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Dr. Maggie Ney discusses Bioidentical Hormone Therapy at the Functional Medicine Discussion Group meeting on April 25, 2024 with moderator Dr. Ben Weitz.  

[If you enjoy this podcast, please give us a rating and review on Apple Podcasts, so more people will find The Rational Wellness Podcast. Also check out the video version on my WeitzChiro YouTube page.] 

 

Podcast Highlights

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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.

 

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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.

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Our two sponsors are Integrative Therapeutics and DUTCH Testing. And if you’re not aware, Integrative Therapeutics is one of the premier,, professional brands of supplements available.  we use a lot of their products in our office. One of their,  most exciting products is their specialized form of curcumin called Theracumin, Theracurmin.  And now they have an even more specialized, more highly absorbable form called Curalieve. They have many other products that can be helpful for hormonal balance as well.

 

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And now we have our other sponsor for this evening is, Dutch Testing, Precision Analytical Labs. And so we have Noah Reed here to tell us a little bit about Dried Urine Testing:

Noah Reed: Yeah, thanks for having me.  I came down from Oregon, so glad to be here with you today.  DUTCH stands for Dried Urine Testing for Comprehensive Hormones, so that’s what the acronym DUTCH stands for.  It’s a four spot dry urine test, so waking two hours later, dinner, and bedtime.  It gives you the average of the sex hormones throughout the day, so it can mirror 24 hour urine, but it’s a little bit easier to collect, because it’s just on a little filter paper. that the patient takes at home, gives you the metabolites, so how the body is detoxing the hormones. You also get adrenal health with that, so you can be able to see the four points of the cortisol curve throughout the day land you see the metabolites of cortisol, how much cortisol is being made and how the body is processing it.  It gives you a little bit of an interesting view there, and then a very small organic acid panel, , gives you melatonin production through the night and 8 hydroxy 2 deoxyguanosine, or 8 OHTG, which is the oxidative stress marker, all in one, easy to use, test that the patient does at home.  We do have doctors on staff, 12 doctors that can walk you through the interpretation as well, so that you can become the hormone expert for your patients.  So that’s a little bit about the DUTCH test. If you have any questions, I’ll be here.  I’d love to answer any more questions for you.  We do kind of pride ourselves on the three things that make us unique.  Our comprehensive, a comprehensive report that’s visually appealing for you to be able to understand your patient’s story. , the support from our clinical clinicians on staff. , and then everything that we do is backed in peer reviewed journals. , so every analyte that we have on our test is actually put in a peer reviewed journal.  Our most recent one that we’re proud of is we were published in the journal Menopause, so we were the first functional test, , to actually be published in the journal Menopause, , showing the efficacy of testing and monitoring, , hormone replacement therapy, , as a part of your patient, , experience.  So, that was a big feather in our cap to be a part of that, and we’d love to talk more about it if you have any questions. 

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Dr. Weitz: Thank you so much, Noah. Our speaker for this evening is Dr. Maggie Nay. She’s a licensed Naturopathic doctor… Unless you want to introduce yourself?  That’s fine. Yeah. Okay. Okay.

Dr. Maggie Ney:  Hi, everybody.  Hi. I’m so excited to be here.  I’m really passionate about women’s health and perimenopause in particular. I find it a very underserved area in the market. So I love to educate women and practitioners, and would love for this to be interactive if you guys have questions, but, I’ll start a little bit about introducing myself.  I’m a naturopathic doctor. I graduated from Bastyr University in Seattle in 2006. I currently co direct the women’s clinic at the Akasha Center for Integrative Medicine, which is like a few blocks away. Thanks I recently co-founded Hello Peri, which is an online resource really devoted to educating women about perimenopause.  I’m a certified practitioner by the Menopause Society. And again, I just really like to help women thrive through the perimenopausal period with a sense of empowerment. I’d like to provide the resources, tools, strategies needed to support hormones and for women to truly feel incredible because I do think this is the time when women can absolutely get after all their dreams, right?  This is the week in Chinese medicine, right? The second coming. You can choose your own path, write your own script, but gosh, it helps to feel really good to be able to do that.

Speaker: Yeah, I don’t think so. You know what? I’ll, I’ll, and she’s like, well,

Dr. Weitz: I can do it. I’ll, I’ll do it. I got it. I got it. I’ll do it. I’ll do it for you.

Dr. Maggie Ney:  Thank you.  I use so many pronouns, so I do just want to just really quickly say however you identify your patient. I do, I do use she/her to identify women, but I know that, you know, everyone identifies a little differently.  But just for the sake of being clear and not too wordy, as you can know, I chat a lot. So. We’re going to, everyone is included. However you or your patients identify yourself. Just want to put that out there. Alright, we can move on. Okay.

So really briefly, let’s just review the four basic hormonal stages that women go through.  So first we have the pre menopause time, which is basically from when you get your first period up until when you start perimenopause. Perimenopause is this time when our higher quality eggs start to decline, and we begin to experience more fluctuating hormonal levels. So women can start to have, , women can have the regular period, but start to have these symptoms, which we’ll get into, and you can still get pregnant.

But the regular rhythmic flow that women used to experience with the regular upping of the estrogen, the decline, progesterone being produced during the second half of the cycle, doesn’t happen as predictably. Menopause, technically, it’s one day, it’s the one year anniversary since your last menstrual period.  And then everything after is the post is post-menopause. I prefer to use post-menopausal years because we get a little hung up on, I’m after menopause, it’s done, it’s over, I’m through it.  But really, once you’re in post-menopause, the hormones are low and you’re going to have low hormones till the day you die.  So it’s not like you’re through with it, you’re in it, really. Symptoms can absolutely change, though, throughout that time.

Okay, so let’s talk a little bit about the unique needs of perimenopausal women. So, again, this is the period of time leading up to menopause. Hormones can start to fluctuate and symptoms can occur in your 30s. For some, sometimes late 40s, and perimenopause is not always a con Do you guys hear me okay?

Perimenopause is not always a constant symptomatic phase. Symptoms can flare with times of higher stress, and this is a hallmark, is that during this perimenopausal time, hormones become even more sensitive to stressors. Right? So if you’re Whatever could be situational, lack of sleep, poor diet, if our body’s at all under stress, our hormones are more easily affected.  Symptoms can last really on average between four and ten years. And I just want to just highlight that. If you’re feeling like crap, I mean that’s a very long time. And once a woman has gone a full year without a period, they’re in menopause. And again, it’s the one year anniversary without a period and patients that are post menopause.

And lifestyle changes become more important than ever during this time, right? Sleeping, hydration, nutrition, movement, dress management, quality relationships, can dramatically affect how a woman experiences perimenopause, right? I always say to my patients, Yeah, in college you can stay up all late, you can drink beer, eat pizza at midnight, wake up and like, go to classes and feel like, happy on your A game, but that just doesn’t happen.

How are you? It’s not like, I would say again, like, you can continue to age with the same level of energy and vitality, even more so than when you were younger, but how we treat our body matters, and it matters more now.  Okay, so I didn’t really say this, but I am going to focus here mostly on hormone therapy, because this is an area that is really not understood most of the time.  Practitioners and women don’t feel like this is an option during the perimenopausal period, so I like to educate on this. But again, if you have questions about some of the other treatments, please ask me.  okay, so, yeah, so, again, we focus on the lifestyle piece. There are vitamins, there’s minerals, there’s herbs, there’s homeopathy.  I know you guys are well trained in this area. That can be helpful. But a lot of women do need that extra hormone support during this time to really feel their best. And most important, all women need to have a conversation. Right, I, this is what fuels me, is that women are denied the option. Women aren’t given the full amount of choices that they can use during this time.

So the benefits of HRT really is greater than the risk for most [00:10:00] symptomatic women. Currently, I think the most recent numbers is like 4-5 percent of women are on hormone therapy, when really upwards to 80 90 percent would be excellent candidates. Doctors and other healthcare practitioners are not getting good training in their schooling to be able to recognize and how to use hormone therapy safely and comfortably. I talk to a lot of doctor colleagues, they just don’t, they know it’s okay, but they don’t feel comfortable.  Okay, so, again, just again to speak about the unique needs of a perimenopausal woman, I’d just like everyone just to be aware of, perimenopausal women are usually in the sandwich generation, right?  They’re at a time in their life where they’re experiencing these hormonal fluctuations that can affect all aspects of our body, mood, brain health, energy, and the ability to manage stressors. At the same time that our lives are often more demanding and stressful. Many women are at the key of their career while also taking care of their own children and aging parents.

And this is a time for patients really to focus on lifestyle more than ever and prioritize personal health and hormone education so they can really show up As their best version of themselves. And for many women, it’s simply a perfect storm. That the hormones and life stressors are happening at this exact time that hormones are shifting.  So, a comprehensive approach to perimenopause. We’re looking at, well, we definitely want to get a very good past medical history. A thorough understanding of their current symptoms, family history, lifestyle. So important to know our patient’s health goals. Because that can help individualize our treatment plan.  And focusing on things like nutrition, hydration, movement. And for the perimenopausal women, it’s really about getting good cardio resistance, right? Lifting weights is more important to build that muscle because we lose more bone mineral density as we go through the perimenopausal journey, so we need to focus on building muscle because it’s good for muscle, it’s good for bones.  Women need to focus on balance and stretching. For nutrition, keeping blood sugar stable, metabolic flexibility, optimizing protein intake, but again, all the other things, morning sunlight, quality relationship, joy, stress management, addressing gut health, supporting detoxification pathways, targeted supplements, and hormone therapy, and if you can include all this in your plan, you’re doing comprehensive, perimenopausal care.

So, I, a few points I want to make that come up to me as a naturopathic doctor. Gosh, I, I’m a natural, I like to call it naturally, they do things naturally. I want to support the natural process of my body and I’m supposed to go through menopause. Why don’t I just honor that and accept it? It makes sense, but we all need to question what is natural these days.

Like, are we supposed to live to 80 and 90? Are we supposed to be? You know, super physical and active mentally and physically. I mean, I know I want to be. I want to be super active and having fun and hiking up until the day I die and, and we’re living longer than ever. We used to die just past menopause and now we’re living, you know, up to half of our life after menopause and to have an expectation that we can do that with the same level of energy and vitality As we did when we were younger, it’s not realistic for most people if they’re not using phones.

For some, yes, again, it’s individualized, but we just need to be aware of this. And there are risks, I’m not quite done, there are risks to not addressing our patient’s health as well. Hot flashes and night sweats aren’t just annoying. They’re not just something you need to embrace and move through. There are consequences to it.  We know that it obviously can disrupt sleep, which can affect every aspect of our life. But there’s also more vascular inflammation when women experience hot flashes and night sweats, which does put them at higher risk of heart disease and dementia.  also for women, Depression and suicide rates are skyrocketing for mid life women.

It is true that [00:14:00] suicide rates for mid life women is, it peaks then. And if a woman is presenting for the first time during this time period with new onset depression or reoccurrence, then it really truly needs to be taken very seriously and we need to recognize and, and discuss the hormonal component as well.

So what’s happening hormonally specifically during perimenopause? So, basically, our estrogen starts to behave a little bit more erratically. So, during the pre menopause years, our estrogen in the follicular phase basically starts off low and basically steadily increases. It gets to a certain point where it signals to the brain to release luteinizing hormone, which triggers the egg to be released, so we ovulate, there’s a little dip in estrogen, and then it boosts back up again, and then it drops.  And then,  during perimenopause, that estrogen just doesn’t really have rhyme or reason. I mean, some months it can [00:15:00] go regularly just like that, and other months the estrogen is just up and down and up and down and up and down throughout the cycle. And women feel it because our brains like stable hormones.

They just do. We do better. That’s why women, have a little mood issue. Sometimes we’re out of population and obviously during the premenstrual time when we’re PMSing, it’s because of these drops in hormones that trigger changes in our neurotransmitters that can affect our mood. So, again, these estrogen fluctuations can lead to more unpredictable mood changes.

70 percent of women in period menopause have mood changes. Anxiety, depression, irritability, moodiness, less able to manage day to day life and depression. And stressors feeling less resilient. So, the stressors that we used to be able to handle with ease can just feel too much. Estrogen fluctuations can also be a trigger for headaches, more aches and pains, and night sweats and hot flashes.

And then, as [00:16:00] progesterone starts to decline, so often during early period menopause, it’s progesterone, which is the first hormone to drop. That will show up in our clients and our patients as difficulty sleeping, difficulty turning our brains off at night, feeling more anxiety on edge, and then having shorter cycles.

So, if you were a 28 day girl, maybe you’re more 27, 26. Which is why it’s really helpful for our patients to track their cycles so we can begin to recognize those subtle shifts.  heavier cycles and more spotting between periods. So these are separating a hormone and getting an idea of what symptoms can be related to what hormones.

And because perimenopause can really be a decade, I do think of it as early versus late perimenopause. Where the earliest symptoms really are the symptoms of that lower progesterone, which we just spoke about, where periods can start to come a little early, sometimes you’ll have two periods in one month, you have heavier periods, [00:17:00] clottier, heavier flow, lower libido, ruminating thoughts, anxiety, depression, less resilient, sleep issues.

And then the later period menopause, you were really starting to see women skip their cycles. You just know you’re kind of later in the transition, you know, maybe go three months, four months.  and then you’ll have more likely women will experience those typical symptoms that we think about. Palm flashes and night sweats that don’t dryness.

So why, I think this is important just to highlight, why? Why are we not talking about this? Well, first, there’s just a lack of training. As I said earlier, there was a recent study that a lot of OBs said that they got maybe an hour of training on how to support menopause, not even perivenopause. So, I always tell my patients who come in, they’re so upset because they feel so ignored and not heard by their doctor that their doctors are probably pretty well intentioned.

They’re just not educated.  there’s certainly a [00:18:00] lack of research and there’s an under representation of women in medical studies.  due to historical biases and also a lot of women have been excluded from studies simply because their hormonal fluctuations are just too hard to control. So let’s just not include them at all because men are much more stable.

And I think it was only in, up until, I might be butchering this, it’s like the early 90s when women had to be included in studies for,  medications to be approved. So that’s all very recent. What doctor do you see? Seriously, if you, if you’re depressed, you’re anxious, you’re having heart palpitations.

You’re irritable, you have headaches, I mean, who do you schedule with? There’s not really one central hub of a person. So that’s why so many people see their therapist, a nutritionist, their primary, a neurologist because they’re getting headaches and tingling, a cardiologist because they’re getting heart palpitations.

And women don’t feel heard or answered. And then there’s simply a shifting narrative. Our narrative of aging has changed. We are not [00:19:00] just going to slow down, right? It’s the 50s, it’s the new 20s, like we, we’re not slowing down, we are active. And our, so our expectations of ourselves We’re not willing to slow down, but there’s just no support, really, in the medical, conventional medical community of how to keep up with that changing narrative.

I just think this is really important because there’s so many symptoms associated with perimenopause. So the most common one are period changes. It’s one thing you can ask from your clients, like, have your periods changed? Some people don’t know, which is why it’s important to track your cycle so you can begin to see mood changes.

Over 70 percent of women experience mood changes during perimenopause. And there was a study that came out a few years ago. They actually studied the term I don’t feel like myself. I mean, how many times have we heard that from our patients and clients? I don’t feel like myself. This was actually studied, I think it was published in Menopause.

I don’t actually know what exactly it was, but it was studied, I mean published, but they studied that and over 70 percent of women [00:20:00] said I don’t feel like myself more than 60 percent of the time over a 12 week period. So, it’s really common. And then so we have the period changes, the mood changes, And then the menopausal symptoms like hot flashes and night sweats and vaginal dryness.

But these other ones are important, and we’ve touched upon them, but less resilient, more irritable, mood swings, heavier menstrual cycle, irregular cycles, tender breasts, headaches, fatigue, brain fog, we, I know we’ve heard that, right? Lack of focus, forgetting where you put things, decreased libido, anxiety, weight gain, worsening PMS, hot flashes, dry skin, changes in body odors, bloating, insomnia, night sweats.  Burping, constipation, worsening allergies, ringing in the ear has been associated.

Dr. Weitz: I thought weight gain was caused by Ozembic deficiency. Ha ha.

Dr. Maggie Ney: Rowdy nose, post nasal drip, hair thinning.  hair loss, more facial hair, heart palpitations, achy joints, [00:21:00] frozen shoulder, right, things that come up in, you see it more in menopausal period, menopausal women, burning tongue is another one, more frequent vaginal infections like yeast or vector vaginosis, not recovering as well after exercise, itchy skin, problems in skin sensations, dizziness, and electric shock sensations.

I list them out because there’s so many. And I always say, like, you need to go get worked up and other things ruled out, but once you do, then you focus on the peri.  and so perimenopause is a clinical diagnosis based on symptoms alone and ruling out other causes. It’s really important because I see people come in, they say, my doctor took my blood and it’s normal, so I’m not in peri.

How often have we heard that, right?  our hormones just fluctuate too much throughout the cycle and cycle to cycle to really be, it’s just, it’s just not based on labs. So we can do a [00:22:00] blood test and rule out peri. You can certainly do a blood test and I think there’s a later slide and it’s suggestive of perimenopause.

We’ll get into that. But, it’s really based on how are you feeling, tracking your cycles, recording your symptoms, and then labs to rule out other causes of your patient’s symptoms. So the main ones, right, that overlap most of the ones, of the symptoms I talked about, are your thyroid, anemia, and autoimmune disorder, vitamin D, B12 deficiency.

So conventional guidelines, true, perimenopause. Hormones change throughout the month and throughout the day, and this is all true, and I share that with my patients. But! There’s really no controversy about testing hormones for fertility, right? Our patients go day two, day three of their cycle, get their FSH tested, maybe get an AMH, get an estradiol, and that speaks to their egg quality, right?

If you do fertility, you’re familiar with it. If, like, this third day of your cycle, your FSH is high, that’s saying low, poor egg [00:23:00] quality. So Anyway, you can kind of extrapolate from that, that maybe you’re more in, in the period zone. But, normal hormones, normal other labs do not exclude perimenopause. They simply provide a little bit more information.

Okay, so, basically, things that are suggestive of perimenopause, but not diagnostic.  and again, I, day 2 or 3, if your FSH is above 10, it could be suggestive. Estradiol above 60 with an FSH could be suggestive of perimenopause. And AMH under 1, suggestive of perimenopause. And then as long as you’re getting those basic, you might as well get a baseline of your other hormones too.

And this is through blood.  Okay, I think I said that. So, oh, so what hap This is important. The definition of menopause is, is, I think, horrific. Right? It’s based upon if you’re getting your period. There are so many women who don’t get their period. Either they have an [00:24:00] IUD, or they don’t have an IUD. They have a hysterectomy.

They have an ablation. So how do you know if you’re in menopause? Well, it really doesn’t matter, right? Menopause is just that one day. But what are some, what are some suggestive? So an FSH above 35 and an estradiol less than 20 on two separate occasions is suggestive of menopause. An AMH less than 0. 2 is suggestive of menopause.

Speaker 6: The slide before, you said it was FSH above 10, but an estrogen above

Dr. Maggie Ney: Yeah, so basically, it used to be that we just checked FSH. And so, if your FSH was a seven, that would be great, you’re good, you’re not impaired, you shouldn’t get pregnant, you know, from a fertility perspective. But, because estradiol, which is released by our ovaries, is the, is the hormone that the brain picks up, To say it doesn’t need to make FSH.  So FSH is the hormone the brain releases to tell the follicles of the ovaries to grow to make [00:25:00] estrogen. So during perimenopause, when things are a little erratic, our estrogen can actually be high on the second day of our period when it really should be low. And if it’s high because of just being in perimenopause and lower egg quality, then it can falsely lower that FSH.  Does that make sense? Yeah. Okay. That’s true.  I mean, this is just comprehensive blood work that I will do if someone’s in, you know, who’s seen me, who’s not, I don’t feel like myself. So, basics. And then we have the Dutch test, which,  I wanted just to give a shout out to. And again, just another way to assess hormones and how you’re metabolizing hormones.

Speaker 7: Yeah, we didn’t quite get that. Oh, sure. Okay.

Dr. Maggie Ney: So basically,  I can talk [00:26:00] about this for a second, but CDC, you want to look at ruling out anemia, your metabolic panel, that’s the basics, your glucose, your electrolyte, your liver, kidney function, basic lipid panel, maybe you guys know, in functional medicine, we’re often doing more of the detailed lipoprotein particle size, but just the basic lipid panel.

Inflammation with your HsCRP, your SED rate, homocysteine is, again, a marker for vascular inflammation. I like always to get a fasting insulin for a metabolic health marker. Your hemoglobin A1c, which is that three month average of blood sugar. TSH is the overall thyroid health marker.  Free T3, Free T4. Sometimes I’ll order the antibodies.  Sometimes I’ll order the reverse T3. Not every single person gets that. A vitamin D, a magnesium, maybe 12, a folate, ANA if you’re presenting with more of those joint pains, and,  fatigue even, and then the hormone testing that we’ve spoken about. I didn’t mention this, but progesterone is a hormone that’s only produced when we [00:27:00] ovulate, so it’s always going to be really low that first few days of your cycle.

You know, if you get your hormones done day two, three, your progesterone’s always going to be low. So, you only produce progesterone after you ovulate, so just the last two weeks of your cycle. So, if you want to get an idea of where your progesterone is, you would time your Dutch test, you know, a week before you expect to get your period, or a week after you ovulate, or you would do your blood test, again, a week after you ovulate, or a week before you expect to get your period.

Dr. Weitz:  I just wanted to point out, for patients where you’re not sure where they’re at, their hormones are fluctuating, Dutch offers a cycle mapping, so you can test your hormones every day, during the course of a month, and kind of see what’s going on.

Dr. Maggie Ney: Yeah, so if you’re a period, you can see some of that more erratic estrogen.

Speaker 7: Yeah? How about if someone is already in their menopause and you want to talk to tweak their hormones? I mean,

Dr. Maggie Ney: personally, I don’t, I go by symptoms. I go by symptoms. If they’re in menopause, they’re not bleeding, I [00:28:00] go by symptoms, I see how you’re feeling, and I might do a blood test to make sure your number’s, number’s not too high, or if they’re not feeling optimal and their levels are very low, then I’ll increase.

Speaker 6: For the Dutch panel, do you order that at the beginning of treatment or is it like, throughout treatment? I don’t,

Dr. Maggie Ney: I mean, I think the Dutch panel is amazing. I don’t necessarily order on every single person, to be honest. It’s not mandatory.  I do discuss it with my patients if they’re curious to dive a little deeper or if they’re having any of the symptoms that I think I would need further support with looking at the,   Metabolizing hormones.

But I would say I like to, when I, I, I think if I’m going to like choose a time to do it after they’re on the hormones. ’cause I want to see how they’re metabolizing the hormones and make sure they’re going down the good pathways because you can feel amazing. It’s true. And still be maybe pushing it down before pathway, right?

For hydroxy estro pathway where you would want to do some more antioxidant work and try to push more towards the two pathway. So [00:29:00] I, if I get them stable on a good dose of hormones and I then I really want to dial in on.  for their support of how they’re metabolized, because it’s not just about how much hormones you make that control how you feel, but it’s also how you metabolize and clear hormones.

So let’s talk a little bit about hormone therapy, because there’s so much confusion. So let’s just get really clear on a few things. HRT stands for hormone replacement therapy, and it’s an umbrella term. It includes bioidentical hormones and synthetic hormones. And so, bioidentical hormones, I mean, I think it’s, it, it has been considered now kind of a marketing term.  That’s what a lot of the conventional doctors will say. It’s marketing, and, and I sort of agree, but it does, it does have a meaning. It means that the hormones have the same molecular structures as our own hormones. And they

Speaker: don’t come from

Dr. Maggie Ney: horses. They don’t come from horses, right, like primarians, and we’re going to talk about that.

But, oh, I mean, I need to, no, that’s a legal question.[00:30:00]

So HRT is the umbrella term in cough. It stands for hormone replacement therapy. Technically, when you’re talking about using hormone therapy for perimenopausal women and menopausal women, the correct terminology is MHT, menopause hormone therapy. Hormone therapy is another term that is kind of the correct usage and the reason usage because HRT technically is about replacing lost hormones.

So if you’re 27 and you’ve gone through early menopause, premature menopause, then you would be on HRT. You would be on a much higher dose of estrogen to replace it. But we’re really using low dose hormone therapy, and it’s a technicality like tomato tomatoes, but I want you to be aware of it because it’s slowly changing.

when people are talking about hormone therapy. So HT is used a lot, like hormone therapy,  ET, EPT is estrogen and progestin gin. So progestin gin is another umbrella term that includes [00:31:00] bioidentical progesterone or,  progestin. So it’s an umbrella term. And then BHRT is bioidentical and then, you know, HT, HRT, MHT are often used interchangeably.

So synthetic hormones, they’ve just been chemically older. They’re not identical. To human hormones.  so let’s just talk about what are some examples of the synthetic hormones. So there’s Premarin, which is what Ben was just talking about, conjugated equine estrogen.

Speaker: Come about? Let’s give, , horses hormones to women.

Dr. Maggie Ney: Well, okay, it actually came about because they used to,  grind up human ovaries to start, and then they would use pregnant women’s urine. And that was got, like, you can’t produce so much of it, so then they, the horses were the next one, so.  Oral birth control pills, it has ethanol, estradiol, which is a synthetic estrogen.

[00:32:00] A marine IUD contains a synthetic progestin, right, it has the levonorgestrel. And, I mean, this is nitpicky, but it’s true, just because something’s synthetic doesn’t make it natural, right? Horse urine is, it’s still natural. I just, I’m just putting, it definitely elicits the ick factor, but as we were talking about correct terminology, it just means that it’s chemically altered.

It’s not identical to our own hormones. And then bioidentical has the same molecular structure as our own hormones. So, bioidentical hormones are plant derived, so they’re made from soy or Mexican wild yams. They’re converted into hormones in a laboratory that have the same molecular structure as our own hormones.

There is no soy or yam in the final product. But because bioidentical hormones look and behave like our own hormones, They can naturally integrate into our own body’s physiology to help restore hormones balance better.  and then there’s, and this is important. There are [00:33:00] FDA approved bioidentical options, meaning you can get them at CVS and RiteAid bioidentical hormones or compounded hormones.

So let’s talk about the FDA approved bioidentical hormones. This is an area, I’m telling you, people are really confused. They want to talk so much about, I want to go bioidentical, I want bioidentical. I see patients come to see me. Asking for bioidenticals, and I say, what are you on? I’m on the patch. I’m on the estradiol patch.

That is a bioidentical hormone. So, again, it’s about just clearing up the misinformation, educating our patients, and together coming up with the best choice for them. So FDA approved means the hormones are evaluated for safety and effectiveness. All the FDA approved bioidentical hormones are dispensed with package inserts, containing extensive product information with detailed risks, potential side effects, they’re commercially available, you can get them at any pharmacy.

And so, some examples of FDA approved bioidentical hormones that are available right now are the estradiol [00:34:00] patch, the gel, there’s a spray, there’s a ring, there’s an oral tablet, there’s vaginal estradiol cream that works locally, not systemically, there’s progesterone capsules, and there’s DHEA vaginal inserts.

So those are all the bioidentical, FDA approved. So let’s talk about the compounding hormones. So the advantages of using compounded, they allow for different routes, dose, formulations. They’re just not available through a regular pharmacy. You can,  allows for products with the fewest ingredients. So commercial products tend to have more inactive ingredients.

I will say, like, vaginal estrogen is so important for women, like, everyone should be on it as they go through menopause because most, I think, 100 percent of women have some sort of vaginal dryness that can affect the genitive urinary syndrome, right? More frequent urination, more prone to UTIs. [00:35:00] And I prescribe vaginal estrogen all the time.

It’s definitely underutilized, but the commercially available one has parabens in it. It just does. And I I don’t, it’s one of those things when I talk to people or I’m out in the medical community, it’s like, it’s so underutilized. It’s like taking food away from starving children and saying, oh, but it’s not organic.

It’s, it’s kind of like that in my mind, so I want it out to everyone. I, but to savvy functional medicine practitioners, like, that’s just something to be aware of, that the vaginocin does have parabens. So I will let my patients know. I mean, some of them don’t care, you know, that’s fine. And some are like, I do everything I can to avoid parabens in my skincare, so can we get this calm?

 and then if you have like,  mast cell sensitivity patients, people who have really reacted just to everything, then I go towards the compounding pharmacies. So what are the common compounded hormones? So we’re going to talk a little bit more about testosterone, but there is no FDA approved testosterone hormone for women.[00:36:00]

So you can get a compounded. Estriol is a weaker form of estrogen. It’s great for vaginal dryness and there’s some great studies on it. Sometimes I’ll get compounded estrogen and testosterone. We talked about how everyone should be on estrogen cream, but there’s a boatload of androgen receptors in the vaginal tissue that respond very well to testosterone.

 there’s VIAS, which was really popular after the Women’s Health Initiative study, if you remember all that study that came out in 2002. We can talk more about that if you’re curious. And then progesterone capsules, the pharmaceutical ones, have peanut oil, so you can get it compacted without peanut oil.

You can get a sustained release, because it helps with sleep. So, you know, some people are like, I’ve been sleeping better, but gosh, it’s not lasting through the night. Then I’ll think about using the sustained release. So what are the FDA approved indications for hormonal therapy? That means there is no controversy.

Like, you can just go ahead and do this. You don’t have to, you don’t need a consent form. You don’t have to be worried about anything. If you’re [00:37:00] struggling with any of these symptoms, this these are FDA approved reasons for using it. If you’re having hot flashes and night sweats, low bone density, so if you’ve been diagnosed with osteopenia, the hormones are FDA approved for that.

Premature hypoestrogenism, that’s just if you go through menopause before age 50, everyone should be on hormones. And then genitourinary symptoms, so vaginal dryness, painful sex. Urinary frequency, frequent urinary tract infections these are all the FDA approved indications. But, hold on, we know from a lot of studies that hormone therapy can, these are studies to support it, can help with your mood, sleep, brain health, joint health, quality of life, and prevention of heart disease.

That is well known, and heart disease is the number one killer of women. So if we’re talking about FDA approved indications, do you know what’s most prescribed for hot flashes and night sweats? Do you guys know? SSRIs. And it’s an off label use of [00:38:00] SSRIs is to treat it for hot flashes and night sweats.

Depression that comes up during perimenopause. What’s the root cause? Probably the hormones, right? Oh, wait, wait, I just complained. So during perimenopause, as your depression, anxiety, more likely to happen, what’s most likely prescribed?  SSRIs. But, but, the root cause is hormones. But the thought of using hormones to address depression or anxiety during perimenopause is like the craziest thing.

Reckless thing because it’s an off label use. We use off label use of medications

Speaker: all the time. It’s being used for IBS. Yes,

Dr. Maggie Ney: yes Okay,

Speaker: so

Dr. Maggie Ney: These are symptoms where you think, maybe I’ll use some estrogen. Hot flashes, night sweats, depression, anxiety, irritability, brain fog, low libido, joint pain, menstrual migraine, super common. If someone gets a headache right around [00:39:00] ovulation, because we said there’s that little dip of estrogen, right before the period, on the first few days of your cycle, A little bit of estrogen can just kind of buffer that dip and can be, , make a profound difference for people.

 any skin changes. Oh, I’m so itchy, burning tongue, ear ringing, or any of the genital urinary syndrome, like any of the vaginal dryness. or urinary tract symptoms, you would think estrogen.

Speaker: Why is it known as atrophic vaginitis? This is a horrific

Dr. Maggie Ney: name.

Speaker: Oh,

Dr. Maggie Ney: okay. Atrophy. I’m sorry, can we just say men get ED as their rebranding?  From impotence to ED, right? Did you? That was like the most brilliant marketing campaign. But we got the suits, we got ED, right? No longer impotent. Like, that sounds horrible. Women go from atrophy, like they, I mean, to vaginitis. GSCAB, basically. It’s not quite as great as, like, Impotent to eat, but anyway.  So [00:40:00] again, these are things we’re thinking of using estrogen therapy for.  If you have a uterus, you always need to have a progesterone to be with it to,  protect the uterine lining. Yes?

Speaker 6:  for as far as, was there something that changed last year where insurances can cover, like, different diagnosis codes for, like, just primarily hormone deficiency or no?

Dr. Maggie Ney:  you mean to cover HRT?

Mm hmm.  HRT is usually covered by insurance. Like, it depends on your insurance if you use the commercially available ones.

Speaker 6: We’re a cash pay program, but, like, for patients that are applying for reimbursement, we’re just curious about doing that. If we gave them, like, a diagnosis code, could they

Dr. Maggie Ney: use that?

Oh, for hmm.  to get it through what, like, CVS?

Speaker 6: , so they pay, they pay us a membership fee for it, and we do, we do repellent screens, injections, and then all the labs, it’s like all included in the membership, the physician visits and stuff.  but I didn’t know if there was like a go [00:41:00] to ICD 10 code that you could use for them to submit that for insurance.

Dr. Maggie Ney:  I don’t know for sure. I think, yeah, I don’t, I don’t know actually to be honest with you. I think,  yeah, it’s a, it’s a subtle question. I know what you’re asking, but I don’t know. You can get

Speaker 6: to the fillable codes

Dr. Maggie Ney: to get it covered,

Speaker 6: just for the hormone deficiency, rather than

Dr. Maggie Ney: like those specific ones.  I mean, there are for office visits, but as far as medications, yeah, I’ve never had like a prior authorization for hormonal therapy. It’s just, it’s just covered. Okay. Not through compounding, but through, okay. So, progesterone, Progesterone. We know that the function, it helps prepare the uterus to accept an embryo, it protects the uterine lining from this unopposed estrogen, which can increase risk of getting,  dysplasia and initial cancer.

Progesterone is anti inflammatory, it’s [00:42:00] immunomodulatory, it inhibits urine contractions, it has a calming effect in the mind. You take it orally, it’s converted into the liver, into allopregnenol, which binds to the GABA receptors, so it does have that calming effect. And it does slow the gut, it can help with sleep,  causes of low levels, well, perimenopause and menopause.  And then the symptoms, we said it a little earlier, but really when you’re thinking perimenopause, you’re thinking your periods are coming a little closer together, multiple in a month, heavier cycles, spotting, insomnia, and anxiety.

Speaker: Do you ever just use progesterone for when you don’t want to take estrogen?

Dr. Maggie Ney: Yes. I do.  There are actually studies that say higher amounts of progesterone can help with cough flashes at night’s wise, like upwards of 300 milligrams.  but sure,  definitely for like the anxiety and the sleep, progesterone can be great. Sometimes I’ll use progesterone on testosterone and not the estrogen.  But let’s talk about testosterone. Testosterone is the most abundant hormone in women. We have more testosterone than estrogen. Plays a key role in muscle mass. Bone [00:43:00] health, confidence, and burning fat keeps our metabolism strong, our libido high. It does start to decline in our 30s, and 50 percent of women’s testosterone levels have been lost by menopause.  So some symptoms of having lower testosterone, low libido, lower confidence, difficulty with orgasms, fatigue, less muscle mass, and difficulty building muscle.  So testosterone therapy. So it’s not FDA approved for women, which is crazy, but it’s just not. Even though there is supporting evidence, we do need more research, but there’s supporting evidence for sexual desire, mood, confidence, energy, vitality, muscle health, possible adverse effects with testosterone. It is too much for your patient’s body.  You can have some acne, hair thinning, increased body hair, anger, irritability. for listening. But it is endorsed by a number of organizations to treat women who [00:44:00] experience, and this is the clinical diagnosis, is hypoactive sexual desire disorder,  in postmenopausal women, which is basically low libido that bothers you.  Alright, so if you have low libido, but it’s not really bothering you, and it’s not bothering your relationship, that doesn’t, you get the definition because it has to be upsetting to you.

Dr. Weitz: Let me just ask, progesterone is available as a supplement. What do you think about women who use something like that?

Dr. Maggie Ney:  yeah, it’s available as a cream, topical. Yeah. I think if you’re using it during perimenopause, that’s fine to see if it helps you, but I would not use cream to protect the uterine lining if you’re postmenopausal on extra due.   So DHEA, it’s also a hormone. It’s a bioidentical hormone, DHEA.  it’s produced by the adrenal glands. It starts to decline in [00:45:00] our 30s. It decreases by an average of 60 percent by the time of menopause. And DHEA is a precursor hormone. Our body turns it into testosterone and estrogen. Our vaginal and vulva tissues are loaded with estrogen and testosterone receptors.  Thanks. So, giving DHEA vaginally can be really effective, because then intracellularly, it’s converted into testosterone and estrogen. And again, there is one FDA approved, it’s called IntraRosa, DHEA that you can get through the pharmacy, but again, you can get it compounded as a DHEA. You can even take DHEA capsule at low dose and insert it vaginally.

Dr. Weitz: Do you like that Bezwecken cube?

Dr. Maggie Ney: I just, I learned that from you. I don’t have much clinical experience, but it sounds good.

Speaker 7: What do you define as low dose?

Dr. Maggie Ney: Like for, okay, so the studies say 6. 5 mg, so that’s like the commercially available one, so you either get it compounded, you can’t really, you can’t find 6.

5 mg, which are, you know, you just have to [00:46:00] see. Just a capsule, like the gel capsule you just A little gel capsule, I don’t, it’s more than dissolved. Instead of swallowing it. Yeah, instead of swallowing it, you can do it vaginally.  you just have to make sure it dissolves, so I would think a capsule may be better than a gel, but I could be wrong.

Just, as long as it stays in you, it doesn’t fall out.  so, yeah, there’s not a tremendous amount of studies, but there are some, and it’s safe to try, it is. I usually test women, and if they’re lower than 100, then I’ll start them on like 5 or 10 milligrams, just to see if they, they get a little better, and I have seen an increase in testosterone levels in the blood.

 So, bioidentical, I mean, I’ve said some of this, but,  here are the treatment options for estrogen that are bioidentical. You can get the patches, estradiol patches, estradiol gels, there’s estradiol tablets, there’s a vagal cream, a vagal tablet, there’s rings, and then you can get a compounded estradiol cream.

 and then we talked about estriol, which has, in the past, been paired with [00:47:00] estradiol in a form of bias. I really don’t do that much anymore. That really came out when we were scared of estrogen. We were scared of estrogen after the Women’s Health Initiative. So we came out with this bias because you can have estrogen and estriol, and estriol has a little estrogen effect.

So you can maybe reduce the estradiol and have more estriol, but estriol doesn’t have the studies to support the heart health and the bone health. So,  I just don’t think it’s needed. Our liver converts estradiol to estriol, so if you’re doing the estradiol, which has the potent effect, and give liver support, then your body’s turning it into estriol.

And then again for progesterone options the commercially available is oral micronized progesterone, also known as Prometrium.  again, you can get it compounded without the peanut oil, sustained release, and then there’s crinum gel, which is an FDA approved bioidentical progesterone gel that is used for fertility and has been looked at a little bit for uterine protection too.

 you, like I said, during, when you’re [00:48:00] menopausal and not bleeding anymore and you’re on estrogen, you have to be on progesterone. Most women love their progesterone. It’s like, helps them sleep, it’s calming, they feel like a warm, cozy blanket’s covering them. Some women feel nothing, they just have to be on it if you’re uterine infected.  And a small percentage of women do not like progesterone. It makes them depressed, weepy, bloated. It’s a small percent, but it’s always good to educate our patients on that. And if that’s the case, and I say, put it internally, you can get your progesterone, just do it vaginally.  the other options are like the Mirena IUD can be used if you can’t take it.  and then there’s other hormone options as well. So, it’s always just, there’s always options, right? There’s always options.  okay, so for

Dr. Weitz: By the way, do you cycle the progesterone or do you give it every day?

Dr. Maggie Ney: I give women the choice. I do educate. There’s really no studies that say cycling is better or safer. I know intuitively that maybe for some people this feels right. Okay. To take,  progesterone to match your cycle, so I fully support [00:49:00] that.  But some women love their progesterone so much, why would I deny it for them the first two weeks, right? If it really helps with sleep and mood and anxiety. So, I educate people. Like, I teach them. You get, progesterone is produced during the second half of the cycle, so if you wanted to mimic the cycle, which some people really are, that feels right to them, I get it.  Then I’ll support them with that.

Speaker 7: How about the impossible?

Dr. Maggie Ney: I don’t routinely do it, but I give women the choice. Same thing. I do give women the choice. I don’t say you have to do it one way or one way is better. I know people have, feel strongly about that, but I see people love their progesterone, so I don’t want to be like, you can’t take it.

It’s better. I’m not, I don’t feel like there’s enough research to support that it is better. In fact, most studies are done, well there’s been some cyclical studies, but it’s really just what the patient wants. I educate. I do. So for testosterone if you wanted to use an FDA approved form of testosterone, then you would prescribe a [00:50:00] man’s testosterone that is FDA approved.

 they come in like 50 milligram tubes, and you would make that tube or packet last 10 days. It’s one tenth the dose. That comes to about a pea sized amount. Or you can put it in a 5cc syringe and use half a cc a day. I don’t usually do that, to be honest with you. I have, like, done it once for someone who really wanted it.

So I usually get it compounded for women. And so, like, the average dose for menopausal women is five milligrams of testosterone, but I’ll usually start, like, at one and work up to see how people feel. So these are all your options.  like, if you’re getting in the weeds of prescribing or helping women through this, It is important to know, like, all the different options, because I’ve had patients who can’t tolerate bioidentical progestin.

They just feel awful, and they need it, and they can’t do it vaginally. And I will then look at some of the combination patches, which [00:51:00] is a bioidentical estradiol with a progestin.  so I’ll try that, or if I do,  a tablet. I mean, there’s just options for people. You just need to, there’s pros and cons.

That’s good. And if anyone has any like specific questions about the pros and cons of any of these options, I’m happy to go through them. But it’s just being familiar, and I don’t think we should label things as good and bad. It’s just the pros and cons, and what’s

Speaker: right for people. But from a functional medicine perspective, which one would you prefer the most of the synthetic progesterone?

Dr. Maggie Ney: Oh, okay, so from a sexual medicine perspective, I think the IUD is great, you know, like at the levonorgestrel, IUDs, localized progestin therapy is wonderful. That’s what I would say. And then you can be on any dose of estrogen and you’re getting the uterine protection. That’s what I would say.  yeah, so you can move on.

 I’m looking at time. So, [00:52:00] I, we can talk about this if you guys are curious about how did we end up to a place when. There used to be, like, 80 percent of women were on hormones and then it dropped to, like, 2%, now it’s, like, currently at, like, 4%, less than 10%. And it’s the Women’s Health Initiative. So, this was the biggest,  study that was done to look at hormone replacement therapy, because prior to this study, which started in the late 1990s, Most women would put on hormones because they saw that, you know, during perimenopause and menopause, women just felt so good, and women seemed to be living longer, and it seemed to, they had all these assumptions from observational studies.

Women lived longer, had less heart disease, they were doing great. So they’re like, alright, well, can we endorse this as like,  preventative medicine? Can we just say all women should go on hormones? I mean, that’s a lofty statement. So they, , put up this study, the Women’s Health Initiative, mainly to see, not a normal example of hot flashes or night sweats, but to see, do women live longer?

And can, is heart disease preventive? [00:53:00] So, this was the first, you know, double blind, randomized, controlled study that looked at two different groups. It had women with a uterus and women without a uterus. So women with a uterus, right, we said you need to take that progestogen to protect the uterine lining, so they used Prempra, which was Premarin, that’s the horse, the estrogen from the horse urine.

And Provera, which was a synthetic progestin, which,  We, we, well, I’ll talk about it a little later, but it’s just, it’s not the best, it’s like the worst progestin to be honest. It’s not metabolically friendly, it’s not breast friendly. But hey, they were doing, I always give people the benefit of the doubt, maybe to a fault, but they were doing the best they can with the knowledge they had at the time.

And then women without a uterus just were put on Pramerane. And then each one of those groups had a placebo. Well, in 2002,  I’m like, was that, was any, was everyone here alive then? No, I think so. Okay.  2002, [00:54:00] I mean, it was huge. The study was stopped short because of, I mean, the daytime television was interrupted.

The NIH president came out and said, you know, we’re stopping this study, sure, women on hormone therapy need to get off of it, there’s an increased risk of breast cancer, heart disease, and stroke. Holy, I mean people were so scared, this is how everyone learned about it. No one looked at the study, there was no, no doctor looked at the study.

Patients heard it at the same time healthcare practitioners heard it, and it caused such a media frenzy. Every newspaper, every news outlet, this was all over the world, the world, everywhere. And this was, I would say, well, many other people say it, in fact,  I’m blanking on his name, but a little bit later,  the greatest tragedy to women’s health was this, because it got women who were doing very well off their hormones.[00:55:00]

And, like I said, before anyone could really look at the data, and we’ll talk about some of the flaws, people that were excellent candidates were taken off their hormones. Women that were 37 who went through premature menopause were taken off their hormones. It was very sad. So,  I’m just going to say what we found, and this is with the PrenPro group.

The women who just took estrogen actually did very well, but this is the PrenPro group. So this is where the, all the fear that came out was based on these numbers. So there were 47 additional cases of gallstones and gallbladder disease and I’m going to just, I put in parentheses the reason why we saw that and that was because of the oral estrogen that was used.

 there were 9 additional diagnoses of breast cancer at year 5. I’m going to just reiterate this because that’s what everyone is so scared of is the breast cancer piece. This was what was found just in the PrEP program. And the women who took PrEP aren’t alone, so just the estrogen. There was 18 percent less risk of breast [00:56:00] cancer.

So there was a decrease, a clinically significant decrease risk of breast cancer in the woman who took estrogen alone. Yet, we are so scared of estrogen.  so it was, if you look at it like this, it was the progestin, the provera part that may have been the trigger for the breast cancer. But anyway, not to say that those nine additional diagnoses aren’t significant, they are, but that’s, that’s the way the media came out, made it seem like every woman had risk, like you were putting yourself at such huge risk.

And again, it’s diagnoses. They had better, the women who were diagnosed had better prognoses. They did not die anymore. No one died. They just had these incidents, I should say. There were eight additional cases of pulmonary embolism. That’s because of the oral estrogen that was used. There’s eight additional strokes.

That’s again has to do with oral intrusion and the timing. That’s another important piece. Seven additional heart attacks. That was due to timing. Six fewer cases of colorectal cancer, five fewer hip fractures, and zero additional deaths.[00:57:00]

Okay, so let’s talk about, let’s break down what was the problems with the study. Well, the age and health of the women study, so 70 percent of the women study. were over 60. Well, that’s not when we usually start women on hormone therapy past 60. We usually start when women are having symptoms, you know, 40s, 50s, early 50s.

The average age was 63. 10 percent of the women were between ages of 50 and 55. We know now, through all the retrospective analysis,  that timing matters when you start hormone therapy. Only oral estrogen was used. We know that oral estrogen is more inflammatory, so there’s higher risk of POTS. strokes, and gallstones.

And then the type of progestin used. So only Provera was used, which is a synthetic progesterone. It’s not metabolically or breast friendly. Women who took Premarin alone had 18 less, 18, 18 percent less breast cancer incidence. So that’s like the [00:58:00] breakdown.

Not if you start within that first 10 years. So if you start within the first 10 years of menopause, much higher chance of getting You get all the benefits, and you can continue taking it to the day you die, and you don’t increase your risk. There’s a slight increase if you start hormone therapy past that 10 year mark.

So you can still start hormone therapy, but the conversation’s a little different.

Speaker: Are you aware of this new study that came out in the Metapod’s Journal? Women over the age of 65 taking hormones, women who were taking estrogen, lower risk of not only breast cancer, but other forms of cancer, lower risk of heart disease, lower risk of all cause mortality.

Speaker 6: Would you say anyone who has a hysterectomy should be on just estrogen? Like, is there a reason why someone would not want to be on just estrogen?

Dr. Maggie Ney: Oh, they, [00:59:00]  yes. If you have a history of like endometriosis, progesterone is really anti inflammatory. If you have endo, it’s really not just a hormone thing or a uterus thing.

It’s really systemic. There’s more inflammation. There’s immune modulatory issues. So I would like to get. progesterone for that. Anyone who has insomnia, anxiety, they would benefit from that. Even if they don’t have a uterus. I don’t, I don’t necessarily put everyone without a uterus on progesterone, but it’s like, why don’t they have a uterus?

And then looking at that as a complete picture, because if it’s like very estrogen driven and, like I said, like endo, a progesterone can be really helpful. So basically, HRT is safe and effective for the vast majority of symptomatic women when starting within the first 10 years of menopause. I’ve given it to people past that 10 year mark.

It’s just a different conversation. All the benefits of heart disease prevention,  is a little different. Ok, so, ok, the study came out in 2002, [01:00:00] and then there was all these retrospective post hoc analysis done that did not make the news, right? There was no, no, nothing written up about this really important finding.

In 2007, it was declared that, when you started, within the first 10 years of menopause, women lived longer, decreased mortality, so less likely to die from all causes. There was improvement in hot flashes in the 90s, reduced incidence of osteoporosis, reduction in diabetes. In 2013, there was another post hoc analysis.

30 percent reduction in mortality. Women who started 60s, no effect with regards to heart disease and mortality, but women who started HRT in their 70s, there was a little slight increased risk of heart disease. And then in 2017, there was a follow up post hoc analysis. There was reduction in heart disease, decreased mortality, decreased osteoporosis, and decrease in reduction in diabetes.

This was, yes, they were looking at the same people, and they were looking at the data. [01:01:00] They, remember the data, the results came out in 2002. They just said it as it applied to everyone. Now they’re like, let’s take a look at this study. Who are these people that had higher rates of strokes? Well, oh my gosh, they were all 72.

Wow, in fact, no one in the 50 year range had a stroke. So that’s what they were doing. They were re analyzing the data through a different lens. Also,

Speaker 5: too, it could be other factors as they’ve aged. Totally. If they’re not overall,

Dr. Maggie Ney: you

Speaker 5: know.

Dr. Maggie Ney: Yeah, I mean big argument is also that women who are on hormones get their mammograms more often too.

So you’re more likely to diagnose a breast cancer as well. Anytime

Speaker 9: you’re in a better mood,

Dr. Maggie Ney: you just do things better.

Speaker 9: You do things better. Absolutely. You remember stuff. Yes, you remember to schedule those appointments.

Dr. Maggie Ney:  So, timing hypothesis. So when you start HRT within the first 10 years of menopause, the benefits outweigh the risks.

We already went through all the benefits. But when it comes to heart disease and dementia, it’s timing [01:02:00] that matters.  so again, why are we afraid of HRT? When you start, hormones matter. The form of hormones matter. So again, oral, more likely to get a clot, the stroke, the gallbladder issue. And really, it’s come down to this is the current reasoning, argument is timing.

The timing hypothesis, estrogen gives the greatest benefit, the most cardiac and cognitive benefits when given early in the menopause transition. And the healthy cell bias hypothesis, estrogen offers the most cognitive and cardiac benefits when the cells are healthy to start, not when disease has already set in.

Speaker 7: Question between the pill versus the patch.  is it true that you get more protection when you take the pill For the heart and the osteoporosis, compared to the patch?

Dr. Maggie Ney: Not with osteoporosis, and then when it comes to the pill, there’s like a little bit more of a reduction in, I think, an LDL, but when it comes to heart disease, same outcome.[01:03:00]

Same outcome. Mm hmm.  this is just a little bit of a summary. Ideally, you can start hormones within the first ten years of menopause, but the sooner the better. I mean, why wait until you’re like eight years post, unless someone’s come to you. But like, most of the time, these symptoms, you Start early and just straight.

It’s the, it’s the best for the vasculature. If you have a uterus, you have to be on progesterone, and  consider transdermal estradiol first if tolerated because it’s less inflammatory, less risk of clots, and she may be on, be on it for the rest of her life. A lot of people are like, I like the, I like Aurora, I want to just take a capsule, and honestly, if they were on it for five years, ten years, I mean, most people are fine.

Less risk of a clot than if you take birth control pills. It’s less of a risk. But because women, and now ACOG, menopause society, say that you can be on hormones until the day you die, and we know clot risk already increases as you get older, why not just start transdermally if you’re open to it?

Speaker 7: How about

Dr. Maggie Ney: Let me finish and then I’ll…I just want to say here, [01:04:00] there’s not a This is true.

There’s no family history that’s a contradication to starting hormones. So, someone could be like, I can’t be on hormones Aunt Sally, Grandma Sue, and my cousin Beatrice had breast cancer. That’s not true.

Speaker 5: Yeah, I’ve had an aunt who had breast cancer, and as soon as I mentioned hormones, all my credibility is gone.

Because their MD has terrified them. He factored on some kind of estrogen suppression. But they won’t talk, they won’t even

Dr. Maggie Ney: know. That’s a little different. I was talking about family history, like mom. But personal history, that’s where things are shifting though. It’s true because, you know, so, so often now breast cancer is caught so early, you know, you get it younger and it is, it is considered a contraindication, you know, I’m, I’m telling you with a date, like, non controversial, like, I mean, this is just the facts now, there’s no family history, but breast cancer is still [01:05:00] traditionally, like, a contraindication, but You know, so much is caught early, and what?

So women are getting breast cancer and cured, let’s say, in their 50s, and then dying from heart disease earlier. Having painful sex, they can’t urinate, they’re seriously depressed. So, again, and I, I come back to, it’s shared decision making, it’s informed consent, it’s patients, if you give them the right information, in a safe place, can make the best decision for themselves.

So things that it would be helpful if you have a family that has heart disease, diabetes, osteoporosis, colon cancer, we know hormone therapy has. Helps to reduce that.  failing history of Alzheimer’s. So there’s been a study that if you have the ApoE gene allele starting estrogen early, the menopause transition seems to be neuroprotective.

But yes, we need more. There wasn’t a lot of research there. Who should not go? I’m just, this is like, we could talk about the nuances, but this is just the facts. Personal history of a lung clot or pulmonary embolism. A personal history of an unprovoked blood clot. So, unprovoked meaning you’re watching TV and [01:06:00] out of nowhere you get a clot.

Where it’s provoked, like you’ve had surgery or you’re in a car accident, that’s provoked.  if you’re homozygous or factor V laden, if you have a personal history of a heart attack, stroke, or if it’s stemmed in place, obviously if you’re pregnant, if you have any unexplained vaginal bleeding or untreated endometrial hyperplasia, if you’re actively undergoing chemo, if you have active breast cancer, and then that’s where I said the prior history of breast cancer.

It is a contraindication, but the conversation is changing.

Speaker 10: Is that lung clot due to oral estrogens? I mean, is, is Is, is that where that comes from, or?

Dr. Maggie Ney: It comes from, yeah, that you already have, like, you have to figure out why you had that in the first place, but, yes, if you have had a history of a clot, then, then hormone therapy is usually contraindicated.

If it’s not, if it was unprovoked, meaning, right, like, the clot that travels from the leg, like, what, what caused that to happen in the first place? Okay, I think this is the final slide. It’s the most important one, and I’ve said it a few times, but The patient and healthcare practitioner, their [01:07:00] team. And patients really should be the CEO of their own health.

Not everything is black and white, especially when it comes to period menopause and menopause care.  there’s nuances. And risk and benefits of hormonal therapy need to be weighed against quality of life. All of this needs to be discussed openly with the patient to make them feel supported and heard.

Is there anything else?

Speaker 9: That’s it. I

Dr. Maggie Ney: can take questions I can ask. This is where you can find me.  you asked about all this, I have to answer your pellets. So, they’re very popular. I don’t recommend them. We have a new practitioner in my office who does do them. We just had, I just presented with her,  kind of like comparing, contrasting, but honestly it’s not, it’s, it’s, it’s important that patients know there’s safe options, like there’s FDA approved insurance covered options.

They need to know all their options. A lot of times women choose a pellet because they didn’t get any answers from their healthcare practitioner [01:08:00] and they’re searching and searching. Someone mentioned pellets. They have it. It’s, it tends to give, like, more super, super physiological doses. There’s benefits to it.

I know women feel amazing on them, many do. I haven’t found that I’m lacking anything in my toolkit with therapies that I talked to you about. They’re

Speaker 5: bioidentical. So

Dr. Maggie Ney: they

Speaker 5: could have a

Dr. Maggie Ney: free Yes, and the downside, yeah, they’re, they’re no creams. You don’t have to worry about transferring a cream to someone else.

If you’re working with a very skilled practitioner, side effects are very little, but I’ve seen in my practice women who have super physiologically high doses of testosterone, I’ve seen voice changes, clitoral enlargement that are permanent, and I’ve seen people feel horrible and I can’t do anything to help them.

Because it’s,  it stays in you. You support them, you can help with liver detox, you can do all those things, but I don’t like a therapy [01:09:00] I cannot take back if someone’s having a side effect.

Speaker 5: They

Dr. Maggie Ney: have to write it out. Why, why do, I mean, there’s arguments. I have my, like I said, my new doctor in our office is doing them.

I just, why? I don’t know. I have safe, effective insurance cover options. My patients feel amazing. Like, I don’t, I don’t need to go there, personally.

Speaker: Yeah, I think that’s, that’s one of the complaints about pellets. You get them in, they’re, it’s too high a dosage. You have to wait for them rather than, you know, using other forms.

So you can slowly titrate up the dosage to get the desired effect.

Speaker 7: Right. Two questions. I’m sorry. So there are standard doses you can’t

Dr. Maggie Ney: For pellets, I mean, you have like one pellet has a certain milligram of dose, and you can, and so titrate up. Basically, yeah. So

Speaker 7: there is that option. Yeah, you can have

Dr. Maggie Ney: a low dose, you can have a [01:10:00] high dose, but even a low dose is, can be high.

Speaker: Or if you start with a low dose, now you’ve got to wait 90 days to increase the dosage

Speaker 6: Versus like cream, do you have a little more flexibility in the dressing? Because you

Dr. Maggie Ney: can, yeah. Totally, I just like to have a little, my patients have a little bit more control. Ooh, a lot. A lot more control. Oh wait, I, you had a question, yeah.

Speaker 7:  how often do you do mammograms on your patients that are on hormones?

Dr. Maggie Ney: I mean, generally once a year, one to two, every, every one to two years. And I like the Sonocini too, that, that’s out of network, but,  it’s a really detailed breast ultrasound, basically. Mm hmm. It’s a nice thing to pair with the Mammos.

Speaker 9: Yes? Are there, , like nutrient depletions to consider with hormone replacement, or like, lifestyle? How do you support your patients going through with lifestyle and nutrition, basically?

Dr. Maggie Ney: Yeah, I mean, that’s a huge part. And sometimes it can help just to get their hormones down so that they’re feeling better and more motivated.

But,  I mean, I do individualize it, but the [01:11:00] overall thing is like, real whole foods first. Get rid of the old processes, and then you can more tweak it. So I do work on upping protein,   upping fiber, metabolic flexibility, meaning if someone, someone should be able to fast a little bit, you know, and not feel dizzy and lightheaded.

And when you incorporate the higher protein, the less processed carbs, you can do that better. More easily switch from burning fat for fuel to burning sugar for fuel. So metabolic flexibility, blood sugar stability, and increasing protein are the three pillars. to supporting women during this time.

Speaker 9: Okay.

There’s not the same, like, you know, oral contraceptives we see, like, you know, B vitamin depletion. Oh, no, there is not

Dr. Maggie Ney: that seen. Yeah. Right. Okay.

I like to test with,  Dutch test to see. Sometimes I’ll go off by simping because they’re having a lot of breast tenderness and clots, but, you know, the tests don’t get, like, not everyone benefits from DIMM because it does lower serum estradiol [01:12:00] levels Boo! So, but if I see someone who is not pushing down the 2 pathway for phase 1 liver detoxification, and they’re heavily in the 16 or 4, I’d like to give it to them.

Implant?

I haven’t seen that a lot, I just don’t have a lot of patients that have been on that. So, but I would say really just to support gut health and liver detoxification would be huge.

 I know people really love it. I, I, I just haven’t gone there. I just, I don’t feel too comfortable with all the safety data. I just, I always say like, I’d like to learn about it. I’d love to get more studies. My patients feel so good. I don’t feel like I’m missing, that doesn’t [01:13:00] appeal to me to like add in my toolkit right now,  because my patients are just doing so great with everything else and, and there is some concern with using it.

And I am a little bit more conservative than maybe some other functional medicine doctors.  but I, , the principles of functional medicine like addressing root cause, gut health, liver correction deficiencies, I mean, I’m so passionate about that. But then I do, I am also a research junkie and I do need to, like, see some safety data before doing some of these other therapies to feel comfortable doing it.

Speaker 7: What is your therapeutic dose for, to start, for esrivalin for testosterone?

Dr. Maggie Ney:  it depends who I’m treating, but if it’s peri, like early peri, the depression, the irritability, they’re still getting their period, I do tend to start at the lowest of. So generally, like, if you’re doing a patch, it’s the 0. 025 milligram patch.

If you’re doing a cream or a gel, it’s the 0. 25. So I start low with the, with the early peri, and then menopausal or late [01:14:00] peri, I do typically start at 0. 375. Sometimes 0. 05, 100mg, but I’ll go up to 300mg sometimes.

Speaker 7: When you go up, can you go down afterwards? Yeah. There’s no

Dr. Maggie Ney: Yeah, go by how you feel,

Speaker 7: yeah. Do you give menopausal women a higher

Dr. Maggie Ney: dose?

Speaker 6: Typically, yes. Of estrogast?

Dr. Maggie Ney: I do.

Speaker 6: What is the conversation you have with your like mid 60 patients that come in wanting to start HRT? You said the conversation was a little bit different.

Dr. Maggie Ney: Conversation’s different with regards to benefits and risks. You’re not going to get this. It doesn’t seem to get the same cardiac benefits or cognitive benefits.

Your risk of getting a clot is higher,  in the first six months. Not forever. Really, it’s that first six months. We’re,  because our, like, the vasculature, our blood vessels do better when they haven’t taken a break from seeing estrogen. So if there’s any, like, plaque that’s developed, estrogen, which is normally anti inflammatory, can be a little bit more [01:15:00] pro inflammatory when given, you know, after that 10 year mark.

The risk isn’t huge. It’s just the, the, you’re going to have heart disease, the prevention of heart disease, the number one killer of women, I cannot say if you’re in their 60s.

Speaker 6: Probably no studies on this, but like, aesthetics wise, like, we have so many female patients that want to, like, improve, obviously, their skin, their elasticity, like, does that improve?

Is that a reason that, like, a 65 year old woman would want to go on it versus

Dr. Maggie Ney: Yeah, better to start younger before all the sagging and, I mean, there’s such a dramatic drop in collagen and elastin as we go through perimenopause and menopause.  yes, hormones are great for the skin, even topical estrogen, you know, if you use what you use for your vaginal area, just put a little bit under your eye, that’s been great.

There are some of those, like, telemed companies need that are now giving estriol face cream. Compounding pharmacies are making estriol face cream. But anyway, that wasn’t really your question, but yes, even just hormone therapy is good for your skin. Again, not FDA approved, but, you know, we can, something, it does help.

Speaker: And Dr. Del Rizzi [01:16:00] now is giving women in their 60s It’s in 70s or, you know, it’s protocol for patients with dementia or Alzheimer’s.

Speaker 6: Replacing that.

Speaker: What about for

Speaker 6: the osteoporosis? ,

Speaker: estrogen and progesterone.

Speaker 6: For osteoporosis, is it, would you have to have testosterone to see if it’s like a significant benefit with reversing osteoporosis?

Oh, estradiol

Dr. Maggie Ney: is only with, not osteoporosis actually,  to be honest, it’s, it’s, it’s osteopenia. Like, it’s not, once you have osteoporosis, maybe estrogen’s helpful, but it’s, it’s most helpful if you can catch it before osteoporosis. When you’re in osteopenia.

Speaker 6: What about testosterone? There’s

Dr. Maggie Ney: been no studies.

But, we know it’s good for muscle, and what’s good for muscle is good for bone, so, yes, we need that. But it is good for musculoskeletal, for sure, testosterone. It’s just

Speaker 6: like most women take estrogen [01:17:00] Left out to dry or like just left off? It’s horrible. We

Dr. Maggie Ney: forget about testosterone. It’s so important. You

Speaker 6: would put, like, recommend to all of them?

Dr. Maggie Ney: I mean, I never like to, I’m never like black and white like that. But yes, testosterone would be a nice thing to add to support bone health if you’re like osteopenic. But I always, with testosterone, it is a controlled substance, so you do need to do a lab test. Unlike estrogen or progesterone where you can really go by symptoms.

If you’re going to prescribe testosterone, you need a blood test.  you need to, and then you need to check again six months after, and then every six months thereafter. You can’t, you can’t prescribe it if your numbers are already high. That’s not right. For

Speaker 7: testing, so you start off with a block, and then do you do the dutch test every six months to see where they’re at?

Dr. Maggie Ney: I mean, I don’t. I think that’s a personal preference. I, I go, I really, again, I really meet the patient where they’re at and what they want.  I don’t know, my patients, some of them are very data driven and want the, lots of testing done. I go by how they feel, [01:18:00] I go and make sure their numbers are safe, you know, maybe a, a Dutch test at one point, I mean, some people say every year,  just to make sure they’re metabolizing everything well, but,  I don’t do a lot of recurrent testing if they’re feeling good.

Speaker 7: And, and when they’re on progesterone and estrogen, they shouldn’t be bleeding at all? No. So if they’re spotty, then

Dr. Maggie Ney: So if you start hormone therapy and you haven’t bled, you know, if you’re, and you haven’t been,  if you’re kind of post menopausal, anything can happen when you’re still peri, right? So let’s say you’re post menopausal, you start on hormone therapy, the first six months, you can bleed, it’s not a red flag, you know, we’ve always been taught post menopausal bleeding is a huge red flag.

You can bleed within the first six months, you don’t have to get nervous or anything like that, but,  that can just happen. But after that, then after that, you would want to work it up. And in which case, yes, sometimes lowering the estrogen or increasing the progesterone would help with that.

Speaker 10: Would you comment on testing topical [01:19:00] hormones during salivary testing?

Dr. Maggie Ney: Yeah, I mean, listen, you could talk to a number of different doctors and get a different response. I, I don’t do a lot of saliva. I mean, I rarely, I just don’t. That’s not what I do, but doctors do do it in love and independence. You kind of do what you’re used to doing. I don’t do the saliva. I tend to, well, use mostly blood.

Okay. I, I get the pros and cons of all of it.  I like the dutch test to add in to see how people are metabolizing and I go by how people feel. I haven’t found that I needed to do like a saliva test to tweak a dose or this or that. I, I haven’t had that issue. I hear my patient, I listen to their symptoms, I look at all their other markers, we do all the lifestyle stuff, so.

I don’t know, I think it’s a tough, you gotta be careful. There’s practitioners out there that really like, I don’t know, do all this testing, all this saliva testing, then I’m going to tweak your dose based on this and come in every three months. I just, I feel bad for the patients. Like, I don’t think it’s always necessary.

It’s like a money maker for the labs, for clinicians, but I don’t [01:20:00] really think it’s necessary. I feel bad. Patients need to know there’s options, right? You know, if a patient wants it, great, they don’t need

Speaker 7: it. How about women with hyperlipidemia? Yeah. Is there any contraindication that you No, in fact it can

Speaker 8: help, can reduce it.

Speaker 5: But my lipid numbers went up and in fact, had nothing to do with my food or eating. Oh sure, it’s genetics mostly. Yeah.

Dr. Maggie Ney: So I do like to have, especially for women like in her 60s and want to start a tournament, I’ll get a coronary calcium score. Let’s get a look and see the artery, the, any calcification.  Make sure that’s okay. You know, that, that’s what I would look at as we individualize and discuss risk. And so if someone has high, really high cholesterol it’s usually genetic and you know I like to look at the arteries of the heart to see if there’s any plaque deposits.

Speaker 7: Is that a,  that’s a,  scanning?  It’s a CT scan. It’s a CT scanning, right? [01:21:00]

Speaker 9: Yes? So I guess this is going off the same type of question but let’s say someone is over 60, you know, 10 years past. menopause coming in, would you personally say the benefits still outweigh the risks, or is it kind of dependent on the person? Yeah, I think they usually do what the patient’s

Dr. Maggie Ney: experiencing, but yeah, the risks are very still slim.

 

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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 appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. If you would like to work with me personally to help you improve your health, I do accept a limited number of new patients per month for a functional medicine consultation.  Some of the areas I specialize in include helping patients with specific health issues like gut problems. neurodegenerative conditions, 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.  Please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111. And we’ll set you up for a new consultation for functional medicine. And I look forward to speaking to everybody next week.

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