Ep. 295 HRT’s Impact On Women’s Health Through Time

Connect with Cynthia Thurlow

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

Submit your questions to support@cynthiathurlow.com

Connect with Dr. Deb Matthew

• On her website
• On Facebook, Instagram, and LinkedIn
• Get a copy of Dr. Matthew’s book, This is Not Normal: A Busy Woman’s Guide to Symptoms of Hormone Imbalance, on Amazon, or download a free copy at www.isityourhormones.com.

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.

Today, I connected with Dr. Deb Matthews, affectionately known as The Happy Hormone Doctor, best-selling author, international speaker, educator, wife and mom of four boys. Today, we spoke at great length about why oral contraceptives should not be used as hormone replacement therapy in perimenopause and menopause. The net impact of these medications, labs that we can advocate using in perimenopause and menopause to get a sense of where we are, how we define premature menopause or premature ovarian insufficiency, why testosterone is so important when we’re considering hormone replacement therapy, the impact of cognitive decline as well as genitourinary symptoms of menopause and ways to address this including PRP, lasers, acoustic wave therapy, and energy medicine. This is the first of two podcasts that I will have with Dr. Matthews. I know you will enjoy this conversation and find it invaluable.

Welcome, Dr. Deb. It’s so good to reconnect with you. 

Dr. Deb Matthews: I’m so glad to be here. 

Cynthia Thurlow: Yes. Well, I got a lot of questions from listeners knowing that we’re going to be connecting, but ironically enough, I’m starting to see a trend emerge and I’m curious what your thoughts are. Why are oral contraceptives being used in menopausal women? Any thoughts on that?

Dr. Deb Matthews: Yeah. Well, you know in medical school, when we are trained to deal with women’s hormone issues, we are trained how to use birth control pills. So, if you are a teenager who’s having heavy periods or irregular cycles, or any kind of menstrual problems, or if you are in your 30s and 40s and you’re having PMS or heavy periods or fibroids or anything wrong with you, we are trained to use birth control pills. And the reason that birth control pills have been somewhat useful is they basically turn off our own hormone production of estrogen and progesterone and replace them with this set amount of, I’m going to call them hormones for just a minute, and we’ll explain in the pill and every different kind of birth control pill has a different version of estrogen and a different version of progesterone or some of them don’t even have both hormones, but they have different doses, different ratios, and so then we can pick different pills to try to get the best results for any given woman. 

And so, when we get to menopause, you know you come in, you’re complaining, maybe your periods have become very irregular, or maybe you’ve just been on birth control pills for a while, and now you are kind of gone into menopause. But your doctor will just say, “Well, might as well just stay on them in order to prevent yourself from having hot flashes or whatever the case may be.” So, the reason that a lot of doctors feel comfortable using birth control pills is because they’re just so used to using birth control pills all the time and they’re scared of, “hormone replacement therapy” because they’re afraid that hormone replacement therapy is going to cause breast cancer. But they’re super comfortable using birth control pills because they use it all the time. Now, that’s not right, but that’s what they think. 

Cynthia Thurlow: Yeah. And it’s interesting. For full disclosure, I just recently did an AMA episode, just solo, first time I’ve done this, answering a lot of HRT questions. And there was a lovely young woman who mentioned, she was like, “I’m finally on HRT. I’m so excited.” And then she disclosed what she was on. And during the course of the podcast, I was like, “This actually isn’t HRT. These are actually oral contraceptives.” And so, I think this is a common thing that I’m starting to hear, that women are assuming that what they are prescribed is actually hormone replacement therapy, when in essence, it’s oral contraceptives. And to your point, there’s still this degree of fear mongering about hormone replacement therapy and concerns over cancer risks. And I know we have talked about Women’s Health Initiative and how in many ways, it wasn’t a great study. The tide is shifting. But I think it takes clinicians many years to change clinical practice. And perhaps some of the newer, younger GYNs and clinicians that are coming through may feel more comfortable. But I’m definitely still seeing a lot of clinicians, not just physicians, nurse practitioners, nurse midwives, etc., who are seemingly very uncomfortable with the concept of HRT.

And what I find really interesting about oral contraceptives, which is certainly something I didn’t know many years ago, is that it can mask symptoms. So, people may think that the symptom may be that they have very heavy periods in perimenopause and the oral contraceptives help take that away. But fully informed consent would then also talk about some of the side effects, the changes to the gut microbiome, depletion nutrients, increased inflammation and oxidative stress. And I think that there’s this disconnect about full disclosure, because I think many people, if they understood that there’s no medication without side effects. But if they understood that oral contraceptives are not as seemingly benign as they are, they might be asking for other options.

Dr. Deb Matthews: Yeah. And of course, the reason that they’re not getting that full disclosure is because I can assure you that they’re not teaching us at medical school that birth control pills deplete your B vitamins or disrupt your gut microbiome, because that’s just not in the lexicon of what we’re taught. And even though you’re hopeful that the younger, newer practitioners are going to learn differently, you got to remember who’s teaching them. It’s the older, established practitioners who’ve been doing it this way for such a long time. So, I also have hope as we go forward. But even just today, I had somebody come in who is a woman in her 40s who isn’t feeling good, and she went to her doctor and talking about it, and she was just told, “Well, it’s just this time of life, and this is just how it is. And you just got to get used to it.” And it’s sad. But the real trouble with the oral contraceptives is that they aren’t actually real hormones. They are manmade chemicals. They are synthetic compounds, molecules that have never before been found on planet Earth, let alone in a woman’s body. And they mimic hormones so they turn off our natural hormones and it’s being replaced by that. And so, sometimes it can have a benefit on certain symptoms. 

Sometimes it can cause certain side effects. Like, I think women aren’t told full disclosure that a lot of birth control pills will really reduce libido because it shuts down testosterone, which is a really important hormone for women. And doctors know this because we use it for acne. If women have a lot of acne or hair growth on their face, sometimes oral contraceptives are prescribed because it lowers testosterone and it might make those symptoms better. But on the other hand, the other thing that testosterone does is it gives us a boost in libido. And so that’s a really common side effect of birth control pills that most women have no idea. 

Cynthia Thurlow: Yeah. It’s kind of a cruel irony. Let’s prevent pregnancy, but then let’s kill your libido. Let’s completely squash it. Which I think for anyone listening when that happens, it’s very hard to try to motivate yourself, to want to initiate or have your partner initiate contact with you in that regard. Now, a lot of the questions that I received were around “We’re in perimenopause, this 10 to 15 years preceding menopause. Are there any labs that give us a sense of where we might be on this trajectory? I’ve read that a follicular-stimulating hormone over 25. I’ve read about this anti-mullerian hormone.” When you are talking to women and they’re coming to you and saying, “I’m not yet menopausal, I’m still getting a cycle.” How do I have a sense of ovarian reserve? How do I have a sense of where I might be on the trajectory of this perimenopausal journey?

Dr. Deb Matthews: Sure. It’s a different conversation if they’re still wanting to be fertile and have children or if they just want to know what the heck is going on with their hormones [Cynthia laughs] and feel better. So, if somebody’s wanting to get pregnant and they think they’re in perimenopause, that’s like a whole nother can of worms. But for the average woman who’s maybe her kids are teenagers already and she just wants to know how she can feel healthy and feel her best. The three hormones I think that I would think about the most to look at would be, as you said, FSH, follicle-stimulating hormone. That’s the one that’s released from the pituitary gland in the brain and it tells the ovaries to make more of these hormones. But it is a direct reflection of how well your ovary is working. And so, as your ovaries are starting to peter out, that FSH hormone is going to go up and up. 

So, when you’re 20 and you got plenty of your– ovaries are going strong, that FSH number is going to be 2, 3, 4, 5 it’s going to be very low. But as our ovaries are kind of ticking off, our FSH will start to rise, as you said in 15, 25, 35. And then when we’re really going through menopause, it can go even up over 100. So, the lab uses 25 as the cut off mark between perimenopausal and postmenopausal. But what is so confusing and really makes women, just makes a lot of women’s head spin because it makes no sense, is their doctor will look at that one blood test and will say, “You are menopausal.” But yet they’re still having periods, and sometimes they’re having like heavy periods every three weeks. So really the definition of menopause is you’ve gone 12 months without a period and this just means that your ovaries aren’t working properly, they’re not making the right amount of hormones, you’re not ovulating, but technically we can’t say that you are menopausal unless you’ve been 12 months without a period.

But so FSH is one that gives us a clue, another one that kind of gives us a clue if we’re still kind of perimenopausal and just on this journey is progesterone. Because progesterone goes down way ahead of estrogen. Estrogen goes down around 50ish and once our estrogen has gone down, our periods will stop. But progesterone often can go down anytime past the age of 35. And so, it’s really common by the time women hit their 40s that their progesterone is low. Mine had already gone down when I was in my late 30s. And this is something that can be measured, but it is not routinely measured. So, you can ask your doctor to measure your hormones and generally the best you’re going to get is that FSH, they’re generally okay with measuring that, although a lot of times they’ll just say, no, we don’t measure hormones. There’s no point, it changes, we don’t do it. And there is truth to that because our hormones change over our menstrual cycle. So, they’re low while we’re on our period. Then estrogen goes up a little bit the week after a period. It spikes way up in the middle of the cycle when we ovulate. And then after we ovulate, progesterone goes way high for those two weeks before your period.

So, we have to know where you are in your cycle in order to interpret the results. And if you happen to be at your doctor’s office on some random Thursday afternoon and you say, “Hey, can you measure my hormones?” A lot of women are told, “Well, no, we don’t do that because it changes all the time, so there’s no point to measure it.” And what I would argue is your blood sugar changes all the time depending on what you’ve eaten, but we measure that all the time. Your blood pressure changes whether you’re sitting down calm and relaxed or whether you just raked the leaves in your yard. But we still measure that. So, we just have to know how to do it properly and interpret it. And what’s really important for progesterone is we want to measure it about a week before your next period is due. We call that the luteal phase of your cycle. That’s when it’s supposed to be really high. And if you measure it at the other times of the month, it doesn’t give us the information that we need. So FSH and progesterone. Do you agree? Are those things that you recommend people look at too?

Cynthia Thurlow: Yeah. I think it’s important, and I would say 50% of the time patients will say to me, my healthcare practitioner said there’s no point in testing my hormones. And I usually use this very similar analogy where I always say it’s important to get a baseline. And even at the stage of I’m in, I still ask to have my hormones drawn because I want to know while I’m on therapy where my levels are, where was the baseline, what are we comparing it to? And I always indicate you can’t track what you don’t measure. And so, for me, I think that is really important. So, I love that you brought up progesterone. And I think for a lot of people, this is the time when we start having those faltering amounts of progesterone. This is when the sleep problems start. This is when they get this uptick in anxiety and depression. And this is when women are prescribed sleeping aids, they’re prescribed antianxiety, antidepressants, and yet what they really need is a little bit of progesterone, which is a whole lot more natural than those other alternatives. 

Dr. Deb Matthews: Yeah. And I remember so distinctly, so when I’m in my late 30s and my progesterone had already gone down because I had a lot of stress, my cortisol was up, too much cortisol makes progesterone go down. There were extraneous circumstances that were pushing me to this. But I was irritable and I was snapping at my kids and snapping at my husband, and I wasn’t myself. I used to be this calm person. I didn’t get upset over things. And now all of a sudden, I was a Karen. We didn’t have Karen’s then, but if you look at Karen’s, they are generally like midlife women who just did stupid things because they kind of lost control. And I think they could use a little bit of progesterone in my unscientific theory here. But I read a book by Suzanne Somers, because my husband found it and he recognized I was not at my best– so anyway, I read the book and I read about how progesterone is this hormone that attaches to receptors on our brain. They’re called GABA receptors and this is the calming effect. This is how Xanax works and how Valium works and how Ambien works. But we don’t have Xanax deficiencies and Ambien deficiencies. We have progesterone deficiencies. I had no idea. I did not learn that at medical school. I learned it from Suzanne Somers’ book.

Cynthia Thurlow: [laughs] I think in a lot of ways Suzanne Somers has taken a bad rap from medical professionals. But yet the irony is when I was in my 40s and I was trying to figure out perimenopause and my GYN was zero help whatsoever because I was offered oral contraceptives, an IUD, an ablation, or if I’m done having kids, let’s just do a hysterectomy, which I said, “No, no and no.” I stumbled upon her book because I wanted to find every book that was written about the perimenopausal period. And I sure enough read it. And I remember looking at my husband and saying I cannot believe I’m going to say this, but there’s actually good information in this book. I’m so glad that she wrote this book. But why, oh why am I reading this book that was written by an actress? And why are healthcare professionals not talking about this with our patients? Why are we not preparing our patients? Because, to your point, in my 30s I had kids at 34 and 36. My husband did a ton of international travel, working in a cardiology practice as an NP, super stressful, a lot of autonomy. My kids were young and I just assumed I was grumpy and fatigued because I wasn’t getting enough sleep, because I had too little people. And I really think it had a lot to do with the reduction in progesterone, which I didn’t realize until a few years later when I started having these crime scene periods. And I was offered the four options I just reiterated. But I have to say that women that have come before us that are trying to make us more aware of our bodies and to not settle for the status quo because our mom’s generation, I remember I was finishing up my NP program, my mom and all of her sisters were taken off of HRT.

Dr. Deb Matthews: Yeah.

Cynthia Thurlow: And my aunts have given me permission to talk about this, so I’m not disclosing anything they were uncomfortable with. But they said, “I hope your generation turns the tide because there are women needlessly suffering.” And I look at my mom as osteoporotic. She’s got some forgetfulness. She said to me, “I didn’t realize that intravaginal estrogen does not have systemic effects. So, I thought I was protected.” I had to ask her, to ask her MD for oral progesterone. And I said, at this point, I know it’s a little controversial because you’re in your 70s, but maybe having an estrogen patch might be helpful. You have to weigh the cost benefits. But I look at my mom’s generation as a generation of women that are suffering now because their HRT was taken away from them. 

Dr. Deb Matthews: Yeah. Somebody actually did a study way back in 2009, so the Women’s Health Initiative, the one that scared everybody, was published in 2002 and that’s when everybody went off their hormones. So, 2009 somebody did a study where they kind of crunched the numbers and they looked at how much osteoporosis, how many hip fractures, because you don’t usually die from a hip fracture, but it’s often like the first step in debilitating, you end up in a nursing home and etc. So, they looked at how many women died because they went off their hormone replacement therapy, and then it was only like 90,000. But it was way more than the estimated number of women who were going to get breast cancer from being on the synthetic form of the hormones, which was actually a very tiny number, but it just got all so overblown. And anyway, it wasn’t the estrogen, it was only the synthetic drug form of progesterone. And there’re lots of different drug forms of progesterone, different oral contraceptives have different ones, probably some are worse and some are better, but we haven’t really teased all that out to know. And clearly the bioidentical form is the one that has not been shown to increase the risk for breast cancer. So, it just seems like why would you want anything else besides the natural one? Just doesn’t really make sense.

Cynthia Thurlow: Exactly. I agree with you wholeheartedly. One thing I did want touch on because I got questions around this, when we’re talking about premature menopause. So average age in the United States is 51, but there are women that go through earlier and I know they are at greater risk for suffering side effects. I think the statistic I read was that 1% of women will go through menopause before the age of 40 and 5% will go through before the age of 45 that’s pretty significant when you think about it. And so, let’s at least touch on some of the things that impact premature ovarian failure as well as the greater risk for dementia because I think this is quite significant. I had many friends who went through infertility in their 40s and early in their 30s even and several of them were told they had premature ovarian failure and I don’t think their providers ever had a conversation to say, “Oh, by the way, it’s even more important for you to take hormone replacement therapy, because your risks for the sequelae of menopause are that much greater.”

Dr. Deb Matthews: Yeah. Well, more now than in the past when women have like– some women have to have a complete hysterectomy very young for cancer, whatever reasons. So, if somebody has to have a complete hysterectomy when they’re very young nowadays, it is the standard of care that we give some kind of hormone replacement therapy, at least up to the time when they naturally would have gone through menopause. Because we know that the more years you live your life without hormones, the greater dementia, osteoporosis and heart disease, and I would add wrinkles and pelvic floor dysfunction, so urinary tract infections and urinary leakage, and loss of muscle mass so that you become weak and frail. Like, there’re many, many factors, many, many changes that predictably happen when our hormone levels are low. And so, if a woman goes through menopause at a younger age, that means that there are going to be more years on the other side of menopause where she’s going to have to live her life without the protective benefits of the hormones.

And so eventually, there are higher risks of all of these things. And that is one of the reasons that for a long while it was the thing to just take women’s ovaries when went in for hysterectomies. So, whatever was wrong, you needed a hysterectomy, they would just take your ovaries too, because if you had enough babies already, they would just decide you didn’t need them anymore. But we’ve learned the hard way that there were just more complications long term and so that’s sort of fallen out of favor. So, for the most part now, women are being told if they do need a hysterectomy, if you don’t at least leave one ovary because of the benefits. So, absolutely, early menopause carries increased risks for long term diseases of aging. 

Cynthia Thurlow: Yeah. And it’s interesting, I think there was a person on TikTok, and I was listening to another podcast and they were talking about this, 27-year-old female who hadn’t had a menstrual cycle for two years. And the concern I had listening to that was if you’re a woman in your 40s, 50s, 60s, you’ve lived a long life with these hormones. And yes, as you transition into menopause, if you take HRT, you’re going to be more protected. But for the individuals that are younger in their 20s and 30s, for whatever reason, whether they’ve had an autoimmune condition, there’s some genetic susceptibility to think that it’s benign to not have a menstrual cycle could have potential catastrophic effects on all the body systems that you are alluded to. So, if you are listening to this podcast and you’re a younger person, please, please, please get this checked out. It is not benign. I just had a conversation with a colleague the other day. She had a woman in her 20s, hadn’t had a cycle for two years, was not anorexic, was concerned about it, and it turned out she had a latent autoimmune condition that was driving this. And so, she’s working with this endocrinologist to try to kind of reverse things. But she was saying two years of having subtherapeutic, suboptimal estrogen levels, progesterone levels, testosterone levels for that matter, can have a potential catastrophic impact on this young woman’s life.

Dr. Deb Matthews: Yeah. And I’ll tell you my story too is, I didn’t really hardly used to have periods at all and I was a teenager. I just thought that was great. Who wants to have a period? And then I got put on birth control pills and carried right along. And I still hardly ever had a period, but who wants to have a period? And then when I decided I wanted to start a family, I went off the birth control pills. And shocker of shockers, I didn’t have a period. And so now it was a problem because now I wanted to have babies. And so, when I went into the gynecologist to get checked out, they found out that I was hypothyroid. Well, I’d been having symptoms of hypothyroidism this whole time and that was probably the reason from the beginning. So, I just want to point out that hypothyroidism is a cause of menstrual irregularities and you can put somebody on birth control pills. And for me, the reason I hadn’t been having a period on the birth control pills was just the dose of the pill that they had given me wasn’t the right one for me. And I didn’t go complain about it because [ Cynthia laughs] I thought I was lucky, because I didn’t know better. But in any case, hypothyroidism is another cause of no periods and birth control pills are fixing the wrong problem.

Cynthia Thurlow: Yeah. It’s such an important point and I’m sorry that you went through that period of time not realizing that there was an underlying reason. What I oftentimes will see, and that was certainly the case with me, with thin phenotype PCOS, they put me on the pill. I had irregular periods. I stayed on the pill for a long time, came off when I got married, wasn’t ovulating, then went down that rabbit hole. And the first thing my GYN said was, “Wow, you’re not ovulating. You probably have thin phenotype PCOS.” And because you’re thin, no one ever suspected you had PCOS. So again, you don’t have to be obese, overweight, and diabetic to have PCOS. You can be a thinner person. So just some things to be thinking about.

Now, we’ve mentioned a couple of different kinds of hormone replacement therapy. We’ve talked a little bit about kind of alluded a little bit to synthetic and why they’re not ideal to the bioidentical options. And I think for a lot of individuals there are bioidentical options that are covered by insurance. It doesn’t all per se have to be compounded. I feel like maybe it’s the space that we exist in, but most people that I know are using compounded bioidentical hormones. But I would imagine there are just as many people that do fine with oral progesterone and estradiol patches and things like that. What is the differentiator for you clinically when you’re working with women to take them? If they’re using the insurance covered patches or they’re using oral progesterone, that is the differentiator for you that makes you think that maybe they need a compounded product? 

Dr. Deb Matthews: That’s a good question. And it gets really complicated because there are actually a lot of factors that go into how we do it. And the first thing that I think I would say to women who are listening and they’re trying to figure out what would be the best thing for them is to some degree you just have to trust your provider. And so, if your provider is really comfortable and confident in working with certain types of bioidentical hormones, I would go with that. Instead of coming in saying I heard so and so say that it needs to be patches or something different. Because all of us practitioners have our own experiences, etc. I think the big message is you need to make sure it’s bioidentical as opposed to synthetic. And a lot of practitioners don’t actually know which of their prescriptions are bioidentical because that term isn’t really used in the medical literature. 

So, a lot of practitioners, when we say bioidentical, they think compounded. And so, if you say I would like bioidentical hormones, they will say I don’t do that. And then they’ll turn around and write your prescription for an estrogen patch that is bioidentical they just didn’t know. So that’s one tricky part is the practitioners sometimes don’t speak the same language, but estrogen patches, as long as it’s just the estrogen in them, is bioidentical. And Prometrium or generic progesterone is bioidentical. And you can get it from your regular pharmacies. Now it’s immediate release, those progesterone capsules, they are in peanut oil. So, if people have peanut allergies, they can’t do that. From the compounding pharmacy we can get sustained release. We can sometimes use vaginal progesterone for women who have heavy bleeding because we can get it closer to the uterine lining. So occasionally, if heavy bleeding is part of the problem and the capsules don’t help, we’ve got other options. But I guess I would say I go person by person. 

I prefer the compounded progesterone capsules because they are sustained release over the immediate release one. Just because I find that for more women, they get better results. But if somebody’s getting really good results from the standard stuff, it’s okay. I really like patches a lot. I feel like they work well. For some women, we’re looking for convenience. Like it’s just too hard to remember all this stuff. And if we can put it all in one cream, it just makes their life so much easier. Sometimes we get better results with patches than with cream for certain women because it’s more sustained, whereas the cream, you have to apply it every day. Sometimes even some women do it twice a day. So, there’re a million different factors that go into personalizing a woman’s prescription.

And I think that’s really the whole point when I talk about somebody doing bioidentical hormones. Really what I mean is yes, the hormones we are using are bioidentical as opposed to synthetic. But that’s just the beginning. What I mean when I say, like, “I do bioidentical hormones is we’re taking a holistic approach at the whole person.” We’re taking all sorts of different factors into account. Your stress, your nutrition, your sleep, toxins in the environment, your gut health, your genetics, how your body metabolizes these hormones. We’re taking all of these things into account and based on all of those things, based on your symptoms, based on your preferences, your lifestyle, do you travel, are you scared of needles? We take all this– Do you have good health insurance? Do you need the cheapest option? Do you want the fastest results? We can come up with a personalized approach and that takes more than a 10-minute visit in and out with your practitioner. So that approach does not fit in our standard medical offices.

Cynthia Thurlow: No, it doesn’t and I think that’s actually one of the best explanations I’ve heard. So, thank you for that. Because I think for so many women, they’re struggling to advocate for themselves. They don’t know what they need to be asking for. I know for myself personally, I did the peanut oil progesterone and the difference between that and compounded for me was night and day. I mean, I jokingly say they will have to pry my progesterone out of my cold dark hands, because six days out of the week it is guaranteed I’m going to have a really good night of sleep. And it works really well for me. But I acknowledge for some people, if the generic works, I wouldn’t mess with it. I don’t think anyone should feel a sense of pressure or urgency that they have to do compounded options if they’re doing really well with alternatives. 

Now, when I’m thinking about testosterone and I know we kind of touched on this together when I saw you a few months ago, testosterone therapy. So, there’s no FDA-approved testosterone for women, so everything has to be prepared specifically for them, whether it’s a compounded cream, I’ve got some provider friends who are using it subcutaneously. You can use it in pellet therapy. Do you feel like testosterone is what we add when we’ve already optimized progesterone and estradiol or is this something that you’ll start frontline like what is your kind of– Again, we’re thinking 30,000 feet, you’re not providing medical advice. What are your thoughts around testosterone? 

Dr. Deb Matthews: I feel like testosterone is so important for women, and so I don’t hold back and use it as an only if necessary. If somebody was low in testosterone, I would absolutely advocate to normalize it because we have 10 times more testosterone than we do estrogen. It’s really important for women. And the reason that we don’t have FDA-approved treatments is because there’s no sort of diagnosis code for which testosterone has been FDA approved to treat. And so, what it would take would be for somebody to do a study which is going to cost, I don’t know, hundreds of millions of dollars. And they have to be able to show that women have one specific thing. It could be urinary incontinence, it could be whatever bone strength, whatever, one thing. Then we would have to do this hundreds of millions of dollars of study by giving all the women the exact same dose of testosterone, because that’s how our studies have to work. And we would have to show that there was a statistically significant improvement so that it could be FDA approved and we would get that. But doesn’t seem to be happening. 

Nobody wants to pony up because testosterone is already out there, it’s from nature. So, testosterone, though, is so important for women, it is so common in the perimenopausal time. So that’s the other hormone that I absolutely would measure if somebody is wondering if they’re in perimenopause and women just feel so much better, it is important for our physical body. So, it is important to maintain our muscle tone because otherwise we notice, like, we keep working out, but we’re just not getting the tone that we expect. It’s important for skin tone. So, without it, we get saggy and droopy. So, we notice the flabby here and the jowls here. It’s really important for sexual health. So, thinking about it in the first place, like having that idea pop into your brain, it’s important for arousal. It’s important for lubrication. So, estrogen helps to keep the vaginal lining moist so it doesn’t become thin and dry and easily tear and damaged. But testosterone is what gives us the lubrication. So, all vaginal dryness is not just estrogen. And that’s another super common thing. Women have vaginal dryness, sex hurts, all they’re going to ever be given from their gynecologist is an estrogen suppository of some ilk.

But if it’s low testosterone, the estrogen is not going to fix that problem. So, testosterone is really, really important for our sexual health, but it’s also so important for how we feel on the inside. This is what gives us confidence, self-esteem, motivation, get up and go, get things done, be efficient, assertiveness, self-confidence, decisiveness. And so, without it, we worry more. We second guess ourselves. We don’t feel so good about ourselves. We feel blah. We just feel flat. We don’t feel like doing things. We procrastinate. We can’t get motivated to go to the gym or to clean out our closets, or to bake the cupcakes for the kid’s party or whatever. And you’re not sick. This is not a disease. But you just know that you could feel better. And it just helps us to feel like ourselves again. And I’m just talking about normal. Just like men at– there’s young men at the gym that go way overboard with testosterone, ridiculous amounts. So, there’s limits to everything. There can be too much of a good thing too. And testosterone, all those hormones can have side effects. But progesterone is so wonderful as a calming hormone to help us sleep soundly, feel more calm, less irritated, so we’re not snapping the heads off our spouse and our kids. And testosterone is the mood stabilizer that gives us our get up and go. 

Cynthia Thurlow: I think it’s so important because I think that there’s this thought process that for women, it’s just about libido. And I love that you addressed some of these executive functioning things, the lack of motivation. I recall at one point, I was on estradiol and testosterone and it turned out I was on a little bit too much. And so, things were abruptly stopped. And I remember feeling like I didn’t even want to get out of bed, let alone get off the couch. And I acknowledged, I was like, “Okay, I’m going to intellectualize why this is occurring.” And I realized it’s because my testosterone was high. And then all of a sudden, my estrogen and testosterone were too low. And so, I said to myself, “somewhere in between is that happy medium.” But for anyone who’s listening and for many individuals thinking that it is solely about libido, it is not. There’s so much more to that vitality piece that I think you’re really alluding to. 

Now, one thing that you touched on but I think doesn’t get enough focus, probably because it’s not a particular sexy subject. This GSM, so genitourinary symptoms of menopause. Let’s talk about this, you mentioned already it’s this interplay between sex hormones. What is your standard methodology for working through this? Because there’s a wide range of options. It is not just about vaginal estradiol. There’s a whole lot more that can be helpful. But there were a lot of questions that came in specific to this. These are always the questions. I used to call it the handle, like my hand on the door and I was leaving the office, that a patient would work up the courage to talk about these things. And these are the types of questions that people are like, “I’m too embarrassed to ask my provider,” but and so I said, “No worries. We’ll ask them during this conversation.”

Dr. Deb Matthews: Yeah. Okay, so important that we’re talking about this because suffering with these symptoms is so unnecessary. We can fix this and the standard of care if you were to get up the nerve and tell your doctor, you’ve got dryness, sex is painful, maybe you’re leaking urine, you may get urinary tract infections. If things are not so good down there, the standard treatment is some kind of vaginal estrogen, which is fine. That can be helpful. And if that fixes all of your problems, wonderful. What I would say is a lot of the standard compounds have parabens in them. They’re not the cleanest forms, but whatever. However, that is not the be all and end all and there is so much more. So, if it’s not fixing everything for you, just know that there is so much more to be done. So, estrogen is important to keep the tissues of the vagina plump and juicy. I mean, it’s not supposed to be dry and thin and friable is the medical word meaning like, can easily tear is what I mean. But testosterone is also really, really important for this lubrication and tissue elasticity. So, both of them are important.

DHEA is another hormone we haven’t talked about. It’s from the adrenal glands. It’s anti-aging hormone. It also can be used by postmenopausal women’s bodies to make estrogen and testosterone. It can be helpful. But the first step for me, if somebody were coming in to complain about this, is I would give them hormones in order to restore hormone normalcy. Now, not all doctors will do that because the standard of care in medicine at this point is if you are more than 10 years out from menopause, then we’re too scared to give you hormone replacement therapy because we’re afraid it’s going to increase your risk for a heart attack. So, I don’t know how far down that road you want to go, but for me, if a woman is complaining of these kinds of symptoms, I would give her hormones and especially I would give it to her to apply. Usually what we do is we have cream applied topically to the labia. So, it’s just a very tiny amount of cream because a lot of women don’t love the vaginal creams that you get from the gynecologist. It’s often a lot of cream. And so, you squirt the cream up there and then it starts squirting back out again and leaking in your underwear and it’s kind of messy and a lot of women just don’t care for it. But here we just use a very tiny amount of cream. You just apply it to the outer part of the vagina. 

One of our friends, Dr. Anna Cabeca, she talks about clitoris to anus. It’s all like really great real estate. That’s how she says it. But it soaks in really well through that mucous membrane tissue and it can get to work. So having adequate hormones is a really important step in getting rid of these symptoms. And if it is not enough, there is more. So other things that we do to help is we use PRP therapy, which is platelet rich plasma. That’s where we draw your blood, we separate out the growth factors and then we do little tiny injections in the pelvic floor to activate stem cells, which are your own cells of youth and rejuvenation that live in your body. We activate these stem cells to grow more collagen fibers and nerve endings and blood vessels. So, we are rejuvenating the tissues to make them younger. And that helps a lot for painful intercourse, for lubrication, for stress incontinence. And the earlier we do this, the smaller the problem, the easier it is to fix. So instead of waiting, sometimes stress incontinence, that means you leak a little bit of urine if you jump or sneeze or you’re jumping on a trampoline or you go for a jog, like a lot of women at CrossFit will go empty their bladder before they start because you just know it’s coming. 

So, if it’s a minor problem like that, we can do a really good job on it. If you wait and wait, it’s only going to get worse over time and eventually it gets to be a harder problem to treat. And then what’s left is surgery. But so urinary incontinence and lubrication, it works really nicely. And there’s more, we have laser therapies. So, there are different kinds of lasers that can be used inside the vagina, which help with lubrication, they help with stress incontinence, they can actually tone and tighten for more sensitivity. All of these treatments, the hormones, the PRP, the laser, they can all improve orgasm response. So, you don’t have to have a problem to get these treatments done if you want them. But the bottom line and there’s acoustic wave therapy, so there’s something that we use a lot for men for erectile dysfunction. It’s these sound waves that cause little– I don’t know, it almost feels like a little elastic band thwacking you, so it’s not particularly painful. But the little sound waves cause microdamage in your tissues. And as your body is repairing from that little microdamage, it’s just rejuvenating things. So, the same thing helps with urinary tract infections, helps with lubrication, helps with orgasms. So, there is no need.

There are so many things out there that can help, but generally speaking, these therapies that I’m talking about are not covered by health insurance, so they’re not offered at your regular doctor’s office. They probably are only vaguely familiar that they even exist. And even the testosterone, as you said, there is no FDA-approved testosterone for women. And so, we either have to get it from the compounding pharmacy, which a lot of practitioners aren’t comfortable recommending a compounding pharmacy. They’ve never written a prescription to a compounding pharmacy before. They don’t even know where to start. They don’t know how to do it. They were not taught. There is a gynecologist in town. What she does is she uses the men’s testosterone. So, it’s packets, and for a man, they’re supposed to use the whole packet every day. Well, men need 10 times more testosterone than women, so what she tells women to do is use one pea-sized amount, which is approximately 1/10th of the packet, which seems incredibly not very vague to me, like probably one day you get more, one day you get less–

Cynthia Thurlow: Right.

Dr. Deb Matthews: –exact. But any case, those are the choices, and so those don’t seem like great choices to your regular doctor, and so all they’re left with is the vaginal estrogen. 

Cynthia Thurlow: Oh, there’s so much more to this. What are your thoughts on vFit and Joylux? These are two devices that are used intravaginally that I have friends that swear they’re like life changing. Do you have any thoughts on those? 

Dr. Deb Matthews: Well. So, energy medicine, the idea that wavelengths of whether it’s light or frequencies or whatever is sort of this whole new frontier. And when I say new, I just mean new to us conventionally trained practitioners. That totally has not made it to kind of mainstream medicine yet. But red light therapy has been used for a lot of things. We use it for hair growth on the head. We can use it for neuropathy, for people who have nerve damage, like from diabetes. So, it certainly can be helpful. And these things are all non– you know you have to pay for them because they’re not covered by insurance. But there’s very minimal to no risk of harm as compared to going in and having a bladder sling surgery in order to prevent your urinary tract leakage. 

Cynthia Thurlow: Yeah. It’s really interesting to me how many things are available and to your point. The traditional allopathic trained providers are probably not utilizing these. And this is where working with a functional or integrative medicine provider can really make a big difference. Dr. Deb, I’m definitely going to have to bring you back because I have so many other avenues, we could kind of dive down. Let’s touch on cognitive decline in menopause. I think we’ll wrap up the conversation around this. I think most if not all women are genuinely concerned about this. They don’t want to deal with what we used to call senile dementia. They understand the Alzheimer’s rates really increase after women go through into menopause. And there was a study from the center for Innovation and Brain Science that shows that women who took transdermal bioidentical estrogen and progesterone were 73% less likely to get dementia and other brain degenerating diseases. I jokingly say the book The XX Brain by Dr. Lisa Mosconi changed the trajectory of my mindset around this but I definitely look at my husband and my kids and I’m like, “I don’t want to be a burden to them it’s really important to me that I remain cognitively sharp.” Let’s talk about some of the changes that are occurring in women’s brains as they’re getting older. 

Dr. Deb Matthews: Yeah. Well, estrogen is so nourishing to our brain, and progesterone and testosterone, all of these hormones are really nourishing to our brain. And as our brain becomes deficient in hormones just like the rest of us, we can see what happens to our skin. Our skin gets thinner, it gets drier, we can see wrinkles well, our bones are getting thinner and whittling down, our muscles are getting thinner. Our brain is shrinking. We just can’t see it. But our brain is physically changing and estrogen and these other hormones nourish the brain in order to keep it more youthful. And just like the hormones minimize the bone loss, they minimize our brain loss. And memory changes are something that’s so scary to all of us and so common. One of the most common things that I hear women complain about when they come in is word finding. Like, they’ll say, “I just can’t get my thoughts right. Like, I know the word that I want to say, but it’s right on the tip of my tongue, and I just can’t find it.” And especially if they have a family history of dementia, you cannot help but worry that this is the first sign of early onset dementia. 

I have a personal story here too, that about a year and a half ago, I was starting to have a ton of night sweats, and my husband was so annoyed by me at night, [Cynthia laughs] I was waking him up, and he said, like, “Listen, you got to go do something about this. This is not working for me.” And so, I had been watching my estrogen and I knew that it was going down. So, I got myself started on some estrogen replacement and within about three nights, I was sleeping through the night. Like, I expected that. I knew that that was– estrogen is really important for sleep. But what I hadn’t fully expected is how my brain turned back on.

Because a lot of times what would happen in my office is my team would come to me when I’m kind of finished seeing patients around 3 o’clock at the end of the day. And then they pepper me with all these questions that they’ve saved up for me, and I would listen to them. And what I found myself saying was, “I’m hearing what you’re telling me, but nothing is happening between my ears. Come back and tell me tomorrow, and I’ll try tomorrow.” And when I got back on estrogen now, my brain could work and I could answer the question. It was, like, dramatic. And a few months later, I heard myself say that to one of my team members. I said, “I hear what you’re saying, but nothing’s going on in between my ears.” And I thought, “Oh, I haven’t said that for a long time.” And I thought, “Damn, I forgot to pick up my prescription, and I’d been off [Cynthia laughs] my estrogen for six days at that point.” 

Like, estrogen plays a really big role. We know this for decades. We have known that estrogen helps minimize the chance of dementia. The problem is, in that darn Women’s Health Initiative study, when we gave women those synthetic pills that we know increase the risk for blood clots, they were having dementia that was starting very quickly and that’s not how dementia works. And so, we hypothesize that these pills were causing maybe little microscopic blood clots not necessarily enough to be called a stroke, but bad enough that it was messing up women’s memory. And so all of a sudden, the narrative 100% changed, instead of estrogen is good for your brain, hormone replacement therapy does not protect your risk for dementia and maybe even increases your chance for dementia. So technically, we’re not supposed to tell women that estrogen can protect them from dementia with that study that you mentioned notwithstanding. 

There are many, many studies that show the benefits of estrogen on the brain, but it has still fallen out of favor in medicine and that’s very frustrating. But we definitely have the preponderance of evidence to show us it’s beneficial. And this is an American problem too, we should say. Many other countries, especially countries in Europe that have socialized medicine. So, like the Scandinavian countries, even in the UK, they know that hormone replacement therapy helps women live longer, have less chronic disease, be healthier, have better quality of life. Therefore, it costs them less to take care of these women when they’re elderly. And so, they give women hormone replacement therapy. It is free and it is bioidentical. So, if you move to England, you can get free bioidentical hormone replacement therapy because they know they’re going to keep you healthier and then they don’t have to pay for your nursing home and your Depends when you’re 85. So, this is an American thing that we don’t do that you know.

Cynthia Thurlow: Really so interesting that the power of the N of 1, the recognition that the lowered estrogen levels were impacting your cognition and also your sleep so significant and then you felt so much better so quickly, I think really speaks to this. It’s interesting when I was doing research for today, I was talking about hot flashes correlate with memory performance. And I know that the patients that were trending, CGMs and glucometers on, the ones that report the most issues related to hot flashes and vasomotor symptoms are also the people struggling the most with blood sugar dysregulation. So, there’s absolutely this degree of propensity related to sex hormones, but then also blood sugar control. And we know we become less insulin sensitive as we are kind of navigating this transition into menopause.

The other thing that I thought was interesting, we’re coming off of three years and massive amounts of stress that high cortisol, which is this not a bad hormone but gets a bad rap. High cortisol is connected to brain atrophy, reduced brain weight, lowered resilience and how important it is. You mentioned estrogen but progesterone also has this protective effect on nerve cells and blood flow. And so, if I want to continue making the argument of why I think we should be having these conversations with our patients so that they’re fully informed about their decision making and cognition, I think for all of us is something we’re all endeavoring to improve upon as we get older.

Dr. Deb Matthews: Yeah. And it’s scary and it’s one of those things that creeps up on us very gradually. So, it’s something that we need to be thinking about now. Like don’t wait until you have the problem because we don’t really have treatments that are particularly helpful once you already have cognitive decline. And that’s not entirely true. There are lots of things that we can do to help that your mainstream doctor can’t write– There’s no prescription that’s really going to fix it. In functional medicine, there’re lots of things that we can do, but the earlier you are looking after yourself, the better. 

Cynthia Thurlow: Absolutely. Well, Dr. Deb, I would love to bring you back and talk about cardiovascular disease and cancer risks and weight loss resistance. There were so many questions from my community. Hopefully, I will be able to convince you to come back on. Please let my listeners know how to connect with you. If they live in your state, how to work with you as a practitioner and where to find you on social media. 

Dr. Deb Matthews: Sure. So I am in Charlotte, North Carolina and we have people fly in to have their initial evaluation. Sometimes we do an initial evaluation over telehealth and then have you actually come in to get your lab results and get your recommendations. But we do need people to come in person to see us in North Carolina. The practice is called Signature Wellness and the website is signaturewellness.org. I am @drdebmatthew on social media and I have a book too. Can I tell them about that? 

Cynthia Thurlow: Absolutely, absolutely.

Dr. Deb Matthews: So, I wrote a book specifically to try to help women understand whether the symptoms are having could be, due to a hormone imbalance. Because that’s the first step. Like is it even your hormones in the first place? The book is called This Is NOT Normal!: A Busy Woman’s Guide to Symptoms of Hormone Imbalance. And it talks about the different– there’s all these little quizzes so you can figure out if is it high cortisol, low testosterone or whatever. There’re some tips for how you can start getting yourself to feel better. There’s more information about that Women’s Health Initiative study and kind of how to talk to your doctor. And there are some resources for where you can go to find a doctor where you live who may be able to help you if your own doctor isn’t the right person. The book is available on Amazon, but you can download a free copy at isityourhormones.com.

Cynthia Thurlow: I love it. Thank you so much for your time today. It’s been invaluable. 

Dr. Deb Matthews: Thank you. 

Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.