The Menopause Hour with Winona
Welcome to The Menopause Hour, the podcast where you’ll find the answers to your most pressing menopause questions—the ones you won't get from your OB/GYN. Hosted by Winona’s Chief Medical Officer, Dr. Michael Green, and Medical Director, Dr. Cat Brown, The Menopause Hour is here to empower you with expert insights, tips, and real talk on navigating menopause with confidence and clarity.Brought to you by Winona – menopause care made easy. Join us each episode as we explore the symptoms, solutions, and science of menopause, all while breaking down the stigmas and misconceptions along the way.
The Menopause Hour with Winona
Episode #30 The FDA’s New Direction and Evolving Menopause Care
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In this episode, Dr. Green and Dr. Cat answer questions focusing on symptom-based menopause care and practical guidance for managing HRT. They discuss why lab testing isn’t useful for dosing, the importance of staying consistent with treatment, and how to navigate early side effects or new symptoms after adding DHEA. The doctors also address persistent hot flashes, night sweats, and concerns about past procedures, while reassuring listeners about the updated FDA removal of the black box warning on vaginal estrogen.
This conversation highlights the value of patience, communication, and personalized adjustments as women move through their menopause journey.
Listeners can continue joining us for Winona Wednesdays, where twice a month we bring these important conversations straight to the comfort of your home. 🎧
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Welcome to the Menopause Hour, your go-to source for answers to your burning menopause questions, the ones you won't get from your OBGYN. Brought to you by Winona, where menopause care is made easy. Download our free Winona community app where thousands of women connect and access exclusive content, expert-led courses, exciting events, and more. It's time to take the guesswork out of your hormonal journey.
SPEAKER_01Oh, hello everyone, and welcome to one of our live Dr. QA's. I am so excited that you guys are all here. I know it can be a little bit hard sometimes to find the time in your schedule. So it says a lot about the fact that you've made the time to be here and you're looking to have questions and answers, and we're gonna get into all of it. So super excited that you're here. Um we have on the call with us the amazing Dr. Green and Dr. Kat. Um, I'll give them a second to introduce themselves in a minute, but just wanted to remind you that if this is your first time here, a little bit about how this works is essentially you can ask our doctors any questions you want. There's really nothing that's off the table. Um, and you can do that by there's a little chat box at the bottom of your screen. You can go ahead and click on that. Um, and you can just Yep, I already see Rosa says hi. Hey Rosa. Um, if you see where Rosa's texting or typing in, that's the right place, you're in the right place. Um, so go ahead and just start throwing any questions you've got right in there. I will say sometimes it gets pretty busy in there. So throw them all in there and we'll get to as many as we can. Um, but while you all are kind of thinking on that, um, I will pass it off to Dr. Green and Dr. Kat to introduce themselves. And I know they want to uh talk about some big changes that have happened recently. Um, so take it away, you all.
SPEAKER_03So hi, first of all, yeah, ask us anything. If you ask us lottery numbers, we'll answer, but it'd probably be wrong. But we'll do our best. So I'm Dr. I'm Mike Green. I am the chief medical officer of Winona. Um I am refined over GYN and um one of the founders. So uh really excited to have you here. Uh this has been a passion. Women's health has been a passion my entire career. Um, but uh Winona has been a particular passion for the last five or so, actually, probably longer years, pretty much been the living and breathing this. Um really exciting um to be able to offer uh this service to women that otherwise uh can't get it. Um and we're really excited to be on the cunning edge of menopause management, hormone replacement therapy. Um, and we feel like we take really good care of our patients. And one of our one of our big things is education. Um we really want patients to understand what's going on, understand um the changes in their body, um, and be a good partner in this decision making. Um we don't want to just tell you what to do. We want to work with you to come up with the best solution for your individual situation. And education and understanding what's going on and asking your questions and having them answered um is super important. So that's why we're here. And please start typing questions in because three of us will chat all night, we'll have a good time, but it won't be as it might be fun, but it won't be as informative as if you ask questions. I'm gonna pass it off to Kat.
SPEAKER_02All right. I'm Dr. Kat Brown. I'm also a board certified OBGYN and I'm the medical director here at Winona. Um, and yeah, so very important to pass on education and knowledge. Um, I love women's health. It's been a passion project for me for most of my life. I went into medicine wanting to be family practice doctor and fell in love with women's health and just gravitated toward that. And we spend much of our career doing obstetrics and period management and all kinds of things, gynecology, but not much emphasis was placed on menopause care and penny perimenopause care because I trained right on the heels of the Women's Health Initiative. Um, started my residency in 2004. So it was right after all that bad press and all the widespread panic about, you know, the fears of hormone therapy and all those things. Um, so it's as I started going through my own transition and deep diving and trying to learn as much as I could to help myself is also when I really started learning more to help patients and when I joined Dr. Green to help patients here at Winona around that same time. Um, and so one of the things we wanted to talk about tonight was a big thing that happened recently. Some of you may have seen in the news that the FDA finally got rid of this black box warning that's been on hormone therapy for decades. Um, and that has been a reason why so many providers um across the country have been, you know, reluctant to prescribe, scared to prescribe, but also the reason why a lot of women wouldn't even take medications that were prescribed, you know, by menopause specialists over the years. Um, because whenever you were prescribed estrogen, you got that little package insert from the pharmacist. And the first thing you see when you open up the prescription information is this big warning saying that beware, you know, this medication may cause stroke, may cause breast cancer, may cause this. And it was just this verbiage that was very scary and kind of blown out of proportion. But unfortunately, this black box persisted for so long. And it was front and center at the beginning of every package insert for hormone therapy. It's not the way we practice at Winona. It's never been the way we practice at Winona. Um, and it's one of those things that is finally like the FDA is catching up to what menopause specialists have been doing for years. Because seeing the research and seeing the data and what the real information is, we know that these medications are very safe for the majority of women that are out there that could benefit from them. So, but this is going to be something that's great to hopefully open up avenues for more women to get the care that they need. Um, so we wanted to just kind of open up and talk about that a little bit. Because if you if you've watched the news or seen anything in the papers, it's all over, you know, the last week or so. Um, I think it was announced last Monday, right, the 10th. Um, yeah. So it's definitely um fresh news. And this came as a result of the FDA held an expert panel on hormone therapy back in July, where they invited all these experts to talk about the benefits of HRT. Um, and really it was getting that information and then getting all the follow-up information with doctors writing in and patients writing in from all over the country, and it forced them to reevaluate and decide to get rid of the black box warning, which is great. And just for, you know, um comparison's sake, there's very few medications that get a black box warning like that, right, Mike? I mean, it's there's medications that I would consider to be a lot more dangerous, you know, that I don't really have a lot of experience with as an OBGYN that don't have black box warnings. Um, so it's kind of crazy to me that this persisted for as long as it did.
SPEAKER_03Yeah, I mean, most medications have something, um, but the amount of things that were tied to estrogen was kind of insane. And not only that, but the black box warnings persist with any kind of estrogen. So even vaginal estrogen had that black box warning, which made absolutely no physiologic sense. So this is a a great victory, really, for women's health. Um, and for those of you going through the menopause transition. My hope is that it's going to embolden a lot of family doctors and internists and even OGYNs that have been reluctant to prescribe HRT because of this, um to embolden them to do the right thing, learn about the latest research. Gee, why did the FDA do this and read up and catch up and understand uh that this data that this was based on is really outdated? And there's tons of studies that have shown how safe HRT is. So it's really exciting. Um, it's kind of uh it's kind of a fun time to live through as a as a menopause specialist and a women's health expert. But let's answer your questions. It looks like there's a bunch of them coming through. So we can talk all night.
SPEAKER_01Absolutely. There are a bunch today, which I love to see. Um, and I just want to say real quick before we jump in, Denise, I see that you said the QA is disabled. What you can do is you can go ahead and just type your questions right in the chat. Um, so there is a QA button that we don't use, but we do we use the chat. Um, it works a little bit better, it's a little bit easier for everyone. So just wanted to uh point you in the right direction there, Denise, real quick. But our first question tonight is from Carolyn. Um and Carolyn is wondering if HRT causes uh periods to start up again after not having a period, she says since 2021.
SPEAKER_02Well, so when you start hormone therapy, if you've gone more than a year without a cycle, um, which we consider you to be in menopause, if you've gone 12 months without a cycle, you can have some response of your uterus to the hormones, meaning that you might have some spotting, some light bleeding as your body is acclimating to the medications, but usually this is temporary, short-lived, and goes away on its own. It's not that the medication is like jump starting your period and restarting things. That's not actually what's happening. It's just that the uterus, the uterine lining is responding to the medication a little bit. So if you just started treatment and this is happening, hang tight, keep keep persisting, keep taking your medication every day, and it should go away on its own. And if it doesn't, you want to talk to your physician who prescribed it.
SPEAKER_03The other thing that can sometimes cause bleeding, um, if you've been on the medicine for a while and then you forget to take it, you go on a trip and you left it at home, missing the medication can sometimes trigger bleeding as well. Um so if it's in the first three months, or if it's because you've forgotten your medicine, it's generally nothing to be concerned about. But if it's beyond that, it sometimes can say that there may be some underlying problem that the medications are exposing or that are just showing up.
SPEAKER_01And our next question tonight is from Rosa. And Rosa's wondering if she will have to be on HRT forever.
SPEAKER_02Well, it's really a personal decision. So, you know, years ago, we used to say that you know, you should be on the lowest dose of hormone therapy for the shortest duration possible. But now all the latest research is showing us that there are so many long-term health benefits to hormone therapy, especially the estrogen component of that and how it can help your bone health, your cardiovascular health, also your cognitive, you know, health and preventing cognitive decline. And so a lot of women, when they learn about those long-term benefits, and if they're feeling well and they're otherwise doing well medically and they don't develop new medical problems that make medications higher risk, a lot of women are choosing to stay on it long term. But it's really a personal decision and something that is individualized for you. So, you know, if you're somebody who doesn't like taking medications or you're hoping to kind of wean down over time, you have that conversation with your physician and let them know, you know, well, when is a good time? Um, and Dr. Green likes to tell a story like, don't do it before your kid's wedding, don't do it before a big trip. You know, if you have something momentous, and I always like to tell women, don't stop your hormone therapy in the dead of summer, either, like right in the middle of the summer, because if you're gonna get a resurgence of symptoms and your hot flashes and night sweats are gonna rebound and come back when you stop the medication, you don't really want that to be when it's 90 degrees outside either, you know, because that would be very difficult to deal with. Um so, but when you decide, and if you decide to go off medication, you can kind of wait and see how your body responds. If your symptoms like the vasomotor symptoms don't come back with a vengeance and you feel good, some women decide to take, you know, to go with that and and just see how they do off the medication. But it's a very personal decision as far as how long you decide to stay on it.
SPEAKER_03Yeah, I like to say, do you, you know, how long do you have to do you have to stay on it? No, you don't, but you might choose to stay on it.
SPEAKER_01Absolutely. And our next question is from Shelly. Uh, and there's a few questions in here, but she says, Um, hi, uh, I've missed my progesterone dose. Does it cause spotting? Um, and then she says, and spotting versus full cycle, how to tell I've never had spotting issues before.
SPEAKER_02Yeah, if you miss doses of your medication, it can definitely, your body can respond with spotting for sure. Um, so it, and it's important if you're taking estrogen hormone therapy and you still have your uterus, it's very important to take that progesterone along with the estrogen. It's the whole point of the progesterone is that it is protecting that uterine lining from overgrowth. Estrogen has so many beneficial effects throughout all the tissues in the body. But the one real negative thing it can do is it causes that uterine lining to kind of fluff up like a shag carpet. Um, and what that can cause is what we call hyperplasia, which is an overgrowth of those cells of the uterine lining, which can lead to cancer if not, you know, checked. And so the progesterone prevents that. It keeps that uterine lining thin while you're on estrogen treatment. So it's very important to take those together.
SPEAKER_01And our next question is from Lisa. Um, and Lisa says, Can you speak to why Winona doctors don't think in labs to test hormones to determine whether your imperiumenopause is important?
SPEAKER_02Well, it's not something that's unique to Winona doctors, actually. So we get this question every QA, I think. Maddie's gonna know the answer by now because she hears our talk.
SPEAKER_01I know, I guess you just give us an answer.
SPEAKER_03We should let Matt answer.
SPEAKER_02But yeah, so it's it's not something that's unique to Winona. This is something that all menopause specialists know, and this is how we practice. So, you know, it's not recommended by the menopause society, not recommended by the American College of OBG WAN. Anybody that treats menopausal patients knows that the best way to treat them is based on symptoms. Labs are not very accurate. Unfortunately, many companies out there will offer to do labs. They'll do salivary hormone testing, they'll offer you Dutch urine hormone testing, they'll do all kinds of stuff. And often there comes an out-of-pocket charge for this, which is how they're benefiting from you and how they're profiting from you. Um, and there was a there was a menopause specialist who just talked at the menopause society annual meeting, and I really like the way she said this. She says, you know, somebody getting hormone labs for a perimenopausal woman gives them the gives the patient the illusion that the pay the doctor cares. Um often I have a lot of patients who are paying out of pocket for labs, and then they're bringing the labs to me because the person who ordered them doesn't even know how to interpret them. So it's it's like garbage in is garbage out. It doesn't give us any information to know how best to treat you. It doesn't tell me how to adjust your dose best. It doesn't tell me what medication is going to be best for you. We know that information based on getting a good history from you and getting your list of symptoms. So a symptom diary and you explaining to us how you're feeling and what you're experiencing is so much more valuable for us to know what it is that would help you as far as treatment.
SPEAKER_03Yeah, I can tell you, I feel really passionately about this because I think a lot of women end up getting marginalized because of the lab testing. Um, they go to their doctor and they have all these symptoms. And they're a well-meaning doctor who's not really well versed in menopause management, but doesn't know better, and they order a bunch of labs, and the labs come back normal and they say, Oh, your labs are normal, this isn't from your hormones. Um and they send them off. Um, and fortunately, some of those find their way to us and we get them treated, and behold, it was our hormones, and they feel a whole lot better. I think I I I'm kind of a cup half full kind of person. And so I I believe that most of these people that were labs are are well-meaning. Um, they're just not well educated in treating them in a post-transition. Unfortunately, there are a few bad players out there that are really just trying to soak patients um and you know, doing it to line their pockets. But I think that's the minority. Um, it does exist. And unfortunately, some of these big lab companies, you know, laboratory tests are a billion-dollar industry, and there's direct-to-consumer marketing now of lab tests. I get ads from Quests almost every day in my email um trying to sell me men's hormone panels and his health panels and all this stuff that I don't need. Um but the lab is trying to sell them to me because they're gonna make a whole lot of money off of them. So unfortunately, there is some of that going on. I think most of it is just well-meaning doctors that that you know just aren't well educated. But the labs are just not helpful. Um, and I like to say that when you make decisions based on bad information, you make bad decisions. Um, and so that's why we don't make decisions based on the labs because they're just bad information. They're not an accurate portrayal of what's going on in your body. Exactly. That's all I've got to say about that.
SPEAKER_01That's all I've got to say about that.
SPEAKER_02There you go.
SPEAKER_01Um, on our next question is from Charlene. Um, and Charlene says, I have started the estrogen progesterone uh therapy four weeks ago. Um and she says, I have breast tenderness continuously since day three. Will this symptom go away?
SPEAKER_02Yes, it will. So typically, whenever you start a hormone treatment of any kind, the breast can respond to that because you know, we do have hormone receptors throughout the breast tissue. Um, and this is your body kind of getting acclimated to the hormone. And so this should get better. If it doesn't, you know, by the time you're getting into you know the six to eight week mark, you know, of the medication, if it's not starting to die down a little bit, let your doctor know. Um, because then we might want to make some adjustments. But typically this is a temporary side effect.
SPEAKER_01And our next question is from Ebony. Um, and she is wondering, she says, how can you start the conversation with your provider if you think that the dose of your current HRT needs to be increased? And she says also, what are the questions that I should be asking myself and my provider?
SPEAKER_02Yeah, so really, you know, don't ever be afraid to start any conversation. I think that um, you know, you could ask just the way you did right now. You could just say, you know, how do I know if I need to increase my dosage? Um, but the best way I tell patients to look at that is to go back and look at your initial symptoms that the reasons why you sought treatment. Um, so if you, you know, if you're one of our patients at Winona, you have in your onboarding in your chart, you can see exactly what symptoms you selected during onboarding and go back and actually kind of qualitatively look at those and think, you know, well, have my hot flashes gotten better? Have I noticed some improvement in my brain fog? You know, is my mood a little bit more stable? Um, and actually go through that list of symptoms to see what's gotten better, what's about the same, or if anything's worse. And we can use that information. That's the information that your doctor will be able to use to decide how best to tweak your dosage to get you feeling better.
SPEAKER_03Yeah, I always say the right dose of medication is the dose that relieves your symptoms without causing side effects. Um, and so if that's what's happening, just don't want to change anything. It's working. Um, and if that's not what's happening, then we may need to make some adjustments because you know we want to get you to be the best you we can um with the medications.
SPEAKER_01Absolutely. And our next question tonight is from Shelly. Um and Shelly is wondering about weight gain on HRT. She says, I've noticed an increase in weight, but I have good energy, but I haven't changed my diet or exercise.
SPEAKER_02So generally, for most women, once they get established on a good dose of their hormone therapy, they tend to notice that there's a better weight distribution, like redistribution on their body, and that meanabelly can start to go away. But initially, whenever you start a hormone treatment of any kind, your metabolism can change, your digestion can slow and in response to changing hormones. Um, and so I usually tell patients to stay away from the scale initially. Focus more about how you feel, um, focus more on your sleep hygiene and trying to do all the other lifestyle modifications that you can do to maximize how you feel and improve your symptoms as well. Because usually the weight management is one of the later benefits that we see from HRT. Um, it's not usually something that happens overnight. And a lot of women, I think that's a common reason for many women to stop their treatment prematurely is because they get on the scale and they see a couple pounds and they kind of freak out. Um, but it's sometimes water weight. It could be bloating, it could be slow digestion. Your body is getting used to taking these medications. And so all your systems are responding to it. So you got to give it some time to adjust. And so don't worry about a couple of pounds initially and just focus on those other things like healthy eating, sleep hygiene, making sure you're drinking plenty of water, making sure you're having good bowel movements every day. You know, as we get older, like it's the simple things like naps, good bowel movements, um, all those things that we avoided, you know, when we were kids. But um, but yeah, those that I would say away from the scale in the beginning.
SPEAKER_01Absolutely. And our next question is from Lisa. Um, and Lisa is wondering does it make sense to prescribe birth control instead of HRT when a patient comes in asking for HRT? She says, My doctor did that, and I'm so confused. I don't need contraception, and the wonky periods aren't that big of a deal.
SPEAKER_02Yeah. So this is unfortunately a bad habit of a lot of obijoans that don't have a lot of experience treating menopause. We do have a hell of a lot of experience using birth control and doing contraceptive management. And so many doctors that don't have the training or the experience in taking care of menopausal patients will go to their go to low dose combination birth control pill and offer that to. Patients. It may give you a little bit of relief with some of your symptoms because the hormones are isomers of our natural bioidentical hormones in our body. So you might get some little benefit. But this is not the right way to treat you, especially if you don't need the contraception. Now, if you do have really irregular, crazy periods, birth control pills might actually be a good option to help regulate those periods, but may not be the best option for treating your perimenopausal and menopausal symptoms.
SPEAKER_03You know, the other thing about birth control pills, which people don't realize, I think, is that they carry a whole lot more risk than HRT. And people have this backwards in their heads, even some LBGYNs, just because they're so used to giving birth control pills out that they don't even think about risks of birth control pills, but they're scared of HRT. Again, this black box warning thing may help with that some. But um, birth control pills are a much higher effective dose of estrogen and progesterone than uh uh HRT. And so they carry a much greater risk of things like stroke and uh blood clots and you know these like scary things. Now, there fortunately those risks are still pretty small, but they're much greater with birth control pills than they are with HRT. So we accept those risks um when we need to prevent pregnancy because pregnancy has even greater risks than birth control pills and all those things. Um but if it's not contraception you're after, you don't really want to treat your menopause management with contraception, you want to treat it with menopause medicine. Um and the HRT has much less risk than the oral contraceptive pills. In fact, uh if you, let's say, need birth control or you're having crazy periods, and so you decide to use birth control pills for those benefits, it's often very useful to add HRT in addition. And this often scares people, oh, I'm gonna have too much hormone. But the truth is, all the risk is really in the birth control pill. So you've already accepted that risk. And the change in risk from adding HRT is really almost insignificant. Um, but the HRT really hits your receptors different than the synthetic hormones in the birth control pills. At least the bioidentical HRT that we prescribe at Winona. And so you can get a lot of benefit from the HRT that you're not getting from the birth control pill. But the birth control pill may be adding benefits such as contraception and psycho control that the HRT is not. And so in some cases, it's reasonable to use both.
SPEAKER_01Absolutely. Um, and our next question is Linda, it's from Linda. Uh Linda is wondering, does Winona have a 10 milligram or a 15 milligram DHE option? She says, I was having a little bit of acne on the 25 milligram, so it's wondering if a lower dose is an option when I have my 10-week checkup.
SPEAKER_02So 25 milligram is the lowest that we carry, but we have had patients make adjustments, you know, to try to cut down, maybe taking it every other day. Um, or, you know, it typically the acne is temporary. You know, this is something that your body can develop in response to starting the medication. So over time, usually that acne side effect will go away. Um, but if it doesn't, I've had patients go to every other day. Um, also have had patients that take a month or two off of DHEA and then restart it later, and they don't have that same side effect. So that's other options you have. But talk to your Winona doctor about that and let them know.
SPEAKER_03So I'll give you a little behind-the-curtain explanation of why we've chosen to do that. So DHEA is a supplement. Um, supplements don't have the same regulatory management as prescription medications. Um, and so you know it's a little bit harder to make sure that a supplement is the type of quality that you would get out of something that's, you know, under direct FDA control, like a prescription medication. Because of that, we found that if we offer one dose of DHEA, it gives us incredible purchasing power. Um, I believe the last order we had was for 10 million units of DHEA. Um, and that only lasts a few months. So when you have, when you're ordering that kind of quantity, you have a lot of say over how it's being made. And so by using just a 25 milligram dose, and either if we have to go lower doing it every other day, or we have to go higher, you're taking two a day, it really gives us the ability to really manage what's going into the DHEA and making sure you're getting the highest quality DHEA that you can possibly get. And I can tell you a couple of years ago, we actually rejected a big batch of DHEA because it didn't pass the testing that we demand. Um, and so we rejected it. Um actually we had to scramble a little bit to make sure we had enough of the patients, but you know, we'd rather do that than give you a product that that's not good. So that's sort of the behind-the-scenes business reason for why we do that. Um, because it it really allows us to get really the highest quality DHEA you can possibly get. And to me, that's the most important thing. Absolutely.
SPEAKER_01And well, speaking of supplements, we have another question. We have a question from Jennifer. Uh, and Jennifer says, Hi, I have been three months in with the DHEA, 25 uh 25 milligrams, and the progesterone estrogen cream. She says, I'm feeling wonderful, but I'm curious if there are any supplements that can't be taken while using them.
SPEAKER_02Well, so I usually recommend if you've taken over-the-counter um supplements that have phytoestrogens in them, I usually recommend stopping those, like things like estroven. Um, there's another popular supplement that is out there that a lot of women come to us taking called dim. Um, and this is supposed to be something that's supposed to enhance your estrogen metabolism. At least that's what they put on the label. Um, and so I really don't really know how much that affects, you know, the efficacy of our meds. And so I don't want anything that's going to interfere with your success and how you're going to feel. So generally, you want to look at the label and look and see if there's any phytoestrogens, anything that could alter estrogen metabolism. Those are the two big ones, estrovin and dim that I recommend going off of. Um other than that, not other, not many other things would interfere. Um, you know, that's why, though, when you fill out the onboarding with us, you know, we ask you, we want to know everything you're taking. This is a time, and this goes for any doctor that you go to see. Don't lie about what you're taking. List everything because that's really how we know that we're being safe by giving it medication that we want to prescribe. It's so crazy to me that I have so many patients that take so many supplements, minerals, all these things, but then all they'll list on their medication list is actually prescription medications because they don't know that there's there's potential interactions between other things. And sometimes I've identified when I ask them, like, are you taking anything else? Something that they're taking a supplement-wise that's interfering with the prescription that they're getting from someone else. And I'm like, these are not good together. Um, so you want to be completely open and transparent and list everything you're taking. So we can do that job, you know, as your physician to make sure that nothing's going to cross-react um or contradict in each other. But those are the two big ones.
SPEAKER_03There's a saying that the two people you never want to lie to are your doctor and your lawyer. Though you might want to add your accountant to that too. Um, you know, one of the things that is kind of really was sort of eye-opening for me is just the huge list of supplements that some people take. I mean, I've seen people come through on 15, 20 different supplements. It's like, that's gotta be a full-time job keeping track of when to take this stuff. Um You know, there are some supplements that are probably worthwhile. Um, but if you're on more than a couple of things, um, you're probably on way more than you need. There's a lot of potential for interactions um with these different things. And some of them we don't even know about because they weren't well studied. Um plus the cost of all these things is tremendous. So uh, you know, there's some basic things, you know. You know, if you're not eating a great diet, a good multivitamin is probably helpful, calcium is probably helpful, um, maybe some vitamin D. There's a few kind of things that are helpful for most people. But um, some of these giant lists of supplements really um, you know, they're they're just not appropriate and they really amplify risk and probably aren't benefiting. So you might want to think about kind of paring down the supplement list, even if it's not a direct contraindication to HRT, just in general as sort of a little piece of life advice.
SPEAKER_02Yeah. And in general, too, the other thing too, that when you're getting supplements and vitamins, you got to know where you're getting them from. Um, because these are not things that are ever regulated by the Food and Drug Administration, because they're they're over the counter. Um, and so this is something that, you know, you want to make sure that that you're getting it from a reputable company. Also, the more outlandish the claims that they say that their supplement is gonna help you with. And, you know, every time they're paying a star or somebody from Hollywood, like multiple millions of dollars to represent them, it's to sell the product. The more outlandish their claims, you got to take that. If it sounds too good to be true, it's probably too good to be true. Um, and after you've spent the $50 or $60 a bottle, you know, they've gotten you for a little bit, and it may not be doing anything to really help you. So just be skeptical, scrutinize anything before you put it in your mouth, you know. It goes for food too. Look, read labels better.
SPEAKER_03Oh, you're muted, Manny.
SPEAKER_01Thank you. Sorry about that. Great. Our next question is from Georgina. Uh, and Georgina says, I have used HRT for two years. Um she says, uh, during those two years, the worst thing is that I cannot really sleep for more than four hours. But she says, and this has a little bit, I think, in with what we were talking about earlier, but she says, I've tried all my blood results. It says that my progesterone is very low. Is it not supposed to be almost normal because I use HRT?
SPEAKER_02So this is going back to the conversation we had earlier that getting hormone labs is not really accurate to tell us what's going on in your body. Um, and so, you know, getting a hormone level, especially when you're taking HRT, but even when you're not, it's it's not very useful to tell us how best to treat you. Um, so I would just, I would discuss with your doctor, you know, if you're one of our patients, talk to your Winona doctor, let them know about how your sleep is. Sometimes it could be related to when you're taking your medication, like what type of what time of day. Um, because sometimes, you know, we usually most women will start off using their meds at night to help them sleep, but there's some women that can get really energized and activated by taking hormones. And so sometimes it could be disrupting that quality of sleep. Like you might be able to fall asleep easy, but you are easily arousable and you don't get into that deeper restorative sleep that you really need. So it might need, you know, the tweaking of timing, but talk to your winona doc.
SPEAKER_03You know, two things also. Uh one is even if these labs were accurate, your progesterone as you try to go through the menopause transition, it's supposed to be low. Um we're not using progesterone really to give you, you know, health benefits. The estrogen is doing that. The the pre as Dr. Kat mentioned earlier, the progesterone is primarily to protect the endometrium, stabilize the endometrium. And we know we're giving you enough for that, and that's not going to show up in a lab value, even if the lab values were accurate. So um even stipulating if you had the ability to get accurate lab values, you wouldn't want to try to push your progesterone up high. It's not really beneficial. The second thing is sleep is a very common symptom. Sleep problems is a very common symptom that menopause transition. However, sleep disruptions have a lot of other potential causes. Um, I mean, there are a lot of men that have a hard time sleeping, right? Um, so if you're on a good dose of HRT and you're still having sleep issues, this may not be coming from your hormones. It may be other issues going on. And so it may be a good reason to see your family doctor or your primary care doctor and look into other potential causes and treatments for sleep disturbances. Um, not everything is coming from your hormones.
SPEAKER_01Absolutely. And our next question is from Lisa. And Lisa is wondering can tenuitis uh be a symptom? She says that's a fun new thing I've been dealing with. Could grief. Tinnitus? Is that what yeah, tinnitus? Yes, sorry.
SPEAKER_03I wasn't curious, it's tendinitis or tinnitus.
SPEAKER_02No, I wasn't sure. That's why I wanted to clarify. So yeah, it's actually a very common symptom that I hear from patients. Um, you know, it's literally because estrogen withdrawal, um, as we get into further into this transition of menopause affects so many tissues throughout the body. But tinnitus, for those that don't know, is like uh the medical term for ringing in the ears. Um, and so very, very common. And um, it's one of those things that sometimes isn't noticed as being a symptom. And sometimes patients will be sent, you know, they'll see their primary care, they'll get sent to ENT, they'll have this whole workup to rule out other sources of it and they don't find anything. Um, and it's important to do that. So, because there are there is some crossover with some of the weirder symptoms of perimenopause and menopause that could be related to other medical conditions. But that yeah, that is a very common symptom that we hear. Another one that's really weird is with the changes in the skin, a lot of women will start to have what we call paresthesias, or they'll have a sense that like something's crawling on their skin. Like you feel like there's like a hair touching you and you go to look and there's nothing there. Or worse, like you feel like a bug is crawling on you and it's nothing there.
SPEAKER_03Um you got me wanting to it.
SPEAKER_02I know, right? Yeah. Um, yeah. So this, these are one of the, these are more obscure symptoms, but we do see them quite often. So it could be related. But but don't ignore, you know, if you have a new symptom that's really concerning, don't ignore it. And, you know, it's still important to work up other sources of that because there are other things that can cause tinnitus, like, you know, ear infections can. Um, and sometimes, you know, sinus problems can cause it too. There's there's a whole slew of things that can cause that. But yeah, it is a common symptom that we see too.
SPEAKER_01Absolutely. And our next question tonight is from Denise. Um, and Denise says, My sister had a stroke at 40, and the only thing they could say um it was from was being on the pill. Does that affect me taking HRT? And then she says, also for some context, I've had a hysterectomy to add to the weight question above, but still have my cervix.
SPEAKER_02Yeah. So having someone in your family have um a DVT or stroke, you know, at a young age is of course concerning. Um, 40 years old is young to have that, but you know, we look at all the risk factors that go into that. You know, do you have a sedentary lifestyle which can lead to more stasis of blood in the blood vessels? Um, or, you know, was there some kind of what we consider to be a high clotting state in your body, like hypercoagulable state? There can be some genetic, you know, forms of problems that um that can lead, you know, put somebody at higher risk of having a stroke or having a blood clot. So sometimes when younger family members might have something like that, you might want to ask them, did they get genetic testing? Did they work them up to see if there was something hereditary that predisposed them to having that medical problem? Because that's what you need to know to know really what your risk is. If they didn't, and if it was solely all they found in the risk factors was birth control, you could chalk it up to the birth control. We see a lot of um DVTs, PEs um related to birth control usage. Um, but having had a hysterectomy, um, you, you know, if you if you still have your cervix, you know, you'll talk to your doctor about that. Um, we need to know if you are still having any kind of cycling at all, because it all depends on how much of the cervix they took. If they leave a little bit of the top of the cervix, there could be some endometrial tissue there. And if you're still having spotting on a monthly basis, you might still need progesterone with your estrogen. So it's important to talk to them about that in more detail.
SPEAKER_01Absolutely. And our next question is how much can pain reduction be attributed to HRT? Um, she says, I've been dealing with hip and back pain and stiffness for two years. Um, I've been taking HRT since November 13th, and I've had significant improvement. She says, Am I experiencing a placebo effect?
SPEAKER_02Actually, no. So here's the thing: the loss of estrogen affects your joints too. Like I mentioned earlier in the call, like it affects so many tissues throughout our body, but specifically like our tendons, our ligaments, our muscles, the joint capsules, the bones, everything. A lot of women start to feel like, gosh, I'm really aging fast. All of a sudden, this arthritis is really kicking in. But it turns out it's the loss of estrogen, those declining estrogen levels that are really exacerbating all those symptoms. Estrogen is a very anti-inflammatory medication hormone. Um, and it really can help all those tissues function at their best. It adds suppleness and elasticity to so many other tissues and throughout the body. And so it can definitely help. And I would say the same thing. Same thing happened for me. Um, I have a slew of back problems myself and all kinds of joint issues after being in the army for 12 years. Um, and so for me, it was a game changer. I really thought like I was, you know, falling apart in my mid-40s. Um, and HRT has made a big difference for me too. So it's not a placebo effect. And many women see this benefit in that their joint pains significantly improve after they start their hormone therapy.
SPEAKER_01Absolutely. And our next question is um, my hot flashes came back around my 10-week check-in. Uh, she says I was on the combo cream. So then I asked my doctor to add in the DHEA. She says, since I started a DHEA four weeks ago, I now have some night sweats, which I didn't have before. Is there a reason why this is happening? And can I expect the night sweats to go away?
SPEAKER_02Well, when you take the DHEA, as your body breaks it down, it's breaking it down into estrogen and testosterone. So your estrogen level is going up a little bit. Um, and and anytime we have large fluctuations in our hormones, that's when you get the majority of your vasomotor symptoms, like the hot flashes and the night sweats. So it could be related to that. So I would give it more time and give your body a chance to acclimate to the DHEA before you make any more wholesale changes on dosage.
SPEAKER_03I would at least keep an eye on this because I guess that's you probably need a little more estrogen in the cream. Um so uh, you know, if you had told me at the 10-week check, hey, I'm doing a lot better, but I'm still having some hot flashes, my go-to would be let's increase the estrogen. Yeah, rather than add DHEA. So now my the way I'm seeing it is that your estrogen was probably not quite there and it's kind of progressed. So it went from hot flashes, now you're added some night sweats. It's possible it's um from the change in the estrogen level from the DHEA. But if you're already at the four-week mark, you're almost past that. But I'd give it a couple, two, two, three, four more weeks. Um, and uh, if you're still experiencing that, it's probably time to increase the dose of the cream.
SPEAKER_01And our next question is from April. Um and April says, Hi, she says, I've always had in the regular period. Um, but she says, I noticed having perimenopause uh when I when I was having heavy period heavy and prolonged periods. After a year, it went away. However, two days after starting the therapy, the heavy period came back and currently, and I'm currently on it right now for about a week. Is this normal? It seemed like it was slowing down today, but it's making me a bit nervous since it's been really heavy for a week.
SPEAKER_02So, whenever I mean, we talked earlier in the call too that sometimes you can get some bleeding changes in response to starting treatment. Um, but if if this is if this is the first time this has happened since you start the medication, I would watch it for now. But if this becomes a persistent issue, and anytime you have a change in your menstrual cycle and your period gets much, much heavier all of a sudden, it warrants an exam to make sure that there's not something else going on. Because there are other things that could be contributing to abnormally heavy bleeding. Um, and if you're bleeding so much to the point where you could become anemic if you're losing too much blood, then that would warrant treatment. Um, and hormone therapy will help with your symptoms of menopause, but it's not going to regulate your bleeding. Typically, it wouldn't affect your bleeding this much to cause heavy, heavy bleeding like this either. It really doesn't affect the bleeding so much. Um, but there could be other sources and other reasons why this is happening.
SPEAKER_03Yeah, the other thing is, you know, just as a little warning, if you're bleeding so much that you're bleeding through pads and soiling your clothes, or you're having to change, you know, a pad an hour or more, that really can't wait. You need to be seen right away. That's too much bleeding. Um, the other thing is that you can message your Winona doctor. Sometimes we can sort of manipulate your HRT on a very short term, like four or five days maybe, to try to get this episode under control. Um, so there are some tricks up our sleeve um if you uh message in. Uh but if it's really significant bleeding, you know I I'm Ken and I have spent enough time uh covering the GYN ER that, you know, we've seen people show up and you know have waited too long and now we're having to transfuse them and do emergency procedures. So So, you know, don't let it get out of control. But so if you're, you know, if it's uncontrollable and you're you're bleeding through pads into your clothes, you need to be seen right away.
SPEAKER_01Absolutely. And our next question is from Marlene. Marlene says, I just ordered the estrogen patch, the progesterone, and the DHE pill DHEA pill. She says, I'm excited to start. Um, she says, Is real testosterone available if DHEA does not help?
SPEAKER_02Not from us here at Winona at this time. Um, you know, what that's one of the other things we're hoping that the FDA is gonna do is that we're hoping that they're gonna change, you know, and and maybe come up with some guidelines for for female marketed testosterone products. Cause right now there are no products that are, you know, FDA approved for women when it comes to testosterone. So anybody that's prescribing testosterone is using a male medication and trying to tweak it to be appropriate for a woman, which most of the time is about a tenth of the dose that you would give a man. Um, so right now, and from state to state, there are different laws as far as telemedicine as to what you require in order to prescribe testosterone. So we don't offer it on our platform um at this time. But hopefully in the future, we'll, you know, maybe we'll see if the FDA continues their pendulum swinging the other way and making this care more readily available for women. Hopefully it will be in the future.
SPEAKER_03I uh I I mean, I would wish it would. I think it's unlikely because um testosterone is considered a controlled substance by the D. So there are some states that have some holdover laws, really. Well, there's a couple of states that are just wide open, but there are some states that have holdover laws from COVID. Um even though we actually started with Nona kind of at the tail end of COVID, we had made a decision not to use COVID rules, but to use the general rules because we knew those were going to go away and we didn't want to offer something and have to snatch it back from people. We didn't think that was a good way to go. It just seemed fair. Um and so we sort of use the most restrictive rules as a global rule for our company just to be super safe and make sure that we're, you know, compliant with all the rules and regulations. We want to do everything right and buy the book and dot our I's and cross our Ts. Um, I think it's important. Um and you know, we're conservative in our approach really to protect, you know, your health and do things well. So if it gets reclassified, which I doubt it will, um that would open up the door, which would be great. I think it'd be wonderful to be able to do this, but I'm I think I'm more pessimistic uh on that one.
SPEAKER_02But earlier in the call, you said you were more glass half full, you know, are you you gave the doctors ordering labs? Mike, I don't know.
SPEAKER_03So I I guess when I when I look at people, I try to give them the benefit of the doubt. Um but uh when I look at the government IOR, I'm doing that.
SPEAKER_01Good point. And it looks like our next question is from Rosa. Um and Rosa says, I haven't started my HRT um waiting for my order. She said I had an ablation procedure because my cycles were so bad that it says due to a large uterus. Will HRT affect it?
SPEAKER_02No, it should not affect your ablation. Um, however, you know, we have we have pretty good data on ablations and how long they last, um, depending on what mode of ablation that you had. And for those that are listening and don't know what an ablation is, it's a procedure that we do to basically cause destruction of the uterine lining so that when your body tries to mount that lining of the uterus to have a period, there's just not enough tissue there. So it treats heavy bleeding, basically. And it's something that we can offer before going to the point of eating a hysterectomy. Um, but the data shows us is that most of the global ablation methods give patients good relief for about 10 years. Um and after that, the uterine tissue can find a way to regrow and regenerate because the body is rebellious and it likes to come back. Um, but no, your your hormone therapy should not affect you know the results of your ablation surgery.
SPEAKER_03And just as a just to go down a little bit of a rabbit hole. So I've been around long enough that um when I came out of residency, we really didn't have an effective way to do an ablation. Um that was a rule of our letting work. So yeah. So that was one of, for me, that's been one of the huge, great changes um in gynecology since I've come out of training. Um, it really has saved a lot of uteruses. So, you know, instead of having to do this big procedure and remove an organ out of somebody, um, we do a little outpatient thing and it works like 85-90% of the time and lasts a good 10 years. And it's a lot of times it lasts long enough to get people through the troll period. Um so even though it doesn't necessarily last forever, it lasts long enough that once it sort of wears off, you're past the period where it's a problem. It's just been a great advance um in medicine that I've seen that's really been super helpful um and allowed us to do things a lot less invasively, which I think is is is a great thing. So total aside, um, but it is kind of a cool thing. But I I mean, I'm not that old, and like how medicine has changed is in just in my career is amazing.
SPEAKER_01And our next question is from Ruth tonight. And she says, she says, hi, she says, I don't really feel like I have many or noticeable symptoms. But she says, but for the benefits you've mentioned, bone and brain health, I would want HRT. How will you determine dosage then?
SPEAKER_02Well, I think that whenever you're considering any medication, you have to look at risks and benefits. And so, you know, I think right now, like our guidelines are not to simply start hormone therapy solely for this for the health benefits, because you have the risk of getting side effects by just taking it for the potential benefits. So if you are otherwise doing well and you're not suffering from symptoms that are bothersome to your day-to-day lifestyle and it's not affecting you negatively, then it may not be a good option because then the risk of the medication could outweigh the benefits for you as far as giving you symptom control. Um, but it's a conversation to have. You know, it's, you know, right now it's not recommended to just put somebody on hormone therapy to prevent, you know, cognitive decline or to prevent osteopenia or osteoporosis, even though estrogen is really effective at maintaining bone health. Um, it's for that indication alone, is not not really the way we practice, you know. And so I think that you have to scrutinize any medication. And I I think that would be a bigger conversation, but you might not be ready quite yet if you're not having symptoms that are bothersome enough to warrant the medication.
SPEAKER_03This does, you know, go to the shared decision making. Um, and so it's a place to have a conversation with an expert that can explain the benefits, the pros and cons. So um, you know, ultimately you can make a good decision that's right for your personal needs. Um and so and that would also go towards dosing. Um but yeah, in general, sort of the general recommendation is we don't really start HRT just for those long-term health benefits without you know the other symptoms. Um, but again, um that is a I think a reasonable place for a conversation and and a shared decision.
SPEAKER_01Absolutely. And our next question tonight is from Violetta. Um, and she says, I have a sensation in my mouth that it feels like it's burning even around my lips. Is this due to hormones dropping?
SPEAKER_02Burning around the lips? It can be. It could be one of those weird symptoms, um, potentially. Every woman's, and that's the thing is that you know, when you really look at a category symptoms of perimenopause and menopause, there can be over 130 different symptoms that women can experience, and every woman is different, and what she experiences is different. So it could potentially be.
SPEAKER_01And our next question is from Mercury. Um, and she says, I've noticed that my appetite has increased tremendously. Is it possible that this is related to treatment?
SPEAKER_02I mean, it's certainly possible when when you are starting hormones of any kind, whether it be hormone therapy or when you know you're younger taking birth control, you know, your metabolism is changing, your your digestion is maybe slowing sometimes, and and sometimes that can affect your appetite. Um what we can do, I mean, this is where you know, we can talk about that medication is not the only thing that you should be doing to really optimize your health and wellness. Like there's lifestyle modifications that you should do. And so if you notice that your appetite is increasing and you look at the foods that you're eating, you know, you want to make sure that you're getting good quality nutrition, making sure that you're getting enough protein in your diet, making sure you're getting good fiber, things that are gonna really stick with you and make you not make you get hungrier faster. You know, um, I think that a lot of women focus on a lot of the like low calorie items, but that don't really have good solid nutrition. You want to focus on whole foods and things that go bad, you know, lots more vegetables and fruits and protein is so very important. And so many women do not get enough protein to maintain their muscle mass. Um, and I think that a lot of women are afraid of eating too much protein because they think they're gonna bulk up, but you would have to eat a ton to really get, you know, muscle like that. Um, but that's something that I would focus on if you're noticing those changes. And also make sure you're drinking plenty of water too. Sometimes us as human beings, we feel hungry when we're actually indeed thirsty. And I would say, I would argue probably more than 80% of Americans walking around right now are probably clinically dehydrated if we were to test them. Um, that we don't drink enough water. As I sip on my coffee, I'm not a good example. Do what I say, not what I do, right?
SPEAKER_03This is mostly water. You know, the other thing is that um this is if it's from the HRT, it's probably temporary. So um the body doesn't like change. And so as you start hormone replacement therapy, there's a sort of change in hormones as your blood level is getting used to the medication, and this should stabilize out. Most people long term find it easier to lose weight while on hormone replacement therapy. Um, but it sometimes takes a while before that benefit shows up. And I have seen some people that have this sort of initial side effect that it typically goes away.
SPEAKER_01Absolutely. And our last question for the night is from Margarita. Um, and she says, That's not good right now, Margarita.
SPEAKER_03I was gonna say, yeah, it's the last question, sir. I know who we're going next, right?
SPEAKER_01She says, My mom is almost 80. Uh, would she be a candidate to take DHEA or use the cream? She says she still complains about some stuff still and is wondering if she could get any relief. She says she's never used anything for menopause that I'm aware of.
SPEAKER_02Yeah, so here's a good conversation. And this was one of the really good pieces of information that we learned from the Women's Health Initiative study was that there is a timing hypothesis, meaning in that we we know what the safest time period is to give a woman hormone therapy. And what that is, is that within 10 years of going through menopause and before the age of 60 are is really the best and safest time for you to initiate hormone therapy. So unfortunately, at 80, it would be probably too dangerous. You know, the risk would far outweigh the ri the benefits for your mom to start treatment at that age. But I mean, it's kudos to you for thinking about it and thinking of ways to try to help your mom, but there's other ways that are more natural, lifestyle modifications that could be better for her health and safer.
SPEAKER_03And, you know, just as a shout out to the FDA again, um, this was a black box warning they did not remove appropriately. Um, I was actually very glad to see that. I was a little worried they're going to be very reactionary and just remove all the warnings, which would also be inappropriate. Right. They they left in place what was appropriate and they took out what was no longer based on the latest data, but the the age over 60, 10 years past menopause. There's really solid data for that. Um, and um, that does remain in the black box warning, and I think appropriately. So again, kudos to the FDA for this big change.
SPEAKER_02Absolutely.
SPEAKER_01Well, thank you everyone so much for coming out tonight. Thank you, Dr. Green and Dr. Kat, for your time. Um, and just as a reminder to everyone as well, if you ever have any other questions, your doctor, your Winona doctor is always available in your portal 24-7. Um, that is a great place to reach out and message them and have these conversations. These same questions you asked today, um, you can ask your Winona doctor anytime. So they'll always be happy to help you with that. Um, they're a great resource to reach out to. But if you're also looking for some other resources, we have our Winona podcast, the menopause hour. Um, so you should be able to find that on all the major uh podcast um like places. So go ahead and check that out. It will have things like these calls. It will also have sometimes we have interviews with some of our ambassadors or um other content as well. So that's a great thing to check out. We also have um a lot of resources on the Winona website. So if you're interested in specific symptoms or kind of diving deeper into articles like that, that is a great place to look. There's articles, there's videos, um, there is there's just really a wealth of knowledge there.
SPEAKER_02Yeah, if you go to the website and and you look at the drop downs, it's under Learn. There are tons of journal articles that are really well written that you can learn about anything you would possibly want to know about perimenopause and menopause. And I don't think enough people utilize that resource.
SPEAKER_01Absolutely. Yeah. Um, well, and again, we're so glad that you all were able to be here. Um, and if you want to join another one of these as well, we have these pretty often. We have them almost every two weeks. So please come join another live Q ⁇ A. We'll answer more of your questions. Um, and we would love to see you there. But depending on where you are right now, um, hope that you have a great rest of your night. And thank you all again so much for coming out. And happy Thanksgiving next week for those celebrations.
SPEAKER_02I mean, I'm already being bombarded with Christmas everything everywhere, everywhere you go. Um, it's like too early for me.
SPEAKER_03I know I'm also journeying on my turkey. Christmas after Thanksgiving.
SPEAKER_01Yeah, well, happy holidays, um, I guess on this end for whatever whatever holiday you are looking forward to right now on our end. But everyone, hope you have a great night, and we'll catch you next time. Thanks for coming out, everyone. Good night.
SPEAKER_03This is a lot of fun.
SPEAKER_00Thanks for spending time with us. We hope today's conversation helped you feel more informed, more supported, and a lot less alone. If you're ready to go deeper, download the Winona app. It's free, it's for you, and it's filled with resources, real stories, expert insights, and a vibrant space to connect with women navigating the same season. Have questions? Join our next live QA. Until next time, take care of yourself. We'll be here when you're ready for more.