00:00:17
Speaker 1: Pushkin.
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Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:00:51
Speaker 3: Elizabeth, you won't believe what I have for breakfast. I put at amami in my yogurt.
00:00:55
Speaker 1: It sounds really good. It actually was, because really it sounds like a great thing. Actually, I'm here today in the studio with Shavan O'Connor. She's a health and science journalist who works closely with me on this show, and she's also the chief content office at Adria. She's joining me today to co host our second AMA or Ask Me Anything episode. This time around, we're answering all your gnacologic health questions. Many of you reached out with really excellent questions about pcos now known as pmos, as we'll get into, We're also going to tackle some of your really thoughtful questions about perimenopause and how it can impact many aspects of your health. Plus we'll answer your questions about hpv UTIs, self, breast exams, hormone support, public floor therapy, golp ones, and lots more. Let's get into it.
00:01:50
Speaker 3: Okay, first question, and this hopefully is a pretty straightforward one. Is it true that most clinical studies are done on males and male rats?
00:01:58
Speaker 1: One hundred percent. Women were not required to be included in medical research until nineteen ninety three, Actually not that many years ago, right, And then more interestingly, only animal studies were recently required to have female animals, and that was in twenty and sixteen, actually two years ago government funding. One hundred percent.
00:02:21
Speaker 3: Let's respond to this question that came in from a lessener. The question is I get frequent UTIs that just won't go away even after many rounds of antibiotics. Oof, I feel for you. What is the best way to prevent UTIs?
00:02:34
Speaker 1: So if your perimen apousal or specifically postmenopausal, so haven't had a period in a while, vaginal estrogen, vaginal estrogen, vaginal estrogen. And this is actually new guidance from policymakers that women who have recurrent UTIs actually should be on vaginal estrogen. And this has also been helpful that the black box warning has been removed from the estrogen labels. But also we forget about like basics like staying well hydrated, practice good hygiene, wiping from front to back, don't hold your urine void frequently within reason, right, you don't want to void too frequently, and very products Vitamin C may be helpful for some people. And then there's the gut in vaginal microbiome, and this is an evolution in terms of UTI prevention and such, but a healthy gut microbiome we find in our practice along with maintenance of a healthy vaginal microbiome you know, impacted by estrogen, but also bringing the pH down and putting in good probiotics may be helpful. And importantly avoid thongs that can actually be irritating to the urethra and such. But also see somebody too, because you also want to make sure you know, these are the basics, but you also want to make sure that there's no anatomical abnormality or that you're not in urinary retention. So always having that adequate work up with imaging and a healthcare provider is always really important.
00:03:55
Speaker 3: Also you said avoiding wearing thongs, okay, so on behalf of women everywhere. Thank you to the listener who sent him this. Next question, she writes, do you have any recommendations for the best underwear for vaginal health and maintaining an appropriate pH level?
00:04:09
Speaker 1: Yes, so the exact opposite of thongs here, White cotton granny pants are really the best. And I love to say that granny panties white cotton, avoiding dyes, having cotton if you can get it organic so it's not chemically processed, also or bleached. Also sometimes like tappants and things like that, you know, boy shorts that don't pull into the bulvar area are probably really important. Also, let's respond to one question about human papillamavirus or HPV. This person writes in I'm confused about HPV. When it goes away on its own, is it still transmissible? And also can people with partners still get HPV even after receiving a vaccine. Eighty percent of women who are sexually active will have HPV at some point in their lifetime, so super super common. But the vast majority of people it actually kind of goes dormant after two or three years. It probably doesn't completely away. We don't really know that There's some people who may clear it completely, but it probably goes dormant because it can definitely get reactivated later in life periods of stressors. We see HPV can like rear its ugly head again in your PAP smear. In terms of transmissibility, if your PAP is negative but you've had HPV in the past, or you've had vaginal warts or any type of HPV related disease, we don't know about the transmissibility. When the virus is dormant, it's probably less so than when it's out. That's just something we don't have data on.
00:05:38
Speaker 3: I know it's a sexually transmitted disease. Is that the only way you can get HPV pretty much? I mean it is a skin to skin kind of contact. There's always questions on in adimate objects or phoemtes, you know, maybe right. So that's why it's always important to that if you're having vaginal ultrasounds that you go to a facility that's cleansing everything totally appropriately. But usually we think of it as skin to skin contact and sexually transmitted.
00:06:05
Speaker 1: After the vaccine, Yep, you one hundred percent can still get HPV. The vaccine only protects against nine types of HPV, and there are over one hundred different types of HPV. The vaccine is important though, because it protects against our two most oncogenic types, which are sixteen and eighteen, so, meaning that those are the two that are like really linked to cancer, and then six and eleven, which are related, which are super common and related to genital wards. So, and then the other five subtypes are also in the vaccine, so that you can still get HPV, but those oncogenic subtypes of sixteen and eighteen are much less so, and the vaccine is protective against those.
00:06:43
Speaker 3: Vaccine is important. Okay, Okay. This next question is something I had literally never heard of until I read it. A non surgical procedure called labial puff, which is an augmentation of the outer lips of the volva. Here's the question. Could you please discuss the procedure called labial puff and whether it's considered safe or not, and also what type of provider would perform this safely?
00:07:05
Speaker 1: So, what happens to the labia when we age or we lose weight, and we see this with gelbes or any type of weight loss or any type of aging, is we actually lose fat in the vulvar region, so a libial puff is actually puffing that area up. That can be with a fat injection from another part of your body called fat grafting or a fat transfer, or it can be with just a typical injection based a high uronic acid based injection, like a typical filler that you would get in your face. Safe, not a lot of things to damage in the area with the injection right, can get some lumpiness if it's a fat transfer, fat graft from what we call fat necrosis, meaning the fat doesn't take the way that it's supposed to. And also if you inject hyaluronic acid doesn't last for a long time, you have to reinject. In terms of who would provide this type of procedure, it might be a plastic surgeon or a reconstructive surgeon who does pelvic work, not all of them do, or it could be a gynecologist actually who does this type of work. But always make sure that if you're going to do something like this reconstructive, an area that is subjected to pressure right you're sitting on a bicycle seat is near the bladders, near the urethra. In terms of comfort, that you go to somebody who does a lot and who specializes in it, and make sure that you always ask about the risk of the procedure specifically with that person.
00:08:28
Speaker 3: Okay, great, what do we know about breast self exams? Should we still be doing them?
00:08:33
Speaker 1: So when I was in training, we taught every woman do a monthly self breast examination. And this can lead to stress and anxiety, and can also lead to people having like a little false sense of reassurance. I don't feel anything, so why should I go get my mammogram? Right? So, there was a study that was published that took women and half of the women in the study performed self and breast examinations and the other half did not. And the women who perform self breast examinations found more benign nodules compared to women who did not do self breast examination, but the risk of dying from breast cancer was the same in both In both groups, it probably reflects that we have great treatments for breast cancer now, right, So I encourage women to have what we call breast awareness, and this is what's recommended now for women who may be a very high risk of breast cancer, who have a family history. Definitely this conversation. So be aware of your breast, don't avoid your breast. If you feel anything that's new or unusual for you, of course bring it to the attention of your provider. If you see anything that's different, maybe a pigmentation change, skin texture change, a new asymmetry, or one breast larger than the other, always have that evaluated. I think we should still offer women's self breast examination and teach them how to perform it, but realize that it's not a must do like we used to recommend.
00:09:54
Speaker 3: Let me say, tire Kusics scores aka TC scores. This is a tool that estimates your lifetime risk of developing breast cancer, right.
00:10:02
Speaker 1: So a Tirecusic score. It gives you your lifetime risk of developing breast cancer based on your personal health history, your reproductive history. Did you use birth control pills, have you used hormone support, What was the age of your first child, when were they born, how many children have you had, number of relatives with breast cancer. It even incorporates some of our newer genetic testing, such as polygenic risk scores, and of course it also incorporates our testing for BROCA one and BROKO two, So you come up with a lifetime risk of developing breast cancer. And this is really important because women who have over a twenty percent chance of developing breast cancer in their lifetime will recommend augmented screening as standard of care with perhaps breast MRIs or contrast enhanced mammograms. Women who have a lifetime risk between fifteen and twenty percent so slightly elevated, we should offer, with shared decision making, a more supplemental screening in addition to just a mammogram and a breast ultrasound. And there are guidelines that actually suggest or have outlined in the guideline that every woman over the age of twenty five should have a yearly tire Kuzk score calculate because it's going to change based on how's your health history changes or how your family history changes. But less than twenty percent of practitioners actually perform a tire Acusic score. And I was recently in a focus group actually of women about women's health, and only a few actually had a few out of twenty to have their Tirecuzik score calculated.
00:11:30
Speaker 3: Take an algorithm you can do online.
00:11:32
Speaker 1: Guess like you can do it yourself. You Google tirecusic score. You can plug it in as ibis eight. I believe that you can plug it in and do your own tire acoustic score.
00:11:41
Speaker 3: Yep.
00:11:41
Speaker 1: Okay.
00:11:41
Speaker 3: So a woman from Brooklyn has a question about cysts. She writes, can benign cysts or fibroadenomas in the breast ever go away on their own?
00:11:49
Speaker 1: So the vast majority of cysts actually do, like seventy percent of simple cyst actually go away on their own. We don't usually intervene with the breast cyst unless it's painful or quite large. Then sometimes we'll drain it. Sometimes if you're on MHT or certain times of your cycle, they're under hormonal influence, so they can get a little bit larger. But the vast majority of what we call simple so just liquid filled says, go away on their own. Biproatgnomas don't usually go away on their own. They can get bigger, they may get a little bit of smaller, so once it's there, it's kind of there, but they can go up and down a little bit. Also. Our next set of questions are about PCOS or polycystic ovarian syndrome, which was very recently named PMOS or polyendocrine metabolic ovarian syndrome.
00:12:35
Speaker 3: Okay, can you first just briefly define PCOS now PMOS, who's most at risk and how's it diagnosed?
00:12:42
Speaker 1: So every woman is at risk, right, and we don't actually know what causes PMOS or PCOS. Maybe there's a genetic influence, an environmental influence, lifestyle influence, environmental exposure influence is probably many different ways to develop PCOS. So PCOS or PMOS is characterized by androgen exs, so either acne or exs hair growth or just biochemically elevated androgen, an elevated dhees or an elevated testosterone, along with menstrual irregularities, so infrequent periods, irregular periods. And also this is how it got its name PCOS. Polycystic ovaries, so multiple cysts on the ovaries, usually in what we call a string of pearls fashion, so very specific way that the ovaries look. And importantly though, and this is what I learned from our endocrinologist when I came to atria, which is so interesting. It's really a metabolic disease, right, So this is why this new name is super super important. So polyendocrine metabolic. It's really much more descriptive because a lot of women were not getting diagnosed appropriately because the silo nature of medicine. But it is a syndrome, which is always difficult because there's probably many different ways to get to this syndrome. And a syndrome means a collection of symptoms. So do you have these symptoms. It doesn't tell us why it's occurring, but you have this collection of symptoms that puts you at metabolic risk. And so we really need to pay attention to your metabolic health because many women are insulin resistant of course, have elevated insulin levels, elevated glucose levels, and some are overweight, but you can also be quite thin and have a PMOS.
00:14:25
Speaker 3: Also, isn't it true that you can also have pmos formerly known as pcos and not actually have cysts.
00:14:32
Speaker 1: One hundred percent. Yeah, the roder Dim criteria, it means you have to have two out of three of the groups of symptoms, and the one group of symptoms that we didn't put in there, actually it's not a symptom. It's a biochemical number basically as an elevated amh or antimularian hormone. So that's actually been recently put into the collection. So you can have elevated androgens biochemically, you can demonstrate elevated androgens acne, hair growth and such. Or you can have minstrual irregularities in frequent periods or irregular periods, or you can have polycystic ovaries or an elevated AMH. Got it.
00:15:12
Speaker 3: We have quite a few more PMOS questions, all right. First question is, given the prevalence of PMS, why has it historically been underdiagnosed and often dismissed? Is this a systemic failure in healthcare?
00:15:23
Speaker 1: Big one definition of the systemic failure in healthcare? I mean, I love the renaming of pcos to pmos because it's going to take it out of its silos. Right, it's a total body issue. You're going to your gynecologists. They don't understand the metabolic implications. Necessarily many do, but many don't actually, so then it just doesn't get diagnosed. The systemic failure comes from one lack of research, lack of education about it to the silo nature of healthcare and for women, meaning that we need to define who that women's health specialist is. And three the lack of research. This issue impacts one out of eight women, right, and probably even more if we really look for it, and we don't know so much about it. You know, we don't even have any FDA improved medications for it. So again, you know, it is the definition of the systemic failure of health care for women.
00:16:16
Speaker 3: Okay, So the next question is from a woman who is forty years old and was diagnosed with PCOS in her twenties. She writes that doctors told her they can't quote fully diagnose pcos because it's difficult to see everything. She says she has had irregular periods for years and takes anostol, which she says helped. Also diabetes runs in her family. Her question is, can p coos ever be reversed? Is there anything besides prescription drugs that you recommend? All right, Elizabeth, what should this woman try?
00:16:44
Speaker 1: Okay? In terms of can it be reversed or cured? Right now, we don't think of a cure for pcos. In terms of it can be managed, right, and it can be managed very effectively with not only medications, right, but really importantly lifestyle because this is a metabolic syndrome, right in terms of insulin resistance, So any lifestyle factor that can help your metabolism is going to help PCOS. So that is getting good sleep, getting good stress management. Working with the nutrition is whole foods, focusing on making sure that you get adequate protein, pay attention to what we call low glycemic index foods or foods that don't spike your glucose because that will decrease your insulin production. And then my favorite one is strength training and exercise. You know, we used to tell women, you know, avoid strength training PCOS is going to stress your system, but we know that muscle is the organ of metabolism and does take up our excess glucose and decreases our insulin when we have more muscle. So definitely, lifestyle is really really important with PCOS. And then beyond lifestyle, if you can't manage everything with lifestyle, you know, using a birth control pill can be very helpful. Met Foreman, which is an insulin sensitizer, is also extremely helpful and commonly used in PCOS. And then androgen blockers such as aldactone or sperna lactone are also very beneficial. I think as we more people involved and more subspecialties involved and looking at what this really is, why does it really occur, will move towards that what we call cure or better management at pcosmos pmos otherwise known are in the past known as pcos.
00:18:26
Speaker 3: Okay, last one, there's a lot of hype around using ozempic for pcos. Are we witnessing a real breakthrough or are we medicalizing symptoms without fully understanding the long term effects.
00:18:37
Speaker 1: I think that glp ones for pcos for many women, are game changers, right, because this is a metabolic issue in terms of I keep going back to insulin resistance and elevated glucose. Elevated insulin and definitely golp ones will decrease visceral bad and help with metabolic issues of course, and so for many women who've been frustrated because remember, birth control pills don't necessarily impact the metabolic issues, they're kind of controlling the symptoms at pmos. Foreman actually is an insulin sensitizer. Oldac tone is just an a blocker of androgen. So really the met format has been what we've really can kind of really impact the basic biology of the issue. And the golp ones I mean met format X differently than glp ones, but it's kind of like met format on steroids, and so for many women who face weight challenges with PMOS, the golp ones can actually be a game changer for them. But not again something just to say, let me just give you this and don't use the lifestyle influences. Also because you have to whenever you use a medication like a golp one, you really have to pay attention to your body composition, making sure that you're building muscle and not losing weight at the expensive muscle. And I think if used very responsibly, with appropriate strength training, appropriate nutrition, they can be really a game changer for women with PMOS. When we come back your questions about perimenopause, and we'll get into whether hormone support can help you feel sexier.
00:20:22
Speaker 3: We received some really great questions from listeners about perimenopause, so let's keep going. The next question is from a listener who lives in the Boston area. She writes, what's the connection between perimenopause and anxiety? Or is my anxiety just elevated because of the other factors in my life right now? Could it be my hormones?
00:20:40
Speaker 1: It's probably everything. Actually, I always say that with hormones, with women with estrogen, progesterone, androgens. Also, you know, we paint our lives on a canvas between you know, with shades of gray, between black and white, you know, and hormones don't necessarily completely change that, but they can definitely shift it. So perimenopause is a transition time where you can have great fluctuations of estrogen which can impact your neurotransmitters, serotonin, dopamine, the GABA receptors. Progesterone is actually declining during perimenopause, So that's really the first thing that we see is this decline in progesterone, which is the calming hormone for us. It's impacting the action of the GABA receptors in the brain, which are those calming like don't get anxious receptors in the brain. And so definitely anxiety is very common at the time of perimenopause, anxiety and irritability, and so so important to remember that there's other factors that may be contributing. Lack of sleep can contribute to mood issues and anxiety family situations. Definitely, this is a period of time where we have the perfect storm of hormones and for many women, life situations just in general, and then you have sleep issues too, so it all goes hand in hand. But yeah, hormones play a very large impact in this.
00:21:57
Speaker 3: Yeah, the same listener added one more question. Can perimenopause affect your digestive system? I'm noticing some changes in my bowel movements. What could be happening here?
00:22:06
Speaker 1: Hormones impact the GI system in many different ways. Actually, again we need more research in this area. But as we are transitioning from you know, perimenopause to menopause, our gut microbiome becomes less diverse. In the gut, more bugs are better, right, This is where you want more bacteria, and you want lots of different bacteria. And then as hormone levels fluctuate and decline, especially estrogen, our bacteria becomes less diverse or we have fewer of the good bacteria. Potentially. It's also the gut microbiome impacts our hormonal status also too, So hormones are excreted through the gut, and the gut microbiome actually impacts whether those hormones are reabsorbed into our body or excreted from our body. Yes, totally fascinating, Its really cool. So that's one thing that can change your gut motility changes for many women. Some women may be more prone to reflux or more prone to bloating. Actually can occur perimenopause constipation, food sensitivities. So the answer to that is yes, your gut can really be impacted by perimenopause and menopause hormonal fluctuations.
00:23:12
Speaker 3: I cannot wait for our gut health up.
00:23:13
Speaker 1: Yeah, it's gonna be good. It's gonna be a good one.
00:23:16
Speaker 3: We received a lengthy email from a woman who will be celebrating her thirty seventh birthday soon. She's been working in an environment that she knows is not the best for her, and it's taking a toll on her physical and emotional well being. She's had a number of respiratory illnesses and other viruses, along with feeling a lot of anxiety. Here's an excerpt from her email. Because of these prolonged stressors, regardless of their exact source, I'm beginning to experience symptoms that sound like perimenopause. She continues. I'm wondering whether you have encountered circumstances like mine before. Where someone knows their body and mind well, approaches health, holistically, values spirituality, breath work, meditation, and yet still finds themselves increasingly physically affected by the demands of daily life. At times, I feel as though I might actually be starting perimenopause. Is that even possible? And remember Elizabeth, she's thirty six, twenty thirty seven.
00:24:06
Speaker 1: You know, perimenopause can start like at thirty five, right, So if we think of perimenopause occurring about ten years younger than the final minstrual period, for some women have their final minstrual period around forty five, so and anything less than forty five is like considered you know, early, so definitely could be perimenopausal. These are words that are applied to transitions, which I always find again difficult, because it's all. It's all. It goes from black to white with shades of gray in between. So this is the shade of gray. If you are constantly stressed by life and not processing that stress effectively, your cortisol is going to be up. And when cortisol goes up, inflammation goes up. And you know, now there's some people talking about links between inflammation and ovarian function. Actually the question really becomes, you know, is this impacting your ovarian longevity when you're living under chronic stress, but definitely the symptoms of stress not processed correctly can mimic the symptoms obviously a perimenopause. So the way to really determine where you are in this transition, to see like what might be beneficial to you, is to check your hormone levels on day three. Actually, so looking at a day three fsh because that will show us is your pituitary working harder to make your ovaries produce estrogen, meaning that your ovaries are not working as well, so they require more gas to make the estrogen. Also the antimularian hormone or AMH, and it's really important to look at these because there are some women who do go through early menopause and a premature bearing failure. Even so, definitely perimenopause can start at thirty five. We need to begin to have these conversations. Symptomology can be sleep disruption, libido issues, brain fog. These are the more common ones that we see in these late reproductive years, so she should get it checked out one hundred percent.
00:25:56
Speaker 3: Next two questions are from people who are not on MHT. One woman writes, I'm in the perimenopause phase, not taking hormones yet, how does MHT affect women who are still who still have a menstrual cycle. Does it make your period stop or change it in any way?
00:26:11
Speaker 1: Usually progesterone is the first hormone that we lose, so it's the first hormone that we support, and we can cycle progesterone in the second half of the cycle, or we can if you're having sleep disruptions, I usually recommend progesterone throughout the cycle so that you can sleep every day. But it shouldn't really necessarily disrupt your cycle because these are not high enough levels to suppress the pituitary. So if you're using one hundred and two hundred milligrams of progesterone orally each day, you're probably not going to change your minstrual cycle, other than you might have less bleeding if you've had heavier bleeding. And again when we also begin to add if you're having hot flashes. We'll sometimes add estrogen earlier in the perimenopausal transition, after progesterone or with progesterone. But again, these levels are just to provide you a baseline so that you don't bottom out, so it usually doesn't really give you enough estrogen to cause heavier bleeding, but usually the puri doesn't stop bleeding. May it better, but some people are a little bit more more sensitive to hormonal manipulations.
00:27:07
Speaker 3: Also got it, Okay, switching gears. Let's talk about feeling sexy. The next question from a listener who writes, you know that feeling around ovulation where you just feel more confident and sexy. Does taking estrogen as MHT bring that feeling back?
00:27:19
Speaker 1: It? Definitely loved this question. I did too. I actually really love this question too. I thought this was great. You know, and our ovulatory estrogen levels are ranged anywhere between like two hundred and five hundred, and sometimes they can get up even higher than that. The levels that we begin to replace two in the menopausal perimenopause institions, these levels are anywhere between, you know, forty and one hundred and twenty. Maybe so they don't get to these high peak levels, but for some women you can definitely feel rejuvenated, feel sexier, feel better with hormone support. Some people will actually feel a little bit better if they have some testosterone at it. Also, because we haven't really talked about testosterone, but testosterone actually starts to go down in a woman in her thirties actually, so there's kind of a steady decline of testosterone, and so adding back testosterone also can really help with the libido. Also, for some women, libido's complex and feeling sexy is complex. A lot of issues that go into that, but definitely hormone support can definitely help with that feeling.
00:28:20
Speaker 3: Here's another great question about something I'm not sure we've actually discussed at length. The listener writes, why isn't pelvic floor therapy more widely recommended. I know a lot of women who have really benefited from it, but it can sometimes go overlooked as an initial suggestion for a range of issues. In my case, hysterectomy was initially recommended to deal with painful uterine fibroid, but luckily a third opinion recommended pelvic floor therapy, which helped immensely.
00:28:45
Speaker 1: So lack of education, lack of knowledge base. It can tell a little story about that. When I was at Slungcattering as a junior surgeon, a patient came to me who and this was back in the late nineties, maybe something like this, and she'd had a pelvic floor therapist, And I was like, that sounds like so stupid and that's just because I had a total lack of education about it. Fast forward, I started private practice. I'm taking care of a lot of women with endometriosis, and one of my very esteemed colleagues I said, you know this patient, I've operated on her, her endo is all gone, but she's still having pelvit pain. He goes, Elizabeth, refer her to pelvic floor therapy. I'm like, you mean that stuff? What is that? And he goes, no, it really works. So I sent her to pilvit floor therapy after doing her endometriosis excision surgery, and she got better and she had what was called pelvit flor dysfunction. Actually that I had to educate myself about that. Nobody had educated me on, despite like the best training in the nation. Right. I think more people are talking about it now. Certainly after that initial encounter with my patient, I always referred people for pelvit floor therapy, antipartum, you know, before deliveries, postpartum, after deliveries, after surgery, with endometriosis, with any type of public floridycefunction. I just think that we need more knowledge out there amongst providers and for women also.
00:30:04
Speaker 3: Okay, The next question is from a listener in New York City who started hormones during perimenopause, and she writes, I'm now well into menopause. Do I need to stop taking it? I'm feeling great.
00:30:15
Speaker 1: No, it's antiquated thinking that we need to stop hormone support. The big reason that a lot of people really recommended in the past that hormone support stopped is because as we age, we're at increase risk of stroke and cardiovascular disease. And we know that oral estrogen does increase our risk of stroke and clotting and perhaps does increase our risk of cardiovascular disease if used in the presence of cardiovascular disease, because it is inflammatory it increases what we call see reactive protein. Oral estrogen is very different and transdermal estrogen that goes across the skin in a cream or a patch right or a gel, so without an increased clotting risk and without an increased stroke risk. And we have this data with reasonably replaced levels of estrogen, and older women are not at elevated risk of stroke with transdermal estrogens. If there are like on a point oh five milligram patch or less, the one thing that you should stop is if you develop an estrogen dependent malignant see like such as breast cancer, then at that time period we do recommend, of course that you stop MHT into mutual cancer. Different story, actually early in the mutro cancer. You can resume your imaget afterwards with for many guyan oncologists, some not many. Yes, as long as you don't have a contraindication and you're feeling good, just make sure your levels are checked, make sure your levels aren't too high as you age into your seventies and such. But so no, you don't need to stop now.
00:31:38
Speaker 3: Good news for women who have children after forty and notice shifts in mood and energy. How do you know if your symptoms are postpartum depression versus perimenopause. How would you approach treating this?
00:31:50
Speaker 1: This is a really great question because we see this not infrequently, and this actually happened to me right I was forty three when I went into really had symptomatic perimenopause, and I had just had a child at forty one. So it's really checking hormone levels to see where you are basically and doing that day three fish and looking listening to the history and the narrative because remember, not all perimenopause is depression, right or anxiety. Right, there's a lot of issues with sleep disruption of course, hot flashes, in addition to mood issues, cognitive issues and such, and then they're all interlinked. But definitely getting to a provider and having things looked at closely actually in terms of where are you what we would say biochemically or hormonally.
00:32:30
Speaker 3: Also, okay, so this is different but similar. Once you've transitioned from peri to menopause, what is happening in the brain. I feel like a different person in terms of my mood's, emotional well being and stress.
00:32:42
Speaker 1: So estrogen is a big impact around brain health. Right. It changes blood blow to the brain, It changes brain energetics, how glucose is utilized, how the mitochondria and the brain work. It changes the size of the brain, the function of the brain, and also the neurotransmitters. Right, all of the neurotransmitters are impacted by estrogen and progesterone fluctuations, dopamine, serotonin, and GABA. We've mentioned those before. The brain seems particularly vulnerable when we're having fluctuations or wide swings in menopause. We're going from very high levels of mid cycle estrogens that can get range up to a thousand for some women right where kind of normal ranges are two to three hundred maybe and down to plummeting down to nothing and then no period for eight weeks and then kind of this shattered glass kind of pattern. The brain doesn't like that. The brain likes a little bit more stability. So after this, the brain does have some does get some adjustment, right, some completely adjust and some areas of brain completely adjusts and others don't. And this is the big question mark, you know, in terms of estrogen protection of brain health. Of course, you know, we know that when we start estrogen early that in that menopausal trends, it would say, even our perimenopausal transition, we need to consider it for women who are at elevated risk of brain health issues a POE four positive and such. And then is estrogen protective when it's initiated appropriately, in the appropriate form and the appropriate dosages. But eventually, if you're not on MHT, you know, some of the cognitive issues do settle in. But women, remember have this too elevated risk of dementia. And how to hormones impact that and how can we be using hormones in a preventive fashion for these individuals to protect our physiology is really important. This is I think a big area of the future of hormones support and the impact on female physiology that in cardiac disease.
00:34:29
Speaker 3: Also, of course, listeners should definitely go back and check out the episode that we did with doctor Richard Isaacson on dementia prevention. He really unpacks the science in a super compelling way. All right, let's get into preventive care and answer a few questions about supplements and such. Many women have questions about how to best care for themselves on a daily basis, not just when symptoms arise. A woman in her early thirties wrote in about with these set of questions, let's do a quick lightning round. Which vitamins or supplements should women take on a daily basis?
00:34:58
Speaker 1: You know, definitely a multi vitamin that comes from recent data from a trial called the Cosmos trial, which was a dementia related trial, and what they showed is that using a multi vitamin was associated with the lower risk of developing cognitive decline and cognitive issues. So in the past, with the multi vitamin, we said, oh, doesn't prevent cancer, maybe a higher mortality rate, but the cosmostrial in my mind changed that. So I always recommend a multivitamin for perimenopausal menopausal women. I also speak to everybody about creatine because creatine is responsible for mitochondrial support and such in our body, and it's important for a muscle building and also brain health protection. Wow, we know that there are some data now link in creatine to brain health protection. Again, we need more data and we're study, but it's a very well tolerated, extremely well studied, extremely safe supplement that women should consider. Between five and ten grams is usually recommended. Outside of those two foundational ones, I usually recommend testing because women really need to also pay attention to their Omega three levels, so their polyant saturated fatty acid levels are super super important actually for brain health. Again, I keep going back to brain health. Yeah, cardiac health also, and of course muscle health and bone health. I recommend checking the Mega three levels and then looking where we're deficient, Like many women are vitamin D deficient, so we definitely need to speak about vitamin D supplementation. But check a vitamin D level, check a B twelve level. Also if you're not eating animal products, you're at risk of having a B twelve deficiency. Super important again for neurologic functioning. I usually recommend a multi vitamin, speak about creating, and then go testing for what you may be deficient and after that. But also a lot of people won't do a Mega three checks in their office, so ask your health care provider for an Omega three check to see where you are with that. If you're not eating a lot of fatty fish and such, you might be deficient on a Mega three s.
00:36:55
Speaker 3: Yeah, you can also, I mean, I know Richard Isaacson recommends Omega quant. It's a direct to consumer test to check your omega levels DTC testing, direct to consumer testing. I love this whole area right now. Actually, there's a lot of platforms. There's a lot of a merging platforms because it really allows you to take control of your health.
00:37:14
Speaker 1: And you know that many doctors or many providers won't check for you looking at LP littlea looking at your omegaquant. You also to make sure that you have somebody help you interpret it too. It's so super important, super super important.
00:37:27
Speaker 3: Don't go totally rogue.
00:37:29
Speaker 1: Still to come, we'll answer more of your questions about hormone support. Stay with us. Let's see what are the causes of painful periods and what steps can I take to address it before it gets worse? Again, great question. This goes back to normalization of pain for women. Right, So, a lot of times, you know, I'll ask in our practice, I'll say, you know, do you have painful periods? On scale of one to ten, how bad is your pain? Right? If I hear two or three, it's like, okay, maybe cramps. If I hear nine to ten, it's like house on fire, that's not And do the painful periods impact your quality of life or activities of daily living? Do you misschool? Do you miss work? These are all important questions. Again, a lot of painful periods are ignored by healthcare providers because we normalize pain in women and symptomology in women. Anytime you have painful periods, definitely have some imaging, have a CEA healthcare provider, have some PEBLC imaging, make sure you don't have fibroids there. Look for endometriosis and adnomiosis, which is endometriosis in the wall of the uterus basically, but the vast majority of heavy, painful periods are actually caused by endometriosis and need attention not only to relieve the symptoms, but to stop the progression of the problem. Right, we forget about that, people like, oh, I can suffer through it, I don't need to do anything about it. I'm like, you should do something about it so it doesn't get worse. This can range anywhere between using a birth control pill or oral contraceptive if you are don't have any contraindications. Some of our progestine or leave an adjustrial containing IUDs are extremely helpful and beneficial. Get that imaging, and if there's a suspicion of endometriosis, which there always should be, see somebody who has a knowledge of endometriosis beyond the ultrasound. Also get you know, talk about getting an MRI and seeing what should be done in the future. But also make sure there's no ovari insists there. Make sure that there's no fibroids there. You know, just make sure that everything is completely evaluated. Don't just assume that it's like, yeah, it does, didn't take a book cramps that you need to make yeah, and yeah, muscle through or just take a birth control hell for get some evaluation for them.
00:39:41
Speaker 3: Yeah, okay, here's a good one. This listener is in perimenopause. She's working with a physician who is not comfortable putting her on hormone therapy. She's forty nine years old and symptomatic, and she's considering going telehealth rout.
00:39:59
Speaker 1: You need to find a doctor who's comfortable. You know. This is really this shows our gap in women's health, and we need to get everybody up to speed, and we need to get people comfortable prescribing hormone, when to prescribe, how to prescribe, And it's an education problem and I think you have to look at you know, you can go in to say, why would that physician not be comfortable with it? This is something safe, it's something nuanced. But I think getting to somebody who's knowledgeable, and then how do you get to them. Menopause Society has menopause practitioners that they list on their website. The telehealth route is very interesting. I am actually supportive of telehealth if used appropriately, because you do have people who are knowledgeable, but they're not seeing you, they're not examining you, they're they don't know you. So I do think that there is a role for telehealth in areas where we don't have practitioners who are up to speed on the current data and the current knowledge base that exists. Now, the hope I have is that we get everybody up to speed. It's so funny to me that women's health is considered a niche area fifty percent of the population. Yeah, women like, why is that? And I always say red flags are I prescribe hormones for everybody, or I prescribe hormones for nobody. It's nuanced, it's a conversation, it's a narrative, and those are two red flags.
00:41:28
Speaker 3: I ask so many great questions. Okay, I can read this next one. It's about MHT. Here's the question. As a listener, my understanding is that doctor Pointer recommends estradal above all. But my doctor prescribed estrogen, which is estrone as a topical cream in addition to Divigel transdermal estradil. Elizabeth, can you jump in and explain.
00:41:50
Speaker 1: So Divigel is a topical estradial gel. It's a brand name point zero two five though is considered low dose. So there are three main types of estrogens. There is estradial, which is the main estrogen in our body es drone, which is a lesser estrogen in the main estrogen after menopause, and then there is estriol, and the vaginal epithelium will respond to all three estrogens. Less data with estrone, though estradial would be the more standard type of topical preparation that we would recommend and use. And some practitioners actually like estriol, which is not FDA approved in the United States, but some women will actually do better with vaginal estriol. So, but the standard really in the United States has been estradial preparations, either ultra low dose in the form of a small suppository or a ring, or a little bit higher dose but still local treatment with the vaginal cream. And it is very standard and very desirable in terms of hormone support.
00:42:55
Speaker 3: So let's continue with the second part of this listener's question. She's from Toronto, by the way, she asks.
00:43:01
Speaker 1: That explains the estrogen. I was like, who prescribes that in the United States? Now I understand the Canada.
00:43:07
Speaker 3: Should I go back and ask for the estradial topical. I'm also shocked that my doctor didn't tell me to apply divigel in the morning buzzing doesn't begin to describe the jolt literally like cocaine.
00:43:18
Speaker 1: I had to take an adavan. So this is an interesting conversation. Right, So there are what we call diurnal variations and hormones throughout the day. Right, So testosterone tends to be higher in the morning. Estrogen or estradial tends to be higher in the morning for women. And I was just having this conversation with our intercrinologists recently because we try to use hormone support and say, oh, steady levels are great, but you know, stety levels might not be so great. We should maybe try to replicate that diurnal variation. So more estrogen in the morning. Progesterone usually we recommend at night. That's not negotiable because that helps with sleep and can make you groggy, But definitely estrogen is usually recommended to be applied in the morning. If you're having hot flashes at night. Sometimes what I'll do is I'll add a little bit of extra estrogen in the evening so that you have like a steady level if you're using a gel. But these are interesting questions for the future. You know, we just assume that stable is better, and stable might not be better. You know, we might need some diurnal variation, we might need some cyclical variation. There was this old fashioned protocol called the Wily protocol, which it was a postmenopausal hormone support therapy that replicated a cycle. But it goes back to like, does the brain respond better to cyclical hormones? Do we respond better overall with our physiology in terms of cyclical hormones throughout the day or throughout the month? And these are like the interesting questions to be answered in the future. But definitely mourning for estrogen is better if you're having hot flashes at night after using your gel in the morning, you know, maybe add a little bit of extra in the evening, but not as much as in the morning. Got it all right?
00:44:50
Speaker 3: We have a handful of questions left, Let's keep going. A listener who is experiencing menopause emailed this, why are the muscles and bones so painful during menopause aside from exercise? What can you do to alleviate pain and discomfort? Are there any recommendations for certain foods or a particular diet that can help.
00:45:08
Speaker 1: There are estrogen receptors all throughout our body, and there are estrogen receptors and all the tissues of our joints. And this is why we see frozen shoulder actually because it tends to be that the shoulders is particularly saturated with estrogen receptor. So as estrogen goes down, the joints and muscles and bones actually respond to lower levels of estrogen in a not so positive way. Right, Lower levels of estrogen are also inflammatory. High levels of estrogen are also super inflammatory, and low levels of estrogen are inflammatory. So definitely anything that's exacerbated with inflammation is going to be made worse with lower estrogen levels. Exercise is super important. Actually, string I go back to strength training to protect your muscles, bones and joints. I recently had an injury and after strength training, I was back in three days. In the past, it would have taken me three months. In my leg would have been huge. I have a knee injury, and I was like, WHOA, this actually really works. Definitely, exercise, exercise, exercise, and movement, movement, movement, but making sure you pay attention to the making sure that you are joint sensitive though in the exercise you're doing, you don't want to over you don't want to overwork a joint that's not healthy. Right, so you need to make sure that you're with a great trainer or pt certain foods. Great question in terms of we want to make sure that we definitely have good omega threes again, right, so we want to have anti inflammatory whole foods. We don't want to have a lot of sugar around because that's inflammatory. So you know, so simple sugar is not good. Sugars from fruits that come with fiber or great fiber good. But definitely an anti inflammatory nutrition plan can be super super helpful.
00:46:43
Speaker 3: Okay, we have a great question which is about what's called unopposed estrogen, so meaning taking estrogen without progesterone. Here's the question.
00:46:52
Speaker 1: It's a long one.
00:46:53
Speaker 3: I was diagnosed with advanced endometriosis when I was forty three after surgery to remove a small internal uterine fibroid. While pursuing fertility treatment, I had several large fibroids on the outside of the uterus that had grown into the walls and were not candidates for removal. I turned fifty in March and I had a hy directomy six months ago. I kept my ovaries. Part of my rational for the hysterectomy is that I would finally be able to start MHT. I recently started applying transdermal estradial and using a vaginal estrone cream. But my GP doesn't think I need to take progesterone because of hysterectomy. Is it okay to take outoposed estrogen or should I be adding progesterone into the mix too.
00:47:33
Speaker 1: I think with previous endometriosis, we do want to add progesterone because endometriosis, remember, is a type of endometrial tissue, not normal dimetrial tissue, but a type of endemetrial tissue that's on the outside of the uterus. So it responds the same way as endometrium does. Right, So estrogen alone is going to make it grow. And there's two concerns with that because for the line of the uros, estrogen the line of the uros grow and pogesterone says stop growing, stop growing, So we want to get that stop growth signal in there. And there's two concerns actually with unopposed estrogen after a diagnosis of endometriosis, even if it's not visible. Actually, the first is just reigniting the endometriosis to come back like you had surgery. For endometriosis, and if some is left behind, we don't want it to grow back and cause a problem and require additional surgery. So definitely progesterone that situation and be super helpful. The other is it's unopposed estrogen. And remember with unopposed estrogen and the uterinelining, actually there's a significantly elevated risk of developing endometrial cancer, and you can definitely develop cancers in endometriosis. So you just want to make sure that you don't have abnormal proliferative tissue. Just because it's not the name, it's still in dumetrial type tissue, so it still responds in a similar fashion, So you don't want it to grow back and you don't want it to convert into a malignancy. I also love this question too because we forget that progesterone also is important for sleep for some people, right, So I'll definitely see people that had hysterectomy and are not on progesterone who can't sleep and are on estrogen and they're like, I can't sleep, I can't sleep. I'm like, well, we should really talk about progesterone, because just because you don't have a uterus doesn't mean that you can't take progesterone, So we have to be cognizant of the breast progestine risk. Progestines are synthetic progestogens. Mouthful, right, but meaning that progesterone there's still a little bit of a question mark after long term use of progesterone and breast cancer. So we don't just add it in because we know that estrogen alone does not increase your risk of breast cancer and progesterone. We have data for five years or so in terms of natural progesterone longer in Europe, but we're waiting for that data to mature. But we know for at least five years of use that you're good in terms of breast cancer risk, and probably longer I think.
00:49:57
Speaker 3: Okay. Same listener also writes, I'm considering taking a statin for genetically high cholesterol that I've had since high school. I had a zero on the coronary artery calcium score, but it is getting higher as I get older. What can you share about statins for genetically high cholesterol?
00:50:14
Speaker 1: Okay, so this is a complex question, but it's great that the SAC is negative, but that does not necessarily mean for everybody that you don't need a statin, certainly for individuals who have a family history a premature coronary artery disease, meaning an individual who has a family history of maybe a relative with an mi I or significant coronary artery disease less than fifty five for men, less than sixty five for women. These are individuals who are an elevated genetic risk. By having a genetically elevated cholesterol also puts you in a different risk category in terms of just a person who has an elevated risk not based on their genetics. And you want to look at LP LITTLEA, which is a very athrogenic type of cholesterol. This is very highly personalized, so you need to look at your family history. You're also your personal history. You know, do you have some insulin resistance, because you're going to have a lower threshold to start a statin. And so if you have had a genetically elevated risk of cholesterol, you know, since your early years, I would really highly suggest that you get to a cardiologist or even we have specialists now who specialize in lipidology basically this is what they study. But getting to a knowledgeable cardiologists for women's cardiology is super important because also important to remember women have soft plaque too. It doesn't show up on a CAC, it's not calcified, and so we also have to look at that too. More advanced testing might be something called a clearly test, where we're looking at soft plaqu or looking at carotids to see if we can see soft plaque, which means that the cholesterol is actually doing something and depositing somewhere. So personal health history, looking at your family history, and then more advanced testing beyond that CAC. And I'm certainly not a cardiologist, but I sit in a room next to like about six cardiologists and listen to them talk all day, and we have great guidance where I am currently. So that makes me extremely respectful of the nuanced nature of lipidology.
00:52:13
Speaker 3: Okay, Our last question is from a former patient of yours, Elizabeth.
00:52:17
Speaker 1: She loves that New Jersey.
00:52:18
Speaker 3: She's fifty three years old and says that she listens to most of the Decoding Women's Health episodes.
00:52:23
Speaker 1: Thank you for that? Why not all of them?
00:52:27
Speaker 3: This is what she wrote. In one of your podcast episodes, you address the dosage of estrogen and how much it takes to protect the heart, brain, and bones. She continues, I'm currently taking point zero two five estradial and one hundred milligrams of micronized progesterone daily. The hot flashes are gone and they don't really have any other symptoms. Am I taking enough to protect my heart, brain, bones, et cetera. I have friends who are taking much higher doses.
00:52:52
Speaker 1: Right, So this begins to get into the question of why are you taking hormones? Is it for symptoms or protection of your physiology? And of course, as we all know, I am like super interested in hormone support not only for symptomology, but also for protection of your physiology. And the studies that have shown for brain health protection and cardiac protecttions, these studies were all done with oral estrogens that get you into a range of around sixty or so. There was once one portion of a study that was done with a lower dose of estrogen, but the vast majority of the studies that show cardiac protection when MHT is initiated within that ten year period. Brain health protection, metabolic protection also are with these doses that get you into this range of sixty. We don't have great data on protection of physiology with low dose hormone support. Is this considered low dose? Yes, this would be considered low dose. And then if you look at bone health, more estrogen the better. Actually, you definitely do get some protection with lower levels of estrogen, but you get better protection with higher dosages and higher levels of estrogen. So I typically have people check hormone levels for two reasons. One, transdermal absorption is more erratic than oral absorption of hormones, and we always recommend trans to start with, of course because of the clotting risk and stroke risk, et cetera. And see reactive protein and inflammatory risk. But the levels are less predictable with transdermal estrogens. If you believe that you're using estrogen to protect your physiology, have your levels checked.
00:54:26
Speaker 3: Yeah. Thank you, Elizabethan. Thank you to our listeners for sending in such fantastic questions so much.
00:54:31
Speaker 1: These were great questions. I am always so impressed with the questions same we covered a lot in today's episode. Thank you to everyone who sent in questions. We hope to respond to more of your questions in the coming weeks, so please keep them coming. Maybe this conversation sparked more questions for you about PCOS now PMOS, or maybe you've got questions about endometriosis, HPV or yeast infections, really anything you're wondering about and would like us to tackle on the show. If you'd like to submit a question, please send us a message at Decoding Women's Health at Pushkin dot fm, or feel free to leave a voicemail at four four five two O one three three eight five. Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Kalalah. It was edited by Amy Gaines McQuaid, mastering by Sarah Buguer. Our associate producer is Sonia Gerwit. Our executive producer is Alexander Garretton. Fact checking by Abigail Abrams. Our theme song was composed by Hannas Brown. Concept and creative development by Shavan O'Connor. Special thanks to Vicky Marrick, Alan Tish, David Saltzman, Doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohne. I'm doctor Elizabeth Pointer. Thanks for listening and until next time
Speaker 1: Pushkin.
00:00:23
Speaker 2: This show is not a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes. Please consult your healthcare professional with any medical questions. Also in this show, we use women as shorthand for people with XX chromosomes. We understand sex and gender are more complex and acknowledge the experiences we describe reach beyond that word.
00:00:51
Speaker 3: Elizabeth, you won't believe what I have for breakfast. I put at amami in my yogurt.
00:00:55
Speaker 1: It sounds really good. It actually was, because really it sounds like a great thing. Actually, I'm here today in the studio with Shavan O'Connor. She's a health and science journalist who works closely with me on this show, and she's also the chief content office at Adria. She's joining me today to co host our second AMA or Ask Me Anything episode. This time around, we're answering all your gnacologic health questions. Many of you reached out with really excellent questions about pcos now known as pmos, as we'll get into, We're also going to tackle some of your really thoughtful questions about perimenopause and how it can impact many aspects of your health. Plus we'll answer your questions about hpv UTIs, self, breast exams, hormone support, public floor therapy, golp ones, and lots more. Let's get into it.
00:01:50
Speaker 3: Okay, first question, and this hopefully is a pretty straightforward one. Is it true that most clinical studies are done on males and male rats?
00:01:58
Speaker 1: One hundred percent. Women were not required to be included in medical research until nineteen ninety three, Actually not that many years ago, right, And then more interestingly, only animal studies were recently required to have female animals, and that was in twenty and sixteen, actually two years ago government funding. One hundred percent.
00:02:21
Speaker 3: Let's respond to this question that came in from a lessener. The question is I get frequent UTIs that just won't go away even after many rounds of antibiotics. Oof, I feel for you. What is the best way to prevent UTIs?
00:02:34
Speaker 1: So if your perimen apousal or specifically postmenopausal, so haven't had a period in a while, vaginal estrogen, vaginal estrogen, vaginal estrogen. And this is actually new guidance from policymakers that women who have recurrent UTIs actually should be on vaginal estrogen. And this has also been helpful that the black box warning has been removed from the estrogen labels. But also we forget about like basics like staying well hydrated, practice good hygiene, wiping from front to back, don't hold your urine void frequently within reason, right, you don't want to void too frequently, and very products Vitamin C may be helpful for some people. And then there's the gut in vaginal microbiome, and this is an evolution in terms of UTI prevention and such, but a healthy gut microbiome we find in our practice along with maintenance of a healthy vaginal microbiome you know, impacted by estrogen, but also bringing the pH down and putting in good probiotics may be helpful. And importantly avoid thongs that can actually be irritating to the urethra and such. But also see somebody too, because you also want to make sure you know, these are the basics, but you also want to make sure that there's no anatomical abnormality or that you're not in urinary retention. So always having that adequate work up with imaging and a healthcare provider is always really important.
00:03:55
Speaker 3: Also you said avoiding wearing thongs, okay, so on behalf of women everywhere. Thank you to the listener who sent him this. Next question, she writes, do you have any recommendations for the best underwear for vaginal health and maintaining an appropriate pH level?
00:04:09
Speaker 1: Yes, so the exact opposite of thongs here, White cotton granny pants are really the best. And I love to say that granny panties white cotton, avoiding dyes, having cotton if you can get it organic so it's not chemically processed, also or bleached. Also sometimes like tappants and things like that, you know, boy shorts that don't pull into the bulvar area are probably really important. Also, let's respond to one question about human papillamavirus or HPV. This person writes in I'm confused about HPV. When it goes away on its own, is it still transmissible? And also can people with partners still get HPV even after receiving a vaccine. Eighty percent of women who are sexually active will have HPV at some point in their lifetime, so super super common. But the vast majority of people it actually kind of goes dormant after two or three years. It probably doesn't completely away. We don't really know that There's some people who may clear it completely, but it probably goes dormant because it can definitely get reactivated later in life periods of stressors. We see HPV can like rear its ugly head again in your PAP smear. In terms of transmissibility, if your PAP is negative but you've had HPV in the past, or you've had vaginal warts or any type of HPV related disease, we don't know about the transmissibility. When the virus is dormant, it's probably less so than when it's out. That's just something we don't have data on.
00:05:38
Speaker 3: I know it's a sexually transmitted disease. Is that the only way you can get HPV pretty much? I mean it is a skin to skin kind of contact. There's always questions on in adimate objects or phoemtes, you know, maybe right. So that's why it's always important to that if you're having vaginal ultrasounds that you go to a facility that's cleansing everything totally appropriately. But usually we think of it as skin to skin contact and sexually transmitted.
00:06:05
Speaker 1: After the vaccine, Yep, you one hundred percent can still get HPV. The vaccine only protects against nine types of HPV, and there are over one hundred different types of HPV. The vaccine is important though, because it protects against our two most oncogenic types, which are sixteen and eighteen, so, meaning that those are the two that are like really linked to cancer, and then six and eleven, which are related, which are super common and related to genital wards. So, and then the other five subtypes are also in the vaccine, so that you can still get HPV, but those oncogenic subtypes of sixteen and eighteen are much less so, and the vaccine is protective against those.
00:06:43
Speaker 3: Vaccine is important. Okay, Okay. This next question is something I had literally never heard of until I read it. A non surgical procedure called labial puff, which is an augmentation of the outer lips of the volva. Here's the question. Could you please discuss the procedure called labial puff and whether it's considered safe or not, and also what type of provider would perform this safely?
00:07:05
Speaker 1: So, what happens to the labia when we age or we lose weight, and we see this with gelbes or any type of weight loss or any type of aging, is we actually lose fat in the vulvar region, so a libial puff is actually puffing that area up. That can be with a fat injection from another part of your body called fat grafting or a fat transfer, or it can be with just a typical injection based a high uronic acid based injection, like a typical filler that you would get in your face. Safe, not a lot of things to damage in the area with the injection right, can get some lumpiness if it's a fat transfer, fat graft from what we call fat necrosis, meaning the fat doesn't take the way that it's supposed to. And also if you inject hyaluronic acid doesn't last for a long time, you have to reinject. In terms of who would provide this type of procedure, it might be a plastic surgeon or a reconstructive surgeon who does pelvic work, not all of them do, or it could be a gynecologist actually who does this type of work. But always make sure that if you're going to do something like this reconstructive, an area that is subjected to pressure right you're sitting on a bicycle seat is near the bladders, near the urethra. In terms of comfort, that you go to somebody who does a lot and who specializes in it, and make sure that you always ask about the risk of the procedure specifically with that person.
00:08:28
Speaker 3: Okay, great, what do we know about breast self exams? Should we still be doing them?
00:08:33
Speaker 1: So when I was in training, we taught every woman do a monthly self breast examination. And this can lead to stress and anxiety, and can also lead to people having like a little false sense of reassurance. I don't feel anything, so why should I go get my mammogram? Right? So, there was a study that was published that took women and half of the women in the study performed self and breast examinations and the other half did not. And the women who perform self breast examinations found more benign nodules compared to women who did not do self breast examination, but the risk of dying from breast cancer was the same in both In both groups, it probably reflects that we have great treatments for breast cancer now, right, So I encourage women to have what we call breast awareness, and this is what's recommended now for women who may be a very high risk of breast cancer, who have a family history. Definitely this conversation. So be aware of your breast, don't avoid your breast. If you feel anything that's new or unusual for you, of course bring it to the attention of your provider. If you see anything that's different, maybe a pigmentation change, skin texture change, a new asymmetry, or one breast larger than the other, always have that evaluated. I think we should still offer women's self breast examination and teach them how to perform it, but realize that it's not a must do like we used to recommend.
00:09:54
Speaker 3: Let me say, tire Kusics scores aka TC scores. This is a tool that estimates your lifetime risk of developing breast cancer, right.
00:10:02
Speaker 1: So a Tirecusic score. It gives you your lifetime risk of developing breast cancer based on your personal health history, your reproductive history. Did you use birth control pills, have you used hormone support, What was the age of your first child, when were they born, how many children have you had, number of relatives with breast cancer. It even incorporates some of our newer genetic testing, such as polygenic risk scores, and of course it also incorporates our testing for BROCA one and BROKO two, So you come up with a lifetime risk of developing breast cancer. And this is really important because women who have over a twenty percent chance of developing breast cancer in their lifetime will recommend augmented screening as standard of care with perhaps breast MRIs or contrast enhanced mammograms. Women who have a lifetime risk between fifteen and twenty percent so slightly elevated, we should offer, with shared decision making, a more supplemental screening in addition to just a mammogram and a breast ultrasound. And there are guidelines that actually suggest or have outlined in the guideline that every woman over the age of twenty five should have a yearly tire Kuzk score calculate because it's going to change based on how's your health history changes or how your family history changes. But less than twenty percent of practitioners actually perform a tire Acusic score. And I was recently in a focus group actually of women about women's health, and only a few actually had a few out of twenty to have their Tirecuzik score calculated.
00:11:30
Speaker 3: Take an algorithm you can do online.
00:11:32
Speaker 1: Guess like you can do it yourself. You Google tirecusic score. You can plug it in as ibis eight. I believe that you can plug it in and do your own tire acoustic score.
00:11:41
Speaker 3: Yep.
00:11:41
Speaker 1: Okay.
00:11:41
Speaker 3: So a woman from Brooklyn has a question about cysts. She writes, can benign cysts or fibroadenomas in the breast ever go away on their own?
00:11:49
Speaker 1: So the vast majority of cysts actually do, like seventy percent of simple cyst actually go away on their own. We don't usually intervene with the breast cyst unless it's painful or quite large. Then sometimes we'll drain it. Sometimes if you're on MHT or certain times of your cycle, they're under hormonal influence, so they can get a little bit larger. But the vast majority of what we call simple so just liquid filled says, go away on their own. Biproatgnomas don't usually go away on their own. They can get bigger, they may get a little bit of smaller, so once it's there, it's kind of there, but they can go up and down a little bit. Also. Our next set of questions are about PCOS or polycystic ovarian syndrome, which was very recently named PMOS or polyendocrine metabolic ovarian syndrome.
00:12:35
Speaker 3: Okay, can you first just briefly define PCOS now PMOS, who's most at risk and how's it diagnosed?
00:12:42
Speaker 1: So every woman is at risk, right, and we don't actually know what causes PMOS or PCOS. Maybe there's a genetic influence, an environmental influence, lifestyle influence, environmental exposure influence is probably many different ways to develop PCOS. So PCOS or PMOS is characterized by androgen exs, so either acne or exs hair growth or just biochemically elevated androgen, an elevated dhees or an elevated testosterone, along with menstrual irregularities, so infrequent periods, irregular periods. And also this is how it got its name PCOS. Polycystic ovaries, so multiple cysts on the ovaries, usually in what we call a string of pearls fashion, so very specific way that the ovaries look. And importantly though, and this is what I learned from our endocrinologist when I came to atria, which is so interesting. It's really a metabolic disease, right, So this is why this new name is super super important. So polyendocrine metabolic. It's really much more descriptive because a lot of women were not getting diagnosed appropriately because the silo nature of medicine. But it is a syndrome, which is always difficult because there's probably many different ways to get to this syndrome. And a syndrome means a collection of symptoms. So do you have these symptoms. It doesn't tell us why it's occurring, but you have this collection of symptoms that puts you at metabolic risk. And so we really need to pay attention to your metabolic health because many women are insulin resistant of course, have elevated insulin levels, elevated glucose levels, and some are overweight, but you can also be quite thin and have a PMOS.
00:14:25
Speaker 3: Also, isn't it true that you can also have pmos formerly known as pcos and not actually have cysts.
00:14:32
Speaker 1: One hundred percent. Yeah, the roder Dim criteria, it means you have to have two out of three of the groups of symptoms, and the one group of symptoms that we didn't put in there, actually it's not a symptom. It's a biochemical number basically as an elevated amh or antimularian hormone. So that's actually been recently put into the collection. So you can have elevated androgens biochemically, you can demonstrate elevated androgens acne, hair growth and such. Or you can have minstrual irregularities in frequent periods or irregular periods, or you can have polycystic ovaries or an elevated AMH. Got it.
00:15:12
Speaker 3: We have quite a few more PMOS questions, all right. First question is, given the prevalence of PMS, why has it historically been underdiagnosed and often dismissed? Is this a systemic failure in healthcare?
00:15:23
Speaker 1: Big one definition of the systemic failure in healthcare? I mean, I love the renaming of pcos to pmos because it's going to take it out of its silos. Right, it's a total body issue. You're going to your gynecologists. They don't understand the metabolic implications. Necessarily many do, but many don't actually, so then it just doesn't get diagnosed. The systemic failure comes from one lack of research, lack of education about it to the silo nature of healthcare and for women, meaning that we need to define who that women's health specialist is. And three the lack of research. This issue impacts one out of eight women, right, and probably even more if we really look for it, and we don't know so much about it. You know, we don't even have any FDA improved medications for it. So again, you know, it is the definition of the systemic failure of health care for women.
00:16:16
Speaker 3: Okay, So the next question is from a woman who is forty years old and was diagnosed with PCOS in her twenties. She writes that doctors told her they can't quote fully diagnose pcos because it's difficult to see everything. She says she has had irregular periods for years and takes anostol, which she says helped. Also diabetes runs in her family. Her question is, can p coos ever be reversed? Is there anything besides prescription drugs that you recommend? All right, Elizabeth, what should this woman try?
00:16:44
Speaker 1: Okay? In terms of can it be reversed or cured? Right now, we don't think of a cure for pcos. In terms of it can be managed, right, and it can be managed very effectively with not only medications, right, but really importantly lifestyle because this is a metabolic syndrome, right in terms of insulin resistance, So any lifestyle factor that can help your metabolism is going to help PCOS. So that is getting good sleep, getting good stress management. Working with the nutrition is whole foods, focusing on making sure that you get adequate protein, pay attention to what we call low glycemic index foods or foods that don't spike your glucose because that will decrease your insulin production. And then my favorite one is strength training and exercise. You know, we used to tell women, you know, avoid strength training PCOS is going to stress your system, but we know that muscle is the organ of metabolism and does take up our excess glucose and decreases our insulin when we have more muscle. So definitely, lifestyle is really really important with PCOS. And then beyond lifestyle, if you can't manage everything with lifestyle, you know, using a birth control pill can be very helpful. Met Foreman, which is an insulin sensitizer, is also extremely helpful and commonly used in PCOS. And then androgen blockers such as aldactone or sperna lactone are also very beneficial. I think as we more people involved and more subspecialties involved and looking at what this really is, why does it really occur, will move towards that what we call cure or better management at pcosmos pmos otherwise known are in the past known as pcos.
00:18:26
Speaker 3: Okay, last one, there's a lot of hype around using ozempic for pcos. Are we witnessing a real breakthrough or are we medicalizing symptoms without fully understanding the long term effects.
00:18:37
Speaker 1: I think that glp ones for pcos for many women, are game changers, right, because this is a metabolic issue in terms of I keep going back to insulin resistance and elevated glucose. Elevated insulin and definitely golp ones will decrease visceral bad and help with metabolic issues of course, and so for many women who've been frustrated because remember, birth control pills don't necessarily impact the metabolic issues, they're kind of controlling the symptoms at pmos. Foreman actually is an insulin sensitizer. Oldac tone is just an a blocker of androgen. So really the met format has been what we've really can kind of really impact the basic biology of the issue. And the golp ones I mean met format X differently than glp ones, but it's kind of like met format on steroids, and so for many women who face weight challenges with PMOS, the golp ones can actually be a game changer for them. But not again something just to say, let me just give you this and don't use the lifestyle influences. Also because you have to whenever you use a medication like a golp one, you really have to pay attention to your body composition, making sure that you're building muscle and not losing weight at the expensive muscle. And I think if used very responsibly, with appropriate strength training, appropriate nutrition, they can be really a game changer for women with PMOS. When we come back your questions about perimenopause, and we'll get into whether hormone support can help you feel sexier.
00:20:22
Speaker 3: We received some really great questions from listeners about perimenopause, so let's keep going. The next question is from a listener who lives in the Boston area. She writes, what's the connection between perimenopause and anxiety? Or is my anxiety just elevated because of the other factors in my life right now? Could it be my hormones?
00:20:40
Speaker 1: It's probably everything. Actually, I always say that with hormones, with women with estrogen, progesterone, androgens. Also, you know, we paint our lives on a canvas between you know, with shades of gray, between black and white, you know, and hormones don't necessarily completely change that, but they can definitely shift it. So perimenopause is a transition time where you can have great fluctuations of estrogen which can impact your neurotransmitters, serotonin, dopamine, the GABA receptors. Progesterone is actually declining during perimenopause, So that's really the first thing that we see is this decline in progesterone, which is the calming hormone for us. It's impacting the action of the GABA receptors in the brain, which are those calming like don't get anxious receptors in the brain. And so definitely anxiety is very common at the time of perimenopause, anxiety and irritability, and so so important to remember that there's other factors that may be contributing. Lack of sleep can contribute to mood issues and anxiety family situations. Definitely, this is a period of time where we have the perfect storm of hormones and for many women, life situations just in general, and then you have sleep issues too, so it all goes hand in hand. But yeah, hormones play a very large impact in this.
00:21:57
Speaker 3: Yeah, the same listener added one more question. Can perimenopause affect your digestive system? I'm noticing some changes in my bowel movements. What could be happening here?
00:22:06
Speaker 1: Hormones impact the GI system in many different ways. Actually, again we need more research in this area. But as we are transitioning from you know, perimenopause to menopause, our gut microbiome becomes less diverse. In the gut, more bugs are better, right, This is where you want more bacteria, and you want lots of different bacteria. And then as hormone levels fluctuate and decline, especially estrogen, our bacteria becomes less diverse or we have fewer of the good bacteria. Potentially. It's also the gut microbiome impacts our hormonal status also too, So hormones are excreted through the gut, and the gut microbiome actually impacts whether those hormones are reabsorbed into our body or excreted from our body. Yes, totally fascinating, Its really cool. So that's one thing that can change your gut motility changes for many women. Some women may be more prone to reflux or more prone to bloating. Actually can occur perimenopause constipation, food sensitivities. So the answer to that is yes, your gut can really be impacted by perimenopause and menopause hormonal fluctuations.
00:23:12
Speaker 3: I cannot wait for our gut health up.
00:23:13
Speaker 1: Yeah, it's gonna be good. It's gonna be a good one.
00:23:16
Speaker 3: We received a lengthy email from a woman who will be celebrating her thirty seventh birthday soon. She's been working in an environment that she knows is not the best for her, and it's taking a toll on her physical and emotional well being. She's had a number of respiratory illnesses and other viruses, along with feeling a lot of anxiety. Here's an excerpt from her email. Because of these prolonged stressors, regardless of their exact source, I'm beginning to experience symptoms that sound like perimenopause. She continues. I'm wondering whether you have encountered circumstances like mine before. Where someone knows their body and mind well, approaches health, holistically, values spirituality, breath work, meditation, and yet still finds themselves increasingly physically affected by the demands of daily life. At times, I feel as though I might actually be starting perimenopause. Is that even possible? And remember Elizabeth, she's thirty six, twenty thirty seven.
00:24:06
Speaker 1: You know, perimenopause can start like at thirty five, right, So if we think of perimenopause occurring about ten years younger than the final minstrual period, for some women have their final minstrual period around forty five, so and anything less than forty five is like considered you know, early, so definitely could be perimenopausal. These are words that are applied to transitions, which I always find again difficult, because it's all. It's all. It goes from black to white with shades of gray in between. So this is the shade of gray. If you are constantly stressed by life and not processing that stress effectively, your cortisol is going to be up. And when cortisol goes up, inflammation goes up. And you know, now there's some people talking about links between inflammation and ovarian function. Actually the question really becomes, you know, is this impacting your ovarian longevity when you're living under chronic stress, but definitely the symptoms of stress not processed correctly can mimic the symptoms obviously a perimenopause. So the way to really determine where you are in this transition, to see like what might be beneficial to you, is to check your hormone levels on day three. Actually, so looking at a day three fsh because that will show us is your pituitary working harder to make your ovaries produce estrogen, meaning that your ovaries are not working as well, so they require more gas to make the estrogen. Also the antimularian hormone or AMH, and it's really important to look at these because there are some women who do go through early menopause and a premature bearing failure. Even so, definitely perimenopause can start at thirty five. We need to begin to have these conversations. Symptomology can be sleep disruption, libido issues, brain fog. These are the more common ones that we see in these late reproductive years, so she should get it checked out one hundred percent.
00:25:56
Speaker 3: Next two questions are from people who are not on MHT. One woman writes, I'm in the perimenopause phase, not taking hormones yet, how does MHT affect women who are still who still have a menstrual cycle. Does it make your period stop or change it in any way?
00:26:11
Speaker 1: Usually progesterone is the first hormone that we lose, so it's the first hormone that we support, and we can cycle progesterone in the second half of the cycle, or we can if you're having sleep disruptions, I usually recommend progesterone throughout the cycle so that you can sleep every day. But it shouldn't really necessarily disrupt your cycle because these are not high enough levels to suppress the pituitary. So if you're using one hundred and two hundred milligrams of progesterone orally each day, you're probably not going to change your minstrual cycle, other than you might have less bleeding if you've had heavier bleeding. And again when we also begin to add if you're having hot flashes. We'll sometimes add estrogen earlier in the perimenopausal transition, after progesterone or with progesterone. But again, these levels are just to provide you a baseline so that you don't bottom out, so it usually doesn't really give you enough estrogen to cause heavier bleeding, but usually the puri doesn't stop bleeding. May it better, but some people are a little bit more more sensitive to hormonal manipulations.
00:27:07
Speaker 3: Also got it, Okay, switching gears. Let's talk about feeling sexy. The next question from a listener who writes, you know that feeling around ovulation where you just feel more confident and sexy. Does taking estrogen as MHT bring that feeling back?
00:27:19
Speaker 1: It? Definitely loved this question. I did too. I actually really love this question too. I thought this was great. You know, and our ovulatory estrogen levels are ranged anywhere between like two hundred and five hundred, and sometimes they can get up even higher than that. The levels that we begin to replace two in the menopausal perimenopause institions, these levels are anywhere between, you know, forty and one hundred and twenty. Maybe so they don't get to these high peak levels, but for some women you can definitely feel rejuvenated, feel sexier, feel better with hormone support. Some people will actually feel a little bit better if they have some testosterone at it. Also, because we haven't really talked about testosterone, but testosterone actually starts to go down in a woman in her thirties actually, so there's kind of a steady decline of testosterone, and so adding back testosterone also can really help with the libido. Also, for some women, libido's complex and feeling sexy is complex. A lot of issues that go into that, but definitely hormone support can definitely help with that feeling.
00:28:20
Speaker 3: Here's another great question about something I'm not sure we've actually discussed at length. The listener writes, why isn't pelvic floor therapy more widely recommended. I know a lot of women who have really benefited from it, but it can sometimes go overlooked as an initial suggestion for a range of issues. In my case, hysterectomy was initially recommended to deal with painful uterine fibroid, but luckily a third opinion recommended pelvic floor therapy, which helped immensely.
00:28:45
Speaker 1: So lack of education, lack of knowledge base. It can tell a little story about that. When I was at Slungcattering as a junior surgeon, a patient came to me who and this was back in the late nineties, maybe something like this, and she'd had a pelvic floor therapist, And I was like, that sounds like so stupid and that's just because I had a total lack of education about it. Fast forward, I started private practice. I'm taking care of a lot of women with endometriosis, and one of my very esteemed colleagues I said, you know this patient, I've operated on her, her endo is all gone, but she's still having pelvit pain. He goes, Elizabeth, refer her to pelvic floor therapy. I'm like, you mean that stuff? What is that? And he goes, no, it really works. So I sent her to pilvit floor therapy after doing her endometriosis excision surgery, and she got better and she had what was called pelvit flor dysfunction. Actually that I had to educate myself about that. Nobody had educated me on, despite like the best training in the nation. Right. I think more people are talking about it now. Certainly after that initial encounter with my patient, I always referred people for pelvit floor therapy, antipartum, you know, before deliveries, postpartum, after deliveries, after surgery, with endometriosis, with any type of public floridycefunction. I just think that we need more knowledge out there amongst providers and for women also.
00:30:04
Speaker 3: Okay, The next question is from a listener in New York City who started hormones during perimenopause, and she writes, I'm now well into menopause. Do I need to stop taking it? I'm feeling great.
00:30:15
Speaker 1: No, it's antiquated thinking that we need to stop hormone support. The big reason that a lot of people really recommended in the past that hormone support stopped is because as we age, we're at increase risk of stroke and cardiovascular disease. And we know that oral estrogen does increase our risk of stroke and clotting and perhaps does increase our risk of cardiovascular disease if used in the presence of cardiovascular disease, because it is inflammatory it increases what we call see reactive protein. Oral estrogen is very different and transdermal estrogen that goes across the skin in a cream or a patch right or a gel, so without an increased clotting risk and without an increased stroke risk. And we have this data with reasonably replaced levels of estrogen, and older women are not at elevated risk of stroke with transdermal estrogens. If there are like on a point oh five milligram patch or less, the one thing that you should stop is if you develop an estrogen dependent malignant see like such as breast cancer, then at that time period we do recommend, of course that you stop MHT into mutual cancer. Different story, actually early in the mutro cancer. You can resume your imaget afterwards with for many guyan oncologists, some not many. Yes, as long as you don't have a contraindication and you're feeling good, just make sure your levels are checked, make sure your levels aren't too high as you age into your seventies and such. But so no, you don't need to stop now.
00:31:38
Speaker 3: Good news for women who have children after forty and notice shifts in mood and energy. How do you know if your symptoms are postpartum depression versus perimenopause. How would you approach treating this?
00:31:50
Speaker 1: This is a really great question because we see this not infrequently, and this actually happened to me right I was forty three when I went into really had symptomatic perimenopause, and I had just had a child at forty one. So it's really checking hormone levels to see where you are basically and doing that day three fish and looking listening to the history and the narrative because remember, not all perimenopause is depression, right or anxiety. Right, there's a lot of issues with sleep disruption of course, hot flashes, in addition to mood issues, cognitive issues and such, and then they're all interlinked. But definitely getting to a provider and having things looked at closely actually in terms of where are you what we would say biochemically or hormonally.
00:32:30
Speaker 3: Also, okay, so this is different but similar. Once you've transitioned from peri to menopause, what is happening in the brain. I feel like a different person in terms of my mood's, emotional well being and stress.
00:32:42
Speaker 1: So estrogen is a big impact around brain health. Right. It changes blood blow to the brain, It changes brain energetics, how glucose is utilized, how the mitochondria and the brain work. It changes the size of the brain, the function of the brain, and also the neurotransmitters. Right, all of the neurotransmitters are impacted by estrogen and progesterone fluctuations, dopamine, serotonin, and GABA. We've mentioned those before. The brain seems particularly vulnerable when we're having fluctuations or wide swings in menopause. We're going from very high levels of mid cycle estrogens that can get range up to a thousand for some women right where kind of normal ranges are two to three hundred maybe and down to plummeting down to nothing and then no period for eight weeks and then kind of this shattered glass kind of pattern. The brain doesn't like that. The brain likes a little bit more stability. So after this, the brain does have some does get some adjustment, right, some completely adjust and some areas of brain completely adjusts and others don't. And this is the big question mark, you know, in terms of estrogen protection of brain health. Of course, you know, we know that when we start estrogen early that in that menopausal trends, it would say, even our perimenopausal transition, we need to consider it for women who are at elevated risk of brain health issues a POE four positive and such. And then is estrogen protective when it's initiated appropriately, in the appropriate form and the appropriate dosages. But eventually, if you're not on MHT, you know, some of the cognitive issues do settle in. But women, remember have this too elevated risk of dementia. And how to hormones impact that and how can we be using hormones in a preventive fashion for these individuals to protect our physiology is really important. This is I think a big area of the future of hormones support and the impact on female physiology that in cardiac disease.
00:34:29
Speaker 3: Also, of course, listeners should definitely go back and check out the episode that we did with doctor Richard Isaacson on dementia prevention. He really unpacks the science in a super compelling way. All right, let's get into preventive care and answer a few questions about supplements and such. Many women have questions about how to best care for themselves on a daily basis, not just when symptoms arise. A woman in her early thirties wrote in about with these set of questions, let's do a quick lightning round. Which vitamins or supplements should women take on a daily basis?
00:34:58
Speaker 1: You know, definitely a multi vitamin that comes from recent data from a trial called the Cosmos trial, which was a dementia related trial, and what they showed is that using a multi vitamin was associated with the lower risk of developing cognitive decline and cognitive issues. So in the past, with the multi vitamin, we said, oh, doesn't prevent cancer, maybe a higher mortality rate, but the cosmostrial in my mind changed that. So I always recommend a multivitamin for perimenopausal menopausal women. I also speak to everybody about creatine because creatine is responsible for mitochondrial support and such in our body, and it's important for a muscle building and also brain health protection. Wow, we know that there are some data now link in creatine to brain health protection. Again, we need more data and we're study, but it's a very well tolerated, extremely well studied, extremely safe supplement that women should consider. Between five and ten grams is usually recommended. Outside of those two foundational ones, I usually recommend testing because women really need to also pay attention to their Omega three levels, so their polyant saturated fatty acid levels are super super important actually for brain health. Again, I keep going back to brain health. Yeah, cardiac health also, and of course muscle health and bone health. I recommend checking the Mega three levels and then looking where we're deficient, Like many women are vitamin D deficient, so we definitely need to speak about vitamin D supplementation. But check a vitamin D level, check a B twelve level. Also if you're not eating animal products, you're at risk of having a B twelve deficiency. Super important again for neurologic functioning. I usually recommend a multi vitamin, speak about creating, and then go testing for what you may be deficient and after that. But also a lot of people won't do a Mega three checks in their office, so ask your health care provider for an Omega three check to see where you are with that. If you're not eating a lot of fatty fish and such, you might be deficient on a Mega three s.
00:36:55
Speaker 3: Yeah, you can also, I mean, I know Richard Isaacson recommends Omega quant. It's a direct to consumer test to check your omega levels DTC testing, direct to consumer testing. I love this whole area right now. Actually, there's a lot of platforms. There's a lot of a merging platforms because it really allows you to take control of your health.
00:37:14
Speaker 1: And you know that many doctors or many providers won't check for you looking at LP littlea looking at your omegaquant. You also to make sure that you have somebody help you interpret it too. It's so super important, super super important.
00:37:27
Speaker 3: Don't go totally rogue.
00:37:29
Speaker 1: Still to come, we'll answer more of your questions about hormone support. Stay with us. Let's see what are the causes of painful periods and what steps can I take to address it before it gets worse? Again, great question. This goes back to normalization of pain for women. Right, So, a lot of times, you know, I'll ask in our practice, I'll say, you know, do you have painful periods? On scale of one to ten, how bad is your pain? Right? If I hear two or three, it's like, okay, maybe cramps. If I hear nine to ten, it's like house on fire, that's not And do the painful periods impact your quality of life or activities of daily living? Do you misschool? Do you miss work? These are all important questions. Again, a lot of painful periods are ignored by healthcare providers because we normalize pain in women and symptomology in women. Anytime you have painful periods, definitely have some imaging, have a CEA healthcare provider, have some PEBLC imaging, make sure you don't have fibroids there. Look for endometriosis and adnomiosis, which is endometriosis in the wall of the uterus basically, but the vast majority of heavy, painful periods are actually caused by endometriosis and need attention not only to relieve the symptoms, but to stop the progression of the problem. Right, we forget about that, people like, oh, I can suffer through it, I don't need to do anything about it. I'm like, you should do something about it so it doesn't get worse. This can range anywhere between using a birth control pill or oral contraceptive if you are don't have any contraindications. Some of our progestine or leave an adjustrial containing IUDs are extremely helpful and beneficial. Get that imaging, and if there's a suspicion of endometriosis, which there always should be, see somebody who has a knowledge of endometriosis beyond the ultrasound. Also get you know, talk about getting an MRI and seeing what should be done in the future. But also make sure there's no ovari insists there. Make sure that there's no fibroids there. You know, just make sure that everything is completely evaluated. Don't just assume that it's like, yeah, it does, didn't take a book cramps that you need to make yeah, and yeah, muscle through or just take a birth control hell for get some evaluation for them.
00:39:41
Speaker 3: Yeah, okay, here's a good one. This listener is in perimenopause. She's working with a physician who is not comfortable putting her on hormone therapy. She's forty nine years old and symptomatic, and she's considering going telehealth rout.
00:39:59
Speaker 1: You need to find a doctor who's comfortable. You know. This is really this shows our gap in women's health, and we need to get everybody up to speed, and we need to get people comfortable prescribing hormone, when to prescribe, how to prescribe, And it's an education problem and I think you have to look at you know, you can go in to say, why would that physician not be comfortable with it? This is something safe, it's something nuanced. But I think getting to somebody who's knowledgeable, and then how do you get to them. Menopause Society has menopause practitioners that they list on their website. The telehealth route is very interesting. I am actually supportive of telehealth if used appropriately, because you do have people who are knowledgeable, but they're not seeing you, they're not examining you, they're they don't know you. So I do think that there is a role for telehealth in areas where we don't have practitioners who are up to speed on the current data and the current knowledge base that exists. Now, the hope I have is that we get everybody up to speed. It's so funny to me that women's health is considered a niche area fifty percent of the population. Yeah, women like, why is that? And I always say red flags are I prescribe hormones for everybody, or I prescribe hormones for nobody. It's nuanced, it's a conversation, it's a narrative, and those are two red flags.
00:41:28
Speaker 3: I ask so many great questions. Okay, I can read this next one. It's about MHT. Here's the question. As a listener, my understanding is that doctor Pointer recommends estradal above all. But my doctor prescribed estrogen, which is estrone as a topical cream in addition to Divigel transdermal estradil. Elizabeth, can you jump in and explain.
00:41:50
Speaker 1: So Divigel is a topical estradial gel. It's a brand name point zero two five though is considered low dose. So there are three main types of estrogens. There is estradial, which is the main estrogen in our body es drone, which is a lesser estrogen in the main estrogen after menopause, and then there is estriol, and the vaginal epithelium will respond to all three estrogens. Less data with estrone, though estradial would be the more standard type of topical preparation that we would recommend and use. And some practitioners actually like estriol, which is not FDA approved in the United States, but some women will actually do better with vaginal estriol. So, but the standard really in the United States has been estradial preparations, either ultra low dose in the form of a small suppository or a ring, or a little bit higher dose but still local treatment with the vaginal cream. And it is very standard and very desirable in terms of hormone support.
00:42:55
Speaker 3: So let's continue with the second part of this listener's question. She's from Toronto, by the way, she asks.
00:43:01
Speaker 1: That explains the estrogen. I was like, who prescribes that in the United States? Now I understand the Canada.
00:43:07
Speaker 3: Should I go back and ask for the estradial topical. I'm also shocked that my doctor didn't tell me to apply divigel in the morning buzzing doesn't begin to describe the jolt literally like cocaine.
00:43:18
Speaker 1: I had to take an adavan. So this is an interesting conversation. Right, So there are what we call diurnal variations and hormones throughout the day. Right, So testosterone tends to be higher in the morning. Estrogen or estradial tends to be higher in the morning for women. And I was just having this conversation with our intercrinologists recently because we try to use hormone support and say, oh, steady levels are great, but you know, stety levels might not be so great. We should maybe try to replicate that diurnal variation. So more estrogen in the morning. Progesterone usually we recommend at night. That's not negotiable because that helps with sleep and can make you groggy, But definitely estrogen is usually recommended to be applied in the morning. If you're having hot flashes at night. Sometimes what I'll do is I'll add a little bit of extra estrogen in the evening so that you have like a steady level if you're using a gel. But these are interesting questions for the future. You know, we just assume that stable is better, and stable might not be better. You know, we might need some diurnal variation, we might need some cyclical variation. There was this old fashioned protocol called the Wily protocol, which it was a postmenopausal hormone support therapy that replicated a cycle. But it goes back to like, does the brain respond better to cyclical hormones? Do we respond better overall with our physiology in terms of cyclical hormones throughout the day or throughout the month? And these are like the interesting questions to be answered in the future. But definitely mourning for estrogen is better if you're having hot flashes at night after using your gel in the morning, you know, maybe add a little bit of extra in the evening, but not as much as in the morning. Got it all right?
00:44:50
Speaker 3: We have a handful of questions left, Let's keep going. A listener who is experiencing menopause emailed this, why are the muscles and bones so painful during menopause aside from exercise? What can you do to alleviate pain and discomfort? Are there any recommendations for certain foods or a particular diet that can help.
00:45:08
Speaker 1: There are estrogen receptors all throughout our body, and there are estrogen receptors and all the tissues of our joints. And this is why we see frozen shoulder actually because it tends to be that the shoulders is particularly saturated with estrogen receptor. So as estrogen goes down, the joints and muscles and bones actually respond to lower levels of estrogen in a not so positive way. Right, Lower levels of estrogen are also inflammatory. High levels of estrogen are also super inflammatory, and low levels of estrogen are inflammatory. So definitely anything that's exacerbated with inflammation is going to be made worse with lower estrogen levels. Exercise is super important. Actually, string I go back to strength training to protect your muscles, bones and joints. I recently had an injury and after strength training, I was back in three days. In the past, it would have taken me three months. In my leg would have been huge. I have a knee injury, and I was like, WHOA, this actually really works. Definitely, exercise, exercise, exercise, and movement, movement, movement, but making sure you pay attention to the making sure that you are joint sensitive though in the exercise you're doing, you don't want to over you don't want to overwork a joint that's not healthy. Right, so you need to make sure that you're with a great trainer or pt certain foods. Great question in terms of we want to make sure that we definitely have good omega threes again, right, so we want to have anti inflammatory whole foods. We don't want to have a lot of sugar around because that's inflammatory. So you know, so simple sugar is not good. Sugars from fruits that come with fiber or great fiber good. But definitely an anti inflammatory nutrition plan can be super super helpful.
00:46:43
Speaker 3: Okay, we have a great question which is about what's called unopposed estrogen, so meaning taking estrogen without progesterone. Here's the question.
00:46:52
Speaker 1: It's a long one.
00:46:53
Speaker 3: I was diagnosed with advanced endometriosis when I was forty three after surgery to remove a small internal uterine fibroid. While pursuing fertility treatment, I had several large fibroids on the outside of the uterus that had grown into the walls and were not candidates for removal. I turned fifty in March and I had a hy directomy six months ago. I kept my ovaries. Part of my rational for the hysterectomy is that I would finally be able to start MHT. I recently started applying transdermal estradial and using a vaginal estrone cream. But my GP doesn't think I need to take progesterone because of hysterectomy. Is it okay to take outoposed estrogen or should I be adding progesterone into the mix too.
00:47:33
Speaker 1: I think with previous endometriosis, we do want to add progesterone because endometriosis, remember, is a type of endometrial tissue, not normal dimetrial tissue, but a type of endemetrial tissue that's on the outside of the uterus. So it responds the same way as endometrium does. Right, So estrogen alone is going to make it grow. And there's two concerns with that because for the line of the uros, estrogen the line of the uros grow and pogesterone says stop growing, stop growing, So we want to get that stop growth signal in there. And there's two concerns actually with unopposed estrogen after a diagnosis of endometriosis, even if it's not visible. Actually, the first is just reigniting the endometriosis to come back like you had surgery. For endometriosis, and if some is left behind, we don't want it to grow back and cause a problem and require additional surgery. So definitely progesterone that situation and be super helpful. The other is it's unopposed estrogen. And remember with unopposed estrogen and the uterinelining, actually there's a significantly elevated risk of developing endometrial cancer, and you can definitely develop cancers in endometriosis. So you just want to make sure that you don't have abnormal proliferative tissue. Just because it's not the name, it's still in dumetrial type tissue, so it still responds in a similar fashion, So you don't want it to grow back and you don't want it to convert into a malignancy. I also love this question too because we forget that progesterone also is important for sleep for some people, right, So I'll definitely see people that had hysterectomy and are not on progesterone who can't sleep and are on estrogen and they're like, I can't sleep, I can't sleep. I'm like, well, we should really talk about progesterone, because just because you don't have a uterus doesn't mean that you can't take progesterone, So we have to be cognizant of the breast progestine risk. Progestines are synthetic progestogens. Mouthful, right, but meaning that progesterone there's still a little bit of a question mark after long term use of progesterone and breast cancer. So we don't just add it in because we know that estrogen alone does not increase your risk of breast cancer and progesterone. We have data for five years or so in terms of natural progesterone longer in Europe, but we're waiting for that data to mature. But we know for at least five years of use that you're good in terms of breast cancer risk, and probably longer I think.
00:49:57
Speaker 3: Okay. Same listener also writes, I'm considering taking a statin for genetically high cholesterol that I've had since high school. I had a zero on the coronary artery calcium score, but it is getting higher as I get older. What can you share about statins for genetically high cholesterol?
00:50:14
Speaker 1: Okay, so this is a complex question, but it's great that the SAC is negative, but that does not necessarily mean for everybody that you don't need a statin, certainly for individuals who have a family history a premature coronary artery disease, meaning an individual who has a family history of maybe a relative with an mi I or significant coronary artery disease less than fifty five for men, less than sixty five for women. These are individuals who are an elevated genetic risk. By having a genetically elevated cholesterol also puts you in a different risk category in terms of just a person who has an elevated risk not based on their genetics. And you want to look at LP LITTLEA, which is a very athrogenic type of cholesterol. This is very highly personalized, so you need to look at your family history. You're also your personal history. You know, do you have some insulin resistance, because you're going to have a lower threshold to start a statin. And so if you have had a genetically elevated risk of cholesterol, you know, since your early years, I would really highly suggest that you get to a cardiologist or even we have specialists now who specialize in lipidology basically this is what they study. But getting to a knowledgeable cardiologists for women's cardiology is super important because also important to remember women have soft plaque too. It doesn't show up on a CAC, it's not calcified, and so we also have to look at that too. More advanced testing might be something called a clearly test, where we're looking at soft plaqu or looking at carotids to see if we can see soft plaque, which means that the cholesterol is actually doing something and depositing somewhere. So personal health history, looking at your family history, and then more advanced testing beyond that CAC. And I'm certainly not a cardiologist, but I sit in a room next to like about six cardiologists and listen to them talk all day, and we have great guidance where I am currently. So that makes me extremely respectful of the nuanced nature of lipidology.
00:52:13
Speaker 3: Okay, Our last question is from a former patient of yours, Elizabeth.
00:52:17
Speaker 1: She loves that New Jersey.
00:52:18
Speaker 3: She's fifty three years old and says that she listens to most of the Decoding Women's Health episodes.
00:52:23
Speaker 1: Thank you for that? Why not all of them?
00:52:27
Speaker 3: This is what she wrote. In one of your podcast episodes, you address the dosage of estrogen and how much it takes to protect the heart, brain, and bones. She continues, I'm currently taking point zero two five estradial and one hundred milligrams of micronized progesterone daily. The hot flashes are gone and they don't really have any other symptoms. Am I taking enough to protect my heart, brain, bones, et cetera. I have friends who are taking much higher doses.
00:52:52
Speaker 1: Right, So this begins to get into the question of why are you taking hormones? Is it for symptoms or protection of your physiology? And of course, as we all know, I am like super interested in hormone support not only for symptomology, but also for protection of your physiology. And the studies that have shown for brain health protection and cardiac protecttions, these studies were all done with oral estrogens that get you into a range of around sixty or so. There was once one portion of a study that was done with a lower dose of estrogen, but the vast majority of the studies that show cardiac protection when MHT is initiated within that ten year period. Brain health protection, metabolic protection also are with these doses that get you into this range of sixty. We don't have great data on protection of physiology with low dose hormone support. Is this considered low dose? Yes, this would be considered low dose. And then if you look at bone health, more estrogen the better. Actually, you definitely do get some protection with lower levels of estrogen, but you get better protection with higher dosages and higher levels of estrogen. So I typically have people check hormone levels for two reasons. One, transdermal absorption is more erratic than oral absorption of hormones, and we always recommend trans to start with, of course because of the clotting risk and stroke risk, et cetera. And see reactive protein and inflammatory risk. But the levels are less predictable with transdermal estrogens. If you believe that you're using estrogen to protect your physiology, have your levels checked.
00:54:26
Speaker 3: Yeah. Thank you, Elizabethan. Thank you to our listeners for sending in such fantastic questions so much.
00:54:31
Speaker 1: These were great questions. I am always so impressed with the questions same we covered a lot in today's episode. Thank you to everyone who sent in questions. We hope to respond to more of your questions in the coming weeks, so please keep them coming. Maybe this conversation sparked more questions for you about PCOS now PMOS, or maybe you've got questions about endometriosis, HPV or yeast infections, really anything you're wondering about and would like us to tackle on the show. If you'd like to submit a question, please send us a message at Decoding Women's Health at Pushkin dot fm, or feel free to leave a voicemail at four four five two O one three three eight five. Decoding Women's Health is a production of Pushkin Industries and the Atria Health and Research Institute. This episode was produced by Kalalah. It was edited by Amy Gaines McQuaid, mastering by Sarah Buguer. Our associate producer is Sonia Gerwit. Our executive producer is Alexander Garretton. Fact checking by Abigail Abrams. Our theme song was composed by Hannas Brown. Concept and creative development by Shavan O'Connor. Special thanks to Vicky Marrick, Alan Tish, David Saltzman, Doctor David Dodick, Sarah Nix, Jacob Goldstein, Leah Rose, Jordan McMillan, Morgan Ratner, Owen Miller, Eric Sandler, and Greta Cohne. I'm doctor Elizabeth Pointer. Thanks for listening and until next time
