Bioidentical Hormone Replacement with Dr. Maggie Ney: Rational Wellness Podcast 330
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Dr. Maggie Ney discusses Bioidentical Hormone Replacement with Dr. Ben Weitz.
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Podcast Highlights
2:38 Perimenopause and Menopause. Menopause is technically one year since your last menstrual period and the average age for most women is age 51. Of course, there are exceptions such as if you’re on an IUD or have had uterine ablation. Perimenopause is when your cycle starts to change a bit, such as coming a day or two late or early and is the time basically leading up to menopause. You might notice that you can’t handle stress as well as you did and you don’t bounce back as quickly from stressors. As we get into later perimenopause, you might notice your cycles skipping. You start getting hot flashes and night sweats and vaginal dryness. There are over 40 different symptoms that have been attributed to perimenopause and menopause. There is a huge emotional piece, including depression and anxiety. Other symptoms include insomnia, joint pain, muscle twitches, worsening headaches and migraines, burning tongue, burning skin, and itchy skin.
8:46 The Women’s Health Initiative Study first published in 2002: Is Hormone Replacement Therapy Dangerous, Increasing the risk of breast cancer, heart disease, and stroke? A lot of women are now afraid of taking hormones because they think that they will have an increased risk of breast cancer. And a lot of doctors are still afraid of prescribing hormones because of this study. But this is a mistake because there were many flaws with this study. To begin with, the average age of the women in this study who were starting to take hormones was age 63, which not when most women start to take hormones. 70% were overweight and 60% were obese and a lot of them were past smokers and had hypertension. The estrogen used was an oral form of conjugated equine estrogen (Premarin) and synthetic form of progesterone known as a progestin (Provera). There was a group of women who did not have a uterus, who were given only estrogen/not progestin and they actually had about 18% less breast cancer, so clearly estrogen does not cause breast cancer. Dr. Ney feels that this study has done irreparable harm for a generation of women and 21 years later we’re still trying to educate women and doctors about bad hormone replacement therapy. (Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women’s Health Initiative Randomized Controlled Trial. JAMA. 2002;288(3):321–333. doi:10.1001/jama.288.3.321)
16:24 Relative risk vs absolute risk. In the women who took the Premarin and Provera they had a 26% increase in breast cancer and this sounds like one in four women got breast cancer. But this was the relative risk. The absolute risk is that after five years 9 extra women per 10,000 were diagnosed with breast cancer, which comes out to about one out of every 1000 women who got breast cancer, so the absolute risk is one in a thousand and not one out of four.
19:30 Dr. Ney’s favorite recommended options for hormone replacement therapy includes the FDA-approved options for estrogen, including a patch, a gel, a spray, or the Femring. Dr. Ney usually starts with estradiol in the patch form. And then she usually recommends a bioidentical progesterone in an oral, micronized pill form, such as Prometrium. You can also recommend hormones made from a compounding pharmacy that are typically in a cream, though while estrogen works well in a cream, progesterone works better in a pill. She used to use the BiEst cream, but not as much any more. She is also not a fan of pellets since if the dosage is too high, you can’t remove them.
Dr. Maggie Ney is a licensed naturopathic doctor and a Menopause Society certified practitioner. She’s the director of the Women’s Clinic at the Akasha Center for Integrative Medicine in Santa Monica, California, where she has been supporting women through perimenopause and menopause since 2006. Dr. Ney is co-founder of HelloPeri, (TheHelloPeri.com) an online resource for women going through perimenopause, and she’s been featured on The Doctors show and Goop for expertise on women’s health and hormones. Her website is DrMaggieNey.com.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting-edge health information. Subscribe to the Rational Wellness Podcast for weekly updates. And to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.
Hello, Rational Wellness podcasters. Today, we will be discussing bio-identical hormone replacement therapy with Dr. Maggie Ney. Today, we’ll be discussing the potential benefits and drawbacks of recommending hormone replacement therapy in postmenopausal women. After menopause, women often experience a number of symptoms, including hot flashes, night sweats, sleep problems, vaginal dryness and atrophy. Postmenopausal women also have an increased risk of heart disease and osteoporosis. It was common for MDs to prescribe hormone replacement therapy prior to the Women’s Health Initiative, which in 2002 reported that postmenopausal women who take hormone replacement therapy have an increased risk of heart attack, strokes, and breast cancer. After the Women’s Health Initiative study was published, most MDs stopped prescribing hormones to postmenopausal women. However, additional analysis of this study has led quite a number of doctors and researchers to conclude that these conclusions may only apply to women who take estrogen derived from horse urine and synthetic progestins, and who don’t start taking hormones until an average of 10 years after menopause. We could probably add some more caveats to that as well.
Dr. Maggie Ney is a licensed naturopathic doctor and a Menopause Society certified practitioner. She’s a director of the Women’s Clinic at the Akasha Center for Integrative Medicine in Santa Monica, California, where she has been supporting women through perimenopause and menopause since 2006. Dr. Ney is co-founder of HelloPeri, an online resource for women going through perimenopause, and she’s been featured on The Doctors show and Goop for expertise on women’s health and hormones. Dr. Ney, thank you so much for joining us.
Dr. Ney: Thanks for having me. I’m happy to be here.
Dr. Weitz: That’s great. Before we get into hormones, perhaps we could define a few of the terms like perimenopause and menopause.
Dr. Ney: Absolutely. Yeah, there’s a lot of confusion, especially since I’ve been really diving into perimenopause and talking about it more. A lot of people are like, “What the heck’s that?” So, menopause is technically one year since your last menstrual period, and the average age for most women is around 51 years old. But again, that definition of one year without your period is tricky if you don’t have a uterus or if you’re on an IUD or uterine ablation. It gets a little confusing if you don’t have your period as a barometer. So, in that case, there’s certain lab testing, and we go by symptoms to determine if you’re in menopause. And specifically if you’re curious and you’re not getting your period, generally two readings of an FSH over 35 and an estradiol under 30 or so are pretty confirmatory that you’re in menopause. So, technically menopause is one day, right? It’s one year since your last menstrual period. Everything after that is considered post-menopause. I consider it the menopausal years because post-menopause gives this idea and perpetuates this myth that menopause is over, and maybe we’ll talk more about that. But it’s really you’re living the rest of your life in these post-menopausal low hormone years, and that can have different symptoms and affects everyone a little differently. And then, perimenopause is the time basically leading up to menopause. It’s around menopause when hormones start to shift. They start to shift, and it can be very subtle. And it can last for some people a decade before your final menstrual period. And I see perimenopause as this just forgotten, neglected time for women where women are having all these new symptoms that they haven’t had before. And then, they see their healthcare practitioners who aren’t really aware that these hormonal changes can be affecting their health, and women feel unheard, and maybe they’re referred to a psychiatrist, a gastroenterologists, a neurologist. I have so many people who’ve had all these specialists, cardiologists, and really it’s this perimenopausal year.
So, it’s like my mission, it’s my joy, it’s my passion to share this so that every woman is knowledgeable and empowered as they enter this time. And I should say some of the major symptoms of perimenopause, the main ones are your cycle starts to change a little bit. And again, I divide perimenopause into early and late. So, early perimenopause, maybe you’re starting to notice your cycle coming a day or two early, or you might be noticing a big one is feeling less resilient, right? So, the stress you used to be able to handle a lot and now it just becomes too much. You don’t bounce back as quickly or stressors that you used to be able to manage now just feel very overwhelming. And then, as we get a little later into perimenopause, you might notice your cycles are skipping. You’re getting more hot flashes and night sweats, vaginal dryness. But really, there’s over 40 symptoms attributed to perimenopause and menopause, and it truly does affect everyone differently.
Dr. Weitz: Maybe you can highlight a few that are often overlooked.
Dr. Ney: Yeah. Really, the emotional piece is so huge. So, depression, anxiety, I mean, 70% of women going through the menopause transition have some mood change that’s significant. And about 60% of women who have a history of depression will have a recurrence. So, a lot of the mood symptoms, the inability to sleep. So, insomnia may be the first symptom to come up, but there’s other ones really, because there’s estrogen and progesterone receptors all throughout our body. So, joint pain, you can get tingling. I have someone with muscle twitches, worsening headaches, worsening migraines, burning tongue, burning skin, itchy skin. There’s a long list.
Dr. Weitz: So, on perimenopause, is progesterone the first hormone that really drops, or is it estrogen?
Dr. Ney: Yeah. Really, we consider progesterone to be the first hormone to begin to drop during a perimenopause. And so, some of those symptoms can be a little bit more anxiety, difficulty sleeping, but also some more spotting or earlier menstrual bleeding, like your period coming a day or two early.
Dr. Weitz: Okay. Yeah. Because you mentioned measuring estrogen as a way to know if you’re in perimenopause. What about measuring progesterone?
Dr. Ney: So, I was speaking before about if you’re unsure if you’re in menopause and you’re not getting your period.
Dr. Weitz: Oh, if you’re in menopause. Oh, okay.
Dr. Ney: Okay. Testing for hormones, again during perimenopause is a little tricky because hormones do naturally fluctuate.
Dr. Weitz: Yeah, they’re going all over the place.
Dr. Ney: Yeah. You don’t need a blood test to diagnose you as being in perimenopause, which again, controversial. I mean, controversial in the sense that some doctors are like, “Oh, your labs are fine. You can’t be perimenopausal because you can have normal looking labs.” But again, there are certain times of your cycle that if you’re really trained in this, you can test and get an idea of where someone is. But with the perimenopause, you got to take with a grain of salt because you can know from one cycle to another cycle, it can be vastly different. So, if you’re looking, you asked about progesterone, typically, we would want to look about a week after you ovulate, which is generally a week before you expect to get your period. You can check your progesterone levels and you want to see it around 10 or above, and you can really confirm ovulation. Sometimes during perimenopause, that will be lower like seven or eight or five. You can tell you ovulated, but the production of progesterone is low. But really with perimenopause, while labs can be helpful and useful, it’s your story. It’s your symptoms, and it’s working with a trained clinician who can really help guide you through this.
Dr. Weitz: I talk to a lot of women that are afraid of taking hormones. They think they’re going to have an increased risk of breast cancer, and a lot of doctors are still not okay with prescribing hormones. So, what did we learn from the 2002 Women’s Health Initiative? Is taking hormones going to increase a women’s risk of breast cancer, heart disease, and blood clots?
Dr. Ney: All right. We learned a lot from the Women’s Health Initiative, and I will share just a personal story that the summer of 2002, which is when the Women’s Health Initiative results were aired. I remember where I was… I don’t know if you remember this then, but it was the summer before I started medical school. I was sitting on my mom’s bed. I think I was watching Days of Our Lives and TV was interrupted. This was the age when we interrupt this television show for an important word from your network. And it was someone standing up there saying Women’s Health Initiatives stopped short. There’s a higher rate of breast cancer, heart disease, stroke. It was scary. And I remember sitting there and being like, “Thank goodness I’m going to naturopathic medical school. I can learn about all these other therapies.” So, as I was diving into this and looking at the research and following the research, we really know now that there were a lot of flaws to that study. We can spend probably hours unpacking it, but let’s get started a little bit to what’s most relevant.
Prior to the Women’s Health Initiative, most doctors were giving hormones because they were noticing women were doing really well. They felt really good, and it seemed like there was less heart disease and women were living longer, but there were no double-blind placebo controlled study. And came the Women’s Health Initiative that started in the late ’90s, and it was the first double-blind placebo controlled study looking at hormones. So, very big deal. It was stopped short a little bit after five years because of a higher incidence of breast cancer, heart disease, and stroke. Obviously, big deal. This announcement, I should say, came out before any doctor really had a chance to look at the study, but it did irreparable harm and for a generation of women, we’re still trying to educate women and doctors about bad hormone replacement therapy. So, basically when we look at the study, there were some flaws in hindsight, like people criticize the study. I mean, I think there were a lot of good things we learned about hormones, a lot of the benefits we talk about hormones come from this study, but you got to look at where there were mistakes and errors.
So, first of all, because they knew that hormones really did help with symptoms like hot flashes and night sweats, and they were mostly concerned of like, “Hey, people are doing great. They’re living longer, they have less heart disease. Does it really do this?” So, the average age of participant was much older. Most women did not have any symptoms. So, the average age was about 63, which is not when most women start hormones. And then, if you look at a little bit more detailed, a lot of the women, like 70% were overweight, 60% were obese, where a lot of them were past smokers. A lot of them had hypertension. So, there were some preexisting cardiovascular conditions to begin with. And again, most women were older. And then, you look at the forms of the hormones used. So, the estrogen was an oral estrogen. It was conjugated equine estrogen, often labeled CEE or Premarin. And there were two groups to this study. There was this group of women that had a uterus and a group of women that did not have a uterus, because we learned before this study that if you give estrogen alone to women with a uterus, you’re increasing their chance of getting uterine cancer. But when you give progesterone, or progestin or progestogen. Progestogen is this umbrella term that encompasses progestin, which is a synthetic progesterone and a progesterone. But they discovered if you gave a progestin that uterine cancer, that risk is negated. So, it’s back to baseline.
So, they had a group of women who had a uterus. They were given Premarin, which is the conjugated equine horse urine metabolites of estrogen. And they were given Provera, which is an oral progestin, which really is not used much today. And the other arm of the study was just given Premarin. A little after five years, they saw that there was a higher incidence of breast cancer. So, more women were being diagnosed with breast cancer in the estrogen and progestin arm, not in the estrogen only, which below people’s mind. So, I’m going to say it again. The women who just took the Premarin actually had about 18% less breast cancer. It wasn’t the estrogen that we know. Estrogen does not cause breast cancer. So, you look at the arm that did have, it did show a little bit more, and I say a little. I’m going to go into how the media took the data and really went wild with it.
Dr. Weitz: Now, let me just challenge you a little bit, not from that study, but to some of the women’s fears about taking estrogen is they’ve also heard that there’s estrogen receptor-positive breast cancer. And we also know that giving drugs to block estrogen is often a treatment for women with breast cancer.
Dr. Ney: Yes, true. Very good point. And that makes a lot of sense intuitively. Well, if you’re taking a drug to block estrogen, why would give estrogen not cause an issue? Breast cancer is very complicated. A lot of variables are involved, and certainly there are breast tumors that grow in the presence of estrogen. So, giving estrogen would cause that tumor to grow, which is one argument of why perhaps the tumors were showing up maybe a little earlier because maybe it was being diagnosed earlier, but estrogen doesn’t cause the tumor to grow. But if you had a tumor that grew in the presence of estrogen, it could stimulate its growth. So, what they found in the arm that took estrogen, the Premarin and the Provera, was that there was about… sorry, there was a higher incidence of breast cancer diagnosis, not death, but diagnosis. So, that stopped people short. And we also found in both groups that there was a higher incidence of heart disease and stroke. So, in unpacking, let’s talk a little bit about breast cancer, because we know that with the Premarin only, there was a reduced risk. And with the estrogen, the Premarin and Provera, there was a slight increased risk. So, when we look at that arm, then it seems logical it was the Provera, the synthetic progesterone, and we know that Provera isn’t as breast or metabolically friendly as our bioidentical or oral micronized progesterone. That’s one leading theory that why there was more breast cancer. The other one, and this is Avrum Bluming who wrote Estrogen Matters, great book, but he talks about how in the control group, so the group that didn’t have any hormones, but that was comparing to the people who took the Premarin and Provera. The people in that group actually had a history of taking hormones. So, their baseline was actually lower. And when you take that into consideration, there wasn’t…
Dr. Weitz: Oh, interesting.
Dr. Ney: Yeah. Isn’t that fascinating?
Dr. Weitz: Wow.
Dr. Ney: So, those are the two leading theories that it was the Provera or both, that maybe the control group had a lower risk to begin with.
Dr. Weitz: Interesting.
Dr. Ney: So, the news came out, 26% increase in breast cancer. Whoa, that sounds a lot, right? It sounds like one in four women got breast cancer. Again, when we look at the data, we have to look at how the research and data is being presented. And there’s this idea of absolute risk and relative risk when we’re presenting and looking at research. And we know from the Women’s Health Initiative, and at least that 26% increased risk of breast cancer that was on every newspaper and every newscaster, which sounds to me and everyone else like it’s one in four women was the relative risk. The absolute risk is the actual number. And it was after year five, nine extra women per 10,000 women that were diagnosed with breast cancer. So, that comes to about one out of 1000 women. Every patient counts. That’s something, one person per 1000.
Dr. Weitz: But it’s not one out of four.
Dr. Ney: It certainly sounds a lot different than one out of four. So, it’s the relative risk, absolute risk that really needs to be looked at when we’re interpreting data.
Dr. Weitz: And we also know that oral estrogen tends to lead to blood clots, which is why very few functional medicine, integrative doctors are recommending oral estrogen. And yet I still see oral estrogen. Often when primary care doctors, or when conventional doctors do recommend hormones, they typically use an oral estrogen still.
Dr. Ney: Interesting. Yeah. If they’re going to use oral, they’re usually not using Premarin anymore. They’re using oral 17 beta-estradiol or bioidentical estradiol. We know that oral estrogen from the Women’s Health Initiative does increase risk of blood clots. When you take oral estrogen, like one out of 1000 women extra cases of blood clot is significant because when you take oral estrogen, it has to be metabolized through the liver. And when it gets metabolized through the liver, it creates more clotting factors that increases your risk. I do always use transdermal. There’s a few cases when oral because transdermal isn’t working. We might try oral. For the vast majority of women that have no health history, had no heart disease who’ve been pregnant, who’ve maybe been on a pill and have never had a clot, it actually could be okay. But because you can be on hormone replacement for the rest of your life, and risk of clot does increase as you get older, why start? It’s the way I see. If it was a short term, and for some women it is, but for most women, it’s a lifelong journey of being on hormones to optimize their health for women. So, if it was a couple years and oral was, they want it because it’s easy, it’s cool. But because it’s a long time, I prefer just getting people started on the transdermal route and there’s a lot of options.
Dr. Weitz: So, what are your favorite options?
Dr. Ney: Well, I educate. I really do. I think this education piece for women about what their options are is not often given. We always use bioidentical hormones. I should say that bioidentical hormones for many conventional practitioners, it’s cringey. It causes this emotional reaction because they’re like, “It doesn’t even mean anything.”
Dr. Weitz: I just had a whole discussion with my primary care doctor about that. It doesn’t really mean anything. I said, “Yes, it does.”
Dr. Ney: And they’re like, “It’s a true medical definition.” Bioidentical, that term came after the Women’s Health Initiative, and it came out as like, “You’re not using those. You’re using something safer and more natural.” And that led to more compounding pharmacies and some pellets. Anyway. So, the definitions, no one really knows what it means, but I’ll tell you what it means. When we are using it, it’s hormones that have the same molecular structure as our own hormones.
Dr. Weitz: Conjugated equine estrogen is completely different.
Dr. Ney: Completely different, yet it bind to the same receptors, but it has a different response in the body. So, bioidentical hormones, and this is important that I think is often confused. There are FDA-approved bioidentical hormone options that you can get through any pharmacy. And then, there’s compounding bioidentical hormones. I educate people on both, and I think what I see most is that a lot of women think you can only get bioidenticals from compounding pharmacies. They do do compounding. I mean, you can but you can also get it from your CVS or Rite Aid or Costco. There’s options. So, the FDA-approved options for estradiol can come in a patch, can come in a gel, can come in a spray, and can come in a ring. And then, usually, the bioidentical progesterone can come in as an oral form, oral micronized progesterone. And then, there’s some combination patches that have the transdermal estradiol combined with a progestin, so not the bioidentical, but usually which one of the progestins, like levonorgestrel. I’m blanking on the other one, but a progestin combined with the bioidentical estradiol.
So, those are the FDA-approved, and then there’s a ring called Femring that delivers bioidentical estradiol. So, you can get all those from your regular pharmacy. Compounding pharmacies, again, can deliver the estradiol and progesterone in various forms. I am a promoter of oral progesterone rather than the creams for the uterine protection. It works really well. It also helps more with sleep and the nervous system response because of its increased production of, or stimulating the GABA receptors. But compounding estradiol, it can come in a lozenge or cream, comes in many different forms.
Dr. Weitz: So, what’s your favorite form of estrogen to use? And a lot of doctors who use compounded typically are using the Bi-Est which is a combination of estradiol and estriol.
Dr. Ney: Yeah. I usually start with estradiol. I usually like the patch, to be honest with you. It’s well tolerated. It’s covered by insurance, and it’s been really easy for my patients. So, that’s usually what I’ll start with. I’ll usually start with the patch and Prometrium or oral micronized progesterone. These are the FDA-approved hormones. I usually start with that. I don’t do as much Bi-Est. I used to when I first started out, did more Bi-Est. I don’t anymore. It’s more harder to… first, I don’t know if it’s really needed to add in that estriol. I think our body can convert estradiol to estriol with good liver function. I think estradiol is the one that has the most potent effect in the body.
Dr. Weitz: Well, the other reason for recommending the Bi-Est is with the idea that the estriol is a weaker estrogen, and maybe it makes it even safer.
Dr. Ney: Exactly. That’s the argument for the Bi-Est. It can be harder to titrate because if you want to go up a little bit, then you’re upping… sometimes estriol can be at a higher dose. It might be too much. So, I don’t tend to go to Bi-Est, but it is an option. I have people who want it, and I discuss pros and cons. And I certainly have some patients that are on it, for sure.
Dr. Weitz: Okay. So, you like the patch. What about some of the other forms? What about pellets?
Dr. Ney: I’m not a fan of pellets personally, because I see the woman in my office that come in with side effects. They come in with their testosterone in the 200 range. It really should be under 70. And they’re irritable and they’re angry and their hair is falling out, and they have acne. And I can’t do anything about it, really. I can support their liver. I can give them emotional support, but you really have to wait those about three months. I know some people really love pellets. It’s not something that I recommend because there is, I feel a lack of safety data. And you’re getting super physiological doses of these hormones. How do you feel about pellets, Ben?
Dr. Weitz: I think as you said, the problem is once you put the pellet in, if it turns out that it’s too much, there’s nothing you can do about it until it takes three months or so. So, I think it’s a problem. I guess some women like the pellets because they don’t have to apply the cream. They don’t have to worry about taking a pill every day. You just forget about it. But I think if you are going to use pellets, you probably need to start low and slowly build it up. But who wants to wait?
Dr. Ney: Yeah. I just don’t do it. I don’t like giving something that I can’t reverse quickly. A lot of women on pellets actually don’t know that there are other options that that’s not really an FDA-approved option. Yeah, it’s something I don’t feel comfortable doing. I’ve talked to women. I was just at a talk this last weekend and some doctors on it and promoting it. It’s something I just don’t feel comfortable. And you know what? My patients feel amazing. I don’t feel like I’m missing something in my toolbox to help people feel sensational. My women feel amazing doing something safe and studied and feel good about that.
Dr. Weitz: So, when it comes to progesterone, there’s normal fluctuations in progesterone, and typically progesterone is higher for two weeks out of the month, and so some doctors feel that you want to try to duplicate that natural rhythm of the body. So, they’ll give women progesterone for two weeks instead of every day. What do you think about that?
Dr. Ney: Let’s divide it up into perimenopause and post menopause. So, yes, our natural cycle has progesterone that’s being produced two weeks out of the month. So, it does make sense. Why don’t we just dose it and match the cycle? That intuitively makes sense. I do present that to women as an option because for the uterine protection, you really need it for like 12 days out of the month minimum. A lot of women actually love their progesterone. They’re sleeping better. They want to take it every night, in which case police take it. I usually give people the choice to see what resonates with them. You give women good information, they tend to are able to make the decision that feels right to them. So, I usually present it as both. There’s no studies… I do, I am research-based. There is no studies that say taking it two weeks out of the month is better than every day. So, I do present the option. For some women, that idea of cycling, it really resonates with them. For other women, they actually don’t like progesterone. A small percentage of women do feel worse on progesterone, in which case they want to take it for the fewer days of the month. So, that’s an option.
Dr. Weitz: One of the downsides is you get your period back, right?
Dr. Ney: No. You don’t, because we don’t dose estrogen high enough. You have to go really high in estrogen to really get your period back. But there is maybe a more chance of spotting, right?
Dr. Weitz: Spotting. Okay, I see.
Dr. Ney: Yeah. Certainly if you’re finding that you’re spotting, we would definitely do it nightly to prevent that from happening. But the dose we use for hormone replacement, technically it’s called MHT, menopause hormone therapy. Because those doses are really quite low. And then, in perimenopause, again, I get the option. Sometimes cycling it can help elongate that luteal phase the last two weeks. You take it for a full two weeks, it can help stretch that cycle out. It can help prevent spotting. I often find that because the cycles are a little irregular, it gets to be annoying for people and confusing of like, “When do I start? When do I do it? Do I stop? I got my period three days early.” So, I usually will say, “Totally fine. You can take it every day or just don’t take it during your bleed week and then start taking it.” It can be a little confusing during perimenopause when your cycles are irregular to cycle it, but some people do and they really like that.
Dr. Weitz: Now, for women who are taking estrogen and progesterone daily, do you periodically give them a week off?
Dr. Ney: Again, individualized, not routinely. If they’re getting their periods, sometimes we’ll say, “You can stop the hormones that week,” for some women, but you just certainly don’t need to.
Dr. Weitz: Yeah. I guess the concept is because hormones normally fluctuate and now you’re taking the same identical level of hormones every single day by not taking it for a week, or somehow you’re producing something that’s more natural.
Dr. Ney: Right, that’s the idea, really mimicking our body’s natural cycle. So, yes, you could take that bleed week off. You can then start up with estrogen and then add in progesterone for the second half of your cycle. Again, I do discuss that as an option. A lot of women just feel so much better on the hormones, so they want to take it, and I think it’s safe. The research is daily. It doesn’t show any difference in safety data. But I understand that idea of matching the cycle resonates with a lot of women.
But I should also say, and especially during perimenopause, we can have worse symptoms when our estrogen levels drop like headaches, worsening hot flashes, and some of that happens on the first few days of your cycle, in which case sometimes for women who get that headache during perimenopause right before their cycle, a little transdermal estrogen getting into your period can actually be really helpful because it just gets cuts that keeps that. It’s the drop in estrogen for many women that trigger a headache. And that happens before your periods. You give a woman a real low dose estradiol level during that drop and some of the headaches can go away.
Dr. Weitz: Do you have any women just taking progesterone only?
Dr. Ney: Totally, yes. Both during peri and post menopause, I like to stagger in producing hormones so women can know how it’s affecting their body individually. So, generally during perimenopause, especially early perimenopause, sometimes progesterone is all you need. I have a lot of women just on progesterone. If they have heavy menstrual flow, spotting, insomnia, the progesterone can be all you need.
Dr. Weitz: What do you think about a woman in her 70s take who wants to initiate hormone replacement, either because they’re still having hot flashes or they want to prevent Alzheimer’s or they’re still having trouble sleeping?
Dr. Ney: Yeah. Unfortunately, there’s a massive group of women who were really denied this option. And now with more education coming out with having more women talking about it, we were like, “What the heck? I missed out. I want it.” It’s a different conversation. It’s a different conversation than what I’m having with you because right now, I’m going to answer your question, but I’ll step back and say what we know is that when you start within the first 10 years of your last menstrual period, or generally before age 60, women have less risk of heart disease, less risk of diabetes.
They live longer, 30% longer perhaps because of the less risk of heart disease, which is the number one killer of women. And what we know, and even the research with brain health, it’s really about starting early because of two theories, the timing hypothesis, which is like there’s this optimal window of starting, which is why I’m so passionate about educating perimenopausal women. So, they have all the information before they sometimes even get to the point of needing it because there is this optimal… hormones are good for you when your cells are healthy, when your vasculature, it’s healthy.
It’s called timing hypothesis. So, you want to start within the first 10 years of menopause, or healthy cell bias, which is like hormones are good when your cells and vasculature are healthy, but they can start to potentially lead to symptoms when you go longer without your body seeing hormones. So, the conversation is definitely different if I’m talking to a 70-year-old woman. By that time, we know that hormones can actually increase your risk of strokes. And the data is a little nuanced, but it seems to not be as good for brain health. And I think it all just comes down to the vasculature.
Estrogen is so good at keeping our blood vessels buoyant and helping produce nitric oxide, and then when you go a long time without seeing estrogen, they can develop more plaque, which naturally happens with age, get a little harder. And then, it seems that when you introduce estrogen later after that 10-year window, instead of the normal anti-inflammatory effect, it has more of a pro-inflammatory effect. It shakes things up a little. The vessels are like, “Ooh. What’s going on? Hello? They haven’t seen estrogen in so long.” And sometimes those little plaques can be chipped off a vessel and can lead to the strokes or heart attack. The risk is not huge.
Dr. Weitz: Yeah. I did hear somebody discussing the concept that plaques might become softened and unstable as a result of introducing estrogen.
Dr. Ney: Yes. I will say the risk is highest in the first year, and then it doesn’t just increase the longer you take hormones. I think it’s the first six to 12 months that the risk of an adverse effect like that happening. So, it’s a different conversation. The benefits aren’t as big, the risks are greater. I really believe in shared decision making. I give my opinion. I go over all the research, and together we make a decision that feels right for the person. When they understand risks, benefits, women can make the best decision for themselves, and I support them.
Dr. Weitz: Yeah. Dr. Dale Bredesen, who’s a neurologist, who’s pioneered a functional medicine integrative approach to preventing and reversing Alzheimer’s, is finding that using hormone replacement even in, women in their later years initiating it then can be very helpful for brain health.
Dr. Ney: Yeah, no, I’ve heard that. I’ve heard from him. And yeah, estrogen does help brain cells neuroplasticity. He’s really pioneering that.
Dr. Weitz: Right, yeah. Let’s see. For women who never took hormones, but they want to do something about the vaginal symptoms, the dryness, the atrophy, what do you recommend for that?
Dr. Ney: Okay, such a good question. So, under talked about and appreciated in the medical community, well, there’s a few options, but I’m just going to say vaginal estrogen is good for all women. Every woman will experience changes in their vulva, vestibule, vaginal tissue. It can affect the bladder. Sometimes if a woman’s only having those vaginal symptoms, then you can give local estrogen. There’s a lot of options.
Dr. Weitz: Estradiol, estriol.
Dr. Ney: Yeah, either one. Let’s go through the FDA and the compounding, I definitely use both here. The FDA A approved, there’s a vaginal cream, which works beautifully. I would like to share with people. The general recommendation is to insert it vaginally. I always have people put it on the outside too. That’s what’s so great about the cream is you can massage it into your labia and your clitoris, your urethra, and it really can be beneficial. So, there’s estradiol cream, very low dose. There is tablets that you can insert vaginally. Again, that doesn’t always address the outside.
So, sometimes if someone doesn’t like the leaking with the cream when they put it inside, I’ll have them do the tablet inside and the estrogen, the cream on the outside. There’s a ring, Estring, which works, set it and forget it. You put it in for three months and take it out. And that’s the local one. There’s the Femring that’s systemic estradiol, but the Estring is local estradiol. Again, even with that, I still will encourage people to put a little cream on just the outside. And there is now FDA-approved form of DHEA.
Dr. Weitz: Right. I was going to ask about that. Yeah.
Dr. Ney: So great. So, our vaginal tissue is loaded with estrogen, testosterone receptors.
Dr. Weitz: There’s even one DHEA vaginal product that’s over the counter.
Dr. Ney: I know, I heard actually. I think you had someone on your podcast.
Dr. Weitz: Yes, yes, yes.
Dr. Ney: And I was, “Oh, my God. What is that product?”
Dr. Weitz: Fiona McCulloch.
Dr. Ney: Yeah. She was talking about… I got to find that. I know that also there’s a doctor who sells a cream that has a DHEA in it. So, there are some over the counter options. So, what DHEA does, some people are drawn, well, sometimes DHEA, the androgen, which is considered, and androgen is to DHEA, testosterone. It’s considered the male hormones which is just wrong because women have plenty of it and need it. But sometimes that works better for women. Women need that, they respond better. So, the DHEA vaginally gets absorbed and then the cells makes estrogen and testosterone.
Dr. Weitz: Yeah, it’s Bezwecken DHEA Cubes.
Dr. Ney: Okay, amazing. How much DHEA is in there?
Dr. Weitz: B-E-Z-W-E-C-K-E-N.
Dr. Ney: Amazing. Do you know how much DHEA does it say is in there or they just say it? We can look later.
Dr. Weitz: Yeah, it’s cocoa butter, DHEA, vitamin E, beeswax.
Dr. Ney: Yeah. Some nice soothing ingredients. The one that’s FDA-approved is 6.5 milligrams. You do it nightly. There is also an estradiol insert, it’s with cocoa butter too, so it can melt a little, address the outside. Those are all FDA-approved options. Compounding, you can get that estriol. Estriol again, is that hormone we talked about that’s a little weaker.
Dr. Weitz: Yeah, it looks like 13 milligrams of DHEA.
Dr. Ney: Oh, okay. All right.
Dr. Weitz: There’s also a vaginal testosterone.
Dr. Ney: Yes. Not over the counter? I mean. I prescribed it through-
Dr. Weitz: Yeah, not over the counter.
Dr. Ney: Yes. Through compounding pharmacy, it can be so helpful for women that test their, it’s really the lower third of our vaginal canal is just loaded with testosterone receptors, and so adding that to a little estradiol or a little estriol, you do have to get it compounded, can be such a powerful therapy to address the dryness and sexual discomfort. Because really, no woman should have to go through that, and it doesn’t have to be this normal part of aging. There are so many options. Also, increased urinary tract infections, which we see with women during this time can be due to the lower estrogen. So, really supporting that is important.
Dr. Weitz: And hyaluronic acid can also be beneficial for lubrication.
Dr. Ney: Yeah, so hyaluronic acid helps to retain moisture, so it can be very helpful and you can get through a compounding pharmacy. You can compound estriol with hyaluronic acid. It’s a nice addition. It works beautifully.
Dr. Weitz: Okay, cool. So, how do we track hormones? What’s the best way to test for hormones?
Dr. Ney: Let’s break it up into peri and post. During perimenopause, our hormones fluctuate so much that you don’t really, I mean, I always do get a baseline, but you don’t need to, I should say get that baseline because they do change so much. And you can go by symptoms and see how a woman feels. But generally, if you want to get an idea where your hormones are at the second or third day of your cycle, you can get a hormone panel. Generally, progesterone will be low there. I see so many women are like, “Look, I have no progesterone. Help me.” And I’m like, “This was done on a part of your cycle when you don’t make any.” I can’t tell how many times.
I even have to correct doctors on that. So, you do hormone second, third day. That’s because that FSH, that follicle stimulating hormone, that’s the time of the cycle where if there is decreased egg quality, egg reserve, or you’re approaching perimenopause, that FSH starts to increase. So, generally, if your FSH is above 10 on that second or third of your cycle, you can assume you’re in this process. But next cycle, it could be normal. Another cycle, it could be super high. It does fluctuate a lot. And then, in post-
Dr. Weitz: And the best day to test to manage progesterone?
Dr. Ney: It’s generally a week after you ovulate or a week before you expect to get your period. So, if you have a 28-day cycle, generally like day 21, 19, 20, 21, 22 is that window where you can look at progesterone. And you can confirm ovulation, which is really helpful because some women don’t know if they’re ovulating. So, that’s an easy test to do.
Dr. Weitz: And we have different ways of testing hormones. We have serum. We have blood spot. We have urine. We have saliva.
Dr. Ney: Yes, we do. And I think every practitioner feels strongly or maybe not about this or has their test they really like. I tend to do blood. It’s easy. They have solid reference ranges. There’s pros and cons. I know that saliva can look more at the bioavailable hormone. The urine test, which I’ll use sometimes, looks at how you’re metabolizing hormones. But I’ll say in my clinical experience, because I’ve been doing this for 18 years and I’ve dabbled with all of those tests, I really find that listening to someone’s story, getting them feeling amazing, getting them on hormones, I don’t need it in their out-of-pocket expenses. And I know that people will argue with this with me.
I’ve had big discussions with people that I should be doing the DUTCH tests on everyone. But if someone’s feeling amazing and I can assess like breast tenderness, any of these symptoms that suggest that I need to really dive deeper. Sometimes if I’m reaching obstacles for someone feeling sensational, really, maybe I’ll do it to see what’s going on. But overall, I can learn a lot from symptoms. I understand some of the therapies that might be used, if you push down the two, the 16, the four pathway to support COMT. You can gain so much from someone’s story.
I just don’t want to devalue that and their symptoms and the dose you’re putting on someone that I often find that I just don’t need it. And some people want it because they’re so educated. They listen. They know what it can provide, and we do it. And I can analyze the test. But I haven’t found, for me personally, that it’s been a game-changer that I’ve needed it to really help people get to hormonal balance. I do look at the gut microbiome. That’s huge. So, yeah, I usually do blood unless I really am like, “What’s going on here? I’m reaching this obstacle.” Then I may do one of the more functional tests. It’s covered by insurance. It’s pretty easy. I do let people know everything. Again, I do a lot of educating, let people know of all the tests. I don’t get a lot of pushback. People feel good. People feel good.
Dr. Weitz: So, besides prescribing estrogen and progesterone for menopausal women, do you ever prescribe testosterone, DHEA, pregnenolone, oxytocin?
Dr. Ney: I do prescribe testosterone. I usually start estrogen, progesterone because that can affect testosterone levels and I see how women do, but I will prescribe testosterone. It’s crazy, but it’s not FDA-approved for women, even though it’s such an important hormone for energy, mood, metabolism, brain health, musculoskeletal health, bone health. But it’s not FDA-approved for women. I will recommend it. I do get a compounded. You have two choices when it comes to treating with testosterone. You can use the FDA-approved option for men, AndroGel, at 1/10 the dose. Women don’t like that. It’s confusing. Everyone’s like, “Just get…” I always educate but yes, I’ll usually get a compounded testosterone cream. I do test for testosterone. I do want the baseline, and it is a controlled substance too, so you need that data. But I prescribe testosterone a lot for women. And then, DHEA, yes, I again test and see if they are low. So, generally, if it’s under 100, I may give a little DHEA. It’s one of those things that’s not as well researched. There is some data in animals and elderly that it does increase longevity and wellbeing. It is a precursor hormone. That’s for sure. We know it works vaginally.
Dr. Weitz: Yeah, it was included in that phase study that was the first study that showed a reversal of epigenetic aging.
Dr. Ney: Yeah, it has definitely. I consider it almost like this indirect biomarker of the aging process. It’s interesting when you start testing. Some people are in 20s and 30s and it’s like, “Let’s just get that up there.” I think the issue with this DHEA, which I find interesting is that it’s available over the counter. Amazing. Great. I think all options should be available, but at like 50 milligrams, you could easily get that. And that to me is too high to start a woman on [inaudible 00:46:01].
Dr. Weitz: Oh, you can get it at five, 10.
Dr. Ney: Right. But it’s available. So, some women reach for that.
Dr. Weitz: Oh, okay.
Dr. Ney: So, I like to just educate, hey, if you’re a woman, start with a five or 10 milligrams because that’s the place to start. I have seen side effects at too high of a dose, like anger, irritability, or acne. So, I just like to educate women on that. But overall, I either see people who don’t notice a difference or they notice that they have even more energy, more stamina with the DHEA. But sure, it is something I’ll try for women when they test. Generally under a 100, and I’ll give a little DHEA and see how they respond.
Dr. Weitz: Is there a benefit to pregnenolone?
Dr. Ney: Some doctors love pregnenolone. I just don’t use it a lot. I know that there are, because it depends on [inaudible 00:46:48].
Dr. Weitz: It also depends on whether or not you test for it.
Dr. Ney: True. True. I don’t always test for it. Do you use pregnenolone a lot?
Dr. Weitz: Well, as a chiropractor, right, we can’t prescribe anything. But pregnenolone is available over the counter, so we do use it sometimes.
Dr. Ney: Yeah. Some of my patients notice when we do use it, they notice better-
Dr. Weitz: I feel like it rounds out the whole hormone picture as a precursor.
Dr. Ney: Yeah, it definitely makes sense like that. Yeah. And again, it’s not one of my go-tos, but I have patients on it. I have dabbled in it. It’s just not usually something that’s my go-to.
Dr. Weitz: Right. Okay. Let’s see. What about nutritional supplements for women in menopause?
Dr. Ney: Yeah, again, very individualized, but generally, I really like, well, mitochondria support, I do like because really important for healthy aging. It’s important for hormones and cellular energy, cellular health. So, I love supporting mitochondria. Generally, a B vitamin I find helpful, a magnesium I find helpful. And adaptogen I think is helpful like maca or ashwagandha. I like that as a baseline. Also, vitamin D levels. Most people need to be on a maintenance dose of vitamin D to keep levels optimized and like an omega-3 fatty acid.
Dr. Weitz: What do you like for a typical maintenance level for vitamin D?
Dr. Ney: Fifty to 70, 50 to 80, around there.
Dr. Weitz: Oh, you’re talking about blood levels, right.
Dr. Ney: Oh, I’m sorry. You meant dosing levels?
Dr. Weitz: Yeah, dosing like 5000, 2000.
Dr. Ney: I find that it’s individualized, to be honest with you. I will track people and figure out what we need to do. So, it’s either 2000 or 5000. I think some people don’t take it every day too. So, I track them and I’m like, “What are you taking? Okay, keep taking that.” If they start to get a little higher like above 60, 70, I’ll definitely move them to 2000. During COVID, I don’t know if you’ve been seeing this, but I saw people with way too high vitamin D levels, like way above 100. So, I had to bring them down. People are really loading up on D. But yeah, you want to be in that optimal range.
It’s not a water-soluble vitamin. It’s a fat soluble vitamin, so it can get stored in the fat. And when it’s way too high, like when it’s above 100, it can lead to symptoms. So, it is something you do want to track if someone’s taking. You just want to make sure 5000. Most of the time, 5000 is great for a maintenance dose, but for some people, it’s too high and 2000 is the safe one. And if you’re not testing, generally 2000.
Dr. Weitz: Right. Sometimes 5000 is not enough. I know for me, if I only take 5000, it drops in the 40s or low 50s. So, I got to-
Dr. Ney: And that is why testing can be really helpful.
Dr. Weitz: Exactly. I’m a big proponent of testing, not guessing.
Dr. Ney: Yeah, absolutely. Certainly for these nutrient levels.
Dr. Weitz: Now, some doctors who prescribe bioidentical hormones automatically put women on some of the supplements like DIM to increase the potential that it’s going to be metabolized safely.
Dr. Ney: Yeah, I do use DIM. It’s not like you’re on hormones, I put you on DIM. And this is sometimes where the DUTCH test can be helpful. So, you can really test not guess. You can really see what pathway you’re going down, the two, the four, the 16. And what DIM does is it helps convert that to pathway, which is the safest pathway. And that’s the pathway we want to, I mean all pathways, we’re going to go down all of them. But certainly if you’re really heavy in the four, which is the one oxidative damage, DNA damage, you want to push the two. Giving DIM just for everyone, it does lower estrogen levels, so you just want to be mindful of that. It seems like everyone should take DIM, but if you’re not on hormones and you’re menopausal, you probably don’t need DIM because it can pull out whatever estrogen you have and make it even lower. Sometimes without testing and if I see someone who started hormones and they’re getting used to it and they feel really good, but they have this breast tenderness and lowering the estrogen is not really the best choice, I’ll do a trial of DIM. And people respond well. So, DIM is something that comfortably testing is nice to know if you actually do need it. We’re looking at estrogen metabolism. There’s a lot you can do lifestyle-wise to promote these healthy pathways. And I always will emphasize that too. If you want to be having daily, well-formed bowel movements, you shouldn’t be bloated or gassy or burping. You should have really good digestion. That says a lot about your gut microbiome, which is really important for metabolizing estrogen. Cruciferous vegetables, which is the precursor to DIM, the indole-3-carbinol, which is found in the broccoli and cauliflower. All of that really helps with phase one. I encourage women to have broccoli sprouts, which is the sulforaphane, which helps with phase two. So, I’m always doing those baseline lifestyle pieces to help with estrogen metabolism.
Dr. Weitz: Right. I’m starting to see estrogen and progesterone over the counter now.
Dr. Ney: Yeah, I know progesterone cream, you can get over the counter.
Dr. Weitz: I’ve seen estrogen now over the counter, one of the popular supplement manufacturers, and I was surprised.
Dr. Ney: Yeah, I know I’ve seen some estriol, I think in some of the Bezwecken product. I don’t know. I probably need to double-check that, but there is some estriol over the counter that I know is available. I don’t know much about estradiol. I’ll have to see what these products are.
Dr. Weitz: Yeah. Okay. I think those are the questions I have. Any other things you want to tell our viewers and listeners? And then, tell us how we can get in touch with you.
Dr. Ney: Yes. I want all women to know that they have a toolkit of treatment options. And I want women to know that this isn’t a normal process. This is not a disease state, but it does require a check-in. And I want women to know that you can continue to age with the same level of energy and vitality and libido and feel really amazing, but how we treat our body does change. So, we need to really, really emphasize those lifestyle pieces become even more important. And we have a suitcase of tools to address perimenopause and menopause from nutrition and sleep to supplements and microbiome support. There’s so much, and hormones.
So, I want people to know there’s options. This is not something they need to suffer through and deal with because I think when you feel your best, you can truly get after all the things in life that light you up. And that is why I want people to not just be… I don’t want their health to be an obstacle to achieving what they want in life. And when you feel good, you can really get after it. And I do think this is our time. Maybe the kids are older. We have a little bit more time, and this is our time to step into our passion and really get after it. But geez, it really helps when we feel good and our hormones are balanced. That’s really what I want all women to walk away with, is knowing there’s options and that they get to write their own script, that they don’t have to live someone else’s script. They can live the life of their dreams.
Dr. Weitz: That’s great. And how can viewers get ahold of you if they want to seek you out?
Dr. Ney: I have a private practice at the Akasha Center for Integrative Medicine, which is in Santa Monica. I’m licensed in the state of California. I see patients all over for educational, for telemedicine. I have a big telemedicine practice as far as prescribing and all of that in the state of California. I see women all over California. So, that’s at the Akasha Center for Integrative Medicine. I also co-founded HelloPeri, which we’re on Instagram, @thehelloperi, which has a lot of information on menopause, perimenopause, everything that has to do that. So, you can find me. On Facebook, I think we’re @thehelloperi as well.
Dr. Weitz: Okay. Thank you, Dr. Ney.
Dr. Ney: Thank you so much for having me on. This was so fun. And for anyone listening, questions, please feel free to DM me. I love to connect with everyone.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardiometabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective. So, if you’re interested, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.
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