee, it's gonna mess up my thyroid levels. Thyroid is a really tricky drug. Um, it's it's just super finicky, and almost anything can affect your thyroid levels. I mean, changing your diet, like going to a you know, a different all of a sudden you decide to do a keto diet or you become a vegetarian, or that can change your thyroid levels. Almost anything can. And that's why your doctor checks your thyroid levels periodically, because you know, it it changes. So, like everything else, HRT can affect thyroid levels either up or down, just because thyroid is such a finicky drug, um, but they're absolutely safe to take together. It might be wise to have your thyroid level checked, you know, six weeks to three months after starting HRT. And that's really true with starting any new medicine and thyroid. Um, that's what I usually recommend. But you can talk to your doctor that's prescribing it for you and they can give you better advice. As I said earlier, I'm the wrong person to ask um about how to manage your thyroid. Um I'm you know, I mean, I know some about it, but that's not my area of specialty. So whoever's prescribing that is going to know more about it than me. Um but that's something to think about. But they are absolutely safe to take together.
SPEAKER_03And our next question comes from Stephanie. And Stephanie is wondering: do I need DHEA in addition to my 50-50 cream? She says, I do have an IUD.
SPEAKER_00So, yeah, the IUD has nothing to do with the DHEA. So DHEA treats, there's a lot of overlap, but in general, DHA treats some different cluster of symptoms than the cream does. And so they tend to work really well together to get that whole spectrum of symptoms under control. So if your doctor thought that DHEA, excuse me, was useful for you, that's what I get for drinking soda instead of water, um, then um I guess I'll get in, I'll get into my water next. I'll be a good boy. Um, if um if you're On a doctor thought DHA was useful for you, it probably is helpful. Um, and and I would recommend continuing it. The IUD, if you have a progesterone containing IUD, then the real question is progesterone. So I'm gonna go down a little rabbit trail here because you brought up the IUD, and I think it's it's kind of important. Um, so um progesterone containing IUDs are generally adequate to protect the lining of the uterus, which is the main reason that we added progesterone to your cream or or whatever treatment you're getting. So in theory, you could use estrogen without progesterone if you have a progesterone-containing IUD, and that would be safe. There is a however. So the problem from my point of view is that I don't really have control over your IUD or really know what's going on with that. So that's all true for the following issues. Number one, your IUD isn't expiring or close to expiring, and there's some controversy about this. So the Morena was originally um a five-year IUD. That's the one most common one people have. They were doing, they did studies to show that it gives contraceptive benefit to seven years, and so they were able to extend the life of that to seven years. We know for five years it provides protection for the lining of the uterus. We don't really know for sure if pushing it out to seven years does. So I become uncomfortable after five years relying on the IUD for protection just because I don't know that there's strong data for that. Um, and again, as I was talking about earlier, that's something that we really worry about is we want to make sure that we don't cause harm and we want to make sure that line here in the uterus is protected, and that's why the progesterone is so key. So um once you get past five years of the IUD, I'm not real comfortable with doing it without progesterone. So that's number one. Number two, if your IUD comes out, either you decide to have it removed or it falls out or it somehow gets displaced, it's no longer giving you protection. Sometimes I worry that somebody is going to have their IUD removed and forget to tell us, and now we're giving them estrogen and they're not getting that progesterone anymore because we assume they still have their IUD. And that kind of worries me. Um, or it could come out and you don't even know it. So it's not uncommon, you know, for an IUD to get tangled in a tampon and come out that way or just get displaced somehow. Um, that happens. Um, and if that were to happen and you don't know about it, we don't know about it, now we're causing you harm by giving you the estrogen without it. So I feel more comfortable personally prescribing both estrogen and progesterone, even in the presence of an IUD. Even though if I was taking my boards and I was answering a test question, the answer to that question would be with the progesterone IUD, progesterone is not necessary for HRT. So there's cyrical right answer on the test, and then there's this sort of nuances. Um, and again, because safety is my number one important thing, um, the safest thing is to add progesterone even in the presence of progesterone IUD. I know that's a big rabbit trail and a lot, not really what you asked, but uh throw it out there anyway because I think it's important.
SPEAKER_03I was gonna say a rabbit trail, Dr. Green? What? Never heard of before. Um, our next question tonight comes from Dusty. Um and Dusty says, Hi, I had a total hysterectomy when I was 42 and am now 54. She says, I did not take HRT, but I am now really seeing hair loss on my head and hair growth on my chin, et cetera, along with other symptoms, loss of a libido, sleeplessness. Um, she says, Is there anything I can safely take at this point to help?
SPEAKER_00So I'm gonna assume that you mean that you had your uterus and ovaries removed. So just we kind of have to do this every time. But um it's it's unfortunate. But when lay people talk about total hysterectomy, um, it's different than when doctors talk about total hysterectomy. So hysterectomy is removal of the uterus, total hysterectomy or complete hysterectomy is removal of the uterus and cervix. But most lay people, when they say total hysterectomy, they mean uterus and ovaries. So I'm gonna answer this question, assuming that's what you mean, because that's usually what people mean, even though technically it's like if I was talking to another doctor, it's not what I would say. So forgive me that. But um, so if you've had both your ovaries out and it's been more than 10 years and you haven't been on HRT, it's really not very safe to start HRT at this point, unfortunately, which I hate to tell you that because it's a bummer. There are other medications that can help. So there are some um medications that help with hair growth, uh, monoxidil and phenastride in particular. Um, so that's something you can talk to your doctor about or go to a dermatologist. So for the hair issues, um, that's something that can be very helpful. For hair growth on your face, um, there's um other things. Um, laser um uh laser hair ablation is really the best thing for that. Um, there's also lactologists of the things that can be used. So there are other treatments for that. Um, if you're having other symptoms of menopause, if you're having all of a sudden you start developing knife, sweats, and hot flashes, um there's a medicine called uh BIOSA that can be helpful as well. Unfortunately, at Winona, we don't have any of those things to offer you, so I apologize. Um, but that's something that you could go to your regular um doctor um or your gynecologist and talk to them about because there are safe ways to help with some of your symptoms, um, but it's kind of you got to go after each symptom with different medicine rather than kind of you know one ring to rule them all, you know, just one medicine. So unfortunately, you're kind of farther out than you really should safely start HRT. And that's kind of back to my original monologue when I was saying that one of the things we learned from that study is that we have to be careful who we prescribe HRT to and make sure that we do it safely. And that was one of the things that we learned is that if you've been 10 years post-menopausal, um, whether that's through natural menopause or surgical menopause, or you're 60 or over, is you really shouldn't be starting HRT for the first time.
SPEAKER_03And it looks like our next question tonight comes from Lisa. Um, and Lisa says, I started Winona in March. I was still having heavy periods. In the last two months, my periods were barely spotting. She says, Yay. Um she says, but now how do I know when I'm actually in menopause?
SPEAKER_00So the funny thing is, HRT doesn't really usually do much for periods. It sometimes makes them a little lighter, but HRT is not gonna make your periods go away prematurely, even though we're using it continuously. Um, it shouldn't make your periods irregular. Um and um, so you're gonna stop having periods one day, and when you hit one year, you can say I'm in menopause. Now, as I kind of alluded to before, honestly, it's not that important because it doesn't really treat, doesn't affect the way we manage your symptoms. So whether you're pre-menopause, postmenopause, we treat you based on your symptoms on your periods. Um, so you know people like to know, and so you are still gonna your periods eventually gonna stop, even with or without the HRT. It's not really gonna change that. So you'll be able to mark that on, you know, this is the day I turn post-menopausal. Um, but it really doesn't affect your treatment.
SPEAKER_03And our next question is from Rose. Um, and Rose says, is it worth it if I can't tolerate estrogen and just take DGA and progesterone?
SPEAKER_00So maybe. Um progesterone by itself can help a little bit, it doesn't help that much. And um, it's honestly it's the progesterone. This is a surprise. Most people have this backwards. It's the progesterone, not the estrogen that gives you that small increased cancer risk. So that everybody's got this wrong. Estrogen doesn't cause breast cancer, it's the progesterone. Um, and that's been studied really well. Honestly, the first study that came out that said that, I didn't believe it. Um, I'm like, ah, there's gotta be something wrong with that study. And then there was a second and a third study. I'm like, okay, it must be true. Um, and so that's what we understand now. So I'm not a big fan of progesterone by itself, although if it's helping your symptoms, it may be worth it. But when you and the DHA kind of treats a different cluster, so that may be beneficial for you as well. So that's probably worth using. When you say you can't tolerate estrogen, um, if you have a health condition where estrogen is not safe, then you probably shouldn't be taking DHA or progesterone either. If it's just that it gives you side effects, it may be that you're on too high a dose or you're not, you we need to change the the way you're getting it, whether it's a cream or a patch or a pill. And sometimes just manipulating the dose or changing the delivery system can help it so that you can tolerate it better. So it's something to think about.
SPEAKER_03Absolutely. And it looks like our next question is another one from Rose as well. It's a little bit of a um two in a row. Um she's wondering, she says, have you seen or heard of estrogen exasperating asthma? She says, I tried the estrogen patch along with the progesterone pill from a different OB, and I believe it made my asthma flare pretty bad.
SPEAKER_00That's interesting. I have not really seen that. Um, you know, weird things happen. Um, and if that was your experience, it's quite possible that was what happened, or it may have been some coincidence. Um, but it's not a typical estrogen side effect. That would be a pretty rare side effect. Um, excuse me. And it may be the dose was too high, or maybe changing delivery systems might be beneficial for you.
SPEAKER_03Absolutely. And it looks like we have about time for one more question. Um, and there's an interesting one I think would be interesting to hear about. We have a question from Nikki. Um and Nikki says, I've seen lots of the news on nicotine helping menopause lately. Can you share more on these new findings?
SPEAKER_00Um, yeah, it's not worth it. So I mean, you know, cocaine helps you stay up and study all night, but I would not recommend it, you know. Um, I mean, uh nicotine has a lot of negative issues um for the human body. And talk about side effects. And there's no way it's gonna help more than HRT. HRT is extremely safe, it's very well studied. Uh we know that it increases longevity and quality of life. Um, so you know, it seems to me this is uh smokers justifying their habit. Um, so no, don't take up cigarette smoking to help your menopause symptoms. Um gosh, I'm trying to remember what it is. There's a cancer, it's like the only cancer that I can't remember which one it is. It might be well, it doesn't matter. But there's a cancer where uh exercise, that that's actually a common one, decreases the risk, but drinking alcohol decreases risk. And so the joke is well, you should just run from bar to bar and you won't get this kind of cancer, right? So um that's actually not the right answer. Um, and so even if nicotine, you know, does maybe help some menopause symptoms, it's not gonna help as much as HRT. And now you got all the risks of nicotine. So, you know, it's like, well, yeah, maybe that's true, but like it's not gonna be worth it.
SPEAKER_03Well, thank you so much for those answers, Dr. Green. And I see that there's a number, and this is how it is quite often on our QA's of questions that we didn't quite get to, but don't worry, there's a few things I want to point you towards. First of all, is your Winona doctor? Um, you can message them in your patient portal. Any of the questions that were in here, these are great questions to send to them. They will answer them just like Dr. Green did. Um, they really want to help, and that's a great place to kind of ask those questions. Um, other resources are we have live Q ⁇ A's like this pretty often. Um, and we also have doctor dialogues. Those happen two to three times a month. So we really hope that you'll join us for the next one and hopefully we can get to your question then. Um again, also I mentioned the menopause uh hour earlier on Spotify. Um, a lot of them have answers to your questions just like this, and you can kind of dive in and take charge of your, you know, your your menopause journey as well by listening to that. And then of course, um go ahead and explore any of our uh medical journals on bywanona.com. We have lots of articles in there just on different symptoms, on what that those can mean. Um, and it might be that your answer is in there somewhere. Um so thank you all though so much for taking the time to be here tonight. I think it says a lot about you all that you're taking the time to be here and that you're diving into your journey, your medical journey, your your menopause journey. Um, it's so great always to see so many people here. Um, and thank you, Dr. Green, so much for giving your time and your answers. I know that everyone always loves that, and I think it's super wonderful just for our audience and um all the Winona patients as well to kind of get a little bit of your time and get to kind of ask their questions and everything. So um thank you everyone for being here. We hope that we'll catch you at the next live QA. Um, and until then, I hope that everyone has a great rest of their night or afternoon, depending on where you might be um in the US. But we'll catch you all next time.
SPEAKER_00Great. Thanks, everybody. For those who didn't get your questions answered, sorry for my rabbit trail. I'll see you next time.
SPEAKER_02Thank you for joining the menopause hour, brought to you by Winona. Menopause care made easy. To learn more, find Winona at bywinona.com and on Instagram at BioWinona. Want to have your questions answered next? Register for our upcoming live QA. Linked in the show notes.