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 #31 Creams vs. Pills, Safety, and Why the FDA Is Finally Catching Up
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In this episode, Dr. Green brings us into a deep dive into hormone replacement therapy (HRT) comparisons and the latest regulatory news on its use. Dr. Green discusses the significant, "long overdue" news about the FDA starting to embrace HRT and change its black box warnings, which should increase its accessibility. This episode also featured opportunities for common patient questions to be answered, covering the differences between HRT cream and pills, the typical timeline for symptom improvement, and general safety guidelines, including advice against acting on treatments without prior communication with your doctor.
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Welcome to the Menopause Hour, your go-to source for answers to your burning menopause questions, the ones you can get from your OBD women. 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_01Hi, everybody. Welcome to another live QA with Winona. This is a great place to learn, connect, and get real answers from our amazing doctor today. So thank you so much for being here. I know it can be hard to find the time. You know you're busy and your schedules are full, especially this time of month with the holidays. You're probably more booked than you ever were because it's December. My name is Ina. I'll be filling in for Maddie today. She actually had her flight delayed like four times. She's somewhere in the air right now. So I guess we can get into this, nevertheless. And whether you've joined us before or it's your first session, we're so glad to have you here. If you're new to Inona, we're all about helping women feel like themselves again from perimenopause to menopause support, hormone therapy solutions to building a community that makes this stage of life empowering instead of isolating as it can feel many of the times. So a bit about how this live QA works. You can ask our doctor, Dr. Green, any questions you want. There's nothing that's off the table. There's a chat box at the bottom of your screen, and you can add them right there. And we'll read them out loud and kind of get them answered for you. And uh, we can get as to as many as we can today in the session. Um, our doctor, Dr. Green, is here to help you understand what's going on in your body, what options are available for you, and things like that. So I'll hand over the floor to Dr. Green to introduce himself and take it away.
SPEAKER_02So hi, welcome. Uh so yeah, all questions are on the table. Not all questions will be answered correctly. So if you ask me the winning lottery numbers, I'll probably get it wrong, but knock yourself out. Um but yeah, feel free to ask me uh any anything that's on your mind. Uh it'd be like a Reddit AMA. So you can ask me about 100-sized ducks or however that goes. Um, so I'm Mike Green. I am an OBGYN. I actually uh did a family practice residency and found out that I really didn't like taking care of sick people and I fell in love with women's house. So I did a whole second residency, um, get formal training at OBGYN, which is really what I've spent my career doing. Uh so gosh, Winona has been here, what, for four and a half years now. Um, and so I um helped launch uh launch Winona. We I've been here since the beginning. I'm uh chief medical officer, one of the founders. So uh really excited about uh this community and about um you know how many women that we've been able to um help because unfortunately uh hormone replacement therapy is just not that accessible because people are afraid of it. They doctors are afraid of it, doctors haven't been educated well on it um for various reasons. Uh we think the pendulum is uh is moving. Um and so uh I know we talked about this on the last QA, but it's it was such big news that uh it kind of doesn't go away. The FDA is sort of starting to embrace um hormone replacement therapy and they're changing some of the warnings, what we call black box warnings, um, on uh hormone products, which is um very, very long over two. By the way, uh don't forget, uh please put your questions in the chat, otherwise I'll just be blogging for an hour, and that's not gonna be fun for anybody. Um I have a lot of patients are are uh messaging me and asking me, you know, now that the FDA you know has changed everything, how is that gonna change the way we're gonna practice medicine? And the answer is it's not. Um, because we've been doing it the right way since the beginning. The FDA has just been very slow at adopting the um, you know, the latest literature as the FDA tends to be. So the FDA is finally catch catching up or starting to catch up. Um, but Winona's been at the forefront from the very beginning. So the good news is we've been doing the right thing um all along, and the FDA is just now finally acknowledging that, yeah, this is kind of what we need to do. Um, so it makes life a little bit easier just because there aren't all these scary warnings on the packages, although it hasn't changed yet, but that's coming. Um, but you know, scary warnings are not, we still do the right thing for the patient, um, regardless of what the government puts on the packaging. Um, so it really isn't going to change the way we do things, but it I'm hoping that it makes us more accessible because hopefully people will be less afraid. Uh doctors will be less afraid to prescribe it. Uh also there was a pretty long period, probably 10, 15 year period, where doctors weren't being trained in the use of HRT, even OBGYNs. Um, and so there's sort of this big void of education in this whole generation of doctors. And that seems to be changing, thankfully. So the newer doctors coming out now are at least starting to get trained on this. So I do think we're um looking at some really positive changes um in the way uh women are going to get more access to healthcare. Uh, but in any case, Wadona's here to uh take care of you, um, whether uh your primary or your OBGAN um is well versed in HRT or not that we certainly are and happy to help you. So uh that being said, um, it looks like we've got some questions. So um why don't we hit some questions?
SPEAKER_01Yeah, wonderful. Thank you.
SPEAKER_02Well, one more thing. Sorry, if you haven't noticed, I've got a bit of a cold. So uh Dr. Kat Brown is uh our medical director. She's usually here with me. Um her, she has a kid with uh a bad GI bug, and so she said she's on puke duty tonight. So I'm feeling in, I've got a bit of a cold, so if I'm a half step behind, that's why. So I apologize. But um anyway, let's hit some questions.
SPEAKER_01Yeah, there's definitely something going around. But thank you so much for being here with us today. And we got so many questions coming through. Let's get right into it. So Laurel asks, is the cream as good as the pills?
SPEAKER_02Uh yes, um, they're they're different. Um, and everyone responds a little bit differently to different medications. The cream and the pills both work great. Um, and it's really, in my opinion, and mostly comes down to personal preference. Um there are some theoretical reasons why the cream is a little bit safer than the pills. The pills have to go through what's called first pass metabolism. What that means is because you swallow them, they go through your GI tract, and everything in the GI tract gets sent to the liver first, and then after the liver takes care of things, it gets sent to the general circulation. The liver is responsible for breaking down the hormones, and so you the liver gets this sort of big burst of hormones, which it you know tries to process, but really can, which you don't really want it to, um, not in the first pass, and then it goes out to the general circulation. When you use a cream, it gets absorbed to the skin directly into your circulation. It eventually gets to the liver where the liver breaks it down, but it doesn't get there all in one shot. And so it's a lot gentler on the liver, which decreases certain risks of HRTD. So from a purely statistical point of view, the cream is actually a little safer than the pills. The truth is the risks are really small. So even if you decrease a risk by a lot, if that risk starts off really small, you haven't really changed it very much. So it's kind of like like I was talking about lottery tickets. If I told you you're twice as likely to win the lottery tomorrow than you are today, you know what? You're still probably not going to win the lottery tomorrow. Because changing the odds of something that's really unlikely, it's still going to be really unlikely. So even though we're decreasing the risk of these really unlikely side effects, they're still remain very unlikely. So the pills and the cream are both safe. They both work well. The cream is technically a little bit safer. Um, and they both work really well.
SPEAKER_01Okay, thank you, Sabat. Uh Laurel, I hope that answers your question. And we have a question from Carol who says, I have an abundance of topical cream. I'm using two pumps a day. Should I be using more?
SPEAKER_02No. So um two pumps a day, assuming that's what your doctor told you to use, is the that's the typical dose. Uh occasionally, when we need to increase a dose, we'll have someone use an extra pump to use up their extra and then send them a stronger cream. But generally, the cream is built for two pumps per day. So here's the thing with the cream. We the the pharmacy always puts a little bit extra in each bottle because we don't want you to run out. And sometimes there's some waste, you know, when the pump is primed and stuff like that. So they always put in some extra because we'd rather have you have a little extra at the end than let them run out early. Also, we run our cycles on a 28-day month. And the reason we do that is the hatches are packaged as a 28-day supply. And we want to keep everything on the same cycle. So we actually send a 30-day supply of cream and we send it every 28 days. So between the extra they put in and those two extra days of cream each month, eventually, if we've been on it long enough, that starts building up when you get a little bit of extra. So that's a normal thing. Um, it's sort of part of the process. Uh, again, we'd rather have you have extra than not enough, but it doesn't mean you're not using it correctly. So keep using two pumps. Now you want to make sure you're depressing that pump all the way down so that you get a full dose each time. Um, but you just want to use two full pumps each time.
SPEAKER_01All right, thank you. And Hadesa does not have a question, but I really love the comment. She says, hello everyone, five months in for me and all looking so well with Winona. And she wants to say thank you. So if you're still in the chat and here, thank you so much for your comment. And we'll move on to Pamela's question. She says, I'm taking oral estrogen from Winona. My gynecologist or menopause specialist told me that oral estrogen, not patches, are connected to heart disease. Why would oral be different than patches for cardiac health?
SPEAKER_02So I respectfully disagree with your in-person doctor. Um estradiol or any really oral estrogen has been shown to decrease the risk of heart disease. Um, and in fact, if you look at women that are taking oral HRT and compare them to women that take no HRT at all, the women that take the oral HRT will live, on average, a longer, healthier life. And one of the big drivers of that is the decrease in cardiovascular risk. So oral estrogen decreases your cardiovascular risk. That's absolutely extremely well documented. Um transdermal, which is the patch or the cream, as I was talking about previously, bypasses that first past metabolism and changes certain risks. And the the risks particularly are strain on the liver, um, which is pretty unusual, um, blood clots, which are also um pretty unusual. And maybe, and we're not sure about this, but maybe a little bit difference in effects of triglycerides. So HRT, whether you take it orally or a patch or a cream, uh will in a big picture improve your lipid picture, your cholesterol picture. So it decreases the LDL, which is the bad cholesterol, it increases the HDL, which is the good cholesterol. However, it can increase triglycerides, which is not something that you necessarily want, but it doesn't typically increase it that much. Some people believe, and there's some data for this, although they're not a huge amount, that the uh patch or the cream has less of an effect on triglycerides than the pill. So I suppose that's maybe what your doctor is talking about is that there is a little bit more of a sort of bad effect on your triglycerides with the oral than there is with the patch or the cream. And if your triglycerides go crazy, that can cause um issues with heart disease. But again, this difference is very small. And the overall difference, um, or sorry, the overall effect of oral estrogen is to decrease your cardiovascular risk. So, all that being said, is the oral estrogen is probably perfectly safe for you. If you feel more comfortable with a patch or cream, we have those options available. So just reach out to uh your Renona doctor.
SPEAKER_01Okay, we hope that answered your question. And Daydra asked, How do I know what stage of menopause I'm in? I'm 58 years old and new to Winona.
SPEAKER_02So this is one of my little pet peeves. Um, the stage of menopause isn't really so important. What's more important is how you feel. But I can tell you what stage of menopause you're in. So um if you're still having periods, you're in pre-menopause or perimenopause, because the definition of menopause is 12 months without a period. So if you go 12 months without a period, that date, that on 365 day, or on the 366 day, you are now menopausal. And a minute later, you're now postmenopausal. So those are sort of the stages of menopause, right? There's like not in menopause or not not there yet. There's perimenopause, menopause, and postmenopause. That 12 month is an arbitrary number, obviously. Um, so we have to pick something because people like to have names for things. Um, and so they sort of arbitrarily picked this 12-month mark, and that's what we call menopause. But honestly, I've seen people go 14, 15, 16 months, and then all of a sudden they get this period out of nowhere. And then they're all mad. Oh, I'm now I have to start, I have to wait 12 more months. Like, well, it doesn't really matter. Um, because what matters is how you feel. So the important thing with treatment is what symptoms you're having and how severe those symptoms are. And that helps us manage your treatment. Whether you're in perimenopause, menopause, or postmenopause is really less important. What's really important are the symptoms you're having. The rest of it is just a name, quite honestly. But that's how you can tell. So if you're still if you've had a period sometime within the last 12 months, then you're not in menopause yet. If you haven't had a period in 12 months, you're in menopause. Um, and if it's exactly 12 months, you're that's menopause. And if it's anything over that, it's postmenopause. So the actual menopause is a very short amount of time.
SPEAKER_01All right. That is something probably everybody here needs to take note of and even tell your friends, but is a question we often see. Um we have Jennifer asking, do you still need to supplement if your DHEA is at 67?
SPEAKER_02So the DHA that they're test if let me back up first first off. Test performers are pretty much useless um because they're just a snapshot in time. And if you check your tests an hour or two later, it's gonna have a totally different number. So they really aren't helpful or useful at all. DHEA is really kind of interesting because the DHEA that we use gets broken down completely into testosterone and estrogen within 30 minutes of taking it. So it's really not gonna affect your DHA levels to any great extent. The other thing is that the blood test that they did, if you look at if you look carefully, it's gonna say DHEA-S or DHEA sulfate. That's the same thing, which is really different than the DHEA supplement that um we're providing. There is a DHEA-S supplement um that is available, um, and that does not get broken down like DHEA does, and that can raise your DHEA levels on your lab tests. So the DHEA level on your lab test is really irrelevant as to whether or not you should take oral DHEA. The oral DHEA is not given to you to affect your DHEA levels, it's given to help increase your testosterone levels. Because what we know is that testosterone decreases with age. So if you look at women in their 50s and you compare them to women in their 20s, they have about half the amount of testosterone. Testosterone, you know, is generally thought of as the male hormone. Um, and it is, it's the dominant hormone in males, just like estrogen is the dominant hormone in females. But a little bit of testosterone for women can be very important. And so since those levels decrease, sometimes supplementing can be helpful if you're having symptoms. And the easiest way to do that is DHEA. It's a very safe and easy way, it's a general way of bringing up your testosterone levels. And then the doses that we use, it won't get you above normal female levels. So now, if you take crazy amounts of DHEA, and there are people that do this, um, you know, 200, 400 milligrams a day, uh, you know, yeah, you can really push those testosterone levels up. In fact, bodybuilders that are juicing generally use about 400 milligrams a day of DHEA in their regimen. Um, but that's not what we're after. If that's what you're after, that's fine. That's a whole different thing. It's not what we do here. Um, we just want to get you back to your minimal levels. And that's what the 25 to 50 milligrams of DHEA will do. So the real question is how are your symptoms? Um, if you're having some decrease in libido, some decreased energy, difficulty losing weight, then DHEA is probably helpful for you. If you don't really have any of that, then you may not need it. But really, that's the important thing rather than the actual uh lab level, because the lab level isn't really telling anything about what we're using the DHEA for.
SPEAKER_01All right. And Marlene says, hello, my name is Marlene. I just started with HRT. Hello, Marlene. And she has an estrogen patch of 0.0375 progesterone and 100 MG and DHEA of 20 MG. How soon should I notice changes and how soon do we titrate up if we need to?
SPEAKER_02Great question. So it's not an all or nothing thing. Um there are some things that are typically kind of early winters. So if you have hot flashes or night sweats, those typically go away pretty quickly, usually within the first month. Some people get relief even more quickly than that. Um sleep issues are usually helped fairly quickly as well. Other things um like hair and skin changes, um, weight loss, those can take a lot longer. Um so generally, what what's gonna happen is unless you're having you know some you know, bad side effects or or or other problems like that, you like to try and keep that dose the same for the first three months. There's gonna be a check-in at 11 weeks. Now, this is kind of a funny thing. You may hear it called the 10-week follow-up. Um, and the reason why is when we first just did this, I thought 10 weeks would be the right time. So we actually scheduled that follow-up at the 10-week mark. And after a little bit, I realized that it was really a week too early, and 11 weeks hit it better. So that follow-up is scheduled to be about a week before your three-month refill. That gives us a week to talk back and forth to see if we need to change the dose. So, anyway, it's actually good 11 weeks, but that nomenclature of 10-week follow-up kind of stuck with the company and I haven't been able to get rid of it. So you get your 10-week follow-up at 11 weeks, and that's when we're gonna check in and say, hey, how are you doing? Are your symptoms better? Are you having any side effects? You know what's going on. And um, then depending on how you feel and how the medicine is working, then we would adjust the dose um based on that. So we really like to wait that long because that's kind of where we know what this dose is gonna do. If we adjust the dose too early, you're gonna end up on a higher dose than you need, and you may end up with side effects because you haven't given the medicine enough time to work. So, again, a lot of times there's some early wins in that first month. Um, and then you know, other stuff starts slowly, gradually getting better. Um it can take three weeks, even four weeks to get full blood levels um from these medications. Um, and then it takes more time for those complete blood levels to really start doing the effects. And that's why there's sort of a delay in this. So it can take a few weeks before you feel much of anything. And then, like I said, by three months, we should have a pretty good idea of whether this dose is working for you or not.
SPEAKER_01Okay, and Tamara says, if I put cream on in the morning, then shower in the evening, am I washing off the treatment? And a second part, can I change from cream to patch?
SPEAKER_02So uh the answers are uh no, yes. So um the cream is pretty much completely absorbed within 30 minutes of applying it. So as long as you wait 30 minutes to bathe, you know, take a shower or swim or bath or go into jacuzzi or whatever, um, you're fine. The cream has absorbed. So if you put the cream on in the morning and you tend to shower at night, um, that's great. We typically recommend using the cream at night because you get more benefit, more of the sleep benefit. So it might you might consider putting it on after your evening shower. Or you might find that you get more benefit with that. Um but what you're doing is fine. If it's working for you, that's great. So um you can put it on in the morning and shower at night, or if you decide you want to try it at night, just put it on after you shower. And the second the answer to the second question which She asked what I forgot what the question was. Sorry. What was the follow-up?
SPEAKER_01Oh, can I change from cream to patch?
SPEAKER_02Oh, uh yes, um, you can. So um, if you would prefer to have a patch, you can message your Wedona doctor and they'll talk to you about it. Um so did she say what cream she's on? No. Okay. So I don't know whether you're on an estrogen-only cream or an estrogen and progesterone cream, but um, just so you know, the patch is estrogen only. So if you switch the patch and you need progesterone, you'll have an estrogen patch and you'll have a progesterone pill. You have to take both. The pill will be every day, and the patch you change twice a week. The other thing is that the patch is a lot tends to be a lot more expensive. Not tends to be, it's more it's a lot more expensive than the cream. Um, so make sure that you find that information out um before you sort of pull the trigger and make sure it's right for you. But yeah, um, we're happy to switch your treatment around. Um, you know, you can go from the pill to the patch to the cream, back and forth, and see what works best for you, and that's fine. I generally recommend giving it that that you know, 11 weeks at three months, um, so you can see how this mode really works for you. But if you just don't like it and it's annoying and you'd rather have a patch, then we can change you more quickly than that. That's fine. So um just message your your window doctor and they'll be happy to help you with that.
SPEAKER_01All right, wonderful. And I just want to remind everyone drop all your questions in the chat. You can have follow-ups. Um, and Amy June uh has commented, I've noticed since using the products, I am very dry. Is this normal?
SPEAKER_02Um the products, I'm not sure what's dry. The products shouldn't dehydrate you, it shouldn't really dry out your skin, and it shouldn't cause you to have vaginal dryness. So I'm not sure what type of dry we're talking about. Um, but it really um shouldn't cause dryness. It may be more the season of the year as it's getting colder and we're putting the heat on. Um, it tends to uh dehydrate the air and make our skin drier. Um so a good you know, moisturizing cream if that's the kind of dry you're talking about, or you might want to drink more water if you're feeling dehydrated. Again, it's this very common thing, you know, in in uh in the fall and the summer. Um we're not running heat. When we run heat, it tends to um dehumidify the air uh in the in our houses. So um it tends to dry us out. So my guess is it may have more to do with that than the products themselves.
SPEAKER_01Okay, thank you. And Catherine says, I'm 41, started HRT patch and progesterone pill in October, felt good until around third week of November, and then started feeling like I had before starting HRT. What is going on? I just want to be normal.
SPEAKER_02So sometimes, and I don't have a well, I have a little bit of an explanation for this. Sometimes there's this sort of honeymoon where you get this like surge of benefit right away, and then it kind of goes away, and then I and then it gets better again. And I don't have hard science for this, but I think what's happening is that your body is is going from like nothing to hormones, um, and it's like, ooh, hormones, and and then it kind of gets used to that level and it really needs a little bit more. Um, and then like I said, it can take a month for the full level to come up, um, and then more time for it to affect. So you started in October. So it's been depending on when in October, it's probably been you know, uh six weeks, a couple months. So you're getting pretty close to that 10-week follow-up, and if you're still feeling that way, you probably need to increase the dose of your medicine.
SPEAKER_01Okay, and Takara says, Does progesterone cream protect the uterine lining?
SPEAKER_02Yes. Well, ours does. So that's a that's a yes with a caveat. So if you look at um the American College of Stetrokinecology, uh ACOG, or the Metopause Society, um, and you look at their statements, they're gonna have a statement that says you have to be very careful uh when about using a progesterone cream for uterine protection. And they are 100% correct about that. You have to be really careful, it has to be done really well in order for it to work. And the problem is that there's a lot of variation in progesterone creams. Compounding in in and of itself is a bit of an art. And there are really good compounding pharmacies and there are not as good compounding pharmacies, um, and there are inconsistent compounding pharmacies, and there are consistent compounding pharmacies. We are the, well, we're being we're told that we're the biggest supplier of compounded HRT in the country. Um, we have our own compounding pharmacies. We have two compounding pharmacies, um, one in Idaho and one in California. Um, and so we have control over how these medications are compounded and um uh you know, dosage, quality, recipe. Um, and so we do a lot of this and we do it really well. And I can tell you that that is that was my biggest concern when we started this company is that if we were going to do this, we had to make darn sure that we were doing the compounding right because we didn't want to put anybody at risk. Um, safety is our number one priority at Winona, um, and it really is. Um, in fact, patients sometimes get mad at us because um we turn patients away that we don't feel this is the right way to treat them. So there are edge cases where it may be okay to use HRT, it may not be. It's kind of questionable. Um, and you know, maybe there's a lot more information that needs to be obtained. And for those people, this type of platform isn't really the safest way to do HRT. And so we turn those people away. Um, and we do it because we want to make sure that they're getting the best treatment, the safest treatment. Safety, safety, safety. That's kind of what we preach here. Um, and so we are really careful about dosing our progesterone cream appropriately and using the correct type of progesterone so that the progesterone can absorb well enough to protect the uterine lining. We've had um over 150,000 patients over the four and a half years, um, and we have not seen any problems with uh the cream not protecting the uterine lining. So we're doing it, we're doing it well and we're doing it right. The problem is that that's not true everywhere, and you know, you can go on Amazon and buy a progesterone cream. I can tell you that I call that progesterone a name only because in order for them to sell it to you without a prescription, uh it doesn't really have any progesterone or it has a teeny, just has just a teeny touch of progesterone in it. Certainly not enough to protect your uterus. And unfortunately, there have been women that have, you know, bought progesterone cream off Amazon or wherever, some non-prescription thing that's marketed as progesterone cream, uh, and assume that they were getting the progesterone they needed and they weren't. And that can be a disaster. I mean, you can develop a uric cancer that way. Um, and so ACOG and Menopause Society is absolutely 100% correct putting that warning out. I totally endorse that warning because it's tricky and it needs to be done well. So we do it well, we do it right, we're extremely careful about that. That's probably the thing we're most careful about. It's kind of a passion of mine. Um, and because of that, um, it works and it's it's safe. Um, but you know, if you see your OBG WAN in person and they don't know about us, they may be worried about it. And, you know, I understand that, and not necessarily inappropriately. Um, but the truth is um we're we're we're doing it well, we're doing it right, and our cream, our progesterone cream will protect your uterine lining. Yeah, let me just say one more thing about that. I know I tend to go off on rabbit trails, so I apologize, but um, that's assuming you're taking it as directed. So every once in a while, people will, you know, we'll give people instructions on how we want them to use it, and then they'll decide to use it differently. Um, and in that case, you know, it may not work as intended. So for instance, the 5200 cream is designed for two pumps per day. If you're only using one pump per day of that cream, that is not going to have enough progesterone for long-term use to protect your uterine lining. So um, every now and then, and I had one uh I had one to a patient today um who told patient services, oh, I don't need refills, I'm using less than they told me. And then patient services, hey, you better reach out to this lady. So I did. I'm like, how are you using it? He said, Oh, but using one pump a day. I'm like, oh, that's not safe. Like we need to we need to change you to a different formulation that's a lower dose, but with a ratio that's gonna be safe for you. So please, if you're gonna do it differently than we than we recommend, message your doctor to make sure that what you're doing is safe, because that's really important. Um, but yes, if he our our creams, when used as directed, um, the progesterone is gonna be enough to keep you safe and protect your neurons. That's a long-winded answer for a pre-direct question. I apologize.
SPEAKER_01Thank you so much. Very informative. And I also think the fact that a lot of our doctors, our Winona patients, speaks to how dedicated we are to safety at Winona. Um, so Melinda actually says, so menopause itself doesn't last that long. How long does it last?
SPEAKER_02Well, it depends on how you talk about menopause. So menopause in some ways lasts forever. Well, until you go on to your next place. Um, but um, you know, there's there's perimenopause, menopause, and postmenopause. So if you're going to talk about postmenopause, that's really menopause is just that transition state between menopause and postmenopause. But that's sort of the medical term. In the sort of vernacular, people say, Oh, I'm menopausal or I'm in menopause. Um, that's sort of after that 12 months with no period, then people will say, Oh, I'm in menopause, and that's what they mean. But technically it's postmenopause. And again, these are all just names. Um, it I don't know. To me, I've always felt it's kind of less important what we call things, um, it's much more important how we treat things, um, and that we get people, you know, the best they can, whatever name you want to put on it. So I'm not uh I'm not big on nomenclature. Um, and you know, we have debates about that. But um, but people do like to name things. So uh, but you can say I'm in I'm in menopause. That would be once you hit that 12 months without period, then everything after that would be say you would be reasonable to say I'm in menopause.
SPEAKER_01Okay, and we have another question from Tamara. I had a hysterosectomy 23 years ago. I was experiencing menopause. Now that I've turned 50, my menopause is out of control. Is this a different stage? Why did my systems increase?
SPEAKER_02So um assuming they left at least one ovarian um in Wow, she said she's 50 and she's but had a hysterectomy 23 years ago.
SPEAKER_01Yes.
SPEAKER_02So you had a hysterectomy really young at 27. So um if assuming they left at least an ovarian, what's happening, what happened probably immediately is there was some decrease in blood flow to your ovaries, and your production of hormones kind of took a hit from that, but your ovaries were still functioning. Now you're getting to that point where your ovaries are naturally kind of biting down and not functioning or transitioning to not functioning. Metaprossis transition where your ovaries become sort of less and less efficient, um, and then eventually they stop producing hormone at all. So, not knowing exactly what happened, my guess is that um they must have left ovarian tissue in, which they would have if they could, um especially at 27. That would be the right way to do it, um, except for very unusual reasons. Um, but still some of the blood flow to the ovaries after hysterectomy can be affected and it can decrease sort of the efficiency of the ovaries. So they probably were making a little bit less hormones, that's why he had some symptoms, but they were still making enough hormones, you know, to do okay. And now you're getting to that age where they're starting to become less efficient. They're eventually going to stop making hormones, and that's why all of a sudden your symptoms are increasing. So that's that's my guess based on the history you gave me.
SPEAKER_01Okay, and Carrie says, hello, thanks for doing this QA session. We're so glad you're getting benefit out of it. I'm currently taking 400 MG of biodentical progesterone pills, and that is giving me 98% relief from symptoms. Does Winona offer biodentical HRT?
SPEAKER_02That's so yes, we only offer bioidentical HRT. We do not offer synthetic HRT. We think there's no advantage to synthetic um HRT or biosimilar as um the drug companies, some of the drug companies like to call it. Um, or um uh equine, the words-based um uh HRT. So all our HRT is bioidentical. Uh 400 milligrams of progesterone, if you're not taking any estrogen, you're really cheating yourself. Um, you may be knocking out some symptoms, but you're not getting the health benefits of estrogen. So um I would suggest that you'd be much better off with 200 milligrams of progesterone and adding some estrogen in there because your body needs the estrogen much more than it needs the progesterone for long-term health benefits. Uh the progesterone, you know, maybe helping some of your symptoms, but you really want more than that. You're kind of cheating yourself with just the progesterone. So that would be my recommendation. Obviously, I don't know all your history, um, but um just based on like sort of the snippet that I know um that you've told us, 400 milligrams for just a lot of progesterone. Um, it's it's generally more than you need. Um, 200 is generally the maximum effective dose as far as the real reason that we use progesterone. And then adding estrogen will also help your symptoms, but it also gives you some really important benefits. It decreases your risk of cardiovascular disease, decreases your risk of osteoporosis, decreases um risk of certain cancers. So it's a lot of extras you get that you're not even feeling that's sort of happening behind the scenes with the estrogen that you're not getting with the progesterone. So you're sort of kind of ripping yourself off using just progesterone. So that's kind of my sense. Um the other thing is that um there was this myth, and this is one of the things that the FDA is changing, that estrogen causes breast cancer. It absolutely does not. Um, so if you look at the studies um that looked at this, the people that got just estrogen actually did not have an increased risk of breast cancer. It was the women that got estrogen and progesterone together would suggest that it was the progesterone that increased their um breast cancer risk. Now, the progesterone they used in those studies was something called provera or radroxy progesterone acetate, which is a synthetic form of progesterin. We say progesterone when it's synthetic and progesterone when it's biodentical. There's some studies with bioidentical progesterone that seems to show that it does not cause an increased risk in breast cancer. Those studies are fairly small, so we don't really have enough data to say that for sure. Um but we do know that at least the synthetic progestins do increase the breast cancer risk. Um biodental progesterone. Like I said, the early studies look like it probably doesn't, but we don't know that for sure. So again, you're sort of accepting some risk um without getting all the better things. Um estrogen is really, really important, and it's really the main hormone that helps the most. So that would be um what I would recommend. However, if you know this is what you want and you insist on it, we do have uh micronis progesterone, which is uh uh biodetical progesterone um in cream or pill form uh that we could prescribe as well.
SPEAKER_01All right, thank you, Dr. Green. And Marlene says, I have a menstrual cycle. Do I need to take my progesterone daily?
SPEAKER_02Yes. So um This is kind of interesting. So remember I just was talking about how there was that this big study where we saw that HRT increased breast cancer risk. And then when they teased it out, it looked turned out that it was the progesterone that was doing it, not the estrogen. And so people got this idea. Gee, we should try and decrease the exposure to progesterone as much as we can. Or maybe if we should only give the progesterone cyclically, like 10 or 14 days after the month. Um, and um, that would, you know, half the amount of progesterone people are being exposed to and maybe take away that breast cancer risk that everybody was worrying about. So that kind of got popular for a while, and then people did studies to see if that really helped. And it turned out it actually didn't help. So it didn't change the risk at all. Um, and what it did was it actually caused more side effects. So it actually caused more abnormal bleeding and other um side effects from because the hormones are cycling um and that was causing issues. So what we found was that using estrogen and progesterone every day um is no more or less risky, but it doesn't increase your risk than cycling the progesterone and it decreases side effects. So I feel that gee, you're not losing anything by doing it and by going sick like you're just increasing your risk. No, I'm sorry, not your risk, your side effects. So why do that? So we recommend taking the estrogen progesterone every day, even if you're still having menstrual cycles. Um it works very well that way. It should not adversely affect your menstrual cycles, uh, meaning that it shouldn't make it worse. Um, for some people, it actually makes them a little bit lighter, a little bit better, but it's really that's not really what it's designed for. Um but um it tends to work very well that way with fewer side effects than using the progesterone cyclically. There are some edge cases where we will use the progesterone um, you know, 14 days out of the month, but um, those are are sort of some some rare things that can come up where we would want to do that. But in general, we recommend using the estrogen or progesterone every day.
SPEAKER_01All right. Our next question comes from Mandy. I've had a complete hysterosectomy. Does this mean I'm postmenopausal?
SPEAKER_02So your meaning of your use of the word complete hysterectomy may be different than mine. Um and this is one of the um this is one of these weird things where the scientific words and the sort of lay words are different. So when doctors talk about hysterectomy, hysterectomy means removal of the uterus. Um a total hysterectomy is removal of the uterus and the cervix. A complete hysterectomy doesn't really have a medical term. If we take ovaries out, that's a different thing and that's called an ooferectomy. So if you've had your uterus removed and your ovaries removed, the medical term for that would be a total hysterectomy, assuming they took your cerverts out with a bilateral oofhorectomy, um, which is a mouthful. And so I understand why people it's late, people don't want to say that. I don't want to say that. Um, and so oftentimes when people patients say they've had a complete hysterectomy, what they really mean is they've had a total hysterectomy with a bilateral ooferectomy. So assuming that's the case, then yes, you're in menopause. And in fact, you're in surgical menopause. So if both ovaries are removed surgically at the same time, or just once you've lost your second ovary, you are now, boom, overnight, you're in menopause. And that's called surgical menopause. That tends to be kind of brutal for people because normal physiologic menopause is sort of this gradual transition. So, I mean, it still causes issues, um, but it's not like one day you're abnormal hormone levels and the next day you're not producing anything. Um, and so your body can adjust some. But when you have surgical menopause where they remove both ovaries, um, it can be really difficult and it can really require an increased dose of hormones to get your symptoms controlled. Also, um, depending on the age that's done, it can really greatly increase risks of uh cardiovascular disease, stroke, and other things if you don't have hormone replacement therapy. There's a big study done looking at women that had both ovaries removed before the age of 40. And those women that did not get hormone replacement therapy had a really much higher risk, um, like seven, tenfold risk of cardiovascular disease and stroke than women that had HRT. So if you're by complete hysterectomy, you're meaning that they took your ovaries out. You really need to get on hormone replacement therapy. It's super important for you.
SPEAKER_01Okay, thank you. And Carrie says, I was told that I shouldn't have. Estrogen yet I am 6.7 in my estrogen levels.
SPEAKER_02So uh as I said at the very beginning, um, and we when we were talking about um someone's DHEA levels, these tests for hormones are useless. So if you tested that two hours later, you'd have a completely different level. Might be way higher, might be way lower. Who knows? It's really random. These tests for hormones are useless, um, and they really shouldn't be done. And that's not just my opinion. The American College of Psychonicology says that, the Metopause Society says that it's just they just aren't useful tests. So, why is someone testing your estrogen? There's two reasons. And I'm um I tend to be an optimist looking at people, and I think most of the time this is done by well-meaning people that just aren't well educated in um hormone replacement therapy. And so um, you know, you have this lab slip and they're doing your health labs, and they're like, oh, I can check the box for a hormone panel, and you can check that, and um, then they get a hormone panel, and then they get these numbers, and they don't really know what to do with the numbers because they don't understand how these hormone numbers aren't an accurate reflection of what's going on in your body. And the reason is these hormone numbers fluctuate, not just from day to day, but even throughout the day. And so it's really just a quick snapshot in time that's not particularly helpful. And I think that's the vast majority of the reason that these labs are done. Unfortunately, there's a small subset um uh of these labs that are ordered strictly to make money. Um, I don't know about you guys, I get emails from Quest like all the time. They're bugging me all the time, and they want me to do all these panels. Oh, we've got this Ben's Health panel. Oh, we have this panel. And they and so, like in this day and age, you can order your own labs. It's kind of weird. Um, and so, you know, there's this direct-to-consumer advertising for these labs. Um, and then even worse, honestly, in my opinion, there's some rogue doctors and and you know, mid-level nurse practitioners that are out there that are that have their own, you know, health spas or what have you, that are doing this just to rack up the bill and make more money. Um, and that's really a shame. But I think that's really the smallest population. Um, I think most people are trying to do the right thing, but that does happen. Um, so in any case, for whatever reason these labs were done, but the labs are really meaningless. So the question is, are you having symptoms? And if you're having symptoms, then we know that you need estrogen replacement. Uh that's the real question. Uh, it has nothing to do with lab values, it's just not one of these things that we test labs for. So, for instance, thyroid replacement labs are extremely helpful and need to be followed to be done right. But like for me, I've got high blood pressure. Um, and I'm on medicine for my high blood pressure. You know what? Nobody checks labs to see what my beta blocker level is. They check my symptom, which is my blood pressure. And if it's too high, they increase it. And if my blood pressure drops too low, they decrease it. And it's based on my symptoms. And that's the way we do HRT is we follow your symptoms um and we adjust the dose, start the dose, or adjust the dose based on your symptoms, not based on lab tests.
SPEAKER_01All right. And Melinda says, can the DHEA capsule be opened up and put in applesauce or et cetera, having difficulty taking pills?
SPEAKER_02It can. Um, and yeah, we have patients that do that either because they have a hard time swallowing it, or um uh the capsule is a gelatin capsule. So if you're a vegan, it's not um, you know, vegan friendly. Um, and so that would be another reason to do it. So the the actual medicine is fine for um it's not plant. I mean, it's plant-based, it's not animal-based, but the the capsules that hold it in. So either because you're having a hard time swelling it or you don't want to have the capsule, it's totally fine to open it up and put it in yogurt or applesauce or or arbor in something um and take it. I do have patients that do that. That's completely acceptable.
SPEAKER_01That's good to know. And Pamela comments or asks, can patients diagnosed with EIN use HRT? So this is endometrial intra EIN. That's a long word.
SPEAKER_02E-I-N. Did you write it out?
SPEAKER_01Uh it's endometrial intrapithelial neoplasia. She did not write it out, but I Googled it.
SPEAKER_02Shouldn't write it out. Okay. Usually it's um either VIN or um um God, see, my cold's getting me know I've lost it. So if it's just if it's if it's coming from the cervix and it's cervical dysplasia or the vagina and its vaginal dysplasia, HRT is fine. If it's coming from the endometrial lining, it may not be. Um so that's something that you'd want to um message the Winona doctor. And if you have a copy of the pathology report, that would be extremely helpful. So um you can upload that report. We're happy to review those. In fact, it helps us. Um and so that would be for this, that would be the right thing to do. We message your Winona doctor, and then you can upload a copy of the report, um, and we can read the pathology report and see exactly what you have, and um then we can determine the safety.
SPEAKER_01Perfect. That's the best way to go about it, uh, Pamela and Amy June comments essentially that's G-I-N.
SPEAKER_02That's what I was blinking on.
SPEAKER_01So C-I-N?
SPEAKER_02C-I-N. That's what I that's what we usually see. That's why the EIN was was surprising. Um it's usually C I N and V-I-N is is uh less likely, but um EIN is an interesting one. So that's something that we want to look at the pathology and see what's really going on.
SPEAKER_01Okay, perfect. And Amy June kind of comments vaginal dryness, essentially how to combat it, deal with it, relieve it.
SPEAKER_02So vaginal dryness is a very common symptom of the menopause transition. Um so the best way to treat vaginal dryness is with a vaginal estrogen cream. The problem with a vaginal estrogen cream is it doesn't really get absorbed. Um, and so it's great at treating vaginal and bladder symptoms because it works at those local tissues, but it's not gonna help your other symptoms. It's not gonna help your hop flashes and your night sweats and your sleep problems and your mood changes and your brain fog and and all those other things. And it's not gonna give you the health benefits of systemic estrogen, either pills or the patches or the or the body cream. So if you're not on anything yet, my recommendation would be to start with either the body cream, the patch, or the pills. And a lot of times that's enough to also help the vaginal dryness. So I would give that a try first because you kind of get more bang for your buck. Then if you find, gee, it helped my hot flashes are gone and my nights are wet, so my moods are better, and I don't have brain fog anymore, but this vaginal dryness is driving me crazy, then we add an S a vaginal estrogen cream to that. Um, and you use both. Uh, and that way you get all that symptom relief from and the the health benefits of the systemic estrogen, but you also get the vaginal benefits of the vaginal estrogen cream because it works topically and it really is the best thing for that.
SPEAKER_01Okay, and uh Stacy asks, why is it that so many doctors have no idea how to treat women when things happen to us? You know, I had a hysteris hysterectomy at 34, kept one ovary, had no symptoms until two years ago. Uh basically, Winona kind of has been helping her. And why is it that doctors nowadays don't really know how to help?
SPEAKER_02So there's a couple of reasons. There's a historic reason, um, which I sort of alluded to at the very beginning. So there was this big study called the Women's Health Initiative Study that came out um in the early 2000s, 2002, I think. Anyway. Um so I'm old. I finished residency in 1999. So I was practicing medicine before that big study came out. Um and at that back in those days, we were giving everybody HRT. We thought it was like a vitamin, like everybody should be on it. Like nine-year-old, oh, here, take the HRT, it's good for you. Um, and then this study came out, and the study said, hey, uh, HRT is not a vitamin, it's a medicine like everything else, and you got to use it correctly. Um, and so we will, you know, at the time we thought we were doing the right thing. We were based on the current literature, we were doing the right thing. We're always evolving and learning more and more. And so that study said, hey, you got to be a little more careful about this. So, you know, you shouldn't start it in women for the first time over 60 or women that are 10 years post-menopause, um, you know, and certain other things like that. And that's basically the big picture of what that study said. Unfortunately, what happened was that study didn't get released in toto. In other words, we didn't get to see the whole study right away. They leaked out little pieces of it. And so one day they leaked out, like the first thing that leaked out is Women's Health Industrial Study is about to be published. This is what it's saying. Doctors are killing you with HRT. You know, they're causing all these problems. And so, you know, New York Times and you know, all the headlines, you know, in more print, doctors killing women with HRT. And I mean, all of us OBGYNs that are around that day, you know, it's kind of like, you know, people any type of old people tell you they know where they were when Kennedy was shot. Like, we know where we were when that headline came out because that phone didn't stop ringing in the office and everybody went off their HRT. People just panicked and stopped the HRT. And maybe six months later, the study finally came out and we could see it. And we all looked at it, and those of us that like took the time and really thought about it realized why we really overreacted to this because that's not what the study said. You know, the study said we just need to be more careful about what we're doing. But the damage was already done. And at that point, everybody was just totally afraid of HRT, everybody had gone off their HRT. Nobody would prescribe HRT anymore because number one, you know, they didn't take the time to read the study. And number two, even if they did, they were afraid they were gonna get sued. Um, and so there were a few of us. I I kept prescribing HRT, but more appropriately. Um, but so then what happened in residency in training, people stopped getting trained on how to use HRT because it was like, look, you got a lot to learn, and nobody's you're never gonna use this stuff because nobody uses it anymore. So this is it's not a history class, right? So there's no point learning about this. And so you had this whole generation, 10, 15 years went by where nobody learned these new doctors, nobody learned how to prescribe HRT. Um, and so you get out of residency and it's just it's not something that you do. Um, and you don't know how to do it, you don't feel comfortable with it, you've been taught that it's wrong and it shouldn't be done. Eventually, more and more studies came out and people, the hysteria kind of passed. And slowly and gradually, you know, as we learn more and more, we realized hey, HRT is really important and it can be done safely. Um, and so that's kind of where the FDA is now finally catching up. Um, and that was the sort of the big announcement last month. Um, but the truth is we've known this for a very long time. I mean, we've known anyone who read that study when it came out six months later knew that. Um, but there's even better data now and more data that's telling us, you know, refining how we use it so that we can use it in a more safe manner. And so, you know, most doctors are younger than me. I mean, I'm I'm 61, so I'm not quite at retirement age, but I'm getting there. Um, so most of the people that are out there sort of were trained in a time when they were trained not to use HRT, and so they never really ignored it. Um, so that's a big part of the problem. The other thing is that um your family doctor. So, as I said at the very beginning, I was I did a family practice residency, so I I I know this firsthand. I think family practice is the hardest specialty because they have to know everything, and then you can't know everything in medicine. So, you know, you try and refer out what you need to, and so the family doc isn't gonna be up on the latest thing about HRT because they have so much stuff that they've got to keep track of. And so, you know, you gotta understand that they're not gonna be, you know, the most knowledgeable about HRT. Your OBGYN, no, they're the people that should be knowledgeable about HRT, but as a generalist OBGYN, and I spent 17 years doing full-scale generalist OBGYN, you spend most of your time taking care of pregnant patients or trying to help people keep from being pregnant. So you do a lot of um obstetrics, you do a lot of contraception, and then you do a lot of surgery. So you do hysterectomies, you take out cis, you you know, do vaginal procedures, we do all kinds of stuff. And then a small part of our practice is we take care of women that are going through the menopause transition. And so it's not really our focus. I mean, we honestly we shouldn't be experts on it, but there's a whole lot of stuff out there. At Winona, this is all we do. So um, we spend all our time doing this, and so we are all experts on this. This is our thing. Um, we used to joke in family practice residency. We used to, you know, there was this derogatory joke about the left eye retina specialists. Like, you know, these guys are so specialized that all they can do is the left eye and only the retina, right? And it was a joke, obviously. But you know, to some extent, I become a left eye retina specialist, right? Doing HRT. I don't deliver babies anymore, I don't do surgery anymore. This is what I do. Um, and so I do it really well. And so at Winona, because you have doctors, but this is what we're doing all day, this is what we specialize in, you know, we're the ones that really need to know all the ins and outs. Um, and so it doesn't mean that your doctor, your in-person doctor isn't great, or maybe they do know a ton about HRT, um, but they also know a bunch of stuff about a bunch of other stuff, and your brain can only know so much. Um, so that's uh again another long-winded answer of a fairly straightforward question, but it it's sort of complex. So I hope that helps. Um, and I I don't want to sound derogatory towards my colleagues, because like I said, um it's really hard doing a little bit of everything. Um, and it's easier for me, it's super easy because I just have to do one thing. And so it's it's pretty easy to be like really knowledgeable about one thing.
SPEAKER_01Okay, well, thank you so much, Dr. Green, and thank you, everyone who joined us. We are at the end of our session today. And if you have more questions, remember that your Winona doctor is always happy and available to answer them. And you can find them in your patient portal and message them there. And you can reach out anytime and ask these same questions that you were asking here today. If you're looking for other resources and you're a podcast lover, just tune into our the menopause hour podcast with Winona on any streaming platform. You can literally learn these things as you're like in the car on the way to work, anywhere in your headphones, just hanging out. Um, and don't forget to explore the Winona app itself. You're gonna find events there and updates, you know, discussions where you can actually kind of communicate in the chat with each other and as you did here, and really is a supportive space where you can share your journey through praimenopause, menopause, and anything you're going through. Um, and really it's the best place to stay in the loop with like upcoming QA's. We do have these about once every two weeks. The next one is December 18th. If you feel like you have more questions and you'd like to join us again, we'd love to have you. And uh, we hope to see you then. So thank you again for joining us. Um, we'll see you next time. And everybody, I hope you're having a wonderful December. And uh thank you so much and have a wonderful evening.
SPEAKER_02Thank you guys.
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.