Episode #7 HRT & Sexual Wellness: Reclaiming Pleasure in Menopause

In this episode, Dr. Green and Dr. Cat dive into menopause, hormone replacement therapy (HRT), and the importance of self-care—just in time for Valentine’s Day. They discuss how menopause affects libido, the benefits of HRT in restoring sexual health, and introduce Blossom, Winona’s orgasm-enhancing cream. The episode also tackles key topics like estrogen therapy, hormonal imbalances, DHEA, and how HRT impacts joint pain, migraines, and metabolism. Plus, they answer audience questions on progesterone options, testosterone and heart health, and HRT safety for those with endometriosis, fibroids, or osteoporosis.

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Transcript

SPEAKER_05 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 0:19

I actually uh did a family practice residency and fell in love with delivering babies and women's health. And so I did a whole second residency to be an OBGYN. So I've been doing that uh basically my career. So I finished residency in 99, so however many years that makes it, a long time. And uh I'm the chief medical officer of Winona and I'm really excited uh to be able to provide this for y'all. So we um you know we unfortunately there's a lot of doctors out there that aren't comfortable prescribing HRT or don't know how to do it, and so people are kind of left in the cold. And so uh we feel um very privileged to be able to fill the gap and get people the help they need. Um we're here to answer your questions, so uh not to just talk, talk, talk. So um put your questions in the chat so um so we can answer them for you, and I'm gonna pass it off to Dr.

unknown 1:15

Kat.

SPEAKER_04 1:16

Hi everyone. I'm Dr. Kat Brown and I'm the medical director at Winona. Um, I'm also a board-certified OBGYN, um, finished my residency a little later than Dr. Green. I graduated in 2008, um, trained in the Army, moved around the United States, um, but I'm originally from the Philadelphia area and I've I've landed back here. I'm in the Philadelphia suburbs now. Um, and I joined Winona back in 2021 because I was actually going through my own challenges with perimenopause. And unfortunately, I think that I was of the generation where we were taught that this was not something we were gonna do. But now, as as we are aging as a population of female OBJans, many of us are demanding better because we don't want to suffer and we're seeing our patients suffering. And I think that um, you know, that was really the impetus for me to learn as much as I could. And while I was advocating for my own care, Dr. Green approached me and asked me to join Winona. And it's been a wonderful journey because um I really, really enjoy helping patients in this time of life. I think that not enough focus is given to women's health and midlife and after. Um, it seems like our worth kind of dwindles down after we're done with our fertility and not a lot of effort was put into it. Um, and I think that that dialogue is changing and the tide is is turning because women are demanding better, you know. And look at all of you out here um, you know, coming for more knowledge and to learn. So thanks for coming out tonight. And we want to enter a bunch of your questions um and help you feel more comfortable with this and let you know that you're not alone in this journey. So um, and normally we kind of talk about a topic of interest, you know, at the start as we're letting you start putting your questions in the chat. And it's February. Um, and what I think of in February, of course, is Valentine's Day. In fact, before I put my daughter to bed tonight, she was trying to get figured out like what she's gonna do for Valentine's for her class. But for us as women, I think that it's really important that you know you think about self-love, and I think that you think about what's good for you. And one of the other things that happens to women in midlife is that our libido and our sex drive can get significantly affected. Um, and that's something that HRT can definitely help. But we also have another product at Winona that we don't talk about as often on these webinars, and it's a product called Blossom, and it's actually an orgasm enhancer. Um, there's a lot of different um medications that people have used over the years. You know, I grew up in my training learning to prescribe something called scream cream, which I hated the name of, but it was a similar product. Basically, it's a product that can help enhance the blood flow to the clitoris and the tissues of the vulva to really make those tissues more receptive to you know sexual contact and get you more in the mood as it's bringing blood flow to the area and to those tissues. And so it can really help with a woman's experience of intercourse or even any sexual activity. It doesn't even have to be penetrative intercourse. Um, but I think it's important that um women know that we have this and it's available. It's something you could, you know, add to your your treatment regimen with us because it can help with your sex life, it can help with that part of things. And why not in February when it's the month of love and you know, Valentine's Day? I think it's uh, you know, something that um you know that we should consider, you know, and and even if you don't have a partner, self-love's important too. You know, that you know, sexual health is important, so something to consider. So wanted to talk about that a little bit and let you know that that's available.

SPEAKER_06 4:53

So do we have some questions piling in, Maddie? Of course we do. Actually, quite a few, I was gonna say. Um so we'll jump into those. I was gonna say, yes, always love a lot of questions, and it looks like we have lots of people from uh that are tuning in from like lots of different states as well, which is also super exciting to see. Um that's one thing I love about Winona too, is just that you know, we're able to like help support women from so many different places, which I think is so cool. Um, but our first question tonight is from Pam. Um and Pam says, I'm perimenopausal and was offered estrogen, but I didn't think that I was having any like low estrogen symptoms. She said, I have primarily no hot flashes or vaginal dryness. She's wondering why I was offered estrogen. I'm just a little confused by this.

SPEAKER_04 5:39

Well, frankly, it's just normal physiology for women that as we age, our estrogen declines. And fundamentally, it's because we're born with all the eggs we're ever going to have. Um, and as that number of eggs and the number of ovulations that we're gonna have left decreases, our estrogen production decreases as well. So even though you may not have those very um classic symptoms that you think of low estrogen related, like hot flashes and night sweats, it's still happening behind the scenes. Your body is still decreasing its estrogen production, um, whether or not you feel it acutely or not. And so for us as OBGYNs, we know that that is by far the most beneficial treatment for you during this time as your body is ramping down that production of its own endogenous estrogen. So even though you don't have those classic symptoms, there are still so many health benefits that you can get from supplementing with estrogen therapy. Um, and it would help with a lot of the other symptoms that aren't so classic too. So, like brain fog and joint pains, all kinds of things. But but that's why it's generally recommended when patients start to come to this transition point in their life.

SPEAKER_01 6:48

Do we get a lot of patients that come that way, like what you're saying? And then they try one of the estrogen products, and they're like, oh my gosh, I didn't even realize, like I got so used to this, I didn't even realize it was happening. And now that it's gone because the estrogen is helping, I realize how much better I feel. Um, and similarly, we we'll have people that, well, I don't think it's doing anything, and they go off, and then a month later they message me, oh my gosh, I need it back. I didn't realize it was helping so much. So it's sometimes subtle, and you don't realize that it sneaks up on you. Absolutely.

SPEAKER_06 7:21

We have another question from Neelam. Um, and uh she uh she says, My question is, and I love having doctors on this call too, so if I mispronounce anything, please correct me, doctors, on this. She says, Can hormonal imbalances cause hyperosema hyperosema or hyperosmia, like uh enhanced smell, maybe?

SPEAKER_04 7:42

Is that what she's referring to? Um H Y P E R O S I M A. I think that's probably what she's referring to. This is a phenomenon that's not talked about as much, but actually, um, when there's hormonal surges in a lot of different parts of our lives, and I we hear about it more in our careers in pregnant women, actually. Like when women are pregnant, they get noses like hound dogs, and you could smell something like two rooms over. Um, and the same thing can happen again in the perimenopause and menopause transition. Um, in fact, I experienced that myself comparatively, like to when I had my three kids. I used to smell things so vividly. And if something smelled awful, I had to like get it out of the house because I could smell it all the time. Um, and that came back with perimenopause for me. So for some women, that can be a symptom. Um, and I'm I'm not quite sure that at an anatomic level, like what exactly the hormone fluctuations are doing to those little cells in our brain, you know, when we smell things, but I I think it's kind of fascinating that it can happen during those two junctures of our lives.

SPEAKER_06 8:47

So absolutely. We have a question next from Kat. And Kat is wondering can you help us understand how DHEA can maybe help us or maybe make us lose hair? And how common is that? Should I be worried about that?

SPEAKER_01 9:04

Let me grab that. So DHEA um gets broken down into testosterone and estrogen, mostly testosterone. And so we use it as a way to help increase testosterone levels. If you take too much DHEA and you really take get too much testosterone, it can cause testosterone side effects, which are masculine, what we call like masculinization. And so male pattern baldness is a potential side effect of DHEA. But we prescribe it at Winona at 25 to 50 milligrams. It's not really enough to do that. We're talking 200, 400 milligrams a day to cause this kind of problem. So the hair loss that you read about with DHEA is really male pattern baldness, it's not sort of increased hair shedding all over. Um, that's a whole different thing. So um it's you know, a lot of times people love to blame the DHEA on normal phenomena or whatever, you know. It's like, oh, I stubbed my toe, is it my hormones? So the DHEA, you'll read about that, it can cause hair loss, but it really causes hair loss in really high levels. So the 25 to 50 milligrams, it really shouldn't. What may be going on is that when you start hormone therapy, um, it can sometimes sort of shock the hair cycles, um, and your hair goes into uh uh an arrest phase where it's not cycling, it's all kind of just dormant. Um, and then it starts falling out altogether. So normally you lose a few hairs every day, but you've got some hairs on the loss phase and some hairs on the growth phase, and so you don't really notice it. But when everything sort of pauses and then starts back up again, everything's going through that fallout phase and it's scary. Um, and that can happen sometimes, it can happen anywhere between a uh you know a month or two after starting HRT or even up to six months, um, depending on on sort of uh how how extreme this is. Uh, I can tell you it it can happen on any kind of major stress. Um, when I was a teenager, when I was 17, uh I got into a terrible car accident. I was in the ICU and hospitalized, and um, and then after I was recovering three, four months later, all my hair started falling out. I'm going bald. And I went to a dermatologist and they explained this to me, and sure enough, it all came back. Um, so it, you know, it's scary. I've been through it myself. Um, but that's probably more likely what's happening um if you're noticing hair shedding than the DHA.

SPEAKER_06 11:31

We have a question from Erica next. And Erica says, um, can you qualify for HRT if you have endometriosis and fibroids?

SPEAKER_04 11:41

Yes, I mean, even though you have those conditions, those are benign conditions that we're very familiar with and well-versed with as gynaecologists. And so, you know, there's some things that we might change about your treatment um compared to other patients, but um, but you're certainly still a good candidate for HRT, even with a history of either of those.

SPEAKER_06 12:01

Absolutely. We have a question from Bia. Um, and Bia says, I'm 48, not yet in menopause. Um, no basomotor symptoms, but frozen shoulder and a few other musculoskeletal issues. I would like to start HRT for bone, muscle, heart, uh, brain health, etc. Am I too young to start?

SPEAKER_04 12:21

Not at all. This is a perfect time to start, actually. So even though you're not having the classic symptoms, you may be having symptoms that have been subtle enough that like they're not standing out too much for you. But the frozen shoulder is actually a really common symptom I've heard from a lot of patients. Um, and the you know, oint joint pains. And honestly, like when you think about reasons why people get joint pains and arthritis and things like that, the age-related arthritis usually happens later. Um, a lot of this is because of loss of estrogen from the joints itself and the joint spaces, like all the tissues optimize their function when they're well lubricated, and the estrogen is making the cartilage and all the joint synovial tissues healthier. And without that, you get all these joint pains. So this is a perfect time to start. So it's not too late at all.

SPEAKER_06 13:09

Absolutely. Uh we have a question from Mariah next, and she says, Hi, um, I'm wondering if the progesterone cream is suitable to protect the lining of the uterus.

SPEAKER_01 13:22

So the answer, the short answer is yes. Um, there's a much longer answer to this, and that is it depends. Um, and so the the problem is that progesterone is a large molecule and it doesn't absorb through the skin as readily as estrogen. Because of that, the S the progesterone creams have to be done correctly, and it's tricky and it needs to be done right. So, one thing is you need to use what's called micronized progesterone because it absorbs better. But even more importantly, you need to dose it correctly. There needs to be enough in the cream to get through so that enough of it gets through the skin and gets absorbed to protect the uterine lining. Unfortunately, not everybody does this well. And even more unfortunately, I mean you can go on Amazon and buy a progesterone cream, it's sort of progesterone in name only. The reason they can sell it without a prescription is it doesn't have very much progesterone in it. And so there have been women that have thought they were getting a good progesterone cream, like off Amazon or somewhere else, uh, and they really weren't getting enough progesterone to protect themselves, and it's they've ended up having problems. And so then appropriately, there's you know, our big organizations like the National, um, the Metopause Society and Um ACOG, and and these people say, hey, you got to be really careful if you're gonna rely on a progesterone cream for endometrial protection. And I 100% agree, you absolutely do, and we absolutely are. So, one of the nice things about Winona is that we use our own compounding pharmacies. So we have complete control over our creams, over the quality, over the doses, this kind of stuff. And you know, we're all experts in using this. So this is something we're extremely careful about. Um, and you know, we've had a lot of patients over the years and we haven't had problems. So we're clearly doing something right. So the answer is yes, it's safe if it's done well and if it's done right. So that's the you know, that's the big caveat.

SPEAKER_06 15:23

We have a question from Marie next. And Marie says, Does testosterone cause issues with the heart? I have a friend that's 61 who was told not to take it because of an increase, an increase in risk with heart issues for testosterone.

SPEAKER_04 15:40

So, I mean, in in general, if you're starting any hormone therapy like from scratch after age 60, there is an increased risk for you, especially in the first couple years of use. Um, and so that that applies to estrogen, but also could be with testosterone as well. And the other thing too is that our bodies can convert one of those hormones to the other, too. And so that could be related to why it increases the risk as well. But it could be just the age-related, like if you're starting something new. Now, if you've already been on treatment prior to age 60, that that the same risk does not apply. It's it's really starting people new after age 60.

SPEAKER_01 16:20

There's um we know that really high levels of testosterone, bodybuilder levels, um, can certainly put a strain on the heart. Um, there was um there's some studies that have been coming out, really for men for TRT, um, where replacement doses of testosterone actually seem to be beneficial for heart health. Um, those studies have not been done in women, um, but one would expect um that again, now replacement doses for women is gonna be a lot lower than replacement doses for men. Um, but if you're replacing testosterone in to normal levels, um, there's reasons to believe that it's probably more cardioprotective, heart healthy than not. But if you overdo it with testosterone, yes, I can definitely put a strain on the heart.

SPEAKER_06 17:05

Awesome. We have a question from Sky next. Um, and Skye says, going through menopause with NA uh NCAH has been total hell. And I'm just curious if you think patients with NCAH or other things or other things with similar symptoms like PCOS should we do any should be doing anything differently. I'm on 0.075 milligram patch and a 200 milligram prometrium cyclically, which has helped with mood and energy, but I'm still having awful PMS in periods.

SPEAKER_04 17:38

So if she's referring to CAH, meaning like congenital adrenal hyperplasia, that's um a condition that really warrants careful care, you know, with an endocrinologist. Um, it's much different. And what's happening hormonally and in your body is so much different than the average woman, um, a lot more challenges. And so I think it's important that you have collaborative care, you know, with one of those specialists and not just, you know, hormone replacement alone. I think that there's a lot bigger picture for your total health that needs to be taken care of with that disorder. So, you know, that's something to be taken into account. Whereas we have a lot of women who, as they enter the perimenopause transition, who have a history of PCOS, which is polycystic ovarian syndrome, where the environment that their body was in when they were actively suffering from symptoms of PCOS changes as the ovaries age. And the hormonal imbalance that they struggle with throughout their fertility years and their younger years is no longer a real issue. And so actually, as women with PCOS history age, they get normal, you know, female physiology when it comes to their reproductive tract. And so they generally still benefit from HRT because they're not still suffering from a lot of those PCOS symptoms as they get older. So a little bit different. Those two conditions are very different medically for us. So for sure.

SPEAKER_06 19:01

Um we've got another question from Melody. And Melody says, I've got a fairly hefty supplement routine, and I'm nervous about whether I should continue or what I should continue to take or stop and how to transition from the supplements to HRT. Um, she says, I'm also worried about not wanting to trade the relief I've filled with supplements for other relief. Do you have any thoughts on that?

SPEAKER_01 19:25

Yeah, go ahead. Go ahead. I was gonna say most there's very few supplements that that need to be stopped when you start HRT. Um, although I think what a lot of my patients find is that when they start the HRT, they realize, hey, I don't need all these supplements anymore because the HRT is doing an even better job of taking care of the symptoms that I started the supplements for. So my advice is start the HRT, list your supplements with your doctor and make sure there is anything that's not safe. And then start the HRT, and then as it starts kicking in, start peeling off some of the supplements, and you might find that you're not needing them anymore. Not only will it save you a whole lot of money because supplements can be expensive, but they're also kind of a hassle. I mean, we see people on you know a dozen or more different things they have to take every day, which to me seems like a full-time job keeping track of. So if you can sort of peel off some of those and you don't notice any difference, and in fact you feel better because the HRT is doing a better job, all the better. So that was the way that's the way I would approach it.

SPEAKER_04 20:30

The other thing, too, is I think that so many of our patients, it's confusing if you go out there trying to search for a supplement for relief in this time period, because I there are so many new companies popping up, and some with the latest, greatest Hollywood star trying to represent them. You have to be very, very aware of you know how much they're pushing it, how who's endorsing it. Um, and if they make a lot of false promises, take that with a grain of salt. Because usually, if they promise you the world, you know, to try to sell you a bottle of their $100 supplement, you you gotta think, like, is this really gonna work? And um, there's so many proprietary blends of supplements coming out. Like a lot of our patients, when they're listing their medication list, and I'm going through it, I'm like, what the heck is this stuff? Like I've never even heard of some of these. Um, and so I'm asking I do a lot of Googling.

SPEAKER_00 21:18

Yeah.

SPEAKER_04 21:19

Well, I'm I'm asking patients to take a picture of their ingredients on their bottle and put it in the portal because otherwise, it would be a lot of work for me to be Googling all these companies and all this stuff. It's just, it's crazy. There are so many supplement companies popping up for menopause relief. Um, and I think unfortunately, it's giving a lot of patients some false hope. And then a couple months into doing it, they're realizing like they're in the same place they were when they started, but now they're down 500 bucks. You know, it's crazy.

SPEAKER_01 21:46

Yeah, unfortunately, you went, yeah, things that sound too good to be true usually are.

SPEAKER_06 21:51

Yes, unfortunately. Definitely. Well, we have another question from Susie, who is watching live in the Facebook group. Um, and Susie says, I'm 58 and had a complete hysterectomy when I was 30 years old. I don't take any HRT, but I now have osteoporosis. I have lots of cancer in my family, so I've been afraid to take hormones. Do you have any thoughts on this, please?

SPEAKER_01 22:18

If you actually have osteoporosis, there are better medications than HRT for your osteoporosis. So you really should um talk to your doctor about that. Um there's some really good medicines for osteoporosis. HRT does a very good job of helping to prevent osteoporosis, or for actual treatment of osteoporosis, it it helps, but there are other medications that are better. Um if by a complete hysterectomy that includes both of your ovaries, um, really once you're 10 years out, your risks from the HRT start going up. So if it's been 20 years and you've never had HRT, there may be some substantial risk for you to start it, and it may be kind of the wrong time to do that, unfortunately. Um that window is sort of shut, not because of the cancer risk, but um uh because of other other risks if you um have been sort of devoid of hormones for 20 years. So um that could be a significant issue.

SPEAKER_04 23:12

However, everyone can get vaginal estrogen. If we're gonna go back to the Valentine's Day theme, I'm gonna keep an eye. You know, so no matter what your history, no matter, you know, even women that have had cancers can use vaginal estrogen safely. Um, and that's something that, you know, we don't talk about as much, but women can experience significant um dryness and vaginal atrophy, um, loss of the elasticity of the vagina and the vulva. And so that can make, you know, experiencing any kind of sexual contact very uncomfortable. And it's an important part of life, it's an important part of relationships. And so vaginal estrogen is something that everyone qualifies for. Um, and if you see a lot of the other menopause docs in the social media space, everyone is trying to advocate for getting that black box warning for vaginal estrogen removed because it we almost think it's so safe that it should be available over the counter, vaginal estrogen. You know, we wish someday, hopefully.

SPEAKER_01 24:11

Yeah, it's really hard to hurt yourself with vaginal estrogen, Karen.

SPEAKER_06 24:14

Yeah. Absolutely. Looks like we have a question from Kate. And Kate is wondering what dose uh should a postmeno uh menopause take of estrodiol?

SPEAKER_04 24:27

Well, it's ever every woman is unique, and so we take into account, like, you know, how bad your symptom profile is, what your your BMI is, um, what medications you've been on in the past. Um, we have an algorithm that Dr. Green actually came up with that kind of helps us to come up with your starting doses, but just being a certain age and being postmenopausal doesn't mean that everyone gets the same dose. It's not a one-sized fits-all solution. And treatment is really individualized. And so I think that that's important. And, you know, also just like any other hormonal medication, sometimes we never really know how you're going to respond until we try it. And so there's a bit of trial and error and tweaking dosages to try to get you to the best regimen and get you feeling your best. And so it's not a one-size-fits-all.

SPEAKER_06 25:15

We have a question next from Kat. And Kat says, I'm starting this at age 53. Do I have to stop at 60?

SPEAKER_04 25:22

No. No. As long as you're starting safely in your early 50s, you can keep going until you're ready to stop. And so, for a lot of women, the more we learn about the benefits of HRT and the benefits of estrogen, many of us don't want to ever stop because we feel so good on it. I'm gonna have to pry it out of my cold dead hands.

SPEAKER_00 25:43

With wonderful skin.

SPEAKER_06 25:47

We have a question next from Allison. And Allison says, Hi, I have terrible migraines which started during perimenopause. Is HRT something that is prescribed to help with migraines ever?

SPEAKER_01 26:00

It can help depending on the cause of your migraines. And if your migraines showed up when your hormones started changing, it very well may be beneficial for you. Um, so you know, there's a lot, obviously, a lot of reasons for migraines, and many many, I'd say most of them aren't hormones, but there definitely are hormonal-related migraines. And for those, uh HRT can help quite a bit. So it very well may help your migraines, especially if they just sort of started popping up as you started going through the menopause transition.

SPEAKER_06 26:31

Absolutely. We have a question next from Lynn, which I feel like you both are going to like this question. Um, but she says, What exactly is perimenopause? She says the symptoms always seem so vague. Um, how do you know when HRT might be the answer?

SPEAKER_04 26:46

Well, so perimenopause is that time period where you start having symptoms, you start experiencing changes before you reach menopause. And for most women, it can be a 10-year period of time. Um so for most women in America, the average age of menopause is 51, which means you could be starting symptoms of perimenopause at 41. Although that's the average. So there's going to be women that are earlier than that, there's going to be women that are older than that that experience it. And the hardest part about it is that this early symptoms are very subtle. And if you're not sure, there's there's quizzes online. We actually have a symptom tracker, like a quiz that we have available in our free resources on our website. That if you're not quite sure, you can always go through that and see and kind of take inventory of your own symptoms to see if if you're going through this or not. But a lot of the early symptoms are subtle. It could start out with menstrual irregularities, sometimes brain fog, um, loss of concentration, hard to stay focused. Um, and a lot of women will also start to notice sleep problems early on. And then after that, they might notice some vaginal dryness, some joint pain. But every woman's journey is unique, and the order in which things happen is not always the same for everyone. Um, in fact, the patient that complained earlier about the migraines, like that is exactly what happened to me. I started having headaches like crazy and went through this million-dollar workup of having my brain scanned and all kinds of stuff, looking for bad things. And ultimately, getting on HRT made the migraines go away. And I had never had them ever in my life. So it was a strange thing. So for some women, it could be that. Um, you know, the way that our hormones change in this time period affects every one of us differently. Just like every woman has a different period, every woman's gonna have a unique perimenopause and menopause experience too.

SPEAKER_06 28:36

Absolutely. We have a question next from Monica, and she says, one of my main questions tonight is how do you handle those of us who are menopausal but are estrogen dominant?

SPEAKER_00 28:49

Oh, we both have to take a deep breath on this one because that's a trigger for you gotta say OBGYN is that's a trigger for OBGYN. So trigger warning.

SPEAKER_04 28:59

Every woman in her identity is estrogen dominant because she's female. But estrogen dominance is actually not a medical problem or actually a real diagnosis in our world. It doesn't even exist. Like if I wanted to type a report to an insurance company, it doesn't even exist as a diagnosis code for me to be able to label someone's condition. So women who have some hormone imbalances, like in the history of PCOS, or they have you know irregular cycles, there could be a hormonal environment where their progesterone and their estrogen are off balance. It doesn't mean that they're like superproducers of estrogen. And that's what I think a lot of women feel like. They are estrogen dominant and they have so much estrogen that they they couldn't possibly benefit from getting estrogen. It's just physiologically impossible for a woman who is aging in her 40s and 50s to have so much estrogen that she wouldn't need estrogen replacement. It's just uh the physiology of the ovary and how it's aging, and it's a universal issue that every woman's estrogen production decreases during this time. So I have yet to meet a woman in midlife who would not benefit from estrogen therapy. So anyway, that's my diplomatic answer on estrogen dominance. But yeah, it's a little triggering because I we have a lot of patients out there that had that diagnosis or someone's told them that, and and unfortunately, it's just not a real condition.

SPEAKER_01 30:27

You know, the uh you know, the the whole PCOS thing. So there is an issue for women who have an imbalance between their estrogen and progesterone, typically in the younger years, um, where the uterine lining is seeing more estrogen than progesterone, and it can cause a problem. So I kind of think that's where this phrase started. Right. Um because it kind of makes sense for that. And then we have to be really careful, make sure they get enough progesterone to keep the uterine environment safe, to keep the uterus safe. And um, that kind of goes back to I think our first or second question about is progesterone in the cream enough to protect the lining of the uterus? Because that's always an issue all through life. Um, if the uterus, the lining of the uterus sees too much estrogen, it will overstimulate it, and that can cause problems. Um, so in that way, I guess there can be sort of estrogen dominance when you're talking about the lining of the uterus, but that sort of got morphed into this weird thing that you know it's not a medical thing, and people have sort of latched onto this. Um, and certainly, even as Dr. Kat was saying, people with PCOS tend that part tends to go away as they start going through the menopause transition. Um, and so even if you had that condition, your estrogen levels are still gonna decrease as your ovary production of estrogen goes down. Um, there's just no other way for it to happen. Um, and so uh if you're having symptoms of the menopause transition, if you're of a certain age, um, estrogen is gonna be beneficial for you, even if someone told you you were estrogen dominant at some point.

SPEAKER_06 32:04

We have a question next from we have a question next from Mary, and Mary says, I have terrible insomnia. What can I take to get back on a normal sleep schedule?

SPEAKER_04 32:18

Well, sometimes starting HRT can significantly help that. Um, but there are some significant lifestyle changes that a lot of us need to make to optimize our sleep hygiene. Um, and that, you know, basic things is making the bedroom only for sleep and sex. Um, you know, not having devices, not having a TV in the bedroom, other things that stimulate us. I mean, there's been studies done that looking at screens constantly keeps our brains too alert and it's really hard to wind down.

SPEAKER_03 32:47

Um, the other thing is to our caffeine consumption. Um, and for some women, if you're like me, and you know, after having a couple kids, like your bladder just wants to empty all the time. So you have to actually start restricting how much you're drinking later into the evening because otherwise you'd be getting up so much to pee. It's the full bladder that's waking you up. Um but the caffeine use and all that kind of thing, I think is important too. Um as a general rule, I think you know, if you tried HRT, your sleep's still not improving. The other thing I like to recommend is melatonin, which is an herbal supplement, and it's a really nice, gentle, natural way. It's what our body produces to help with our circadian rhythms and our sleep cycles. And if you're not producing that in adequate amounts anymore, your sleep can get really disordered. And so taking melatonin supplements can help. Um, and so that's something that can help. But a lot of women, their sleep really improves once they get on HRT and they're estrogen. I think it really helps.

SPEAKER_01 33:45

Alcohol is another one. Uh oh, yeah. Um, so drinking alcohol late at night or even in the evening um can really affect your sleep. Um, so you know, and that's kind of oh, I'll drink, I'll have a drink and it'll help me fall asleep, which it might, but then your sleep is actually gonna be terrible. Um, so you're not gonna get good sleep and you're not gonna feel well rested. So that's another one I would tack in there. As we were joking about uh last time when we had our uh nutrition experts, like so we're telling you to be a day drinker, right?

SPEAKER_06 34:20

Um it looks like we have a question from Mariah. And Mariah said, I feel like I was having some side effects with the progesterone pill. I was extra anxious and had some sweaty hands and feet. Would the progesterone cream have less side effects than the pill?

SPEAKER_04 34:35

Yeah, actually, the anxiety is not a very common symptom with progesterone. Um, so it may not have necessarily been that, but um, you can certainly, I mean, if you take a topical medication, a topical hormone compared to oral, it can reduce your risk of GI side effects, you know, and the the gastrointestin intestinal processing that has to happen when you take a pill. Um, but it's totally up to you if you wanted to try a different method, but it could be something else that's causing those symptoms as well.

SPEAKER_01 35:05

Although I have seen normally progesterone is sedating, yeah. It's a calming thing, but I have seen some people where it's activating like caffeine. Um, and so um that does happen. Sometimes people uh, you know, we tell we usually recommend taking the progesterone at night because it's sedating, but every now and then there's somebody that's oh my gosh, I like took a progesterone, I'm like, hmm, can't sleep. That's really take it in the morning, you know. Um and the other weird thing about progesterone is in rarely, but maybe 1% or less, it causes crazy dreams. Um so um for that, you also would take it in the morning and it solves it. I found, and this is totally anecdotal. I don't have hard evidence for this, but it seems like the the cream tends to pack less of a punch as far as that kind of stuff goes. Um, I think for those where the progesterone is activating, it's less activating. For those where it's sedating, it's probably a little less sedating. For some reason, the the oral uh capsules, micronized progesterone capsules, it just seems to hit a little bit harder, a little bit quicker, whereas the cream seems to space out more. But again, that's different for every person. But it might be worth a try.

SPEAKER_06 36:16

Our next question is from Justine. And Justine says, I started HRT with Winona in November. I am 54 and in my first year of menopause, so still very new to this. She says, anyway, gratefully some of the troublesome symptoms have abated. My hot flashes, my hot flashes, night sweats are gone. Um, but she says, I do have a lingering issue now of an increase of appetite. Do you have any advice for that?

SPEAKER_04 36:41

So I think that one of the biggest things is that you have to look at your nutrition and you have to most of the time when we feel hungry, it could actually be thirst. And we none of us really get enough water. I mean, I have a big glass of water here that I'm sipping on. Um, but the other thing too is that another thing that I think it's real important, and we talked about this last month, or the last um QA that we did with the nutritionist, too, is that I think a lot of women in midlife don't get nearly enough protein in their diet. Um, and the thing is, is that unless you're getting those really good macronutrients that are going to help keep your body full and satisfied, there's a lot more hunger and a lot more cravings. Um, and so you really have to make sure that you're cognizant of like how much protein you're getting in and how much fiber you're getting in, um, you know, and healthy fats. And, you know, it's not a matter of good fat, good foods and bad foods. It's more about those macronutrients and really making sure that you get those. Um, because when I talk to women about how much protein they're eating, they're most of the time eating less than half of what their daily goal should be. And so, um, and I know I track it some days to make sure that I'm staying on track because if I don't pay attention to it, I won't get as much protein in my diet as I should. And then I feel hungrier all the time. Protein really helps. Yeah.

SPEAKER_06 38:06

Absolutely. And we have another question from Facebook. Um, and Raquel is wondering does HRT cause bleeding?

SPEAKER_04 38:15

Well, for some patients, as they start HRT, the HRT affects all the tissues in the body. And so part of that could be that your endometrium and that uterus is affected by the hormone changes. And so some women may experience some light bleeding or spotting as they start HRT. And if you're still having periods and you haven't actually gone through a menopause yet, it can change the quality of your periods too a little bit. Um, but not every woman goes through that. So it's something that we're aware of. It's it is common, but it doesn't happen to everyone.

SPEAKER_01 38:47

And you know, HRT is very different from birth control pills. So birth control pills, excuse me, and a lot of people think, oh, hormones are hormones. But birth control pills are really designed to take over the hormones of the body and they shut the ovaries down, and then they take over, and that's how they keep you from getting pregnant. Um, but it also does a nice job of controlling your cycle. So the two things that birth control does that HRT doesn't is it keeps you from getting pregnant, um, and it does a better job controlling cycles. HRT in general really shouldn't affect your cycles in the long run. Um, it may make them a little lighter, it look you know, a little bit better, but it not like birth control pills because HRT does not shut the ovaries down, it does not take control of your hormone, it basically comes alongside the ovary and just sort of adds what the ovary is not picking. Um so it's a really different concept. Um, and so that's why the whole kind of bleeding changes are different. Pretty normal to have some abnormal bleeding in the first cycle or two, even three. But if you're all of a sudden, if you've been on this for six months, nine months, a year, and you're on your stable dose, you're not forgetting your meds, and you start bleeding, you know, there may be something else that's causing the bleeding, and um that's going to be worth uh looking into. So let your doctor know if you have unscheduled bleeding. Um, that could be important.

SPEAKER_06 40:14

Absolutely. And we have a question from Tina, and Tina says, I'm in perimenopause, but concerned about how do I know which hormones to take.

SPEAKER_04 40:24

Well, you know, really it's just about talking about your symptoms with a provider who feels comfortable and they can can tell you what you need. Um, we can really look at a patient's symptom profile and and figure out what it is that we need to add in to get them feeling better. So it's really a conversation that you can have and and come up with that plan together. Absolutely.

SPEAKER_06 40:48

And we have a question from Stacy. Um Stacy says, I started banana last month and then started taking DHEA a week and a half later, and I felt it right away. The pill with the cream helped me, aches went away, not painful sex, sleeping great where before I wasn't. My question is, how does doing HRT affect my thyroid levels?

SPEAKER_04 41:08

Well, so it really shouldn't directly affect your thyroid at all. However, for some women that have thyroid disorders, if you know there's a lot of different changes in their health and a lot of different changes in their lifestyle, those changes could could be what affects the thyroid. So if you're someone who's had to adjust your dosage of thyroid medication a lot, um, as you're getting um, you know, regulated and getting treatment with HRT, you just want to make sure you keep up with those regular checkups and those, you know, getting your thyroid function test checked and make sure that you're staying on top of it with the doctor who's managing that for you. But it doesn't directly affect the thyroid negatively.

SPEAKER_01 41:46

Yeah, thyroid replacement is tricky. Um, it's a really fickle drug, so to speak. Um, and that's why they have to check all the time to see um if you know adjustments need to be made. And from many people, you know, adjustments are sort of made all the time. It seems like every little thing can affect um the amount of thyroid replacement you need if if that's what's going on. And HRT is another one of those little things that could do it, but it doesn't directly affect your thyroid. Um, so uh it's it's safe to take if you have a thyroid disorder.

SPEAKER_06 42:20

And we have a question next from Liz. And Liz says, What is DHEA?

SPEAKER_04 42:26

So DHEA is an acronym for dehydroependosterone. Um, and it's basically you're laughing at me.

SPEAKER_00 42:34

Yeah, because my podcast comes up with that. Good on you, that's why I got you around.

SPEAKER_04 42:41

Anyway, it it is a precursor hormone that's produced in the body naturally. Um, it's typically produced in the adrenal gland. And what happens is as your body metabolizes it, it gets broken down into estrogen and testosterone. So it's it's part of the normal hormone cascade. Like when we're in medical school, we have to memorize this big flowchart of like how cholesterol gets broken down into sex hormones and DHAs along that pathway. Um, so it's it's something that we can give as a supplement to help boost your natural testosterone, because we can't prescribe testosterone directly through our platform via telemedicine just because testosterone is considered like a controlled substance in the United States because a lot of people abuse it for various reasons, like bodybuilders, athletes, things like that. And when I was in the army, we saw a lot of army soldiers abusing testosterone as well to be able to run faster, lift harder, you know, and be a better gung-ho soldier carrying those big packs. But anyway, um DHUA DHE is our way of naturally boosting your testosterone a little gentler. Um, and so it's it's a way that we can do that because even though we're women, testosterone is still a very important hormone in our bodies. Um, it really drives our energy level, our metality. Metabolism, it can drive our libido as well, which is a really important part too. So that's that's what the DHEA is.

SPEAKER_00 44:08

Back to Valentine's Day.

SPEAKER_04 44:09

Yeah.

SPEAKER_06 44:14

We have a question next from Ia. And Ia says, I just started with HRT cream. I put it on the more I put it on in the morning. Is that okay? Or should I put it on at night? What's the difference?

SPEAKER_04 44:26

The best time to put it on is when you can fit it into your life and remember to take it at the same time each day. So for every woman, that's going to be different. A lot of women use it at night. Some women use it during the day, but really it's about what's best for you. And if you're gonna try to do if I say it's best at night, but then you can never remember at night, it's not gonna help you. So do what works for you and what works for your schedule.

SPEAKER_01 44:47

The other thing I I suggest is um experiment a little bit. See how you feel if you use it in the morning, see how you feel when you use it at night, and see what works best for your individual situation because everybody responds so differently to this that it's not a one-size-fits-all kind of thing.

SPEAKER_02 45:04

Right.

SPEAKER_06 45:06

Um, we have a question from Tamara next. And Tamara says, I am posting a puzzle, um, age 57 and no cycle for two years. I did receive the cream and a DHEA. I tried the cream only the other evening, and I did have some racing thoughts and a little bit of an anxious night. Um, the next day, I was a little tired, low mood, an odd feeling. I did one pump to ease into, but I did stop the treatment. So please advise if for if I'm a bit sensitive to the meds, but I would like to continue. Maybe I need to do the patch and separate the progesterone to determine what each are doing.

SPEAKER_04 45:42

I really think two nights of trying the medication is really just not enough time for your body to acclimate. So, you know, as you're starting a treatment, like you really need to give your body a few weeks to really, with using it every day regularly, to really see the benefits and to make sure that you're tolerating it well. Um, you know, there can be a lot of other factors involved, but I think that really focusing and this, you know, bringing it back to your nutrition and your sleep hygiene while you're starting a new medication, any medication, you've got to do your best to normalize everything else that's happening in your life and taking care of those other things so that your body can acclimate to the medication for you know first. So, you know, taking it for two nights, it hasn't even reached therapeutic levels in your body for you to be seeing any real negative effects yet. So um, so try try to go back to it. Try to give it at least a solid two weeks of using it regularly before you make a judgment about it, I think.

SPEAKER_01 46:39

The other thing, if it was the racing thoughts keeping up, try it in the morning. Um, and that may um make it a little bit easier.

SPEAKER_06 46:48

Absolutely. Um we have a question from Stacy, and Stacy says, Does taking DHEA cause breast tenderness?

SPEAKER_04 46:56

It can, because what really the breast tenderness is coming from is the estrogen component. So if even if you're just taking DHEA alone, what that does is that after being broken down in your body, it breaks down into testosterone and estrogen. So with any increase in estrogen, you can get a little bit of inflammation of the breast tissue, and that can equate to some tenderness. But usually it's a temporary thing that happens for most women, and as your body acclimates, it goes away. Um, it's normally the hormone fluctuations so much that can cause the breast tenderness. That's why so many women get breast tenderness in their premenstrual week, you know, before they get their cycle. And their the hormones are just up and down. And so, same thing as you're starting new medication, you can get breast tenderness, and then it usually resolves with time.

SPEAKER_06 47:41

Absolutely. Um, we have a question from Natalie, and Natalie says, after a partial hysterectomy, which hormones are expected to be replaced?

SPEAKER_04 47:52

So maybe we should have the conversation about partial hysterectomies and hysterectomies.

SPEAKER_01 47:57

We know what she means, but yeah, there's another trigger.

SPEAKER_04 48:02

Well, yeah, so for the word hysterectomy literally means removal of the uterus. So a lot of women will use the term hysterectomy, meaning like their whole female organ system, but there's actually tubes and ovaries, and so having the ovaries removed is an oophorectomy, having the fallopian tubes removed is a scalpingectomy. Um, so there's a lot of different medical terms that we use, and we're we're so used to this in our careers, like having to decipher what a patient means by a partial hysterectomy. Um, because to me, a partial hysterectomy means maybe you had your cervix left and only the uterus was removed. But anyway, if you just had your uterus removed and you still have your ovaries in place, you're still producing hormones. Your ovaries are still functioning. The uterus doesn't produce any hormones, neither do the tubes. And so if you have the uterus and the tubes removed, it doesn't really affect your hormonal environment at all. It's really not until the ovaries are removed or until the ovaries start that aging process as we near menopause that we really see changes in the hormones.

SPEAKER_01 49:05

So I'm gonna jump in with a however. Yes, because that's absolutely 100% correct. And um, I wouldn't say anything else on my oral boards, but um you know, for some there is some shared blood flow um between the uterus and the ovaries, and you know, it is a not uncommon phenomena that um the ovaries function a little bit less or or more poorly, particularly right after hysterectomy. Um, kind of go into a shock state. And I've seen it with tubes too, which is less less there's still some shared blood flow. There's kind of it's hard to understand. I think maybe it's an inflammatory response. Um, but there is, you know, there are some women who get their tubes tied and they experience some hormonal fluctuations. So there's definitely some tie-in there, even though we know that the ovaries have their own blood flow and the uterus has its own blood flow, and that's why we're able to remove the uterus without removing the ovaries, because they have their own blood flow. But there's still some shared blood flow, there's inflammation that goes on, and so it it I think it's not uncommon to see some symptoms show up, even though on paper it shouldn't, because you still have your ovaries. So I don't think that's totally uncommon.

SPEAKER_04 50:18

Yeah. Nowadays, like with so many women, when they're having hysterectomies, having minimally invasive hysterectomies, meaning laparoscopic or robotic, the way that we do these is not the way that we learn when we were back in school and in residency. We were clamping and cutting and putting sutures on. Now we're using all this technology, which is using heat waves and sound waves. Um, and as much as the the reps and the companies that make these pieces of technology tell us that the energy stays in the little jaw of this device, I think there could be some lateral thermal spread and maybe even some tissue destruction from those tools too. I think that's that's another possible.

SPEAKER_01 51:02

Because we don't trust it. I know that's where I am.

SPEAKER_06 51:05

Yeah. Um, another uh question. And this one woman is wondering what medical test, if any, should women undergo before starting HRT?

SPEAKER_04 51:20

Well, I really require that you, if you're over age 40, that you're getting your mammograms. And then if you um still have a cervix, you're getting a pap smear regularly and still getting an exam that way. And if you're over age 50, you should be getting a screening colonoscopy and you should get a baseline bone density scan because these are part of your normal preventive health care. There is absolutely, and this is the first time we've talked about it tonight, but normally we talk about this a lot, no reason to get any kind of hormone test or any kind of hormone levels before starting HRT. Just those other preventive health care, you know, needs that you have for your overall wellness, that's all that I would require.

SPEAKER_01 51:57

So, yeah, I mean, you need to do your normal stuff. That's important. Um, it doesn't have anything to do with your HRT, but it has a lot to do with your health. Um, on the other hand, um and everybody has their own way of approaching this. For me, require is a is a kind of a hard word. Um, so I would even if I would recommend that you do all this stuff, but I would still prescribe HRT if you decide it's not something that you want to do. So, and the way I think about it is um I would sure expect my mechanic to fix my brakes even if I didn't want to get an oil change. Um, I like that. So, you know, to me, it's like look, this is what you should do. It's common sense, it's good for you, it's healthy. Um, but we also need to deal with your hormones, and they're not necessarily linked. Um, but yes, please get your health maintenance done. It's so important. Um, and you know, for longevity, for staying healthy and vibrant, and you really, really want to do that. Um, it really prevents, you know, a lot of problems down the road. So um if you don't take care of your body, your body won't take care of you, right?

SPEAKER_06 53:07

And it looks like we have time for one last question, um, and then we'll need to wrap up for tonight. Um, but Samantha is wondering, she says, I've heard that women are using vaginal estrogen on their skin. Is this effective? Is it safe? Is there any research?

SPEAKER_04 53:24

Well, so we're we're learning more about the benefits of estrogen on the skin, and and actually, you know, it's we have a new face cream that actually contains estriol and tretinoin. Um, generally, I don't recommend using a vaginal estrogen cream on the surface skin because they're formulated differently. Um, the tissue of the vagina is much like the tissue of the inside of your mouth, and it's a thinner mucosa. The cream that we you know make for the vagina has a different quality to it for the pen for penetrating that tissue. Whereas a cream that we're gonna make for the surface of the skin of the face has to penetrate many more layers, and so that that base of cream is different, and how it how it apply, you know, applies to the skin and how it works is different. So I'd I wouldn't recommend like taking your vaginal cream and lathering your face in it or putting it anywhere else. Um yeah, because they specifically like our compounding pharmacists, they're they're making these products specifically for the tissue that it's intended to be absorbed on. Um and it's not going to be as effective when it when you put it in a different place or a different location. But yeah, we're seeing lots of great benefits, you know, and we haven't talked about the skin cream tonight, but um this is something that we just added in in the last year um at Winona. There are a couple other companies that have similar products too, but really, you know, no, nobody has an estriol tretinoin cream.

SPEAKER_01 54:46

Not that one, but no, there's other people that have just estriol. I think they have astriol creams, they have tritinoin creams, but we're I mean, I'm sure there's somebody out in the world that has it, but of all the big companies, that's something unique to Winona that we've developed is an estrool tretinoin cream, and they really seem to work well together. Um, I like to I gotta tell the story because you already know what it what's coming because they've heard it every every two weeks. But uh so my wife has been on tretinoin forever, and so she started our estrool tretinoin cream, and it has a much lower dose of tretinoin than what she'd been using. Um, and it's amazing. And uh in fact, she went to a girls' night, and all the ladies were like, You got work done, and she had she just had our cream, and they're they didn't believe her. One of them wanted to fill, oh, there's fillers, come on, and it was just the estrool tretinoin cream, and of course, often they are all calling me up. How can I get some of those creams? So it does it. We spent a long time developing. We the different iterations we went through perfecting this stuff, it's kind of crazy. We actually were talking about this cream before we launched our company. That's how long we've been working on this thing. So we have a it it's uh and it's better than any of our expectations. It's really, really tremendous.

SPEAKER_02 56:02

So um patients love it.

SPEAKER_01 56:07

I can tell you my wife is not going to let me take it away from her, that's for sure.

SPEAKER_06 56:14

Not that I was well, well, thank you, doctors, so much for taking the time to answer all these questions. And I'm so glad that everyone who's here can make it tonight to this live QA. Just a reminder, we know that there were some questions that were answered. Um, we do have live QA's and doctor dialogues pretty regularly, so you can always tune back into these to ask your questions. Also, your Winona doctor is available 24-7 in your patient portal. Please reach out to them. That's what they're there for. They want to answer these questions just as much as we love answering them tonight. Um, and as well, these QA sessions, if you're interested in hearing past ones, we also have a Winona podcast that we do these as podcasts. So it's a good thing to listen to if you're going to work, on the way home, on the gym. Um, lots of ways to listen and kind of get your questions answered that way as well. Um, but thank you again, everyone, for joining. Thank you, doctors. Um, and I hope everyone has a wonderful night. We'll catch you next time.

SPEAKER_05 57:08

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