Hormonal Health with Dr. Howard Liebowitz: Rational Wellness Podcast 115
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Dr. Howard Liebowitz discusses Hormonal Health for Women with Dr. Ben Weitz.
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Podcast Highlights
4:10 Why shouldn’t women simply go through menopause and let their hormones decline naturally? Dr. Liebowitz argues that hormones are about procreation and when women are no longer able to procreate, they hit menopause and their female hormone production shuts down. When this happens, their health starts to decline, as if mother nature is tossing women out the window. Dr. Liebowitz feels that bioidentical hormones are not just for alleviating night sweats and hot flashes and brain fog, but also for preventing the heart disease, insulin resistance, high blood pressure, autoimmune diseases, and even the incidence of cancer that tends to occur in women after menopause.
6:26 Women who take bioidentical hormones starting in perimenopause or menopause are better able to maintain their bone density, their metabolism, insulin sensitivity, and are better able to maintain optimal weight. Dr. Liebowitz said that he’s seen bone densities improve in women on hormones without any bone density drugs, just good diet, exercise, and hormones. Their bodies continue to function like a younger woman’s body would.
8:56 Dr. Liebowitz noted that thyroid hormone tends to decrease in women with age and they may need to add thyroid hormones as well. If your thyroid hormone is low, your other hormones don’t work very well. Dr. Liebowitz pointed our that to accurately assess your thyroid status, you should not just rely on measuring TSH levels. If you have elevated levels of reverse T3, which is an inactive form of T3, you can have an underperforming thyroid with a normal TSH. He recommends running the total T3 and the reverse T3 and a healthy ratio should be between 10-14. If this ratio is too low, even if the TSh is normal, then this can be a problem. Dr. Liebowitz said that he also likes his patients to measure their basal body temperature to assess their metabolism and their thyroid function. This is done by putting a thermometer under your arm pit immediately upon rising. Normal basal body temperature should be 97.8 degrees or higher. He likes his patients to test it over a 7 to 10 day period, and if it averages too low, this patient may benefit from taking thyroid hormone, esp. if they have symptoms of low thyroid.
12:25 Dr. Liebowitz does not like to use Synthroid, which is a synthetic form of T4, and he thinks that Synthroid should be taken off the market. He starts his patients off with dessicated porcine thyroid, like Armour, and he likes the fact that these products contain T4 with some T3.
13:29 Some doctors and patients are fearful of women taking hormones after menopause since the 2002 Women’s Health Initiative study, the largest randomized clinical trial done on hormone replacement therapy, found that women who took estrogen and progesterone had an increased risk of heart attacks, strokes, and breast cancer. Dr. Liebowitz explained that this study used estrogen that was extracted from the urine of a pregnant horse–Premarin, along with Prempro, a synthetic progestin, which do not have the same effects as using bioidentical estrogen and progesterone, which are believed to be much safer. Also, this study included a subgroup of women who had had hysterectomies and were not given the progestin, had a lower risk of breast cancer and heart attack: A Reappraisal of Women’s Health Initiative Estrogen-Alone Trial: Long Term Outcomes in Women 50-59 Years of Age. In addition, Dr. Liebowitz noted that in the group taking estrogen plus progestin, they did not cycle the progestin 2 weeks on and 2 weeks off like what happens with natural progesterone levels. In addition, the Women’s Health Initiative did not start women on hormones until approximately 10 years after menopause, and the most protective way to take hormones is to start right around the time of the onset of menopause or during the perimenopausal period. These women do the best.
16:46 Dr. Liebowitz said that he prefers to prescribe bioidentical hormones that are extracted from wild yams, which are chemically identical what the human body makes. He usually recommends the estrogen in a transdermal cream or a pellet implanted under the skin. This form of estrogen does directly into the bloodstream and avoids the first pass through the liver, which happens with oral forms of estrogen, and which can increase clotting factors and could increase the risk of stroke. The only hormone it is safe to take orally is progesterone and he will have women take a progesterone capsule once a day for 14 days and then not for 14 days. At that point, he has women continue to take estrogen and testosterone. Throughout their lives, except during pregnancy, women have their progesterone cycle on and off and this leads the body to slough off the uterine lining, which is healthy and reduces the risk of endometrial cancer. If you give progesterone continuously, you make women pseudo-pregnant and when women are pregnant, they tend to have high blood pressure and insulin resistance and gain weight and have a higher risk of stroke. The downside of prescribing cyclical progesterone is that a woman is likely to get her period back, which most women would rather avoid. Dr. Liebowitz acknowledged that is the biggest argument to the cyclical use of progesterone, but he said that since he doesn’t replace the hormones to the levels they were when the women were younger, they may have a very light period or no period at all.
22:26 Dr. Liebowitz prefers to use estradiol, since estriol is not absorbed that well transdermally, though he will use vaginal estriol. He used to use a Biest pellet containing estradiol and estriol and that worked very well, but he hasn’t been able to find that formulation anymore, so now he usually uses mostly estradiol. Henoted that he usually recommends the women he treats to take 6.5 mg of iodine, which has been shown to help convert the estradiol into estriol, which is a more protective estrogen and women with good levels of estriol tend to have less breast cancer. By the way, the amount of iodine in a multivitamin is typically 150 mcg, which is not enough for this benefit.
25:25 Dr. Liebowitz also often recommends testosterone for menopausal women because it stimulates their libido, helps their brain, helps with energy, it’s a neurotransmitter, it helps with bone density, it helps with metabolism, it helps with maintaining muscle, it helps women to exercise better, and it even reduces the risk of breast cancer. So testosterone is very beneficial for women and also very safe.
27:02 For women who complain about vaginal dryness and atrophy, Dr Liebowitz finds that the best thing is to raise their levels of estradiol and monitor the FSH levels. He recommends giving enough estradiol to drive the FSH levels down by 50%. If the women he treats still have vaginal dryness, he may add in some vaginal estriol. He has not recommended vaginal testosterone or DHEA. He has not found it helpful to recommend pregnenolone. He does sometimes recommends DHEA for women, which can also be a libido booster for them.
30:19 Dr. Liebowitz typically tests for hormones using blood, but he said that it is important that the testing be done at the right time with respect to the application of the hormones. He admits that these hormones do fluctuate, but he finds serum testing, esp. for the FSH levels to be quite accurate. Dr. Liebowitz also likes to test using a 24 hour urine collection, which allows you to look at hormone metabolites, like the 2, 4, and 16-hydroxyestrone levels, as well as levels of estradiol and estriol, the E2:E3 ratio, which can impact the risk of breast cancer. We can intervene if the E2:E3 ratio is too low, we can have women supplement with iodine, which can help raise estriol levels. And if the 2:16 ratio is off, we can use DIM and Indole-3-carbonol supplements to improve it. In fact, Dr. Liebowitz likes to put all his women patients on DIM and iodine even without testing to lower their risk of breast cancer.
33:39 Dr. Liebowitz prefers the paleo diet for post-menopausal women because it is the diet that we evolved to eat over hundreds of thousands of years this is the diet that allowed us to survive. He does not like his patients to eat soy, because it is a poor quality protein and it is highly processed. Some would argue that the phytoestrogens are protective against breast cancer, but Dr. Liebowitz said that if patients need estrogen, he prefers to give them estrogen and not soy.
38:18 Dr. Liebowitz described his approach to hormone replacement for men and women is that hormones make us healthier. And when we lose our hormones, our health starts to decline.
Dr. Howard Liebowitz is an internal Medical Doctor whose practice is focused on anti-aging, including the use of bioidentical hormone replacement therapy, ozone, and IV vitamins, among other treatment approaches. He is trained in Functional Medicine and believes in the importance of a healthy diet, exercise, and lifestyle. His website is Liebowitz Longevity.com and his office number is (310) 393-2333.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Podcast Transcript
Dr. Weitz: This is Dr. Ben Weitz with The Rational Wellness Podcast bringing you cutting-edge information on health and nutrition, from the latest scientific research and by interviewing the top experts in the field. Please subscribe to The Rational Wellness Podcast on iTunes and YouTube, and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to The Rational Wellness Podcast, please go to … It’s no longer iTunes. Go to the Apple podcast app, and give us ratings and review. That way more people can find out about The Rational Wellness Podcast. Also, if you’d like to see a video version, you can go to my Weitzchiro YouTube page. And if you go to my website, drweitz.com, you can get a complete transcript and detailed show notes.
Our topic for today is hormone replacement therapy with Dr. Howard Liebowitz. Hormone replacement therapy is typically recommended for women after menopause. Menopause is when a woman’s body is shutting off its reproductive capabilities. It’s a sharp decrease in estrogen and progesterone production by the ovaries resulting in a host of symptoms including hot flashes, night sweats, brain fog, mood swings, depression, weight gain, vaginal dryness, hair loss, and fatigue. The technical definition of menopause is when a woman goes 12 months without a menstrual period. The long-term effects of menopause include an increased risk of osteoporosis and of cardiovascular disease. One approach to help women with the symptoms of menopause is to replace the estrogen and progesterone, another hormones that have declined with menopause.
Dr. Howard Liebowitz is an internal medical doctor who practice emergency and trauma medicine for 25 years before training in functional medicine. He worked as a physician at the Pritikin Longevity Center for a number of years. His practice today is focused on anti=aging including the use of hormone replacement therapy among other treatment approaches. Dr. Liebowitz, thank you so much for joining me today.
Dr. Liebowitz: Thank you, Dr. Weitz. I’m happy to be here.
Dr. Weitz: Excellent. So how did you find your way to functional medicine from a traditional medical practice?
Dr. Liebowitz: Well, it was a long journey. At that time I was married and my ex-wife was a gynecologist. And her practice started at the age where she was doing mostly delivering babies and things like that. She started getting interested in hormone replacement as our patients needed it, and I’ve been working the emergency room for 20 or 25 years and was starting to get a little burned out. So I started to tag along with her in some of these conferences. I found them very interesting. And then it led me to the A4M conferences. And one thing leads to another and I started to network with people and meet people. And then I ended up with The Jeffrey Bland IFM Conferences, the Institute of Functional Medicine Conferences. I thought those were fascinating. And little by little, I just gradually got more intrigued and curious about this approach to medicine which was so different than the traditional approach to medicine. And I started to see as we started to treat some people some amazing improvements that you don’t normally get by just writing prescriptions. So I became more and more intrigued by this and curious by this, and it just led me down the path.
Dr. Weitz: Cool. Why shouldn’t women simply go through menopause gracefully? Let their hormones decline naturally, wouldn’t that be the natural way to do things?
Dr. Liebowitz: Yeah. It is the more natural way to do things, and I get this question from a lot of women especially women who particularly want to be “more natural” about it. But the problem with that is that I think mother nature kind of plays a dirty trick on women because hormones for women are all about procreation. And when women are no longer able to procreate, when they hit menopause and their ovaries shut down, a lot of their other health parameters start to decline. It’s like mother nature almost tosses them out the window and says, “Well, you’re not really going to be contributing to society anymore so we don’t need you around,” and their health starts to decline. So it’s not just a matter of dealing with night sweats and hot flashes and memory and brain fog and things like that, we also see an increased incidence of heart disease which is tremendous in women.
Their incidence of heart disease approaches that of men when they lose their hormones and it’s well-known that estrogen can be cardioprotective for women. Their incidence of osteoporosis skyrockets and this is huge problem as women age because the risk of fractures dramatically goes up for them. As well as other things like autoimmune diseases and insulin resistance, and high blood pressure and even the incidence of cancer. If you look at the incidence of breast cancer, most women will get breast cancer in their later years not when they’re young, not when they’re ovulating and not when they’re of reproductive age. It’s when they are beyond the reproductive years that there’s a dramatic increase in the incidence of breast cancer. When I approach women and men for that matter with hormones, it’s not just to get rid of those symptoms which is easy to do. I call that the tip of the iceberg, but it’s really to put women’s health back and help them stay healthier as they age and avoid what I call age-related diseases.
Dr. Weitz: What are some of the benefits that can result from a perimenopausal or postmenopausal women taking hormones?
Dr. Liebowitz: Well, the biggest two I approach is really reducing the risk of heart disease, I think is dramatic, and helping them maintain bone density. And my women who are on postmenopausal hormones and they go on their hormones right around the time of menopause. In other words, there’s not a long gap with no hormones and we’ve monitored the bone densities and I’ve seen women on hormones with their bone densities actually improving without any of the bone density drugs, just good diets and exercise and hormones, maintains optimal health and their bodies continue to function like a younger woman’s body would.
Also, I find that it helps maintain their metabolism and in addition to looking at the female reproductive hormones, I look at all the hormones. So the thyroid plays a big role in there as well. And I keep an eye on that, and replace that as needed but it helps with metabolism as a lot of women start to gain weight as they go through menopause because things happen in the metabolism that slows down and they don’t change their eating habits and they slowly start to gain weight.
Maintaining optimal weight is important because it helps avoid things like insulin resistance and potentially, even adult onset diabetes which can contribute also to high blood pressure and the increased incidence of heart disease. So it’s a whole big sort of approach to general health. It’s not just a one-problem, one-fix kind of an issue. It’s part and parcel to maintaining optimal health as women age.
Dr. Weitz: It’s almost like a whole symphony of different hormones that are all involved.
Dr. Liebowitz: Yeah. I mean, a lot of people refer to it that way, the symphony. You have all these instruments on the stage playing music together and if one of those instruments, say, is represented by a hormone and that one instrument is out, the rest of the symphony doesn’t sound very good, and that’s kind of the way hormones work together. You really need to look at them all. You really need to balance them all because the human body is very complex and you can’t just go in there and fix one thing and expect everything else to be corrected.
Dr. Weitz: Does thyroid hormone tend to decrease with age as well?
Dr. Liebowitz: Yes, it does and it’s very well-known that it decreases with age. And I’ve heard people talking at lectures and things like that where they say that up to 80% of the population as we age are going to end up requiring some hormone supplementation. And the way we look at thyroid hormone today is not even very accurate because a lot of people will only look at the pituitary response called the TSH, the thyroid stimulating hormone. And it’s not always very revealing in terms of what’s going on with the total body thyroid. And without having a good thyroid level, a lot of the other hormones don’t work very well.
Dr. Weitz: So how do you monitor thyroid? What’s the key thing that you look at? What are the key levels that you’re concerned with?
Dr. Liebowitz: There are two primary hormones I like to get. One is the total T3 and the reverse T3. And I look at the ratio of those. So, the total T3 to reverse T3 ratio should be around 10 to 14. And I find a lot of my patients extremely low with normal TSH. So what can happen is your thyroid can start to produce this inactive form of thyroid called reverse T3, and it can help to lower your TSH. So if you’re just looking at TSH, you can miss the boat on a lot of these patients.
The other thing I have a lot of them do is what’s called the basal body temperature. So the basal body temperature is a very sensitive way to check your metabolism. And as our metabolism slows down, our body will run cooler. So checking the basal body temperature over a period of, says, 7 to 10 different readings and then averaging them out, I like to see that they’re in the normal range. Our normal basal body temperature is 97.8 or higher. And if they’re not averaging over that number, that’s a very good indicator that the thyroid is low.
Dr. Weitz: Let’s say you have a woman who averages lower than the normal level on the basal body temperature, but their TSH is, say, I don’t know, three, three and a half, would you consider adding thyroid hormone in that patient?
Dr. Liebowitz: That person sounds like the type of person who would benefit from having some thyroid hormone. And lot of people are afraid of the thyroid hormone but it’s like all of our other hormones. As we get older, hormones decline. It’s just a fact of life. There’s nothing in our body that’s going to be maintained at an optimal useful level when we start getting into a 50s and 60s and 70s. It’s very, very common that these hormone productions are starting to deteriorate. So you put the whole picture together where you look at the numbers, you look at the lab, you look at the basal body temperatures and then there’s a whole list of symptoms associated with low thyroid. And I go through the symptom list with my patients, and you get a feeling for how their metabolism is based on all this information. And then I make the decision of whether they need to be placed on thyroid or not because it’s not a cavalier kind of a decision. It ends up being a lifelong decision to start taking thyroid.
Dr. Weitz: Do you typically start them with a desiccated porcine thyroid product or do you tend to use Synthroid?
Dr. Liebowitz: I never use Synthroid. I think Synthroid should be taken off the market. The porcine, like you mentioned, the desiccated porcine hormones are the best. They’re very similar to our human hormones, and you need to give a T3 product in addition to a T4. The body is supposed to convert the T4 into the active form of T3. Synthroid is a synthetic T4 and many times, it does not get converted to the active form of T3, yet it will lower the TSH. So a lot of patients I see are taking Synthroid and they have a low TSH and their doctors are telling them that they have a good thyroid level but then lo and behold, they don’t because they’re not making any T3.
Dr. Weitz: Getting back to female hormones estrogen and progesterone, didn’t the 2002 Women’s Health Initiative, the largest randomized clinical trial done on hormone replacement therapy show that women who take estrogen and progesterone have an increased risk of heart attacks, strokes and breast cancer?
Dr. Liebowitz: Yeah. This is a terrible study. It was very poorly done and there was actually a subcategory of women in that group that had hysterectomies that they didn’t give the equine progestin to. And actually, that group of women did not have any increased incidence of breast cancer and nobody seems to want to talk about that. But it doesn’t seem like replacing women’s estrogens causes breast cancer. It seems like the combination of using an estrogen and in this case, they’re horse hormones. They’re not even the hormone the horse wants because they come out in the urine so there are metabolite of the horse hormones of the pregnant horse. That’s where the word Premarin comes from. It’s pregnant mare, comes up with the word Premarin.
So these are pregnant horses with metabolic urinary estrogens combined with a metabolic and product of progesterone called progestin, and they took that hormone every day, and they took it orally so there’s a lot of aberration to the protocol that they were using because, number one, women don’t have progesterone every day. They only have it for half of the month. They go on progesterone. They go out on progesterone. So it wasn’t cycled, because cyclical progesterone has been shown to cause cellular turnover so there was continual stimulation of the breast tissue with these hormones the way they were given. And the group that didn’t take the continuous progesterone or the progestin did not have any increased incidence of breast cancer. So to me, it’s a useless study. It doesn’t tell me anything actually. If anything, it encourages us to use estrogen if you do it correctly because there isn’t any increased risk of breast cancer.
Dr. Weitz: Not only that but most of the women weren’t even started on hormones until approximately 10 years after menopause.
Dr. Liebowitz: Yeah. And if we look at when women get breast cancer, it’s after menopause. So these women probably had already started to develop a breast cancer that was very early. It was very undetected and unfortunately, a lot of breast cancer is hormone sensitive. And if you put somebody on a hormone who has already developed the breast cancer, you potentially are going to make that cancer grow. So waiting is actually the worst thing you can do. I recommend women start their hormones right around the time of menopause or even before they hit menopause, in the perimenopausal period. And there are some studies going on that are actually demonstrating that those women do the best, the women who actually start their hormones before they’ve lost their hormones. They sail right through menopause and their body never even knows they hit menopause. We replace it as it’s going down and the body never even experiences that drop of hormone. Those women do the best.
Dr. Weitz: What type of hormones do you prescribe to women who need them?
Dr. Liebowitz: Well, they’re called bioidenticals. They’re extracted from wild yams. The reason they’re called bioidentical is because they’re chemically identical to what the human body makes. And I don’t know why yams make hormones the same as humans do but they’ve been studied and they chemically are virtually identical. The body can’t distinguish one over the other, and if you give those to women, I generally do it with transdermal creams or I used pellets which are implanted under the skin. So these go directly into the bloodstream. I like to bypass the digestive tract because we avoid what’s called first pass through the liver. Sometimes if the hormone goes to the liver in a high concentration orally ingested, it can increase clotting factors and it can increase the risk of the strokes and things like that.
Although I just spoke to a pharmacy today and they were talking about an oral preparation they have that’s a lipophilic formula. And it also is able to be taken orally and bypasses the liver, which I’m just very interested. I just heard about this today, so I’m going to look into this a little more. But most of the hormones we don’t do orally. We do them transdermal creams or pellets under the skin. The only hormone that’s safe to take orally is progesterone. It hasn’t been shown to cause any problems orally, so I have women take a progesterone capsule once a day for 14 days each month. And then the rest of the time they’re using estrogen and testosterone.
Dr. Weitz: So you have them cycle the progesterone?
Dr. Liebowitz: Yeah. They go on it for two weeks and they go off it for two weeks. If you look at normal female hormone patterns before women hit menopause, that’s what their bodies have always done. I have a chart here. I don’t know if you can see this.
Dr. Weitz: Okay.
Dr. Liebowitz: But this bottom line is progesterone and this is estrogen. You can see estrogen goes up. It’s spiked on day 11 and then it dropped right around the time of ovulation. After the woman ovulated in the middle of the month, this is when the progesterone went up. This is the progesterone curve and the estrogen went up again. So both hormones went up and they spiked on day 21, and that was their most fertile time of the month. And if they didn’t conceive around day 21, then from 21 to 28, both hormones drop very quickly and that withdrawal of hormone allow the lining of the uterus to come out. So the menstrual cycle is actually withdrawal bleeding from the hormones declining like this.
But the important thing from this graph you can see is that women only had progesterone for two weeks. They had progesterone for two weeks on and they had no progesterone for the first two weeks. This is day 1 to 15, there’s no progesterone. That’s the way I give women their hormones back. It’s very simple. I just put back what they had before. I can’t recreate the human anatomy, so I just put back what they had before. If you do it any other way, you’re basically creating some entity that doesn’t exist in nature except when the woman is pregnant. So women who are pregnant, they have continuous progesterone and the progesterone sustains the lining of the uterus so it supports the pregnancy.
What you’re doing if you give women continuous progesterone is you’re making them pseudo-pregnant. And they’re going to have consequences from that, so women in pregnancy have high blood pressure often. They have insulin resistance. They gain a huge amount of weight. They sometimes have strokes. I mean, there’s all sort of complications of pregnancy. We used to joke about it in school. We used to call it the disease of pregnancy because pregnancy causes a lot of medical problems and when you deliver the baby, all those problems go away. So if you’re going to give women continuous progesterone, you’re going to potentially recreate the problems of pregnancy.
Dr. Weitz: Now, the downside of cycling their progesterone is that a woman is liable to continue to get her period or start getting her period back again. And a lot of women will tell you that one of the few benefits of menopause is that they stop getting their period.
Dr. Liebowitz: That’s probably the biggest argument I hear to the process I’m doing. But I think when I explained to the women why we’re doing it this way and I showed them that chart, and I explained the physiology of what we’re trying to accomplish, most of them are very happy to accept the consequences of having some type of a menstrual cycle. And a lot of times because I don’t put the hormones back all the way to the level they had them when there were young, they don’t have to have hormones that high. Many, many times the women have a very light period and some women feel really good with the hormone replacement that’s a little lower with no period. But the most important thing is really to put the hormones back in that rhythm. That cyclical rhythm is what the body was programmed for. And regardless of how high or low the hormones are, it’s the pattern of hormones that I think is the most important.
Dr. Weitz: Now, in terms of estrogen, do you prefer recommending estradiol, estriol, or a combination of those two?
Dr. Liebowitz: I primarily use estradiol. But estriol doesn’t go into the skin very well as a transdermal cream. I do give a lot of women vaginal estriol but also it doesn’t absorb that well. And we used to be able to get a Biest pellet which is estradiol and estriol, and that worked really well. I really liked those and I was using those exclusively. But now, the pellet formulations for some reason have changed, and I haven’t been able to find the estriol in the pellets anymore. So the applications are mostly estradiol.
I do recommend women take iodine, and I have them take iodine at fairly good doses because iodine has been shown to help convert the estradiol into estriol naturally in their body. So we tried to do that. Estriol, as you probably know, has been shown to be what we call a protective estrogen. It’s been shown to help lower the risk of breast cancer and the women who have good estriol levels actually have less breast cancer.
There’s a great study done on Japanese women because the Japanese women have the lowest incidence of breast cancer in the world. And the Japanese eat a lot of kelp and seaweed so they have a lot of iodine in their diet, and those women have been shown to have a very low incidence of breast cancer. So iodine as a supplement is what I recommend all women on hormones take.
Dr. Weitz: What level of iodine?
Dr. Liebowitz: I’ve been using about 6.5 milligrams. Their initial study said that the Japanese women eat between 15 and 25 milligrams a day but then I read another study that said that some of these numbers were overinflated and that those numbers are too high and that it’s probably more around 5 to 10 milligrams a day. So I have a preparation from one of the companies that actually makes the thyroid that’s at 6.5 milligrams, and that’s what I have women taking now.
Dr. Weitz: Interesting. So just for people listening who are taking a multivitamin that has iodine in it, the typical dosage found in a multivitamin is 150 micrograms. And you’re talking about 5 to 10 milligrams, so that won’t be sufficient.
Dr. Liebowitz: Yeah, exactly. And a lot of times, people get misinformation. They tell me, “Oh, I have iodine in my vitamin supplement,” but their iodine, what’s the recommended daily allowance which is minimal compared to what’s needed to actually have an impact on estrogen metabolism.
Dr. Weitz: Right. Do you typically recommend testosterone for menopausal women as well?
Dr. Liebowitz: Yeah. Testosterone is a fabulous hormone for women. And I think it’s overlooked by a lot of practitioners because it’s always felt to be a male hormone. But it’s not on this chart that I showed you, but testosterone would generally tend to rise around ovulation which is right around here and it goes up and it kind of follows the progesterone curve here. And the reason testosterone goes up in women is because it stimulates their libido, so mother nature wanted women to be more interested in having sex when she’s ovulating obviously because that increases your chances of conceiving. But we found that testosterone has a lot of other benefits for women in addition to libido. It actually helps the brain. It’s a neurotransmitter. It helps with energy. It helps with bone density. It helps with muscle development and maintaining lean body mass. It helps with metabolism. It helps women exercise better, and it’s also been shown to even help lower the risk for breast cancer. So it’s a fantastic hormone for women and there’s no downside to it. I’ve had women taking very large doses of testosterone with no adverse consequences other than sometimes they would get a little facial hair or acne problems, and that’s very easy to deal with. But it’s a very safe hormone for women and very beneficial.
Dr. Weitz: Interesting. So, for women who are having difficulties with vaginal atrophy and dryness, you mentioned topical estriol. I’ve heard practitioners who use or recommend topical testosterone and there’s even supplements of topical DHEA. What do you think is the most effective for that use?
Dr. Liebowitz: Well, I think the best thing is to get a woman’s estradiol level up. When you replace a woman’s estrogen postmenopausally and you get the level to a good therapeutic level, and I document that by following the FSH. It’s a pituitary hormone. And estrogen will drive down the FSH. So, when I see the FSH reduced, I know that woman is getting enough estrogen. And usually if she’s getting enough estrogen to lower her FSH about 50% from where she’s starting, most women won’t have any more vaginal dryness. They don’t even need anything topically or locally or vaginally. They have enough systemic estrogen like they were when they were younger. They don’t have vaginal dryness when they have good levels of estrogen.
Occasionally, I have women who, for one reason or another, can’t accomplish good levels of estradiol and then I add in some vaginal estriol that they apply vaginally which helps the lining of the mucosa, and sometimes even vaginal estradiol will do it. I have never used DHEA or testosterone vaginally. I accomplish what we need to accomplish usually with estradiol or estriol.
Dr. Weitz: Okay. Do you recommend for some women DHEA and/or pregnenolone?
Dr. Liebowitz: I haven’t been using pregnenolone. Pregnenolone, if you look at the metabolic pathway chart of the adrenal gland hormones, and I actually have a copy of that here too although I don’t know if you’d be able to see it on here. But these are the metabolic pathways of renal glands hormones. You’ve probably seen this.
Dr. Weitz: I have many times, of course.
Dr. Liebowitz: Pregnenolone is way up here at the top. We call pregnenolone the mother of all hormones. So when I give somebody hormones, I like to know what I’m giving them. I like to be able to say, “I’m giving you this for this specific reason.” And when you get somebody pregnenolone, you really don’t know what it’s going to end up. It’s going to go down these pathways and it could go this way, this way, this way. It’s the mother of all hormones and you really can’t control where it’s going.
So I’ve never found it to be particularly therapeutically helpful. I do give women some DHEA sometimes, especially for women who are complaining of a lot of libido problems. I think for women, DHEA can be a good libido booster. It’s also a good libido booster for men although a lot of men because they usually have much higher testosterone, I think the testosterone overpowers the DHEA. And a lot of men don’t feel anything from DHEA. And I think DHEA can be helpful for women, and I have used it. I do use it.
Dr. Weitz: What is the best way to test for hormones, especially while women are taking bioidentical hormones? We have serum. We have the urine. We have dried urine. We have saliva.
Dr. Liebowitz: I like to test primarily with blood. And you need to time the blood test correctly so you don’t get false elevated readings especially when women are on their hormones. So I give my women patients very specific instructions about when to apply the hormones and when to draw the blood tests. But you get criticized a lot because people say, “Well, the hormones fluctuate. The blood tests aren’t accurate.” But if you’re looking at pituitary hormones, if you’re looking at FSH for estrogen and you’re looking at TSH for thyroid, those hormones don’t fluctuate that fast and you can get a very good idea especially with FSH as to how much estrogen these women are absorbing and if they need more or not.
And then the other way that I like to look at hormones which I think is even better is with 24-hour urine collections because those give you big window picture of what hormones look like over a 24-hour period. It’s great for the thyroid and of course, it’s excellent, maybe one of the only good ways to look at the adrenal glands. And then it also very helpful to look at female hormones because you can also see how the estrogen is being metabolized and that it’s being broken down into metabolites that have been identified as being harmful and increasing the risk of breast cancer. It’s nice to be able to see that metabolism because we can intervene, and we can lower the risk of breast cancer by having an impact on these metabolites.
Dr. Weitz: So what would you see that might indicate that a woman has had higher risk of breast cancer?
Dr. Liebowitz: Well, one of the things we look at is the 2/16 hydroxyestrone ratios and then we also look at this. There’s an E2:E1 ratio that we look at. E2:E3 ratio, the E3 is the estriol. And when the estriol is low, you’re going to have very low E2:E3 ratio will be too low and what we try to do is raise estriol. And that’s what iodine does. And then when the 2/16 ratios are off, we use things like DIM as a supplement and we use five indole carbinol. And there are other supplements that we can have an impact on those ratios also. So I get a lot of women … Actually I put women on these supplements anyway even without measuring them because I figure the cost of taking those supplements far outweigh … It increases the benefit of the risk of developing breast cancer. So I think it’s worth it to take these supplements. All my women patients, I put on DIM and I put on iodine just empirically even if they don’t do the testing just to lower the risk of breast cancer.
Dr. Weitz: Interesting. What’s the best diet for menopausal women to follow?
Dr. Liebowitz: Well, I am partial to the paleo diet. There’s a lot of different diets out there these days. I happen to like paleo diet because I like the sort of genetic evolutionary component to it. The theory behind it is that humans evolved hundreds of thousands of years ago and the food that we were eating at that time is what helped make us a successful species and allowed us to survive.
And now what we’re eating is very different. We’re eating a lot of processed foods, a lot of man-made foods. And a lot of our diet changed 7,000 to 10,000 years ago when we went through what’s called the agricultural revolution. So, up until that time, there was no baking and there was no dairy, no cheese, no cream, no milk. So we started eating dairy products and wheat and baked goods only 7,000 to 10,000 years ago and our genes go back hundreds of thousands of years.
So I like to eat a diet that’s more representative of where we were genetically in an evolutionary cycle rather than something more recent. And then although 7,000 to 10,000 years ago sounds like a long time, when you look at that compared to 400,000 or 500,000 years, it’s nothing. It’s a blink. And yet it had dramatic change to the way we eat. So the paleo diet takes us back to that era of eating before the agricultural revolution. And I think it’s a much healthier way for everybody, men and women, to eat. And I try to encourage my patients to follow that as much as they can.
Dr. Weitz: All right. Should women be including soy in their diet?
Dr. Liebowitz: I don’t particularly like soy. I think it’s a poor quality protein, and it’s a highly processed form of protein. You have to extract it from the soybeans and things like that. I don’t encourage it, no.
Dr. Weitz: What about the fact that it has phytoestrogens?
Dr. Liebowitz: Well, if women are needing estrogens, I give them estrogen. I don’t seek out some other random source for it. I go right to what we’re trying to accomplish and just give them what they need.
Dr. Weitz: Yeah. I guess some people have argued that there have been some studies that have shown that women who consume the most soy had the lowest risk of breast cancer. The argument being that these plant-based estrogens, these phytoestrogens glom onto the estrogen receptor sites and block stronger estrogen, so therefore they may decrease risk of breast cancer.
Dr. Liebowitz: Well, there’s a lot of different things that will impact the risk of breast cancer and that’s only one of them. I mean if we look at all the pollutants, the toxins and the insecticides and everything else and all of the toxic exposures, I mean there are so many things I think that really increase women’s risk of breast cancer. And I think that’s just one of them.
Dr. Weitz: Yeah. You’re talking about all the environmental estrogens that are found in these bisphenol A and pesticides and all of these other chemicals that we come into contact with.
Dr. Liebowitz: Plastics and I mean-
Dr. Weitz: Flame-retardant chemicals, Teflon.
Dr. Liebowitz: Yeah. It’s all over the place. And it’s very difficult in our modern day and age to avoid these toxic exposures, it’s impossible.
Dr. Weitz: Yeah, I know. I was reading about these chemicals PFOA and PFOS which are produced when they make Teflon and some of these waterproof coatings. And these companies have been dumping them into the waters and they’re found in the waterways in more than half the states around the country. Recently, there was a report that came out that they’re actually much more dangerous in much lower levels. And we thought they were, so we decided to stop even testing for them. It’s a great response.
Dr. Liebowitz: Just hide our head in the sand.
Dr. Weitz: Exactly.
Dr. Liebowitz: And think the problem will go away.
Dr. Weitz: Yeah, toxic world. That’s why it’s probably a good idea to do some detox from time to time.
Dr. Liebowitz: Yeah, exactly. I agree.
Dr. Weitz: Okay, Dr. Liebowitz, this was really good information. Any final thoughts you want to leave our listeners with?
Dr. Liebowitz: Just in general, I think that hormones get a bad rep. I think there are too many people out there who claim that hormones cause cancer. I don’t think hormones cause cancer. My approach to hormone replacement both for men and for women is that hormones make us healthier. And when we lose our hormones is when our health starts to decline. My approach to hormone replacement is basically just that, is putting back hormones that we had before, putting them back in a way that we had them before and the whole approach and the reason and the idea to do that is because it keeps our body functioning like we did when we were younger and that’s the period of time when we’re the healthiest. My approach to hormones is to replace missing hormones to help us function and stay healthier as we age. It’s very well-known and maybe we’ll do a talk like this on testosterone for men because it’s very well-known that testosterone makes men healthier. And I believe the same thing at some point is going to come out about hormones for women. It just hasn’t been proven yet.
Dr. Weitz: Great. How can our listeners and viewers get hold of you and find out about seeing you or et cetera?
Dr. Liebowitz: Well, they could Google my name. It’s Howard Liebowitz, L-I-E-B-O-W-I-T-Z, MD. I have a website [Liebowitz Longevity.com.]and my name will pop up on the website. It will pop up. I have an office in Santa Monica on 6th street. And that’s probably the best way to find me, is just to Google my name. I do have some YouTube videos like you do, and that’s probably the best way. All the information about my office will be on my website.
Dr. Weitz: Excellent. Thank you.
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