Ep. 227 The Upgrade: A Unique Perspective on Perimenopause and Menopause with Dr. Louann Brizendine

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I was happy to connect with Dr. Louann Brizendine today! She is the founder of the Women’s Mood and Hormone Clinic at UCSF. She completed her degree in Neurobiology at UC Berkeley, graduated from Yale School of Medicine, and did her internship and residency at Harvard Medical School. She also served on both the faculties of Harvard University and the University of California at San Francisco. Dr. Brizendine founded the Women’s Mood and Hormone Clinic at UCSF. Her New York Times bestseller, The Female Brain, and its follow-up, The Male Brain, continue to be read around the world.

Today, we dive deeply into her new book, The Upgrade: How the Female Brain Gets Stronger and Better in Midlife and Beyond, which was released in April 2022.

“Your brain will not be at its healthiest with alcohol and caffeine in your body.”

– Dr. Louann Brizendine


  • The transition and the upgrade stage of life explained
  • Celebrating the transitional time of life and not fearing it
  • How hormones help guide behavior
  • Transition Stages 1,2,3 and what they mean
  • Then onward to the 3 stages of “The Upgrade”
  • Estrogen fluctuations that affect sleep
  • Be aware of caffeine in your food and drinks and how it may affect your sleep.
  • If you are having a problem staying asleep, you may want to cut back on alcohol or drink it earlier in the day.
  • The Women’s Health Initiative – (almost 20 years ago) disastrous misinterpretations and negative implications it caused by instilling fear in women to not use Estrogen – including osteoporosis, brain fog, anxiety, and sleep disruptions
  • Hormone Replacement Therapy – now viewed as a positive and much-needed step in women’s health
  • Women between the ages of 40-50 should get a bone density scan as one of the determining factors of whether or not to begin hormone replacement therapy.
  • Dr. Brizendine suggests that women should not be fearful of using therapies today to help balance hormones.
  • Cynthia discusses the loss of cognition later in life as another correlative symptom of not receiving needed hormones.
  • Dr. Brizendine advocates doing your own research regarding HRT and not depending only on information from major pharmaceutical companies.
  • Cynthia and Dr. Brizendine discuss the importance of keeping an open mind when it comes to synthetic hormones because of the good they can do.
  • If you are not well and do not feel like you can go on, please, immediately, seek out a doctor who can prescribe medications or hormones to help your particular and unique situation. Be your best and do not suffer in silence any longer.
  • Cynthia says the transitional time of life should and can be a very good time in your life.
  • Consider reading Dr. Brizendine’s book(s) to learn more and to keep it as a valuable resource.

Connect with Cynthia Thurlow

Connect with Dr. Brizendine

Dr. Louann Brizendine’s Book

Resource Mentioned

NAMS – North American Menopause Website


Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
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Today, I had the honor of connecting with Dr. Louann Brizendine. She completed her degree in neurobiology at UC Berkeley, graduated from Yale School of Medicine and did her internship and residency at Harvard Medical School. And she helped found the Women’s Mood & Hormone Clinic at UCSF. Today, we dove deep into her new book called The Upgrade. We talked about terminology and how this is largely a byproduct of the patriarchy. She has coined some new terms for perimenopause and menopause, namely the transition and the upgrade. We spoke at length about how our hormones impact behavior, the hormonal fluctuations that happen at middle age involving our sex hormones, and the impact on behavior, the role of estrogen, the impact of caffeine and alcohol on brain health, as well as cognitive health. We spoke at great length about the Women’s Health Initiative and how this study has largely been wrongly interpreted and is impacted well women care over the last 20 years as well as influencing a whole generation of clinicians to be fearful of utilizing hormone replacement therapy.
We discussed the differences between synthetic and bioidentical hormones. We spoke at great length about some of the side effects that can happen in middle age if you are not on hormone replacement therapy, specifically bone health and your neurologic impact, because Dr. Brizendine is actually also a neuropsychiatrist. We spoke about medications that can utilize to help with bridging symptoms that women experience in the perimenopause and menopause at transition, including micro dosing of antidepressants and anti-anxiety and anti-psychotic medications. I hope you will love this discussion. I was so impressed by Dr. Brizendine’s commitment to excellence for women, her advocacy, and her continued support of women not settling for unacceptable behavior and treatment.
[Everyday Wellness theme music]
Welcome, Dr. Brizendine, it’s so nice to be connected with you, I have so thoroughly enjoyed your most recent book. And we’ve really been looking forward to our conversation.
Louann Brizendine: Thanks for having me, Cynthia, I just really appreciate the opportunity to get to speak to you, and also to your audience and see if we can give them a few tidbits as we go along that will really improve their life and their well-being.
Cynthia Thurlow: So, I love your background. You have a background in neurobiology, then you went to medical school. Did you always know that you wanted to be in a position where you would help serve women, because one of the things about your background that I’ve found seems to be pretty clear is that you are a huge women’s advocate, and you want women to really understand their own unique physiology and how that impacts our mood and how we perceive the world.
Louann Brizendine: Absolutely. Well, I always like the phrase, “Biology is destiny, unless you know what it’s doing to you.” And that phrase comes out of all of my training. I trained in neurobiology as an undergraduate at UC Berkeley before I went to Yale Medical School, and that’s where– I think at Berkeley– because, our bodies, our cells came out in the era when I was there the first issues of Ms. Magazine, I was certainly very involved in all of the movement for women taking charge of their own bodies and taking charge of their own health. And those are the days when you were not even allowed to have a credit card until 1971 or 72 if you were a woman without your husband signature on it. We forget, I mean, and of course, abortion was illegal. So, that’s our bodies ourselves. So, I think of this book The Upgrade, I just came out with, I think of it as a new version of our bodies ourselves for women in the second half of life, from 40, 40 plus. Just when you think it’s over, it’s not over. It’s beginning again a new with your true self right in the center of your honesty and your authenticity of who you really are, and you’re able to let go of some of the people pleasing all of the things we do in our fertility years, the fertility dance, I like to call it. It’s not a bad thing, it re-causes us hormones.
Remember, hormone’s purpose is to cause a behavior. So, the hormone’s purpose is to cause the behavior, the up and down and the hormones and the menstrual cycle and we can do a little deep dive on that. But they’re pushing you to behave in a flirtatious come eitherway, and to do what Mother Nature’s bidding as Mother Nature wants you at that age to go out and find the best sperm. So going out and finding the best sperms what you’re supposed to do, especially three or four days before ovulation every month, and your hormones push you to do that. We sway our hips more, we talk in a higher voice. We actually may speak more, we put a little bit more makeup, we dress sexier. I mean, all the studies show that we do it unconsciously, it’s not on purpose. And so, the hormones are driving us under the hood, in ways we don’t even know.
So, then the cool thing is, is that when you get to what I call the transition in The Upgrade, that you’re transitioning from the developmental stage of life, which is called the fertility stage. You’re into a developmental stage of life that heretofore has never had a name to it. In the year 1900, the average age of death for a woman was age 49. So, to even get to the menopause, I mean, [chuckles] this is a new phenomenon completely. This developmental stage has not been even given a name. I thought The Upgrade was an appropriate name for the for women going into the second half of life where you really have the chance to choose more of your direction than you did before when the fertility hormones were pushing you in a certain direction.
Cynthia Thurlow: I think it’s such a beautiful reframe. For listeners, perimenopause is the transition and menopause is the upgrade. And I love the reframing because terminology and words matter. I love in the book that you mentioned fossil words created by men and pharma. So, let’s just be very clear that this terminology was not created by women, it was created largely probably by male physicians, and the pharmaceutical industry to try to create a time in a woman’s life. But I think for many, if not all women, when I connect with them on social media, or women that I work with one on one, the prevailing thought processes that middle ages when all these things and we lose our looks, our body composition changes, we suddenly start having trouble sleeping. And so much of your book that I took away from it is we need to celebrate this transitional time in our lives. We need to not fear it.
One thing that I think is really interesting, and I’ve started mentioning this more frequently, and my poor husband hears me talk about this all the time. But how many women in middle age are finally freed from the desire to be a people pleaser? I am a card-carrying former people pleaser. And so–
Louann Brizendine: [laughs] True.
Cynthia Thurlow: Exactly. As we lose estrogen, it starts impacting our behavior, not in negative ways. And I think back to when I was a new nurse practitioner, I was in my 20s, my whole backgrounds in cardiology. I was very much a people pleaser. That’s why I did really well with these very adrenaline junky fueled, predominantly male physicians, I got along really well with them because that people pleasing came out. And it was a really nice symbiotic relationship. And I look at it now and I’m like, I would never do well in that environment now, ever.
Louann Brizendine: As you speak about it, and those of us who’ve been in the medical world understand, like you’re saying that people pleasing thing that the attractive 20 something year old assistant to the male aggressive cardiologist in those days. I mean, of course, there’s lots of women now in cardiology, but in those days, and it’s still very, very predominant. I have an uncle who’s still practicing medicine in his early 80s. And he practices on Friday nights and Saturdays. And I think that the reason he still likes to do it is he likes to go hang out with all the young nurses. So let’s just be clear, let’s tell our secret, [Cynthia laughs] Cynthia. Okay, the secret if people could look in behind the scenes in the medical world, what goes on in this kind of flirtatious thing that goes on between the male physicians and the female, either nurse practitioners or staff, and so young, attractive females and usually older alpha male doctors, is that’s the dynamic. And so it’s not only people pleasing that goes on. For sure it’s people pleasing, but it’s also flirtatious people pleasing to the males in an authority position over us.
Cynthia Thurlow: It’s really interesting. So, you’ve alluded to these how hormones help guide behavior. Let’s talk a little bit about women that are still in their peak fertile years, how these hormones this careful orchestration influences behaviors that you’ve alluded to, and how that starts to shift as we are heading into the beginning stages of perimenopause. And for a lot of women, they’re not even aware it’s happening late 30s, early 40s. And all of a sudden, maybe they’re starting to see some changes and disruption in their sleep, maybe they’re experiencing more anxiety, maybe they’re getting changes in their menstrual cycle. I think actually describing some of the physiology that goes on would be super helpful, because we don’t realize until we start having a problem, we take our hormones for granted.
Louann Brizendine: Yeah. Our hormones are just doing what they’re doing. I call it in the book, okay, let’s talk about the Transition Stage 1, Transition Stage 2, Transition Stage 3, and 4 Stage, the transition before you go into the upgrade stage one, upgrade stage two and upgrade stage three. For all of you listeners, that’s just the arc, the arc that we go through. So, let’s attach some ages and a few symptoms to those. So firstly, perimenopause/transition stage one can start anywhere between like, it’s in the window of like, it’s the pre transition stage, 38 to 42 is where I plop it down, because it’s also like you say, Cynthia, it’s not necessarily something that we paid much attention to. It just seems maybe it’s just a little bit more difficulty cooling down after a workup out. Like you used to not even think about cooling down, but you just cool down, and then all of a sudden, you’re feeling like, “Gosh, 15 minutes later, why am I so hot?” That’s basically the beginning of what we call The Thermostat. There’s a thermostat in your brain, it’s like you go to your thermostat in your house and you’re going to– in a group of people of 10 people, and in a room, you change the temperature up 10 degrees, everybody’s going to be hot, taking off layers with that 10-degree change.
However, if you’re a woman that’s starting in your transition, and as a transition does more, the estrogen changes in your brain actually narrow that window of temperature receptivity down to maybe one or two degrees change. And you, in the room of 10 other people who are not in the transition, or perimenopause, you are hot, you’re taking off layers, and everybody else is going, “What’s the problem?” You’re saying, “Open the windows.” So that gets more and more at each stage of transition. And sometimes throwing the covers off at night is the beginning of that. And you don’t want your partner like wrapping his arms all around you because you feel like it’s just too hot. So, you’re pushing him away. And that becomes more and more with each stage two of the transition, stage three. Those are the very typical, I call them “the biological indications of the hormone piece.”
Now the anxiety, depression, irritability piece of that also is attached to the stages of the transition. It’s like a little bit like having PMS pop up, not just at the last two days before you start bleeding of your cycle. But it can pop up in little windows throughout the month. And that can also tell you that usually that starts to happen in the transition stage two, like about age 42 to 45, 46. That’s really when we can really start to notice some of those. And I describe this all in the book, and it’s nice to be able to pinpoint where you are in the transition. I think it’s very helpful.
The measurements of your hormones don’t really tell you much. You can go to the doctor; you can get the measure if you want. But remember, they change every hour on the hour. So, it’s just kind of like throwing a dart at a dartboard, it’s just luck if you get something back. That will tell you something about where you are in that transition. I know some people are now measuring AMH, that’s a hormone that can maybe tell you how far you are from the menopause. So, that may be worth doing, although it’s only about 50% correct. So, don’t confuse yourself with that. The best thing to do is [unintelligible [00:13:50] your own symptoms are.
Cynthia Thurlow: And it’s interesting because it’s as unique as we are, and I can’t tell you how many friends of mine blissfully made it through their 40s. No problems. Hit 50 like a wall. How many women start struggling in their late 30s. But I think of the transition or perimenopause as a whole as a barometer of how well we’re taking care of ourselves. Meaning, if we are still insulin sensitive, we’re exercising, we’re getting enough sleep, that transition will probably be less fraught with concerns than the average woman that is probably not– we become less insulin sensitive as we’re having these fluctuating amounts of estrogen and estradiol. But the women that I see struggling the most are the people who eat and drink alcohol like they did when they were 20. Don’t really exercise, don’t manage their stress, don’t prioritize sleep. And so, I always think of it as a barometer. Typically, the way women are feeling in their 40s is largely impacted by the way that they’re living their lifestyles.
Louann Brizendine: Yes, okay. Let’s get down to brass tacks here, Cynthia. People who turn to page 86, which is called Louann’s Sleep Program. Think of this stage of life, you’re 40-to-50-year old’s life, and the way you can visualize it. And let’s think of about a little stool with three legs on the stool, we need to have all three legs to basically make it stable, so that you can sit on. So, this is your life between 40 to 50. One of the legs of the stool is sleep, one of the legs of the stool is like exercise and muscles, and the other leg of the stool is your diet or other substances that you put in your body or don’t put in your body. Okay, shall we do a deep dive in on those three–[crosstalk]
Cynthia Thurlow: I would love for you to do that.
Louann Brizendine: I know there’s a lot in the book about it, so you could find more details about it. It’s really important, because let’s think of the sleep first because as your hormone, estrogen goes down and fluctuates, remember, sometimes it can be really low– just to give you some numbers, it can go from a level of 10 or 20, up to a level of 400. Right in the middle of cycle, willy-nilly. I mean, it’s just all over the map, because as the ovaries are starting to retire, they’re spurting out things now. And then they’re basically going back to sleep, and this this all we can– there’s a biology behind that. But that’s the bottom line.
Sleep, when you’re awake, your brain cells are going to chat, chat, chat to each other all day long, problem solving, whatever, and they’re throwing out proteins. They’re throwing trash all over the place in your brain, is this like really trashy stuff all over your brain. And so, at night, when you sleep, those little neurons, they shrink back from each other, leaving a little space in between for the brain to actually hose out all the trash. So, parents they had those little cleaners that go around and hose everything off at night or the first thing in the morning and they wake you up. We got to let the brain get hosed out at night of the trash to start the new day or you’re not going to be fresh the next day. Listen, ladies, there’s nothing more important than this cornerstone, then this leg of the stool is really important. You’ve got to get that right.
I’m going to tell you some things that are not so pleasant now, for all of us that in our 20s and 30s. We may be used to do whatever we did. We would have like three double espressos in the morning, and we would drink whatever we wanted at night, etc. We slept like a baby, and it was not a problem. Okay. There’s still some women who go through their 40s like that, [laughs] but not very many, because you start having all the glitches and you don’t want to interrupt your sleep. So, if you drink a cup of coffee, any caffeine, even a lot of dark chocolate or even energy drinks, whatever. Read the labels because you’ll be surprised at what caffeine is. And so anyway, read those labels, they’ll have caffeine in a lot of things. Caffeine at noon will still be in your bloodstream and brain at midnight. Not long but enough of it, because of the hormone fluctuations, you will be stimulated to not be able to fall asleep.
Ladies, if you’re having trouble falling asleep, the falling asleep, technical name is called “initial insomnia.” Falling asleep, if that’s where you’re having a trouble, think caffeine, just think caffeine and go at it. I mean, you ladies you know how to make a life plan, you know how to figure out like, “Okay, for the next two weeks, I’m going to test drive this for myself, just to see how that’s working for me. I am going to reduce just going straight to decaf, or whatever it is by 11 o’clock or noon, and see how my sleep changes.”
I have a lot of women in the category of probably about 15% of women, 20% of women that have so much difficulty at this time with sleep, that’s also making them depressed and moody and irritable and brain fog, all this that we have to go at it in a serious way. So, if you’re in that 20% of women, we’re going to pull you all the way down to being abstinent. Happy and abstinent. And so the you may be in that category and you can do it yourself. You don’t have to go to a fancy doctor like me to find that out. That’s why I wrote the book is like “Anybody who reads this book, it doesn’t have to go to a fancy hormone doctor. They got figure all out right there for yourselves.” You’re all smart women who can do this. So that’s that little pillars. Does that make sense to you, Cynthia?
Cynthia Thurlow: Absolutely. It’s so important because I talk so much about how sleep is so foundational to our health, the role of the glymphatic system, which is this waste and recycling process that goes on at night. And how many people don’t understand that their lifestyle choices whether it’s caffeine or alcohol or an inflammatory diet can adversely impact their sleep quality. Again, we still think of ourselves as being 20, but we can’t eat and behave like we did when we were 20.
Louann Brizendine: Protect your brain cells, ladies, that’s the name. That’s basically that subtitle of the book, How the Female Brain, blah, blah, blah. The female brain in the second half of life is what this book is all about and how to protect your brain at this stage of life and have it be your best, and then also preventing dementia, preventing brain fog, preventing all this other stuff, preventing depression and anxiety. So, there’s lots of tips all through the book for preventing those kinds of things and living your best life.
Cynthia Thurlow: Absolutely. What is your thought process or what are your discussions like with your patients around alcohol? I see so many of my own patients that suddenly start not tolerating alcohol, even small amounts of alcohol in their transitional and upgraded years. I’ve been asking more and more clinicians when they come on, Dr. Lara Briden, Dr. Sara Gottfried, this year in particular asking their opinions of the use of alcohol, and there’s been a pretty unified front, and I would imagine that your prevailing philosophies are probably very similar.
Louann Brizendine: Okay, drumroll, we did the caffeine. Okay. [laughs] Here’s a drumroll for alcohol. So, if you are having trouble staying asleep at night, like you’ll go to sleep for a couple of hours, and then you’ll wake up and not be able to get back to sleep, that is typical of women who have a problem with the alcohol. That can be your barometer. Let’s just focus on that group, because what I basically tell them is, if you’re going to have like a glass of wine at dinner, do it by 6:00, 6:30 PM, because you want your system to metabolize it by time you’re going to bed, whatever 10:00 through 11:00. I know around our house since pandemic, it’s like pushed almost to midnight every night. But if you’re living in a house with teenagers, you’ll never get to see them unless you’re up at midnight, but you got to get the alcohol, like it’s down to a minimum.
For women in that 20% group that’s having trouble with their sleep, trouble with their mood, trouble with irritability, all kinds of thing, I say like, okay, let’s try to aim also for abstinence on that, at least to do test drive for two weeks and see what improvement you get individually. It’s a very individual thing. Alcohol is such a part of our dining out culture, etc.
Basically, if I had a prescription for all of you, ladies, I would take you off of alcohol and off of caffeine for starting at this stage of life, because your brain really is not going to be able to be at its healthiest with those substances in your body. And as well as when we start talking about HRT a little bit, makes it very clear that HRT, plus alcohol increases your risk of cancer. It increases your risk of all kinds of things. It increases your risk of heart problems, increases your risk of breast cancer, increases your risk. If all of you ladies were my sisters, I would really want to give you the best possible formula, which would be, give yourself a gift of getting off the alcohol and the caffeine.
Cynthia Thurlow: I think that’s really very wise. The direction, the conversation I was hoping it would go in would be to talk a bit about the Women’s Health Initiative. Women that are familiar with this podcast know that I talk about this quite a lot. I was finishing up my nurse practitioner program when the WHI research came out. It changed the trajectory of recommendations for patients, it certainly changed the trajectory of my mother’s generation, all of her siblings. It’s interesting, I was listening to a podcast yesterday with Peter Attia, and he was saying that he thinks it’s probably the most detrimental study that has been wrongfully interpreted. And it’s had such a profound impact on generations of clinicians, as well as women and their loved ones.
I would love to talk about the Women’s Health Initiative, vis-à-vis brain health, and what is your prevailing philosophy that’s come out of that, because I know for myself, I was safely in cardiology, I didn’t have to deal with it. [chuckles] It was generally I would turf it back to the GYNs and a primary care. But certainly, now that I am a middle-aged woman myself, I take hormone therapy very seriously. I think there’s still a lot of clinicians, a lot of patients who are terrified of the concept of utilizing hormone therapies when it’s completely appropriate to do so.
Louann Brizendine: Yes, a tragedy. This is the 20th anniversary, Cynthia, 2002, the 20th anniversary of the WHI. And I talk a little bit about this in my introduction, as you probably remember. I can see that you and I are birds of a feather, we’re thinking along the same line. We’ll go talk about the disasters that it caused because it basically was wrongly interpreted. The average age woman who’s 63, 64, she was a smoker, also a drinker, and also there had more women with breast cancer genes in the category of– It really was mess. It was taken very seriously. Within days the editor of the New England Journal of Medicine, who was a woman at the time, so she took herself and her sisters off of all hormones were like, with 35% of women were taking in at the time, and it dropped within a few years down to 5% to 8%. So, all of those women for all of these years who haven’t had it, now we’re looking what happens to you if you don’t have it.
The other big problem for women out there, another reason I wrote the book is because I am not an OBGYN. And I trained in psychiatry and neurology. I started the Women’s Mood & Hormone Clinic in 1994. So, this is way before the WHI came out. So, I practiced in my clinic for almost a decade before the effects really hit of that. And I was helping women with their anxiety and depression during the perimenopause and menopause with adding estrogen to those women who had depression along with their antidepressants and getting really great results. All my OBGYN friends in my university at that time, they had all trained in giving HRT to women and stuff. They were the OBGYNs, they did below the waist for hormones, and Louann did above the neck. So, they would send their patients across the street to my clinic to Louann’s clinic above the neck if they were having problems with sleep, or anxiety, or depression, or all those kinds of things that are considered, or brain fog. The brain parts of the transition and the upgrade. We were working hand in hand together really well, and then when that hit, they all went to what was the mantra for the OBGYN profession? “Nobody gets hormone, no hormones, you cannot get me to write a prescription for HRT.” And then what happened is all of those women who would have been the professors for the next generation for 20 years, did not teach anything to their new residents and interns about HRT. What you have now in the country, the reason women are scrambling without being able to find anybody in certain communities, all the communities in the country have a few doctors in their community that are very high price that do the HRT’s. It’s not available to all women, which I feel very badly about.
Now, 20% only of OBGYN residents to this day, only 20% of the residency programs, give them even one lecture on hormone replacement therapy. They are coming out not having any education on it. So, they don’t know, they don’t think about it. You know how it is when your professors aren’t interested in something or they’ve just turfed it, they just say, “No, we’re not doing that because we don’t want to be sued.” This is 20 years, ladies. And so now we have all of these women that didn’t get HRT, what do we have? We have an epidemic of osteoporosis, for one thing. All of these women, I’m sure your mother and your mother’s friends and your mother’s siblings, your aunts probably, they all have osteoporosis now at the maximum level because they did not get any HRT, getting the estrogen at the transition. And the brain fog anxiety, not to mention just like the sleep disruption.
This is okay. We don’t want women out there suffering needlessly. And the information now so, of course, for your listeners, if you really want to choose somebody in your community, go onto the NAMS website, the North American Menopause Society website, and choose a practitioner that is a member of NAMS in your community, because they are the ones who are trained in this area, and they will help you with your hormone replacement therapy, and they’re the head of the game. And then, the APA is way behind the game still, etc. So, if you read all of these. There’s really a lot of catch up to do. And I think one of the issues, the thing that’s pushing it the most is women have more Alzheimer’s than men. And the thinking is that the estrogen deficit that we get after age 50, let’s say, is really one of the potential preventions of dementia and Alzheimer’s for women. I don’t want to say that it is. I want to say that it’s being heavily researched, and that information may not come out for definitively for another 20 years. It’s a very long study and difficult to look at, because of all the other factors.
The reason I focus on the bones, is the bones are something we can focus on that we know and that we can scan. So, if you’re a woman between 40 and 50, and you get a DEXA scan, which is that scan for your– it’s a funny thing, just lay down on the bed, and this whole thing just goes [mimics laser] and you’re done. I mean, it’s like a 30 second thing, and you get your score, and you find out where you are on the bone score. Now I’m 69, and I have had HRT, and I take the patch. I talk about all my own story in the book too, so if you want to hear all the grisly details [laughs] also my own story, you can read that in the book. I think I was about 52 when I started taking the patch. And my bone density most recently was about 1.5 standard deviations above a 35-year-old woman.
Cynthia Thurlow: Thant’s amazing.
Louann Brizendine: I don’t do a huge amount of weight bearing. I do some, I try to do enough exercise. I’m very clear that if you are a woman and you find out in that age group, you’re in that age group between 40 and 50, that your bone scan shows that you are already a standard deviation or two, which basically means you’re low on your bone density, and you don’t have a genetic risk for breast cancer or anything like that, you should seriously consider taking HRT for a number of years. And 10 years is that a number of years that is considered that women can safely take it without, having any– if you’re not drinking alcohol, you can safely take it up to 10 years. And now that number keeps being pushed further too. All of people like me that all the doctors in practice, at least in San Francisco, we’ve got lots of patients in their 80s and even 90s are still taking their patch. It will continue to be– it’s a moving target. But anyway, so that’s my little hobbyhorse, the WHI, the HRT issue and really encouraging women to realize that this whole era of the last 20 years came, doctors are giving you information from a flawed study that’s 20 years old at this point. And I don’t want the next generation of women to end up having harm from lack of something that’s available.
Remember, we’re not in the year 1900, everybody of women’s average age of death was 49. I know it’s a funny number because it’s got to do with infant mortality and lots of other things. But still, at that age, a lot of women did not live past, even passed in into their menopause. They didn’t live past 50. So, we are in a different era. Remember, men, have something called andropause that they make sperm, so they make sperm up until the day they die, and they even make sperm after that. For days after they’re even dead, they keep making sperm. Men make sperm even into the grave, ladies, and they continue to make testosterone as well. So, remember, testosterone gets converted into your brain and bones into estrogen. So that’s basically men have– an average age man at 60, and a woman at 60, if she’s not taking HRT. He has four times as much estrogen in his body and brain as she has.
Cynthia Thurlow: It’s unbelievable.
Louann Brizendine: Isn’t that amazing, Cynthia? It really helps you realize why men don’t get osteoporosis and why they get maybe less Alzheimer’s and less dementia. It should be the word dementia, not Alzheimer’s, maybe a very specific disease. Men get other things and their testosterone causes other problems. [laughs] Let’s be clear. However, I just want to contrast it to what’s going on for women’s health right now.
Cynthia Thurlow: Well, I think it’s such an important discussion. And one that I echo, I’ve been able to watch both personally and professionally, the net impact. My mother and I talk very openly about this. My mom, she’s 76, just had a total hip replacement. She has terrible osteoporosis. Terrible. Thankfully, she’s had no fall, she’s otherwise pretty active. Her recovery has been pretty benign. But we’ve had some very honest discussions about the cognitive impact on the brain of that loss of estradiol. So, the predominant form of estrogen before our bodies go into the upgrade. And conversations that I’ve encouraged her to have with her own physicians because I’m starting to notice, and she is as well that there are certain things she used to be able to multitask like a king. I mean, she was had a very demanding job until she retired. And there are just certain things she’s starting to notice that are coming harder and harder. I think for a lot of people listening, the bones may not seem as tangible right now, the muscle mass loss may not be as tangible right now. They may not even be thinking about heart disease, but when you start talking about cognitive decline, you start talking about that loss of insulin signaling and the loss of estradiol. And you just really think about the net impact. Why are women at greater risk of going or developing dementia later in life?
For me, it really comes down to– the thing that I think about the most is that loss of cognition, because that impacts not just the individual, but their loved ones, their family members, etc. I’m so glad that you touched on so many of these things. For anyone that’s listening, there’s also important distinctions. When we’re looking at the WHI, they were using synthetic pregnant measure and progestins versus some of these bioidentical hormones that are now being used. I think they also get a bad rap, because there’s a lot of pseudoscience that goes along with that, and pill mills and hormone pellets. And we don’t even have to go down that rabbit hole. But I’m curious when you are working with your patients, are you differentiating between different types of hormonal replacement therapies? Meaning, are you using synthetics or bioidenticals? Is that important to you? The reason why I’m asking is a lot of the questions that I got preceding our discussion were specific to that. They were curious to know what your thoughts on that as well.
Louann Brizendine: I just want to clear up all of our thinking in terminology because it’s really important because the word bio identical hormone, it basically means this is something is chemically identical to what your ovary makes, for example, are chemically identical to what your adrenal glands make. Just identical to the human form. And so estradiol, for example, is the name of the most prevalent estrogen that females make during your fertile years. Basically, that’s what’s in many of the pills, and many of the patches right now are just basically estradiol. And so, I prefer to use those. But I think that this issue of natural hormones and bioidentical versus, it’s become a little moot and that many of the prescribed hormones are all bioidentical, natural to that. You could use those words for them. And so, it’s only a marketing ploy right now.
Pharmaceutical industry in the United States is probably the biggest marketing industry that we have. So, beware of what they tell you. Do your own research. It’s not that if this is something that’s a prescription that’s made by your pharmacy, or made by a pharmaceutical company, that it’s not bioidentical. They will put bio identical on the label just because it’s nonsensical to them because they’ve put estradiol on the label because estradiol is the bioidentical hormone. It’s just that one step. And it is the natural hormone. I think the idea of getting really expensive, custom made “bioidentical hormones.” Although I do talk a lot about that in the book, just in terms of how you can think through this and how you can think through what you’re getting, specifically. As for some women, that is helpful if they’re not responding well to the regular prescribed dosages of the prescribed forms of those.
This, by the way, Dr. [unintelligible [00:38:06] she’s basically has shown that the pregnant mare’s urine, which is a natural– think about it, that’s a natural hormone, it comes from pregnant mares. My God, it’s not made in the lab. It’s the pregnant mare hormone which was called Premarin. It actually has more stimulatory function on brain function than the natural hormones from humans. So, if you’re someone who’s got some cognition problems, you might do better on pregnant mare’s urine. Don’t take it with a complete blanket, like bioidentical is good and anything else is bad. Just try to have a bit of an open mind. I mean, know your stuff, but have an open mind because I believe that each of you is an individual. And what’s going to be right for you is going to be something that’s– you get to test– I like to give women stuff for their toolbox. I think of all the hormones I can give, the things I can prescribe, the antidepressants I can prescribe, whatever it is I can prescribe I want to give them those in their toolbox to try for themselves to see how that works for them. I think that that’s really important.
Don’t you think, Cynthia, from your work with patients is that– we, people in the health care professional, we need to help our patients be able to realize that they are so individual and unique that my role is to partner with them, and to help them be able to get tools that I can give them because I can write prescriptions to use in their toolbox to work things out to the best of their health cognition and well-being and sleep. Let’s not forget sleep. [chuckles]
Cynthia Thurlow: No, it’s so important, and how grateful I am that you are doing work in this space because the concept of bio-individuality is something that I honor. Even when I was working in cardiology, I definitely honored because I would have clinicians that would work with me that would say, “Everyone with high blood pressure gets this drug at this dose.” And I used to say, “That’s not how it works.” I’ve learned certain demographics and sizes of patients need different dosing. I learned very early on that if I wanted to decrease the likelihood of people having side effects, I would start low and slow. And you could always go up if need be. I love that you mentioned the distinction between synthetic and bioidentical hormones. The reason why I share this now is that for a long time, I used to feel like thyroid medicine need had to have Nature Throid, or Armour Thyroid, they were so superior.
Well, the laugh is on me because when Nature Throid disappeared off the market two years ago, I went on this whole journey of experiencing compounded versus synthetic varieties. And what am I taking right now? Synthetic T4 and Synthetic T3, and it actually works really well for me. I want to be really clear that you can still have synthetic hormones that work well for your body, and that we don’t want to pass judgment across all of synthetic options, because for some people, that might be the only thing that works well for them.
Louann Brizendine: Absolutely. I’m glad that you brought that up, because it’s really important. I think that you’re thinking about it too, because it is so funny that we had this discussion a few minutes ago about the male-female, the alpha male, like physician, and you and I are probably always, we were being more subtle, starting on lower doses. I was always the low dose queen, because probably because of my own experiences that we were taught in medicine that only petite Asian women are the ones who needed to have lower doses, or anything. But that’s not true. I’m not a petite Asian woman and I have to have the tiniest doses of things. I can react really badly to even to the lowest dose of a normal thing. I have to cut pills in halves and even quarters to give them a try for myself.
Long time ago, I started using things for women who have the anxiety, depression– I remember, I still ran into one of my friends and former patients, when she was going through the perimenopause and menopause, I tried her on the formula I just use this because Prozac was the only thing that came in liquid form in those days. All of them now, I think come in liquid form. But she said, she used to take three drops out of the dropper, of the liquid dropper of Prozac in the morning when she was going through the perimenopause, and she says it completely saved her life.
And so that was about that she was taking about the equivalent of one or two milligrams, and the standard dose is 10, 20, 30 so she was taking maybe 1/10 or one half or a tiny, tiny, tiny dose of the normal, because I wasn’t really treating full blown clinical depression with my women patients in the clinic that were going through perimenopause and through the transition years. I was treating things that were kind of changes in hormone related that was taking wallop on their mood and their anxiety and their sense of well-being. I remember one woman she said it the best that came into my clinic saying like, “Dr. Brizendine–” she’s this beautiful woman has these gorgeous kids, and a great job. She said, “I have everything. I have the best husband, I have the best life, I’ve got everything, but if it weren’t for them, I would not want to go on living. I feel that bad inside.” I often get the women in my clinic, and everybody else, they look like they’re just fine, and they’re faking it. They’re faking it really well to the point, other people don’t know they’re faking it really well. But inside they are miserable, and to have more sanity. “I don’t feel like I would go on living if it weren’t for my husband kids because I feel that badly inside, my mood. If I could I would just like to kill myself.”
So that’s how bad it gets in perimenopause for a certain set of women. I just want to put words to that because if somebody listening are one of those women and everybody thinks you’re just fine, but you know you’re not fine, I want you to get to a doctor that will help you with that. And getting your hormones, getting your estrogen given back to you is one of the cornerstones of it. Getting your sleep in order is one of it, getting your exercise and diet is a one of the things. But also, you are allowed, ladies, to be asked some of these other things to help you through this period too, which could be like either– I like to use liquid Prozac, because it has fewer side effects. And it doesn’t make you gain as much weight as some of the other antidepressants do. But you could also have the Zoloft, Paxil or Lexapro for any of those that work for you in usually small doses that are not used at the same level for someone who has a full-blown clinical depression in the hospital. I just want to put a pitch out that I’ve not simply found that was true in people that you’ve heard talk about this.
Cynthia Thurlow: Yeah. Well, I think it goes without saying that there’s this assumption that if everything looks good on the outside, then everything is fine on the inside. And I’ll be the first person to say that those transitional years really can throw you for a loop. And I think it’s so important to mention that the micro dosing, so subtherapeutic levels to traditional antidepressant, antianxiety therapies is really very helpful, because in cardiology, we generally gave those traditional doses and I knew if I gave a certain amount to my thin little old lady who was depressed and needed to put on some weight, I knew exactly what dose to use of Zoloft. But I think it’s important to understand that you are very thoughtfully tinkering these doses specifically for these transitional years, women may have episodes with these fluctuating amounts of estradiol and progesterone and testosterone that can impact mood so significantly, are using other antidepressants, other than the SSRIs, or is that your predominant area of focus right now?
Louann Brizendine: You can use the tricyclics like nortriptyline or amitriptyline or Elavil. Sometimes in small doses at bedtime, if someone’s having a lot of trouble sleeping, I try generally to stay away from the Ambien and Xanaxs and the benzodiazepine category, because fortunately, it has blowback. I mean, we wouldn’t travel a lot, you’re changing trends, time zones, and stuff, maybe you’ll take, you can take two nights in a row of a benzodiazepine, or an Ambien or something like that. And then you get blowback on the third night. It doesn’t get blowback on the third night– to save your life, you can’t fall asleep and stuff. And then unfortunately, you get into this horrible rhythm. And those medicines will cause depression as something that will start to creep up on you if you continuously take them and cause also cognitive impairment.
I never say never about any drug. And the antidepressant called Remeron, which is Mirtazapine, it’s generic. I like to use that for women who are really having a problem keeping on any weight and have a lot of trouble with sleep. I take like the 7.5 to the smallest, they come in sometimes, I let people cut that in half to start with or even half of that, because that’s a really great sleeping med and that’s not an SSRI.
Effexor was the one, the Venlafaxine was one that was used a lot, or the paroxetine, Brisdelle, was the one that was actually rebranded by the pharmaceutical industry for specifically for women in the perimenopause. The only problem with that one is, I tend not to use that one anymore, because it causes so much weight gain. And, of course, remember, Remeron, the Mirtazapine will also cause weight gain. So, each individual woman had to fine tune this for each of them is this the bottom line. We have some other favorite ones, there’s all the SNRIs, SSRI. There’s lots of categories now and antidepressants and new ones coming on the market at all times. Some women that have a lot of trouble with their mood, and they have a little bit of bipolar history in their family or something, a little bit bipolar themselves. They do well little times on Lamotrigine, a little bit of Lamictal. We can figure out ways in which to have things– I call it a tailor-made pharmaceutical mix for people that will help you get through this. We know that if you’ve had a depression or anxiety before you hit these perimenopause, transition years of 40 to 52 or 53.
You are more likely by maybe two, three or four times to have mood anxiety, depressed and a lot of difficulties brain fog with this transition period. I don’t want you to suffer in silence. What is this? Pull up your socks, it’s not just you, it’s your family, it’s the people that love you. There’s many layers of reasons to try to– most of all, is that the world needs you. I mean, all the people you interact with, we need you to be your best. You need you to be your best, you may not even realize that you need you to be your best until you then are getting back to your best. I don’t like women to suffer. The suffering silence business is like, that’s old fashion, let’s get rid of that. And doctors that believe in this WHI study of 2002, 20 years ago, and just still live by it. They are doing women a great service. And they don’t do it on purpose. It’s not intentional. They don’t even know. They have lack of knowledge. So, you all have more knowledge than they do about this oftentimes.
Cynthia Thurlow: Well, I think one of the things that I learned as an undergrad was that we are designed to evolve shift and change throughout our lifetime. A lot of the rhetoric that I shared with patients as a new nurse practitioner, is largely disproven. And I’m thinking about a lot of the nutritional recommendations we used to provide to patients. But I think if you’re a clinician or you are treating women of middle age, and you aren’t looking more closely at how that study has impacted women on such a profound and significant level as well as clinicians. And you’re not open minded enough to pivot, change your mind. Say, “This is what I did before, this is now,” you’re really doing a tremendous disservice to women. And it’s interesting, it wasn’t until, I myself hit the wall of perimenopause that I really started to understand that no one prepared me for this time period in my life. Not my mom, because that generation didn’t talk about it. Not my grandmother, not my schooling, not my girlfriends, because no one wanted to talk about it. There’s a degree of shame about aging, that really doesn’t need to be there.
I think on so many levels, at least, it’s been my experience as a 51-year-old woman that this has been the most gratifying time in my life. Like all of a sudden shedding means, should to’s, and the woulda, shoulda, coulda’s, I mean, all of those are gone. And I really do endeavor to make sure that other women understand that this should be a really freeing time in our lives. I’m curious, are you working on any new projects? Do you think you have another book, we were talking about that before we started recording, because these books are such a labor of love? And your book is obviously one of my favorites that I’ve read, specific to women in middle age. And, again, the terminology is so important. What are you working on right now?
Louann Brizendine: Well, mostly, I’m working on the different aspects of the book. This book that just came out, if you read The Female Brain, which was one of the former books. If you read the Chapter seven called The Mature Female Brain in that book, that’s a short chapter of basically about this whole book’s aspects. But also, in this book, if you’re already past the stage of the perimenopause, menopause stage and you’re already into the upgrade, then you can just turn directly to Chapters five, six, and seven in this new book, The Upgrade. And then even in the later chapters, I talk in Chapter 14, about dementia, and basically a lot of things about things you can do for your cognitive health. But also, a lot about– and even in the last part, I talk about, like this stage of like age 70, 80, 90, when your kind of thinking about more end-of-life things.
My editors and I decided not to put age is attached to the chapters, because it’s such a fluid time for all of us. Women were at different stages at different ages. But I think in the 60s, 70s, 80s, you start to go through a different time when you start to– but you’re looking at your adult children. So, there’s a Chapter eight, which is basically how you think about being a mother to adult children, which is a whole another chapter. So, I’m working a lot with other women that are trying to figure out how to be a mother and mother their adult children who basically not to manage, manipulate, or mother them. Forget it. They won’t even talk to you return your texts or your phone calls, forget it. So don’t do that, ladies.
And also, the phrase, “My help is not helpful.” When they’re in their 30s, my son just turned 33 last week. When they hit this stage, they want very little advice. It’s a whole another– so if you’re in that transition, ladies, you can turn to Chapter seven, eight and nine. And it goes on from there. If you’re in your 80s, or 90s, Chapters 15 and 16 may be more for you. I’m working on that whole transition into– I didn’t feel like I could write this book until I had some legitimacy and experience myself of coming– I didn’t think I would, because I felt like I had done the whole thing with The Female Brain. I went from the moment of conception to The Mature Female Brain. But that book came out when I was like 53 or 54. I felt this one I really needed to– I didn’t know what I was going to write this one until I had this whole new experience. After this, it’s a wow, there’s so much left, there’s so much more. And the feeling of authenticity and the feeling of going forward to the things that are really, really, deeply important to you in your life. Like your relationship with your loved ones, your relationships with your families, your relationship with your siblings, the relationships with your friends and yourself.
There’s all of these things that you basically can spend more time and to become more and more important to you as another part of your life where you’re fertility life and the early part of your career is passed and you are wanting to give something back to the younger generation. There’s all of those aspects that will become more important to you as you hit your late 50s and your 60s and into your 70s. So, I’m just trying to give back. I’m just really focusing on giving back right now, Cynthia.
Cynthia Thurlow: Well, I’m so very grateful. It’s a book that is a very important one, and one that I’ve started gifting to my family members that need this message as well as patients and clients. Let my listeners know how to connect with you. Obviously, we’ll have links to all of your social media and your books, but let them know the easiest way to connect with you outside of this podcast.
Louann Brizendine: Yeah, and they can just go to my website which is louannbrizendine.com. And I’ve got all kinds of information there and information on how to get in touch with me and all that kind of stuff. I think social, as you probably know it is a mixed bag because it’s not great self-care to spend too much time on social. I have a lot of stuff on social, on Instagram, on TikTok. TikTok, I gave this little like the muscle tip because your muscles communicate with your brain. I have a lot of stuff in the book about diet and nutrition and muscles. But muscles are really important because the study of 80-year-olds who spent had the best cognition were also those who had the best leg strength. So, I did a little TikTok thing on like how squeezing your butt, your butt is one of the biggest muscles. So, ladies, butt squeezes are really an important thing. And that TikTok video was like very, very popular one so. [crosstalk]
Cynthia Thurlow: I love that. I love that you’re on TikTok–
Louann Brizendine: [crosstalk] -Instagram or the old Facebook page, I still have one of those. I have a lot of stuff on my Facebook page. So, they can go to social if they want to see some more things. But mostly, I would say, if you’ve got The Female Brain book, and then The Upgrade book and you have those together, I think that you can just marinate yourself in those and you get all the wisdom I have to give you. [chuckles]
Cynthia Thurlow: It’s wonderful. It’s been such a pleasure to connect with you. I’ve really been looking forward to our conversation. I’m so very grateful that we were able to connect on a weekend to record this.
Louann Brizendine: Absolutely, Cynthia, thanks so much. And thanks to all of your audience for listening. I’m just hopeful that they will all upgrade themselves to a point where they just fall in love again with themselves and their own life.
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Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.