Progesterone with Dr. LaKeischa McMillan: Rational Wellness Podcast 387

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Dr. LaKeischa McMillan discusses Progesterone with Dr. Ben Weitz.

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Podcast Highlights

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Dr. LaKeischa McMillan is an Integrative Obstetrician-Gynecologist who wrote a best selling book, The Other PMS: Your Survival Guide for Perimenopause and Menopause, and she lectures frequently on perimenopausal and menopausal health and hormones.  Her website is IntegrativeGynSolutions.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. Hello, Rational Wellness Podcasters.

Today our topic is progesterone, and we’ll be joined by Dr. Lakeisha McMillan. Because I am a somebody who studies history and thinks that history is really important so we don’t repeat the wrong history. I would like to start this discussion by giving a little talk about the history of hormone replacement therapy, specifically in the United States.  So, hormone therapy [00:01:00] replacement today continues to be controversial in the mainstream medical community, and when we go through this, you’ll understand why. So, part of this discussion of the history comes from an article I recently read in Circulation. It’s from 2023, and it’s called Rethinking Menopausal Hormone Therapy for Whom, What, When, and How Long.

So, hormone therapy, or replacement hormone therapy, abbreviated HRT, started during the Great Depression. with estrogen derived from the urine of pregnant women. In order to save money, this was replaced with estrogen derived from the urine of horses, referred to as conjugated equine estrogen, which I think is outrageous.  Such therapy became gradually more popular, and after the popular book Feminine Forever, published in 1966, which proposed that menopause was a state of hormone deficiency that led to painful intercourse, the loss of sex appeal, and youth. This, combined with the changing status of women in the feminist movement, HRT became increasingly prescribed, with annual prescriptions exceeding 50 million by the 1970s. But then some studies showed that just taking estrogen increased the risk of endometrial cancer. And this led to a decrease in the use of HRT, until it was discovered that if we combine progesterone with estrogen, this protected the uterine lining.  Then, in the 1990s, several studies, including the Nurses Health Study, showed that HRT reduced the risk of cardiovascular disease. This led to an all time high of 90 million prescriptions of HRT in the U.S.. 

But then, the infamous, and I use the word infamous carefully, Women’s Health Initiative study was published in 2002.  And this showed that those who took oral conjugated equine estrogens and Medroxyprogesterone Acetate had an increased risk of breast cancer, heart disease risk, stroke, blood clots, leading to an approximately 80 percent decline in prescriptions for HRT in the U.S. and a similar decline worldwide. Since that study, there have been a number of looking back at the Women’s Health Initiative Study, re analyzing the data and there have been a number of studies showing that when prescribed in a [00:04:00] proper form, at the proper time, that the risks of HRT are minimal at worst or don’t exist at all to Help us sort out some of this information about HRT, and in particular, I wanted to focus today’s talk about progesterone, which doesn’t get talked about as much as estrogen.

We have asked Dr. Lakeisha McMillan to join us today. Dr. Lakeisha McMillan is an integrative OBGYN. She graduated from Loma Linda University School of Medicine, where my good friend Dr. Arista Vojdani also teaches. Dr. Lakeisha wrote a best selling book, The Other PMS, Your Survival Guide for Perimenopause and Menopause.  And she lectures frequently on perimenopause and menopausal health and hormones. On social media, she’s known as the hormone hottie. So, Dr. Lakeisha, thank you for joining us today.

Dr. McMillan: Thank you so much for having me here. I’m so excited to be here with your community. I love, I always love coming into communities that already have this foundation of wellness a conversation that’s already going.  And so I feel so at home to be able to just jump in and kind of, you know, give some more of my opinions as well as and be able to help build this foundation even stronger. So thank you for the invitation for having me here today.

Dr. Weitz: Absolutely. I just wanted to mention something on my mind. One of the reasons I wanted to read that intro was because in thinking about hormone replacement therapy, I thought, I can’t believe that we are giving women hormones from horses. And I just thought, you know what, if that was proposed to men, yeah, we’re just going to give you hormones from horses. There’s no way that would have happened. But anyway,…

Dr. McMillan: You said it, you said it, you said it! I mean, seriously, yes.  And I was looking back at kind of like the social construct of menopause, and I think that’s part of it as well. I remember doing a CME a few years ago, and it took me through the history of how we even looked at menopause. And I think that’s part of the story too, is that It began in the 1600s of looking at it as a moral, failure on women’s parts.  Like all of a sudden you weren’t holy enough, you weren’t doing your part, and so you had this wandering organ that started wandering about your body causing hysteria, right? And so we have to be able, this is why I love these discussions, because this is another layer to that foundation, right? And then, you know, we’re, like you said, it was like, oh, we think we found the fountain of youth.

This estrogen seems to be the [00:07:00] answer to all the questions and all the problems. And I think that’s when we get in trouble, when we think we have this panacea, when we think we have this utopia, we have the one thing. Stop looking at somebody as a whole person and being able to address that whole person.  So I love the wellness part of, of your, of your approach, your practice, your discussions. And you’re right. If we had said to men, Hey, let’s make. This, cheaper so that we can manufacture it in mass. But you know what? We’re not going to give you the biological equivalent. We’re going to actually make a synthetic formula that can act the same way.  So it’s like we’re making a different key that can fit in the lock, but we’re not going to worry about what that key does after it turns on the lock. Right?

Dr. Weitz: Right. 

Dr. McMillan:  We’re just going to give you this synthetic form. And you’re right. Like, what are you doing?

Dr. Weitz: Exactly. And even [00:08:00] worse, what if we said we were going to take the hormones from a duck or something and give them to a man?  Exactly. But some guys might be saying, Horse, Horse Hormone? Maybe I’ll take that. Absolutely. Anyway so I want to start by talking about progesterone and the benefits and functions in a woman’s body, and then eventually make our way to the risks later on in the discussion. So let’s talk about some of the benefits of progesterone.  And I know one of the things that I heard you talk about in one of your discussions that I don’t think is very well known are the neurological benefits.

Dr. McMillan: Oh, I’m so glad you’re starting this discussion here because what it does is it actually helps to challenge an old paradigm that most physicians have been taught, which is, Women that have hysterectomies that don’t have a uterus [00:09:00] don’t need progesterone because as you so eloquently stated in the beginning with the history is that we were like, oh, there was a time where we saw progesterone helped with preventing that uterine cancer.  If you just gave estrogen unopposed, then you had this outcome. And so there is this thought, oh, progesterone has only one benefit, but like you’re saying, we are now understanding that the metabolites of progesterone, so progesterone can actually turn into what we call neurosteroids, and those neurosteroids cross over the blood brain barrier and go into the brain and interact with neurotransmitters.

And it can impact the serotonergic pathway, dopaminergic pathway, cholinergic pathways. And so what are we looking at? Progesterone can help with pain. We know that there have been studies that actually looked at progesterone [00:10:00] being a form of an analgesic because we know it has those properties. It was actually, I know, in my OBGYN literature, back, you know, in a historic literature, they actually looked at it to, to actually administrate it to women in labor.  But the half life is very short. It wasn’t that, you know, powerful. So it was not a long lived option for labor and delivery. But we know that progesterone can be helpful with our own pain pathways. It can actually help to block some of those COX pathways, the COX 2 inhibitors and those type of paths with the prostaglandin pathway is actually what it interacts with.

So then it can actually help women that may have issues with having pain with their periods. So that’s only one of the things that progesterone can do. It can interact with the serotonergic pathway which helps with our mood, which helps with making, you know, that making it Sorry, it interacts with, say, the GABA pathways [00:11:00] and making sure that it calms down that, that shoulders raising up to our ears that, you know, oh, okay, everything’s okay.  You don’t have to be so super anxious, those type of things. So that is one of the benefits that progesterone has just a You have them and a lot of people don’t talk about it. And what I see in my work with helping with perimenopausal menopausal women is that when I give them progesterone, they go, Oh, it’s almost like you see it just in their face, they just, Oh, thank you.  I feel so much better.

Dr. Weitz: Yeah, I have two thoughts. I wanted to touch on both from one is. When you talk about the fact that progesterone metabolism leads to these neuroactive steroids, it would be really cool if, like, Dutch testing actually measured those neuroactive steroids. Wouldn’t that be cool? Because we get [00:12:00] so much into the metabolism of estrogen, but we don’t learn that much about the metabolism of progesterone.  Progesterone. And this would be very cool to look at. And then the other question I have is about the idea of possibly using progesterone for men, because I’ve had a discussion with neurologists about using progesterone after a brain injury. And it’s, there is good data showing after a traumatic brain injury that Progesterone can have some benefits and I’m sure it must be related to these neuroactive steroids.

Dr. McMillan: You know, that is a very interesting and promising area. I’m so glad you brought that up. That actually just made my brain start ticking. I was like, Ooh, yes, that actually sounds really great because again, it can help with the analgesia. It can help with the cholinergic pathway. It can help with the serotonergic pathway, the [00:13:00] dopaminergic pathway that can help with that reward pathway.  focus and being able to help these various brain structures literally heal or actually give them protection as they heal. So there’s so much that could be explored through that. I love that. I love that discussion.

Dr. Weitz: So besides neurological, what are some of the other benefits of progesterone?

Dr. McMillan: So progesterone also helps, of course, women, you know, if we go back to the basics, I always like to start there.  It helps you to have a set interval of your cycle. So it helps with that 28, 30, 32 day cycle. I always say think of progesterone as being in charge of the lawnmower service. So what happens is if you think of your period in terms of grass growing, the estrogen helps the grass grow tall, or proliferation of the uterine lining, progesterone kind of holds back the lawnmowers until it gets the signal.

Was there an egg fertilized or not? If it doesn’t, if there was no egg fertilized [00:14:00] and it says, okay guys, we’re gonna help mow the lawn in two weeks, right? So it helps to make sure that. One, your breast tissue doesn’t get overstimulated by estrogen as well. It also helps to make sure that you have this nice type of increase or crescendo, decrescendo of your hormones during that set interval.

And progesterone also helps with metabolism. So we know that it can help with making sure that your body is able to it helps with the kidneys and helps them to dump off those, the, what the, oh, sorry, I’m getting all tongue tied here, y’all, because I have so much going in my brain. 

Dr. Weitz: Well, benefits of progesterone for the kidneys.

Dr. McMillan: Kidney, it has protection so that you can actually dump all the metabolites that you’re not using, so it can get rid of those toxins as well. So progesterone has all these different types of jobs, I call them, that progesterone will do.

Dr. Weitz: Right, and it works as a perfect companion with estrogen.

Dr. McMillan: Absolutely. Absolutely.

Dr. Weitz: So when you prescribe progesterone it’s common for doctors to give women progesterone every day of the month. And they assume that most women don’t want to get a period anymore. And it’s not surprising. And I, I suspect that a lot of women don’t want to get their period, but what is the best way to prescribe progesterone to menopausal women?

Dr. McMillan: That’s a great question. Okay. So to menopausal women, um, I actually look at the individual and I’ll look at their testing and their symptomology. So if they’re having issues, so if they’re menopausal, which means they’re not having a period anymore, they’ve gone through that transition, then I will prescribe a low dose of continuous progesterone.  If they can tolerate it. That’s the other [00:16:00] thing, because if you cont, if you do a continuous progesterone type of pro pr preparation, you can actually downregulate estrogen receptors and they won’t get the benefit of the estrogen that they have on board. So then they can represent with either an intensifying of their vasomotor symptoms or they can have a surgence of that where they didn’t have it before. So that’s where I say, look at the individual, see what their symptoms are and look at their tests that you, that you’ve decided to run. If they are perimenopausal, which means that they could be still having a cycle. It could be this intermittent, or it could not be a regular interval.

Then I will say, Hey, let’s go ahead and create a set interval. which means we either look at your, if you can map out your cycle now and we can find the luteal phase, then we can do that and just support the luteal phase. And that will be where you cycle your progesterone. If you can’t, then I say, [00:17:00] let’s just, let’s make one.  So then we look at the calendar and I find it easy just to follow the calendar days. And so in the beginning, I have to, You know, counsel them that it’s going to be a little rocky road. You may have some intermittent irregular spotting, but about month two to three, it may start getting in a set interval.  And that way we can create this luteal phase that’s supportive.

Dr. Weitz: What about doing that cycle mapping testing from Dutch that helps you?

Dr. McMillan: Absolutely. You can absolutely do that. You can do the cycle mapping. I do cycle mapping though with my patients if they are having an interval. If there’s, if they’re having a set if they’re still having cycles pretty consistently, when I say consistently, I’m saying if they haven’t had a gap for, if they have like a six month gap, they haven’t had a cycle, then I say, well, let’s just do the Dutch complete where I look at the just, we just look and see what’s going on with how you’re metabolizing them. But if they’re like, Oh, I have one, maybe [00:18:00] like every other month or every 45 days. And I say, yeah, let’s do the cycle mapping so we can see what’s going on in your cycle, in your interval.

Dr. Weitz: Now, when looking at hormones measurement of hormones during perimenopause, they tend to be a little bit all over the place.  So how do you decide this patient needs? hormones or how much hormones given the fact that it’s sort of erratic depending upon when you measure it.

Dr. McMillan: That’s a great question. This is where the art of medicine comes in. And this is where I sit and I really dial into what they’re experiencing in terms of their symptoms.  What is the most impactful in their life and where are we trying to go? And so then I take my expertise and put that into the mix too. So what I’ve come to find is that when you have a perimenopausal woman, say for instance, her biggest issue is sleep. And she’s not, and say she’s having an erratic cycle.  So she’s now having this cycle that is now spacing out, is now, you know, further apart. I will say, hey, maybe we should do a little bit of continuous. And I, when I say a little bit, I’m talking low dose, maybe starting at 12. 5 milligrams or even 25 milligrams, titrating up just slowly. And then when she feels the difference, because most women can build that change in their hormones. And she’s like, Oh, my sleep is now interrupted again. Maybe she doesn’t have enough progesterone. Then I’ll bump it up a little bit for just those 14 days and then come back down. So it’s, it’s more of, this is where the art comes in. Like you said, their hormones can be all, like we say, all over the place.

We can have this. cycle that we were looking at and we’re not sure where we’ve caught them in their cycle. So I really have to explain this is what I’m doing. This is how this may show up for you because you [00:20:00] may have some intermittent spotting. It may take us a month to get everything in, in order. So it’s really a matter of setting the expectations of why I’m doing what I’m doing and what to expect and how long it’s probably going to get us to get you feeling back into your, your own body again.

Dr. Weitz: So with respect to testing, what kind of testing do you like to do?

Dr. McMillan: I do a combination. So I will look at the Dutch testing, the urine testing for the metabolites because I want to see how your body is metabolized. I want to see What pathway your body actually likes to favor. I like to see if you need some certain types of minerals or organic acids that will help those different process pathways.  I also know that your gut is very important. So I want to make sure your gut microbiome is intact, so I will actually have patients do a gut testing and look at their microbiome, [00:21:00] and I look at your thyroid, because I know the thyroid sometimes gets gets taxed with everything else that’s going on, and I want to make sure that we’re not missing something that could be thyroid related that has an overlapping symptomology with hormone depletion.

Dr. Weitz: So far, so good. younger women who say have some hormone issues. Can we increase progesterone levels naturally? Is there some benefit with using chase tree or maca or other herbs or inositol or healthy diet?

Dr. McMillan: Oh, you are speaking my language. Oh my God. If you have a video portion for your podcast, people will see me clapping on screen.  I, you are saying everything. 

Dr. Weitz: Yeah, it’s, it’s on YouTube as well.

Dr. McMillan: Awesome. Awesome. Awesome. Because yes, the straight answer is yes. So if I do have patients that are [00:22:00] early perimenopause, when I say early, they’re like, maybe in their late thirties, early forties, and they are having some extreme symptoms.  One, we have a really frank conversation and I asked them about their life. I ask them, what is going on? And, and they, and I need a timeline of what has happened. How did we get here? And then I say, okay, do the testing. And when we do the testing and I review the testing and I know the information that they’ve given me, then I’ll say, okay, you could be a candidate for doing some natural, like maybe even seed cycling, you know, doing certain seeds at certain times in their cycle to, to help boost their own natural progesterone along with those herbal supplementations. Because we know that the adrenals, when they get pulled on, they actually can interrupt the entire system. So all that you’ve said, yes, I utilize all of that. I use maca root. I will use adrenal. I’ll use [00:23:00] ashwagandha to calm down the adrenals. I’ll even use licorice root for those that are a good candidate for licorice root to convert their cortisone to cortisol.  So that they have the right fuel on board. So that while we’re doing this and taking care of the, of the ovaries and making sure that they can produce, we haven’t neglected other areas that are under attack as well.

Dr. Weitz: Yeah. I like the adrenals. Let’s see. So, when you prescribe hormone therapy, what type of hormones do you like to prescribe and in what form and how do you like to cycle it or use it consistently, et cetera?

Dr. McMillan: Oh, wonderful question. I really like using something that’s transdermal. We know that if we use the skin and we bypass that first pass metabolism, that’s usually the best, right? Now, progesterone, you can use bioidentical progesterone that is in an [00:24:00] oral form. I usually use that from a compounding pharmacy, and we know that that can actually help with the uterine protection but there are some patients that just can’t tolerate capsules. They don’t do well with it. They don’t like it. And so I will use a cream or suppository form. So I’ll use cream forms, suppositories, patches. I’ve even done pellets where I’ll, you know, you place that little pellet right under the skin and let the body naturally utilize it as needed.  But the dosing really is based on the patient’s labs or the, what I see in those labs, especially the gut and making sure that I don’t overload the system and it can’t process what I’ve put inside.

Dr. Weitz: When it comes to estrogen, you use Estradiol, or do you use

Dr. McMillan: Bias? Yes, I use Estradiol, but I do there are times I’ll use Bias, so I’ll use Estriol, Estradiol, if that person is if I do the Dutch, and I see that they are [00:25:00] not pushing towards that Estriol pathway, because some people naturally push to the E3 pathway, and when they do that, It actually, E3 is not that estrogenic, but it kinda takes up space, is what I, the way I think about it, and I’m like, okay, I don’t necessarily need you to make more estriol, I really want you to make the estradiol, so that you can utilize that, and feel the difference.

So that’s when I’ll say if I see them making more E3, naturally, I will just use estradiol. But if they’re not making too much of that through the Dutch and I see the, the gauges are saying which one, you know, which type of E1 that they’re making, then I may do an 80 20 or a 50 50. There are some, I have one patient now, I think about it, and she was at a 50 50.

And I was like, Oh, let’s try 80 20. Cause I looked at her stuff. She wasn’t making that much E3 and I switched her to 80 20 and she didn’t do well on it. [00:26:00] Like her body just liked the 50 50. So we had to put her back on that. So that’s another thing, really listening to your patients when they come back and tell you, I don’t feel good on this.

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Dr. Weitz:  Yeah, I know some doctors are real big believers in estradiol and feel that that’s really the hormone they should be taking. Yeah,

Dr. McMillan: I think it really is a matter of the art because you have to remember that you’re, if you think of it this way, [00:28:00] I think of it as Putting something on a conveyor belt and if I put too much and the conveyor belt speed is slow then I’m gonna have the Lucy the Lucille Ball type of Situation right where you have all these chocolates coming down the conveyor belt and you got to stuff the chocolate somewhere Because you don’t have the containers ready Right?

Right. So that’s the way that I’m thinking. And then I also use testosterone. I think, I think testosterone is, is woefully underutilized in women. And we know that there are some papers that have come out and they’ve said, well, testosterone is great for overall wellbeing. Well, what does that mean?

That’s like your mood. That’s like motivation that can be focused. And so we, when I tell women, you know, you make testosterone, they’re like, what? They’re like, really? I’m like, yes. And you make it in your ovaries and in your adrenals. And so your body needs that. And when I give them some of that [00:29:00] testosterone, they’re just like, Ooh, I feel so much better.  Like energy wise, even I feel like I can be my, myself again.

Dr. Weitz: What about Pregnenolone, DHEA,…

Dr. McMillan: Oh man, yes. I use that in my perimenopausal women more so because in, in the way that I’m thinking, it’s actually helping to stimulate what they can still produce.

Dr. Weitz: The precursor.

Dr. McMillan: Exactly. So it can be taken in the body and the body can say, Oh, I know what to do with this.  I want to make this. They’re not, they don’t have enough of Progesterone. They don’t have enough of the testosterone because you remember the pregnenolone is like that parent molecule. And so it can go down. I call it the Plinko. So it’ll go down and it’ll go wherever it’s needed. And that is why I like that.  I like DHEA. I like a small dose of DHEA for women because DHEA tends to go down the androgenic pathway and you don’t want to make those heavy [00:30:00] androgenic hormones. I just was joking with a patient earlier. And she was like, Oh, well, you know, can I just go ahead and up my DHEA? And I was like, well, now let’s, let’s do that gingerly because you don’t want to become this pimply hairy person.  Right. Like, oh yeah, no, no, no, no. So yes, I use those as supports to help the system be able to do what it needs to do.

Dr. Weitz: Right. So what about the benefits of natural progesterone versus synthetic progestins?

Dr. McMillan: Oh, that is such a huge topic. So I have to go back to something you said in the beginning, which was that whole WHI study.  And I feel like I have a special connection with that study because I was an intern.

Dr. Weitz: Oh, okay.

Dr. McMillan: That study came out in July of 2002. I just started July one and we [00:31:00] is the middle of July. My program director, we’re sitting there morning report, waiting for her to come through the door. She walks in waving this paper.  Like this was FedEx to my home. We have to stop everybody. We have to stop. And what happened is that if you look at it, so now I’ve been practicing for 20 plus years now, my initial my initial introduction into being a full fledged doctor is don’t do this anymore. It’s. It’s bad, it’s bad, it’s bad, but we didn’t have the ability and the support systems in place for us to go back and dig into that information and find out.

And I’m saying all this to say, the progesterone that was studied in that study or was given in that study was a progestin. And so we have this nomenclature that if anything has this chemical structure that looks like this, we call it progesterone. And that’s where a lot of the [00:32:00] confusion can come about.

So when you’re talking about this to your patients or colleagues, you really should say, is this a progestin or a progesterone? or progestogen. So a progestin is that synthetic. This is the one I was talking about earlier that is made to look like progesterone. It can fit in the receptor, it can kind of turn it on and make it do some things, but then when the body breaks it down, it breaks it down into these metabolites that the body has no idea what to do with, versus Your human progesterone and your bio identical progesterone, which looks chemically just like what your body used to make, it fits in the receptor, it turns on the receptor, it does what it needs to do, it breaks down to the same metabolites.

Your body takes it and goes, Oh, okay. This goes over to the kidney. This goes over to the GI system so that we can get rid of them. And that is why it’s really important to, to know the difference. [00:33:00] And that’s why I take time with my patients to help them understand bioidentical versus synthetic versus the medroxyprogesterone acetate, what’s in your birth control pills, what’s In your IUDs, you know, these are, yes, we call them progesterone.  They’re under the same umbrella, but that’s just for nomenclature. And for us to be able to do our studies, it does not give you the full story of the molecule.

Dr. Weitz: So where are we in terms of safety of HRT considering the Women’s Health Initiative, other studies, et cetera, and, you know, is the main problem with the Women’s Health Initiative, is it the timing hypothesis, a lot of people criticize the fact that most of these women were not put on hormones till 10 or more years after menopause, and some of the cardiovascular Disease risk had already occurred because [00:34:00] they went that period of time without the protection of estrogen or is it more about the fact that they were using these synthetic forms and horse estrogen and synthetic progestins Or is it really a fact that whatever increased risk of breast cancer was there was very very small anyway what do we do with, and where are we what do you tell you women is taking a bioidentical hormone replacement therapy?  Does that increase your risk of breast cancer?

Dr. McMillan: I’m going to answer that last question first, and I’m going to say no, it does not.

Dr. Weitz: Okay.

Dr. McMillan: Learn that does not increase your risk for breast cancer. Now let’s go back and look at the study, like you said. So now what we learned is that when they went back and looked at the statistical analysis, the statistical significance of that breast cancer, what looked like a breast cancer bump, was not [00:35:00] statistically significant above your risk of just being a woman.  So there were a couple of cases, but when they did all of the analysis, the statistical analysis, there was not an increased risk. There have been subsequent studies, like you said in the beginning, that have looked at bioidenticals, that have looked at the studies, that have re evaluated the data. And we’re saying what we need to help people understand is that hormones do not cause cancer.

There are some cancers that can be fed or augmented by certain hormones. That’s what we need to understand. But bioidentical hormones are not the ones that can do that. We need to make sure that you differentiate that study was synthetic. We don’t use those anymore. Like, if somebody is trying to give you Prim Pro Primarin, the, no, absolutely not.  The bio identical ones, and [00:36:00] this is where I stay a lot of my time in teaching, is that it’s bio identical. It looks just like what your body used to make. It breaks it down the same. It does not increase your risk. There’s so many other life factors that do. And we need to look at that as a whole picture so that we can have that as part of a conversation as well.

Dr. Weitz: And when it comes to cardiovascular risk, a big factor is not using oral estrogen.

Dr. McMillan: Yes. So the, the cardiovascular, I’m glad you said that. So when you use oral estrogen, what typically happens is that you’re with first pass metabolism, you tend to make estrone, which is the E1 versus the E2. And then when you look through the Dutch test, if you use Dutch tests to look at the metabolism, it, for some people, they push towards the 4 OH E1 pathway.  And if you don’t have enough of your anti inflammatories like your glutathione, your, your great antioxidants. they can cause that [00:37:00] DNA damage that changes the DNA and can cause these cancerous cells to grow. So this is where this nuance comes in. This is why I really like adding the Dutch so I can know intrinsically where your body likes to push things, right?  And so that’s why I do like to use transdermal estradiol. The body usually takes it and breaks it down and make it makes the form that your body really likes. And can metabolize and utilize correctly.

Dr. Weitz: Are you familiar with this study that came out in May of this year? It was in menopause and it was the title of the study was use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses.

Dr. McMillan: No, I need to get that. Okay, it’s,

Dr. Weitz: it’s kind of a confusing study. It’s it generally showed that Hormone Replacement Therapy is [00:38:00] safe in women over 65 years of age, but they had these different arms and, one of the arms where they were taking progestin seemed to be safer than taking progesterone.  So I don’t know. It was a very sort of confusing study. Generally, it was showed that hormone replacement therapy is safe and beneficial, but it was a little confusing.

Dr. McMillan: I’m going to have to look that way. I’m already going on Google Scholar right now. Like, because so one of my, one of my philosophies is that I believe depending on your patients their, their lifestyle, what they’re looking to accomplish, that Hormone Replacement Therapy, or I like to call it BHRT, is going to be a part of their lives longer than what we have initially said because of all the [00:39:00] benefits, especially the osteoporosis benefit.

Right. Preventing osteoporosis. That’s a big deal. Huge. We know that that is the number two. It’s like, it’s cardiovascular for women. When we’re talking about morbidity and mortality, it’s cardiovascular number one, osteoporosis number two, and then breast cancer. And, and breast cancer, I always say has a great PR department.  That’s why a lot of people think it’s number one, right?

Dr. Weitz:  Far more women die of heart disease. Exactly.

Dr. McMillan: Exactly. A hundred

Dr. Weitz: times more.

Dr. McMillan: And when we look at what these hormones can do, and, and I, tend to think the way that they were looking at the WHI was like, Hey, how can we prevent this? Oh, what happens that women’s risk of heart disease goes up when their hormones go down?  I think that was a great hypothesis, a great place to start, because we wanted to prevent these things from happening. And so I have a discussion with my patients saying, Hey, I mean, I [00:40:00] have, Marathoners, I have cyclists, I have people that are very, very active, and they’re now pushing their 60s and mid 60s, and they’re saying to me, okay, do I have to stop this?  And I go, you know what, let’s continue to monitor. I believe in monitoring and seeing how your life changes, so that we can be very responsible about this. But not just cut you off so that you decline significantly and rapidly.

Dr. Weitz: Right. What you mentioned seed cycling. I suspect that some of the listeners are going to go, what?

Dr. McMillan: Yes. Seed cycling. And you probably hear me typing because I love it.

Dr. Weitz: So this is when you’re taking certain kinds of seeds, like flax seeds. Yes,

Dr. McMillan: absolutely.

Dr. Weitz: And other kinds of seeds that have a different effect on different types of hormones. Right?

Dr. McMillan: Yes. [00:41:00] Yes. So, so like I said, when you’re in that perimenopausal phase, or if you are some of my, you know, women that are still in there for, for, fertility phase of life and they just need some, some, some, some help with making sure that their hormones are going where they should.

I tell them about seed cycling. So days one to 14 of your cycle. This is where you have menstruation and to ovulation. You can do one to two tablespoons of ground flax seeds. along with one to two tablespoons of ground pumpkin seeds. And I tell them to go to like mom’s organic market or someplace that has them whole where you can get them and you can use your more, you know, your pestle and you can actually ground them a little bit.

You can put them over your salads. You can put them in your food. You can use, you can put them in your shakes. And so that’s, that’s the first half and that’s going to help with your estrogens that’s going to support that, [00:42:00] that phase. Days 15 to 28 are ovulation 2 menstruation. That’s 1 to 2 tablespoons of sunflower seeds, ground sunflower seeds.  And 1 to 2 tablespoons of ground sesame seeds. And this supports your progesterone production. So that’s the seed cycling that I, that I tell patients to do.

Dr. Weitz: Cool. That’s a great clinical pearl.

Dr. McMillan: Wonderful.

Dr. Weitz: So what do you think about Pellet Therapy?

Dr. McMillan: I think it has a place. And I know that the, some people are all or none.  I tend to live in gray areas. I like, I like the, I like the ability to have some flexibility. And, and as somebody, and I can tell my own story. 

Dr. Weitz: In the functional medicine world, we sometimes have to live in gray areas.

Dr. McMillan: Yes, yes. And, and, and my own story, I’ve done pellet therapy myself. I remember this was now, oof, 10 years ago.  This was 10 years ago. I [00:43:00] was 40 years old. And I had, you know, been going through a lot of life changes, a lot of life changes. situations had hit me. And I believe that really those stressors pulled on my physiology in such a way that it made me slam into perimenopause. And one of those things was my testosterone numbers.  It was not even measurable in the bloodstream and my adrenals were shot. My DHEA number was 37. It was horrible. And so I did pellets. I did one round, I did two rounds of testosterone pellets, but I’m one of those people that metabolizes towards the androgen, more androgenic hormones. And so I got the acne, I got the oily skin, my hair was shedding.

I was like, nope, this is not it. Now the benefits were excellent. I will tell you that, right? Excellent. But this is where I, the second round. So most people will [00:44:00] do pellets every four months. So like, once every four months. So when I was time for my next round, I went down in dosing, but still had the same level that it showed up in my bloodstream, still had the same types of symptoms of side effects.

And that’s when I switched over to creams. And the testosterone cream for me has been wonderful. It has really allowed me to build muscle again. I go into the gym and I feel the difference. My clarity of thought has definitely improved. My mood is better. And now that I’m, you know, in that phase of life where I’m really going into that transition, it has really helped with sleep.

I was out of my cream for a while. I started having a little warmth. Splash in my face. I was like, Whoa, what is this? So this is where pellets to me are for someone that knows they’re not going to really utilize the creams like they should, because creams you have to be consistent. [00:45:00] You have to take it the same time every day.

And sometimes you may have to do multiple applications in the day to get your bioavailability in the range that is helpful for you. So that’s why I say, You know, there are different tools for different people. Now, the discussion comes around the levels at which some people are trying to have, you know, women at you know, is, is this, you know, they’re going past the physiological range.

And yeah, you feel great for a while. I will say, I mean, when my levels were really high, they were great, but then the side effects were, were something I did not want to deal with.

Dr. Weitz: I want to go back to testing again for a minute. I have two questions. One is, what is the best way to monitor women who are taking hormones?  There’s some dispute. Some people feel that using salivary hormone testing is better to [00:46:00] measure topical hormones. We have serum, we have Dutch Urine Testing. And then the second question is, I’ve talked to some practitioners who say there’s no point in testing women’s hormones after menopause because their low period doesn’t matter.

Dr. McMillan: Okay, y’all, this is one of my gray areas. This is where I’m gonna sound like I’m sidestepping the question, so I’m just gonna say it up front. So, I feel that The practitioner has to know what they’re looking for and what will change their management. So for me, I do Dutch testing, I do serum testing, and part of the Dutch that I do looks at the adrenals through saliva.  Right. Okay. So I get all that and I do the blood for thyroid. That’s just an easier fit. Sure. Yeah. But I think for patients, [00:47:00] once they’re on a regimen, if they are getting better and improving, I will do a follow up of serum testing alone, just to see what’s available in the serum. If they are Does,

Dr. Weitz: does serum accurately reflect transdermal hormone use?

Dr. McMillan: For me, it gives me a guide post so that this is what I was saying. So if they’re doing fine and their levels were increasing and their levels were changing in the serum on the, on the transdermal, particularly creams, because I have a, most of my ladies are on creams, if not all of them I can think of, and they, it does change in the, in their levels on the serum.  But then I have some where it stops working, like their symptoms get worse. Something happens and they’re like, Oh, I don’t feel the way I need it. 

Dr. Weitz: By the way, why do you use the creams versus the patch?

Dr. McMillan: Oh, I use both. I’m sorry. I meant to say both. So it [00:48:00] depends. I have some people where I started them on creams because it was just easier, I think, to start that way.  And it’s easier to titrate. And it was like, OK, we’ve maxed out on this. Let’s go to the patch. And they actually metabolize the patch better. You know, so I will say that if they’re, they’ve been fine and then something happens and they’re not fine anymore, then I’ll go back to Dutch testing. Cause I’m like something in the metabolic pathway has been interrupted.

I’ll go back and say, okay, what has changed in your life? Because clearly there’s something, either they went on a cruise or they’ve, they’re selling their practice or they’re, you know, something has happened. There’s a stressor and that gives me more information. So I have, I have a few in my, in my, I call it my hormone hottie handbag that I’ll pull out according to what is presented to me.

But I say for practitioners, [00:49:00] get a, a regimen that you are comfortable with, that you know, you know it, and you know what you’re going to do with the information. You have a protocol in your head. And I don’t live just on protocol, but at least it gives me a foundation. And then I can make the adjustments and kind of change the levers, the levers that way.

Dr. Weitz: And let’s say you’re working with a woman who’s not taken hormones before, and she’s menopausal, and you measure her serum levels of hormones, and they’re really low, what, how does that guide your care? Does it change?

Dr. McMillan: It will, it at least will help me see what’s going on from the adrenal side. Cause you remember your, the adrenals are, are, should take over at least a little bit.

Dr. Weitz: Right. Yeah, of course.

Dr. McMillan: I should see something happening in the bloodstream. And that’ll at least guide me as to how much, what I’m going to prescribe. The amount.

Dr. Weitz: So even though their estrogen, their progesterone [00:50:00] are low, there’s a difference between being this low and this low.

Dr. McMillan: Yes, to me. Okay. And what I’ve come to find over the years.  Yes. And what they’re telling me. So I have some women that I would, I would say, Oh my gosh, you’ve been in menopause for say five years. And I’ll ask them, do they have any vasomotor symptoms? And they’re like, no, I don’t have any, I don’t have any hot flashes nights. So it’s that, you know, that vaginal dryness, the triad, right.

And I get their, their serum levels say I, you know, if I used to just do serum only be, in the beginning before I did that. And say I got their serum levels, and I could notice their estradiol was not that below 5 register. It was actually like about 10. And I’m like, oh, okay, so clearly you’re making enough that it’s not impacting you symptom wise.

Now, let’s talk about do you have enough on board for your cardiovascular, for your brain health, for your breast health, all of that. [00:51:00] And that’s where we start, that’s where the conversation goes from there.

Dr. Weitz: So what about women who’ve been in menopause, haven’t been taking hormones, they’ve been in menopause for 10, 20, 30 years, maybe they’re even in their 70s or 80s but they’re struggling with sleep, they have other issues, does it make sense to put them on hormones and or progesterone. 

Dr. McMillan: You ask some great questions, great questions because this is where I would probably, people would probably go, why is she going to do that? Oh my gosh. But I’m just like, why are we letting women be miserable? So this is where I would start them on progesterone, a little bit of progesterone.

And this is the person I would monitor even more closely. And I want to make sure they’re metabolizing everything okay, [00:52:00] because I know that they have liver and kidney and all of these other systems have decreased in the way that they, their production and their performance. So, and it’s interesting because I look at my mom and she’s in her mid 70s, and she had a hysterectomy in her 30s, and she was never placed on any hormone therapy, and I look at the, at all of her comorbidities now, and mainly it’s heart, mainly it’s cardiovascular, and I wish I could just bathe her.

Hormones now. I was like, Oh my gosh. I even cause she has some CHF and I went down the rabbit hole and I saw a small study on how testosterone can be utilized in treating CHF. And I was like, Oh my gosh. But of course I do not treat my mother. So I am respectful of her cardiologist and they are wonderful.

She has an amazing team. I mean, to the point where they even call me up and they’ll, you know, Schedule stuff according to my schedule [00:53:00] when I can get there. But I wish we had this information and now I’m utilizing it for myself so that I can make sure as I age, I don’t turn on certain genes that I know are in my line.

Dr. Weitz: So sometimes in these women, you’ll just prescribe progesterone.

Dr. McMillan: We can start there. We can start very low. I have had a 70 year old woman that could not sleep. Actually, she was just Her mind was just waking up at that 3 a. m. It was at 2, 3 o’clock in the morning. So of course, I was like, let’s go down the blood sugar pathway.  Let’s make sure you’re not bottoming out having that that phenomenon in the middle of the night where your blood sugar drops, you know, and I was like, let, let me be mindful of the internal medicine side of things. Right. And she wasn’t, it wasn’t happening. And her hemoglobin A1c was great.

Her fasting blood sugars were great. And I said, you know what? Let’s try a little bit, let’s just try a little bit of your, [00:54:00] of progesterone. And I gave her a little testosterone, I think, at the time. And she came back and was like, thank you. She was like, I’m, I’m not sleeping like I did when I was younger.  She was like, but at least it’s better. Better.

Dr. Weitz: Yeah, I was just thinking of this one patient who has just horrible sleep. She’s in her later 70s, but 10, 15 years ago, she had an unexplained blood clot. And as far as we know, there’s no risk factors. We’ve done detailed testing. We don’t see any genetic risk, but no doctor wants to put her on hormones.

Dr. McMillan: Well, okay. This is where I would say testosterone, remember some of your testosterone aromatizes into estrogen. So sometimes just starting a little bit of testosterone could give them a little bit of estrogen that would be helpful without giving them the estradiol.

Dr. Weitz: And progesterone doesn’t increase clot risk, right?

Dr. McMillan: No. No, it does not. It does not.

Dr. Weitz: And we also have Dr. Dale Bredesen, who’s been pioneering the use of hormone replacement therapy in older women for the prevention and reversal of Alzheimer’s.

Dr. McMillan: Yes. 

Dr. Weitz: And other neurodegenerative diseases.

Dr. McMillan: Because we need this for our brains! Leave me alone. We are one big bag of hormones.  This is why I also say To women, you can’t go to your doctor and say, test, give me the test for perimenopause or menopause. They’re just like, they wouldn’t test me for that. I was like, well, there is, it’s, there’s a nuance to this. You, there are different things that we look at because we’re bag of hormones.  You have to say which hormones you, we need to look at and pull that story together to give us the story of you. But yes, there’s so much neural protection with our hormones.

Dr. Weitz: This has been a great discussion, Dr. Lakeisha.

Dr. McMillan: Thank you. My pleasure. Same here. I’ve enjoyed my time.

Dr. Weitz: How can listeners, viewers, find out more about you, get in touch with you work with you, or use some of your programs?

Dr. McMillan: Awesome. Yes. If you want to be one of my hormone hotties, go ahead and grab the freebie that I always give out. It is cracking your hormone code. It is hormonequiz. co. co and take your hormone quiz and crack your hormone code. After you do that, you will get an email that Invites you to make your consult, virtual consult visit with me by going to talkhormones.com. And that’s the way that you can get in touch with me. Now you can follow me on all social media platforms at Dr. Lakeisha M. D. That’s D R L A K E-I-S-C-H-A-M-D.

Dr. Weitz: Great. And do you also have a podcast or have you had a podcast?

Dr. McMillan: I do. I have my Hormone Hotty Hotline podcast, so you guys can come on and listen to this on any of your favorite platforms.  It’s where Hormone Hotties come and share their stories. I have experts like Dr. Ben here to come and give their expert opinions, and then I give my corner. the corner of a perimenopausal doctor because I’m in the fight with y’all.

Dr. Weitz: Great. Thank you so much.

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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 want to 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.