Ep. 284 HRT’s Misconceptions & Misinformation with Cynthia Thurlow, NP & Intermittent Fasting Expert 

Today, I am thrilled to welcome all of my wonderful, Everyday Wellness listeners to a special episode of the podcast they specifically requested – an Ask Me Anything session with yours truly!

Interestingly, the subject that resonated most among listeners was hormone replacement therapy. To be crystal clear, I am here only to provide general insights and share information. If I answer your question today, I earnestly recommend that you listen, learn, and then find a practitioner who can best support your particular needs. 

It is essential to remember that we are all bio-individuals. So what works for me may not work for someone else. I also want to ensure that women who choose not to pursue HRT are fully informed about the potential consequences of that choice. So, I appeal to you not to let fear dictate your decision-making around HRT if it is appropriate for you. 

I believe informed consent is paramount, regardless of how you navigate the perimenopause and menopause phases of your life, and I ask you to embark on this journey with me, free from judgment. 

Stay tuned for my advice, recommendations, and resources!

“If you are indeed in menopause, you deserve to have hormone replacement therapy, and you absolutely deserve not to have to wake up four to five times a night because you are getting hot flashes!”

– Cynthia Thurlow

IN THIS EPISODE YOU WILL LEARN:

• Is it too late to start HRT at 62? 
• What is the net impact of menopause? 
• Why is estrogen essential for health and wellness?
• The benefits of progesterone therapy.
• What is the best time to take progesterone?
• How would I approach hormone therapy with a 52-year-old who has had a partial hysterectomy and has been in menopause for two years?
• When is the best time to start HRT?
• Adrenal support for perimenopause. 
• For how long should a woman stay on HRT?
• How can you increase your progesterone without taking a pill?
• Janet is 57 and still has a menstrual cycle. Does she need HRT

Connect with Cynthia Thurlow

• Follow on Twitter, Instagram & LinkedIn
• Check out Cynthia’s website

Ep. 94 – Reclaim Your Vibrancy, Sexuality, Health and Happiness! – with Dr. Anna Cabeca

Ep. 211 – Addressing the Root Cause of Hormonal Imbalances with Dr. Sara Gottfried

Ep. 220 A Detailed Guide to Healthy Hormones with Dr. Lara Briden

Transcript:

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.
To my wonderful Everyday Wellness listeners, the must requested AMA version with moi. No guests, no one else, just me. And I have to thank everyone because I received hundreds of questions and this will keep me busy for probably the next six to twelve months, I’m not exaggerating. My team and I tried to sequester the questions into different topics and without question, the most common area where I received questions was in hormone replacement therapy. And I want to be really clear, I am not anyone’s nurse practitioner that’s listening to this podcast, so this is not medical advice. I’m speaking in generalities and I would certainly encourage you, if you listen to this podcast, if I answer one of your questions or you are inspired to take the information and better educate yourself and find a practitioner that’s going to be able to support you and your needs, that’s great.

I also want to provide another disclaimer and just say that we are all bio-individuals. What is right for me may not be right for someone else, but I don’t want anyone that’s listening to be fear mongered into not considering HRT if that is appropriate for you. I also want women that are choosing not to take HRT to be fully informed so that you understand the potential ramifications of that choice. Again, no judgment. I think fully informed consent is important irrespective of how you choose to navigate perimenopause and menopause.

So, let’s dive in. First question is from Joyce. She said, “At 62, is it too late to be looking into HRT? You have spoken about how important it is for our heart and bones.” Joyce, thank you so much for your question. It is my understanding that we confer the most benefits when this is initiated within the first five years of that final menstrual cycle. This does not, however, mean that you, in conjunction with your GYN, primary care provider, nurse practitioner and nurse midwife, that there may not be clinical indications. And here’s the thing about menopause that I think a lot of women don’t realize you can look healthy from the outside and have tremendous amounts of inflammation and oxidative stress. It is a byproduct of the hormonal changes that are occurring in our bodies at this stage of life. So, Joyce, what I would recommend is that you have a conversation with your internist, your GYN. North American Menopause Society is a good resource.

However, I want to be clear, not every clinician that is listed in that directory is pro HRT. And I’ve found this out the hard way, trying to refer clients to local providers. So due diligence, get on the NAMS website, check out the practitioners there, look at their websites, see what the general overall theme is. Call the offices. You are absolutely entitled to be able to do that. The other thing is to ask your colleagues, friends that live locally, who they use, if they are an HRT, are they happy? Another thing to consider is to go through www.ifm.org. This is The Institute for Functional Medicine, again not everyone affiliated with that group is also pro HRT, but at least will give you additional options. You can get on their websites, their profiles, take a look at them. So, I hope that helps. I think the answer is it’s very bio- individual, very dependent on the individual, and certainly something worth discussing with your healthcare provider.

The next question is from Kathy. “I’m seven years post menopause and many of the initial annoying symptoms like brain fog and hot flashes are over. But I wonder if Longevity Health would benefit from HRT. Is it too late to start if you haven’t had any before? I’m 64.” So again, another question. Obviously, there’s a lot of misinformation about women at this life stage. I think it’s important to at least document, discuss the net impact, their systemic impact, when we are losing progesterone and losing estradiol. About 25% of women are still making enough testosterone, so the majority of us are not. And progesterone therapy can be incredibly beneficial, not just for sleep and anxiety and stress reduction, but we have sex hormone receptors on nearly every cell of our bodies. And so, it impacts bone, it impacts heart health, it impacts brain and cognition.

There’s a reason why women are at greatest risk for developing dementia in menopause, and a lot of it has to do with the changes in insulin sensitivity, but also that loss of estradiol. And so, this is a very important thing to discuss with your healthcare provider. Again, go back to those other resources I mentioned, NAMS and IFM. I also like to suggest and I will ask my team to link up several podcasts, Dr. Avram Bluming and Dr. Carol Tavris. I did an amazing podcast with them. They wrote a book called Why Estrogen Matters. There’s another book that I would recommend called The XX Brain with Dr. Lisa Mosconi. I have not yet interviewed her for the podcast, but I do hope too.

Another great resource would be the podcast I did with Dr. Felice Gersh. I’ve done several with her, but my second one in particular, I think it’s the number one downloaded podcast in the past two and a half years. To give you some idea of how information packed that resource is. The other thing is, a lot of these practitioners that I interview on the podcast, many of them have multistate licenses, many of them are able to practice across state lines legally. And I would definitely encourage you to check out some of those resources based on where you live.

Okay, next question is from Sonya. “I take progesterone before going to bed. I recently heard that progesterone peaks in the morning, therefore that is when you should take it. What do you suggest taking for when to take progesterone?” Okay, Sonya, we know that progesterone has a sedating effect and if you’re on enough of it, at least 200 milligrams at night, it will upregulate GABA and actually make you sleepy. That’s why I don’t recommend that women take progesterone during the day. I’ve had reports of women falling asleep and for most of us we don’t want to be doing that. I think it is absolutely appropriate to take it at night again, because it is sedating, and that’s when I take it if that is any assistance whatsoever.

Next is Amanda. “I just turned 51 and in another show, you mentioned not waiting until menopause to start HRT. I want to see my doctor to start HRT now, I know progesterone is a good one, and I can be on it for life without concern. What dosing method do you prefer for progesterone and estrogen, topical, oral, intravaginally? I know you said adding testosterone should be last and you don’t like the pellets. Anything else I should know? Does The XX Brain go into detail about this information so I can learn more read about that before my appointment.”

Amanda, thanks for this question. What I would say is progesterone is easy to take. I generally recommend that we want to keep those receptors sharp. So, I don’t take progesterone one night a week, and I just augment my sleep stack, which I’m sure there’ll be plenty of questions about that when I get to the sleep webinar that will be featured in July. When it comes to estradiol or estrogen, there are many different ways to use HRT. Some people like compounded creams. Some people like patches. There are troches. Yes, you can use it intravaginally. I find for some women; they like to start off with intravaginal estrogen because they’re having so many genitourinary symptoms. And this is a pretty easy way to at least ameliorate those symptoms. And for anyone that doesn’t know, as we are losing estrogen in our vaginas, it actually changes the pH. and because of the loss of estrogen, the lactobacilli that are there, they start to die off and it can just make it much more hospitable for not only urinary tract infections, but dryness and just painful sex and things that are not fun. So intravaginal estrogen can be very helpful.

There are some women who, when they start patches or compounded estrogen, they don’t need intravaginal estrogen, others do. I do find that some of my thinner, tinier patients really do benefit from taking both, but it’s highly bio individual. Dr. Anna Cabeca has a wonderful product that is external DHEA, which can be converted over into some of those other metabolites. And that is a nice product. We will link that up in the show notes as well. Your other question was about testosterone. The unfortunate thing about testosterone, there’s no FDA-approved testosterone at this time. I don’t foresee that that’s going to change anytime soon. I don’t love pellets because they’re so wildly unpredictable and I do find that compounded testosterone is a good starting point. But obviously you optimize estrogen and progesterone first before adding testosterone. That’s the best way to do it.

Does The XX Brain go into detail? XX Brain just talks about the brain and sex hormones and what changes in perimenopause and menopause. You’ll hear reoccurring themes about great books that I think are really helpful. I’ve been able to interview some of the best and brightest in the health and wellness space, and so I would definitely recommend going back and listening to specific podcasts, Dr. Anna Cabeca, Dr. Lara Briden, Dr. Sara Gottfried. They’ve all written great books and great resources in these areas. That would be a great way to kind of fill in your knowledge base.

Next question is from Ladon. “I’m 53 and have been in menopause for two years. I’ve had a partial hysterectomy, so she still has her ovaries. I’ve chosen to take bioidentical hormones to support my health and longevity, but I’ve had to make adjustments. Is this because I still have ovaries? How would you approach hormone therapy with someone like me?” So, I don’t know what types of HRT you’ve been on. I don’t know if it’s oral progesterone, if it’s just been transdermal progesterone, what types of estrogen therapy you’ve tried? What I would say to you is if you feel like you’re not getting anywhere, it could be dosage mediated, it could be absorption. This is where labs and symptoms are really important, getting a really good history.

In fact, I used to tell my NP and PA students that worked with me, 90% of what you need you get from a clinical history. So, what is sleep like? Are you having vasomotor symptoms? Are you having hot flashes? How’s your energy? How’s your mood? Do you have a libido? All of these things are super important. And then looking at the other metrics, like, have you had a DEXA? What’s the body composition like? There’s a lot of different things that have to be played into, but I think most clinicians want to start low and slow, and I think that’s completely reasonable. I also think it’s important when we’re talking about hormone replacement therapy that we are also considering the fact that we want to provide some detoxification support. So, making sure that you are taking care of proper nutrition, you’re dialing in on sleep, you’re addressing stress, you’re working on gut health, you’re removing inflammatory foods, you’re lifting weights, not overdoing cardio. There’re so many different variables. So, when you say that it’s not effective, I’m not sure. I just don’t have enough information but those are things to think about.

Okay, next question is from Marily and she said, “I would like to know what supplements best mimic HRT. I’m unable to take it due to factor V Leiden, which is a bleeding disorder, something that she was born with, besides eating well, lifting weights, sleep, what supplements would you suggest for those of us who can’t take HRT?” I would say without question, adrenal support. This is where we know in perimenopause and menopause that we are less stress resilient. So really understanding how important it is to make sure you are nourishing your adrenals. This is where I think adaptogenic herbs can be very helpful. Magnesium, vitamin C, being proactive about managing stress. And this is not 5 minutes of meditation once a week. I find a lot of women head into menopause and they are still like high charging women. They are living and behaving like they did in their 20s and 30s which means not enough rest, not enough downtime, not enough decompression or sympathetic dominant.

I don’t know per se of any supplements that are going to replace hormones. But what I do find in most of my women that either are cancer survivors or they’ve got coagulation or bleeding disorders, then we’re really working on the fundamentals. So, the lifestyle, adrenal support, making sure their thyroids are properly supported, I think all of that is very beneficial. I would say making sure your sleep metrics are really dialed in, like are you really getting 90 minutes of deep and REM sleep? Do you have high quality sleep? Are you getting sufficient amounts of sleep? Are you lifting weights? Are you eating anti-inflammatory nutrition? And for anyone that’s listening, we cannot eat like we did when we are 20 years old, especially in perimenopause and menopause. The more insulin sensitive you are, the more discretionary carbohydrate you can consume. But I don’t recommend processed carb variety, certainly not consumed with any regularity.

I really love nonstarchy vegetables. I’m a huge fan of low glycemic fruit. I have a little bit of fruit every single day. I mean, I love berries and they tend to be on the lower glycemic index, which means they are not going to have as much net effect on your blood sugar. I’m also pretty insulin sensitive, so I can get away with occasionally having tropical fruit, but that’s not my norm. So, getting back to your original question, this is a great question for your GYN or your integrative medicine doctor to ask them what their recommendations are. Obviously, we are limited because of the factor V Leiden, but adrenal support is something that I would definitely discuss or at least look into.

Next question is from Jenny. “Once a woman starts HRT to offset the perimenopausal symptoms, anxiety, insomnia, hot flashes, how many years is it expected that she stay on it? Will things settle down after menopause so that HRT is no longer needed? No one talks about how long it is needed'” Jenny, the real question is there used to be a finite thought process that you take it for 5-10 years and then you stop. Well, the more that I have looked at the research and talked to experts, certainly on the podcast, is that women should be able to stay on this long term as we are losing our sex hormones heading into perimenopause and menopause, there are benefits to staying on it. For many people, HRT is life changing. It improves their sleep quality, their libido, their bone strength, their heart health, their brain and cognitive health and something to think about and Lisa Mosconi talks about this that our brains in our 60s and 70s are made in our 40s and 50s.

So, I think it’s important to understand that there are benefits to having healthy menopausal dosing parameters, even perimenopausal dosing parameters to help protect those very important parts of our cognitive health, our bone health, our heart health, which are systemic. So, to answer your question, Jenny, it’s my understanding that it is fine as long as you’re monitored to be on long term HRT therapy. And more and more I’m hearing clinicians, even Peter Attia recently said that he likes to start women on HRT before menopause just because it helps to buffer a lot of symptoms they experienced. I think it’s highly dependent on the individual. I had more symptoms in early perimenopause than I did the rest of perimenopause into menopause. And I think a lot of that had to do with lifestyle.

We know that if you look at the research on blood sugar dysregulation, that is the primary driver of hot flashes. And so, all these vasomotor symptoms that many women experience that are incredibly debilitating are likely a byproduct of lifestyle. So, we really want to make sure as we are navigating those 10 to 15 years of perimenopause, that we’re really taking good care of ourselves. So, sleep, stress, anti-inflammatory nutrition, right types of exercise, not eating too frequently, etc.

Okay, so this is a question from Melanie. “I want to lean out and really have my muscles show. What do you suggest to do? HRT, a round of Anavar or testosterone? I am not overweight, just want to lean out.” Well, I don’t know Melanie’s age, so that is challenging because it’s hard to answer this from the perspective of are you in menopause, are you in perimenopause, are you still peak fertile years? Although I would imagine most of my listeners are probably north of 35 or 40.

I would say first and foremost most of what you see in terms of muscular development is a byproduct of nutrition and also strength training and high-quality sleep. So those are the fundamentals. You have to lift heavy enough to stimulate the muscles, you’ve got to eat enough protein to stimulate muscle protein synthesis. You have to have repair and recovery, so that’s where sleep comes in. And I think then after you’ve dialed all that in, this is where body composition changes can be related to a variety of things. It could be that your insulin is high. It could be that your blood sugar is not properly regulated, and those two things alone, high cortisol can put you into fat storage mode. I don’t like seeing women just solely given testosterone because more often than not, there’s some other underlying issue that needs to be addressed. And so, I see a lot of providers that are giving testosterone out like candy. And so, I think we have to be careful when we’re doing that.

The number one reason, at least in men for why they have low testosterone is related to insulin resistance and exposure to estrogen mimicking chemicals. The same can apply to women. We have a lot less testosterone, but it’s very potent in our bodies. And I just see a lot of women who are given too much testosterone. In fact, I had a conversation with a GYN recently specifically about this and how they were concerned that women were getting way too high physiologic dosing on testosterone therapy, and they almost get like, an addiction to how they feel. And so, I think that we just have to be careful. I think testosterone therapy absolutely has a place. I think it is very bio-individual, and I don’t like to see testosterone solely dosed without looking at other reasons for whether or not it is actually low or whether or not someone would benefit from progesterone and estrogen first.

Okay, this is a question from Nicole. “What are your thoughts on bioidentical HRT progesterone for women in perimenopause? Is there a way to increase progesterone without a cream or a pill?” This is a great question. Now, I know there are a lot of people out there that will say you can eat X food and it’s going to increase your progesterone. I mean, there are nutrition aspects to the luteal phase that can be helpful, whether it’s squash or lentils, but it’s not going to replace your endogenous secretion of progesterone. Like, let me be very clear, there’s no food that’s going to replace the progesterone that you are losing as your ovaries are going into decline. There are ways with technology and Dr. Amy Killen talks about these things. So, I want to give her a little nod and we can include that podcast episode. There are some people that are going to great lengths to preserve their ovarian function, and that’s not what I’m talking about here.

I think that HRT actually progesterone can be a great first step in perimenopause for a lot of women. They get put on antidepressants, antianxiety agents, sleeping aids, when all they need is some good old progesterone in the last five to seven days of their cycle. The last two weeks see a lot of different clinical variation on this. But understanding what’s going on physiologically as our bodies are navigating perimenopause makes sense about progesterone. I think progesterone is fine to cycle while you’re still cycling. Obviously when you are in menopause, it is completely appropriate to take that most days of the week. I know Dr. Anna Cabeca and I had a recent conversation and she agrees, three to four days a month without oral progesterone, if you have a uterus, is what you need and that’s what protects the uterus when we’re trying to have this balance between estrogen and progesterone. So, oral progesterone is going to be most efficacious. And so, yes, I think that is a great first step. Again, oral progesterone is inexpensive. It is generic. I think when I was taking it before, it was anywhere from $6 to $9 for several months’ worth. Mine is now compounded because I just had some variations. When you get generics, you can get about 20% variance and it was just impacting my sleep enough that it was worth it. So now compounded variations are more expensive, but definitely some good things to kind of start off with.

Next is Tina. “I was told by my OB/GYN NP that even though I’m on HRT and she’s actually not on HRT, which she mentions here, norethisterone acetate and ethinyl estradiol tablets, which are actually oral contraceptives, I will still experience menopausal symptoms like my body heating up four to five times in the middle of the night, is this true?” Well, Tina is not on HRT. This is actually the pill. There are a lot of women that are kept on oral contraceptives. This is not HRT. This is keeping your body in a very low hormone state because it knocks out the negative feedback loop between your brain and your ovaries. So, I would go back to your NP and I would ask for HRT. I mean, that is very different. If you are indeed in menopause, you deserve to have hormone replacement therapy, that is not what oral contraceptives are. And you absolutely deserve to not have to wake up four to five times a night because you’re getting hot flashes, that’s cruel.

Next question, is from Janet. “As a 57-year-old female still having a menstrual cycle, do I need to take hormones? I am 5’6″ and 145 pounds. I sleep great, never had a hot flash. I work out regularly with weights and do cardio as well as playing my new love pickleball.” Pickleball is like the new thing y’all, I mean, people are really really excited about pickleball. My husband and I keep mentioning that we’re going to have to learn how to play. “My labs have been good, slightly low in testosterone and using cream for a few years and levels have come up.” I’m assuming, Janet, you’re referring to testosterone cream. Fasting glucose is below 80. Fasting insulin was good too. Since I’m not having any symptoms of menopause, do I need hormones?”

Janet’s not my patient, I don’t know enough about her history. This is a good example that not everyone in perimenopause, late perimenopause because at 57, that’s late. That’s really late because the average woman is going into menopause at 51. So, to give you some sense, this is like an outlier person, which is fine, because there are people that will go through at an earlier stage anyway. So, Janet is asking, does she need hormones? I think this is a question for your GYN, especially if they are already giving you testosterone. From my perspective, we have to think about brain, bone, heart health. Like I said earlier, if you looked at my labs during the time that I was off HRT, on the outside, I am healthy, I am fit, I look good, I sleep well. The amount of inflammation going on in my body was really really high. Maybe at some point I’ll bring my functional medicine doctor on and we can unpack some of what we’ve done. But I don’t think because you’re not having symptoms, that means that there’s not a lot of inflammation going on internally. So, what I would say is, have the conversation with your GYN or your internist or whomever you see. Ask them what their opinion is.

Every woman listening, if you are appropriate for HRT, you should be able to be properly counseled. You should be given full disclosure about the ramifications of taking HRT as well as not taking HRT. I finished my nurse practitioner program in 2001 and in 2002 is when the WHI, the Women’s Health Initiative study came out and everything changed. An entire generation of clinicians are fearful to prescribe hormones, and an entire generation of women are fearful to take hormones. I am from a very large family, and my aunts have said to me over and over again, I’m hoping your generation is going to change the narrative for women because we’re now seeing and we’re now witnessing the side effects, osteoporosis, cognitive decline, etc. And so, Janet, the right way to answer this is have that conversation with your primary care provider or GYN, so they can help you decide for yourself what the best route moving forward is. It’s impossible for me to say that based on what you’ve shared? And as I always say, this is not medical advice. We’re just speaking kind of big generalities.

Last question. This is from Katia. “I’m wondering if I need to stop my bioidenticals for a few days a month, or can I go without ever stopping my progesterone and my EstroGel? Well, Katia, what I would say is have a conversation with your GYN. Generally speaking, I will hold my progesterone, this is me personally. This is what I do, and this is what I have the support of my team with. I take my progesterone six days a week. So, the intent is to have three to four days out of the month where I don’t take progesterone. And you’ll be amazed, like, my sleep is not bad, but it’s just helping to kind of reset that receptor.

Now, if you’re taking EstroGel or you’re taking an estrogen patch or you’re taking an estrogen cream, I would discuss with your prescribing provider to see what their recommendations are. I know that there’s a lot that’s evolving and shifting in this space and so I think that these are all really great questions. And as I said, I cut so many great questions, I think that it will end up taking me many, many months to get through them all. And as you can tell, my voice is a little bit hoarse. I recorded with one of my favorite podcast hosts, Dhru Purohit earlier today. We recorded for about 2 hours. So, I’m feeling a little froggy.

Got one more question that I think we can tackle, although this is a question coming from someone who lives in the UK, and so I can’t per se fully answer the question because they do things a little differently there. So, this is from Diana, “In the UK, bioidentical HRT lozenges tend to contain a 1:1 ratio of estradiol and estriol with progesterone added in it. This composition differs from the bioidentical HRT supplied by state doctors, where the HRT patches, gels, and sprays contain only estradiol. For a postmenopausal, women who can’t transdermally absorb the hormones contained in the patches, gels or sprays and therefore uses the bioidentical HRT lozenges. Would it be detrimental for such a woman to continue to use bioidentical HRT lozenges which contain the combo of estradiol and estriol? Would she need more estradiol than estriol?” It is impossible for me to answer that question.

Again, bio-individuality really rules here. Number two, I don’t know what your labs look like. I think this is a really great question for your prescribing provider. I know troches and like lozenges are kind of in their own special entity. Certainly, there are some providers who like to have a combination of estradiol and estriol to protect the breasts. Obviously, each individual has to make a decision based on what makes the most sense. And so, this is really a good question. I don’t mean to be evasive, but I don’t know your labs, I don’t know your symptoms. Obviously, there are lots of women that have compounded preparations that still don’t absorb hormones well, sometimes the preparations, like the base in which the compounded products are in, have to be switched over. So, there’s a lot of different variables and definitely worth discussing with your healthcare practitioner to see what their recommendations are. Again, things are done a little different in the UK than they are here. And so, I don’t want to be giving any misinformation.

Well, you all, this has been fun. Like I said, we’ve got quite a few [chuckles] lots, hundreds of questions to go through, but today is very HRT focused, talking about perimenopause, menopause, HRT, taking breaks, book recommendations. Like I mentioned, there are a lot of different providers and podcasts I mentioned in here and books. Definitely a lot of great resources. Obviously, if you’re not already subscribed to the podcast, I would definitely recommend that because we’ve got some pretty dynamic, upcoming podcast guests and we have a really stellar group of clinicians and experts coming out over the next several months.

Thanks so much, ladies. Keep those questions coming.

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