Episode #8 Hormones & Heart Health: Why HRT Matters in Menopause

In this episode, Dr. Green and Dr. Cat dive into heart health, menopause, and the benefits of hormone replacement therapy (HRT) in honor of American Heart Month. They debunk common myths about HRT and cardiovascular risk, discuss how HRT supports longevity and overall wellness, and answer key audience questions on weight gain, metabolic changes, and bone health.

The episode also covers starting HRT after age 60, the benefits of DHEA, and the differences between HRT and birth control.

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Transcript

SPEAKER_00 0:00

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_01 0:20

I actually did a family practice residency as well, and I'm a glutton for punishment, so I did a whole second residency so I could do women's health, which is what I fell in love with during uh my family practice days. Uh so I basically spent my career um doing that. And um so we uh launched Winona, oh, it's almost four years now, um, and uh this has been like the coolest thing that I've ever done um to be able to bring really much needed HRT treatment to a huge audience, to a huge amount of women that um don't really have access to it for various reasons. So um we're really excited um to be able to provide that for you. One of our big pushes, one of our our our big culture at Winona is education. Um you know, we're not here to tell you what to do, we're here to educate you so that you can make a best decision for yourself. And that's what this is all about. We want to answer your questions. Um there's a lot of crazy misinformation out there, um, and it's hard to tell kind of what's real and what's not, and it tends to generate a bunch of questions. And so, you know, we want you to see that we're real people, we're not AI bots here to answer your questions. So put your questions in the chat. Um, otherwise the three of us will have a great conversation, but it won't be very helpful for you. So I'm gonna hand it off um to our medical director, uh Dr. Kat Brown.

SPEAKER_03 1:45

All right, thank you. Yeah, a lot of patients still think we're bots, so it's it's nice to be able to connect with people outside the portal for sure. Um, I'm Dr. Kat Brown, I'm a medical director at Winona, and I'm also a board certified OBGYN located in the suburbs of Philadelphia and take care of a patient in a few states, but also help to curate some of our educational content on the website for our patients as well, um, just to make sure that the information we're putting out for you is valid and helpful. And like Dr. Green said, you know, knowledge is so very important, and I think it's so very important for you to learn as much as you can about your own body so that you can make the best decisions for yourself moving forward. But normally at the beginning of one of these, while we're waiting for you to all put your questions in the chat, we usually talk about a topic of interest. And February is um a special month, it's American Heart Month. It's um a month where we're supposed to focus on, you know, preventing heart disease, cardiovascular health awareness. I think one of the days in February, I forget specifically what day it was, but it was Where Red Day, um, you know, and it kind of coincides with uh from Valentine's Day too. But, you know, this is a good topic to talk about because so many women out there are afraid of starting HRT and afraid of risks of HRT, but actually more women die from heart disease every month and every year in the United States than any other issue. It's it's a leading cause of death for women. So the fact that it's American Heart Month, it's something really important for us to talk about. Um, and we all often think of like those classic symptoms, and a lot of people think of like a middle-aged or older man having a crushing chest pain. Sometimes in women, the symptoms can be very subtle and they can be very different. And often when women have signs or symptoms of a heart problem, it's not recognized as easily and as quickly because the symptoms are not classic. So, you know, the other thing that heart that's important as far as heart health is that starting HRT can actually improve your cardiovascular health. As we lose estrogen from the body, so many things happen to all the tissues in our body. But when we add estrogen therapy in for patients that are going through perimenopause and menopause, it helps to keep that heart muscle healthy. It helps to keep the vessels that are feeding the heart more elastic and more open. Um so it decreases your risk of atherosclerosis in those vessels too. So something to think about and something very important to keep in mind. You know, move your body every day, feed your body nutrition that keeps your heart healthy, avoid those things that are gonna put more stress on your heart. Um, so it's important to think about. I don't know if you want to add anything to that, Dr. Green.

SPEAKER_01 4:23

You know, I think that's one of the big, you know, I said there's misinformation. And I have a lot of patients come on and say, I'm I want to start HRT, but I'm worried it's gonna cause me to have a heart attack or or you know, have a family history of heart disease. And it's actually quite the opposite. Um, so women that are on HRT in the long run have a lower risk of cardiovascular disease than those that aren't. Um, so it's actually really good for your heart. It if you look at the big picture, um, women that are appropriate candidates that uh are on HRT uh on average have a longer life expectancy than those that aren't. And um, more than just a longer life expectancy, but a healthier, longer life expectancy. I saw this hilarious cartoon the other day. Uh, it was in Facebook, but it was this old guy all crunched over, he could barely move, you know, and he's at the doctor's office, and the doctor says, You remember all that healthy living that got you 10 extra years? Well, this is it. So, you know, you don't want to just live long, you want to live long and healthy. This really helps you do both.

SPEAKER_04 5:26

Well, yeah, thank you. Yeah, I was gonna say thank you all so much for going over that a little bit. I think it's interesting always to I think hear what you both have to kind of say and what's going on in the health world. I think is such a great thing to um kind of touch on. So thanks for sharing about that with us. Um, but yeah, if if you both are ready, we can kind of jump into the questions we have here. We've got a lot to get into. Um, so our first question tonight is from Marie. Um, and Marie is wondering can the facial cream be applied under the eyes for dark circles?

SPEAKER_03 5:59

Yeah, the facial cream can be applied around the eyes, but the one thing that you have to be careful of is that sometimes it can be very drying. And the thing about dark circles is that there's no quick fix for dark circles. Um, sometimes there can be a genetic component to it. If you're somebody who's prone to allergies, that can also make you more prone to having the dark circles as well. Um what this, what the facial cream will really do for around the eye is help, you know, um reverse the signs of aging around the eye. So like fine lines and wrinkles around the eye, it can help to make that junction between the dark circle and your cheek a little bit um, you know, more subtle and and and less severe. Um, but you really have to make sure that you're moisturizing in between using the face cream as well, because the the area and the skin around the eye can is very thin compared to the rest of the face, and so it's really easy to dry out.

SPEAKER_01 6:50

So you really want to use it sparingly in the thin tissues.

SPEAKER_04 6:56

We have a question next from Jennifer. Um and Jennifer says, I started HRT two weeks ago, already feeling so much better. I am 50 and wondering how long I would need to take HRT or when should I decide to stop?

SPEAKER_03 7:10

Well, I think it's really a personal decision. I mean, when when we were both in training, I think you know, we talked to women about the lowest dose for the shortest amount of time possible. Um, but really studies are showing that actually continuing on HRT can help you with so many lifetime health benefits. And so a lot of women are choosing to continue it as long as they can safely. Um, and what you have to do is revisit your overall health and wellness and what medications you're on, what medical problems might be creeping up as you age, and to determine each year, you know, is it safe to continue? Um, so it's a personal decision I think every patient can make.

SPEAKER_01 7:45

Yeah, if you look at the average woman's on HRT for about five years, um, but that's an average. So there's a whole lot of people that are longer, and there's some people that are shorter. Um, and so you know, one strategy is every few years you can see what happens if you go off of it and see how you feel. Um, and your body may tell you, nope, you need to go right back on. So if you're gonna do that, don't do it like right before your kid's wedding or something. You know, do it during kind of a less stressful time. Um, but that is something you can do as a trial, you know, every few years to see if it's still benefiting you. But again, um, like you know, like Dr. Kat says, some people decide that they want to be on it indefinitely for the underlying health benefits. Um, that, you know, and that's definitely there as well.

SPEAKER_04 8:31

Um, we have another question that's along the same lines, though a little bit more on the other side. Um, they're wondering, they say, I'm 62, am I too late to start HRT?

SPEAKER_03 8:42

So there's increased risk for women starting HRT after age 60, um, especially because of it's basically from the distance and time from when you actually went through menopause. But after age 60, the studies show that you have an increased risk of cardiovascular events that are negative for those first couple years after starting HRT, if you start after age 60. So when we talk about cardiovascular events, we're talking about heart attack, uh, stroke, uh, blood clots in the legs or the lungs that can happen. So, you know, those overall risks for the average population are low, but they're significantly increased if you start after the age of 60. But there's other things that you can use, and there's, you know, like vaginal estrogen, which is another form of HRT that's not so much for the systemic symptoms, but can help with some of those uh genito-urinary symptoms of menopause like vaginal dryness, vaginal atrophy, pain with intercourse, and that's perfectly safe to start at any age, is vaginal estrogen that's topical. So that's something that you you still can start safely.

SPEAKER_01 9:42

Yeah, I want to. This is always confusing for people because we just got finished telling you that HRT decreases your risk of cardiovascular disease, and now we're saying, well, you're 62, it's too risky for you because of cardiovascular disease. So it seems like, well, which is it? Um, and so the the issue is that there's actually a slight increased risk the first two years that you're on uh the medication, and then that reverses and your risk starts decreasing each year. The concept is if your estrogen if you still have some estrogen around, you haven't really done enough damage to your cardiovascular system that that increased risk is going to be that significant. But the farther away you are from menopause, the less, the more damage has been done because the estrogen hasn't been around. And so that initial first two years of risk starts becoming significant. And the statistics say that 60 is sort of the tipping point. And the number is um once you're over 60, on average, you have a seven per 10,000 chance per year of more of having a cardiovascular event than you would have without it. So if you put 10,000 women age 60 or over on HRT, seven of them will have a cardiovascular event that they wouldn't have had otherwise in the first two years. Now, if you survive the first two years, your risk now starts going down again. Um, but it's sort of rolling the dice, and that's not something that we like to do in medicine. So that's the numbers, and that's why like we spent this whole amount of time telling you that this lowers your cardiovascular, and then we're telling you, well, no, sorry, it's too risky because of cardiovascular. It's like, well, what is it? But that's the uh that's the issue.

SPEAKER_03 11:24

And I think a lot of patients hear that uh 60 cutoff, and then they worry that they're gonna have to stop their HRT. And it's really, you know, the important part of that is starting HRT de novo after age 60 is what increases your risk. So if you're already on HRT, you don't have to stop cold turkey at age 60, because if you've already been on treatment, that risk is not the same.

SPEAKER_04 11:45

So absolutely. Um, we have another question from Angie. Um, and Angie is wondering can you order just a DHEA if you are already on estrogen and progesterone?

SPEAKER_03 11:58

Sure. And it's important um if you're already taking estrogen and progesterone to let us know what dosage you're on because we want to make sure that giving you the DHEA is going to be complementary to what you're already taking. Um, because the DHEA gets broken down into estrogen and testosterone, we want to make sure we have to take that into account as to what estrogen dose you're already on. So, but yes, I have a lot of patients that do it that way.

SPEAKER_04 12:21

Absolutely. Um and then we have another question. This one's maybe a little bit more general, but I do think that this is something that a lot of people wonder about just with HRT. But um they say, hi, I've just started HRT, what should I expect?

SPEAKER_03 12:35

So that's it's a pretty vague, uh wide-ranging question. But um, I think the biggest thing when you're first starting treatment is that you need to give your body and your yourself some grace as your body gets acclimated to the medication. So that's probably my number one advice. So many patients are anxious, you know, and and and as human beings, we want results like yesterday. So often I have patients like hopping on the scale every day and doing all these things and wondering when all their symptoms are gonna stop. Um, but what you really need to focus on when you're starting the treatment, first make it a habit. Try to find what fits into your schedule the best and when you're gonna use your medication. And you want to be able to use it at generally the same time each day and get that rhythm so that you are consistently taking it because that's when it's gonna be more effective and getting to that therapeutic dose in your body. Um, the other thing I think it's really important anytime you're starting a new medication to optimize your sleep, optimize your hydration, making sure you're drinking plenty of water. Um, and also focus on your nutrition and exercise and moving your body. Stay away from the scale the first couple weeks. You know, you're not gonna see the weight loss that you're seeking right away. It doesn't happen overnight. And first thing you have to do is to get your body used to the medication. And I really wouldn't start examining whether or not you think the medication's working for several weeks after getting it on board and taking it regularly. So that's that's really my two cents about what to expect when you're first starting.

SPEAKER_01 14:03

Yeah, I would add, you know, along the same lines, it's kind of a bummer because um, if you're gonna have side effects, they tend to show up early. Um, and then the good news is they tend to go away as well. But the benefits tend to show up late. So it's like, okay, you're all excited, you're starting this new thing, you're excited about the benefits, and all it's doing is causing you misery. It's like, well, why am I doing this? But if you can hang in there for a few weeks, those side effects tend to go away, and then the benefits start rolling in. So it's kind of a bummer that that's the way it works. Um, wish I could design it differently. Um, but don't be surprised if you have some side effects early on, those, you know, some breast tenderness, even some hot flashes that you didn't have before as your body's getting used to the medicine. Um, those do go away usually within a few weeks, um, and then you start noticing the benefits. So you kind of got to hang in there. This is a long-term thing, it's not a quick fix, unfortunately. You know, it's the idea, I want patience and I want it now. Right. So it doesn't quite work that way.

SPEAKER_04 15:08

Definitely. Well, we have another question from a different Angie this time. But Angie is wondering um, why can't estrogen cream be applied to the breasts? Do you want to take that, Mike?

SPEAKER_01 15:21

Well, yeah, it's honestly it probably could. Um the we shy away from the idea of just putting a bunch of hormones right on the breast tissue because breast tissue can be very sensitive to hormones. So um there's honestly no science behind why you shouldn't put it on the breast. It just kind of sounds like a bad idea. Um, and um, you know, we don't want to stimulate the breast tissue. There's probably increased risk of having some of those breast side effects like uh breast swelling and tenderness if you apply it directly there. So just out of an abundance of caution, we recommend not doing. I mean, there's plenty of other places where you have skin, so why put it there? Um, you know, there's no point sort of you know shaking the rattle at something. Um, so uh, you know, there's really not a whole lot of science about it, but it just doesn't sound like a good idea, quite honestly.

SPEAKER_04 16:18

Absolutely. We have a question next from Heather who is wondering, she says, Can I keep my IUD and start on HRT for peribenopause symptoms?

SPEAKER_03 16:27

Absolutely. So I have lots of patients that have an IUD in place for contraception, or maybe for another reason, like heavy periods. Um, and it's perfectly safe to keep that in place while you start treatment with HRT. So they can be used together.

SPEAKER_01 16:42

Yeah, and be aware that HRT does not provide contraceptive benefits. So it's actually a really nice combination because you have excellent birth control, um, but the IUD is not going to help the symptoms of menopause transition. Um, and the HRT is going to help those symptoms, but it's not going to provide birth control. So the two together, it's really a nice marriage and they work well together.

SPEAKER_04 17:03

Absolutely. And we have another question about the cream and where you can apply it. Um, but Roshanda is wondering: is the forearm the only place to put the cream, or where else could it be put?

SPEAKER_03 17:15

So basically any non-hairbearing part of your skin is a safe place to put the cream. So most women do the forearm just because it's the easiest, you know, so you can apply the cream right on your forearm and rub your forearms together. But I have other patients that use the inner thighs or the backs of the knees. Um, and so you know, you can rotate if you want. Um, really, you have to do what works easiest for you.

SPEAKER_04 17:39

And we have a question next from Corey. And Corey is wondering: is the combined estrogen and progesterone cream dosed adequately enough to protect the uterus?

SPEAKER_03 17:50

Yes.

SPEAKER_02 17:52

100%.

SPEAKER_03 17:53

Yeah, we use micronized progesterone in our cream, and we formulated it so that the progesterone dose is adequate to help protect that uterine lining.

SPEAKER_01 18:02

I can tell you this is something that when we were um first starting out, I was a little worried about, and I spent a lot of time talking to our compound pharmacists who are like the smartest people you ever met, um, and you know, checking the literature and making sure because look, number one, two, three, four, five, etc., is safety. Um, the last thing I want to do is hurt anybody. Um, and so we want to make sure that what we're doing is safe and you know, and effective. But look, if I relieve your hot flashes, but give you a uterine cancer, I haven't done you any favors. Um we are very, very careful um about formulating our cream in such a way that it does provide protection of the end metral lining, it's the uterine lining. Uh, it's something we're actually kind of really like anal about, like we're OCD about this. Um we have systems in place in our software where it won't allow the doctor to prescribe something that we don't think is adequate. So we're super careful about this. We've had a ton of patients, we haven't seen problems, so we know we're doing it right. Um, but the problem is you really need a really quality compounding pharmacy, um, and you can't cut corners. And one of the big advantages we have is we have our own compounding pharmacies. We have one in Idaho and one in California. We have control over that. Um, and so we're able to make sure that we do it right, and it's something that we're exceedingly careful about.

SPEAKER_04 19:30

Amazing. Um, and we have a question next from Angeline. And Angeline says, I'm curious about patients who have been getting results in relation to bone density. In relation to that, has HRT been helpful?

SPEAKER_03 19:45

Well, so bone density is something that can be um basically a result of several different things. So, you know, there's a genetic component to how strong our bones are. Um, also, it has a lot to do with our nutrition and and what nutrients we're putting in our body as well. But also, if you're an exerciser, someone who does resistance training or weight training, you're gonna have stronger bones overall compared to someone who's sedentary. So the estrogen component of HRT can also help with bone health well. Um, but it's it's really something that's multifactorial and many different things go into help maintaining your bone health. So, like if we have a patient who maybe had a bone density scan and is starting to show signs of osteopenia, you know, being on HRT can help to a certain degree, but there's other medications out there that might be better to help them to rebuild their bone and to maintain their bone density as they age.

SPEAKER_01 20:36

So and it's not a one or the other, you can actually use both and they complement each other. So um, and then you know calcium and vitamin D are important um as well. So, right in the nutrition part. So there's there's a lot of aspects to it. But HRT is definitely part of the puzzle that helps maintain um your bone mineral density as you age.

SPEAKER_04 21:01

Hey, well, sorry if I paused for a second, but it's good to be back. Um, hopefully I didn't miss too much.

SPEAKER_01 21:07

Um, froze up.

SPEAKER_04 21:10

Oh my goodness. Well, I'm glad to see everyone again. I was a little worried there for a second. Um, but were you all finishing up the question? Is that where we were at? Perfect, awesome. Well, we have another question here um from Carla. And Carla's wondering what is the maximum time from when you went through menopause? Um she said, like, what is the maximum time from when you went through menopause? Um, she says, I'm 52, no period for five years for the fewest side effects.

SPEAKER_03 21:40

Well, so like we talked about earlier with that magic window of turning 60 and the risk of HRT and starting it after age 60 is increased. Um, there is also a period of time from the time you completed menopause too. And then generally that's 10 years. So if you stopped having periods at say 46, and once you turn 56, even though you're under Age 60, if it's been greater than 10 years since that final period, you can also be at increased risk. So you really want to start HRT if you're looking to start it within that 10-year window. I don't know why someone wouldn't want to wait after the 10 years anyway, because you're suffering with symptoms that entire time. For me, in my point of view, why suffer with symptoms? When you have symptoms that are bothersome enough to your life, that's when you should start treatment. You know, you don't want to wait necessarily.

SPEAKER_01 22:28

Yeah, you don't have to wait until menopause either. It's totally appropriate to use these medications when you're still having regular menstrual cycles if you're having symptoms. So you probably even better.

SPEAKER_04 22:38

Absolutely. And it looks like we have another question from um Myrna. And she is wondering where can we see what is in the estrogen cream? As I'm highly allergic to a lot of ingredients. She says I want to know what I'm using, but I'm excited and I ordered my first order.

SPEAKER_03 22:55

Yeah, all of that information, our ingredients list is located right on the website. So if you go back to the site where you onboarded, um you can go to the page on the combo cream and you can see all the components of the cream. Um so it's it's readily available for everyone to read on the website.

SPEAKER_01 23:13

And if you have a hard time finding it, you can always ask patient services and they'll send you the list. Um, so um, you know, I know sometimes it's hard to negotiate through websites and find the piece of information you need. Um, but um, so you can always reach out to our patient care team or to your doctor, and we can help with that information as well. Absolutely.

SPEAKER_04 23:34

And we have a question next from Andrea. And I do hear this question occasionally from women in WWG. So I think it's a good thing one to touch on as well. Um, but Andrea says, what about the benefits of testosterone and why doesn't Winona offer it?

SPEAKER_03 23:51

So the main reason is that testosterone is a controlled substance in the US. Um, state by state, there are requirements for you know who can prescribe it and who can't. But basically, um we don't do it because of that. So we give you DHEA in lieu of testosterone. It's a way of gently increasing your testosterone level with a medication. So basically, DHEA is a hormone precursor supplement that when you take it gets broken down into testosterone and estrogen. So it's a safer way for us to gently increase your testosterone level to normal female levels. Um, testosterone is some one of those things that we have to be very careful with, and if you get too much of it, you can get masculinizing side effects. Um, and it's a controlled substance because it's very widely abused in various populations. People that are bodybuilding, military community, um, you know, so it's a lot of a lot of different people using it. Also, there's not a product out there that's FDA approved for women necessarily. Testosterone typically is is given as a medication for men, even though we as women have testosterone. Um, and it's important that you know we we take that into account too, because we do have both estrogen and testosterone in our system. So, but that's why we don't prescribe it on our platform.

SPEAKER_02 25:04

Absolutely.

SPEAKER_04 25:06

And we have a question next from Emily. Um and Emily says the DHEA causes me sometimes to feel a little bit irritable. Is it okay to just take the cream without using the DHEA?

SPEAKER_03 25:17

Yes. I mean, if if you find that when you take the DHEA, you don't feel like your best self, you let your doctor know. And it's perfectly fine. It's an optional addition. Not every patient needs it or wants it. Um, and everyone responds to medications differently. So if if you find that it just doesn't work good for you, that's perfectly fine to use the cream by itself.

SPEAKER_01 25:36

The other thing that's interesting with DHEA, I've had um many patients, um, my wife being one of them, that um found when they first started DHEA that it was making them irritable and you know, having side effects, and they eventually stop it, um feel better for a while, and then sort of these side effects or not side effects symptoms start popping up where DHE might be helpful, and they try it again, and lo and behold, six months later, it's not causing those side effects anymore. So if it's been a while, it might be worth a trial and see how you do on it because the body changes. It's I'm not really sure why, quite honestly. Um, but um, but it happens. So some people that don't tolerate it, they wait a while and they try it again, and lo and behold, it actually works better for them. So it's it's maybe worth revisiting after some time goes by.

SPEAKER_04 26:24

Okay. And we have a question from Kathleen. And Kathleen says, it has been five years since my full hysterectomy. Is it too late to start HRT?

SPEAKER_03 26:34

It's not too late if you're under the age of 60, even though it's it's been five years since your hysterectomy, you could still start HRT as long as you're under 60.

SPEAKER_04 26:43

All right. That's always good to hear. Yes. And we have a question next from Mary. And Mary says, is there a progesterone-only pill?

SPEAKER_03 26:54

There is. So, I mean, there there are some patients that choose to just take progesterone itself. Um, however, you know, take it alone. But however, progesterone alone sometimes isn't enough to really help relieve a lot of the symptoms of perimenopause and menopause. Estrogen is really our powerhouse hormone for women. Um, and as the estrogen declines, you know, there's so many symptoms that start as a result of that. So giving your body back progesterone can help symptoms somewhat, but it may not give you the full effect and relief that you really desire for a lot of the symptoms that you're experiencing.

SPEAKER_04 27:30

And we have a question next from Lisa. And Lisa's asking, do all the doctors prescribe blood tests, or if not, how do they monitor our hormones?

SPEAKER_03 27:40

So this is a common question. I think we get this during every webinar we do, and often I would say I answer this question at least 10, 15 times a day from patients too. This is one condition in medicine where a blood test is not required. So your female hormones are so variable and they can be up and down, and they're released in such an erratic, pulsatile fashion that getting hormone labs is really not helpful. And it's not just our opinion here at Winona. This is the opinion of the Menopause Society, the American College of OBGYN. No one out there in our profession recommends getting baseline hormone labs to guide your treatment. This is something unlike anything else, right? So with a thyroid disorder, you check thyroid levels, you replace. If you have iron deficiency anemia, you check your iron levels and you give iron in certain doses. This is something completely different. When it comes to perimenopause and menopause, the best way to treat is based on your symptoms. So the best thing that we need from you is a symptom profile or symptom diary. So, and then we can take a look at that and try a dose for you and then make adjustments based on how your symptoms respond to that dose. So no blood tests are needed, and no salivary tests are needed, and no hormone from urine tests are needed. So please don't waste your money on those. There's a lot of people out there that really will take your money and promise you lots of things, but it's not needed at all to be able to start HRT.

SPEAKER_01 29:03

Yeah, this is uh something I'm fairly passionate about because um it really negatively affects women and it's really unfair. Um, I we get a lot of women um come on Winona, they went to their doctor, they had all the normal symptoms of the menopause transition. Their well-meaning doctor, I'm sure, didn't wasn't educated enough to know how you're supposed to do this, and they looked at their Quest lab sheet and oh, I can check an estradiol. So they check the labs, the labs come back normal and they say, Oh, this isn't from your hormones, you don't need HRT. Um, and they sort of get dismissed. Um, and again, I think it's a well-meaning, you know, well well-meaning doctor for the most part, um, but they're not sort of up on the latest literature, well-versed in menopause management. And then what happens is, you know, these poor people suffer. Um, and then they eventually find us. We listen to their symptoms, listen to their body, we say, gee, this is clearly gonna help. And we prescribe HRT, and lo and behold, you know, they message us in a month, oh my gosh, I can't believe how much better I feel. Um, and so it makes me happy that we're helping, but it makes me sad that um they got dismissed originally. Um and again, you know, I I don't think it's some evil doctor or some stupid doctor, or you know, especially, you know, family docs, they they have a hard job, they got to know something about everything, and there's no way they can keep up on all of that. So um, you know, it's well-meaning people, but it it women do end up getting dismissed and they don't get the treatment they want. So the whole lab thing, um it's one of my my passions to talk about because I think it it really ends up harming women. And then unfortunately, you know, there's a small percent of unscrupulous people that are just out there to take your money um and they'll charge you a thousand dollars for a Dutch urine test, which is basically useless. Um, and then you know, it's almost like well, forgive me if you like this, but you know, getting your palm red or um your your tarot card, you know, that kind of thing. Um, I think it just takes advantage of people. You know, you have these women that are having, you know, really significant symptoms that are affecting their quality of life, and they're sort of reaching out in desperation to get help, and instead they're, you know, unfortunately, there's a small percentage of people that are taking advantage of it. And so sort of both sides of that, the well-meaning person that's just not doing it right, and the few individuals, uh, you know, I'd say the vast majority that are, you know, just out to take your money, you know, it's both sides of that situation are just not good. Um, so it's something that we feel very strongly about and we try to educate about.

SPEAKER_04 31:48

Um, we have a question next from Marissa. Marissa says, My main issue has been significant weight gain around my midsection. She says, My doctor thinks it's a post-menopausal issue. She says, I'm getting work done, um, but I've never used HRT before. Does it make sense to use HRT now?

SPEAKER_03 32:07

Well, certainly, if you have other symptoms as well, or if if you found that the weight gain really started around the time you were starting to have the hormonal changes of perimenopause, it definitely could be helpful for you. Um there's there's really a constellation of things that happen to our bodies as we age. You know, our metabolism really revs down. Um, because we deal with insomnia a lot and perimenopause and menopause, we don't get restorative sleep, which then puts our body in a constant high stress state with high cortisol levels, high stress hormone levels. And so no matter how hard you try, it can sometimes be a losing battle trying to lose weight. You're like you're doing all the right things, but you're not seeing results. So for a lot of women, as we balance their hormones and they start to feel better and they start to get more, you know, quality restorative sleep, and their hormones are more balanced, they're out of that high stress state, they start to see results finally from all the things that they're doing with their nutrition and exercise. Um, and so that's something. And the other thing is you have to think about there's other factors that can really you know really lead to weight gain too. So the way that our body uses its sugar stores and the way that we respond to insulin, so many different things can affect how well our bodies can really process what we eat. So it's important to make sure that you're getting screened for diabetes, um, also making sure that you're getting screened for thyroid disorders, and they're more common in women than in men, and it's something that can also affect weight gain too. Um, but definitely HRT could help, like it helps a lot of patients.

SPEAKER_01 33:33

And let me just point out it's a long game. Um, so you know, a lot of people they'll message me uh in a month, I haven't lost any weight. I'm like, yeah, I wouldn't have expected you to. I mean, I I wish it worked that way, but usually this is three, six months um before you start seeing you know really significant positive results. Um but for a lot of women it's there. Um, but it's a it's one of the really late benefits from HRT. Whereas like the hot flashes, they tend to go away very quickly. Um the wait that tends to be a lot longer. Um so you've got to be in it, it's kind of a long haul. This is a long game thing, um, but it can help for many women.

SPEAKER_04 34:16

Okay. We have a question next from Tanya. And Tanya is um is asking, what happens if I get pregnant while on HRT?

SPEAKER_03 34:25

If you're taking HRT and you have a positive pregnancy test, you need to let us know and you need to stop your HRT, unfortunately. So there are so many things that are happening in your body, but you don't want to be exposing a growing baby to extra hormones that um you know that could do harm to the baby. So you would want to stop your treatment.

SPEAKER_01 34:43

Although there's no reason to think that it will cause birth defects. So if you do, if you're on HRT and you get pregnant, um, you don't have to, you haven't caused, you know, it won't cause birth defects, or you haven't caused any harm to your baby, but it's not you you don't want to sort of mess with your hormones in pregnancy. So it's something that you're gonna want to smell. Um, but don't think, oh my gosh, I've hurt my baby, I've caused birth defects. It won't do that.

SPEAKER_04 35:10

Um, we have a question next from Lisa, and Lisa says, so which one do you start with? The cream, the patch, or the pill, is one better than the other?

SPEAKER_03 35:19

It's really about patient preference. So, you know, it really is what you think you can incorporate into your lifestyle the easiest. If you're someone that's already taking pills in the morning and it would just be easiest to add another pill to that regimen, you know, then that might be the way to go. Um, if you're somebody who doesn't take medication regularly and maybe, you know, just wants to do something less frequently, maybe a patch would be better. However, if you've reacted to band-aids or medical tape when you've had your blood drawn and you you get, you know, rashes or skin irritation from the adhesives, a patch is not the way to go. So you have to take that into account as well. But it's really about what you think would work best for you. Um, and I always use the analogy that it's like trying on close. You know, every woman likes a different style, different fit, different cut. You never really know how you're gonna do until you try it. And I often will have patients that start one regimen and one type of medication, like maybe with the cream, and then they say, I really am not remembering to do this. I need to switch to something easier. And we switch them to something different. Um, so it really is sometimes trial and error, but pick what you think you can fit into your day-to-day life the easiest. It has to be easy for you to remember to take it regularly.

SPEAKER_04 36:28

Um, and we have a question next from Daphna. And Daphna's wondering, she says, I have a different taste in my mouth. Is that from the HRT?

SPEAKER_03 36:36

I've never heard that as a side effect of HRT, um, but I'm sure it's it's possible. But I I've had women talk about having a different taste in their mouth or being um a little bit more sensitive to smells from the hormone changes of perimenopause and menopause, too. So there can be a lot of different factors that could be affecting that.

SPEAKER_01 36:54

Yeah, that's would be a really unusual side effect, but um everybody's unique, so it's certainly possible, but it's certainly not something we hear. Um it's not a not a common one, that's for sure.

SPEAKER_04 37:08

We have a question from Jane next. And Jane says, Can you start Rinona if you are still having regular periods? She said, My OB suggested no and recommended an IUD and a patch, which I don't really want to do.

SPEAKER_03 37:22

Yeah, this is also another misconception. Along with ordering blood tests in labs, a lot of doctors out there really believe that it's not safe to take HRT until your period finishes. But really, it's safest to start whenever your symptoms are bothersome enough. For a lot of women, they're still having regular mencies, still having periods, but they're still, you know, they're they're dealing with insomnia, they're dealing with the hot flashes and night sweats, and it is perfectly safe to start HRT before your final period happens. So it's it's best to get the treatment on board when your symptoms are bothersome enough that you want to feel better. And so if that happens when you're still having periods, then that's fine.

SPEAKER_01 38:00

This is another little pet peep of mine as well. Um, is the whole, well, take a birth control pill, it'll work just as well as HRT. And the answer is no, it won't. Um, what happens is look, before I did Winona, I was doing full-scale OBGYN. Um, and I can tell you that most of my day was taking care of pregnant women or taking care of people for birth control. Um, some of my day was um doing surgery or signing people up for surgery or taking care of them after surgery, and a teeny part of my day was doing HRT. Um, so I mean I prescribed HRT in my office, um, not opposed to it, but it's not something I did very much. Mostly I was dealing with pregnancy, keeping people from getting pregnant. Um, and so birth control pills and other forms of birth control, I was writing all the time, totally comfortable. Boy, I could tell you everything about them. HRT is kind of every now and then. Um, and so people tend to go with what they're most comfortable with, including doctors. Uh and so most OBGNs are very comfortable with birth control methods, it's what they kind of do. Um, and so you know, it's like, well, you need hormones. Here's the easy way to get hormones because I'm comfortable with it, I know how to prescribe it. And so they use birth control as their sort of go-to thing. But unfortunately, hormonal birth control may help a little bit, but it's not going to help as much as hormone replacement therapy because HRT is really designed specifically to take care of this problem. Uh, and actually, this is something that a lot of movies don't understand. Um, but using HRT and birth control actually can work quite well. Um, if you need contraception, you can be on birth control, and then if you're still having symptoms of the menopause transition, HRT can come in and supplement that and really work in a little bit different way than the hormones in the birth control pill and help your symptoms that the birth control pill is not doing. So um it's kind of it's almost kind of a lazy way to do it, is just, oh, this is what I'm comfortable with, so I'll just throw birth control pills at people. Um, birth controls have a lot more risk than HRT and they don't work as well. So, like, why do that? Um, so it's not wrong to be on contraception if you need contraception. Birth control also works better at controlling uh menstrual issues. So if you're having heavy periods, something like that, an IUD can work great for that. Um, but it's not going to work as well for the symptoms of the menopause transition. And so HRT in addition can be really helpful.

SPEAKER_04 40:38

Okay. Um and we have a question next from Jill. And this is something that I also see a lot of women kind of talking about and discussing in WWG as well. So I think it would be great to also have like a doctor's perspective on it. But she's wondering, do I need to let my OBGYN know that I've started Winona?

SPEAKER_03 40:57

You should. I mean, when you go for your annual visit and you absolutely still need an in-person doctor to do an exam, because we can't do that through the computer. You still need a breast exam and a pelvic exam, and if you still have your uterus, you still need a pap smear. But it's very important that you tell your doctor, any of your doctors, what medications you're taking. This is indeed a medication, so you should be including it on your list. And if you happen to have the doctor who, like maybe you went to them with your symptoms and they said, no, no, I don't want you on that. I'm not going to prescribe it for you. And then you end up starting HRT with us. Don't be afraid to let them know that you have started and how good you feel. Um, we've actually had quite a few patients whose doctors have kind of converted after seeing their patients do well. Um, and patients then are able to switch off and sometimes leave winona as far as getting their you know HRT from us and are able to get their HRT from their provider in person because their provider sees how well they do, sometimes how well their health looks, you know, how well their other labs look. Um, and then they're convinced that, oh wow, like this is really making a difference. And so we're changing hearts and minds of doctors indirectly, I think.

SPEAKER_01 42:07

Yeah, we're kind of got a funny business model because yeah, we're losing your business, but we see that as a big win.

unknown 42:13

Yeah.

SPEAKER_01 42:13

Um, because yeah, we won over another doctor, and now that means they're gonna be able to provide this care for other people. And that's great. That's part of the mission. So we're very happy when that happens.

SPEAKER_03 42:22

Yeah, but the other thing is we we first do no harm. That's one of the oaths that we have to take. And you absolutely should be honest with every physician that's taking care of you about what you're taking. Don't don't lie, don't omit anything.

SPEAKER_01 42:35

Yeah, they say there's two people you should never lie to, your doctor and your lawyer, right?

SPEAKER_03 42:39

Or your accountant too.

SPEAKER_01 42:41

Yeah, yeah, yeah. Well, there are certain things your count is like, I don't hear that. Um yeah, uh, and I've coached patients before that are afraid to tell their doctor. I'm like, look, you're hiring your doctor, your doctor's not hiring you. Um, so you know, you don't have to make your doctor happy. That's not how the doctor-patient relationship goes. Um, the doctor is supposed to be taking care of your health. Um, he's not necessarily supposed to, it's nice when they're friendly and all that, but you're hiring the doctor. They're they're working for you, not the other way around.

SPEAKER_04 43:14

Absolutely. And we have a question next coming from Julie. Um and Julie says, I am just exhausted all the time. She says, Will HRT help? And or is there something else that I can incorporate to help with it? And then she says, as a side note, I am very active, eat healthy, but I'm healthy otherwise.

SPEAKER_03 43:35

Yeah, I think for a lot of women who are really affected by some of the sleep disorders of perimetopause and menopause, that's something that can make such a huge difference when you start HRT. You know, getting quality sleep makes such a big difference about you know your with your energy the following day. Um, the other thing too, back to the DHEA, for a lot of women, taking the DHEA in the morning really helps give them a boost throughout the day. It could really help combat fatigue and help with your energy level and give you that kind of natural boost. In addition to that, like I always tell patients to kind of look at what they're eating nutritionally too and make sure you're getting enough B complex vitamins in your diet. And if not, take a supplement. Sometimes that can help. But I think HRT can help a lot with that. And overall, women have more energy and feel better. You know, it's it's about providing um vitality and and wellness to you over time too. And I think that will really help.

SPEAKER_04 44:33

And we have a question next from Shanan. Um, and she is wondering can PCOS be addressed with HRT?

SPEAKER_03 44:41

Well, not directly. Um, but sometimes, you know, as you're going through perimenopause, if you were someone who was really affected by polycystic ovarian syndrome symptoms throughout your reproductive years, a lot of that tends to start to change as your ovaries are aging. And that missed that imbalance of hormones that you had with PCOS starts to kind of reverse itself as the ovaries age and their production of hormones changes over time. So a lot of times, you know, you'll notice that your symptoms get milder from the PCOS as time goes on. So women that have PCOS can absolutely still take HRT and do very well with it. If you're still having a lot of symptoms of the PCOS, meaning like the unwanted hair growth in different areas, um, you know, or or some of the other irregularities, um, then sometimes we hold off in the DHEA until those symptoms kind of lessen over time. Um, but most women with PCOS do very well, you know, on HRT.

SPEAKER_01 45:35

Yeah, it's kind of there's a few medical conditions that people tend to age out of. Um, childhood asthma is a great example. Um, not everybody, there's plenty of adults that have asthma, but a lot of kids kind of grow out of that. Um, and PCOS is another one that women tend to age out of as their sort of hormone production changes as their uh, you know, as the the age process happens. So it's it's one of the few benefits, I guess, of getting older for some women.

SPEAKER_04 46:06

Um, and we have a question from Heather. And Heather is wondering what is a timing that I should use for the cream if I feel like it's been causing me some trouble sleeping or having sleep issues.

SPEAKER_03 46:17

If you're taking it before bed and you're you're feeling like you're not sleeping as well, there's some women who get energized when taking any kind of hormone. And so sometimes I usually encourage them to try to experiment with using it during the day instead. So, you know, moving the application to the morning or even midday sometimes can be more helpful. Um, sometimes you just have to experiment to figure out what works best for your body because not everyone follows patterns.

SPEAKER_01 46:41

The progesterone in particular is interesting because for most people it's sedating, but there's a certain percentage, I I'd estimate maybe 5% where it's really activating like caffeine. And in that case, taking it in the morning is better. And then there's an even smaller percentage where it just gives them crazy dreams, um, sometimes unpleasant. Um, and so you know that happens occasionally as well, and then taking it in the morning fixes it. So, you know, you really want to listen to your body. Um, try, you know, it's fine to try different things and see what works for you because again, everybody's body behaves differently. It's very interesting, actually.

SPEAKER_04 47:17

Okay. Um, we have a question from Stacy, and Stacy is wondering if I'm on the DHEA, how will I know if the dose needs to be adjusted?

SPEAKER_03 47:28

Well, so basically, the reason why we give DHEA is to really complement the HRT, but it really can help with symptoms like fatigue, low energy, it can help with uh weight loss, it can also help with libido. And so if you're still suffering from those symptoms and you're not noticing the positive improvements that you're desiring, then sometimes we'll want to increase the dose. So, generally, after you've started treatment with us, you know, after you know, 10 weeks, we check in with you to kind of see how you're feeling. And if you're not really noticing much of a difference, we like to go back and explore, you know, back to your initial symptoms to see what is actually improved, what still needs improvement, so that we can make adjustments appropriately to get you feeling better.

SPEAKER_04 48:09

Um, and our next question comes from Heather. And Heather is wondering what is the difference of what Winona offers versus bioidentical hormone pellets.

SPEAKER_03 48:22

This is another thing that we talk about a lot.

SPEAKER_01 48:26

I am not a fan, I'll tell you straight out, I am not a fan of the pellets. Um I kind of joke that the the best reason to do the pellets is because it makes your doctor a lot of money, um, which is kind of a bad reason to do pellets. Um the the problem with pellets is you you get this thing, it's an invasive procedure, you get this thing inserted in you, which in and of itself has risks, and then you're stuck with it for three to four months. If you have side effects or it's not something that you like, it's too bad, so sad, you got to live with this for you know the next three or four months um until it finally wears off. So that's one of the problems with pellets. The other thing is that the most of the pellets are testosterone-based, like the bio T. And the concept to me just I don't like when things don't make sense logically. And so the concept is if we shove enough testosterone in your body, your body is gonna take that testosterone and break it down into estrogen, and you really need the estrogen. Um, well, let's start with estrogen then. So it's it's kind of a backwards way of doing it. Um, and so you're basically giving these big doses of testosterone that you probably don't need. In fact, your body doesn't think you need it, which is why it breaks it down. Um, and testosterone is a funny drug. Um, it will give some euphoria when it's first given. And so you get your first pellet and you feel great, you're on top. Oh my god, this is amazing. Um, and then maybe the second pellet is not quite as good. And by the third pellet, now you start getting, you know, facial hair and male pattern baldness, and god forbid, sometimes even voice deepening that may be irreversible. Another really scary masculinization, meaning you get chloromegaly if it really goes overboard. Um, and so testosterone in small amounts can be really helpful for women, but if you overdo it, it can cause a lot of problems. And because you're getting these pellets and you're stuck with it for three or four months, if somebody overdoes it and they tend to do it because that's sort of the theory behind the pellets, it can cause a lot of harm. Um, and so again, the first do no harm um is you know, again, like the guiding principle that we're all supposed to follow. And it's uh, you know, it's an invasive procedure with a lot of potential risk. Um, and you know, the benefits can be there, but they're not going to be any greater than more traditional treatments. Um and so to me, it they don't really make a lot of sense. Um, I understand why docs are doing it, um, but uh not necessarily for the best reasons. That's my two cents.

SPEAKER_04 51:04

We have a question next from Carla. And Carla says, if you apply the cream at night, aren't you washing it off in the morning when you shower, or has it absorbed by then?

SPEAKER_03 51:14

So generally, when you're applying the cream, it's absorbed within 30 minutes of application. You know, you want to rub it in until the skin pretty much dries. Um, but by the time the morning comes, it's absorbed, you know, the and so there's very little risk of washing it off or even transferring it to someone else as long as you've rubbed it in completely.

SPEAKER_01 51:33

And some people will tell me, well, I still see evidence of the cream, you know, in the morning, but that's evidence of the cream itself, not the hormones. The hormones have already, but there is you know a cream that carries those hormones, and they may leave a little residual that you can wash off as fine. But the hormones are well absorbed by them.

SPEAKER_04 51:55

Um, we next have a question from Mary. And Mary says, Can you talk about how cancer relates to HRT? Because I don't have um, I do not have breast cancer. Um I don't have. Oh no.

SPEAKER_01 52:09

Our bot froze up again. We've got to put another quarter in her.

SPEAKER_03 52:19

Well, I guess we could just add lib on this one, you know, until we get her back.

SPEAKER_01 52:23

But um you got the gist of the question. So yeah.

SPEAKER_03 52:25

Yeah, yeah. So I think a lot of women come to us when they're interested in HRT and their fear is about cancer. I think that's probably one of the most common questions we get from patients, you know, especially if they've had a family history or even a remote family member that's had breast cancer or some other type of GYN cancer. Um, and it's something that, you know, we certainly like to talk to you about as far as what your personal risk is. Um, if you've had a history of a personal cancer or you've had testing for a genetic syndrome that can make you at increased risk for a cancer, then you really are too high risk because those those conditions, you know, can be make you higher risk to take HRT for the recurrence of cancer or development of cancer. Like if you have a BRCA1 gene or if you've personally had a breast cancer before, then you wouldn't be a good candidate to get HRT from us. Um however, the general population for most of us, you know, if we don't have one of those really high risk conditions, our overall risk is fairly low. Um, and and studies show that actually the increased risk is when you use progesterone plus estrogen, but using estrogen alone can actually improve your risk and decrease your risk of breast cancer. Um, also looking at other things like colon cancer, HRT can reduce your risk of developing colon cancer over time as well. Um, and I have to think about that being that, you know, from estrogen really helping improve the quality of the tissues and the colon, um, you know, overall in the body. Um, so it's one of those things that anytime you take any medication, there's no medication without risk. There's risk to everything, there's risk to taking Tylenol if you take too much. Um, so for you as a patient, you have to weigh the good, the bad, the pros, the cons, look at your own personal situation. We can kind of help talk you through it when we're counseling you about treatment, but you ultimately you have to make the best decision for you in your life.

SPEAKER_01 54:18

And uh we said this earlier, but again, I'm a big picture guy. Um, and if you look at the overall risk, because look, the one statement I can make that everybody in the world will agree with is that eventually everybody has to die at least once, right? Um, so you know, something's gonna get you eventually. The idea is to put it off as long as possible, as long as you're you know enjoying life and living healthy, you know, yeah, you're you're healthy and and life is good, you want to put that off as long as you can. And HRT is going to do that. So, on average, if you use HRT, you're more likely to live a longer, healthier life than you're not. Something's gonna get you someday, you know, you might get hit by a truck or you might get a cancer or you might have a heart attack. Um, that's gonna happen eventually. Um, the idea is to put it off as long as possible, and HRT will help you do that. So you can pick out individual things that, okay, well, maybe it raises risk of this, although it lowers risk of that. But the big picture, it helps you achieve what most people want to achieve, and that's to live a long, healthy life. I think that's the healthy way to look at it.

SPEAKER_04 55:26

Um, well, it looks like we have time for one more question. Um, and I think the last question tonight is going to be from Natalie. Um, and Natalie is wondering: do you have any recommendations for low sex drive during perimenopause?

SPEAKER_03 55:40

So, really, um, I think that overall the combination of HRT with estrogen and also the DHEA supplement can help a lot of patients. Um, you know, and so the DHEA really helps by helping to boost that testosterone level, um, but also helps with your energy. Um, and and for us as women, I think that the other really important thing to remember is that our largest sex organ, the thing that really drives our libido is right here. It's our brain. Um, and so I think that it's another thing to take care of. So when you um are starting HRT and you're in this period of time, you know, really getting quality sleep, taking care of your body overall, reducing that stress level, all these things can really help with your overall um functioning in all aspects of your life, but can really help with your sex life as well and help with the libido. But I think that that's something that a lot of women don't consider. We know we think that there's some just some magic pill or something that we can just help. Um, but really we need to be in the right headspace. You really need to kind of do the work to really make your your overall body well and better. Um, and the HRT can help with that.

SPEAKER_01 56:48

Yeah, one other thing that we haven't really mentioned tonight is the estrogen cream.

SPEAKER_03 56:53

And vaginal estrogen cream.

SPEAKER_01 56:54

No, there's blossom too. So, yeah, there's two things we haven't mentioned. So, vaginal estrogen cream, um, you know, one of the common symptoms of the menopause transition is vaginal and bladder symptoms, thinning of the vagina, atrophy, pain with intercourse, dryness, um, and that can be a real detriment. Um, and let's face it, if sex hurts and isn't fun, you're not gonna want to do it. Um, and so really treating the vagina topically with estrogen can make a huge difference in the health of the vaginal tissues. Um, it can help thicken them up, increase lubrication, decrease pain, um, especially if it's really thin, you're having tearing, this can fix that. Um, and so it's a it's a treatment that a lot of people forget about, um, but I think a really important one that can really help if that's part of the underlying cause. Um, and then um finally I'll let you hit the blossom cream.

SPEAKER_03 57:53

Yeah, we talked about this in the last webinar, but um, yeah, one of the things that we do offer that's kind of an add-on to the HRT if you decide to get treatment with Winona is blossom cream, which basically is a medication that you apply to the clitoris that helps to increase blood flow to the area to help get you in the mood, helps you know, blood rush to the area to kind of make you feel a little bit more sexy and more receptive to sexual activity. Um, it's usually applied 30 minutes before intended activity, and it can really help with um achieving orgasm, achieving lubrication, achieving arousal. Um, and so that's something that you can always add to the regimen as well to kind of help with those symptoms as well. But um, but you need to think about it and and have the you know the preemptive thought to apply the blossom, you know, when you think you're going to be active for it to be helpful.

SPEAKER_01 58:43

So the active ingredients identify the same ingredient in Viagra. So it's you know, it's not fair that just men get the Viagra, right? So um it's something that again, the way it works for men is by increasing blood flow, and that's how it works for women as well. So it can be, but it's applied topically, which makes it super safe. Really, almost no side effects. Um, so that's one of the real benefits of it.

SPEAKER_04 59:06

Absolutely. Well, and just a uh reminder to everyone who is here, I hope that you got a lot of your questions answered. But we know that there's always so many questions, and we love that so many of you are here and really just like leaning into your health journey and what that looks like. Um, if you're Winona patient, your Winona doctor is available 24-7 in your patient portal. So any of these questions that you're having, that is a great place to ask those. They're here to help you. Um, that's what they love. I love what you were all saying too earlier about um, you know, do no harm. And I think that that also goes over to the rest of the doctors at Winona. So um, that's a great place to add all your questions there. Um, also, if you're interested in there, we always have lots of live live QA's and doctor dialogues happening every month. Um, but if you'd love to check out some other conversations we've had, we also have a Winona podcast um called the Menopause Hour, where you can also listen to some more of these conversations and get some more questions answered. If you're kind of interested in diving, you know, down deep into the rabbit hole of kind of what's going on. That's a great place to do that. Um, but again, thank you so much for coming. We're so glad that you were here and you took the time out of your evening to be with us. Um, and thank you, Dr. Green and Dr. Kat, for just taking your time also and sharing with us. It's always so interesting getting to hear your all's perspectives. Um, but always a great time. And we hopefully we will see everyone next time. Um, but have a great night, everyone. Um, and thanks for coming.

SPEAKER_03 1:00:29

Yes, thanks for coming out.

SPEAKER_00 1:00:31

Thanks for night, everyone. Thank 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 buywinona. Want to have your questions answered next? Register for our upcoming live QA. Linked in the show notes.