The Menopause Hour with Winona

Episode #11 Beyond the Symptoms: The Power of Bioidentical Hormones

• Winona • Season 1 • Episode 11

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0:00 | 58:05

In this episode, Dr. Cat Brown and Dr. Green break down the evolving journey of menopause and the power of personalized, science-backed hormone care. The conversation addresses safety concerns, common myths, and the stigma surrounding menopause, offering practical advice on advocating for yourself and working with your provider. If you're curious about the difference between synthetic and bioidentical hormones or ready to take a proactive approach to your health and well-being, this episode is for you.

 

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SPEAKER_00

Welcome to the Menopause Hour, your go-to source for empowering answers to your burning menopause questions, the ones you won't get from your OBGYN. Brought to you by Winona, Menopause Care Made Easy, and hosted by our experts, CMO Dr. Michael Green and Medical Director, Dr. Kat Brown.

SPEAKER_05

Hello, everyone, and welcome to another one of our Winona live QA's with our Winona doctors. As you can see, we have a couple of our amazing Winona doctors here with us today. So I'm really excited for everyone kind of to be able to get to know them. If they don't already know them, they're a great, great part of our team here at Winona and excited to get into some of the questions that you might have. If you haven't been here before, um, first of all, we're so glad that you've come to one of our live QAs. You can go ahead and start putting your questions down in the chat. Um, and then we'll jump into those in just a minute. Um it usually fills up pretty quick, so I would recommend going ahead and running there now, putting anything that might have been on your head or on your brain over like the last little bit in there. Um, so we can jump into that. Um, and then just wanted to also point your attention that if you didn't know, um Winona also has recently started a podcast, which is super exciting. Um it's called The Menopause Hour, and you can get it on Spotify. Um, and it features also the two doctors here with us, which is super exciting. So um if you've ever wanted you want to listen to more questions, kind of that you have uh be dived into, um that's a great place also on your way to work, on your workouts, um, a great place to tune in there as well. But if you're here with us today, that's super exciting because it means you're live, you're here. Um, I feel like questions kind of in the moment are always really great ones as well, because we can do follow-up, we can talk a little about the nuances, everything that goes into that. Um, but I will pass it off as well to the doctors to go ahead and introduce themselves. Um, and I think that they have a little bit of stuff to chat about, and then we'll get into the questions. Um, so Dr. Green, I'll I'll pass it off to you first.

SPEAKER_03

So hi, my name is Mike Green. Uh I'm the chief medical officer of Winona. Um I started my career in family practice thinking that's what I wanted to do, and then fell in love with Women Tel. So I did a whole second residency um uh to become OBGYN, um, which I uh I did full-scale OBGN for about 17 years, then worked as OE hospice, and then um my little side gig of this thing called Monona turned into uh my life. Um so we're so excited to be here. But it's been just a thrill to be able to take care of you, and you know, we consider education to be really, really important. Um I mean, I think it it's so important for you to understand what's going on with your body, what's going on with the medications that you're using, why we're choosing those, you know, all that stuff. And the better informed you are, um the better choices you can make um for your own healthcare journey, which is super important. So that's what this is all about. Try to help um answer your questions and you know, make sure that you understand everything that's going on. Then I will pass it off to Dr. Kat.

SPEAKER_04

Thank you. Thank you. Uh and I'm Dr. Kat Brown, I'm the medical director at Winona. Um, I was the first doctor that Dr. Green hired after himself. But um I'm a board-certified OBGYN as well. Um, I'm located in the Greater Philadelphia area. Um, and this is just something that I love to do is to take care of women and to really help them throughout their entire lifespan. But now that um I myself am paramenopausal and going through this and experiencing everything that my patients are experiencing, I can also really, you know, empathize and sympathize with what you're going through because I'm going through it as well. Um, I'm also on HRT and it's changed my life for the better. Um, so I think that it's something I definitely want to make sure that more women have access to and have it readily available. Um, and also we're glad you came out tonight because I firmly believe that knowledge is power. So, you know, as much as you can learn about yourself, about your body, about how it works best, um, you know, empower yourself because we know that when women learn more about health care, they actually take better care of not only of themselves, but also everyone else in their family. It's like this positive ripple effect in families and across the country when women really take the reins. Um, so that's something that we really feel strongly about. And and Winona, we really want to educate you as well as provide your medical care. So um that's something that we feel is is really important. Um, and something else, so usually each month we have a topic, you know, to kind of chat about as you're starting to get your questions in the chat. Um, and I took it upon myself, you know, one day to just go through and see, you know, all these special themes that each month have and if there's any health-related ones. And April actually has um a special, you know, designation as being move more month, which I thought was interesting. I hadn't heard that. You know, we have like cardiovascular disease month and we have breast cancer awareness month, but April being move more a month, you know, I think is really important. Um, you know, as the weather is starting to clear in many areas and we're starting to get outside more, it's so important, especially in perimenopause and menopause, and just as aging as women, that we really take the time to move our body and to find a form of movement and exercise that really brings us joy and like lifts us up because that really helps with maintaining our vitality and our health as we age and as we you know go through this transition, it really is really helpful. So I thought that would be interesting to talk about. And so if you don't, if you're someone who doesn't really have a regimen, an exercise regimen, um it's time to find something that you really truly enjoy. And not everyone's definition of exercise has to be the same. Dr. Green loves going to the gym. He and his wife go to the gym. I'm more of a like, let me get outside, go hiking, be in my garden. I'll do like a million squats in the garden as I'm doing work in the garden. But I'm not really a big fan of like being in the gym 24-7. Um, but my husband's a gym rat. So there's all kinds of different strokes for different folks, you know, and and it, but it's the most important thing is that you find something that's meaningful to you and that makes your body feel good and keep doing it as much as possible. Because the more you move, the stronger you'll be, the healthier, healthier you'll stay over time as well. So I don't know if you want to add to that, Mike.

SPEAKER_03

I would just say, you know, I think people when people ask me what's the best kind of exercise I should do, and the answer is the best kind of exercise you should do is the kind of exercise you will do. Um you need to find something that you like. Um, so and like like you said, it's different for everybody. Um, and you might have to try a few things until you like, yeah, I really like this. It's kind of nice. I remember uh, you know, I was always my wife was doing like yoga and stuff like that. She's always been in great shape. I always wanted her to be my gym partner, and she finally tried it. She goes, Oh, I really like this, I'm surprised. And we've been going to the gym together ever since. So um, you know, try different things out, find something that you like that you'll stick with. Um, you know, you don't have to do it perfectly, but if you do it regularly, that's the most important thing.

SPEAKER_04

Exactly. Exactly. And some of you might notice I'm in Scrubs, so I'm actually at the hospital. So um just to give you a disclaimer, if if I get a phone call and I need to go run and do something emergently, I will come back if I can, but you'll be in the capable hands of Maddie and Dr. Green if I do have to run. Um, but just to let you know, that might be a possibility.

SPEAKER_05

I love it. I feel like that's a that's a fun aspect. It's you know, seeing our doctors in action. That's so great. There we go. There you go. Well, that that's I love hearing a little bit kind of about what, you know, the the thing of this month is and kind of how we can like lean into that as well. Um, and I know we have a few questions to kind of jump into as well. Um, and one of our first ones is from Jill Johnson. And Jill is wondering is everyone's estrogen dose different? And how do you determine that?

unknown

Mm-hmm.

SPEAKER_04

So typically, you know, we take several different things into account, but we have a nice algorithm that Dr. Green came up with to kind of help us to know where to start somebody. And it is individualized, you know, to your age and kind of your symptom profile. Um, and you know, we we have our best guess as to where to start a patient based on those things, but then sometimes we might need to make adjustments and and based on how your symptoms respond, we might need to adjust fire and change the dosage here or there. But not everyone has started on the same dose, no.

SPEAKER_03

I'll tell a funny story about that because um it's true, although there's only so many doses. And I've had people, you know, they go on the Facebook group and like, well, these people are on the same dose as me. You said it was individualized. Well, it is, but you know, there's only so many choices, and there's a lot of women out there. And then I had someone get all mad at me because somebody was on something. I gave some, you gave someone on the Facebook group something you didn't give me. I'm like, well, yeah, because it's individualized. So it's funny how people get funny about that. But um, it it is individualized, but then again, you know, there's only so many choices. So um, if you ask around, there will be people that are on a similar or the same thing as you.

SPEAKER_05

Absolutely. And we have a question from Lillian Hearn. Um, and Lillian's wondering why is my exact anxiety and depression worse right before my period.

SPEAKER_04

Well, the simple answer to that is that there's a lot of hormonal changes that are occurring right before your period. And so there's a lot of shifts, and and the way that that happens so quickly, and the way that the female hormones are erratic throughout the month, but specifically that week before, is really why many women get those symptoms leading up to their period. And sometimes it can be extreme. You know, we we talk about PMS as one aspect of things before periods, but sometimes there can be even severe changes where we call it PMDD, which is a premenstrual dysphoric disorder, which is actually like a clinical diagnosis. I mean, it can be pretty severe for some patients, but you're not alone. It's very, very common. Um, and so a lot of women experience this.

SPEAKER_03

It's interesting that the same mechanism that causes that is part of why women experience so many symptoms during the menopause transition. Um, because the ovaries, as they become less and less efficient, are still trying to get hormone out, but they kind of get it out in spurts. So it really makes the levels, you know, not so stable and kind of up and down. And that's one of the ways HRT helps, is it helps stabilize and give you a nice steady amount of hormone throughout the month, which is why it's best to use HRT every day rather than cyclically. Um, but the body doesn't like change, especially hormones jumping all around. Um, and so that's the mechanism that's causing those symptoms before your period, but it's the same mechanism, at least in for some of the symptoms of the menopause transition that cause that.

SPEAKER_05

And we have a question from Amy next. Um and Amy says, Hello from Virginia. She says, I have thin, fine hair. Do I need to worry about hair loss while on the cream and DHEA?

SPEAKER_04

Well, typically with aging and going through perimenopause and menopause thinning of the hair is something we see pretty commonly. If you're already starting out with fine hair, um, you know, there's a possibility as your hormones are adjusting that you might notice some change in the sequence of when you're shedding hair and when it's regrowing. And that can be a natural phenomenon. But for most women, when they start adding estrogen into the equation, it usually helps with the appearance of skin and hair and nails over time. So most women see a positive, you know, effect on their hair from the medication, especially the estrogen.

SPEAKER_03

That's one of those that takes a long time, though, because the hair cycles are so long. It's a three to six month cycle. So, you know, by the time it kind of starts cycling around and improving, it can be a while. So some of the some of the symptoms get better pretty quickly, but hair changes tend to take a while. So you got to hang in there to get that benefit.

unknown

Yeah.

SPEAKER_05

And we have a question next from Aisha, and she's wondering what options are available for breast cancer survivors outside of testosterone?

SPEAKER_04

Well, so really, if you're a breast cancer survivor and you need an enhanced level of surveillance, it's really best for you not to get HRT via telemedicine like a service like ours. Um, really, because of your history and because of your increased risk of recurrence, um, and you know, especially if you had a breast cancer that was receptive to hormones, it really is best for you to be served and cared for by an in-person provider who can more appropriately monitor and examine you and just keep that surveillance. So there are options out there, but most doctors are going to want to stay away from giving you hormones if you've had a breast cancer history. So they might they might want to explore other options.

SPEAKER_05

And we have a question next from Angela, um, also about testosterone, but she's wondering: is testosterone recommended for every woman? How do I know if I should start it?

SPEAKER_04

Well, so the really quick answer is that, you know, in the United States, testosterone is really not approved or recommended for women. However, you know, we in the specialty, you know, taking care of women know that, you know, women have testosterone just as much as men and and can respond positively to it. However, testosterone can be widely abused and misused, and so it's considered like a controlled substance. So we don't specifically prescribe testosterone on our platform. We use another medication that's a precursor hormone supplement to help gently raise your testosterone levels, and that's something called DHEA. And so that's something that we offer to patients. It's an optional addition to your HRT, but that's how we can help you gently raise your testosterone levels.

SPEAKER_03

Testosterone is a really tricky medication for women. Um, it has what's called a narrow therapeutic window, which means that the difference between the amount that makes you that that treats your symptoms and the amount that gives you side effects is really thin ice. So it's it's hard to hit. Um, and so for for men, because their testosterone is so much greater, there's a lot bigger leeway, and so it's a lot harder to sort of hurt somebody. But it's really easy to overshoot testosterone and cause really bad side effects. Um, and some of them can even be permanent. So um that's why, besides the fact that it's a controlled substance, it's something that really needs to be monitored very closely. That's the nice thing about DHEA in the doses that we prescribe, it's enough to get you into a normal female range, but not enough to push you beyond that. So it's just a much safer way of doing it, and you know, it's gentle, but it does work, then it will raise your levels. It's just not, it's not going to turn you into a professional bodybuilder. Um, so if that's what you're after, there's other ways to do that, but it's that's not something that we do here. Um, but it won't also do that by mistake, which is um what I think most people are worried about.

SPEAKER_05

And we have a question next from Nicole. Uh and Nicole's wondering how long does it take for the HRT to work?

SPEAKER_04

So sometimes for some women, they can get relief from some of the vasomotor symptoms like hot flashes and night sweats the soonest. But some of the other benefits, like you know, Dr. Green mentioned earlier about the changes in hair, those things can happen later on. So the other thing too is that for hormonally related waking, seeing a benefit of some weight loss also is one of the later benefits of starting HRT. Um, most often it's the hot flashes and night sweats that respond early, then also also sleep will get improved as well as you get the dosage um, you know, well established in your body. And then the brain fog usually typically starts to improve. But every woman's pattern and how their symptoms respond is kind of on a different cycle, and every woman may respond differently. But we do know that some of those later benefits, you know, for most women, we have to tell them that to stick in there because our human nature is that we want instant gratification and we want to feel better like yesterday. So, you know, I often get messages from patients saying, Well, I started the medication last week. Why am I not feeling that all my symptoms are improved? And you really have to give it time. It takes time to establish the medication in your system for your body to welcome the medication and get the dose, you know, steady in your system before you start to see the benefits and to see that pendulum swing the other way.

SPEAKER_05

And our next question is um my mother had breast cancer. Should I be concerned about using HRT? She says my breast exams have always been fine.

SPEAKER_04

So if you have a family history of breast cancer, that doesn't mean that you're not a good candidate for HRT. Now, the caveat with that though is that if you had a first-degree relative that you know had breast cancer and tested positive for a genetic syndrome that can cause the breast cancer, that makes you a bit higher risk for breast cancer than the average population. So that would be the only reason that you know we might not want to prescribe for you if you have like one of the BRCA genes. But just a family history doesn't preclude you or disqualify you from getting treatment.

SPEAKER_05

And we have a question next from Laura. And Laura says, Have you heard of TMJ or jaw issues related to menopause?

SPEAKER_04

Yeah, I mean the joints everywhere in the body can be affected by the loss of estrogen. You know, it's amazing when you think about how many different receptors throughout the body, you know, are really need estrogen to function optimally. And when you remove that estrogen and those levels are declining, the joints can respond. And sometimes for some women that might, you know, equate to you know arthritis or joint pain, stiffness. But sometimes it can happen, you know, it can be related to the joints. And the TMJ is for other patients listening, might be, you know, that don't aren't familiar with that term, it's temporomandibular joint. It's this joint here, you know, where your mandible joins, and it's like our chewing joint, basically. So you can get clicking and you know, stiffness and and pain, which can then lead to like tension going up and causing headaches. Um, I have had patients complain of that, and it it certainly can be a possibility, but every woman's experience of symptoms is unique, you know, and every woman will have a different constellation of symptoms. That's what makes it so difficult to recognize and to treat. And um, you know, and I think for women themselves to even recognize what's going on because these symptoms start to creep in and you wonder, like, what's happening? Am I falling apart? Like, what's going on?

SPEAKER_03

The other thing is that TMJ can be um exacerbated by stress and anxiety. Um, especially if you're, you know, a a uh tooth grinder, you know, in your sleep, you know, is a way that you express your stress and anxiety and that kind of thing. And so um HRT can help reduce anxiety and some stress levels that you start feeling better, and that can also kind of secondarily help your TMJ as well. So there are um you know direct and indirect ways that that HRT may be able to help with that.

SPEAKER_05

Absolutely. And we have the question next from Jen. And Jen is wondering what kind of hormone is in the pills? Is it plant-based, bioidentical, or what is it?

SPEAKER_04

Yeah, so if you're talking about the pill form, uh, you know, we have estrogen and progesterone pills. You know, typically um our HRT and those hormones are plant-derived, um, and they are bioidentical, meaning that they are identical chemically in their structure to the hormones, the same hormones that your body would be creating on its own. Um, and the same thing, you know, with the DHEA as well. DHEA is a hormone that our body you know produces on its own.

SPEAKER_05

Um, we have a question from Odetta next. She says, I'm 55 years old, uh 55 years old, and would like to know the difference between HRT and BHRT. I'm considering taking one of them, and I'm wondering if I'm too old to start now.

SPEAKER_03

So it's kind of nomenclature. Um, so I guess all BHRT is HRT, but not all HRT is BHRT. So the B is the bioidentical. So there are forms of HRT that are synthetic. Um the drug companies like to call them biosimilar, like they're almost bioidentical, not quite. Um, but they're um but BHRT generally means that it's uh bioidentical HRT. Um, and honestly, I'm lazy, so I just write HRT. Um I guess I should distinguish maybe. Um, but what we use is always BHRT. It's always that's it's what we use at WinOne as bioidentic, but that's the difference between that. 55 is not too late to start necessarily. The the general rule of thumb is that as long as you start before 60, um, you get um all the benefits and including the long-term health benefits. The exception would be if you're more than 10 years since completing menopause. So um, you know, that's that's a possibility, although if you're having symptoms, it's probably unlikely unless you had uh surgical menopause a long time ago. But um 55 is is actually not too late, um, and you still have a lot of uh you know, ability to get in a lot of time to get benefit out of this.

SPEAKER_05

And we have a question next from Heidi. And Heidi is wondering do I need to monitor things like blood pressure, cholesterol, or hormone levels regularly?

SPEAKER_04

Well, you should be getting monitored for your blood pressure and your cholesterol levels just as a part of your preventive health care, you know, getting a yearly physical and having a primary care physician. But hormone levels are not necessary to follow. However, the only hormone you should get checked as a woman is your thyroid periodically. When you get Your annual labs to check your kidney function and your blood count. That should be something they screen for periodically as well. But your female hormone levels like estrogen and FSH and progesterone, they're useless to us for really treating you. It doesn't help us to take better care of you. You know, this is something that you know, menopause and hormone therapy is best treated based on symptoms. Um, and any menopause specialist who knows how to take care of patients and cares for them well will practice that way. Um, even our national governing bodies that give us guidelines to help treat patients, like the American College of OBGYN and the National Menopause Society, they recommend against the routine lab screening. However, someone out there will try to take your money and get you to do lab tests, or they might let's get you to do a salivary test or urine hormone testing. It really is not useful to us to take good care of you, so you don't need to do that. Save your money.

SPEAKER_03

Yeah, so yeah, I always say, you know, um, just because we're taking care of your hormones doesn't mean that you don't need to take care of everything else. So you still need to you still need to go see your doctor every year. It's really important. Um my grandfather when I learned to drive you if you don't take care of your car, your car won't take care of you. Used to hammer that you gotta get your oil changed and all that. And that's the same thing with your body. If you don't take care of your body, your body won't take care of you. So you still gotta get your you know, your routine health maintenance. That's super important. Um can't emphasize that enough. Um, but hormone tests, not not useful. They're useful at emptying your wallet, but apart from that, they're not very helpful.

SPEAKER_05

Um, our next question is what are the bioidentical hormones in the products derived from and what makes them bioidentical?

SPEAKER_04

Well, we answered that a little bit earlier, you know, when we explained that bioidentical just means that it's identical structurally to the hormones that your body creates on its own. Um, you know, initially we used to say that most of our hormones were derived from yams, but then there was like a worldwide yam shortage. Um, so we were still using a plant-based source to help drive the hormones. So um, you know, that's something that you know we stand by, but not always yams.

SPEAKER_02

Yeah, that's kind of interesting. We first started four years ago. Actually, that's what we should have talked about. April, this is our fourth year, four-year anniversary.

SPEAKER_04

Oh, yeah. Well, you can talk about it now. Yeah.

SPEAKER_02

I just realized that that's what we should have opened with. Anyway, happy birthday to us, right? Um, but when we first started out, um like it was all yam-based.

SPEAKER_03

There was this, there's a special kind of it sounds crazy, like, come on, there's yams all over the grocery store, but it's a special kind of yam that they get these from. And then as bioidentical hormones became you know more popular and more sought after, I they couldn't keep up. And so um there are other you know, root vegetables that they um that they get these from, you know, similar. But so we we don't want to mislead people, so we can't promise that they're actually coming from yams, maybe from a different vegetable, but they're all coming from um plant sources. But yeah, four years. It's kind of cool. I still have a few patients from the old days. It's kind of neat when they message in. It's kind of exciting.

SPEAKER_01

Yeah.

SPEAKER_05

Um, our next question is from Nicole. And Nicole is asking, How does the cream work and why do they say your anxiety may get worse when beginning?

SPEAKER_04

Well, how does the cream work? Is basically, you know, the hormones are embedded in the cream. And so when you're applying the cream on your skin and rubbing it in, this the hormones are actually absorbed directly through the skin into your bloodstream. And then they're circulated in your bloodstream to the tissues that are intended to receive them. So that's how the medicine gets in your body. Whereas when you take a pill, you have to swallow the pill, it gets broken down by your stomach, gets you know filtered by the liver, and then gets into the bloodstream to get to the other tissues. And so that's basically how the cream works, is it just gets absorbed through the skin. Now, sometimes, you know, whenever you have sudden changes in your hormone levels, like we were talking about in the beginning of the call about PMS and changes before the period, anytime you have a big swing in hormones, your mood can respond. Um, you know, the body doesn't like the sharp swings. And so when you first start treatment, sometimes your symptoms might feel a little bit worse, your mood might be a little bit off, you might be a little bit, you know, short-tempered or whatever. Everyone can respond a little bit differently, but that's mainly due to the change in that hormonal environment. And it will get better the more you continue to acclimate to the medications.

SPEAKER_03

It takes about three weeks to achieve a good steady state. Um, and that's one of the bummers, honestly, is it's you know, we talked about how it takes a while for the symptoms to go away and get better. Um, and so it's like, wow, you take this new thing, you're all excited, and all you get is side effects for three weeks. And that's it's it's a bummer. I wish we could design it differently. The good news is you get past that part where you get that steady state, and those go away, and then you start reaping the rewards. So um it is kind of a delayed satisfaction on that. Um, but that's um that's what's going on. By the way, just to I I know you didn't mean this, but um, you don't actually get the medicine into your blood system by like rubbing the the well. No, I know. I just I'm worried someone's gonna imagine, oh, I gotta really rub it in.

SPEAKER_04

Um, yeah, it gets absorbed by the little fine vessels in the skin. Yeah.

SPEAKER_03

So it's just yeah, you apply it and you can just you know do that.

SPEAKER_04

Yeah, don't cut your skin open trying to rub it in vigorously.

SPEAKER_03

Well, it's kind of interesting. Um, you know, when we do surgery, there's a whole scrubbing technique of the hands.

SPEAKER_02

Um and it turns there was a study, it turns out this whole like doing this and all that doesn't do anything different than just putting it on and sitting there.

SPEAKER_03

The difference is that this distracts you, so you leave the the uh medicine on your hands to kill the bacteria longer if you actually distract yourself by scrubbing and stuff. But it when I started out, everybody was using these like kind of harsh scrub brushes, and it's like you're not killing bacteria by scrubbing them, but that was kind of the thing, and now um we have different techniques for the most part, um, but it's kind of the same idea. It just kind of reminded me of that. It's kind of a kind of a funny thing. It's like, yeah, no, you can't really kill bacteria by squashing them.

SPEAKER_05

Um, we have another question from Crystal. Um, and Crystal is wondering, she says, can you share more on shrinking and vaginal atrophy? What helps?

SPEAKER_04

Well, so basically, you know, what happens is we get these age-related related changes in the vaginal tissue. So when we're young and healthy and in the prime of our lives as women, we have normal folds, which are called rugations in the vagina. The vaginal tissue or mucosa is thick and it's more elastic, more supple, more moisturized. And when those tissues lose estrogen, the tissue becomes thinner. We lose that elasticity and the stretchability of the vagina. So those folds or rugations go away. Um, and honestly, if you don't use it, you'll lose it. So if you are not actually, you know, having penetrative intercourse, if nothing's going in the vagina to keep it stretched and exercised, um, and you're not supplementing with estrogen, what can happen over time is the vagina can get more narrow. And then when you do try to introduce something, like, say for us as a gynecologist, if we go to examine a patient who hasn't had sex in many years or hasn't been using estrogen, simply putting a speculum in can be extraordinarily painful, um, can actually cause tearing of the skin. And that can happen for women when they go to try to be sexually active after they've not had estrogen in their system or not had anything in the vagina for a long period of time. So, you know, that's why people say it shrinks. It's just that the the tissue actually, you know, is is getting more firm, less elastic, um, less moisturized over time, too. So that's basically to explain what happens there.

SPEAKER_03

So that's fortunately, it's it's pretty easy to treat um with estrogen. We have a estrogen vaginal cream that works extremely well for that. Um, and uh, you know, it's interesting. I was around when Viagra came out, and um, there was this huge kind of thing that people didn't talk about where these older couples were coming in, and all of a sudden they'd had a marriage for a long time that was working without intercourse, and now the husband was potent again, and the they hadn't used it for so long that the the lady you know was having pain and problems, and so we had to kind of slow things down, get her on some estrogen cream, get her vagina back into good health so that they could both enjoy the Viagra from both sides. It was just kind of an interesting problem. I didn't really see much talk about it, um, but I saw a lot of it in my office at the time.

SPEAKER_05

And our next question comes from Nicole, and Nicole is wondering um, she says, does it, but does HRT really help with the excess weight that I have gained because it's like horrible?

SPEAKER_04

Well, so you know, weight gain can be from a variety of reasons. I mean, there's a lot of things that change as we get older. Um, one of the aging things that can happen too is that our metabolism is changing, but also when your hormones are fluctuating and you're losing estrogen, you're also in this high stress state, too. So you're not sleeping as well, you're dealing with night, night sweats and hot flashes, and your body is not getting, you know, the rest and you know, rejuvenation that it needs each day. So that cortisol high stress level can also cause you to hold on to weight. Um, and a lot of you know, women start to experience weight gain, especially in the middle of their torso, the infamous menobelly, you know, we talk about, you know, and feeling more full in the abdomen when you maybe never dealt with that before. Um, it's very, very common for women to accumulate weight there. So typically, you know, for the hormonal relation to weight gain, starting HRT should help that, but not in isolation. Like you still need to eat well, you still need to think about your nutrition, you still need to move your body, like we talked about at the top of the call, like move more a month. You know, so it's very important that you have a total, you know, wellness picture in your body. So, like just taking a medication is not the only answer. You need to make positive changes to help improve, you know, your strength. We also lose muscle mass as women as we age. And so it's really important to maintain your muscle health and fitness and do some weight resistance, um, you know, resistance exercises to keep those muscles healthy. Because if you lose muscle mass and you're not, you don't have as much muscle, your metabolism really, really slows down. Um, and so you know, you're replacing muscle with fat and and you're not really um you know able to metabolize your meals, it doesn't matter how little you eat, you're still not gonna burn the calories that you take in. Um, and so that's something to consider too. But it but it should help for many women.

SPEAKER_03

You know, it's interesting. It's kind of like uh, you know, you get these charitable organizations where somebody has promised to match funds. Um, and so that's kind of how HRT is with exercise and diet. It's like exercise and diet help, and then HRT is like matching funds, so it helps even more. Um, but you still have to get the original funds to get the matching funds.

SPEAKER_01

So um I like that idea.

SPEAKER_03

Yeah, it'll give you you know more benefit for what you were normally doing, um, but you have to still do the right things. So um it's not a magic pill, um, but it does help. Um, and um, as we were saying earlier, that unfortunately that's one of the ones that takes a while before you really see the benefits.

SPEAKER_05

And we have a question from Laura next. Um, and Laura says, I read on the website that patients can be reevaluated every 10 weeks to determine if adjustment and treatment is needed. Can this be done sooner and what would this entail?

SPEAKER_04

So you can message us on the portal on the platform anytime you want. Now, generally, when someone's first starting HRT, we don't really like to make wholesale changes in those first few weeks, especially, or even in the first two months, because it really takes time for your body to acclimate to the dose. Um, but you know, after that first 10-week period, you know, really we want to reevaluate to kind of see like, are all your symptoms improved? Is there still room for improvement? Is there something that's you know particularly bothersome that you want us to address more? And we can make changes based on what symptoms are still bothering you. Um but if you've been on meds for a year and then all of a sudden you start to have symptoms creep back, you can message us anytime. Um, and we can always discuss if we need to make changes. And so, you know, I I caution patients from making changes too early or too quickly, especially if you've only had an onset of new symptoms. Um hold on a second. I'm gonna go unmute and let you finish. Okay. Okay.

SPEAKER_02

I hope someone's not ready to have a baby.

SPEAKER_03

Um, so um the uh when I designed this thing, um, I designed it like um I do in my office. So if you were to come into my office and I was gonna start you on HRT, I would start you on the dose and I would bring you back in about three months um and we'd discuss and see how it was going. And then if everything was good, I'd give you a year's worth of refills and I'd see you back every year. Um and so that's what we do at Winona. It's really the same thing. Um, and so the the the interesting thing is I originally thought 10 weeks was going to be the sweet spot, but 10 weeks was a little bit early. So you actually get your follow-up at 11 weeks. Um, that it's about a week before that three-month refill is due, and it gives us enough time to kind of go back and forth if we need to adjust it. Um, but that 10-week nomenclature, the naming of the 10-week just stuck. So we all still call it a 10-week follow-up, even though we changed it to 11 weeks, but that's kind of small potatoes. But so you don't necessarily get a follow-up every 10 weeks, you get that first follow-up in 10 weeks, and then generally we reach out to you every year, but or you know, 10 weeks and then every year is the general pattern, but you can reach out to us at any time. Um, and um occasionally um I've had patients upset because I didn't reach out to them, and so I tell them the same thing. I tell my mom when she gets mad about that. I say the phone works both ways. Um, so you can always reach out to us um anytime, and we're very happy to answer your questions or or debug stuff. But as Dr. Kat was saying, if you make changes too early on, you know, as we were saying, the body doesn't like changes, so it takes a while after you make that change to get the benefit of that change. So if you're just constantly changing, you're never gonna get to that steady state, that sweet spot where you're getting the benefit without the side effects. So that's like that's the one of the big reasons why we like to try and kind of get you through that first few months to see where your body's gonna be once you get into that steady state.

SPEAKER_05

And we have a question next from Lisa, who's tuning in on our Facebook stream. Um, and Lisa's wondering should you still take progesterone even if you don't have a uterus?

SPEAKER_03

Almost always no. There's a few exceptions. There's always an exception that makes the rule. Um, but in general, the real benefit of progesterone is to protect the uterine lining from estrogen. So estrogen is great. It estrogen estrogen receptors in almost every cell in the body. And for the most part, estrogen is beneficial almost everywhere. The one exception is that it can overstimulate the lining of the uterus, and if left unchecked, that can cause problems. And so the progesterone is added to help balance that estrogen and keep the lining of the uterus healthy. That's the most important reason of why we add progesterone. If you've had a hysterectomy, your uterus is sitting in a pathology lab somewhere, and we don't really need to protect it from the estrogen, right? So if you don't have a uterus in your body, then we don't have to worry about that. Progesterone has side effects. Um, it's interesting. This is uh an answer on the test that most people get wrong, but it, you know, estrogen does not increase your risk of breast cancer, but progesterone does, not by a lot, um, but there is a slight increased risk of breast cancer when you take progesterone. Progesterone also can stimulate appetite and it can work against you in that whole weight loss thing we were just talking about. Um, and so it's not like a freebie. Um, and so there's no point adding a medication that has potential risk and side effects if you're not getting the main benefit out of it. So, in general, for most people, if they've had a hysterectomy, we do not recommend progesterone. Um, endometriosis, for example, isn't is an exception because it's really the same mechanism. There can be endometriosis tissues outside of the body, and it's the same idea of overstimulation. So the progesterone helps protect that even if you don't have a uterus. But like I said, there are some exceptions, but for the most part, uh, we do not recommend progesterone if you've had a hysterectomy.

SPEAKER_05

And our next question is from Leslie. Um, and Leslie says, she says she just started treatment a few days ago, um, but she's wondering if you can use the vaginal cream for burning and itching with the regular estrogen and progesterone cream and DHEA.

SPEAKER_03

Yes. So um the big exception to the thing I just said, again, there's always an exception, vaginal estrogen does not really get absorbed into the circulation in any meaningful way. Um, and so actually, that's the one kind of estrogen you can give without having to worry about progesterone. So if you still have a uterus and all you have is all you need is vaginal estrogen, you actually don't need progesterone with that. Um so likewise, because it just works locally on the vaginal tissues, it's safe to use that along with the other medications. It's not going to raise your estrogen levels too high because it's not really getting absorbed. Um, the systemic HRT, the cream or the pill or the patch, will help the vaginal tissues, but it doesn't help as well as the estrogen cream and it takes longer. So if your vaginal symptoms are sort of subtle or not too bad, the um cream or the pill or the patch may be enough. Um, but if it's you know pretty significant, adding the estrogen vaginal cream is safe and can be really effective for that.

SPEAKER_05

Absolutely. Um and we have a question from Heather next. And Heather is wondering how long can a post-menopausal woman stay on HRT?

SPEAKER_03

So the answer is as long as it's helpful. Um, and honestly, some people choose to stay on HRT forever for the cardiovascular benefits. This is really actually, I was just um mentoring a doctor about this. There used to be this mantra for HRT that you should use the lowest dose for the shortest amount of time possible. And in fact, that's still in textbooks because mantras don't go away very easily. But that idea has really been changing. Um, and we've you know we've learned that there are these tremendous health benefits to hormone replacement therapy apart from just symptom control. So it really decreases your cardiovascular risk, decreases your risk of osteoporosis, decreases um certain cancers. So there are these benefits of HRT that are long-lasting and may or may not be a reason to stay on it for a long period of time. But at minimum, as long as it's helping and relieving your symptoms, there's no reason to stop it. That um there's this age of 60 thing that confuses people along those lines, and that it's not really safe to start HRT for the first time if you're 60 or over. But if you're on HRT, you can continue it even after you turn 60. There's a logical reason where it's a little complicated, probably more than you guys want to hear. But um, but that is a safe way to use it. It's fine to continue taking it as long as it's helpful, no matter what your age.

SPEAKER_05

And we have a question next from Susan. And Susan is wondering which is more effective, the estrogen, progesterone cream combination, or taking the estrogen um or having the estrogen patch and the oral progesterone pill.

SPEAKER_03

So they both work great, and um, neither works better than the other. Uh, you know, it depends on what dose you're on, of course, um, but they all have various doses, so um, we can adjust the doses needed. It really comes down to um personal preference and cost. The um, you know, the patch is is put on your skin, you wear it all the time, and you change it twice a week. And some people like the convenience of only having to deal with it twice a week. Whereas the cream you apply to your skin usually each night at bedtime, um, so it's kind of a once-a-day thing. On the other hand, some people find it annoying to wear a patch all the time. Um, and if you're one of these people that kind of get rashes easily, especially like from band-aids and stuff, the adhesive in the patch can um irritate the skin sometimes. Um it also is supposed to stay on when you swim and in the ocean and that kind of thing. But if you're, you know, if that's your big sport is swimming, it may not be the best thing for you because it can sometimes come off. So there's different things. Um, and it really kind of depends on personal preference. But they, as far as efficacy, as far as what actually works, they both work great. And um, they they one doesn't work better than the other.

SPEAKER_05

And we have a question next from Carrie. And Carrie says, I'm 11 weeks into my HRT cream therapy. She says I was feeling a lot better, um, but then suddenly I started feeling a little bit fatigued again and having some achy bones. Any suggestions? What's going on here?

SPEAKER_03

You need to adjust your dose sometimes. Um, and so uh the needs of the body change from time to time, um, and sometimes. You can kind of get your body can um accommodate to a dose, and sometimes you need to push the dose a little bit. Um, or sometimes it's the other way around and you're doing great, and all of a sudden you're out of nowhere, you're starting to get some side effects, and it's time to back off a little bit. So it is dynamic. Um, some women are on the same dose for long periods of time, but it's not uncommon to have to adjust the dose now and then. So it may be that what was working for the last 11 weeks isn't quite hitting it, and we need to goose it a little bit and give you a little bit more. So that's something that you can um message in to your Winona doctor, and we can um help you and make suggestions.

SPEAKER_05

And we have a question next from Nicole, and Nicole says, My doctor put me on 50 milligrams of Zoloft to reduce my periper menopause symptoms. I don't like being on it. Is it better to be on HRT instead?

SPEAKER_03

So in general, in my opinion, yes. Um there are, for instance, the patient that um at the very beginning that with the breast cancer, that would be a great use of Zoloft because it's not going to affect the breast cancer and it will help with some of the symptoms. Um, HRT actually works at the root cause. Um, so not only does it address the symptoms, but it addresses symptoms better and comprehensively because it actually works at the root cause. Whereas Zoloft sort of helps with symptoms by sort of masking the symptoms, which isn't necessarily a bad thing, um, but I'd rather have a comprehensive treatment that's really working at the underlying cost, and that's what HRT does. Besides that, as I mentioned just a little bit ago, HRT gives you other health benefits that Zoloft isn't, such as decreased risk of cardiovascular disease and um osteoporosis and all that stuff. So I think in general, if the Zoloft is only for your um symptoms of menopause, then I think you're probably gonna, most people are gonna be better off on HRT.

SPEAKER_05

And we have a question next from Amber. Um Amber says, When I talked to my rev regular OBGYN, they refuse HRT because they said it would mess up my cycle since my cycle is so regular. How likely is it that I will lose my regular cycle with HRT?

SPEAKER_03

It's very unlikely. Um for better or for worse, HRT is not, doesn't really change the cycles much. Um, which in your case is good news. Um, but for some people, you know, if their cycles are pretty bad, HRT isn't great at helping those. Um so that's kind of the one symptom of the menopause transition HRT isn't super great at. Um but in your case, where you have nice regular cycles, it really shouldn't change those. Now, the caveat to that is that that's assuming that you're using daily HRT. Um so some people try to cycle HRT, um, which you know was it was an idea that was popular 10 or 15 years ago and has kind of fallen out of favor because it ends up just causing more symptoms, a little bit of havoc with your cycles can cause spotting and bleeding. So if you're using HRT continuously where you're taking it every day, it really shouldn't affect your cycles, you know, positive or negatively. Absolutely.

SPEAKER_05

Um and we have a question from Deborah next. And Deborah's wondering will this help my energy levels?

SPEAKER_03

Typically, yes, um, through various mechanisms. Um uh so probably the one of the biggest mechanisms is sleep. So one of the big symptoms, the very common symptoms of the menopause transition is is people aren't sleeping well. Um, and sometimes it's just they aren't sleeping well, sometimes it's because they're waking up with hot flashes or they're having to pee all night. Um, and HRT can help that. Um, and um, and then um you know, with the increased sleep benefit, you get all a myriad of other benefits as well.

SPEAKER_05

Absolutely. Um, we have a question next from Stacy. And Stacy says, Um, I have joint and muscle pain, which impedes my workouts. I hear this is often a menopause symptom. She says, I've been reading GLP1s may assist with uh may assist with receptors and joints to help with this pain. Curious about your thoughts on this or what you've heard in the medical community.

SPEAKER_03

So um joint and muscle pains, particularly joint pains, are a very common symptom of menopause transition. On the other hand, there are lots of things that can cause joint pain. So um, you know, uh from my various uh things I probably shouldn't have done in my youth, you know, my knees sometimes hurt me. So it's not because I'm going through menopause. So, you know, people get joint pain sometimes, but it is a very common symptom of the menopause transition. And so if that's what's driving your joint pain, HRT can help. Um, even if it's not directly related, estrogen can work as an anti-inflammatory and help even non-horm-related joint pain to some extent. So it is definitely something that can help. The GLP1s is really interesting. Um, that is another interest of mine. Um, we are learning all kinds of or seeing all kinds of anecdotal things with GLP1s. Um, and I have seen people um have improvement in joint and muscle pain. Um, it definitely has an anti-inflammatory effect that quite honestly we don't totally understand right now. Um, it's an interesting drug. So um you give it to someone for diabetes or weight loss, and all of a sudden, you know, their um their joint pain is better, their fibromyalgia is better, um, all these you know various things. Um, I can tell you for me, um, those who have um sort of followed me um through Winona for the last four years have noticed a big transformation. I've lost 20% of my body weight um on a GLP one. And I, according to my wife, used to snore really badly. Well, I know because she used to like get me to wake me up to get me to stop snoring. And um this cured it. I don't snore anymore. And in fact, I went off for about a month um and she said the snoring came right back. So as soon as I went back on. So there's all these like weird things that the GLP ones help with. Um, I know I totally digress, but you kind of hit an area of my interest. Um, and it does seem to work pretty well as an anti-inflammatory as well, and so you seem to get some joint and muscle benefits, but again, that's anecdotal. I don't know there's any good studies out yet. Um, I haven't seen any, um, but we we are seeing that.

SPEAKER_05

Um well and welcome back, Dr. Kat. For the last two minutes. We're glad to have you back for sure.

SPEAKER_02

Is it a boy or a girl?

SPEAKER_04

Oh, it wasn't a delivery, it was another another issue, unfortunately.

SPEAKER_03

So I used to play video games in the call room, and uh, you know, and uh I used to play a game called World of Warcraft, and uh I remember one time I was playing with a bunch of people online and I had to run to do a delivery, and then I came back and then we were playing some more, and another guy went to get a pizza, and they were giving him our time, and it took him longer to go get his pizza than me to deliver a blue pizza.

SPEAKER_01

Nice, so funny.

SPEAKER_02

Um anyway, I digress. What happens when you leave? You they get all these crazy stories.

SPEAKER_05

Um, we have a question next from Christina, and Christina's wondering: is it okay to take HRT while on birth control?

SPEAKER_04

Yes, if you're still at a age where you need to prevent pregnancy and you don't have another way to do so, you should stay on your birth control. We usually recommend women stay on it until they're 50, um, you know, if it's safe for you to take, but you can start HRT even while you're still in your birth control because HRT will not prevent against pregnancy. It will not prevent you from ovulating, and that's what you need to birth control for. So yeah, they can be taken together safely.

SPEAKER_03

You know, it's interesting. This is something that raises eyebrows. Um, and you know, your family doc or your OBJ and may say may think that's not right or weird. And and I'll be honest with you, I was a little surprised how well it worked myself. Um, so um when we started doing this, we started giving HRT to women on birth control, and I was really pleasantly surprised at how well it works really well. Um, it really seems to hit the receptors differently than the synthetic hormones in birth control. Um, and so it's not something that's sort of necessarily widely talked about, I think. And I think a lot of doctors are surprised by that. So you may, when you go see your regular doctor for your annual checkup, may raise some eyebrows. Um, but it is something that's very safe and it does seem to work.

SPEAKER_05

Um, and we have a question from Maureen next, and she says, you can get the you can get DHEA over the counter. So, what's the difference between that and getting a prescription of DHEA that we prescribe at Winona?

SPEAKER_04

So the main difference is the quality. So, you know, when you buy a supplement or a vitamin or a mineral, anything over the counter, you don't really know that what you're actually buying and what's on the label is actually what you're getting. You know, supplements are generally they're not regulated by the FDA, they're not needing to be, you know, studied or you know confirmed for consistency, whereas we at Winona have actually found a supplier that we trust. Um, and we've you know independently tested our supply. Um, and so we feel really confident that our quality of our DHEA is is superior to what you can buy off the shelf elsewhere. So, but you know, as a consumer and as a patient, you have the choice, but you know, that's why we recommend our DHEA over others.

SPEAKER_03

Yeah, I can tell you about a year and a half, maybe it's two years now, uh, we rejected a big batch of DHEA um because it didn't meet our standards. Um, and it actually caused a little problem for us. We had to send out just 30 at a time until we could, you know, get the next, get the next supply in. But you know, it we weren't gonna take, you know, we're very, very picky. Um, and we want to make sure that what we're giving you is exactly what you you know what we say it is and what's in there, and it's pure and it's good. Uh, I think our last order, um, I think we ordered 10 million units um uh of DHEA. So when you're um the manufacturer, my understanding was they actually it expanded their manufacturing process for us um because um, you know, we when you order that kind of volume, you have a lot of control and a lot of say um over the quality and what goes in it. So um it's something that we're extremely picky about because it is a supplement um and it's not regulated the same way that um that other pharmaceuticals are. So we we want to be extra careful with that.

SPEAKER_05

Absolutely. And it looks like we have time for one last question. Um, and I did want to just note to everyone who's watching, um, if you didn't get your question answered this time around, uh, we'll have these live QA's. We have events like this twice a month. Um, we would love to see you at our next one. Um, as I mentioned at the beginning as well, we have our podcast. It's called the menopause hour. Um, you can find it on Spotify. Um, and their QA sessions just like this, where you can kind of listen to that on the way to work. You can listen to it as you work out. Um, those are great places to also get some of your questions answered there. Um, and also your Winona doctor is always available 24-7 in your patient portal. Um, so that's a really great place to the all of these questions that you're sending, that's a great place to ask your doctor that as well. Um they're they're really there to kind of hear that from you. Um, and they love to answer your questions and kind of help you figure out what next steps you might need to take. Um, but for our last question for tonight is from Mary. Um and Mary is wondering, is it normal to get your period when you start the cream?

SPEAKER_04

Well, so for some women that with their starting HRT, you know, for the first time, they can get changes in their bleeding pattern. So if you are have already stopped your periods and you're, you know, postmenopausal, it can be normal to have a little bit of spotting as you're starting. Or if you're still getting periods, whether they be regular or not, you can have some changes in your bleeding pattern when you start your HRT. And that can be normal because your body, your uterus is responding to the change in hormonal environment. And usually these changes are temporary.

SPEAKER_03

Let me jump in because while you're out saving a life, um, I said something that may be confusing. Um, because someone asked, she said she had nice regular cycles in her OBGN, told her not to start HRT because it was going to mess up her cycle. So we're talking about the first month or two. Um, it can um cause changes. After that, you should go back to whatever your normal state is. Um, and that's kind of what I was talking about kind of long term, is that this really should not affect your cycles. Um, first month or two, all bets are kind of off. Um, but you know, our rule of thumb is if it's three months and you're still having irregular bleeding, that's something that we probably want to look into because it's not what's expected from HRT.

SPEAKER_05

Well, thank you, Dr. Green, and thank you, Dr. Kat, for lending your time tonight. I know that these QA sessions are widely loved and appreciated. Um, and I love getting to be on them and hearing your answers as well. So thank you so much for your all's time, and thank you, everyone, who made time in their schedules also to come out for their live QAs. Um, we're really glad you're here. And we hope that we'll see you uh at one of our next events or listening to our podcast or in our Facebook group in WWG, um, commenting up a storm, making posts. That's a great place also to um find some community as well. Um, but thanks again, doctors, and I hope everyone has a great night.

SPEAKER_04

Yes, have a good night, everyone.

SPEAKER_00

Thank you for joining the Menopause Hour, brought to you by Winona. Menopause care made easy. To learn more, find Winona at BiWinona.com and on Instagram at BiWinona. Want to have your questions answered next? Register for our upcoming live QA. Linked in the show notes.