What to do About Women's Hormones

Rick, Greg, and nurse practitioner Caitlin wrap up their women's hormonal health series with a practical episode focused on what to actually do. They start with the lifestyle foundation — resistance training, protein, sleep, and stress — and then move into the full menu of hormone therapy options: estrogen (why the patch is often the safest bet), progesterone, testosterone for women, and vaginal estrogen. They also discuss GLP-1 medications and how they fit into a whole-patient approach. If you've been listening to this series and wondering "okay, but what do I do?" — this is the episode.

For informational and educational purposes only. Consult your personal medical provider before starting any hormone replacement, supplement, or medication.

Transcript

SPEAKER_01 0:24

Okay, welcome back. We are we are we're close. Yeah, we are close. That is let's try our technology stuff here. There we go. We don't want to be that close to the thing. A little too close. All right. So we are back. Yeah. My name is Greg. And I'm Rick. Rick and Healthier Healthier Ever After. We are here talking about how to be healthier after. We've been talking for a couple weeks about uh women's health, uh, hormonal kind of the the life cycle of hormones. I don't know why that keeps a little bit of me. Yeah. Uh what happens over lifestyle. And tonight we we still have Caitlin. We're gonna bring Caitlin on. Here we are again. Thanks for being here. No problem. Taking time with us. She is uh a nurse practitioner, extraordinaire, and very passionate about uh these things and has been super helpful in uh in kind of helping us have this conversation. Uh tonight we want to talk a little bit more about specifically what to do for women. And and some of this is going to be just reiterating a lot of the same things we have talked about again and again and again, but it's it is it's that important. Um, before starting any uh weight loss regimen, exercise program, uh dietary supplement, medication, particularly hormone replacement. Um, we certainly recommend that you you discuss that with your personal medical provider. This is for information and education only. So with that, we will uh get into it. There is um so so you know, we summary, we talked a little bit last time about sort of the the reproductive years and the perimetopausal decade, I guess. Um and what that means and and and the fluctuations, um, especially with women, the their fluctuations are are much more erratic. It's not kind of that gradual decline in testosterone that a male experiences, and and so it can cause a lot of um crazy symptoms that come and go and or worse. And and a lot of a lot of that has to do with how it affects um you know the weight loss, like like a lot of it affects weight gain, you know, the things that we talked about that last time, the things that you normally have done, quit working, and all of a sudden you're you're on a few panels here and there, and and then you realize I really want to get into something. And and so we'll talk about that a little bit, like what to do. So, so let's get into that. How do we start this off? I'm uh I am a perimenopausal woman. What do I do about it, Caitlin?

SPEAKER_05 2:48

You're a perimenopausal woman, and usually you have a few complaints, a few issues with the universe.

SPEAKER_01 2:54

What did you call it? The the uh smoking gun complaints versus the well, yeah.

SPEAKER_05 3:02

Previously we were talking about smoking gun complaints. Weight gain isn't necessarily what I would consider a smoking gun, but it is in there. Um, when women come in to me and they're telling telling me about you know symptoms and things like that. I think earlier we were talking about, you know, my number one is I don't feel like myself, and I'm uh everything's weird. I can't explain it and they can't put their finger on it. Um, number two is their sleep's really dinky. They're waking up at two, three, four in the morning for no good reason, you know, no anxiety, no no issues, but they fall asleep just fine. And then that third one is the weight gain. So those are the top three complaints I hear. And usually we say, you know, it's just a good chat. We're hearing, we're talking all about aspects of lifestyle, menstrual cycles, things like that. Um, but yeah, first things first, we always do some basics. And I think, you know, we kind of have some notes that calls it the non-negotiables. And this is just general guidelines, but to optimize women's health, we really have to like talk about different things. Um the number one thing is are we moving? Are we getting exercise? Are we doing some resistance training? Like, but our bones are only as healthy as the resistance from our muscles make them. And so if you know that that pull on our muscles and our tendons and ligaments and things like that, that actually tells the bone to be stronger. And so when we're losing estrogen, you're never going to have more bone mass than you have in your 30s. From then on, you're going downhill. Yeah, you're not you're you're breaking it down more than you're building it, right?

SPEAKER_01 4:36

So right. And and that's why um, you know, it's not I I think the way oftentimes we think about resistance training, like I'm gonna lift weights because I'm gonna get jacked.

SPEAKER_00 4:45

Yeah.

SPEAKER_01 4:45

Right, right. What we're talking about, it's it's it's that important though to keep the muscle that you have. It's it's it's what we're trying to do is is slow down or stop the the loss that is inevitably going to happen as you age. Right. Um because one of the big things is that we've talked about this again and again, is is muscles are where metabolism happens.

unknown 5:09

Right.

SPEAKER_01 5:10

That's where you're burnt in calories. That's where you're uh, you know, it it just it does so much good.

SPEAKER_02 5:16

All the things. I mean, we're talking insulin, uh, insulin resistance and and and uptake of um glucose. Um, you're talking about your resting metabolic rate, which is what we're talking about, you know, you get the amount of calories you burn to just live and breathe. And then uh, you know, what Caitlin just already mentioned, uh, you know, your bone strength and all that, plus just flat out, um just flat out how you feel, right? No one weak.

SPEAKER_05 5:42

Um quality of life, you know. I mean, we know, we all know because we work in the ER, when people stop moving, they fall, they get injured, they end up in the ER. And then we know falls are really, really huge. And I mean, I'm taking care of women who aren't just perimenopausal. I'm taking care of the women in the 60s and 70s. They might not be doing hormone replacement or whatever, but we're still in this big realm, this big category of women who really are like struggling with some of these big issues. And I tell women, I was like, stop pushing off your chair, use your abs, like all these things. There's all sorts of things you can do to really use body weight and resistance. And you know, there's a lot of statistics and research out there that says there's different kinds that are better than others, and now we know, you know, and women were always taught, you gotta go for a run, you gotta go do cardio, you gotta be thin and lean. And no, skinny's not healthy, muscle is healthy. It's a whole shift on what we know about women's health and what keeps women healthy. So muscles actually keep us healthy. And I think, you know, when I was younger, you know, you'd well you'd hear women all the time like, yeah, and then I got into my 40s and my metabolism tanked. And I remember reading a really awesome book that talked about how, especially like active women and sporty women when they're in high school, or you know, dancers or gymnasts or whatever, we're we're all active through the high school years, possibly into college years. We're we're playing intramural sports, we're doing all sorts of things, we're active. And then in our 30s, it starts to dip a little bit, our muscle mass, that high school, college years muscle mass kind of dips. When we hit the 40s, it kind of curves off and takes a nosedive. And then all of a sudden we're like, my muscles, my uh metabolism just tanked. Well, metabolism isn't this magical beast that like lives in you, it's your muscles. When you lose muscle mass, you lose that part of you that's just eating calories without you even needing to do anything. And then the more you do something with them, it eats more calories. So that's a huge thing I hit with human right off the bat.

SPEAKER_01 7:45

So so using muscles, maintaining muscles is important. And then uh, you know, here we go again, talking about also along the same lines is your protein intake.

SPEAKER_02 7:55

Feeding muscles. I mean, your your muscles, you can only do so much with your muscles if if um if they don't have fuel to you know, amino acids, essentially that's all a protein is is amino acids to help them grow. Um, you can do all the working out and moving you want, but there's really nothing there uh to support it.

SPEAKER_05 8:14

Well, protein's really important, not just for muscle retention and telling your body, hey, don't don't eat my muscles while I'm actively losing weight. Eat this protein, eat use this other fuel. But also, I know as an inpatient nurse, if you've got wounds and you're not eating good, good protein, you won't heal. So post-surgery, post all these other things, protein is essential. And when we have a liver that stores backup sources of sugar, that's our sugar food storage, is what I call it. Your liver, our body doesn't like retain protein. It's not for like, oh, I didn't eat my 30 grams of protein. No, well, guess what?

SPEAKER_01 8:53

You do it sugar and fat.

SPEAKER_02 8:56

Well, we do in reverse thinking about that. We actually do. They're called your muscles. You will you will waste. I like your muscles.

SPEAKER_00 9:06

That's your thing.

SPEAKER_05 9:08

They are so if you don't want your muscles to go away while you're in active weight loss, I always say, hey, if you give it good protein and and good healthy carbs, I'm a huge advocate for good healthy fruits and vegetables and good carbs. But if you give your body enough of that and then push it towards the fat storage, it's pointing you more towards your body, more towards using that fat storage. It's not gonna look at your muscles and say, oh, well, you're not giving me anything else. I'm gonna eat my I'm gonna eat some muscle for dinner. And yeah, like when you think about your muscles as your food, as your protein food storage, you're like, oh I'm not doing a very good job. So yeah, we gotta.

SPEAKER_02 9:45

You don't, if you don't give your body that, it'll take it. And um, it's so important. And and really we talked about this when we did our stuff on the men's stuff, like and what we just kind of dove into because we've been doing this for the last several weeks, is you know, we're really just diving into the non-negotiables, really the things that are um the foundation. It's like you can do all the hormone replacement therapy you want, but if you don't have a a base, a foundation of some things that you're working on lifestyle-wise, um you can throw, you can throw all the medications, all the hormones at a problem you want. And and it's the catalyst is the lifestyle. Yeah. Is that would you agree with that, Caitlin? What's your thoughts on that?

SPEAKER_05 10:28

Oh, yeah. I I think that like we can do all the hormones and everything we want, but if we're not telling our body, hey, we're not just in homeostasis because we're giving it all the hormones, we're plugging in all the things that each cell needs for information. If we're not using that energy, it where's it gonna go? We've got to tell the body, hey, we got to keep moving, you know, we've got to keep functioning appropriately. And so, like activity, the protein, yeah, it all goes together. We have it's all a package deal for sure.

SPEAKER_02 10:57

Absolutely. And we you've talked about sleep, and one of the biggest things you notice when hormones um are out of regulation, like is your sleep. That's the like almost the first sign that you um basically that's your first signal to smoke in the air. Smoking gun. Smoking gun.

SPEAKER_00 11:13

Smoking gun, low progesterone.

SPEAKER_01 11:15

Well, and and you talk about that, like like poor sleep is a result of some of these hormonal changes and low, you know, erratic levels and things like that. But then it's like this crazy cycle because poor sleep is is also a like your your sleep is a hormonal regulator. You get you have poor sleep, that's gonna increase your cortisol, which uh disrupts your hunger hormones and your insulin response. And so, so it's like the crazy cycle to get better sleep and enough sleep.

SPEAKER_05 11:50

Yeah, yeah, just sleep all by itself. If we could just solve that problem, you know, and progesterone really helps a lot of women.

SPEAKER_04 11:57

And yeah, I yeah, there is we could go on and on about good sleep and the benefits of that.

SPEAKER_01 12:03

Well, and it's we could probably do a whole episode because maybe we should on on you know, just it's not just like go to bed earlier. You know, there's there's some there's some like sleep hygiene, there's things you can do to manage, you know, your light exposure and um alcohol consumption, the room temperature, yeah, not eating too late, you know, other reflux.

SPEAKER_05 12:26

Yeah, yeah, there's a lot of things.

SPEAKER_02 12:28

Eating, uh, even bringing up eating even more specifically, uh, when do you drink or consume caffeine? People don't realize caffeine has a half-life, like a medication, and it's six to eight hours. So if you're getting that late caffeine at five o'clock, you're like, it's fine. I go to bed at 10 or 11. You know, you actually may still have the effects of that caffeine. Yeah, it's it's really big. I I had a one patient that I know um, she was she was really frustrated with her sleep, and it didn't sound to be hormonal. You know, she was having difficulty falling asleep, not staying asleep. But um, and all all we did is take away her three o'clock caffeine and move it to noon. Yeah, she's like, I'm I'm sleeping.

SPEAKER_05 13:07

Yeah, I've even had patients who are like, oh, I can drink a full coffee, you know, full non-decaf, full coffee, or I can drink a monster at 7 p.m. and go right to bed. They can go to sleep, but we know statistically, like throughout their sleep cycle, they're not getting deeper restorative sleep. Just getting light sleep isn't doesn't mean it's restorative. So that's the big word I tend to use more as restorative sleep. Sleep that's actually getting you into REM. That you're actually dreaming, you're actually processing things, and then you're actually feeling restored in the morning. Not to mention, you know, we've got also sleep apnea. We've got acid reflux when people eat too late or eat, they eat the wrong things, it's waking them up all night, kind of irpy burpy. We've got the sleep apnea that some people aren't even aware of, you know. So those are some complex sleep issues, but you know, even on the surface, just you know, even some basic hygiene and moving caffeine differently. And hygiene's a weird word. That sounds like a weird word, but you know, talking like how we we're talking about not being on yourself. Right, trying to sleep skills or choosing a boring activity before bed, like reading before bed or crocheting before bed. You know what?

SPEAKER_01 14:17

Even that because even that reading, one of the things that that some people find beneficial, like a lot of people will you know, read um to go to sleep. So you get in bed, you read, and and then then you have a book that's really, really good.

SPEAKER_03 14:33

Oh, I know, and you're up till 3 a.m. Right.

SPEAKER_01 14:35

I'm often told patients, you know, one of the things to to try doing is don't do anything in bed that isn't sleeping. Like if you if you can't fall asleep and you need to read a book, get out of your bed, go sit in the recliner, go sit a chair, read until you feel sleepy, then get back in bed, yeah, right, and and go to sleep, not read in bed because it trains your body like this is at this point where I am to sleep.

SPEAKER_05 14:58

Yeah, right, or even TV. They, I mean, we there's tons of data that says don't put a ding TV in your room, it's hard on relationships, sleep, and all the things. And yeah, I like that idea because then you can go go somewhere else to watch your TV. When you feel tired, your brain knows my room is for sleeping, and that's what I do.

SPEAKER_01 15:14

So, yeah, that's a good training it. That's a good point. So, okay, so we get good sleep. The next thing, it's it's we talk about this as well, but this is and it's not easy, is you need to just reduce your stress. Yeah, just stop stressing, stop having chronic stress, just don't stress.

SPEAKER_03 15:32

Is it that easy to you? Oh, you guys, you guys are you cute men, you that's so cute. Um, that's not how women work. So cute.

SPEAKER_02 15:42

Yeah, I just want to pull a seat because you've got the door.

SPEAKER_03 15:46

Oh, totally, because you know, me and my five kids and all the chores they're not doing and all the food they're eating me out of the house and kids. Yeah, there's nothing to stress about. My home, my home, my yard, all that stuff. No.

SPEAKER_02 15:58

What can we do? I mean, specifically from your perspective, and and even more specifically on the women's side of things, because we we give this perspective as medical providers um and as and as men, but like, is there anything specifically that you I know you kind of hit on some stuff last uh episode about some of your advice um about self-care, but anything specifically that you could add to that as far as the women you see and stuff that you're like, hey, these are these are the things that I think are like these I know I can't take away your stress, but like how can I at least reduce that can help reduce it.

SPEAKER_05 16:30

Those are, yeah, like I said, there are some non-modifiables. I mean, you can't control if your like mother-in-law passed away, or if you somebody crashed into in the car, or you can't control if you know your husband's work is a pain in the neck, or you can't control that thing. So we always focus on the things we can. And I tell women, you know, look at your body, look at your life. Give yourself kind of a theoretical hug and say, hey, this body, I only have one of them. It's given me beautiful kids. If that's what you've chosen to do, it's taken me on amazing adventures. I'm able to help people, I'm able to serve, I'm able, whatever, whatever's gone on in your life, give yourself a hug and say, hey, listen, like we got to start taking care of this long term. There's a reason life expectancy is into our 80s. If we're going into menopause, you know, in our 50s, we got 30 years. And personally, I don't want to just live till I'm like 90 and be miserable. I want those to be really good, healthy, productive years where I'm a great grandma, you know, and I'm doing all sorts of fun activities. So talking to women and saying chronic stress will kill you, we know that those elevated cortisol hormones literally decrease your immune system. They change your cardiovascular risk profile. It's all sorts of things. So when I talk to women about it, it's mostly start saying no with love. Just start look at what's in your on your plate and say, these are my kids. This is my job, this is my relationship with my spouse. Everything else is just extra. And if I've got to say no to some of those things so that I can recover, so I can rebuild back after a stressful event or illness or life something happened, it's okay. And we need to start supporting each other in that as well. And when I can look at a woman who's an amazing wife, an amazing mother, an amazing daughter, and all these aspects, who never has told anybody no in her whole life, she literally feels like she's breaking a bone by saying no to somebody. And if we don't start supporting people and saying, hey, let me take this off your plate, you can say no. You get to say no for your future. And I think that's huge for women. And the more men that say, hey, honey, no, I'm taking this off your plate. You do so much around this place, you do so much for our family. Take some stuff, unburden them a little bit until these women can start saying, Hey, I would love to help you with that, but this isn't gonna help me or my family out right now if I do this. So it's it's tricky because literally women's eyes fill up with tears, these amazing women, and they don't know how to say no in a nice, kind, loving manner.

SPEAKER_01 19:15

I tried that, I tried that with my wife. I I said, Hey, let me take that off your plate. She says, No, that's my creme brulee.

SPEAKER_03 19:21

Smart woman. See, she knows what's important.

SPEAKER_01 19:24

She's got what's happening. But there also are there are some positive things. And this is this is almost like when we talk about medications and and and specific hormone treatments that that are really individualized. Yeah, you know, when we talk with Cliff about compound pharmacy, like it's getting the right dose for the right patient at the right time. Um, there are some active things that that people can do. And this is going to be different for everybody, but you can sometimes find a thing, like you know, things like meditation or time outdoors, you know, hike in the woods, um, social connections, you know, talking with a friend, deep breathing, journaling, like there's activities there that are active, positive things that you can do that have clinically been shown to have a measurable physiologic effect on reducing stress. So we don't want to forget about those things. And again, that's gonna be an individual thing. Like, what is it right that you can do that that will do that for you?

SPEAKER_05 20:15

And I talk to women a lot about, you know, like, hey, what if you always want to do what are your hobbies? And they're like, Well, I clean my house. And I'm like, that's not a hobby. No, that's not a hobby. Like, I'm talking like stuff that you've always craved, you've always wanted to try. You've you know what I mean? Because getting women to think outside the box, hey, your babies aren't babies anymore. They can make themselves a sandwich. You go do something with a girlfriend, go out to lunch, go take a painting class, go read a book in a park somewhere, turn your phone off for an hour. You can you can do this, you know. And I think that's huge. Like just these self-care things, you know, us women, we tell ourselves so many things like, oh, that gym membership, it's gonna cost so much, and you know, and oh, but you know, I don't know, have a friend to go with to yoga. And it's like, you know, there's all these things we tell ourselves. But once we start getting empowered and brave and saying, no, you know what, I've always wanted to try that. I'm gonna go try that, you know, and you know, whatever the activity is, and it's huge. It's amazing to see transformations that way.

SPEAKER_01 21:12

And then and then finally on these kind of lifestyle things, we can talk, we could probably talk a whole other episode on uh on the Mediterranean style of nutrition. I mean, there's there's some things, it's just real foods, healthy foods, beans, whole grains, those types of um food choices, yeah. Um can can also help with this. Uh let's get into um then so those are the kind of the lifestyle things that are we call it the non-negotiables. Though those are what we start with, those are things that we really want to have as a as kind of a basis for for our health creation lifestyle transformation. Yeah. Um but now let's get into okay, after I've got those things going, it's just not quite enough. What are the hormone therapy out? Like some people just really do need to replace some hormones, right?

SPEAKER_05 22:00

Right. And and I I always trust women, there's some amazing unicorn women out there who never have had a hot flash in their menopause journey. They've never had any of that. They've never really had miserable symptoms. And I don't know what it is, but it's magic. So even if, and this is the first thing I want to say, even if you don't have symptoms that are debilitating, even if they're just kind of bothersome, or even if you've never had the hot, the dreaded hot flashes, you know, there's still chronic illness like trending underneath the surface.

SPEAKER_00 22:31

Yeah.

SPEAKER_05 22:32

Just because you don't have hot flashes doesn't mean you're not going to have bone loss over the span of your lifetime. So hormones are very considered preventative. It's not just symptomatic. Most of the time, it's the symptoms that get the women in the office, you know, taking time out of their busy lives to come deal with it. But but it still is preventative to get us to the 80s and 90s and you know, not having brittle bones and stuff like that.

SPEAKER_01 22:54

So we're not thinking about hormone therapy options only as treating the symptoms I'm experiencing during perimetopause, but but it is it is really preparing myself to remain healthy for a much longer. Yeah.

SPEAKER_05 23:06

Maintaining metabolic, yeah, maintaining metabolic health, maintaining cardiovascular fitness, maintaining muscle mass, which is only going to help with everything else, maintaining bone, eye, joint health to keep us moving so that we can keep ambulating so we don't have falls. It's multi-system. So yeah, it's not just symptom control. There are women out there who are magic and never have symptoms control.

SPEAKER_02 23:32

What I'm hearing is sorry to cut you off, Caitlin. The thing that I'm hearing here is that we have this lifespan. We know we're gonna all live to be, I mean, you know, heaven forbid an accident or something rare that happens. But if we can make it into our 80s, the idea behind some of this hormone replacement therapy for women is that we can get into our 80s in a good way. Like not that we're just barely making it into our 80s and the last five years of our life is miserable, but actually, can we get into our later years? And so maybe, yeah, your last year of life is a little bit rough, but not the last decade of your life.

SPEAKER_05 24:10

Right. I like to say we're not limping into our 80s, we're blowing right into them on, you know, like a race car would come out of it.

SPEAKER_02 24:18

Arguably it's much easier when you think about this where the science is right now. I just made change, but with peptides and hormone replacement therapy and all that stuff, it's uh it's much easier to think that it's gonna be easier to improve the quality of life before we can start it uh lengthening life. Yeah, like we could probably improve quality of life easier and sooner. We probably have the tech, the technology is here to improve your quality of life before it is to actually lengthen life where people are living healthy into their hundreds.

SPEAKER_05 24:48

Right. Yeah. And there's, you know, that whole cohort that got hormone replacement snatched away from them, you know, from when we see the effects of that. That, yeah, we're seeing that in the ER. They're still, you know, in southern Utah, the life expectancy for an average woman is 84. So they're still living a long time, but that last 10 to 15 years is chronic UTIs, bone breaks, vertebra, is you know, stress fractures. There's a lot of problems with that. And personally, I don't know that I need to live past 84 or 85, but I don't want that last 10 years to be miserable. I don't want that. I don't want to be a burden on somebody. I don't need to be in a character.

SPEAKER_00 25:28

It's quality over quantity.

SPEAKER_05 25:30

It is, and I'm okay with having quality over quantity. If I get quantity and it's excellent too, then that's fine too.

SPEAKER_02 25:36

But no, it's there you go, Rick. What why why did it when it said quantity and we started talking about old?

SPEAKER_01 25:42

Well, it just said quality, it just said quality and it went right to no, I think it was the old, it goes right into Rick.

SPEAKER_02 25:48

Wow.

SPEAKER_05 25:49

But yeah, I think when we talk about different, you know, we were talking about hormone therapy options. So it's not just an you know, and obviously I let I love it when patients are making their own choices. I give them good information so they can make the best choice that works for them, that's tolerable, that works with their life, right? So it's not just, but but I'm definitely forward with the fact that even without symptoms, every woman's body requires a little bit of something to carry it along to keep it from eating more bone than it, you know, more bone than it's building in, etc. So, but when we talk about hormone replacement options, you know, just starting out with estrogen, one of the big contraindications, I think we talked about this last time, was an unprovoked DVT and PE. Well, what does that mean? It means that you have a clot in your leg or in your lung that we can't explain, we can't figure out why. Some and we don't ever want those, right? But they're more common after surgery, they're more common after you've been on long flights and things like that.

SPEAKER_00 26:49

Yeah.

SPEAKER_05 26:50

And um I think that with estrogen, the biggest, the biggest improvement we've seen with estrogen is now we have therapies that essentially don't raise your clotting risk at all, which was the big fight, which is why like women shouldn't be on one of the big fights, why women shouldn't be on estrogen and things like that. We have transdermal options, we have gels, we have foams. Personally, most of my patients really appreciate hi, Rick. Are you right as I talk to women and talk to people about women, but uh um, I think that my patient's favorite is topical, like so an estrogen patch, essentially. So there's lots of forms, there's lots of brands. Sometimes the patch is kind of big and it's circular, sometimes it's small and rectangular. Every woman's body is different, every skin type's different. Um, sometimes one brand of patch loves to stick on a woman's skin and the other brand doesn't like it. So I always tell women, hey, like I will do whatever to see if transdermal, like the patch will work for you the best because it's the safest option by far. So fiddle around with it. Talk to your pharmacists and take your box and say, hey, I had this brand the last time, whatever brand or you know, manufacturer. I didn't particularly like it. Do you have something else that's the same dose? And try a different size patch. And I guarantee it might take a month or two. But women come to me and they're like, this one is sticking on me perfect. And I sweat and I sit in the hot tub and da-da-da. So I feel really confident for that for most women, we can find you a patch that'll work with your skin, whether it's too dry, too oily, too sensitive to whatever. And then once we find that that manufacturer, I'll just specialty order it. We'll go mail order, it'll come to your house every month. It's a lot cheaper anyway. You know what I mean? So there's plenty of ways to keep it very safe. Um, there's also a pill form. Some women, some of my women who've been on hormone replacement for a time, their provider started them on the oral form. I always risk assess for any kind of clot issues, anything like that. You know, and if they choose to try the transdermal, it still has a very low risk of clotting events, breast cancer, you know, any any kind of exacerbation stuff. But like, um, and if they want to try the transdermal, because they're like, hey, I only have to change that once a week. I don't mind that. So they'll try it. And sometimes they say, you know, I kind of like the pill better, I just remembered it easier. And that's okay because overall risk is still very low in hormone replacement with estrogen because it's such a tiny dose, it's not birth control doses. So there's lots of forms of that. There's also creams and stuff like that. Once women kind of find a dose that they like, you can have it compounded. I prefer to kind of keep things separate until we find a dose because every woman likes a little more progesterone, a little less estrogen. I like to keep things separate, but ascent, but eventually people can choose to do a combined medication, have it compounded, whatever, if they want to keep it simple. It's it's a lot more expensive that way. Insurance doesn't usually love to cover any of that.

SPEAKER_01 29:52

But but you're you would you're saying it's it's probably better or uh to to individualize each of those separately. Yeah, at least initially simple combo formula.

SPEAKER_05 30:03

And when you think about it this way, if we're starting more hormone replacement and perimenopause, you're still making your own hormones. So what we're giving you right now in a couple years, we might need to incrementally go up with your estrogen and go up with your progesterone. So we might still have to tweak, fine-tune things, you know. I mean, theoretically, once a woman's in menopause and she's like, let's rock and roll this dose for the rest of time, then it's like, hey, you can you can do a lot of things with that, but it gets a lot more costly, it gets a lot more complicated at that point, but it's doable. And I've known some women on certain creams and different compounded formulations. But yeah, I like keeping it a separate, and usually it's a lot more cost-effective.

SPEAKER_01 30:41

So those are the two big ones. Um, for where now let's talk a little bit about uh testosterone.

SPEAKER_02 30:47

Testosterone. This is one that is like commonly thought of just as a male hormone, right?

SPEAKER_05 30:52

Right, right. Um, commonly thought of for like obviously testosterone is commonly thought of as a male hormone. Obviously, there's some dosing considerations and things in women. Um, women do make testosterone. We make a small amount. Obviously, in situations like PCOS, their body may be making more testosterone, which is a good thing.

SPEAKER_01 31:11

Or did you mean PMOS?

SPEAKER_05 31:14

PMO, PMOS, you're right. I need to get I need to get with the program. I got a new name for it.

SPEAKER_01 31:20

I need to use it couple of weeks to let your hand go.

SPEAKER_05 31:22

I know. It's hard to get my brain around it. So I when I have women come in and they have symptoms of maybe PMOS or facial hair, acne, weight gain, just different things like hydrinitis, things like that, then I kind of start looking at okay, what is our testosterone level? I always I like to check that and kind of get a baseline number. That's one of the few things in perimenopause that I kind of like to see a number so I can kind of adjust and we can associate symptoms with. But really, obviously, for women, the most common form is a gel or a cream. Um, most of the time, you know, when women like, for example, the most commonly prescribed testosterone cream that I do for women, it comes in a compounded formulation. It's a cream, but it comes in almost like a gel deodorant stick. Have you ever used one of those where it like clicks and it squishes up a little amount? Yeah. So this testosterone cream, most women do really well with it. Um, and I say use one to two clicks. So start out with one click, and I say when you get in the shower in the morning, shower, wash, you know, you get out, you put your deodorant on, put your testosterone cream right there. Like, not right there, sorry, usually in the in the in the groin area or in some out of the way place that you're not gonna like necessarily rub up against any animals or any people that way. Yeah, but it's it's if you're consistent with it, I get the most consistent results out of it to where I know exactly what your numbers are gonna look like at six to eight weeks. And usually it's a pretty strong, you know, you know, bump. Women don't, it's just like with men's testosterone, they don't necessarily feel this huge surge of whatever overnight. Usually at about two months, they're like, hey, I do feel better. Hey, I've noticed libidos increase, my muscle mass, okay.

SPEAKER_01 33:04

The dosing, the dosing for women is gonna be much less than you would for a male patient. So that's again a case for very individualized care. It's it's also worth noting that um testosterone therapy for women is not currently FDA approved in the United States. Um we there's there's good evidence, there's increasing evidence that supports it, uh the benefits, but uh but it's it's it's considered an off-label usage.

SPEAKER_03 33:34

Uh why do you think that is, you guys?

SPEAKER_05 33:39

Why do you think it's it's optional? Even though I make it optional.

SPEAKER_02 33:43

Uh we we don't we know the answer. We know the answer to that. The uh um no, it's it's it's the same reason why we did one trial in 2002 and it just was shut everything, shut everything down because it was honestly easier rather than to look at the study and say, hey, wait, what what did we miss here? Right. Um over 40 years this was great, and then over one study in nine months this got bad. It's the same reason, right? It's like you know, it's just predominantly it's just easier to tell women to buck up, and that's just how you feel now. And it is to say, hey, we there's a problem here and we're missing something, and let's look into it. Now, I do think that's changing and evolving. I think that um I do I do think it's getting much better, but I mean, predominantly it's been Mel's running most of the medical organizations trials and everything else that we do in healthcare, yeah.

SPEAKER_05 34:40

Right there, and we're we're we're finally getting more women OBGYN.

SPEAKER_00 34:46

Yeah, this is beyond here.

SPEAKER_03 34:50

That's why and I just needed somebody to say it.

SPEAKER_05 34:53

It's just the beast in the room, and I think that we're getting more female providers in the workforce, we're getting more female OBGYNs that are saying, Hey, this doesn't make any sense. Yeah, and we're getting more women in general in the workforce that are like, hey, I'm not dead just because I'm done having babies or I didn't have babies, my health matters. And we have more of a voice at the time.

SPEAKER_01 35:13

So you you have you've mentioned previously about um the girl parts. Uh-huh. Um, and I think that's that's worth there are some there are some people that uh can't really tolerate or aren't really candidates for like systemic hormone replacement, but there's um vaginal estrogen that helps a lot with kind of some of those things. It's not the same as the systemic stuff, but it it's helpful in some patients.

SPEAKER_05 35:36

Right. And I wouldn't say that women, I've never had a woman not tolerate hormone replacement medications, which it sounds crazy. Now, they might not be appropriate, but I've never had somebody not tolerate it because they're at such a low dose, even if they felt like garbage on birth control when they were in their 20s, those are such high doses. Right hormone replacement, I've actually, especially stepwise and titrating and making sure everybody feels good. I've never had somebody not tolerate it.

SPEAKER_00 36:01

Perfect.

SPEAKER_05 36:02

So, but I would say on the on the flip side of that, there's some women who are inappropriate for hormone replacement therapy. So, like those women who have gone longer than 10 years post-menopausal. So after that one year of not having a period, that starts menopause and then 10 years. So they've got that window, they might be inappropriate for it. It's a conversation. Additionally, women over the age of 60 to 65, they say, hey, even if, say, you went into menopause at 57, theoretically, your 10-year window, which 57, wow, that's pretty, you know, that's late, but I've seen them. I've seen women that way. 57 to 67, maybe after 65, they're saying maybe we shouldn't be starting it even after 65. We still might have like cardiovascular disease and other issues that we would wake back up and wake the beast up. So, so there are certain considerations that way. So that's always a risk versus benefit. It's always a conversation with the patient. It's looking at lifestyle, activity, health, overall health, and things like that. But that's one of those considerations. And if if there are women who are like, you know what, you know, they just don't fit that bill or risk versus benefit, it's not appropriate. I say, hey, but guess what? You know what's appropriate for everyone? Vaginal estrogen, especially for women to prevent UTIs. We prevent like a loss of that subcutaneous fat and the blood flow and all those parts down there.

SPEAKER_02 37:22

So atrophic vaginis, uh atrophic vaginitis, so uh dryness and then um and then uh chronic recurrent UTIs.

SPEAKER_05 37:30

Right. And you mean and not just the dryness, but atrophy. It's literally like we all know going into the ER, like I as an ER nurse, like when we go in to put in a catheter and a cute little lady, and they're those parts aren't in the same place, things move drastically. It's also including like pelvic floor therapy. We've got to do a lot of stuff. That's some major organs down there that move and change just because we're not getting a lot of estrogen all of a sudden. And so, you know, it's not just dryness and intimacy issues, and yeah, I'm getting chronic UTIs. It's also just structure changes altogether because of atrophy. We're losing blood flow, we're losing subcutaneous tissue because blood flow means that that tissue is just going to kind of dry up, get really friable, is the medical term for just really thin paper-like tissue. And it's painful, even to use toilet paper just after to go to the bathroom. Women are like, it hurts so bad, it's like sandpaper. So that's incredibly a big issue for me. That's not just quality of life, that's potential like UTIs, and we've seen plenty of UTIs that go really, really bad on these portions, which become which become dangerous as you age. Right, definitely. And I mean, like, you know, you get enough of those, and we've got some chronic issues, you're on chronic antibiotic therapy, which isn't super great, and nothing we want to do. And I've had patients who I've prescribed vaginal estrogen for, and within a couple months of doing a follow-up, they come back and they're like, I cannot believe it. It's not perfect, but oh my gosh, like everything's so much different. I I'm not, I didn't have my UTI this month, and I, you know, I like it just doesn't hurt to like pee, like just that, you know, and so these poor women are just happy with that. So if that's all we can do, that's amazing. I still prescribe vaginal estrogen for women who you're even doing systemic therapy. And you would think, like, why if it's if the hormones going all over in my whole body, why would I need it down there? Some women, like I said, just need more estrogen, need a little bit less or whatever. And if we're only booping up their levels a little bit systemically, maybe they need a little bit more like locally and topically. And so I always give that to women just because they'll notice, they notice. You guys would notice if your parts were changing, they notice. And so they're and so I say, hey, go ahead and use like peace-sized amount and just you know, daily. If that's what you want to do, you'll know if you know, if you need it or if you don't. So they always have that on hand. So I think that's a it's a huge one. That's a huge resource.

SPEAKER_01 40:02

Well, great.

SPEAKER_05 40:03

Yep.

SPEAKER_01 40:04

What else we got?

SPEAKER_02 40:05

Well, I think the last one would be um, with all of this, we know the body starts changing. Uh, me and Rick are huge advocates of um metabolic health and weight loss, and that's kind of really what got this whole thing going. And and we know that this is all related. So um, can you just give us a brief summary of what you're seeing with GLP1s and and all the things that come along with this peri and postmenopausal state?

SPEAKER_05 40:34

I do. Um, for most of my women that come in, I would say probably three-quarters of them aren't even wanting to deal with weight loss. They just know something's not right and they know the weight loss will figure itself out, and that'll be a later discussion. So a lot of the times we don't even go there. I do my basic vitals and my weights and stuff like that. But I really have to read the room because when you walk into a room and your only focus is, well, you've gained weight. They've heard that from plenty of other male providers. Like that's kind of they've they've done that, been there, but you know, and they're doing the best they can. So about three-quarters of the women I talk to, yes, that's a complaint, but that's not something they actively want to work on. The other quarter, it's all part of the same conversation. We just we just do what we need to do at the time. But I think with GLP1s, I mean, guidelines are saying, hey, metabolic support is essential to prevent chronic disease, chronic cardiovascular disease, insulin dependence or insulin resistance and things like that. So I think that GLP1s, the way I use them with my patients, and I is I say, hey, give your heart a give your body a hug. We're doing a lot of all at once, we're stabilizing hormones, and eventually we kind of work into this GLP one weight loss kind of situation. It's not wrong. All of the resources are saying GLP ones are excellent at maintaining metabolic health. And so when I talk to women though about it, I say, hey, low and slow. We like to have a little bit of GLP medication that fine-tuned, we like to fine-tune that low, low dose as low as we can get you to where you're still hungry for good protein, clean eating. You still eating still sounds great. We get a lot of dopamine from eating. We still want to be able to eat, but we're just having help with the snacks. We're still having help with just not feeling like, man, I just everything's going on and I'm just snacky and I just got to go like run to my snacks. So I use a very like low dose, low anti-inflammatory kind of settings to where it's just meant to be one tool in the toolbox. There's lots of tools in a toolbox. It wouldn't be the most optimal to use a hammer if you need a screwdriver, right? So GLP1s for me is like the hammer. It's great for some things. It's not everything. We got to use all our other tools. We got to do our resistance training, we got to manage our hormones effectively, manage stress, self-care, all the things. Because great, GLP1 might help with a little bit. It might help you manage weight, get to a healthy goal range. And we discuss all the all the ways, you know, all the monikers of a healthy, healthy goal weight. But also we got to use all other things. So absolutely I use it in a in a holistic setting, you know, whole patient kind of whole patient-centered care kind of setting, but it's all part of the conversation. But I don't, I don't push it if that's not really their um priority at the time and they kind of want to work on hormones and stabilizing things, feeling like they're not growling at their kids for every little thing and they're sleeping better, and you know, because a lot of women feel like, hey, I feel like I could focus on losing weight and being more active and eating, you know, with or without a GLP1, if I just felt like everything else kind of felt better.

SPEAKER_01 43:40

So okay, awesome. Well, thank you. So uh summary, I guess it would be so we have the tools. There's plenty of tools. The tools exist, evidence is uh is growing about their benefits. And it sounds like what I guess summarizing, I would say the most effective uh approach combines the lifestyle as a foundation. We talk about these, you know, the non-negotiables, lifestyle um changes uh in a sustainable way, uh, along with targeted therapies individualized to a woman's uh personal kind of history, goals, and biology, which is uh really an individual thing. So start the conversation with your provider, and you know, if they're not having it, find someone who is, because it really is it it's something that takes, as Caitlin was saying, it's it's something that takes um a lot of effort to maybe get to the the right therapy, the the individualized care that you uh need at this time in your life.

SPEAKER_05 44:38

But it's worth it in the long run. It's I mean it's it's it's an investment that pays off for sure. So yeah.

SPEAKER_01 44:46

Well, thank you for being here with us. These last this has been a fun, uh, fun little series of episodes, and we may have to have you on again when we get stuck on those things.

SPEAKER_02 44:56

Yeah, you can say no to a lot of things, Caitlin, but don't just don't say no to us, right? I wouldn't dream of that.

SPEAKER_03 45:03

You all know me better than that. You know that I could say no. I I could I can be sassy.

SPEAKER_01 45:08

All right, well, thanks so much. And uh and again, our hope is that uh this is helpful advice and uh and uh everyone here listening can uh get and remain healthier ever after. Yep.