Transcript of What’s REALLY Going on with Hormones in Women's Bodies through Menopause | Mel Robbins

What are the top five things that people complain to you about when they come see you for help with nutrition and hormones? And how do you attack fixing them?

The number, I would say number one, two, and three. Okay, so number one is definitely the weight gain. The weight gain is very frustrating because if you're an active person, we're already living in a world that's working against us. We already talked about this world. The default is that we are going to be in the categories of medically overweight or obese, 73% of Americans are there now. Wow. It's going to be at 85% before we know it. We're already working against this. Most of us are already metabolically challenged. We're already fighting against this battle. Then we got to deal with the estrogen going down, which makes you less active, less energetic, and losing your muscle mass. So now you have more fat, and it's making your mood a little bit lower. We can The therapies that I recommend, a lot of them have to do with things to counteract the changes in the lowering of estrogen. Okay, like what? Walking more. What I tell women is our cortisol levels can be really high when we're doing tons and tons of high-intensity exercise. It's better to have a baseline of walking, and you can do bouts of a hit if you want, but really having more activity.

It's called NEET, non-exercise exercise, activity, thermogenesis. Need activity is actually a bigger driver of our weight.

What is that last word? Thermogenesis? Non-activity, non-electric? I can't keep up with what... What is thermogenesis?

That's a big word. Non-exercise. Yeah. Activity, thermogenesis. Thermogenesis is metabolism.

Okay, so what is a non-exercise? Is walking is not- Walking.

Okay. If you're not walking for exercise, so the thought is you You wear a watch or you wear a pedometer, you park farther, you take the stairs, you take your dog for a walk, all the stuff that you don't count as exercise, that's non-exercise activity thermogenesis. That has to go up. If you're in perimenopause and you want to fight the weight gain, that's where it starts.

The reason why running or hit classes aren't the greatest thing for women in this category is because it spikes your cortisol. Yeah. What does that have to do with estrogen?

Women tend to do activities. The other thing that happens during when your estrogen is going down is you're less stress resilient. I'll give an example for women who even aren't in menopause or perimenopause, the week before your period, you're just less stress resilient. You can't handle the things that you usually can handle. Yes. So your mini PMS is happening for a few years now. So is PMS- A mini menopause.

It's a drop in your estrogen and progesterone in the middle of your normal cycle. Yes. No shit. I didn't know that. That's what's happening.

That's when your body is like, Oh, she didn't get pregnant. The egg didn't get fertilized. We got to shed this lining. They dropped the hormones. So you get to basically the lowest level of estrogen and progesterone, and then you shed your lining, which is your period, and then you start all over again.

Wow. Will the things that you're saying that help for somebody in URI or menopause itself also help with PMS symptoms? Yes. That is a revelation.

It is for me, too. I thought to myself, wow, the same things that we are doing to improve our nutrition during our cycle, we just expand on that. The late Ludial phase, which is that PMS phase of the cycle, is what's happening.

I like that... Oh, that's not another name for menopause. I was going to say, I think it's sexier to say, I'm in my late Loudeo phase, not menopause. The late Loudeo phase. Loudeo phase. But you're talking... That's a period.

Yeah, that's the week before your period. That's PMS. So the one surprising thing that people have to understand is that hormone replacement therapy does not help with the weight gain part. The weight gain part is not an indication to go get hormones. The things that I told you about, the exercise changes, and I'll talk to you about more changes that we can do, more neat activity, more weight training. That's going to help the weight loss.

Okay, what else do we need to do for the weight loss? Because I know everybody's leaning in. Yes. Because I thought if you get the patch or the bioidenticals, your body will snap back into the way it's supposed to.

And that's what's so frustrating for women. The hot flashes definitely get better, right? Like, that's one of the indications for hormonal therapy. People will have pain with sex or have dryness. That definitely... Hrt definitely helps with that. Okay. But the weight gain portion is not so easy to address just with hormones because there's a multiple things going on. You're less active, you're losing more muscle mass, your sleep is dysregulated. So then your appetite, as we talked about, your cravings, your hunger, your appetite are all increased because you're not sleeping well. So you end up having a situation that can't just be solved by adding hormones. I think about adding hormones It's like putting gas in your car. You can add gas to your car, but if there's a traffic jam, you're not going anywhere. Our hormones are like a complicated highway system. In LA right now, there's a complicated web of highways that are backed up. It doesn't matter how much gas you pump into the car, it's not going to go anywhere. The ways to un clog that traffic, to keep that traffic moving, is the sleep, the exercise, the weight training, the food choices.

Sleep is another thing. As frustrating as it sounds, the more you can improve your sleep, the better that weight loss part will become because your appetite, as we said, your hormones, your hunger hormones, are really dysregulated when you don't sleep. You want to have a good night's sleep, but often you can't sleep because your hormones are disrupted. It's the cycle. One of the things I tell people is really, really try your best to improve your sleep hygiene. If you haven't started a routine to improve your sleep hygiene, start it now in perimenopause Okay, now tell us your top three things for a better night's sleep. Top three things for a better night's sleep.

Cold room. Okay.

Your body temperature has to drop by one degree to fall asleep. How do you get that done fast? You could take a shower, You can cool down the room, you can get into pajamas that cool your body. You want to cool your core body temperature. That's how you'll fall asleep. Love that. Pitch black. If you can't control the curtains and the light, then wear a face mask or I mask. There are good studies on the few studies that we have. One is on menopausal women. Even if you have an ambient light in the room, like a light coming through the window, it will stop weight loss if you're on a weight loss plan. Really? Circadian rhythm disruption, especially during that time, seems to really mess up the hormones in that sense. So you want to You want to have a pitch black room. Then the third thing is you want a nightly routine. You want to prepare your brain and your body for sleep because your body loves routines. Our bodies are It's built on rhythms and cycles. If every night you go to sleep at 8:00 PM or 9:00 PM, so at 8:45, you start to turn off all the lights, you put away your phone, you start to brush your teeth, you're cluing in your body that it's time for sleep.

So keeping that same time and routine is essential for good sleep. People will sleep one day at nine o'clock and the next day at 11:00 and the They're massively disrupting their sleep cycles. There's some data now that shows that it's maybe more important to stay on the same bedtime than even the total number of hours slept.

Wow. Are there certain foods that we should be eating more of or less of to help with the menopause symptoms and hormone regulation? For everybody's benefit, I just want to remind everybody, this is your second appearance. We did a huge show on hunger and craving and the neuroscience and biology of it. That will be linked in the show notes along with both of your books. But if you had to bottom line it for people that are really wanting to use food to regulate hormone, what are the top recommendations?

Remember that I likened it to PMS in the sense that you're less stress resilient. What I mean is that the things that spike your cortisol are just now more and at a lower threshold. Caffeine, alcohol, sugar.

Shit, are we not going to have fun now, too? I mean...

It's like all the... People say to me, I always drank this much caffeine, and they always eat this much sugar.

Yes, or had a glass of wine or did whatever. What the hell is going on?

Yeah, and that's because now your hormones have changed and your metabolisms change. You're also less insulin sensitive. You know, you've heard the term insulin resistance?

Yes. What does that mean?

That happens during menopause.

What is insulin resistance?

Insulin resistance means that when the sugar is trying to get into your cells, the insulin has to open the door to let the sugar in. That's insulin.

Oh.

Yeah. So it usually matches, meaning when you have a lot of- So what does it mean when you're insulin resistant?

The door is shut, the door is open.

The door is shut, and you don't hear it as easily. You're knocking louder and louder to try to get in. And the insulin is like, Dude, we just let sugar in. We're not going to let more sugar in. And the body is like, no, but I need to get it out of the bloodstream. I need to put it. And the insulin is like, no, but the cell is packed. It can't take any more sugar. And so while they're having these fights and discussion, that's called insulin resistance. And so when insulin When insulin resistance happens, the body gets signals to store fat, to say, let's get this sugar out of here because it's not going into the cell, so we got to put it somewhere. So we end up when insulin resistance happens, not only do you have a higher risk of getting type 2 diabetes because your sugar level is so high all the time, you also have more signaling to store fat.

Oh, man.

So insulin resistance is something So that we can control by saying, well, if the cells are so full of sugar and they can't let any more sugar in- You better eat some vegetables. You better just cut some of that sugar out. Okay. And add in some things that help you lower the blood sugar in your body, which is fiber. So fiber is one of the most helpful things that you can add to your diet besides cutting down the sugar because your cells are overwhelmed with sugar, cut down the sugar. Add more fiber so that your blood sugar can be regulated in your body. Move more like we said. Yeah.

Add in weight training.

Sleep more. Sleep more. Remember the water that we talked about in the other episode, water, our thirst centers are often mixed with our hunger centers, like the signals can be mixed. You want to hydrate enough so that you are not eating mindlessly And then, of course, there's- So in the trick there, just for those of you that have not heard the other episode, is when you feel your appetite coming on, in order to determine whether or not you just have a mindless craving, you can say, Would I like a bowl of vegetables right now?

And if the answer is no, that means you're not actually hungry. Another trick is drink a glass of water because that typically can satiate that appetite that flares up. Why do we have anxiety? Why is there an increase in anxiety during PMS and menopause?

Remember that sister, the progesterone sister? Yes. She was a calming one. She was the one who was keeping you chillaxed and careful. When progesterone goes down, you don't have that chillaxer anymore. You don't have someone to keep you calm. Like that sister that was inside saying, Calm down. It's okay, Mel. You'll be fine. Your progesterone levels are lower, and all of a sudden, you are anxious about everything. The things that never made you anxious before are making you anxious. The sleep, you wake up in the middle of night, you're like, Oh my God, I can't believe X, Y, and Z happened. And it starts a whole anxiety spiral. A lot of women during menopause have crippling anxiety.

Does hormone replacement therapy tend to help with anxiety? Yes.

If progesterone replacement.

Got you. Can you explain what a hormone is?

Yeah.

I'm not sure I would know how to explain what a hormone is and what it does.

Yeah, that's a great question. I always feel like there's so much confusion about hormones. Hormones is a chemical messenger. In my analogy of the highway, it's the car. It's the car. It travels from your brain or from your ovaries to wherever it needs to go. It can go to the muscle, it can go to the heart, it can It's a traveling message, and we need it. Our bodies cannot function without hormones. People get so annoyed with hormones, but you cannot function without your hormones, even cortisol. Cortisol is a good hormone. It can It has to be balanced.

What is the estrogen? Oh, I'm getting this now. The fun party sister- The social one. The social one is driving one car, and When she arrives, it's time to party. Yes. When the progesterone sister is driving another car, when she arrives, party's over. Yes.

And she calms everybody down. Let's just chillax now, guys. Let's just tone it down. Is Is insulin a hormone? Insulin is a hormone.

Really? So when insulin gets in the car, what is insulin telling you?

Insulin is telling you to open the door to let the glucose in. It's signaling to store. It's a storage signal, meaning that our body sends insulin out to say, Hey, we need to store a little more glucose here because there's glucose coming in. So it's a messenger to tell people, thyroid hormone is also, it goes all over It's in place. People think, Oh, thyroid hormone is just about weight. No. It's controlling weight, temperature, it's controlling heart rate, it's controlling a million things. It's not just going to one destination.

Wow.

So So you can't just replace hormones and think that it's going to have one effect. For example, we see people getting high, high doses of thyroid hormone. I say to people that more is not always better, right? It's not just doing one thing. It's doing five different things. And one of the things it's doing is it's going to the heart. If you send too much thyroid hormone to the heart, you're going to have all kinds of problems, including arrhythmias, heart palpitations. People that are taking too high doses of thyroid hormone will have heart problems often. It's like playing with fire.

Wow. They're just driving in the wrong direction or they're not arriving where they used to arrive, and that's what's making the changes. The hormones are the root cause of PMS and menopause. Yes. Wow. For some of the symptoms, hormone replacement therapy will alleviate symptoms. Yes. But for other things like the fat redistribution or the losing muscle tone, that you're going to have to make lifestyle changes.

Yeah. So the other hormone that we didn't talk about, but that's really important, even in women, is testosterone. Really? Testosterone is actually in higher levels, like four times the level of estrogen or progesterone. It's high.

In women? Yes. Really?

And we always think about testosterone is like a male hormone, right? Of course, males have much higher levels of testosterone than women. But our testosterone is also high compared to our other hormones. Having testosterone there. So Testosterone is the sister. That doesn't live as close to the other sisters, but testosterone is the leader. It's the one, it's the muscular, it's the It's the aggressive. It's the leader sister. So Testosterone is something that we get a spike of testosterone at ovulation. So if you know your cycle, roughly Maybe a week after your period is when your testosterone levels are peaking. That's when you want to build the most muscle. That's when your libido will be the highest. Your confidence levels will be similar to the other gender. People that take too much testosterone, for example, when they're taking a replacement and they go overwork, they'll be angry, aggressive, and maybe even a risk-taking behavior. We know that testosterone can be good in small amounts, especially for women during perimenopause and during the cycle, if you're lower than you need to be. But of course, you don't want to overdo, and people overdo it all the time.

How do you figure out what to take?

Yeah, I know. I know. There's so much misinformation out there. What are the big ones?

Yeah, give me some of the big myths.

Big example. The one thing that all doctors can agree about that no hormones is that those pellets that people get are no good.

I don't know what the hell a pellet is. I've just heard about this. What the hell are pellets?

So pellets are testosterone releasing, extended It's supposed to release testosterone that they implant under the skin, and it's supposed to release testosterone.

Yes.

What happens is you keep this in there for months, okay, and you get it replaced. And what's happening is that you can't adjust the levels. So you're getting, and most of these pellets are giving you super therapeutic levels. And like I said, hormones are not something that you just want to add because they're doing a lot of other things besides maybe the one thing that you're targeting. Okay. And so what we say is, why would you use an implantable testosterone that can't be titrated, that usually releases too much in the same dose in every woman? Why would you do that? The answer is that you can charge. You can charge for testosterone pellets. When you do testosterone, a cream or ingestible, it's not money in the pocket of the practitioner. I know once I said this on social media and people went crazy because they said, I love I take testosterone pellets, and I said, great. But make sure your levels are at the level that you want it and not way high, because I bet you that a lot of people who are taking testosterone pellets are at super therapeutic levels, and we've seen so many negative side effects from those levels.

So hormone replacement can be so amazing, but go to the right person, choose the right dosing. And even if you do pellets, great. Choose what's right for you, but make sure you're not getting levels that are too high for your body.

I am so glad you said this because we had another amazing person on who uses pellets herself and was so excited about them that I'm like, I got to get me some pellets. I got to go. I got to get in there and get the pellets. I got testosterone. Chris Robbins, get ready because the libido is coming back. But I'm glad that you gave us the reason why, so that you can make a choice for yourself. Yes. Is it true that women of different races experience menopause differently? Yes.

The problem is, again, Mel, is that not only are we not educating our doctors or the population about menopause, we don't even know the differences between different backgrounds, different races, different ethnicities.

Because they're not studying it?

They're just not studying it. We're just finding out now that people present different... I mean, we're I guess at the basic levels of finding out that women present differently with heart attacks than men, and that women produce, will be shamed for symptoms that are actually real because they just think, Oh, she's just a complainer.

Well, and then the other thing that I have really not appreciated is that there is an acknowledgement that you get foggier. Yeah. And there's an acknowledgement that you will start to feel flabbier and start gaining weight in places that you've never had it before. But there's no what to do. That it's this, Oh, well, yeah, me too, or, Yep, that'll happen, and everything will go back to where it should be when you're 60 or you're 10 years into this. I am sorry, I'm not settling for that. That's one of the reasons, Dr. Amy, I wanted you on. I think it'd be really helpful if you could walk us through the day of what you would recommend for anyone to either better manage PMS or have a better routine that's aligned with your recommendations and the science out there to help us both regulate our hormones and do the proactive steps to feel better during these very normal changes?

Yeah, that's a great question. I'll start with saying that we live in a society that has a problem with women getting older. We basically have been told that if you don't fit into the societal ideals of young, fertile women, that you're no longer worthy, that you're no longer beautiful, that you're no longer wanted, that you're no longer smart and motivated. I think that that's one of the biggest challenges that we are going to have to face in this next generation where we feel good even into our 40s and 50s. If we do the things that we're going to talk about, this could last till our 70s, and we When we look younger and feel younger. We already know the biological age, like our age of our cells, is completely different, 20 years different than our chronological age. You're really just 35 right now.

Thank you. Thank you, which is why I'm pissed off that I have a dry vagina I sweat at night and I feel like somebody's grandmother.

Exactly. Here's how we move through the day. You wake up, hopefully without an alarm. This is really important because we talked about sleep, how it helps with appetite regulation. We just, as a society, shit on sleep and don't allow ourselves to sleep. They say, go camping, go somewhere where there's no ambient light and there's no distractions and social media and see actually what time you sleep and wake up. I bet you you're not a night owl like you thought. It's really just a societal thing that we try to escape from our days at night. You're going to get an adequate night of sleep. You're going to go get that sun Sunlight in the morning. So circadian biology, again, the light that you get in the morning tells every cell in your body that it's morning. The benefit of that is that our hormones need that input. If our hormones don't get input from our brains and our bodies that, Hey, it's time to release now, cortisol. Cortisol is high first thing in the morning. Then it causes hormonal dysregulation, which is like how people say, Oh, I feel so tired all day, or adrenal fatigue, I feel so burned out.

It's not that the adrenals are burned out. There's no such thing as adrenal burnout. The That word, adrenal fatigue makes it sound like these adrenal glands get tired. Yeah, they don't. No, it's this hormonal highway that we're talking about gets clogged. It's not just the adrenals, it's coming from the thyroid, it's coming from the brain. The whole traffic jam is happening because of all the other things, the lifestyle, the age-related hormone changes. You want to get up, you want to retune those clocks. Those clocks can get damaged if you misalign them so long, so many times.

Yeah. If you live in your parents' basement and you never get outside or you spend hours and hours and hours in the daytime inside. Well, what I love about this, I think And just to keep with the analogy because the visuals really helped me put it all together. It's almost as if the circadian rhythm and the sunlight in the morning is like the remote starter to your car. Yes.

It's unclogging that It's keeping those roads open and clean. You can know, okay, it's time to drive. Like everything's opened up. So you get the circadian rhythm. Remember that if you start to damage those cars, you basically get these things called senescent cells. The word is a very scientific word, but basically it means your cells become zombie cells, and they no longer It can work. The car doesn't work, but it actually... The emissions from the car is inflammatory signals. And aging, and all the things that come with aging is these cars that are broken down, and they're sending off these inflammatory signals to your whole body. And that's the process of aging. We need to clean those cars up and get those out of there if they're not working. So keeping with that analogy, we don't want senescent. Senescent cells is the big area of anti-aging that we're trying to understand How do we clear those out fast, or how do we not break down those? So then you want to... Working out in the morning actually has been shown in studies to be not necessarily the only ideal time to work out, but the best time to stay with a routine.

People are compliant with exercise when it happens in the morning.

Well, it's common sense because your day doesn't hijack your energy and your time.

I see it over and over again, especially in women, because- Sorry, go ahead. No, because women, we are doing everything for everyone. Our mental load starts from the morning. And so if you don't get that workout in, there's a big chance that you're not going to make time for it later because the kid needs a ride, your husband needs you to be home, the meeting came up, somebody needs you to be somewhere. So get it done in the morning if possible. There's a second peak time that seemed to be equivalent, late afternoon. Okay. And late afternoon, you get a little bit of surge. It's a better time to muscle build. So if you're doing two mini workouts that you could just split it up. And then high protein. High protein. Protein is one of the biggest things that doesn't happen with women in perimenopause, because what happens is women think that you're They're starting to be skinny, and when they start to see themselves gaining some middle section weight, they often cut down even more, and you're in this very tight calorie restriction. What you really need to do is eat more protein more fiber, more real foods, and less of that ultra-process crap.

Having a high protein breakfast, dopamine booster breakfast, high fiber. We know we talked about that a lot in the other episode. Then you want to do your biggest concentrated tasks of the day early in the day.

So that you don't spike your cortisol. Exactly. Boom. I'm getting this. I am getting this.

Then if you're someone who can do a meditation or a nap, the best time to do it is when your cortisol is naturally low between about 1:00 to 04:00 PM. When your cortisol dips, it's a great time to either do a power nap, 20 minutes, do a meditation, do something calming, because remember, when your progesterone is dropping, you're likely more anxious, you're overwhelmed. It's a nice break from the day when you can do it, do something that's very centering, prayer, whatever it is.

Let me ask you a question about that. These menopausal symptoms that you're talking about. I've heard what I think is probably a myth, that if you just ride it out, just like three years, Mel, ride out the hot flashes, the dryness, the bitchiness, all this stuff, the brain fog. And in three years, you'll just snap right back. Is that true?

Well, what happens is that your body just starts to get used to it. And so you're operating at a level that's just stable. There's no squeezing of the toothpaste. There's nothing there. Your body starts to accommodate. It's not that it's snapping back, but that the symptoms seem to go away, a lot of the symptoms that were really troublesome during menopause. It's often the time where people feel a little reprieved. But remember that disease risk goes way up after menopause. Our hormones protect us from heart disease, and all of the disease and all of the disease of aging. Once you hit menopause, you start to have an increased risk of all of those inflammatory diseases.

Okay, wow. Yet another thing to look forward to. Is there Is there anything more that we should know about the increased risk of inflammatory diseases?

One of the big criticisms of hormone replacement therapy was that it would cause cancer. But now we know that it's the opposite, that actually hormones actually protect us from a lot of these diseases, especially heart disease. For women, it can actually be protective. In the right population of women, very close to the start of menopause or perimenopause, the earlier you start it, the better risk protection you get from a hormone replacement therapy.

What is the biggest myth around menopause?

I think the biggest, honestly, my biggest pet peeve about menopause is the fact that women feel shame around it, and they can't have conversations with their doctors. They often feel like they're marginalized and they're not listened to from their provider when they say, Oh, I have this correlation, the symptoms that I don't feel right, feel tired, but I feel anxious, my sleep is off, and they often get a prescription and no explanation about what's happening. And I know countless women who've just come home with anti-anxiety medications, and no one explains to them that there's a lot going on in your body that could explain why you're feeling this anxiety at this time, and there are things that you can do. Not to say there's anything wrong with medications. There's a great need for medications, but there's also a big need for education around menopause.

I agree. There is a huge need for education, not only around menopause, but also around women's hormonal health and cycles in general. I consider myself to be a very well-educated person. I'm intellectually curious. I read all the time, and I have flunked this topic. When I've gone to my doctor or to my OB-GYN, it feels like people are like, Yeah, well, it's going to last till you're 60. You can do hormones or whatever. You're going to have to tolerate the weight gain. It'll disappear by the time you're 60. I hate that.

I think the term is gaslighting like medical gaslighting, where women just feel like they're not listened to, and their complaints are just dismissed. And I think that's something we really need to work on as a society, because, like I said, Age 40, age 50, age 60, is now very different than it was even just 20 years ago. Women are doing things in their 40s, 50s, and 60s that did not do. We're changing the... We got to change the conversation. It's not that, Oh, you're just worried, you're just stressed, you're just getting old and dismissing their concerns. These people are running companies. They're leading countries. We need to have conversations about what they could be doing to optimize themselves at that level, not just saying, Oh, well, you're just getting old.

What would you advise any of us who feel like we are just not getting the answers from the doctors that we're seeing? Do you just change your doctor? I mean, what do you do?

I think in this day and age, we have enough physicians that are interested, educated, and can be an advocate for you that you should go seek that out. Because I think that we're changing the conversation not only within not in ourselves, but in the medical community of saying, Hey, listen, if a woman comes to you with these complaints, don't just write it off as separate things. Think about where is she in her cycles? Where is she with her hormones? Could it be I love this. One big myth that I want to bust is that you must check your hormone levels to diagnose a hormone problem or menopause. There's this big myth that in order to be considered in menopause or perimenopause, you must get your hormone levels checked because that's what you hear on the internet. Menopause is not a diagnosis of hormone levels. It is a diagnosis of symptomology, and the definition has nothing to do with the level of hormones. A lot of people spend thousands and thousands of dollars trying to get testing to figure out what their hormone levels are, but that's not necessarily the first place you need to Well, when should you get your hormone levels tested?

If you're getting replacement therapy and you're trying to troubleshoot something. But the diagnosis of menopause is not made through a lab test.

Well, that's one thing that we learned today, that the diagnosis of menopause is made after you have gone an entire year without menstruating.

The problem is that, like I said, there's a lot of misinformation There's a lack of research, and there's a lack of interest, to be honest. I think that all of those things make menopause an area that is mismanaged, that is an area like If you look on the internet and you look for supplements around PMS or menopause or hormones, it's a wild, wild West. I mean, clearly, people are looking to alternative practitioners and online therapy for their hormonal concerns. But when you see what's out there, it is very scary. That's a clear sign that women are looking for answers, and so we need to have more information. Even the basic things like we talked about here, this should be basic education for all women.

What is hormone replacement therapy?

So menopausal hormone therapy, which is what we call it, is giving hormones to treat symptoms of menopause or to prevent complications associated with menopause, like osteoporosis.

Can you explain the different types of hormone replacement therapies, Dr. Gunther?

Yeah. So there's evidence-based FDA-approved, and then there are scams. I would think that's the best way to sort it out. So many people get hung up on the term bioidentical, which is really a meaningless term. It's a medically meaningless term. Whether a hormone is the same or similar to what your body makes doesn't make it safe. I could give you a high amount of epinephrine and cause harm to you, but that's something your body makes. So I can give somebody tons of estrogen and give them endometrial cancer. So whether something similar to what your body makes or not doesn't make it safe. What makes it safe is, is it studied? Is it safe? Is it effective? And is it something that can be... We know exactly how much you're getting. So one of the big problems is a lot of people are using compounded medications or pellets, and we don't know what's actually in those things from an actual amount of hormone. If I give you an estrogen patch, I know how much is going to be absorbed. There have been studies that have been done. I know if you put it on a different body part, that's going to affect absorption because all of this has been done.

With compounded products, none of that exists. None of it. I don't know how much is getting across your skin. I don't know how much you're ingesting. I don't know how much is being absorbed. Would you want to have a broken gas gage, or would you want to have a gas gage that works? You would want know what you're putting into your body. I would say there are FDA-approved therapies, and there are many good ones out there. There's estradiol, which is the main hormone that the ovary makes, and we have pharmaceutical variations of those. Another big myth is that some hormones are plant-based. That, again, is a marketing jargon. Is that not true? Well, I mean, petroleum is plant-based, too, if you want to look at it that way. You take strawberries, and then you expose the chemical that you extract from strawberries to a multi-step chemical process to break bonds and convert it into estradiol. So, yeah, it's plant-based, but it's not. They used a starting chemical found in a plant and converted it into estradiol. That doesn't make it any better than if I made estradiol by assembling it from different molecules. It's the same thing.

Your body can't tell the difference. We just make it from strawberries, which is called a semi-synthesis, because it's cheaper than making it by hypothesis, which is assembling the molecules itself. So it's a total marketing thing. Plant-based, it means nothing. Nobody's grinding up yams and putting them into pills and giving them to you.

How do I know that I'm I'm doing the right thing? I listen to you and I'm like, yes, yes, yes. I love it. Take it down. Take it down. Go, go, go, Dr. Gunther. Thank God you're out there cleaning up the internet for us. But then I'm like, shit, what am I asking my So if I'm going into my gynecologist and I'm interested in hormone replacement therapy, what is the proper thing to ask for so that I am in the land of research and in the land of things we can measure versus in the fringe areas of the other stuff?

So if you're getting a prescription that doesn't have a package insert with it. What does a package insert mean? So whenever you get any prescription and there's this little folded up book and you unfold in it, it's all the risks and benefits, and it's this big thing. If it doesn't have that, then it's not FDA approved.

Oh, okay. So all the things that you get from the compound pharmacy, not FDA approved? No. Because they haven't... How could they be? Because the package Sourcing has been through clinical trial after clinical trial, and it's had to have been tested and passed through all these hoops for your safety and so that you, as a doctor, can understand what you're actually prescribing me.

Yeah. There's this whole loophole for compounded medications, and so they don't have to have that package insert. They don't have to tell you about risks of blood clots or risks of this. They don't have to tell you any of that. That's a big problem, and it makes people think that they're safer. Because look, if I gave you two things, one had a I said it had a black box warning on it and the other one didn't, you're going to automatically think the one that doesn't have the black box warning on is safer. Well, it doesn't have the black box warning because it wasn't required because it's not FDA approved.

Oh, my God. When I was going through perimenopause, I got bioidentical hormones from a compound pharmacy, and I thought I was fancy. I thought this is high-end medicine. They have taken something for me. This is how How uninformed I was. They have literally, because of the word bioidentical, I thought it meant, Oh, well, somehow this is custom formulated for me to match my hormones. It is bioidentical, which sounds really fancy and trustworthy. And then I would get this packet from a compound pharmacy, and it would have these tubes in it. And there were all these warnings like, Don't expose to light. Don't do this. Do that. Now, did I follow those? Of course not. Was I precise in how much I would squirt on my No, if I'm being honest. And so I thought that I was having the better result when I can see now what you're basically saying is that no, not really.

You were having the inferior. You were paying more and getting less. Because we all think when someone's customizing something for us that we're getting better, we're trustworthy, we believe people. And no menopause society recommends compounded hormones. They're not not recommended by the North American, or we now call them, they're now called the Menopause Society. The National Academies for Science, Medicine and Engineering don't recommend compounded hormones. The International Menopause Society, the British Menopause Society, none of them recommend compounded hormones because it takes science and research to know how to get hormones through a skin. It takes science and research to know how to get them from your gut into your bloodstream. When you make hormones, they just get dumped into your bloodstream from your body. You're not eating them. You're not absorbing them. You're not rubbing them on your skin. You didn't evolve to get hormones that way. Now, it doesn't matter that we have modern medicine for a reason. It doesn't mean you shouldn't take them because we didn't evolve for that. But funny thing, it takes science to figure out how to make these molecules work for us. There are several issues with using compounded products.

People may be getting more of a hormone than they think they're getting. You might be getting more estrogen than you need, which could Would put you at risk for endometrial cancer. You might be getting not enough progesterone, which would put you at risk for endometrial cancer, or you might not be getting enough estrogen, putting you at risk for osteoporosis. So you think that you're preventing osteoporosis, but you're not. Why would you want... This This is the analogy I use. Using FDA-approved hormones is like going to the gas station that has the gallons on it, and you can choose whichever gas you want. You fill your car and you have a working gas gage, and you're like, I know what's in there, and that's important. Getting these compounded formulations or pellets is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you. And let him fill your tank. And, oh, he's going to flip that switch off so you don't know how much is in there because you should trust him because he knows. That's the difference.

I am speechless. It's not very often that I don't have anything to say. And you just took a flamethrower to the entire idea of bioidentical hormones. I would never, ever try it again. And then I would add on top, by the way, you've brought the science and the research and a very compelling analogy, I'm going to add one more. As somebody who already has ADHD and has increased brain fog due to menopause, I am not that great at being consistent at storing things the right way or using it the right way. And so I'm probably over-undedosing, even if it was made in a way that was clinically sound. And so case closed, not doing bioidentical hormones.

Yeah, and I would say, move away from using bioidentical and just call them compounded, because bioidentical doesn't mean anything. Bioidentical is a marketing term used to describe hormones that are plant-based, that are identical to what your body makes. But estradiol that you get from an FDA-approved company, I use an estrogen patch, it's estradiol.

I've got it on right now.

The estradiol in the patch is no different from the estradiol, the compounding pharmacy is using. They're both buying the raw hormone from the same place. The difference is the pharmaceutical company has studied how to give that estradiol to you in a reliable dosing manner. The compounding pharmacy has not done that work. They don't have that. And because of that, they're not FDA approved because you have to show to the FDA, and it's expensive, you have to do all those kinds. So they haven't submitted that data. They're just making things up. So you have a precise studied formulation. But the big thing is, they're not buying fancier hormones. All the raw hormone comes from the same one or two plants in the world. It's like me buying cheerios and putting them in a cheerio box or putting them in a glass jar with a ribbon around. But they're the same product. Except the delivery mechanism is different. So that's why I tell people, every estrogen that I would prescribe you from the FDA or from an FDA-approved source, with the exception of Premrin, is bioidentical and plant-based.

So everything Everything is the same.

Just forget that word. Okay. Yeah, because when people use the word bioidentical, it tells me that they think women are dumb.

Well, clearly, I am in this area. Well, no, seriously, I can own it because here's the thing. It is confusing as hell. And there's so much misinformation. And when you walk into the doctor's office and you are simultaneously erupting at your family because you're all over the place with your emotions. I'm speaking for myself here. And then next thing you know, you're sweating like Niagara Falls. And then next thing you know, your vagina feels like the Sahara Desert. And next thing you know, you can't remember where your car keys are or where you put your dog because you can't remember. And you are losing your mind and somebody says to you, oh, bioidentical, and I can send you. You're like, thank you. I'll take it, whatever. And so I had no idea. And I used it for three years, and I thought I had the fancy thing. And so I want to be very clear about something, and you listen keenly to me, Dr. Gunther, to make sure I have this correct, because I'm putting my lawyer head on, and I'm feeling the association of compounding pharmacists writing us a seiths and desists letter. And so I want to be very clear about what she has said.

Number one, it is a fact that the Menopause Society does not recommend that you use a compound delivery formula for any hormone replacement therapy because it has not gone through FDA approval. Number two, the distinction that we're talking about is not the actual hormone. So they're using the same stuff. The reason why it is important that you understand this is because the delivery mechanism of the pharmaceutical product like Estradol has gone through FDA approval, which means the researchers and scientists and doctors know how your body is going to absorb it. They know the rate of delivery. They know that it has been tested. And so it is what the Menopause Society is recommending if you are going to do hormone replacement therapy. Did I get that right?

Yeah. The other important thing is when you have an FDA-approved medication, they're batch tested. So what that means is, whatever, however many, one bottle in 50, one bottle in I don't know what it is, is tested to make sure it has what it claims. But when you're mixing up product after product, one at a time, there's no batch testing that can be done. You're talking about a whole different thing in quality control. The only time we ever recommend a compounded product is if there is a true allergy to... There's no pharmaceutical option because of a true allergy. That's where we rely on compounding pharmacies for that situation. One example might be Prometrium, oral progesterone. The brand in the United States is made with peanut oil. If you have a peanut allergy, you can't take that product. The options are then to take a different pharmaceutical or to get progesterone compounded by a compounding pharmacy without peanut oil.

That makes sense. In that instance, where you have a real full allergy, you might recommend a compound pharmacy. But otherwise, 100%, as literally the number one gynecologist myth-busting, you are out there setting the medical facts straight. The Menopause Society, and your medical recommendation is to absolutely not be using the compounding formulas, but to be using the FDA-approved delivery mechanisms that are prescribed by your OB-GYN. Right. Wow. I am learning so much, and I know you are, too. We We need to take a quick break to hear a word from our sponsors. While you listen to the amazing sponsors, would you please share this episode with someone who needs to hear it, which is basically every single woman in your life. Don't you dare go anywhere, because when we come back, we are going to keep talking about exactly what you can do to relieve the symptoms of menopause. We have so much more to learn from the amazing Dr. Jenn Gunther. And later on, we're going to talk about exactly how you can talk to your doctor in order to get the care that you need. All right, stay with us. We'll be right back.

Welcome back. It's your friend Mel Robbins, and I am here with the incredible myth-busting and unbelievably empowering Dr. Jenn Gunther. She is telling you everything that you need to know about menopause. So Dr. Gunther, how do I know that I'm doing the right thing?

What people need to remember, the takeaway is, there's really very few things you need to know about hormones. The two main estrogens that we recommend are either estradiol, and if you're stuck on the term bioidentical, that is bioidentical. Now, I'd like people to throw that term away, but sometimes it's hard. So the estradiol that I would give you in a patch or a pill from a pharmaceutical company that is bioidentical. You have that. You want to learn estradiol, and then you want to learn premrin, which is conjugated equine estrogens. That's only actual natural estrogen because it comes from horse urine. So now- Horse urine? Yeah. Natural means the substance exists in nature and it's being used unchanged.

How the hell they figure out that horse urine is something that...

Yeah, horse urine's got all kinds of estrogens in it. It's a crazy thing. Those are the two things you need to learn. You need to learn estradiol and you need to learn premrin, which is the trade name for conjugated equine estrogens. And then you need to learn oral or transvaginal or transdermal. So against the skin, through the vagina or by mouth. Got And we recommend the number one starting treatment we generally recommend is transdermal estradiol. Here, I'll show you.

I'm going to show you mine right now because I'm probably due to take it off. I have to do it like every four days. Let me get down here. Okay. Here it is. So this is and look, my dead skin is on it. That's disgusting. So you have a patch? Yeah. So I have a patch. I'm going to hold it up right there. Yeah. I have to replace it every four days. Change my life. And so I can trust. I trust knowing that if I put this on every Every four days, and this is considered transdermal.

That's transdermal. It goes through the skin.

So if you were to like, I wouldn't put it here, obviously, but you just stick it to yourself.

Yeah, but you only want to put it in the place that the package insert says. Because it's been studied. They've studied it in different locations that the absorption can change. So if you put it on your belly versus putting it on your thigh or putting on your butt, you might get a different absorption of the amount of estrogen. And you don't want that. You want to know what you're getting.

Yeah, that's right. And I've also learned because I had no that you could also insert something into the vagina for hormone replacement therapy. Yeah. I should probably butt my pants to finish the interview here.

Yes. So there's a transvaginal ring that also has estrogen and can be absorbed that way into the body. And there's also a ring where the estrogen just stays in the vagina. And if you're having vaginal dryness, you have urinary tract infections, pain with sex, vaginal estrogen can be very effective for that. And And so some people who have no other symptoms of menopause, feel great, they feel fine, but they have vaginal dryness. They don't want to take a medication that goes throughout their body. They want to just use a vaginal estrogen. So we have that. That's a great option. When you're using estrogen that goes through your body, about 50 % of people will get a good level in their vagina, but some people won't. But from a take home standpoint, there is absorbing through the skin or through the vagina, and there is taking it by mouth. And we believe that absorbing it through the skin has the lower risk risk of blood clots. So that's why what people need to learn is the first-line therapy for menopause is transdermal estradiol.

You mentioned pellets a couple of times. What are those?

So pellets are implants that you go to a medical doctor or a nurse practitioner. And I think maybe even in some places there's naturopaths who insert them. I don't really know because I'm not really involved with it. Maybe they don't. I'm not sure. They can either have estrogen, they can have estrogen and parenostrum. Maybe they have other hormones, and they don't really know. They're made in compounding pharmacies and they're implanted. They're not batch tested, so you don't know how much hormone you're getting. My understanding of it is it's based on a proprietary system. So you get your blood drawn, they follow your hormone levels, and then they decide when you get the next pellet based on that. But we don't recommend hormone levels for giving hormone therapy. It's not based on levels, it's based on symptoms. I don't need I don't even know what your estrogen level is if you're 47 and starting it. I don't even need to know what your estrogen level is when you're 42. I only need to know that if I'm worried that you have premature menopause. This system, it's not recommended. There have also been issues with pellets with complications and side effects not being reported to the FDA, which is also another concern.

We don't actually know how many people have problems versus pharmaceutical companies when they get adverse events reported, those are passed on to the FDA because there's big penalties, my understanding, for not doing that.

Is the pellet a delivery mechanism?

Yeah. It's an implant that sits in the body because I don't do it. I don't really know much about it because it's not recommended. I don't know that much about it. But what can happen is it can produce very high levels of hormones, and then it drops off. In some cases, you can be exposed to the levels of testosterone that we might give someone if they're transitioning. The kind that can cause you to develop an enlarged clitoris, the kind that can cause you to develop these changes from having too high of a testosterone. We don't know when you're using those hormones, then how much progesterone to give you to protect your uterus. So there's all different kinds of issues associated with them, and they're very expensive as well. So they're just not recommended.

Do you have to have your blood drawn to have this assessed effectively? No. No.

If you're 45 years or older, you do not need a blood test to get started on menopausal hormone therapy. If you're 11 and having a growth spurt, no one's like, Oh, why are you having a growth spurt? We should check your blood. We would expect you to have a growth spurt at age 11. If you had a growth spurt at age 3, that would be different. And that's the same thing for menopause. So if you're 45 or older and you're having hot flashes, you're having vaginal dryness, you're having irregular periods, it's not a mystery. We're expecting it to happen. The average age of menopause is 51, right? However, it's happening to you when you're 39, well, that's It's different. We need to know, is this an earlier menopause or is this happening for another reason? If you're under the age of 45, you need the blood work because you need to make sure that you understand why your periods have stopped. Now, if you're just having hot flashes, that's a different story. The bloodwork is really if you've skipped periods. Say you're 42, you haven't had a period in three months, you need to have bloodwork because we should figure out why that's happened.

But if you're 45 and you're having bad hot flashes and you've had a couple of irregular periods. That was me. That's no mystery. You're starting in the menopause transition. Right if the the average age of onset for the menopause transition is 45, well, you know what? 50% of people are going to be younger than 45, and 50% of people are going to be older. So it has to be put in context. The internet wants absolutes. The internet wants, test my hormones, don't test my hormones. The internet wants this or that. But medicine is more nuanced than that. And so the The only absolute I can say is if you're younger than 45 and you've skipped more than two periods, then you need to have bloodwork done because we need to know why. Is it an earlier menopause? Is it another condition that's caused your periods to stop? If you're 45 or older, it's not a mystery why you've gone two months without a period.

That makes a lot of sense.

One thing that we didn't talk about is one of the contraindications for starting estrogen is being more than 10 years from your last period or over the age And so in general, that is associated with an increased risk of dementia and an increased risk of cardiovascular disease. We want to avoid starting it when people are older now. It doesn't mean like age 60, if you're 60 years on one day, that that's like a hard stop. But I think it's just important for people to understand that there's a a timing. If somebody, for example, their last period was 55, we might not cut them off at 60 because there might be a bit of wiggle room there. But in general, we recommend if people are going to start hormones, that it's going to be within 10 years under the age of 60. That's the ideal situation and the lowest risk situation.

I can't believe I didn't know this. In fact, I can't believe how much I'm learning from you today. I thought I knew a lot about this topic, but you're just constantly amazing me with new information. I know as you listen, you're thinking the the same thing. We also need to take a quick break to hear a word from our sponsors because they allow me to bring you world-class expert advice from the amazing Dr. Jenn Gunther. So do me a favor, listen to our sponsors, and please take a minute and share this episode with someone who needs to hear this. This could truly change their life. Don't you dare go anywhere, because when we come back, I'm going to be waiting here with Dr. Gunther, and you're going to hear more on how to deal with your symptoms. Plus, how to talk to your loved ones so that they better understand what you're going through, and how to talk to your doctor so you get the care that you deserve. Stay with us. Welcome back. It's your friend Mel Robbins. I am here with Dr. Jenn Gunther. So Dr. Jenn Gunther. One of the things that I'm sitting here thinking about is the fact that my friends and I all talk about menopause, right?

Because we're all in the thick of it. But more than half of the women that I know are scared of HRT. I know it's because of the fact that I think it was 1991 when there was that huge study that was released. I think it was the Women's Health Initiative that cast HRT in a negative light. If I really think about it, it was 1991. I was just out of college and my mom was going through menopause. I remember the huge debate was that HRT causes cancer. It cast such a negative light on this therapy that's available for women to treat menopause symptoms. I understand that the study has been harshly criticized. It's now 30 years later, but it's very clear to me that the fear that it created, it's still lingering and it's keeping a lot of women from even exploring hormone replacement therapy as a safe option for them. Can you tell us more about this study and how you think about it as a medical doctor?

Well, the Women's Health Initiative was the largest clinical trial. I think that's ever been done. It It was designed to tell whether hormone therapy, menopausal hormone therapy, was going to actually reduce the risk of heart disease and without increasing the risk of breast cancer. Also, there were other arms that looked at exercise eyes that looked at calcium replacement. There are quite a few different arms of the Women's Health Initiative. The arm with estrogen plus... When it was Premarin, that was used. Premarin plus progestin. That was stopped early because they reached the threshold of concern about breast cancer. Now, going into the Women's Health Initiative, we knew that there was a very low risk of breast cancer associated with menopausal hormone therapy. So this wasn't like a surprise. It was the threshold that was reached. It was communicated to the public in a way that is typically not done. Usually, there aren't press releases when a study is halted. Usually, we wait, we get the data, the article is published. So It's peer reviewed, and we have all of that. That didn't happen. That created this big hoopla, where lots of things got taken out of context, lots of things accelerated in ways that were uncontrollable because fear sells.

I don't know how many major news stories were dedicated to the WHI, but it was really out of proportion. Then when more information came out and when there were more studies that came out, that never gets the same attention. We know that estrogen plus a progestin is associated with an increased risk of breast cancer, but those aren't the hormones that we typically prescribe now. That's the difference. We believe that the progestins, which are slightly different molecules than progesterone, carry the higher breast cancer risk. It's still acceptable and in the safe range to take that the hormone progesterone is lower risk, and that if you don't need a progesterone or a progestin that that risk is the lowest. So I would say to people, if you're taking a transdermal estrogen and oral progesterone, which is our standard starting therapy, we believe that the risk of breast cancer is very low. It's not probably zero, but that it is very, very low. We believe that if you're taking estrogen alone, that risk is even lower. Some people believe it's zero. Other people believe it may be a little bit higher. And again, it depends how you look at the data.

So absolutes are very difficult. And so the risks are very low. So if you're somebody suffering with hot flashes, if you're somebody who is at high risk for osteoporosis, if you're someone who's struggling with depression in the menopause transition, if you have things that estrogen can treat, then those risks are likely very small in comparison. However, if you're at someone at very high risk for cardiovascular disease, then estrogen may not be the best therapy for you. And so it really comes down to an individualization. But I would say for the majority of people who are suffering with symptoms related to menopause, who have things that hormone therapy can treat, that menopausal hormone therapy appears to be a very, very safe option. You just have to look at it in context. If you're somebody who is at higher risk for cardiovascular disease, but not super high risk, then transdermal is probably okay, but oral isn't because there's a higher risk of blood clots associated with oral. You just have to look at what is it going to do for you. I'm very high risk for osteoporosis. My mother died from osteoporosis. I have quite a high FRAX score, which is a risk calculator.

That's the main reason that I'm on menopausal hormone therapy, because my risk of osteoporosis is pretty significant, and I'm already getting closer and closer to osteoporosis of osteopenia. It's It's a concern for me from a health standpoint. That's why I'm taking it. People always want us to say zero risk. Getting a car has a risk. I always like to not talk in those kinds of absolutes and say, what's the reason you're on it? And what is the risk-benefit ratio for you? For the majority of people, the risk-benefit ratio is absolutely going to be in the favor of benefit. But there are some situations where it might not be. So for example, somebody at very high risk for cardiovascular disease, someone who's previously had a blood clot, someone who's previously had a heart attack. So you have to put it in perspective.

Thank you for that because, Dr. Gunther, I've been really surprised by the number of my friends who are suffering through menopause and perimenopause and just completely the quality of their life is impacted who have been afraid to try hormone replacement therapy or even talk to their doctor about it because somewhere in the back of their head, they think it causes breast cancer, and that's why they're not even considering it. And so I appreciate you just clearing the air a little bit so that people know that you should at least go talk to your doctor about it.

Yeah. And there are calculators that can help you determine your breast cancer risk, right? So I would recommend, I think we heard it was a Olivia Munn, who was talking about, I believe that's who it was recently talking about, she had a breast cancer risk assessment, which led to her having an MRI, which led to an early diagnosis of a breast cancer. And so there's all kinds of... There's several easy tools that we can do to help explain things more in context for you. If somebody comes to me and they have something that menopausal hormone therapy can help, I do something called an ASCVD score. It calculates your cardiovascular risk. We need your lipids and we need your lipids, and we need to know your blood sugar your blood pressure and a few other things. And so we can calculate that. I need to see a mammogram and I need to ask you some questions about your breast cancer history risk. That's important because at a certain level, when your breast cancer risk is higher based on other factors, there's also a conversation to be had about medications that lower your risk of breast cancer.

So there's bigger discussions to have. But so you can do these risk calculators and you say, look, well, I'm somebody who's got hot flashes. Menopausal hormone therapy is a gold standard. I have low There's no risk for these other reason, so there would be no reason not to go on it. But again, everybody weighs risks differently. And so versus you're somebody that you've got a pretty high cardiovascular risk. So can we talk about one of these other treatments for your hot flashes? Or you're somebody who's got a history of breast cancer. So can we talk about one of these other medications for hot flashes?

I want to ask a couple more questions about HRT. So someone listens to this episode. They They feel very seen and validated. They go into their OB-GYN. They say, I want to assess the risks. And let's just say you try it. Okay, you make the personal decision with the recommendation of your doctor should go on the standard protocol. How do you know if it's working?

Well, so are your symptoms improving? So it's really, except for- And how long does it take? Pretty quick. So Unless you're someone like me taking it for osteoporosis prevention, because I don't feel any different, right? And that's, again, a really important reason to take an FDA-approved medication because I wanted to protect my bones. I need to know what I'm absorbing, right? So If you have hot flashes, most people see a pretty significant improvement within four weeks. Depending on how much better people feel, sometimes we might give an eight-week try before switching doses. It just depends on how people feel on the medication. Usually with something like hot flashes, you're going to see an improvement pretty quickly. With depression, usually within a couple of months as well. There So I always like to talk about with menopausal hormone therapy, there's green light indications, meaning these are like the FDA approved solid reasons. Hot flashes, night sweats, gold standard. Osteoporosis prevention, FDA approved. And if you have, and we didn't talk about this, but if you have menopause before the age of 45, we do recommend everybody take hormones regardless of symptoms until at least the average age of menopause.

And then at that average age, you can decide if you want to stay on or not like everybody else.

What is the average age of menopause?

Fifty-one. But so say you're starting it for... So you've got these green light indications, great. Everybody believes that the benefits outweigh the risks as long as you're in the right category for that. Then there are more yellow light indications, things where it hasn't broached, where it's recommended in the guidelines, but there's pretty good data to support it. So for example, depression in the menopause transition can be very helpful for that. Many of us would try it if somebody's got a sleep disturbance, even if they don't think they're waking up with hot flashes, because sometimes people don't wake up. But what it's doing is it's disrupting your sleep architecture, so you don't have as much deep sleep. So it might be worth a try to see. For example, I still get the occasional hot flash, but even when I was, I don't wake up, but I'm so hot, I wake my partner up. I'm just a super deep sleeper, but I've still had disrupted sleep. So you might not realize that. So it might be worth a try to see. The data for joint pain, it's not really that great. I mean, maybe it's going to help 20 % of people with joint pain, so it wouldn't mean it would be wrong to try, but it would be...

You just want to... If it doesn't work, you're not going to keep pushing the dose higher and higher and higher because you're like, Well, it was a chance, and maybe it's going to work, maybe it's not. There's some evidence to show that it may reduce your risk of type 2 diabetes. So again, if you're somebody at very high risk, that might be a conversation to have. Those are like these yellow light indications. And then if you have brain fog. So brain fog, specifically, there aren't studies to tell us that estrogen treats brain fog. And in fact, people perform better than they think when they have brain fog, so on cognitive testing. So it's this symptom that we don't really understand. So you could certainly have brain fog from depression, right? You could have brain fog because you're not sleeping well. So all of these other things could come into play. But if your only symptom were brain fog, then I might be like, it's less clear you're going to get a benefit from that. And maybe there's a discussion to have about what might be the other factors. But if you've also We've done a depression questionnaire, you're scoring higher for depression, well, brain fog is a symptom of depression, too.

So let's get that treated and let's see. Then let's also work on the other foundations, like exercise and eating healthy, because there is one study that looks at the healthy things you're supposed to do in menopause, get your right exercise, eat a fiber-rich healthy diet, and not smoke. I think it was only 8% of women did all three.

Wow. Why is it that there is so little information about hormonology Cone changes and menopause? You go to your doctor and it's like, Oh, well, you're going to deal with this for about 10 years, and then that's just the way that it is. What is up with this?

If you go to PubMed, which is basically Google for healthcare professionals, which is where it's like a repository of medical studies, and you put in the word pregnancy, you'll get about 1.1 million articles. All important. Great stuff, right? It's important that we have healthy pregnancies and we deliver children in a healthy way, et cetera. When you put in the word menopause, we get 94,000 articles. We only get 10% of the funding. That means 10% of the brainpower, 10% of the research for the last third of our lives. We do live a little bit longer than men, but we're going to spend 20% of that in poor health, in decline, in disability. This is avoidable.

I hear the word menopause, and I think out to pasture, you're done.

I thought that for a long time, too. Then I'm Gen X. You know what? To hell with that. I want to live a good life. I want to feel like I can go to the gym, I can play with grand babies, I can roll on the floor, I can climb a mountain, I can run a company, I can do all these things. I'm refusing to just accept the medical definition of getting older for a woman, which is very different than a man. When we're born, we have about a million plus or minus eggs. From birth until we die, we're slowly losing that egg count, and it starts accelerating as we get older. By the time we're 30, we're down to about 10% of our egg supply.

Well, hold on a second. By the time you're 30, you've already lost 90% of the eggs that you were born with? That's correct. I don't know why I never knew that. I feel dumb that I've gone through 55 years of my life, and I did not know that we're down to about 10% At 40, 3%. 3% at 40?

3%, 3%, mm-hmm.

Wow. You lose your period because you have no more eggs, so there's no more need to go through that cycle.

You can't ovulate. Yeah. There's nothing left. Holy cow. But doesn't it make sense now?

Of course it makes sense.

Why it's harder to get pregnant when you're older, why you're more likely to have a chromosomal abnormality, because the number and quality of your eggs is declining with age. What happens for females is that our The endocrine system, especially the ovaries, age at twice as fast a rate than the rest of our body. The endocrine system is where our hormones are created. All of our estradiol, our progesterone, and about at least half of our testosterone is created in those ovaries every single month, every single day. However, when we get to perimenopause, things start changing. When we get to full menopause, we have no eggs left. The ovaries decline. We're losing our ovaries at the average age of 51. They stop producing sex hormones. We basically are forced to live the last third of our lives without the benefit of estrogen, progesterone, and about half of our testosterone.

I get this at a level, but I've never understood this before. Because when you really just put it in the context of you're born with a million eggs, and from the moment you start your menstrual cycle and the hormones are going up and down, there is a purpose associated with the design of your body. And once that stops, everything gets disrupted in your body. Why has nobody studied this? What the hell?

People are studying it. When we look at OB/GYN, the residency. And that's what you are, right? Yes. I'm OB/GYN, women's health. Super proud of what I learned in my training. Pediatric, gynecology, gynecology, oncology, surgery, babies, fertility, all this stuff. Menopause got shoved in this tiny little box. She's going to have a few hot flashes and maybe some vaginal dryness. Her bones might get a little weaker And that's it. We only want to give her estrogen. If she can't tolerate anything else, if nothing else is working, then fine, give it to her. But you might kill her.

Wow.

Our body's thrived on this hormone for 50 years, 51 years on average.

And by this hormone, you mean estrogen?

Estrogen, and testosterone, and progesterone. We were living our lives managing our stress, managing our weight, doing all the things. And then all of a sudden, you can't put your finger on it, but something's changed.

That's exactly what everybody says. And whether this is happening to you or you've heard your sister or your mother or your partner say this, we start going, I'm doing the same stuff I've always done. My pants are not fitting. I am grouchy. Suddenly, I feel like I have ADHD or brain fog or dementia. I don't feel like myself in my body.

You are every single patient who comes to my office. This exact same story.

What would you, as a gynecologist, do when a woman would come in, as they did for years and years and years before you became one of the world's leading experts in this? What would you do as a doctor?

I'll tell you a story away from my training. We had gynecology clinic in residency, and I was an intern. We had OBS divided into two sections. In gyneclinic, we had the surgical cases coming in. All the residents would line up, like six or seven of us, and the upper levels would run for the surgery cases because they want to operate. Us, interns, would be left with whatever was left. They'd be like, Oh, you got a WW.

A WW?

A WW in Room 12. Good luck with In a WW, this wasn't written in the chart. My professors never said this. This was Laure handed down from an upper-level resident. You can do it with a Texas accent because that's where I trained. These guys in cowboy boots walking up and down the hall, You got a WW in Room 12. Good luck with that. It meant whiny woman. Here was this woman coming in, and this was a public health hospital. She's desperate. She can't sleep. She's gaining weight. She's not happy. She's having maybe headaches. Mistakes. Just this laundry list of very vague complaints. But she was still having periods. Maybe irregular, maybe heavier, maybe lighter, maybe... You were like, It's just part of aging. If she came in complaining of libido, I was a deer in the headlights. I didn't know what to tell her. We were taught nothing about the female sexual response or medications that might help or go out and have some wine, relax, get a new boyfriend. All the other complaints, I start sending her to other specialists. Let's go see a cardiologist for the palpitations and a neurologist for your headaches.

She'd walk out of my office with six referrals, and I didn't know enough to say, Let's try some hormone therapy and see if these things get better. I'll do some blood work. Let's make sure it's not autoimmune disease or hypothyroidism. I was doing that. I just think back on that and that we can do so much better. We got to do a better job training every single healthcare professional in all specialties about how special menopause is and what the lack of estrogen is doing to each and every organ system. Each female has a unique expression of our menopause. Where you may have had palpitations, frozen shoulder and dry vagina, I would have had hot flashes night sweats and horrible rage. Doctors like a checklist of symptoms. It's how we're trained. Recall. But we're trained to look for ducks. How does it? Is it walk like a duck, talk like a duck? It's a duck. Everyone's duck a little bit different.

You mentioned that every organ in a female body-Yes. Every organ system, yeah. Every organ system has receptors or has what for estrogen?

That's where the research is really exciting right now, is that Duke University did this elegant study looking at frozen shoulder, which is adhesive capsulitis, so common in women, especially in menopause. Finally, a woman, head of an orthopedic surgery department, talked to the woman, head of an OB-GYN department at a big university, and they're like, Something may right. They did the studies, and they showed that women on hormone therapy have a lower chance of frozen shoulder. They pulled all the data, and they're like, Why would that be? Why? Then now they're going in and doing biopsies of all these joints and saying, There's tons of estrogen receptors here. When we lose that estrogen, we're seeing mass. It's an anti-inflammatory hormone in the bones and joints. We have arthralgia, joint pain, capsulitis, all of this stuff tremendously flares. Some of your listeners are like, Oh, my God, right now, I had frozen shoulder. So really, really common, or hip pain or joint pain, or you can't roll over in the bed. It's so painful. And you have no injury.

I'm sitting here feeling one revelatory, Oh, my God, oh, my God, oh, my God. There are times in bed where I am laying there and I will go to roll over, and it's as if I have to prime my myself over I'm so stiff. Wow. That makes so much sense, actually. If the estrogen receptors are in your organ system, that then presumes that it's impacting liver function, kidney function, everything.

Lung function, heart function, brain function, genital urinary function, as we know, bones, osteoporosis, we've forever. That's a no-brainer.

Wow. And so I want you, as you're listening to Dr. Haver, to just really think about this for a second. That every single aspect of your organ system, from your brain to every organ to your muscles, all of it is used to functioning with estrogen. It makes so much sense. If you take out one of the main ingredients to the female body's optimal health, of course everything is going to go haywire. How do you know if your hormones are out of whack? And what role do hormones play in your gut? And I would love to selfishly focus on women, if that's possible.

Listen, you said that you had a chance to go down to the Ultra Wellness Center and see our docs. Not everybody can come see us. Yes. So this is why I write book after book after book to be how to manuals to help you identify where your problems are and what to do about them. And in the Young Forever, I have a whole series of quizzes that aren't fancy tests. They're literally just questions you answer and you get a score and you go, Oh, wow, my hormones are out of whack, or my detox system is not good, or I'm way inflamed, or I have magnesium deficiency, like those questions I just rolled off what your symptoms would be. So it's pretty easy to identify what's going on. Now, women in particular have way more complex hormonal history than men. Men go through andropause, and they lower their testosterone. That sounds weird.

Andropause?

Yeah, it's male menopause, basically.

And what happens when dudes go through male menopause?

They get low libido, sex drive, trouble having erections, lose a muscle mass, get a little more soft and round. Basically, that's what happens.

And grumpy because of those things. And grumpy.

Low motivation, a little depressed. But with women, they go through puberty, and then they have their teenage cycles, and then they have their 20s cycles, and their 30s cycles, and there are 40 cycles, and then 50s. So it changes every decade. Women have changing hormones, and everything happens from PMS to irregular cycles, to heavy bleeding, to PCOS, to PCOS, to perimenopause, to menopause. And So there's no one prescription for all of it. But essentially what we do know is that just like everything else we talked about, the things that cause imbalance in our body that we listed off, the food stress, toxins, et cetera, and the ingredients for health are also influencing our hormones.

And what role do hormones play? So if we had to just even get more basic. What are hormones? No, I'm serious because I think we throw around these terms, but I personally am like, well, what role does the hormone play?

Hormones are like the communication command and control centers in your body.

I thought the neurotransmitters were.

They are regulatory pathways that affect your brain a lot, and they do work on areas of your body. But in your brain, you have something that's like a command center. It's called the hypothalamus. Okay. This is like a radio traffic control on an airport.

For those of you who are not watching this on YouTube, I want you to know that Dr. Hyman is pointing right between the eyebrows. And I think the reason why we all get that scrunchy wrinkle right there is because that is the command center.

It's a little bit inside. I can't quite touch it because it's inside my head. Okay.

What's it called again?

The hypothalamus.

Hypothalamus.

And that's controlling our sex hormones like estrogen, testosterone, progesterone, and so on. It's controlling our stress hormones like cortisol. It's controlling our hormones that have to do with a growth hormone. There's thyroid hormones. All these hormones are controlled by this command and control center. Okay. And so what happens, particularly with women, is that they not only have trouble with their sex hormones because of all the stresses and toxins and everything in our life, but the also thyroid problems are really big and often underdiagnosed. And then you get insulin, which is becoming out of balance as you get older.

Is insulin a hormone?

Insulin is a signaling hormone, peptide made by your pancreas. Okay. And that regulates blood sugar and insulin. I mean, blood sugar and your body. But it also, when it's out of balance and you eat too much sugar and starch, you get this increasing belly fat and weight gain, and that's caused by insulin. And then there's stress hormone, it's cortisol. So women are subjected, particularly as they get into their 30s and 40s to this imbalances in sex hormones, thyroid hormones, stress hormones, and blood sugar control hormones, insulin. And those are like the four horsemen of the Apocalypse when they got out of balance. And so functional medicine, you don't have to treat each one separately. If you do the basic things, you get your lifestyle sorted out, you eat right, you exercise, you learn stress reduction techniques, you get enough sleep, you take your basic supplements, you get rid of all the crap in your life as best you can. Your hormones will reset. You don't actually have to treat them directly. Now, sometimes you do if women have menopausal stuff like terrible hot flashes or vaginal dryness or whatever. But if you're drinking-Check, check.

What about the thickening in the middle? That's the one that's bothering me now. I'm I'm not down with that. No, that's not good.

No.

He just looked down to see the thickening in the middle. I saw that.

But that's the insulin part. That's the blood sugar control.

So what do I do? Because I'm getting so many people writing about this, too, because I've been talking about it. I'm like, this is not fair. I have stopped drinking. I have the healthiest lifestyle I've ever had. I exercise every day. I eat the three quarters of the vegetables, clean protein. I get outside in the morning. I'm doing it all. Check, check, check, check, check. What the fuck is going on?

I I mean, definitely hormones change. So sometimes there's things to tweak. Sometimes there's ways you can modify your diet a little bit or exercise a little differently to regulate this. But it's checking what's going on. Maybe your thyroid is a little off, or maybe your insulin is a little higher than you think and you have more insulin resistance, or maybe you need to increase testosterone because that gets lower, too, and that increases muscle mass and body fat loss. It's like a symphony that you have to be a conductor and make sure it's all playing in, too.

The visual I got was Whac-a-mole. The second I hit the insulin correctly, the other thing shoots up.

No, it's not like that. It's not like that. It actually all works the other way. It's actually when you treat the root causes, then everything gets better.

Hey, it's Mel. Thank you so much for being here. If you enjoyed that video, by God, please subscribe because I don't want you to miss a thing. Thank you so much for being here. We've got so much amazing stuff coming. Thank you so much for sending this stuff to your friends and your family. I love you. We create these videos for you, so make sure you subscribe.