Ep. 356 Menopause, Heart Health and HRT with Dr. Felice Gersh

I am delighted to reconnect with Dr. Felice Gersh today for our fourth discussion. 

Dr. Gersh is a globally recognized expert on women’s hormones. As the Medical Director of the Integrative Medical Group of Irvine, she often collaborates with numerous research organizations. 

In our discussion today, we dive into cardiovascular disease risks and menopause, highlighting the metabolic transition that menopause represents and exploring risk factors like preeclampsia, gestational diabetes, and PCOS. We get into the use of oral contraceptives, particularly before the age of 20, early puberty, and premature ovarian failure, while examining the role of the RAS system, synthetic hormones, and the differences between estrone and estradiol. We discuss the optimal timing for starting hormone replacement therapy and explain why we should love our menstrual cycles, addressing the risks related to circadian rhythm disruption. We also look at arterial changes, cholesterol dynamics, the autonomic nervous system, gut health and cardiac wellness in menopause, and proactive ways to support our bodies. 

I am confident you will find today’s conversation with Dr. Felice Gersh most enlightening and informative.

“Why would we treat menopause differently? It is naturally the end of metabolic wellness in the female. So it is just a hormone insufficiency state when you are perimenopause and a true deficiency state when you are in menopause.”

– Dr. Felice Gersh

IN THIS EPISODE YOU WILL LEARN

• Why women need to understand basic female physiology 
• How pregnancy-induced insulin resistance and leaky gut can lead to cardiovascular issues later in life
• Dr. Gersh highlights the importance of metabolic health in pregnancy and menopause
• Why it is risky for young women to use oral contraceptives
• What irregular bleeding in perimenopausal women might indicate
• Why the inflammatory response is critical for survival, even though it may become problematic if not properly regulated
• How estrogen is a family of hormones, not a single hormone
• How estradiol differs from estrone
• Why should menopause be treated like any other hormone deficiency state?
• The optimal time for hormone replacement therapy
• Why post-menopausal women are more susceptible to heart attacks than men

Connect with Cynthia Thurlow

• Follow on Twitter
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• Submit your questions to support@cynthiathurlow.com

Connect with Dr. Felice Gersh

• On her website: Integrative Medical Group of Irvine
• Instagram

All of Dr. Gersh’s books are available on Amazon

Ep. 297 Dr. Felice Gersh: Estrogen, Immunity & Menopause Mysteries

Ep. 237 Perimenopause and Menopause: What You Didn’t Know with Dr. Felice Gersh

Ep. 221 Part 1- An Integrative Approach to PCOS and Menstrual Irregularities with Dr. Felice Gersh

Transcript

Cynthia Thurlow: [00:00:02] 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. 

[00:00:30] Today, I had the honor of reconnecting with Dr. Felice Gersh. This is our fourth conversation together. She’s a globally recognized expert on women’s hormones and frequently collaborates with numerous research organizations and is the Medical Director of the Integrative Medical Group of Irvine.

[00:00:46] Today, we spoke at great length about cardiovascular disease risks in menopause, how menopause is the metabolic transition, risk factors for cardiovascular complications, inclusive of preeclampsia, gestational diabetes, PCOS, use of oral contraceptives, especially before the age of 20, early puberty and premature ovarian failure, the role of the RAS system, synthetic hormones, differentiators between estrone and estradiol, timing of starting hormone replacement therapy, why we should love our menstrual cycles, risks of circadian rhythm disruption, and extensive conversations surrounding changes in our arteries, cholesterol, autonomic nervous system, gut and heart in menopause and the things that we can do proactively to support our bodies. I know you will love this conversation as much as I did recording it.

[00:01:53] Let’s jump right in, because this is the number one killer of women. There’s one death for women every 80 seconds from cardiovascular disease. There’s not enough focus and attention on this, especially in this very special time in our lives in menopause, when we’re no longer fertile, but this loss of estrogen, unless it’s being replaced, has profound catastrophic impact on our health. So, from your clinical experience, when you’re talking to women that are in perimenopause, navigating that transition into menopause, I’m sure that cardiovascular risk probably comes into the conversation because you’re such a diligent and thoughtful provider. But I thought it would be interesting for listeners to fully understand and appreciate how much estrogen impacts immune function, inflammatory response, healing in the body, etc. 

Dr. Felice Gersh: [00:02:41] Well, that is for sure in every single aspect of the cardiovascular system, and you mentioned a whole bunch of them right then, is heavily, I mean, incredibly impacted by female hormones. And it is so poorly acknowledged that is the case. And it’s really very simple when you think about why that would be. It really comes down to survival of the species and reproductive success. So, once you acknowledge whether you want to have babies. I keep thinking I’m like the ultimate feminist, [Cynthia laughs] I totally want women to control their reproductive destiny, have babies when and if they want them. But whether you want them or not, you need to understand basic physiology of the female 101, which is the female body evolved for the purpose of reproductive success in a human, that means being able to be fertile, to get pregnant and carry the pregnancy to term without complications for mother or for the fetus, and then to be able to nurse that baby for at least a couple of years, going back to early times, and then be able to survive to raise that child and several others, to do this repetitively, to raise at least a couple of children, to survive to their own sexual maturity.

[00:04:09] And so, to that end, you need to have robust, healthy organ systems of every type. And for sure, the cardiovascular system is critical. When you just recognize even one little fact, which is that the placenta has to have incredible vascularity and blood flow, and the ability to deliver all the nutrients and oxygen, you need to be able to pump at least 50% more blood volume around the body of when you’re pregnant, so you have to have a very energetic heart, and that is not really well understood even by cardiologists. And you need to have a vascular system that can be able to improve its state of being in order to create new blood vessels, angiogenesis, so that you can perfuse all the areas of the body on a growing uterus. And it’s so amazing, the whole state of pregnancy and how involved the cardiovascular system has to be. And then you end up having the master hormone estradiol, and that has to be coordinating all the organ systems to work together to keep that pregnant woman and the fertile woman healthy and going for many years. 

[00:05:19] So nature, though, has sort of an end stop time, and that’s called the menopausal transition, when fertility declines and then is gone, and our beautiful life hormones from the ovary, and though we have the top of the heap is the estradiol, and then it’s sidekick, progesterone. And testosterone is a separate issue, because that’s really more of that is produced directly or indirectly by the adrenal gland, so that’s a topic for another day. But when you lose those vital life hormones and your fertility goes away, it’s really important for every woman to realize this is a huge metabolic transition, and not for the better. No matter how healthy a woman is, no matter how hard she tries to do everything right with her lifestyle, she cannot spontaneously get healthier because she goes through menopause, because those vital life hormones are sustaining every organ system, and especially the cardiovascular system, which is the highway of the body, producing the ability to supply every organ system with oxygen and nutrients and for the immune system to circulate and then be able to help deal with injuries, trauma, dead cells, infections, and so on. And of course, to perfuse that vital organ, the brain, and to take the impurities away and maintain a healthy blood brain barrier so you don’t have what we call like leaky brain and so on, so it’s just an incredible loss of metabolic homeostasis. 

[00:06:56] And when you go detail by detail, which we can do, looking at the specifics of what does estradiol do in the various parts and so on of the cardiovascular system, it is shocking. Like we were chatting before we started about how so many women and their medical providers don’t realize this huge shift in the ability of the body to optimize everything, including the cardiovascular system with the transition into menopause. 

Cynthia Thurlow: [00:07:28] What are some of the risk factors when you’re doing a history, maybe you have a new patient, someone comes to you, what are some of the harbingers of concern for you in terms of cardiovascular disease risk in younger women as they make that transition? Because I recently interviewed Dr. Tom Dayspring, and he was kind of identifying, these are things that I will lean into if a young woman mentioned she has a history of preeclampsia or gestational diabetes, things that will put people at greater risk for developing vascular issues as they get older. 

Dr. Felice Gersh: [00:08:01] Well, we’ll go into that in a moment. And just to say, as an Ob/Gyn, I delivered thousands of babies. This was so evident to me, like decades ago, but this is only now just coming out as, “Oh, risk factors, including pregnancy-related complications.” It’s like, where have you been guys? [Cynthia laughs] Like you obviously ignored everything involving obstetrics because this was so evident. And it’s like giant duh. So, the biggest stress test of a female is pregnancy. 

[00:08:31] Now, everyone knows a stress test. You get on the treadmill, you have a stress echo, and you put the body under some stress, like, you make them run or you inject something that creates a stress, and then you see the response of the heart, and you see if there are issues and there are, like I said, when you are pregnant, you have to pump at least 50% more blood. It is a huge stress on the heart. If you don’t have a healthy cardiovascular system, then you are going to fail your stress test of pregnancy. 

[00:09:02] And basically, when you are pregnant, you become mildly insulin resistant. And there’s a purpose to that. When you are pregnant, you develop almost immediately leaky gut. Now we say, “Oh, my God. How can you get leaky gut?” It’s because it’s a mechanism. That’s why only really healthy people should be pregnant, and that’s why only young people are supposed to be pregnant. And the older you are, the higher risk you are. I mean, we’ve known that in obstetrics forever, a pregnant 40-year-old has a much higher risk potential than a healthy 25-year-old. 

[00:09:36] So, when you look at what is happening in a pregnancy, like with insulin resistance, like you mentioned, gestational diabetes, well, how do you get fat quickly if you’re pregnant in ancient times, when there wasn’t food at every corner? Well, the way that it happened is nature would make you mildly insulin resistant, and what does that mean? It means that the insulin you’re producing is less effective, so you’re going to then have your pancreas make more of the insulin. So, insulin is the hormone that really encourages the production and storage of fat, that’s why pregnant women can eat very little more, sometimes not eat more at all, and they still gain weight because of this inherent insulin resistant status, which is created by a leaky gut. That’s why, when you’re not pregnant, you don’t want to have leaky gut, among many other reasons, so you end up having higher glucose levels in your blood, and you’ll have higher insulin. And the higher glucose in the blood is necessary because it passes through the placenta into the baby, so that you can grow that baby in a relatively short amount of time to get a healthy baby, so you have this amazing system. 

[00:10:50] But everything is, like, on thin ice in pregnancy. If you don’t have good metabolic health going in, then that mild state of insulin resistance turns into full blown gestational diabetes, that’s why gestational diabetes is a thing, and women could have no sign of diabetes prior to pregnancy, and then it seems to, like, resolve afterwards. But that underlying metabolic, we’ll say, sort of dark clouds hanging over that woman, they’re still there, and then what happens, they’re being okay, as long as they have their ovarian function. That magical hormone, estradiol, which optimizes glucose transport, it helps maintain proper insulin function. It’s just the metabolic homeostasis hormone, so when you lose that, you lose that one thing that was keeping you on track and that’s why, when you go through the menopausal transition women who previously had gestational diabetes have enormously higher risk of developing regular, garden variety, unfortunately, very unhealthy type 2 diabetes. 

[00:12:04] What about like preeclampsia or gestational hypertension? Well, if you do not have the healthiest state of metabolic health going into pregnancy, when you’re pregnant, you have to then create all these new blood vessels, and you have all these dynamics happening with the placenta, and you have to be able to deal with all of that. If you have any borderline state of metabolic health, then you may have problems with gestational hypertension and preeclampsia, which is really heavily a vascular disease. And then, once again, when you lose your estradiol with the onset of menopausal transition, and then thereafter, you will have a much higher potential to develop hypertension. 

[00:12:52] And in fact, even without that history, by age 65, as a general statement, 75% of women will develop hypertension, or at least they’re on the track for pre-hypertension, which is a thing now recognizing that’s like the early stages like pre-diabetes to diabetes, but these so called pre conditions are not, like, okay status, they’re actually bad status. Things are really happening that are harmful. So, we can then use pregnancy as sort of a bellwether of what will happen later in terms of that sort of those problems. But what else? In addition to pregnancy, there is irregular cycles. So, we now know that women who’ve had any history of infertility, any kind of infertility, and if they’ve had irregular cycles, then they also. And of course, the poster child for that is of course polycystic ovary syndrome, they will have a much higher risk of having these metabolic dysfunctions as a transition into menopause.

[00:14:00] So, basically, in now the gynecological world, it is acknowledged, although not necessarily actually acknowledged in a sense that you do something about it. It’s written that fertility is a vital sign. Now, what’s a vital sign? Like your blood pressure, your pulse, your temperature, so fertility is a vital sign. If you are of the reproductive age and you’re a female and you are infertile, even if you’re not trying to get pregnant, you have all the signs of being infertile, like no periods, irregular periods, then that is a big, bright light, red light going off saying, “This individual has metabolic dysfunction.” That’s why it drives me crazy if you just treat them with birth control pills, it’s like a cover up. And that’s another risk factor that is totally under acknowledged.

[00:14:54] Young women and the data only goes to teenagers, like anyone under the age of 20. And that doesn’t mean if you’re 21, it’s okay, it just means we have no data. And what am I talking about? I’m talking about use of oral contraceptives or similars, that women who are started on them prior to the age of 20 have an increased lifetime risk of cardiovascular events. That’s like a big deal because now it is considered in the conventional medical world, okay, to start any girl, and these are girls, any girl on oral contraceptives, as long as you are one year out from her first period, that’s it. And we have girls who are starting their periods way too young, like they could be nine, they could be 10, that’s how you could have the case of a 10-year-old getting raped and getting pregnant. It’s like who could get pregnant when you’re 10 years old, they’re starting their periods at age nine, that’s another thing we’ll mention as a risk factor. 

[00:15:56] Early onset of puberty is another risk factor for cardiovascular death or events later on when you lose your hormones, because that is not a good thing to start your period so early. But for girls who do start their period early or whatever the age it is, once they’re out 12 months from their first period, if they have acne, if they have irregular cycles, if they have cramps. By the way in terms of cycle problems, it’s not just irregular, it’s like PMS, it’s like really heavy, it’s like really painful, those are all in the category of abnormal cycles in some form or fashion. So, any girl who is in that category or sometimes they just say, “I don’t want a period,” so, the mom doesn’t know, she doesn’t know. She says, “Okay, put my 13-year-old daughter on birth control pills,” because she thinks, well, it’s regulating their periods, and this way if they’re in sports, they don’t have their period when they’re in competition. I mean where they’re liking that concept, but unfortunately, you’re affecting basic metabolic functions in a way that is harmful, whether we like it or not, you just have to tell the truth about that, so if you’re started on these oral contraceptives or similars, patches, rings, and you started at young ages, it actually has an impact on cardiovascular risk for the rest of that person’s life. 

[00:17:12] And like I said, it’s not that if you start when you’re 20 or 21 or 22, you know that there’s no risk. We just have no data. And the reason we have no data is because 90% of American females are on some form of hormonal contraceptives by the time they get into their 20s, so there’s no control group, how do you– Who are you comparing against? They’re all in that category, so that makes it almost impossible to then backtrack and see, well, is there an increased risk? It’s like everybody, so it doesn’t look like there’s an increased risk, but it’s a problem because as you mentioned just at the get go, cardiovascular events, heart attacks, strokes are the number one killer of women out doing virtually everything else combined, that’s like how big a deal it is. 

[00:18:03] And it would be okay if you said, “Well, look, everyone has to die. If you die of a heart attack [Cynthia laughs] in your sleep when you’re 100, that’s okay.” But we’re talking that a very significant percentage are younger women and often in their prime, and if you have any of these precursor risk factors, everything kind of gets bumped up by a decade. 

[00:18:26] Another risk factor that doesn’t really get its fair share of attention is early onset of menopause, that is a big deal. And it’s so shocking when you think, well, if you start your menopause at an early age. And if we look at what menopause categories are, so normal is considered 45 to 55, so that’s a whole decade right there that’s considered normal. And the definition of menopause, which is totally arbitrary, is 12 consecutive months without any vaginal bleeding. And I say vaginal bleeding because if you go nine months and you have no bleeding, and suddenly you start spotting or bleeding, the last thing as an OB/GYN that I would assume is that after nine months you spontaneously ovulated. I would call that abnormal bleeding until proven otherwise. So, I mean, we don’t know what that is. We don’t know what that bleeding means. 

[00:19:14] And in fact, when they talk about late onset of menopause as a risk factor, it’s like, “Hey, you guys, that’s because you have a crazy definition of menopause.” You’re saying any bleeding counts as a– Like start from square once again like if you go nine months and then you start having spotting, that means the clock starts over again. So, and then you wait another nine months and then you have some more little bleeding and the clock starts over again. So, they say, “Well, if you have late onset of menopause, that’s a risk factor,” but that’s because these women aren’t actually ovulating. These are not normal cycles. This is dysfunctional uterine bleeding or it could be even worse. It could be endometrial hyperplasia, adenomatous, or precancerous, or even endometrial adenocarcinoma, we don’t know what that bleeding is if you don’t investigate it. But that’s not like you’re still ovulating, but they call that late menopause, that’s not late menopause that’s ongoing abnormal bleeding that’s going on for years, and it needs to be [chuckles] evaluated and needs to be addressed, but they’ll put that into that category, that’s why that is nonsense. If a woman has normal cycles and she has a later onset of menopause, that’s a good thing. Not if she has random bleeding going on sporadically for years. 

[00:20:30] So, the normal menopause is supposedly 45 to 55, and that’s when you actually have no more periods. So late menopause is over 55, early is 40, right up to 45, and premature is prior to 40. The earlier you lose your ovarian function, the worse off you are [chuckles] and that is proven without a shadow of a doubt. These are life giving supporting hormones, and so it is a risk factor for earlier onset of every cardiometabolic. So, we put that together, cardiometabolic. So, metabolic would be things like obesity and diabetes and all the unbelievable risk factors that come along, like kidney disease and so on, that are part and parcel of diabetes. And it’s when you actually break it down. Well, like, what does estradiol do? Like we talked about cholesterol. Well, it has a huge role in the liver production of cholesterol, where 90% of the cholesterol circulating in the body comes from liver-produced cholesterol, only 10% is from diet. And then if we look at the liver and the production of cholesterol and the recycling of cholesterol, all of that is under the control of estradiol. 

[00:21:50] And then if you look at just every aspect of vascular health, everything, all under control. And I had a paper published about not even a year and a half ago that was in Mayo Clinic proceedings on the renin-angiotensin aldosterone system, which most doctors, even cardiologists think it’s evil. [chuckles] [Cynthia laughs] They think down with that system, like it gives you high blood pressure, and we have a lot of pharmaceuticals that are addressed at modulating that system. You may have heard of some of them like ACE inhibitors and the ARBs, the angiotensin receptor blocker drugs. So, these are things like lisinopril is an ACE inhibitor and losartan is an ARB, so these are really common drugs, and they’re modulating this RAS system, the renin-angiotensin aldosterone system. 

[00:22:39] Well, estradiol is the master regulator of this system. And this system has two branches, anti and a pro-inflammatory branch each. And without estradiol, it defaults into the pro-inflammatory branch, and that causes vasoconstriction, because it’s a life-saving system that’s really designed to modulate how the body responds to a stress, like an infection trying to take hold in you or an injury from trauma. 

[00:23:17] And if you just think about it, if you are in an injury situation and you have a big laceration, your body is going to want to constrict your arteries so that you don’t develop hypovolemic shock, you want to maintain your blood pressure so you don’t die from shock, and then you’re going to want to clot because you want to stop that bleeding, so you’re going to aggregate your platelets and activate them to create clotting and then you’re going to want to activate your immune system, because you don’t want infection bacteria to come into that wound, so you’re going to activate your immune system to go and run to the scene of the injury to start exploding with their inflammatory cytokines to kill any invading pathogens that are trying to get in, and then that’s like the pro-inflammatory stage.

[00:24:08] When you don’t have enough estradiol, you stay in that situation, so you have vasoconstriction, and your platelets are in a more pro-clotting situation, and your immune cells are in an active pro-inflammatory state of creating inflammation, even when there is no invading pathogen and there is no damaged tissue that needs to be addressed. And then the estradiol not only institutes that inflammation, but it also goes into the off switch so that you go into the healing resolution, so you have growth factors, healing factors, you can create new blood vessels, new tissue, all of that is under the control of estradiol. 

[00:24:50] And in the normal state, when you’re not injured, when you don’t have a pathogen trying to invade you, you are in the calm anti-inflammatory rest system, where the blood vessels are dilated and you don’t have constriction, so you don’t have high blood pressure, your platelets are not activated, you don’t spontaneously clot, you don’t have activated immune cells, so they’re not creating the inflammatory response anywhere in the body, and you’re healing and maintaining all of your tissues because you’re in that sort of maintenance state where everything is kind of being surveilled and maintained in a good calm state. 

[00:25:28] So, it gets so confusing even to doctors because they don’t understand that in order for this system, this RAS system which is so critical for survival to be properly modulated and not be in the default pro-inflammatory state in that whole pathway, you need to have estradiol, and they get mixed up, because when women go on birth control pills, for example or they’re given, like in the women’s health initiative, conjugated equine estrogens that are given orally, those types of estrogens are different from estradiol. 

[00:26:04] Well, the birth control pill, estrogen, Ethinylestradiol is technically an endocrine disruptor or a xenoestrogen. And the conjugated equine estrogens when given orally contains a whole array of different things that you would never even have in a human body, but both of them primarily will turn into estrone, which is a different type of estrogen. So, it’s important to understand that estrogen is not a hormone, it’s a family of hormones. And just like B vitamins, there’s not a B vitamin, there’s a vitamin that has a big letter B and then a number and then a word that goes with it, like B1 is thiamine, B12 is cobalamin. 

[00:26:44] Well, estrogen has a big letter E and then a one, a two or a three, there’s a four, but that’s a fetal estrogen, we won’t go there. And the two, E2 is estradiol, that’s the one that the ovaries make. E3 is estriol, that’s the dominant one of pregnancy that the placenta makes, which creates a whole different scenario of your immune system and leaky gut. You don’t want to try to recreate pregnancy in a nonpregnant woman, not that you could anyway, but that is never our goal, that’s nonsensical. And E1 is estrone, which is in balance with estradiol in a normal healthy reproductive female as the body needs it. 

[00:27:24] But those other estrogens, like from the WOMEN’S HEALTH INITIATIVE and in birth control pills, they turn primarily into estrone. Estrone acts on one receptor, and estradiol works on all the receptors for estrogen, and in a balanced way. And if you think of it in sort of simplistic terms, E1 operates the receptor that is on immune cells called innate immune cells. They’re the primary first responders if you have an injury or an infection. So, you’re like turning on the switch for the immune system to be in an activated pro-inflammatory state when you have predominantly E1 in the body and that is a problem. [chuckles] And that also is the estrogen that is made in fat tissue under an inflammatory state, which is what happens to women after menopause, because they go into that pro-inflammatory state, which some clever person termed inflammaging, but it’s only that pro-inflammatory state because you don’t have the balanced estradiol, and you go down that default pathway into only the pro inflammatory and it’s fed by inflammation, even causing more estrone being produced by the transformation of adrenal androgens, they’re like male type hormones, but women have them too, and the bulk of them come from the adrenal gland, and they’re like DHEA, DHEAS, you may have heard of those, and they get converted into estrone. 

[00:28:59] And there is an enzyme that can convert estrone to estradiol, but when you have a lot of inflammation, that enzyme is downregulated, so it works less well. So, you sort of get stuck into producing all this estrone, and it’s stuck as estrone, which turns the on switch for inflammation, so you’re in this pro-inflammatory state that’s gets like this snowball effect, because you then have more inflammation, which then causes more of this estrone, but that is not the same as having estradiol from your ovary, and doctors don’t seem to get it. I mean, it’s not that hard. It’s not rocket science that you have different estrogens, they have different effects, and if you have the wrong one, you get an imbalance of how the immune system is responding. 

[00:29:47] And people know this with fats. That’s another like good analogy. Like, if you have someone who’s eating lots of processed food and it contains a lot of trans fat, which you’re not even supposed to have, but put into these foods, but it’s also converted from processed oils and stuff, you can actually– Not intentionally, but it turns into trans fat, but when you made these, they put trans fat on purpose, so these were very bad for people. Trans fat is very bad. So, you wouldn’t say never have food with fat, although they did say that, but that was wrong, right? Never eat food with fat, because fat is evil. Well, trans fat is evil, but omega-3 and the monounsaturated fatty acids from like olives and the best type of olive oil, and if you have walnuts that are nice and fresh. You have to have fat from avocados, they’re called essentially fatty acids, you have to have fat in your body to survive, and so, you cannot equate evil trans fat with these healthy essential fats. 

[00:30:55] But that’s what they did to poor estradiol, they gave it, it’s like the evil twin, and you have these other estrogens that would never even be in a human body, like Ethynilestradiol from a birth control pill, or the forced urine product that would never be in a human body, and you put it into it, dry it, put in a tablet, and then you take all the bad stuff that happens, and then you put it on the poor estradiol, [chuckles] and then women don’t get proper treatment, and they learn to fear their own beautiful hormones. And it’s so simple once you just get down to it and you look at all the amazing things it that estradiol does throughout the cardiovascular system with the enzyme systems that it controls. And if you’re interested, we can go into all the different enzyme systems, which are fascinating, that are all modulated, and not just the ones that are in the pathways of the RAS system, it’s like a whole slew of other ones as well. 

[00:31:50] But once you understand that fertility is a vital sign, that nature made it so that women would be optimally healthy during the reproductive years, and that estradiol is the master of everything that has to do with on and off for inflammation and vascular health and heart health, the myocardium, the conduction system of the heart, so you don’t have palpitations, and atrial fibrillation, which is now rampant after menopause, all these things are under the control, under the umbrella control of estradiol. And when you lose it, you lose all the controls of these systems. 

[00:32:26] And so, if we just think of menopause as what it is, it’s really simple. It’s a hormone deficiency state, and we treat it like any other hormone deficiency state. If you don’t have thyroid, because you had to have your thyroid gland removed, or you get Hashimoto’s and you’re not making thyroid properly, nobody would say, “Eh, whatever, just eat more vegetables or just suck it up,” [chuckles] nobody would say that if you didn’t have thyroid hormone or you can name any other hormone. 

[00:32:55] If you have type 1 diabetes, we would definitely give you insulin. We wouldn’t say, “Eh, too bad for you, you can die.” We don’t do that for any other hormone deficiency. Why would we treat menopause differently? It is natural, but so what? It’s naturally the end of metabolic wellness in the female. So, it’s so simple. And just think of it as what it is, just a hormone insufficiency state when you are in perimenopause and a true deficiency state when you are in menopause. 

Cynthia Thurlow: [00:33:26] That’s a beautiful explanation and I love that you touched on menopause is natural, but it’s not optimal. And I think for many listeners, when you ran through the list of things that can put us at greater risk for developing cardiovascular complications and menopause, that encompasses a large percentage of women. I think just the infertility and oral contraceptive use in and of itself, how many of my generation were started on oral contraceptives in our teens because of irregularities in their menstrual cycle? And at that time, I had very regular cycles. I had thin phenotype PCOS, so not surprising that that was the effective fix for that problem. 

[00:34:08] But for people that are listening, I’m curious when we’re talking about timing of hormone replacement therapy, we’re talking about whether in perimenopause, transitioning into menopause, or starting in menopause. I know there’s this role of timing. There’s this hypothesis, which I think we’ve learned that we have windows in which it’s most optimal, but it doesn’t necessarily mean that if someone’s 10 years in that they may not be a candidate. They’re really looking at healthy endothelial tissue, so we’re looking at the lining of these blood vessels and the progression of cardiovascular disease risk, what are your thoughts on timing? Like when you’re working with your patients, I’m sure you’re probably having conversations in their 30s so that they’re getting prepared for perimenopause and later menopause, but if you had an optimal window in which you like to start HRT, where is that window for most people? Again, not medical advice, but kind of broad sweep strokes on someone’s hormones to be optimized. 

Dr. Felice Gersh: [00:35:07] Well, if you could know when the last ovulation would occur, the last period, they don’t exactly match, but they’re similars, then it would be at least five years before that or up to 10 years before that, because we now know, and this is not controversial, that bad things are happening in many organ systems, like bone is being lost. And bone is actually part of the cardiometabolic system, it’s not just a structural creation. It actually is a hormonal organ. It’s an endocrine organ. It actually makes a hormone that helps regulate brain cognition, and also glucose regulation. So, everything turns out makes hormones, like muscle makes hormones. So even the things that you don’t even think of as endocrine or hormone producing are really part of this whole cardiovascular system. 

[00:35:58] So bone, cartilage is lost years before the last period occurs. We know that plaque is forming and vascular changes are occurring years before the last period happens. Brain cognition issues, even like vaginal dryness and sexual changes, sleep changes, mood changes, all these things can long precede that so-called diagnosis of menopause. So, we need to recognize, that’s why I said perimenopause is hormonal supplementation. We wouldn’t wait for someone to have zero thyroid hormone production before we would give them thyroid supplementation, nobody would expect that to happen, that only happens if you have irradiation like radioactive iodine or have your thyroid surgically removed. It’s never a zero thyroid production otherwise, but it’s too low, it’s too low for optimal health. 

[00:36:51] The same thing– Once we just say it’s an endocrine organ, we need these hormones, it’s a hormone insufficiency, we need to supplement it to get it closer to optimization. And that’s part of the problem, because it’s never been viewed and still isn’t viewed as just a hormone insufficiency deficiency state. It’s only viewed from a symptomatic state. It’s like, well, the only symptoms that we treat are night sweats and hot flashes. And if you are not in menopause officially, by the definition, we wouldn’t even think of treating you in the conventional world with hormones. We would give you, like, well, now there’s new drugs that are neurokinin three blockers. I mean, antagonist. It’s like we have all these new drugs, or we would give the old time, like gabapentin, or we give an SSRI, we’ll give you some Paxil, or we’ll give you Prozac or something like that for your hot flashes or a tranquilizer and then a sleeping pill. And it’s this type of approach obviously have a hormone insufficiency and we’ll give you hormones. No, that isn’t the way it goes. 

[00:37:57] And of course, I view it differently, you view it differently. If you are insufficiently producing a hormone, which happens years before. And that’s why I love doing menstrual mapping, because we can actually get multiple samples throughout a menstrual cycle, even a woman who’s having still regular cycles, and then see, “Oh, my gosh. Here’s like an optimal menstrual cycle hormone mapping, and here’s yours. You ovulate, but like the spike of estradiol, that precedes the spike of LH, that triggers ovulation. The normal spike, we’ll say is like this, okay? And this is you. [chuckles] [Cynthia laughs] It’s like a little bitty bump, and then the LH should be like this, and yours is like this. And then the progesterone goes up, but it should be like this, like a big like rounded mountain, okay? And this is yours,” so you have– 

[00:38:48] And then it’s usually the cycle is shorter because it’s an insufficient luteal phase. So, you don’t make progesterone long enough or as much as you should. And the estradiol is the spike is responsible. It’s not creating an optimal ovulation because you have older eggs, egg quality is diminished, so you end up with poor progesterone production, shorter luteal phase, that’s like classic for having perimenopausal cycles, they’re shorter. And a lot of women will have a lot of changes in how they feel about everything in their body, just things are different. And often the estradiol is significantly reduced when you look at optimal cycle. 

[00:39:30] And so depending on where they are, how the actual hormones look, in the early, early part, I may just give them a phytoestrogen supplement that– Because phytoestrogens, those are the estrogen like products. They’re like magic sauce of fruits and vegetables, grains and nuts and seeds. It’s like, amazing that nature gave us this gift of plant-based pretend, but similar and very healthy estrogen like molecules. And in the very early phases of perimenopause, often that will actually be an okay thing to do, and then maybe give some progesterone. But that’s why you have to keep monitoring, because that’s not going to hold forever. And then you want to give some estradiol supplementation. So, it’s not suppressing the ovaries, it’s not like giving birth control, and it’s also not contraceptives, which is important to know because these women in the perimenopause, sometimes they fool us and they get pregnant. [chuckles] It’s like surprise. And often it’s like twins because they–

[00:40:31] Well, sometimes what happens is the estradiol level goes so low that the brain says, “What? I need more estradiol?” And it shoots out more LH and then FSH. And the ovaries still have eggs, even though they’re not the greatest, but they’re still potentially viable, and you get this hyperstim. Like you would do to someone if you were trying to collect eggs for egg freezing or for IVF, you get this hyperstim, and suddenly they put out two eggs and they both just happen to fertilize, oh, now you have twins. So, the highest group of twin babies is actually the early 40s because they’re still sort of fertile enough that they can be like hyperstim. That’s what you would do if you wanted to get pregnant, and you were like 42, and you go to the IVF center and they say, “Well, let’s give you some medication to hyperstimulate you and get better eggs out, get more eggs out.” 

[00:41:28] And of course, in the old days when they did that, you got octomom, but we don’t do that anymore. But that can happen naturally with twins and even rarely triplets, but more twins are much more probable. And so, you got to be aware that when we give hormone supplementation, this is not in any way creating a contraceptive and may even be making you more fertile, because by giving you the progesterone, that’s what we do for people who have short luteal phases when we’re trying to help them maintain a pregnancy. So we may be enhancing your fertility, not taking it away, so people need to be aware of that if they do not want to conceive. 

[00:42:06] But remember fertility is a vital sign, and the more fertile you are, the healthier you are, so you can also keep that in mind and maybe just use condoms or Phexxi or a diaphragm, which I still fit people with, and it’s not really archaic, it’s just coming back in fashion or as people want to try, who are responsible and a little bit older are responsible to take charge of their contraceptive choices, and they can kind of think about it and they’re more planning and thoughtful so that they can actually use the barrier methods very effectively, which is much safer for people who can be responsible to do that. 

[00:42:45] And so it’s definitely time. Once you are starting to have changes in your menstrual cycle, changes in your sleep. I mean, we got to look for more subtle symptoms than just night sweats and hot flashes. Of course, if you have night sweats and hot flashes, that’s like, “Okay, giant buzzer goes off, you’re having something.” Of course you got to check for other things. It’s always a rule out. You want to make sure they don’t have hyperthyroidism or some other disease or an infection that can give you night sweats and hot flashes, but 9/10 plus times it’ll be perimenopause. 

[00:43:15] So, we definitely would look for subtle signs like palpitations, joint pains, mood swings, sleeping changes, just generally feeling more fatigued, malaise, loss of sex drive. Because a lot of people think, “Oh, sex drive is all about testosterone,” not at all. Estradiol is critical for sex drive. In fact, it’s like the trigger for functionality and production of oxytocin, which is really essential for having orgasmic function, which people don’t realize. It’s a symphony of all these hormones together, it’s not just one. It’s like if you had a baseball team, even if you had the best pitcher, that’s not a team to win the game, you’re not going to win the world series with just a fabulous pitcher, so, you need the whole array of hormones. And at the top, if I was creating like a pyramid, like which is like the top of the heap, it’s going to be the estradiol, but they’re all important. I mean, it’s like you need every hormone, it’s not like you can live with just one hormone, and just because it’s the most important you need the whole team. 

[00:44:22] And so it’s just really very detective work to look at– There’s some obvious things like the age, somebody comes in and they’re 44 and they’re having even a few of these symptoms. It’s like, “Duh,” if you figure you’re going to be in menopause somewhere between 45 and 55, most medically probable, you’re there because things are changing years before that last period happens, and so we got to be on this. 

[00:44:45] And if we want to prevent that early loss of collagen and bone and vascular decline and changes in the brain and throughout the whole body, the gastrointestinal tract, like the incidence of colon cancer rises dramatically with menopause. The vast majority of cancers actually occur post menopause, and that includes breast cancer, which the vast majority occur after menopause. And the ones that occur prior now we believe are mainly related to endocrine disruptors, like the chemicals in our environment that interfere with normal hormone signaling. And so that is really the underlying key. And then plus tons of unfortunate, like chemicals in our food, antibiotic use, which has destroyed our microbiomes and so on, so it’s a complex thing, but it’s not because you have hormones that you ever get breast cancer. It’s like, in spite of them, not because of them. 

[00:45:40] There are actual mechanisms in the menstrual cycle. That’s why the menstrual cycle is to be beloved. We just spend most of our lives as women trying to get rid of it instead of embracing it and understanding that it actually has mechanisms built into it to actually reduce cancer risk. Because when you get the spike of estradiol, it turns on tumor suppressor genes. When you get the peak of progesterone in the second half, the luteal phase, it also turns on tumor suppressor genes. And these hormones turn on and off the receptor functionality. So, you have more receptor function for progesterone when you have higher estrogen. And then the high progesterone suppresses the estrogen receptors, the estrogen rises the receptor function for testosterone and progesterone decreases it, so we have this yin yang between how the hormones turn on and off the receptors. If you think of a receptor like a mouth, and it can kind of open and close to a certain degree and these are required for optimal function of all the body, including the immune system and its surveillance. 

[00:46:48] And estradiol also is the key to having proper circadian rhythm, which now we know when it’s off. Like, if you live a life of jet lag, whether it’s intentional because you stay up late at night or you have a shift work type of job, or you’re traveling across time zones, or you just have insomnia, whatever the reason, if you’re not getting adequate sleep or you’re jumping across time zones, you will have higher risk for everything bad, everything from depression, anxiety, diabetes, obesity, cancer, heart disease, heart attacks, strokes, you name it, infertility [chuckles]. Every problem is intensified in a negative way if you do not have proper circadian rhythm. And estradiol is a very key part of that and in fact the ovaries are incredibly circadian. 

[00:47:43] The ovaries have receptors to melatonin, the hormone that is so key to maintaining our proper sleep. But so much more glucose regulation, it’s a potent antioxidant, and it’s essential for ovulation and proper fertility and regulation of ovarian function in health. So, these are really key things. And if without estradiol, that’s why so many women, somehow they don’t understand what’s going on, why they can’t sleep. Like you said, suddenly their sleep is gone. And when women were taken off their hormones, when the Women’s Health Initiative first came out, and they suddenly now I can’t sleep, I feel horrible, and that increased all their risk for every bad thing that can happen to you, and that’s why it’s so sad that what happened. Even the wrong hormones were better than no hormones, that’s like the ultimate amazing thing, that even those hormones, which were the wrong ones turned out that for women in their 50s, it reduced all cause of mortality by 30%. So, if you were on those wrong hormones in your 50s, you had a lower risk of death of every cause by 30% [chuckles] There’s no drug that’s ever been created that can lower your risk of all-cause mortality by 30%. And that was the wrong type of hormone. 

[00:49:01] Just imagine if we did a study with the right kind, which is never going to be done because no one’s ever going to fund it. So, we have to rely so much on science rather than large clinical studies now, because that’s where we are. But we have to deal with reality, because no one has an interest to fund another woman’s health initiative type study using the right hormones, it’s not going to happen. So, we just have to rely on our wits, our knowledge, our scientific acumen to make our clinical decisions now, it’s just the way it is. 

Cynthia Thurlow: [00:49:33] So interesting, the way that things have evolved since the WHI, and something that I want to make sure we definitely touch on before we kind of end our conversation is talking specifically about things like in cardiology, I saw a lot of patients with heart failure, diastolic dysfunction. So when we talk about the heart cycle, our heart fills in systole and then gets pumped out of the left ventricle. And then diastole is when it’s this passive, passive filling of blood in the heart, and it’s very common to see this in older patients. And so, I was fascinated when I was preparing for a conversation, realizing that the changes in sex hormones specific to estradiol actually leads to diastolic dysfunction, so you get the stiff ventricle that this is oftentimes where you’ll see in many instances, people will develop heart failure related to diastolic dysfunction. But let’s talk about some of the changes that go on. I know we’ve alluded to some of them, but I think for many people, this will make it sound a bit more tangible. 

Dr. Felice Gersh: [00:50:38] Well, and let me just do a very quick overview of the different ways that estradiol directly affects the cardiovascular structures. So, if we look at the arteries. So, in order for an artery to be healthy, you have to have a healthy lining called the intima. Well, estradiol is the key on switch for an enzyme called endothelial nitric oxide synthase, which causes the production of nitric oxide, which is a gas which we can’t measure, but we can indirectly measure it by getting a blood test for ADMA. 

[00:51:15] But nitric oxide is essential for vascular health. It also has many other benefits. It keeps platelets from clumping and clotting. It just maintains the health of antioxidant status, so you don’t have inflammation, which damages everything. So, it maintains vascular dilation, so you don’t have constriction and hypertension. So nitric oxide is essential for vascular health. And without estradiol, you will not have adequate nitric oxide production, and that’s a huge problem. 

[00:51:51] And then if we look at prostacyclin. So, prostacyclins also maintain vascular health and keep platelets from clumping. And estradiol once again helps to create these essential prostacyclins, the COX enzyme system, that’s what’s interfered with when you take an NSAID, a nonsteroidal anti-inflammatory, and these COX enzymes come in different numbers. COX-1 is the one that keeps everything wonderful and happy and peaceful. COX-2 is what we would have that would be instituted if you have an inflammatory state, so it would be only triggered inflammation. And that is the one that is supposed to be knocked down or blocked by the NSAIDs. But they actually block also to some degree COX-1, which is why they are associated. If you take an NSAID for at least three days, you have tripled your risk, especially as you’re older, of having a heart attack or stroke, that’s why long-term NSAIDs are really counterproductive. They’re only good to take very short term, like up to three days. But it turns out that estradiol maintains this whole enzyme system, the COX enzymes that keeps you in that happy COX-1, except if you need to initiate an inflammatory response, because it’s modulating that whole inflammatory on and off switch. 

[00:53:13] And then if we look at like cholesterol. So, cholesterol will only become problematic if it is oxidized, because if it’s rancid, we call it oxidized LDL, then it is damaged tissue. Damaged tissue is recognized by the immune cells, and then they gobble it up because it’s just damaged tissue. So, cholesterol travels around the body in little envelopes called apolipoproteins. They’re like, if you wrote a cheque, you can’t just drop it in the mailbox, you put it in an envelope. You can’t drop cholesterol in the blood, it needs an envelope, these are the apolipoproteins. So, these are structures, and if the cholesterol gets oxidized or rancid, then it gets picked up, like gobbled up by the gobblers, the macrophages, and these macrophages are attracted to damaged tissue. If you also have damaged lining, the intima of the artery, they line up along the damaged artery inside.

[00:54:08] Here’s the blood flowing, and there are cracks in fissures, and these immune cells carrying the oxidized cholesterol work their way in through the cracks and fissures into the actual wall of the artery, where they create even more inflammation, and through the signaling agents call more inflammatory cells creating basically a pile of junk in your artery wall, and if it’s very inflammatory, it can erupt like a pimple popping, okay? And it pops, and it goes into where the blood is flowing, and that little hole in the artery that was created by the rupture, a little clot forms on it, like a little scab. Like if you ruptured a pimple, and if that breaks off, it travels downstream, it might as well be a rock at that point, it’s not dissolved, it will be like a boulder, and it will block the artery somewhere, and that can trigger, if it’s in the brain, a stroke. If it’s in the heart, then it’s a heart attack. If it’s in the vascular system of the intestines, it’s ischemic bowel, so it’s like blocking blood flow. So, you’re not going to have oxygen downstream. And in the heart, in women, that will trigger a heart attack. 

[00:55:11] And what people die from a heart attack isn’t the loss of oxygen to the muscle, killing the muscle that comes later, that causes heart failure. Like you mentioned different types of heart failure. But initially, what happens is it triggers an arrhythmia. And after menopause, women’s sort of system involving maintaining proper rhythm becomes much more fragile, and women will go into a fatal arrhythmia. And women die from first heart attacks dramatically higher than men. And it doesn’t take as much for women to get triggered into a fatal arrhythmia. And it doesn’t have to be like a big area of the heart that has oxygen obstructed from the blood vessel. It could be a tiny little one, because it’s not about loss of oxygen to large areas of the muscle of the heart. It’s just that it triggers this arrhythmia through the electrical conduction system that can be fatal, totally fatal. 

[00:56:13] And so it turns out that estradiol modulates an enzyme called paraoxonase one, also known as (PON1) that prevents oxidation of cholesterol. That’s why premenopausal women have a much lower rate of having plaque formed, because they have this beautiful enzyme that helps to protect the oxidations of cholesterol, so it doesn’t happen. As well, cholesterol goes way up after menopause because the receptors on the liver, called LDL receptors– So when you have old cholesterol, it comes back to the liver, and it’s carried by these apolipoproteins, called A1, so that’s also known as reverse cholesterol. They come to the liver, and they dock like a spaceship in a docking port, and then they go back into the liver, and then they either get recycled if needed, or they go out the bile duct that’s like the trash chute into the intestine, where if you have binders, like lots of fiber in your diet, you can poop it out. Okay? And that’s why things that are very binding, like oatmeal it like has the little heart from the American Heart Association because it can bind cholesterol in the gut, and then you poop it out. 

[00:57:30] So in order for those receptors on the liver to take back the cholesterol, to get it out of the circulation, you need those receptors working. Well, it turns out estradiol maintains the functionality of the receptors on the liver to pull the cholesterol out of the blood. Without estradiol present, the cholesterol just accumulates in the blood, and then it’s subjected to more oxidation potential, because of more inflammation that occurs after menopause in an absence of adequate estradiol. So, you can see how this is, like, just as devastating. And then when you have problems, you get leaky gut because you don’t have the right estrogen and the right microbiome is related to hormones too. And then when you have inflammation in your gut, it affects your liver, so now you have inflammation in your liver. And after menopause, women have much higher rates of nonalcoholic fatty liver. And then you have a dysregulated liver that becomes a factory for glucose and triglycerides, which are fats and cholesterol.

[00:58:26] The liver is like a manufacturing center, and it’s dysregulated when you have this impaired gut barrier and you have dysbiosis or the wrong microbial population in the gut, which happens virtually to every woman as she goes into menopause. And then you have dysregulated liver and then you have all this glucose and triglycerides, and you have all of this cholesterol being spewed out, and you can’t even get it back out again. So, you can see how this creates cardiometabolic total chaos. And I mentioned glucose regulation is controlled under estradiol. The glucose transport system of how the glucose from in the blood gets into the cells is under the control of estradiol. Without estradiol, the cells that need the glucose for energy can’t even get them. 

[00:59:13] And the mitochondria, now, you mentioned about the heart. So, the heart I mentioned of a woman who’s pregnant has to be incredibly more energetic than that of a man. Well, the mitochondria of a woman’s heart are special. They are able to produce more energy. In order to do that, you need estradiol. In order to make energy and what’s called the electron transport chain, you need to have estradiol. And then as a side effect of creating energy, you have a byproduct that’s very toxic called superoxide, and it cannot get out of the mitochondria. It’s like stuck in the mitochondria unless it’s converted into hydrogen peroxide, which can diffuse out of the mitochondria, and in the cell be converted into harmless water. But that won’t happen if you don’t have an estradiol, because the enzyme system that turns superoxide, this toxic waste product caused by the production of energy, needs to have this enzyme to convert it, and that’s called manganese superoxide dismutase. That enzyme requires estradiol to work. So, if you don’t have estradiol, you’re not going to make energy properly. And what energy you do make, it creates this toxic waste product that you can’t get converted to get it out of the mitochondria, so it kills the mitochondria. 

[01:00:31] So now you have a problem of a poorly energetic heart. This is unique to women, and so it’s ignored. And you can see it on an echocardiogram that the heart, when it’s relaxing, like you mentioned, the diastolic phase. So, the diastolic phase is when blood pressure is lower because the heart is filling, not pumping. The pumping part is systolic, and that is reflected in the higher pressure, the blood pressure, like 120. And then when it’s relaxing and refilling, that’s the lower blood pressure, because there’s nothing coming out of the heart at that time into the blood vessel, so the pressure goes down, and that would be like 120/80. 

[01:01:13] So the diastolic part, the filling part is unique to women in that the heart is, like you mentioned, stiffer because the mitochondria are not functioning properly. And so, it’s like you see it on. This is a pretend version, so a normal heart would be pumping smoothly and with diastolic dysfunction, it would be, like, stiffer when it– So, the contraction part is fine. It’s the opening when it’s refilling that it’s stiffer, and that is called mild diastolic dysfunction. And it can lead to a type of heart failure that’s pretty unique to women that’s called heart failure with preserved ejection fraction. In other words, the heart is still pumping the blood out, but it’s actually– So that’s called preserved ejection fraction, but it’s actually a dysfunctional heart, big time, because it is not relaxing properly. And that heart can kill you. Okay, that kind of heart failure can kill women. 

[01:02:09] And heart failure is not a rare condition. And the cardiologists are not even looking for diastolic dysfunction like that. And even when they see it, they often discount it and say, “Oh, lots of women have that.” Yeah, it’s really bad. It’s a sure sign that it’s an energetic deficient heart, so these are huge things. And then the whole electrical conduction system that’s controlled through the autonomic nervous system is regulated by estradiol. The neurotransmitters that cause heart rhythms is all controlled– It’s a neurological kind of thing, it’s all controlled through estradiol, which is why women are so prone to atrial fibrillation, and they’re prone to having supraventricular tachycardias, where they have palpitations and rapid heartbeats. 

[01:02:57] So many women I see, they go to the cardiologist, and they’re just put on beta blockers, which are drugs that sort of slow the heart rate down, which can be helpful, but it’s not addressing the root cause, which is that they’re having conduction problems because their autonomic nervous system is dysregulated because they don’t have enough estradiol. [chuckles] And so you can see how there’s just such a wide array of issues that come into play. And it’s like, fascinating. I mean, and this is like not even covering everything because it’s complex and simple at the same time. 

[01:03:34] On a molecular basis, it’s really complex when you look at pathways and all of this and that. But when you just look at is, it’s all designed for pregnancy success and reproductive success. And you need to have a strong energetic heart, you need to have really healthy arteries, you need to be able to create an incredible placenta, you need to have the proper hormones to keep you in the proper time zone, to have proper digestion, all these things need to be optimized for reproductive success. When you don’t have reproduction any longer because nature deems you too old and too risky and the reproductive capabilities go away, so too do these vital hormones, and then you’re going to suffer in every organ system and hugely, I mean, just hugely, in the cardiovascular system. And the best ultimate way is to start early in perimenopause where, like you said, wherever you are, it’s where you are, you just go and do the best you can wherever you are. I deem it, you’re never too late, and that’s not the conventional approach. They say if you’re out over 60 and you haven’t been on hormones, or even if you have been and you reach 60, like now, you’re too old, that’s illogical. That’s just bizarre, actually, when you think about it, there’s nothing that changes between 59 and 61. 

[01:04:51] And all women go into menopause at different ages. So why would you think every woman is the same at 60 when some women went into menopause at 42 and some went in at 57? I mean, I’m just like an evidence-based person. Here I’m looking at the data and the evidence, and there’s no logical reason to think that estradiol would turn on you at any age or ever. You know that this confusion between the different estrogens and the different receptors and getting all this mixed up and the evil twin attacking the reputation of the good twin it’s just got to stop, it’s just a vital life hormone, like a really vital life hormone. And when you don’t have enough, it’s like simple thinking, you just give it. And you try to give it at a level and a rhythm that mimics as reasonably close as we can, it’s not the same, we’re not giving you a new set of ovaries, but to be reasonably similar to the rhythms and levels that you would have when you’re healthy, it’s like in your early 20s, it’s just simple thinking. 

Cynthia Thurlow: [01:05:54] I love your pragmatism, and I’m so glad that we had this conversation today. As I state and I always state every time that we connect, I could talk to you for hours. Please let listeners know how to connect with you, how to get access to working with you if they live in the state of California, how to access your wonderful books, which are behind you. 

Dr. Felice Gersh: [01:06:15] Yes. So, I’m still an old-fashioned doctor. I have a regular brick and mortar practice. I’m actually sitting in a converted exam room. There’s actually an exam table right over there. [laughter] I just took this room and just made it my little photo studio here so that I could have a place to go that’s quiet. And so, I see patients here every day. In fact, I have one to see in a few moments. And so, even if you’re out of state, you have to get on a plane and come to lovely southern California vacation Mecca and see me. 

[01:06:42] And if you’re in California the way the laws are, it’s kind of weird, you don’t actually ever have to see me, but I really like it if you actually do see me, because once again, I like to do exams. And in my office, we do a lot of imaging. Like, we do ultrasounds of your heart. We do ultrasounds of your arteries. Like, we actually want to know the status. I just love data. We get the most advanced lipid and inflammation markers and all of those things, because the first step in solving a problem is to know where you are in the problem to define the problem. 

[01:07:16] And I don’t believe you’re ever too old. Of course, earlier is better for everything when you’re doing something that’s good for you, but you’re never too old. You just have to see where you are in terms of vascular damage and then do the best we can to stop it, so you don’t have progression and to even reverse some things. So, I just see people here in my practice. It’s Integrative Medical Group of Irvine in Irvine, California, that’s in Orange County, California. And I also have my Instagram live and I’m hoping to write more books, but my book for menopause. Menopause: 50 Things You Need to Know. I am very proud to say that Good Housekeeping Magazine chose it as the number one best menopause book. 

Cynthia Thurlow: [01:07:58] Aww, that’s wonderful. 

Dr. Felice Gersh: [01:08:00] So, I was really proud of it. It’s like a little mini encyclopedia. And I plan to write more books and have courses. I do have a course, like hormones 101, like how to take hormones that you can acquire through my website. It’s really designed for practitioners, but anybody can look at it and take the course, and at least it gives you an idea of how I would start people on hormones. It can get much more complicated than that, but it gives you like the basic 101 course on how to take hormones or prescribe hormones, so I think that that’s a good place to start for patients or providers if they’re kind of new to this game, because part of my mission is to educate both providers and the public on the basics of women’s health, and so hormones are kind of foundational to that. 

Cynthia Thurlow: [01:08:50] Well, thank you for the work that you do. It’s always a pleasure to connect with you. 

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