Rethinking Bioidentical Hormone Replacement Therapy with Dr. Felice Gersh: Rational Wellness Podcast 414

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Dr. Felice Gersh discusses the Rethinking Bioidentical Hormone Replacement Therapy with Dr. Ben Weitz.

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Podcast Highlights

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Dr. Felice Gersh is a board certified obstetrician and gynecologist and she is fellowship-trained in Integrative Medicine. Dr. Gersh is the Director of the Integrative Medical Group of Irvine, where she continues to see patients. The website is Integrativemgi.com and the phone is (949) 753-7475. She also lectures and writes on various topics relevant to women and she is the best selling author of three books, Menopause: 50 Things You Need to Know, PCOS SOS, and PCOS SOS Fertility Fast Track. 

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.

Hello, Rational Wellness podcasters. Today we’ll be discussing hormone replacement therapy and post-menopausal women, and we’ll be speaking with my friend Dr. Felice Gersh. And Dr. Gersh is a huge proponent of estrogen, specifically estradiol. And I always like to say that if Estradiol hired a spokesperson, they could do no better than hire Dr. Gersh. However, she does have some controversial views on hormones. While there are still many physicians who feel that taking hormones is risky, unfortunately much of this view is based on the results of the Women’s Health Initiative study that was first published in 2002. However, where do you think we are right now?  Do you think most mainstream doctors have come around to the idea that hormones are now generally safe, or you think we’re not quite there yet?

Dr. Gersh: I think we’re huge distances from reaching that milestone of the majority of doctors welcoming and not being afraid of hormones for women. In fact, we were just chatting before we started that I just listened this morning to a video by a very mainstream upper level person at a major clinic.  I’ll leave it at that, who is a woman. Basically she was just parroting all the talking points of the Women’s Health Initiative. Like  they were still all a hundred percent valid and, you know, reasonable and should be the guidelines for what we do today. So, and I see patients all the time that come to me because they don’t know where else to go.  Sometimes they fly across many state lines because their regular doctors will not give them hormones. They say they’re so dangerous, they won’t do it. Or they reach an age and they say, I’m gonna stop them because now you’ve reached the age when they’re going to suddenly turn from yesterday being okay to tomorrow.  They’re going to be deadly hormones, I’m gonna stop them today. And so they want to, sometimes they go off of them and they say, now I feel horrible, but my doctor won’t put me back on them. So I think we have a lot of work to do and yes, I am always honest about. Being controversial, but I always say I am totally science evidence-based, although sometimes it can’t be clinically science [00:03:00] study-based because we don’t have the studies, but we have to still make decisions today.  You know, it’s like you’re lost in the woods, you don’t have Google maps, you can do nothing. You can sit down and hope somebody comes to save you, or you make your best decision looking at the paths that exist and so on. That’s how I feel we are, we have to make the best decisions because no decision, doing nothing is actually a decision.  It’s not doing nothing. You’re, you know, because it has consequences if you don’t go on hormones and you don’t get more chances, like, well, let’s do a redo. There’s no redos, right? 

Dr. Weitz:  So I think, in general, those of us who are in the natural medicine world or the integrative or the functional medicine world, we often find ourselves trying to go by evidence.  But because what qualifies as a valid scientific study is a double-blind placebo controlled trial, which is really designed to test a drug. Very difficult to test diet that way. Very difficult to test natural methods that way. And doing these types of studies that are considered valid on enough people, women, men, et cetera, requires in today’s world, millions and millions of dollars.  And so if you’re talking about a compound that’s natural, that can’t be patented. If you’re talking about food, if you’re talking about exercise, if you’re talking about nutritional supplements, which are not going to become multi-billion dollar drugs, it’s very hard to justify those types of studies. So, we have to sometimes deal with studies that are not quite as valid as we’d like based on the model that’s what’s considered valid. And maybe we need to rethink that.  If the model for a valid scientific study is always based on a format that works for drugs, but doesn’t work for natural methods.

Dr. Gersh: Absolutely. You said it perfectly and what seems to be very much we’ll call it even a fad right now, are these meta-analyses, right?  Yes. So they take what studies have been done. This is how you publish in the academia. Oh, well, you know, you take studies that have been done and then you run them through these statistical algorithms, which nobody can understand. You know, we don’t even know what these words mean when they sort of go into their methodology, like, what the heck are you talking about?  But they take, you know, disparate studies done on, you know, varied populations using different hormonal ingredients for different lengths of time. They put them all together and then they draw conclusions like you’re now dealing with a bigger population. But every time they do that, it includes the Women’s Health Initiative, which is so domineering, it’s so huge compared to these other little studies that it, the end result is it’s always just a reevaluation of the Women’s Health Initiative and it just comes out over and over the same, and it’s been written many times.  No one is ever, no government, no entity is ever going to do another funding of a giant study like the Women’s Health Initiative. Which really had some arms that were interesting, but overall, I think it’s been devastating to women’s health over the last 20 plus years. And no study is ever going to be done, like using bioidentical hormones in different doses, different regimen.  It’s just never going to be done. So we have no choice, but to use the scientific data that we have or else we will never go anywhere. And this is the way that it will be forever. And no woman will have, I, in my opinion, the chance for optimizing longevity.  When we look back on, and I went, I was a two years ago, I had one of my bucket list trips and I went to Egypt.  So I’m looking at all these amazing diagrams on the walls of tombs and temples and all of it. And everyone in the picture, they’re all young people and it’s like, well, did not, the Egyptians not like old people, you know? So then I looked it up. If you lived through childhood, which was not the usual many people died in, in infancy and childhood, but if you survived that and you became an adult and you were a woman, your typical, you know, age that you could live to would be 35. I don’t think menopause was an issue. That’s, there were exceptions. There were the occasional really ancient people out there, but that’s, that was typical, you know, if we took a results typical, you may live to 35. And then I looked at, well, what about in the year 1200? Okay. That was more recent. In the, if you look at the entire spectrum of millennia of humanity [00:08:00] on earth, the average lifespan, if you survived childhood once again was around 50 ish. Okay. So just around like you, you didn’t have a long span of time in menopause. And once again, there were always outliers.  So the idea that you spend maybe half your life as a menopausal woman is really modern, you know? So it’s not like we’ve been dealing with this problem for thousands of years. We were just trying to survive to even get to menopause, let alone live a life as a menopausal woman. So, you know, we’re dealing now I call it the medical Whack-a-Mole, where as every problem comes about and everyone has been in very strong agreement that women live a little bit longer than men, but with more chronic diseases and more chronic ills and suffering. So you, we just do this whack-a-mole of, well, now you have this condition, we’ll give you this drug or do this procedure, and it’s one after another.  And it varies with the severity in each woman, of which organ system seems to get the most heavily impacted. And that’s why when they have these studies that show, oh my goodness, we found a link between dementia and osteoporosis. It’s like, duh. Because they all have similar underlying mechanisms so forth.  Here’s a link to everything. And they say, oh, link between this and this. It’s like, duh. So the bottom line is, my goal is to make healthcare really cheap. You know, like you don’t have to have cardiovascular surgery, you don’t have implants, you don’t have joint replacements. Of course things will happen, but if we can take steps, I mean, accidents happen, but if we can take steps proactively to lower the degenerative processes associated with aging of affecting every organ system and especially the brain, which now we’re talking about massive numbers of people in the baby boomer population, of which I am a baby boomer.

Dr. Weitz: And me too.

Dr. Gersh: There you go. Becoming demented to the point that they cannot have self care. Like who’s going to take care of all these people? You know, we’re going to have massive facilities, memory care, places where we lock ’em up so they don’t wander about the streets. I mean, what on earth by the way, 

Dr. Weitz:  …at the cost of a hundred grand a year.

Dr. Gersh: Yeah. I think that this is cheap if you give some hormones and then you do all the lifestyle stuff.  I always say hormones are foundational, but sufficient. You start with that, you know, and I just, I’m just a simple thinker. I think. Well, if you had to have your thyroid gland removed, which is like right here, and because it got really big, like you had this gigantic goiter for whatever reason, you lived in the Midwest and you never had iodine in your diet, ever.  Right? You got this giant goiter, it’s pressed, you may

Dr. Weitz: You lived in the goiter belt. 

Dr. Gersh: Yeah. You can’t breathe. You can’t, they had no choice, okay? You can’t shrink it. So they took it out and now you have no thyroid hormone. No one would say, the solution to your problem of having no thyroid hormone is, let’s put you on Prozac, or let’s give you Ambian for sleep.  Or, I mean, it’s like, this is like crazy, you know, if, and no one would even say things like, well, here’s your meditation. You know, no, that is not the solution. Those all could be useful, but they’re not the solution to having no thyroid hormone. So if you don’t have any estradiol being produced by your ovaries or progesterone, or if any other hormone, whether it’s thyroid, testosterone, is below optimal levels, you supplement or replace it.  I mean, it’s like simple thinking. You need these hormones. If you don’t have them, you give them. I mean, it’s like. Like what is what? This is not rocket science here, you know?

Dr. Weitz: So, I want to make a comment about your perspective on healthcare. I want to make a comment about brain, Bredesen and I never properly introduce you.  So then I want to introduce you and then we’ll get onto the next question. So the first comment I wanna make is that essentially what you’re saying is we should turn our sick care system actually into a healthcare system where we promote health and not simply treat diseases. And then number two, on the brain health, I don’t know if you saw the New York Times piece in which they attacked Dr.  Bredesen’s functional medicine approach to preventing and reversing Alzheimer’s disease as basically being unproven and being too expensive and being completely invalid. And it’s just amazing that they attacked this natural program that has helped thousands of patients. And yes, they haven’t had a randomized clinical doubleblind placebo control trial using a functional medicine approach. But they are presently conducting  such a study. Of course, it’s not going to be with a hundred thousand people, but little yeah, 75 people, but it will be published next year and hopefully that will start to turn the tide.  But and yet the alternatives are these medications that reduce amyloid in the brain. These monoclonal antibody drugs that cost 40, 50, $60,000 a year and don’t make anybody better. The most they do is, make people worse at a slower rate. Right. And have all these side effects like bleeding in the brain and all kind know

Dr. Gersh: I’m, yeah, I,

Dr. Weitz: And you know, it’s so sad that we’re so closed minded to an alternative approach.  And if you look at, even if his program costs whatever you want to say over a period of a few years, let’s say at the max it’s going to cost you $10,000, but compared to paying $60,000 a year for when he’s monoclonal antibody drugs and then having to pay a hundred thousand dollars a year to be in a memory care facility for years on end and having no quality of life.  And for those who read the article, please go to the comments. ’cause there was a comment from one of the women who was in the study and she said, I am Sally. I was mentioned in the study and kind of breaking up prior to following the Bredesen program, which was the most beneficial thing I ever did.  I didn’t wanna live anymore and now my life is totally turned around and I can function and I can go to work and I’m a new person. So make sure you read that comment.

Dr. Gersh: well. Yeah, I was just brokenhearted reading that and it is true that when you hold things to a standard that is unattainable because no one’s going to pay for those kinds of studies, right.  And when you look at what is being actually promoted, as therapeutics for dementias and Alzheimer’s, which are not beneficial in heart if at all. In fact, when they’ve done studies comparing Aricept, which probably made billions of dollars to sure. To placebos. They couldn’t really find any difference.  And it was all subjective. It’s like Mary smiled today, she’s obviously doing better, but it might have been gasp, but we don’t know. But you know, it’s like so unbelievable slowing. It’s like so hard. They’re slowing the progress and it’s hard to even really measure that. And by the way, I checked out, it’s about 20,000 a month now in memory care.  So the price just doubled.

Dr. Weitz: Wow. And by the way, they do nothing to help you in those facilities. You know? They don’t do anything. Good luck to give you any therapeutic care. Yeah. And by the way, one of the reasons why we’re mentioning the Bredesen program is because Dr. Bredesen is an advocate for women sometimes in their seventies to start taking hormones and finding that they’re a [00:16:00] huge benefit.

Dr. Gersh: Well, I remember years and years ago, it was be, well before the Women’s Health Initiative came out, I was at a lecture and they showed slides of. Neurons. So this was not in a person. This was like in a culture medium. And in the culture medium, they had two sets of neurons and one culture medium contained estradiol and it looked like a lush forest. These neurons were so happy, right? And in the other one they looked like dead sticks. And there were no, there was no estradiol. And it’s like, I picked that one, the one that looked, that’s me. I want that my to be my brain and so on. And by the way, just a little bragging writes here in his latest book, Dr. Dale Bredesen mentioned me as big pro an advocate for hormones. It’s like, thank you. Very cool. And so of course I, I support what he’s doing and I’m going to be as much as anybody else, a person to say there’s no way that we know now that we can [00:17:00] actually reverse the very end stages of every disease.

But there, like if you are in the end stages of heart failure. In the end stages of diabetes, right, of an end stage disease. The best you can do is a little improvement. Okay? Sure. But it wasn’t that long ago that it was said that you can’t reverse diabetes. Now we know. I mean now it’s proven. No, I’m gonna say in the, at least the first decade of, and pre-diabetes can always be reversed.  Right. And diabetes in the first decade, you can reverse it. We know that there’s like autoimmune in the conventional world, they say you can’t reverse autoimmune diseases, but we know in the early stages you can reverse it.

Dr. Weitz: Yes.

Dr. Gersh: So, so we’re turning the tide on how you even view chronic diseases, that they can be reversed.  And I a hundred percent believe knowing the resilience, the neuroplasticity of the brain. And that’s what I look at in terms of the hormones. And as you know from. Previous recent [00:18:00] conversations that I’ve expanded in terms of my advocacy to include progesterone and also I do talk, you know, on the benefits of every other hormone because we don’t wanna leave them outta the mix here.  They’re all important, right? I just, you know, put estrogen at sort of the pi, the pinnacle, right? They all work in this beautiful, you know, synergy of symphony and all those kinds of words that we use to talk about how they work together. But definitely in especially the earlier stages of cognitive decline, you can have massive reversal due to neuroplasticity, you can improve inflammation.  We now know that underlying neuroinflammation, which is aligned with systemic inflammation and then all the other systems of the body, the autonomic nervous system, the gut microbiome, all these things interlink and it’s related to both lifestyle and hormones and all of these critical factors that when you get things better and [00:19:00] neuroinflammation goes down, you improve.

And we know that cognitive health and emotional health are completely interconnected. So when you know they go together and they’re both now related to neuroinflammation. And then, you know, you get into the nitty gritty of well, you know, energy and mitochondria and these are wonderful, fun topics to go into.  And, but when we get to the point where I wish we would be, I think we should be, but I don’t know why we’re not universally, but it’s growing of, and it’s more growing from the bottom up than the top down. You know, it’s coming from the population that is of women that is now, they’re demanding hormones.  It’s not coming from the academics, you know, at the top, you know? Right. Coming by saying, let’s get everyone in and give them hormones for life. That isn’t what’s happening. It’s the women themselves who are now the demanding factor here in driving this machine of wanting hormones and then getting [00:20:00] other.

Practitioners, some of which know what they’re doing, and some are just trying to know what they’re doing. You know, I, I assume everyone has good motives. Yeah. And to try to help women. But if we get to a point where we could say hormones are good, you know, like there are many things to be afraid of on this planet, but, you know, bioidentical hormones should not be on the list.

You know, how about chemicals and deadly guns? And we can make a lot of lists of things to be afraid of, but, you know, bioidentical hormones just should not be on that list. Right? Then you get to this really complex issue and I really hate it when I call it like the hormone wars of different groups who are promoting the benefits of hormones for women and throughout menopause.

You know, starting now in the perimenopause, which is now the thing, recognizing all the harm that is happening years, like a decade. Before and then really escalating in the previous five years [00:21:00] before that artificial label of now you’re menopausal which is arbitrarily defined as 12 consecutive months without any bleeding.

Right. And you know, so if you’re a hyster ized, it’s like, good luck you had that. So I don’t go into menopause because I had a hysterectomy. Yeah, you do. Okay. Forget the language. You know, it’s about ovarian. Aging. It’s not about your uterus. The uterus is a recipient of the hormones just like your brain and your every other organ system in the body.  But if we can get to the point of saying hormones are beneficial, and losing them is harmful, by the way, everyone agrees that losing them is harmful, but they can’t get to the other side of the mountain of saying and giving them is beneficial.

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Dr. Gersh:  Losing. I know, I’ve always thought that was insane.

Dr. Weitz:  How can these hormones that have been in your body for decades and we know are responsible for women having lower rates of heart disease and having all these other benefits that suddenly after menopause, putting those hormones back is now harmful?

Dr. Gersh: So, absolutely. So here’s the problem. There are studies that show that you have and one just got published.  It’s like really upsetting in a way because people read these things. It was a recent study looking at in the uk thousands of women who had early onset of menopause, like around age 40 or a little before age 40, which we know is [00:24:00] bad, right? Right. The longer you have your hormones, the better off your organ systems are.

Dr. Weitz: Right?

Dr. Gersh: And they found hardly surprising that the women who went into early menopause had higher. Rates and earlier onset of dementias. Okay. We, you and I knew that, but they had to prove it again. So good for proving that. Like we said, it’s been kind of universally agreed that losing hormones is not good for women to lose them.  And the earlier you lose them, the more rapidly you start having problems. But what they also said in that article, they said women who used hormones, at least like for 11 years or longer, they had higher rates of dementia, the hormone users. So, oh my goodness. So how could that be? Once again, how can it be Of course, I’m sure.  That it was, you know, Prempro because, you know, they just took any what were you on Hormones they didn’t like say what kind of hormones like were you on hormones? Okay. Did you fill a prescription? I mean, they’re not even talking to you.

Dr. Weitz: You’re pointing to the fact that Prempro is estrogen from a horse and synthetic progestin as opposed to bioidentical natural estrogen and progesterone.

Dr. Gersh: Technically they are endocrine disruptors, that they’re not human hormones, right? And anything that is not a natural human hormone is an endocrine disruptor. It means it acts differently on the production distribution, utilization elimination, degradation of hormones in our body. It’s not the same. So they’re basically endocrine disruptors.  And we now know that they have harmful effects, like dramatically increasing the risk of blood clots with the conjugated equine estrogens and increasing dementia and breast cancer from hydroxy progesterone acetate. But in any case, that’s what was written in the article, like, so the longer you’re on hormones, the more likely you’re gonna have dementia.  So. This obviously makes, how can this be? If you have your own [00:26:00] natural hormones longer, you have less dementia. But if you give hormones back, you have more dementia. So what did this come down to? It obviously is what we’re giving and how we’re giving it. I mean, it’s like such a simplistic, obvious solu answer to how can, if you have natural hormones, everything is good, but when you give hormones, things are not good, you know?

So it has to be how we’re giving them, what we’re giving them. I mean, of course, we all recognize this, that, you know, the Prempro product was not the ideal product. But now we are in this situation where even among the groups and they’re growing clearly in response to women’s demands as well, of giving hormones that giving hormones is good and beneficial for the long run for the life of the woman.

Then the question really comes down to, What are we going to give? How are we going to give it? And this is really where I’m doing my most focusing now is because I am so tired of defending hormones, which I will continue to do. Okay. Because I have to still do it because, you know, there’s still maligned it.  Like if you constantly had to defend avocados, I used to have to do that because like, fat is not evil. I know there’s fat in avocados, but avocados are not evil. Neither are walnuts. They’re not evil, you know? So, but I don’t have to defend fat so much anymore. But I still, I have to defend hormones. But now

Dr. Weitz: I think we’re going to put a tariff against hormones.

Dr. Gersh: I.  We can, but you can’t stock up forever. They do expire, but but the thing is, this is where we do not have adequate studies and we probably never will. This is like a huge problem. So I look at the data that’s, that we do have, some of them are very talk about studies. Some of them could be like 10 people, you know?  I mean, because it’s collecting scientific data. It’s not like a big randomized study because no one’s funding them and there isn’t enough interest in these topics and which is so sad. But women have to make a decision and providers have to decide what they’re gonna be providing in their prescriptions.  And it’s all over the place now, as you know. And of course you’re going to have different outcomes. I mean, one of the little truisms that I always have to spew is dose matters. You know, like, like how could dose not matter? Right? But you know, the mantra after the Women’s Health Initiative was the smallest dose.  For the shortest amount of time and the smallest dose to suppress night sweats and hot flashes because that was the only indication and still remains pretty much the only official indication is suppress night sweats and hot flashes. Forget about everything else. And it turns out it can consider it a blessing or a curse that the amount of estrogen, even a little progesterone or testosterone, seems to be able to do it.

That will suppress night sweats and hot flashes is like a whiff, but the amount that you would want to actually do more than that is going to be a higher amount. Now it does turn out as well that the amount of estradiol to help to stop bone loss. So it will slow the the, you know, the resorption of bone is also a relatively small amount, but the problem is that it’s not gonna be the same if you want to work on brain, if the, if you think about growth factors, okay?  One of the problems that’s never ending is the uterus. And nobody wants to have the uterine lining grow because if you grow it, you must shed it. You can’t grow the uterine lining and then [00:30:00] just let it keep growing. It’s gonna become unstable, fall out, and then you get random bleeding, and that’s not acceptable to anybody.

And you’ve gotta do something. So you so the solution that’s most common now is to give tiny amounts of estradiol. Often if you measure the level in the blood, which is the gold standard, and it’s measured in picograms per milliliter, the levels remain in the menopausal range. They’re so low because you can still have, if you go from a level that is 15 to 30, which is still menopausal level you can actually have some reduction.  It may take 12 weeks. I mean, that’s the kind of length of time. Stick with it for 12 weeks and see to suppress night sweats and hot flashes. You’re not sure, like, what is that? Is that placebo? It takes eight to 12 weeks. But in any case, giving little bits of estradiol will help in that regard.  It seems, but you’re not gonna grow too much. [00:31:00] You will still grow a little bit of uterine lining over time, like drip. If from the faucet, if the drain is plugged, eventually. The sink basin will be filled with water and overflow, and eventually some women will start having random bleeding even on these teensy doses.

Dr. Weitz: Let me just step in for one second. For those who aren’t following exactly. What you’re saying is during a normal woman while she’s menstruating, her hormones will cause uterine lining to grow. And then because there’s a natural cycle for the progesterone, as the progesterone drops during the last two weeks of the cycle, and then during the period the uterine lining is shed.  So you never get this extra buildup of the uterine lining. And now if you start taking hormones and you take them every day and you don’t get that natural period, you’ll potentially have the ute uterine lining grow and not be shed ’cause you’re no longer having this [00:32:00] cyclical situation and having a period.

Dr. Gersh: Right? So a normal female cycle has estradiol and it’s not gonna be the same level through the whole cycle and. Then after you ovulate, which is like around mid cycle, then you make progesterone, and then if you’re not pregnant, it comes down and the estrogen and the estradiol and the progesterone levels.  Plummet, you know, stroop, they really plummet. And then the uterine lining is shed in a coordinated, organized fashion. So it’s not like random pieces just falling out over the next three weeks. So it’s like a coordinated elimination of the uterine lining. But if you don’t want to have, if you’re like. 55 and you or your provider said, well, who wants to bleed after menopause?  So we are gonna try to keep you from bleeding and still give you hormones. And that’s sort of a diametrically opposed situation here, [00:33:00] because if you have a woman and you don’t want her to bleed, but you want her to have hormones, then you have to make certain accommodations like give tiny doses of estradiol to have less growth factor effect so that you’ll grow less uterine lining because there’s a dose relationship here.

And then you give progesterone and it’s typically given as an oral pill every night. Typically in a dose of a hundred milligrams. Sometimes people go higher and you give it every night because progesterone has sort of both synergistic and antagonistic effects with estradiol, depending on the situation and in the uterine lining.  It actually suppresses growth. And so it blocks the growth and then it makes the lining see like flourish. We call it secretory. And, but if you give tiny amounts, progesterone down regulates the [00:34:00] receptors. There’s this sort of interaction of the receptors of these different hormones. They, nothing is like com is simple.  It’s all complex. So progesterone downregulates the function of the receptors of estrogen. So you give progesterone all the time, every day to suppress the function and growth of the uterine lining, you know, and the function of the estrogen. And then you give tiny amounts of estrogen, usually keeping the levels within the menopausal ranges that women would have.

And then you, the goal is not to bleed. Although occasionally, like I said, the women will bleed anyway. But here’s the problem with that. That is not in any way aligned with the way a human, female body would ever work at any time in her life. And so there’s a lot of compromises that go into that in terms of long-term outcome.

And I think that is one of the contributors to why they’re not showing when they do [00:35:00] studies, like long-term benefits from hormones, and there’s a variety of things that are going into that. If you don’t give enough estradiol to create growth factors to grow the uterine lining, why would you think you’re creating brain derived neurotrophic factor, nerve growth factor, vascular endothelial growth factor, any of the growth factors that are necessary to create new blood vessels, tissue healing, rejuvenation of our neurons in our brains, and so on.

Why would you think that? Then when you look at what happens in the brain as far as the neurotransmitters, estradiol is key to the production and function of serotonin from which comes melatonin for sleep, acetylcholine, which helps make memories and modulates the vagus nerve function of the autonomic nervous system.

Dopamine, oxytocin, which is a really important little, I mean, you can call it a neuro hormone or a peptide. [00:36:00] It’s kind of on the line, but all of these rely on adequate amounts of estradiol, so there’s so many things that are estradiol related and the immune system, we know this. There’s data showing that low amounts of estradiol, like what you would have during the menstrual bleeding phase, the shedding phase.

Low levels of estradiol are actually more pro-inflammatory and high levels are very anti-inflammatory. And if you think about the menstrual cycle, it’s a great guide to everything female. In the menstrual cycle. When you’re bleeding, your estradiol levels are really low. There actually can go into menopausal range for a couple of days, and that’s when you’re most pro-inflammatory.

Because shedding, the uterine lining is actually of an inflammatory process. You make inflammatory prostaglandins in the uterine cavity that triggers some cramping. It’s like a mini version of labor, which actually is, you know, a pro-inflammatory state, right? [00:37:00] And you get cramping and the dropping of the progesterone.

Progesterone is very anti-inflammatory as well, so you are more pro-inflammatory. So it. Is this what you want? You want to create a pro-inflammatory state in your menopausal women? I don’t think so. And you need adequate estradiol to maintain the optimal gut microbiome, the diversity and that protective mucus coating that keeps you from getting leaky gut, you know, and maintains gut lining integrity.

All of that is dose related, so. And you need to also have this beautiful cycling because when you stop the progesterone, it actually is like a reboot to the receptor function. It’s like, okay, like reboot, and then the estrogen receptors come back online because they’ve been now downed by the progesterone for that phase of the menstrual cycle.

And also progesterone down regulates [00:38:00] testosterone receptors. So that’s why during the luteal phase of the menstrual cycle, women have lower libido because nature doesn’t care if women have sex when they’re no longer fertile. ’cause you can’t get pregnant in the luteal phase. So it’s like, go to the next lady, you know, whatever.

You know, it’s like. Not tonight, dear. I’m go to go somewhere else because that’s nature’s way. It’s all about reproduction and success and there’s no reason for there to be libido in the luteal phase. Nothing. You’re not gonna conceive, and that’s all, it’s all about reproductive success. And so why would we wanna do that to women in menopause?

And then we give them testosterone while we’re downregulating their testosterone receptors. There’s like, but people aren’t thinking these things through. And you know, I realize that it’s not fun to have a period, but there are ways to make it manageable. Plus there are people that don’t like to brush their teeth or floss and then they just, you know, just get over it.  You know, this is how we’re made. It’s, 

Dr. Weitz:  but for those who aren’t following, where Dr. Gersh is going is she’s advocating for taking progesterone cyclically essentially for two weeks out of the month. Correct.

Dr. Gersh: Yeah, because that’s just how we’re made. I like, don’t blame me for how we evolved. You know? It’s just, you know, it’s like, like some people don’t like to sleep.  And then you’re gonna pay a price for it. Like, I like to go to bed. I’m not saying me, I’m saying some arbitrary person says, I like to stay up. I’m a night owl. You know, although humans are diurnal, we’re not nocturnal, but they think they are nocturnal. And I like to stay up till three o’clock in the morning and then I get up at six, but sometimes I take two hour naps in the afternoon.  It’s like, that is not beneficial in the long run. That is not optimal. But, you know, if that’s what you wanna do, that’s your choice. But I think people should have choices, but I think they should know what’s optimal. I mean, I’m sorry that we’re diurnal, we’re not nocturnal. And we’re supposed to have, we’re supposed to eat at certain times.

We’re supposed to sleep at certain [00:40:00] times. And for people who don’t like to exercise, it’s like I, like someone says. I don’t wanna sweat, so I don’t wanna exercise. It’s like, well, that’s your choice, but there’s a price to be paid for that. And it’s like, I don’t wanna bleed. It’s like, well, okay, but there is a price to be paid for that.  But pe the women are not getting informed. They’re not being told. But if you don’t bleed, it means you can’t have levels of hormones and rhythms of hormones that are what we’re designed to have to optimize everything. And now, and the rhythms affect gene expression, like tumor suppressor genes and so on.  It’s not little matter here

Dr. Weitz: now to go the next level up. If we really wanted to duplicate a woman’s natural hormones. They don’t have a consistent level of estrogen the whole time, and even for two weeks, they don’t have a consistent level of progesterone. It ramps up and it ramps down. And the same thing with the estrogen.  So ideally we should have a pattern of taking these hormones so they ramp up and slowly ramp down, shouldn’t we?

Dr. Gersh: Well, I have a few patients who are doing sort of that kind of a rhythm, but in reality we have to be also cognizant and, you know, like

Dr. Weitz: practical.

Dr. Gersh: We, if we make something so complex

Dr. Weitz: right,

Dr. Gersh: then we’re probably gonna have no one doing it.  And there was so, there, this is for my patients who are like more advanced I will do something that matches and this is not too complex. Say you’re using an estrogen patch, right? That’s a simple thing to use. Right. There was a study published where they used progesterone that as a 200 milligrams as an oral pill in this study, and they used a 0.1 milligram estrodiol patch, and what they did is the women had no estrogen.  They did what they call flow mediated [00:42:00] dilation. That’s what they use a lot in studies to look at if the artery is constricted or dilated. Right. And the answer is you want it to be dilated. Okay. You don’t want it to be constricted. Right. Okay. So without any estradiol, the artery was constricted. They added the one patch of 0.1 milligram, the artery dilated.  Then they gave 200 milligrams oral progesterone, and sad to say the artery constricted again. But most importantly, they actually measured the estradiol level in the serum. And it was like in the eighties. Okay, so 80 picograms per male. Many women never even get to that level. Okay. That’s the 0.1 patch, the highest dose patch.  And, but then when they added the oral progesterone, the artery constricted. Then another study, they did the same thing. No estrogen artery constricted. But this time they did two of the 0.1 milligram patches and they measured the level of estradiol, and it was in the one 20. [00:43:00] Okay. And then they added 300 milligrams of vaginal progesterone, and then the artery stayed dilated.  So that’s it. I mean, that’s the studies that I got. I don’t, I can’t say, well, let’s do another study. Well, I wanna do another study, but it hasn’t been done. But if you just look at that data, what does it tell you that when you have. 200, that’s what they use, 200 of oral progesterone combined with a level of estradiol that gets up into the eighties that the artery constricts.

But if you give, you know, a level up into the one twenties and you give the vaginal progesterone 300, the artery stays dilated. So for my patients who are open to this, I tell them to use the progesterone vaginally. I tell them we can do and we can give the estradiol any way they want. [00:44:00] Patches, gels, creams.  What I wanna know is what is the level in the blood, because that’s what I’m dealing with, you know? But if I do patches, then I’ll say, well, let’s try what they did in the study. We’ll do one patch when you’re not on the progesterone and two patches when you’re on the progesterone. That’s not hard for people to handle.

Okay. Then if they really wanna do that spike of estradiol, I’ll tell them for one day. For one day, maybe use two and a half or three patches for one day. You know, very few people wanna deal with that. But if they really say, some patients like, I wanna mimic the menstrual cycle more, then we’ll just try to get a level up into the three hundreds picograms per mil for like one day.

Okay. We can do that. It’s like one day in the mid cycle, like around day 12. Okay. Then for the progesterone. I will usually give 200 and rarely 300 vaginally for that, for those two [00:45:00] weeks. And we have a lot of data on vaginal progesterone because that’s what’s used all the time in infertility cases.

Like every IVF patient, all the infertility patients, we have a lot of data and we know levels and what is achieved with vaginal progesterone. And the pill that is used orally actually is approved. And that you, if you go to Mexico to buy your progesterone, or if you live in Mexico and you buy your progesterone on the box, the same micronized, progesterone on the box, it says oral or vaginal.

Okay? And there’s a lot of studies using these identical pills, using them intravaginally. And when you do it intravaginally, the levels that are achieved in the blood. Are physiologically aligned with luteal phase levels. When you take it orally, the levels that you get with like a hundred, if you actually measure progesterone in the blood, you get levels of like 1, 2, 3, that now those are really [00:46:00] low levels of progesterone.

You’re hardly getting any progesterone. That’s like the crazy thing. And progesterone is good, okay? But what you do get is a lot of metabolites of progesterone because when you take it orally, it goes through the stomach, the digestive tract, and ends up in the liver. And the liver is a metabolic powerhouse of transformation.

It converts things and it converts 80 to 90% of the progesterone that’s taken orally into other stuff called metabolites. The dominant one being allopregnanolone, which is good, but too much of a good thing is a bad thing. And then we actually have published studies showing that if you take a hundred milligrams.

You should be getting two and a half times the level of allopregnanolone that is max, you know, two and a half times the maximum level you’d ever have naturally in a luteal face. This, you know, when you’re making progesterone during a menstrual cycle, and so if you take 200, you’re getting [00:47:00] five times the upper limit of what you’d ever have naturally.

And allopregnanolone, which is an antidepressant anti-anxiety, it actually is neuroprotective and it activates the gabaa receptor. So GABA is the inhibitory neurotransmitter in the brain that creates calmness and sedation welcomes you into sleep. Okay? But once again, too much of a good thing is a bad thing.

So there is published data showing that too much allopregnanolone, just the right amount is great. Too much can over activate GABA and create impairment to memory formation. And may we don’t have long-term data, may increase the long-term risk of dementia, which may be a contributing factor to these studies that say the longer you’re on hormones, the wrong type, you know, they’re not given the right way, the more you’re going to get dementia.

But, and [00:48:00] also there’s. I, we don’t have a ton. We have a lot of data on Allop Pregna, but not enough looking at it as a hormone replacement. ’cause you know, they’re looking at it in different ways. It’s actually as a synthetic version is used for postpartum depression. And by the way, in postpartum depression, the synthetic version of Allop, which it turns into allopregnanolone.  It’s a controlled substance. It’s a Schedule four controlled drug. It’s in the same category of drugs like Valium, Xanax, Ambien, and because it has all the same warnings, because those drugs, they don’t actually work in exactly the same mechanism, but they create the same effect. Activating GABA too much.  GABA can make you too sedated. That’s why they have warnings about don’t drive, and it could be addicting and this and that because they’re worried that it’s why did they make it a controlled substance, you know, the same like Ambien and so on, and Valium, because it has, there’s worrisome. [00:49:00] And then so we’re giving this to women and they don’t even know.  And a lot of women feel it though. They say when they take like, especially 200, but even 100, they feel, I feel drugged. Like, I’m so sleepy. Or like, I feel like I have a hangover the next minute.

Dr. Weitz: So I would challenge you there that a lot of the doctors I talk to who prescribe bioidentical hormones say that.  They don’t hear that from their women patients, that most of the women patients feel better, have better brain health, can sleep better. We have all this data that these metabolites of progesterone, like allopregnanolone, which are called neuro steroids, actually are beneficial for the brain. We even have studies showing that they can be used even in men after traumatic brain injury, that they reduce neuronal loss and enhance myelination and improved brain recovery.  So, I don’t think the experience of most women taking [00:50:00] progesterone matches what you’re saying.

Dr. Gersh: Well, I have given thousands of progesterone oral prescriptions out. So I know that there are many women who definitely feel the effects, but not all. Some of them, they love it. But here’s the thing. They also love their nightly Valium.  They also because they like sedated at night. But you know what? Sedate? We know that if you give Valium every night to a woman and this is being done, you know, Xanax every night, it’s being done that long-term. That does increase their risk of long-term dementias because it does affect the ability of the memory formation.  So here’s the thing a lot, by the way, the myelin, that seems to come from progesterone, no. Allopregnanolone is a natural metabolite of progesterone and the brain can make. From cholesterol can make progesterone, and it does. And then from progesterone the enzyme five alpha reductase is in the brain.  It will convert progesterone to allopregnanolone and progesterone is and should be used, I believe, for traumatic brain injuries for stroke because it, and, but a lot of the research shows that progesterone has its own receptors and progesterone itself. Is responsible for a lot of the positive brain effects.

And Allopregnanolone also has its own separate receptors, and it also is responsible for benefits. But so is progesterone. And progesterone is the dominant one for the myelin. Myelin, not the allopregnanolone. And so usually when people are treated for allop with allopurinol they’re getting progesterone.  Okay? So you don’t know how much exactly is progesterone in the brain versus allopregnanolone, but when they actually reg, look at the, what’s happening with the receptors, a lot of the benefits to the brain are from the progesterone receptor activation, not the allopregnanolone, but allopregnanolone is [00:52:00] beneficial.  And and absolutely I want people to have allopregnanolone, but I want them to have it in the natural way that they should get it. Not a giant bolus pouring out from the liver in you know what? Because you took it orally. When you take. Progesterone vaginally. You get systemic levels that are equal matched to what a woman would naturally have in her.

Her actual luteal phase. When you do oral progesterone 200, the levels of progesterone that are achieved in the blood will be like three or four. In a normal menstrual cycle, anything under 10 is considered. You didn’t even have a good ovulation. That’s like totally inadequate. And for fertility, you wanna be in the upper teens or even the low twenties of progesterone level.

So. Recognizing that progesterone has its receptors everywhere in the body, in it’s, it activates and is good for a skin and bone. [00:53:00] And the immune system, it’s very anti-inflammatory. It has a complete amazing interconnection with the endocannabinoid system along with estradiol and in the brain. It has its own receptors that are very good for neuroprotection and can downregulate as an anti-inflammatory agent.

When you have the activation of the microglia, if you have brain trauma and you get this over exaggerated inflammatory response, it helps to dampen it. That’s all from progesterone and then in the brain and in the liver and elsewhere, progesterone is naturally converted as needed to its metabolite, allopregnanolone to create the optimal effect.

But when you give progesterone orally, you’re not achieving any. Adequate amount of progesterone. You think you’re getting progesterone, you’re not. That’s why we get terrible bleeding irregularities if we start raising the dose of estradiol, because the amount of [00:54:00] progesterone isn’t up to the levels it should be to create what’s called complete secretory transformation of the endometrium.

When you give it vaginally, the data shows at 300 milligrams. Vaginally will pretty much a hundred percent give you complete secretory transformation, and it actually activates within the endometrium coming up from the vagina before it gets into the bloodstream. So you get both this amazing effect on the uterine lining.

That’s why it’s used in fertility cases all the time, because you make the uterine lining perfect, complete secretory transformation for implantation of an embryo. But if you’re not pregnant, you have the perfect uterine lining for elimination for the perfect period. That’s what I’m finding when you get women to use it vaginally and most of them are highly accepting of it, don’t, you know, it, they’re, the it factor is really not what people think.  They don’t have a problem, but they get, instead of [00:55:00] like multi-day of heavy bleeding or cramps, they get like three days of not heavy bleeding and it’s like over and because it’s proper secretory transformation. I think this is underlying a lot of women in the reproductive years not having normal periods because they don’t make enough progesterone and then they don’t have proper secretory transformation.  But I’m finding most women, although 300 is like a hundred percent, 200 is close. It’s close. And we don’t have at this time a 300 pill. 

Dr. Weitz:  So, so you’re using a 200 pill? 

Dr. Gersh: I am, but I’m seeing what happens and I’m measuring level. I measure, I was taught don’t measure progesterone levels. I never did before. I don’t.  And I’m thinking, why didn’t I do that? Now that I’m doing it, I’m shocked. Although I’m not surprised because this has already been studied and published. I’m just now finding out and re replicating what the studies already said, which is that when you take it orally, the levels you achieve in the blood are teensy and then you get all this massive [00:56:00] allopregnanolone.  But I’m not down downplaying the benefits of allopregnanolone. I’m just saying everything should be in the right amount at the right time. And when you take it orally, you get boluses that is not natural. And you’re getting at a minimum with a hundred, two and half percent, two and a half percent, two and a half times the amount you would ever have.  Naturally they, we have studies published showing that 40 milligrams. Of oral progesterone will give you the op maximum amount of allopregnanolone in the blood that you would get during a luteal phase. So what I’m doing, just so y’all and I made this up, I mean there’s no data to prove that anything I’m saying now, okay, not there is for all the other stuff I said that’s published.  But this what I’m gonna tell you for women who say when you take them off the oral progesterone. But I love it. I love it. I can’t sleep. Most of those women are not on optimal estradiol. ’cause that’s estradiols effect on sleep is not appreciated [00:57:00] when you give these tiny doses, because remember I mentioned a little bit ago, estradiol is critical.

For acetylcholine function and production, which activates the vagus nerve so you get more calm and sleep. But also serotonin neurons in the brain require estradiol, so you make more serotonin and you can’t make melatonin without first making serotonin and you have better gut microbiome. And that’s where a ton of melatonin is made.

And serotonin is made in the gut, right? So you’re going to have better microbiome. Production of these really essential, and of course, they work in synergy with our own entero enterocytes, our own cells that make these neurotransmitters. By the way, you get what? Better GLP one. That’s where it comes from.

Estradiol helps to maintain the GLP one, producing Entero. Enterocytes, so you don’t lose, get appetite dysregulation and start having insulin resistance and get obese. Okay? Because, you [00:58:00] know, getting those all problems of women going through menopause. So the bottom line is that when you take, this is what I made up 25 milligrams.  20 to 25. So that’s still below the maximum that you would ever have in a normal luteal phase. But often it’s just, and this is, I’m treating it, this is giving progesterone to give allopregnanolone. Okay? This is my way of giving Allopregnanolone at a sub. Maximum dose. So I’m giving a little bit just to help them while they’re getting adjusted.

Not decision shouldn’t be for life. Well, I’m getting their estradiol levels up. These are like usually new patients or transformative patients. You know, we’re changing their regimen and and that often is enough progesterone to help them to fall asleep and stay asleep. And then I do all the other sleep hygiene things like use a sleep mask that know if you don’t have a really pitch [00:59:00] black room, even a little bit of light filtering through the eyelids will suppress your melatonin production.

And I use very small doses of melatonin on a regular basis for those women, like half a milligram, that they take two hours. But I also know that they’re essentially like jet lag. So I’ll give them like nine or 10 milligrams of melatonin for three nights. That will actually click back the the master clock and help with the circadian rhythm readjustment.

So, but I’m just putting all this together. You know, I’m still new at what I’ve just told you because I was buying into the oral progesterone too. I mean, I still have a lot of patients on that, and as I see them, I’m introducing them to the concept. And I am so happy to say that the vast majority say, sure.

When you know, let me try it. You know, like what’s the harm in trying it? And I’m getting really good results. And here’s another little weird sounding thing. There’s actually published data that you can put it in the rectum. [01:00:00] Actually for women who say, well, I think there’s a little leakage. I don’t like it, blah, blah, blah.

You know, it’s like, well, you get really good serum. You don’t get that first pass with the uterus, but you get really good serum levels. If they just poke it up into the rectum and then they go to bed and then there’s no any leakage because it, the rectal sphincter, you know, keeps it there. So, and for women who have, they say, well, you know, it’s a little dry.

It’s not dissolving well. And I don’t have any data on this either, but I know other people have tried it, you know, just run it under a little bit of water before you put it in. So it just sort of loosens it. By the way, that happens when women use, like the vaginal inserts of estradiol, if their vaginal canal is kind of dry, those little tablets and inserts that they put in, you know, like, like vame and things like that, they they don’t dissolve, they don’t dis, it’s too dry in there.  So if you wet them first and then put it in, it works.

Dr. Weitz: I see.

Dr. Gersh: I don’t know, just sort of something that we try and then I test levels, so I’m always gonna know if we achieve good levels or not. I know that’s a lot, and that’s [01:01:00] not what most people are doing. I know I’m an outlier. I know I’m an outlier, but that’s okay.  It’s science, it’s ev, it’s science based, not. And in clinical studies with 10 people. Okay. Right.

Dr. Weitz: Hey, this has been a fascinating discussion. I do have to get on with patients, so let me now give people a little more information about you. Dr. Felice Gersh is a board certified obstetrician and gynecologist.  She’s fellowship trained in integrative medicine. She’s the director of the Integrative Medical Group of Irvine where she continues to see patients. She lectures around the world, writes on various topics relevant to women. She’s a bestselling author of three books, menopause, 50 Things You Need to Know.  P-C-O-S-S-O-S and P-C-O-S-S-O-S, fertility Fast Track, which you can order through her website. And what’s your website?

Dr. Gersh: It’s integrative mgi.com. 

Dr. Weitz: Okay. And your phone number for patients who wanna get ahold to make an appointment to see you?

Dr. Gersh: Oh, sure. Yep. It’s 949-753-7475.

Dr. Weitz: Thank you so much, Felice.

Dr. Gersh: Thank you. Thank you for letting me present my new ideas.

Dr. Weitz: It’s, this was fascinating. I think everybody who listens to this, who’s into this is going to be just the, it was like going to a Jeffrey Bland seminar where your neurons are all tingling. Thank you. 

Dr. Gersh:  Well go address your patients and I’ll do the same and have a wonderful day.

Dr. Weitz: You too. Bye.

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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 very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. As you may know, I continue to accept a limited number of new patients per month for functional medicine if you would like help.  Overcoming a gut or other chronic health condition and want to prevent chronic problems and wanna promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111 and we can set you up for a consultation for functional medicine and I will talk to everybody next week.