I am delighted to have my dear friend, Dr. Anna Cabeca, joining me for the fourth time today. She was with me before on episodes 94, 202, and 317.
Today, we dive into various questions from listeners about their GYN concerns, covering why suffering is optional in perimenopause and menopause and why we must refine ourselves during that life stage. We discuss the symptoms of perimenopause, explaining the best time to start using bioidentical hormones, issues with pellet therapy, especially testosterone, and various kinds of bioidentical hormones and vaginal estrogen. We also look at DHEA and testosterone therapies, symptoms to watch out for, sexual health, treatment therapy options for incontinence, and vaginal rejuvenation.
I know you will love this invaluable discussion with Dr Anna Cabeca.
IN THIS EPISODE YOU WILL LEARN:
How to navigate perimenopause and menopause proactively rather than reactively
What are the early signs of perimenopause?
Dr. Anna discusses her approach to starting bioidentical hormones
The importance of detoxification and gut health
Various types of hormone applications, including progesterone, pregnenolone, DHEA, testosterone, and estrogen
The importance of addressing the underlying cause of hormonal imbalances
What role do hormonal therapies play in maintaining vaginal health?
The limitations of certain incontinence medications
Dr. Anna introduces her Sexual CPR program
Dr. Anna shares her experience with vaginal rejuvenation procedures
Why we must only use personal care products containing clean, non-toxic ingredients
“Estrogen helps decrease vaginal atrophy, but it does not improve the elasticity and muscle of the vagina and the bladder.”
-Anna Cabeca
Connect with Cynthia Thurlow
Follow on Twitter
Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Dr. Anna Cabeca
On her website
On social media: @the girlfriend doctor
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 recording for the fourth time with my dear friend, Dr. Anna Cabeca. She has previously joined me on Episodes 94, 202 and 317.
[00:00:43] Today, we featured a grab bag of listeners questions with GYN-related concerns, we spoke about why suffering is optional in perimenopause and menopause, and how important it is to refine ourselves at this stage of life, symptoms to look out for in perimenopause, when to start bioidentical hormones, issues related to pellet therapy, especially testosterone, different types of bioidentical hormones and hormones, as well as vaginal estrogen and the differences between this and DHEA and testosterone therapies, when to increase doses, symptoms to watch out for, the importance of sexual health, as well as different types of incontinence and treatment therapies and lastly, vaginal rejuvenation. I know you will find this to be an invaluable discussion, as I did while recording it with Dr. Anna.
[00:01:40] Dr. Anna, always a pleasure to reconnect with you. And like I was saying to you before we started recording, you are absolutely the perfect person to be asking these questions of, because I feel like there is still some degree of lack of appreciation for how women are aging and how their symptoms impact them so substantially and if their concerns aren't being taken or addressed properly, can really skew the way that they view their health moving long term. So, perimenopause and menopause, if we live long enough, we're going to make that transition, but we should do it proactively and not reactively.
Dr. Anna Cabeca: [00:02:20] Absolutely. Absolutely. And I think that's like part of aging gracefully or refining our lives, our mind, body, and spirit as we age. Cynthia, as you're talking about this, like, how are we aging? Sometimes it's that concept of just having to power through the suffering. This is a rite of passage, but it's not true. Suffering is optional. It is, it really is. Menopause is mandatory, suffering is optional. So, it's important to look, okay, what can we do? What do we need to do to adapt with the shift in our hormones naturally and to create balance, to create a grace, longevity, fierceness, power, all those good things that we want.
[00:03:02] I reflect back on the Camino this summer. When I was walking the Camino de Santiago, I met this beautiful woman, she is 72 years old. The beautiful white hair and all these fine lines and she was tall and lithe. When she walked around, she had so much energy and you could just see just so healthy. And I said to her, I said, “You know, oftentimes women are suffering in midlife or in menopause, or they feel like they're just too old.” And she said, “Why do they think that? It’s not it at all. It is a period of refining.” And I love that she used the word refining because we often think, recreate, reinvent, even rejuvenate or regenerate. Those are pretty harsh words. I mean, they're like refining. So, it's a period of refinement, and it really is often about less, not more. And that is something I've come to realize in my now 30 years of medical practice.
Cynthia Thurlow: [00:04:01] Well, and I think for so many of us, what you can get away with in your 20s and 30s don't serve us in our 40s, 50s, 60, and beyond. And I'm so grateful. I was thinking about this the other day. There were many years where I got up at 04:30 AM in the morning to go to the gym, to punish my body before I round it on patients in the hospital and I had a super stressful job. And for any nurse practitioners that do hospital-based medicine, I totally understand. And then, when I made that pivot eight years ago, and I started sleeping more, and I started investing more in myself as a human being. And I was telling someone recently, if I let my body sleep in naturally, it's 6:00, 6:30, 7:00 before I'll get up.
[00:04:46] It changes the whole way I look at my entire day because I'm well rested, I've slept well. The years of having terrible insomnia and not understanding why are gone. And I think for many, many women, some of these symptoms start in their mid to late 30s, and they're told that they're too young for perimenopause. So, when you're counseling your younger patients, what are some of the first things that you're identifying for them to be looking out for in that early perimenopausal timeframe? Because I'm sure that we have people listening to this recording that are wondering, what are the things I need to be thinking about proactively?
Dr. Anna Cabeca: [00:05:29] Yeah. And I think the first thing is, if you're not on birth control pills, let your period be an indicator. Our period, the health of our period, the color of the blood flow, the quantity, etc., all of that. I mean, that's old Chinese medicine traditionally looked at that as what is the symptom, right. And so, looking at if our period’s changing, the other thing is, how are our moods? Do we feel more moody a week or two before a period? And, I will say, if you only hate your partner two weeks out of the month, [Cynthia laughs] it's your hormones and not necessarily your partner.
[00:06:07] And so those things kind of identifying, getting in tune with what your body's telling you, that's really important. Forgetfulness, is there a cyclical pattern to it, what part of your menstrual cycle do you feel more on, more energetic? What period do you feel like you're called to rest more, restore more and pay attention to that? And I have four daughters from age 16 to age 35. And so, I always talk to my older ones about what is your period telling you? I mean, like, what's going on? and to pay attention to those signs and symptoms. Especially, again, it's never too early to start empowering your body and nourish, I mean, like, to really nourish your body as you go through these hormonal changes, whether they're monthly or through perimenopause or menopause.
Cynthia Thurlow: [00:06:59] That's all so important. And being more attuned to our bodies, I think for so many of us, and I was certainly one of these women that was on oral contraceptives to fix my irregular periods from my late teens until I got married. And I didn't actually realize I had no PMS until I was off of the pill. And then I realized I actually didn't have terrible PMS. I didn't feel poorly. And for me, very likely could have been exacerbated by the fact that I have PCOS. So, I had less circulating progesterone and the progestins, which are the synthetic progesterone alternative, were very likely magnifying all of those symptoms I was experiencing. And so, when I finally put two and two together, I was like, there is no shame, women need reliable contraception with at full stop, no explanation needed.
[00:07:51] But for so many people not realizing that the pill can potentially magnify a lot of the symptoms we experience because our body isn’t able to do what it would otherwise naturally do if it were not having these synthetic hormones involved.
Dr. Anna Cabeca: [00:08:05] And I think it's really key connection to make with PCOS physiology. So, whether we have a diagnosis or not, PCOS physiology can be predominantly insulin resistance, and there's an irregular menstrual cycle with that, very similar to perimenopause and menopause, we become more insulin resistant., Cynthia, I'm thinking about you and your audience too. When I had a client, 27 years old, and she'd had maybe two or three periods a year, she was continuing to gain weight, acne, facial hirsutism, only 27 years old. And so, she came in to see me in my private practice here in Dallas, and she'd been offered birth control pills, the antidepressant, to help with her moods and all this stuff. Nothing was helping her. So, I did a two-hour oral glucose challenge test with insulin.
[00:08:57] That's when we're drawing insulin at 0, 30 minutes, 1 hour and 2 hours, along with glucose. Her fasting glucose was 69. Her hemoglobin A1c was 5.2. I mean, the doctor's looking at that. We're missing a big picture now. Just looking at her two-hour glucose curve was pretty good, 2 hours it was still a little high, but her insulin went up to 76 at 1 hour, and it was at 79 at 2 hours, completely insulin resistant. So, you miss that if you're not looking at these things. And as we age, right, we're not looking at how our body is tolerating insulin, but we're becoming insulin prepared.
Dr. Anna Cabeca: And that's why, your great books and your great teaching and wearing continuous glucose monitors helps so much with intermittent fasting to create that insulin sensitivity, which helps with hormonal balance. And I think that connection because there's so many people suffer with this diagnosis of PCOS, and they feel like they have fat genes, acne genes, hairy genes. And in reality, they have Amazonian warrior genes. I mean, they're the leaders, they build muscle, they're powerful. And so, I want women hearing, if you've had that diagnosis or suspicious of it, there are answers, it is not a destiny, diagnosis is not a destiny.
Cynthia Thurlow: [00:10:20] I so agree. And I'm an example of thin phenotype PCOS, which is why I was never properly diagnosed. But the irony is when I started going in for infertility treatments, because I wasn't ovulating, and they put me on Clomid. And then I did IUI to get pregnant. Remember having a conversation with multiple aunts and each one of them said, “Oh, that's what I had to do.” And I thought to myself, why aren't we having these conversations with our family members to at least make them aware? There are multiple family members that very likely have some genetic susceptibility, these luteal phase defects, which is the lack of progesterone, which exacerbates all of these. These symptoms that you're referring to.
[00:11:03] Now, one of the questions that came in multiple times was, “How do I know when I'm ready to start bioidentical hormones? My doctors are not open, so I don't know who to go to. Thank you.” That question is asked so frequently. I could add 10 names to that question, but many women feel like they are struggling to find providers that will actually address with bioidentical hormones and not waiting until they go into menopause. Because we know the research suggests starting bioidenticals when you're younger can actually be very helpful for alleviating a lot of the symptoms that women experience in perimenopause.
Dr. Anna Cabeca: [00:11:42] Yeah, it's a really good question and the answer is so individual. So, teach my approach to that answer. And so, if a patient comes in, whatever the situation, I do my foundations first. I want them to do, the Keto-Green 16 recipes in my book, Keto-Green 16, because it's the shortest, quickest, easiest, and they're excellent medicinal recipes. I want them to work with intermittent fasting. Follow that. And I support them with adaptogens. For me, it's my formula, Mighty Maca Plus adaptogenic. Through the years, we've shown an increase in day 21 progesterone within two months. And so, it helps support your body's natural hormonal production as well as detoxification elimination. It's very alkalinizing and I have clients check their urine pH.
[00:12:31] I mean, I want them to do this first because it takes more than hormones to fix our hormones. And take it from me, it was able to extend my menopause from till age 56 because of these practices and principles versus my early diagnosis of menopause initially at age 39, and full-blown perimenopause at 48. I had to learn to shift things in order to preserve ovarian function and adrenal function. So, then it's like if I like to clean up, you've got to clean up the terrain, so to speak. So, detoxification becomes key. What could be causing the hormonal insufficiency and the imbalance to begin with. Is it cortisol? Is it insulin resistance? Is it hormone disruptors?
[00:13:19] There's something genetic with methylation defect or it could be anything. And so, a sulfation defect, especially anything that can affect our P450 enzymes in our liver. So, we want to clean that up. Just like you send a car in to get an oil change. We want to do a good filtering and because it's going to have to process our hormones and we want to, if we're replacing hormone, replenishing-- I like to say I replenish hormones, not replace them. If we're replenishing hormones, then we want to do it safely. So, your body's metabolizing them well. And that also comes in why the medicinal menus are so important. And fixing the gut, healing the gut is critical to hormone balance because of our estrobolome and it's also critical for longevity.
[00:14:06] So, with that said, I want the foundations taken care of and yet still very symptomatic. I can say, “Look, I'd like to start you on these hormones now.” We may be able to wean off them, especially that perimenopause time period. So, but I rather seriously, within 16 days, we see an 80% to 90% improvement in symptoms and we can retest and see where do we need to supplement. So then, the adaptogens come in. I start with my progesterone and pregnenolone combination first. That's my balance cream because those are the mother hormones. And from there we'll support our steroid hormones, our sex hormones, DHEA, testosterone, and estrogen, so we'll support those, top down that way and that's the first hormone.
[00:14:57] Statistically from age 35 to 55, we lose 75% of our progesterone. So why wouldn't we be replacing it? In contrast, we lose 50% of our estrogen during that time. So then when do we add in estrogen again? Gosh, we can talk about this a lot. Cynthia, I'm going off on a tangent, but I usually start with adaptogens, cleaning up and detoxing and then progesterone and pregnenolone, usually cyclically in the perimenopause, and then continuously with the exception of one day off a week or three to five days off per month in the post-menopause, and then DHEA, and then testosterone and estrogen.
Cynthia Thurlow: [00:15:40] I think that one thing that this really reaffirms is how critically important lifestyle is, because how many women listening maybe got started on replenishing their hormones. Let's find that reframe. And they then find that they start gaining weight, and likely because the foundational elements had not been addressed. And I do think the alkaline diet is really very, very important, really encouraging us to eat nutrient-dense vegetables and to be conscientious about how we're choosing to eat. The irony is, and I cannot make this up, I was in Facebook the other night, and there were a bunch of women in my area talking about your book. [laughs]
Dr. Anna Cabeca: [00:16:20] Oh, my goodness, it’s awesome.
Cynthia Thurlow: [00:16:21] They were looking for support for one another. Can we read the book together and create a support system? And I jumped in and I said, I can't make this up. I was like Dr. Anna and I are friends. I will make sure that when we have our conversation this week, I let her know. So, in Richmond, Virginia, there's group of women that are reading your book right now, and they were talking about the success that they are having because they are starting with that lifestyle piece. So just to share that with you, because I think it's so serendipitous that happened this week. And then were connecting as well. And thank you for talking about how you go about thinking about hormones.
[00:16:59] It seems to me that there are a lot of well-meaning practitioners that will jump right to testosterone. And I have a lot of our colleagues sharing with me that they have women, maybe they're getting pellet therapy, maybe not, but they have very high levels, supraphysiologic levels of testosterone. And have you found that this has really been a byproduct of, as an example, the pellet industry or practitioners that maybe are not fully understanding or appreciating why we really have to look at the lifestyle piece first? It's not to suggest that women don't need testosterone, because I think testosterone is very important for women that do need it, including myself.
[00:17:38] But having said that, I'm sure you're probably getting referrals or women that are showing up in your offices that are having supraphysiologic, which means higher than it should be in otherwise healthy females. Again, broad level concepts, how are you going about having those conversations of helping them understand that their levels are not in an optimal range to protect them or for their health?
Dr. Anna Cabeca: [00:18:02] Yeah, it's a super important conversation. I have [unintelligible [00:18:05] for pellet companies, and I've instructed others on appropriate use of pellets over the years. And I consider pellet therapy a short-term interval. First of all, when I keep getting injections and incisions all over you regularly that's number one. But second is because of those high physiologic levels, it can be so nice when you're like that perimenopause, menopause transition. I can't do one more thing like taking a vitamin, let alone a pill or whatever, any day is just crazy. That's so nice to get that pellet in at ideally a physiologic level.
[00:18:47] And the issue that is with these high levels, when we have high levels, testosterone, like we are with birth control pills, they're suppressive to our own body's glandular and natural production. So, what happens when you stop? You get a complete withdrawal issue. And so, there's published scientific articles on depression and suicide post testosterone withdrawal. And so, I don't want that to happen to anyone. Not to mention those high physiology drives behavior. What happens with that higher testosterone physiology? Anger, affairs, I mean I've heard it all, and I have a client recent and I'm seeing this again and again because of that phenomenon. Now that we've had clients on-- people who have been on pellets for five years. I've seen a couple clients just recently and both of them in their 60s and just crashing from the pellet, didn't feel good on it anymore. Just felt like that--
[00:19:44] Of course, because you've now interrupted a part of the HPA axis. This is not well defined, but it is presenting itself. And again, we have longstanding literature on the testosterone withdrawal issue, and we know about birth control pills, on the suppressive effect of the ovaries. So, what are we doing now with these testosterone levels? So, again, because the receptor sites haven't been addressed, the underlying reason for the low testosterone hasn't been addressed. And it really is-- it can be just normal aging. But in your 20s, 30s, even 40s, that's not normal aging. That is not normal aging to have, below optimal levels of testosterone, something's going on in the HPA axis or the toxicity syndrome. So, we've got to look at that because that creates longevity or blue zones, right.
[00:20:35] They're 100-year-old. This is where I always go into a theoretical tailspin. But in the longest living populations we have aren’t on handfuls of supplements or pills, or hormones, and they're not living in our environment either. So, none of them are living an average American lifestyle. So, I think we have to pay attention to how do we really optimize our health for longevity? As a longevity expert, I want to optimize honestly from the inside out. And, Cynthia, I'm a clinician. I've been a physician for over 30 years. And your skin tells so much. Your energy shows so much, and that can't be replaced.
Cynthia Thurlow: [00:21:25] Absolutely. And I think for a lot of people, it's understanding that if you have chosen to get a pellet and it's a short-term effect, I think that that is reasonable. I can't tell you how many women end up in programs of mine and they'll say, “Oh, I think my testosterone levels are low.” They share their lab work and their testosterone is not low. It's just they have been so super physiologic, so high for so long, that they notice the subtleties as they are coming back down within a normal, healthy range for a woman. And certainly, someone said to me the other day, which I agree with, is normal, is not per se optimal.
[00:22:01] So, there are traditional allopathic ranges for medications, for hormones, and then there are functional integrative ranges, which tend to be a little bit more narrow. So, ensuring that you're working with someone that's going to be open minded enough to facilitate those conversations, I think is very important. Other questions about hormone replacement therapy. This is specific to you. What applications do you prefer? I know you're going to say bio-individual. I am currently taking a cream for estradiol and testosterone and a capsule for progesterone, both from a compounding pharmacy. I keep hearing that other forms might be superior, but what I'm currently using is working well for me. Thank you for sharing your expertise.
Dr. Anna Cabeca: [00:22:43] I love it. I mean, I think if it's working well for you, that's your answer. And as long as you don't tell me you're on oral estrogen, because in the long term, oral estrogen definitely over age 50 or if any inflammation or early signs of cardiovascular disease or anything like that, we don't want you on oral estrogen, it increases risk of stroke and blood clots. So that's where I draw the line there. Again, being this for so long, I can't think of any modality I haven't used from, with my clients, injections, troche, rapid dissolved lozenges, vaginal suppositories, creams, and you name it. But I will say this is where it is, exactly bio-individual.
[00:23:27] Depending on how you're doing and your symptoms you want to look at, how was it working for you on a cyclical pattern? Are you needing, do you feel better if you're applying the cream twice a day? If you're using the topical estrogen cream, is the progesterone at night enough? Your memory and brain is still great and sharp during the day. And paying attention to those. I always, again, like looking at progesterone and pregnenolone from the top, DHEA, because that's a precursor to testosterone and estrogen. And research supports DHEA and longevity. So, we want those numbers to be optimal too. And again, that the amount you're on is not a suppressive amount, but a replenishing amount, which is key.
[00:24:19] So, gosh, there's so many different ways to use hormones, and I've used different modalities throughout the years for clients and for myself. Over time, we change it up. The other caution I say is with a lot of press about vaginal estrogen, vaginal estrogen. And it's important to recognize that, first of all, vaginal estrogen works on a mucosa lining. So, the first lining, the inside of our mouth is the mucosa, same with the inside of the vagina, but it doesn't work on the underlying connective tissue and muscle. DHEA does. And that's why I prefer DHEA, vulvar and vaginal, etc. But the other thing is, estrogen can transfer to a male partner, and they typically don't need more estrogen, although there are some men I think could use some estrogen.
Cynthia Thurlow: [00:25:09] Yes. Well, and that's one of the things that you mentioned to me when we were recording for your podcast was how long that estrogen can be transmissible. This was something that I think is very important for women that are using vaginal estrogen therapies to understand that it is not just you insert the vaginal estrogen at night and then by morning if you want to have sex with your partner, in some people it can last, I think 12 to 18 hours is what you had shared with me. And I thought, “Oh my gosh, how many women don’t realize that?” I assumed if I used it at night, but what was interesting was just the understanding that for many of us we assume that 8, 10, 12 hours later.
[00:25:50] But to your point, so many men are insulin-resistant that they don't want more estrogen exposure. That can be problematic. So, how do you typically counsel. So, it sounds like you're using more DHEA products given the fact that it is better absorption, you mentioned, into the muscle, which I think is really-- [crosstalk]
Dr. Anna Cabeca: [00:26:09] It affects the muscle. Yeah.
Cynthia Thurlow: [00:26:10] So, that's really interesting.
Dr. Anna Cabeca: [00:26:12] Yeah. So, you see that and again, I've been doing this a long time, [Cynthia laughs] and as a vaginal surgeon, right, for incontinence, etc., estrogen, it helps decrease the vaginal atrophy, but it doesn't improve the elasticity and the muscle of the vagina and the bladder. And so, I was doing incontinence surgeries and I wanted to get great results. So, I started using DHEA and testosterone vaginally preoperatively. Estrogen just wasn't enough. So, I just replaced it with DHEA and testosterone preop. And then they come back for their preop appointment, like two months. I want them good tissue because you've seen bulletin boards for mesh erosions and all that stuff. I don't want any of my patients to deal with that.
[00:26:56] Well, then they come back in for their preop-appointment a couple days before their scheduled surgery. They're like, “Dr. Anna, I ran 5 miles. I didn't have to wear a panty liner. I'm not leaking anymore.” And I was like, “Good for you, bad for me.”
[laughter]
[00:27:12] So, but that's how I discovered this like using this and the difference it makes over estrogen, it is superior, is far superior to estrogen vaginally, without a doubt. And although there are sometimes still want to condition the vagina with estrogen, I just have found that DHEA in and of itself or with testosterone is far superior. And being a gynecologist too, what really made me look up the research is I had a client, I was doing her Pap smear, and I was like, “There's a ton of cream in here. What is this?” She goes, “Are you kidding me? I used a-- It was a [unintelligible 00:27:50] suppository two days ago.” And I was like, “Are you sure it was two days ago?” And she goes, “Absolutely.” And I was like, “It's not absorbing.” And that thing is the more postmenopausal. If we don't have that good hormonal condition, we have lack of absorption, so it's even a slower absorption rate.
Cynthia Thurlow: [00:28:09] So, I know that if we live long enough in menopause, the statistical likelihood we will develop. It's a terrible acronym, GSM genitourinary symptoms of menopause. I think by age 60, it's like 70%. By the time you're 70, it's 80% to 90%. So, what you're saying is, as we're making this transition from perimenopause into menopause, we're losing estrogen in the vaginal walls. It impacts the pH, which impacts the lactobacillus, which are the microorganisms that are there to help secrete mucus and keep everything moist. I'm going to make analogy. So, if we think about estrogen, yes, it is helpful, but it's not ultimately impacting the elasticity, which for so many women is really the biggest issue with why they're having painful sex.
Dr. Anna Cabeca: [00:29:00] Painful sex and incontinence.
Cynthia Thurlow: [00:29:01] Yeah. And what's interesting to me is how many of my cardiovascular patients were on chronic, long-term, low-level antibiotic therapy because they had chronic urinary tract infections. And if they didn't take the prophylactic antibiotics, they ended up developing significant urosepsis. And so, for anyone that's listening that doesn't know what that is, it's when you can get an infection in the blood, it can kill you as an older patient. And yet we know that vaginal estrogen, DHEA, testosterone are all very safe to use vaginally. They are not systemically absorbed that I'm aware of. Correct me if I'm wrong.
Dr. Anna Cabeca: [00:29:39] Not to any significant degree. They work at the cellular level, but again, depends on dosage.
Cynthia Thurlow: [00:29:46] Yeah. So, something to be thinking about if you are not currently taking one of these. And your Julva cream has been amazing. It's something that I know that jokingly said there was one time we were at an event talking and you opened up your purse and you had a bunch of them and you were just handing them out. And I was like, “This is fantastic.” This is when you are friends with a GYN and they're thinking about your health on such a substantial level. But that's why Julva, I think-- [crosstalk]
Dr. Anna Cabeca: [00:30:12] We get personal.
[laughter]
Cynthia Thurlow: [00:30:14] For sure. Okay. Questions also about HRT. How do you know when to increase estrogen versus progesterone dosing? Are there specific symptoms that you are looking for? I know that's nuanced.
Dr. Anna Cabeca: [00:30:29] Yeah. And again, like, first thing that comes to mind, I'd like to take a look at your genetics. Because some people can't tolerate progesterone very well, and especially oral progesterone. Also, if you're in a high stress state, is shunting directly to cortisol, and you're going to start gaining weight and you will know right away that this is not working for you. And so, there's ways we manipulate transdermally. Certainly, the pregnenolone with progesterone has a nice even distribution and half life, so we have to look at that. And as far as your symptoms, one thing is, I do lab testing, I like to test client’s labs but depending on how you're getting the hormones, whether it's oral, transdermal, troche, vaginal, injection, pellet, etc., it's going to depend on how we look at that.
[00:31:19] Is it going to be blood work? Is it going to be urine? Is it going to be salivary? What are we going to look at? With that said, initially when I evaluate my clients, I look at initial blood works. I look at total estrogens and estradiol level. I look at free and total testosterone, DHEA sulfate. And you've got to look at the thyroid, you've got to look at other markers. I look at other markers for longevity in my routine labs. And then, I typically will follow up with a DUTCH test because I've been doing this 30 years. I'm a good clinician, solid right? And I always teach my physicians that I'm training, ultimately, you have to treat the patient and not the labs.
[00:32:03] There is such bio-individuality to how we need it. So, if deciding to use a low-dose estrogen patch on you to start, I'm also going to counsel you. Look, “You may need more, you may need less. We're going to see how you do with this. And then also we're going to watch your estrogen detoxification pathway.” And the same with progesterone for myself and for many of my clients, we do oral progesterone at night, taking a few breaks, do oral progesterone at night and use the balance cream, the progesterone with pregnenolone during the day. My mind is just better that way. And I notice it has those benefits. So, we've got that covered.
[00:32:45] I have another physician client, and she's on 400 mg of oral progesterone, only bio identical at night. And so that's a heavy dose for me. I need 100 and I use the cream. So, I get it 24 hours distribution versus a 16-hour with just the oral progesterone. So, when we look at those things, what works into your lifestyle, because that matters too. Do you have small children? Then I don't necessarily want topical hormone creams. And I rarely want you rubbing it on your arms where you're going to embrace a kid, let alone testosterone. So, we're going to look at how do we want to use that too, like injection, etc. So, when do we need to increase versus decrease really is individual and it depends on your symptoms.
[00:33:33] There are people and this is where testosterone has gotten into so much trouble. They just like, “Oh, a little is good, a lot's going to better.” And then you're super physiologic until you maybe crash or have some other physiologic side effects. So, you have to pay attention to that. The ebb and flow is really important. It really is bio individuality with that, but knowing if you're still getting hot flashes on estrogen, well, first I really work to make you as insulin sensitive as possible because insulin resistance is a key contributor to unrelenting hot flashes.
[00:34:10] So, if you're still having hot flashes on estrogen and you are insulin sensitive and we need to increase the estrogen, but if you're insulin resistant, we got to keep working on that insulin sensitivity and usually within two weeks, like with your program, with intermittent fasting, with mine with Keto-Green 16 you become insulin sensitive relatively quickly to make a difference.
Cynthia Thurlow: [00:34:34] Anyone that just listened to Dr. Anna's explanation, it gives you a sense of how nuanced hormone therapy and lifestyle measures really are that there's no one size fits all. Obviously, I will tell people that if you want the least expensive, most accessible option, it's probably an estrogen patch and maybe some oral micronized progesterone. Unfortunately, there is no FDA-approved testosterone for women yet, but we hope that that will change. Obviously, there is inexpensive. It should be over-the-counter. I think that's the running joke, vaginal estrogen but now we're learning that we want also some DHEA to help with the elasticity, which for many women is what drives a lot of those vaginal symptoms, painful sex, etc.
[00:35:22] Okay, for females in general with low libido and motivation, where this is going. Talking about testosterone, I'm not going to have you give us, where your numbers like to be for total and free testosterone. Having said that, right now, I've seen some clinicians use AndroGel and use a 10th of the dose, which has got to be really challenging because those packets are pretty small. You can create compounded testosterone creams. What is the differentiator when you go from using the compounded options to using subcutaneous or injectable testosterone?
Dr. Anna Cabeca: [00:36:02] So, looking at subcutaneous or injectable testosterone versus topical, it really depends on your absorption. This is one thing that I recognized in my practice many years ago, is that if I have a client who's on a transdermal hormone, whatever it may be, and they're not absorbing it, they're not feeling any different or they're having to use a significant amount more. They have gut issues, there is a GI issue, there's a dysbiosis, something's going on, clean up the gut. They can use a fraction of the dose of hormones, and it is proven true over and over again. So, I always say our complexion is a reflection of digestion.
[laughter]
[00:36:46] It's really key. So, if we're not absorbing well, we need to ask those deeper questions. But in the meantime, can certainly use injectables, also rapid release oral. I use compounding pharmacies very, very frequently. Probably, the majority of my hormone combinations are compounded because I like tailoring it to the patient plus they can increase and decrease with precision as they get more in tune with what their body's needing. And so, I love the elegance of that, but yet still can use patches and oral. But when it comes to testosterone, I don't like the other ingredients in the AndroGel and I don't like the ingredients in EstroGel. [laughs] There's a list of hormone disruptors in there. And also, again, the risk of transference with those products. So, I'd rather have a woman who has perimenopause in their mid to late 40s or whatever it may be, if we are just small kids, I'm 58 with a 16-year-old not hugging me as much as she used to, but would think, okay, injection instead or a rapid dissolve tablet.
[00:37:56] Those are some ways to optimize the testosterone therapy when it comes to that. But again, it takes more than hormones to fix our hormones. And with that said and being in sexual health and medicine for so long, they created a program called sexual CPR. Because when someone tells me I'm having an issue with my libido, my desire is not there. I'm fine once we get started, but my desire's not there or whatever the situation may be. That's like a six-hour conversation. So, I created a program to really address all the areas that can be affecting us.
[00:38:30] Many people don't realize an antihistamine can affect your desire and ability to orgasm. I mean, little things like that and there's so much, there is so much to it and it's also true in the testosterone replacing community and the clinics. Like, okay, libido is up for the first round or two rounds, but after that, not noticing a significant increase. It really, again, it depends on what's going on. And so that has to be dug into deeper. And usually it always find issues with a dysbiosis or toxins, some toxic burden that is affecting the physiology there when it comes to those-- when you become testosterone resistant. Your libido becomes testosterone resistant and the clients think they just have to go up and up and up and then they have clitoromegaly, hoarseness of the voice, hirsutism and those are challenging side effects.
Cynthia Thurlow: [00:39:32] Yeah. And sometimes they don't go away, which is the bigger concern that, especially for women that don't want to walk around with a very, very deep voice. I have a very distinctive deep voice, but we're talking about male depth, baritone sounding voices. And I think it's so important for female physicians to be having those conversations or clinicians in general, because there's so much shame around sex. I think even though we are evolving as a society, I think there's so much shame around having sex, not having sex, not feeling like having sex. It sometimes can be challenging to initiate the conversation with your provider. What are some of the things that you do to facilitate an environment with your patients that permits them to feel comfortable enough to share? Because I think this is so important, and it's probably very likely intuitively what is part of your personality, but what helps create the space to have those conversations?
Dr. Anna Cabeca: [00:40:31] One thing that I learned to do, as a physician, is always have a conversation with my client first. You're not on the exam table. And that's happened to me. That's why I didn't want my patients to go through that. “Go care, get undressed. Your doctor will come in to see you. And that's your first time meeting them.” I'm like, “Gross, that is just terrible.” [Cynthia laughs] I was in my 20s for my first GYN. I still am traumatized by that experience. It was just terrible. And then lay down and open your legs. “Are you kidding me? This is how we practice medicine. No way.” So, I have conversations with my clients where their clothes on. I like to get to know who my client is because I do ask her personal questions.
[00:41:13] Have you had adverse childhood experiences? Is there a history of sexual abuse? Is there anything else that you want to share with me? As we get into the conversation and talking about libido and it's intimate in my questionnaires also, I want to get to know you, and I make sure that when a patient comes in to see me, they know that I've looked at least some of their paperwork that they've sent in to me. And so, they feel like, okay, you're in safe hands. And I want that feeling when I go somewhere. So, I want that for my patients.
Cynthia Thurlow: [00:41:47] Yeah. It's interesting to me. I can recall being a young woman and getting a referral to a male GYN, and it was exactly that. He could not have been more professional. But I remember thinking, “Oh, my goodness. It's not like you're looking in my ear. I'm having a full pelvic exam.” And literally, the first time I'm meeting you, I'm in a paper gown, flat on my back and that did not facilitate feeling comfortable, at least it's certainly not for myself. Since that point in time, always made sure I've had female GYNs or midwives for that purpose.
Dr. Anna Cabeca: [00:42:22] I have to add in on that because going into this, and you have to ask if patients start to advocate, then we change a system. So, advocate for that, really. But I also, again, I'll talk with a patient in my office first, then go to the exam room. I had a physician in my practice recently. She was my patient and she's like, “No GYN has ever listened to my lungs or heart.” I do eyes, ears, mouth, lungs, thyroid, abdomen before I ever do your breasts and then pelvic exam. So, it just like questions, interaction, get rid of the stress, relax, you're in again. I want my clients to feel like they're in good hands.
[00:43:11] I want to feel that same way. So, I think, we should start advocating for that, honestly to the best of our ability. But it's a challenge in the busy insurance-based practices, you've got 5-10 minutes with a patient. They have to be dressed and ready, but at least to examine them. I don't know, I don't practice that way anymore. But I remember when that was the challenge is still new patients always came into my office first.
Cynthia Thurlow: [00:43:40] Which makes a great deal of sense. And I'll share a funny/not funny story. There was a very well-respected cardiologist male that I used to work with, and when I transitioned from seeing patients in the hospital to the office, he was explaining his strategy, and he said, “You never sit, and if the patient has a list, you have to get it from them.” And I said, “What do you mean?” And he said, “If he who has the list is in control.” And that was his mentality. He said, “I look at the list, I see where the questions are. I answer them quickly so that I can stay on task.” And I think that in many instances, that is what has become modern day medicine for many people.
[00:44:18] It's that they have such little time, and it's not that they don't want to spend time with their patients. It is a byproduct of our insurance industry, and we have to continue advocating for ourselves, because I can't think of any provider I want to see, and I want to feel like they can't sit down and have a conversation with me. And especially when you're in a situation where you're having a female pelvic exam.
[00:44:42] A lot of questions came in around incontinence. Let's briefly touch on-- there's different types of incontinence. What do you think are the things that are most effective for urge and stress incontinence as examples?
Dr. Anna Cabeca: [00:44:54] Yeah. So, when we look at the different incontinence, there are so many. There's postvoid dribbling. So that means after you urinate, you're still dribbling, you haven't completely emptied and that can be an issue with structure, typically the urethra and weakness of the urethral sphincter, the opening of the urethra. And there's stress incontinence, cough, sneeze, laugh, and then you leak. Urge incontinence, like, I got to get to the bathroom and I can't make it there in time kind of feeling, like all of a sudden, I've got the urge to go. And there's overflow incontinence, your bladders get really, really full and start to leak as a result of increased intravesicular, which is increased bladder pressure over that small sphincter for the urethra. And then that pushes, creates pressure on the urethra. So, you have incontinence that way.
[00:45:42] So, there are these different kinds, but I have found that universally, you've got to address healthy vaginal and gut microbiome. You've got to address the gut microbiome in for our repair, prevention, natural secretions, etc., is key to have good normal flora. So that's one thing. With stress incontinence, we want to work on structure and function. So, first we look at, okay, well, what's going on? Is it weakness of the urethra and that's typically what it is, the bladder neck. There's some weakness there, also can make people more susceptible to that chronic urinary tract infection. And this is where we want to do pelvic floor exercises and hormones. For me, I will start with Julva. If I need to, I'll go on to testosterone. And so, we want to improve structure and function.
[00:46:39] If we're still not getting improvement, and then we want to look at, how can we further support this, our anatomical structure, and that's with stress urinary incontinence. We also want to remove things that are proinflammatory to the bladder. Again, that's why check your urine pH, get it alkaline, make sure you're on a good probiotic or eating good probiotic-rich foods. Want to decrease inflammation in our body. Inflammation affects every aspect in our body including our bladder. And then certain foods can be triggers for irritability or irritation of the bladder walls. So, especially in the case of urge incontinence. Caffeine's a good example, red peppers for many are good examples and I’m just starting tell clients to keep a bladder diary. First of all, how frequently are you going through the day? What's your trigger? Are you emptying completely? relaxing, emptying, taking extra 10 seconds and then getting up and going about your day. So, figuring out what is helping and what's not.
[00:47:48] There are medications for urge incontinence, there are adrenergic blockers such as Detrol LA. That's a very common one that’s prescribed, that contributes further to dry eyes, dry mouth, and dry vagina. So, I haven't written a prescription for that in decades. But really through dietary nutrition, there's a lot that can be done for the urgency. And again, same thing. Even with urgency incontinence, these symptoms will resolve with appropriate hormonal therapy and improving inflammation.
Cynthia Thurlow: [00:48:21] It's really interesting/exciting because I think when I was a new nurse practitioner, I can’t tell you how many of my patients were on these drugs like Ditropan, that dry everything out. So, you just exacerbate. It’s like one drug treats one thing and then creates five other symptoms. And that has been the mainstay in many instances with some of these chronic issues. Where does vaginal rejuvenation fall into? When I say this, a lot of the lasers that you’re seeing that are being utilized, I’m not per se talking about vaginal rejuvenation surgically, but the lasers that seem to be cropping up, I've even seen them in nonmedical offices. And I can't fathom [Cynthia laughs] going somewhere other than a medical facility for a procedure like that in such a sensitive body part.
Dr. Anna Cabeca: [00:49:09] Oh, absolutely. It's evolved over time. Like now we can use red light and radiofrequencies which are less traumatic than the many laser versions of old. And so, one thing that American college were talking about vulvovaginal rejuvenation procedures, ACOG or American College of OB/GYN came out with a statement a few years ago that said, while it may show some benefit pre-menopause, post menopause has no benefit. And the reason that statement came out that way was, first of all, if you don't condition the vagina like you said, it'll get drier, thin as we age. We don't want that. So, we reverse the hands of time by using the hormonal therapies. Nothing better. No hyaluronic acid by itself, nothing better than using.
[00:50:01] For me, it's the DHEA and/or DHEA and testosterone, sometimes combining progesterone and estrogen in there too, if I'm not getting where we need to be so to speak. So, when you recondition the vagina, radiofrequency, etc., works really, really well to help with strengthening and tightening the pelvic floor, to improving vaginal and vulvar conditioning, and then to maintain those results. I tell clients one of the best ways for vaginal rejuvenation is to use a vibrator, seriously. And now they've got some redlight vibrators, combination of red light and vibration. That's a nice combination, put Julva on it or hormonal cream, insert it into the vagina, watch 10 to 15 minutes of Instagram scrolling or whatever, [Cynthia laughs] and then you're good. That can really help. [laughs]
Cynthia Thurlow: [00:51:01] I think it's important to have these conversations because many people are not having these conversations. That's why I love you as a friend, but also all of the wonderful work that you do to help support women at whatever stage of life they're in. Now, I would love for you to share what's new? What are you working on? Are you working on a new supplement? Are you writing a new book? You're always working on something.
Dr. Anna Cabeca: [00:51:27] I am and I would say all of the above right now. [Cynthia laughs] You know, it's always like, “Okay, I have to hold myself back from doing too much at any one time,” but I'm working on my next book. Our mutual friend and writer is not available. It breaks my heart. So, I am slowly working on my next book, and I'm also creating a lubricant because there's so much junk and like Julva helps you can use it as a lubricant, but also, adding additional lubrication that is therapeutic specifically for the menopausal or postmenopausal vagina. So, it's a combination of really nourishing ingredients and gives that nice sensation and feeling. So, been working on that. Hope to have that out by early next year. I'll send you some as soon as I get it. You can be one of my beta testers, actually, I'll say I have a beta test here. I will send you a bottle today.
Cynthia Thurlow: [00:52:21] Oh, please do. I'll be excited.
Dr. Anna Cabeca: [00:52:23] You will love it and it's clean. There is no nasty chemicals, there's no aspartame, there's no propylene glycol. Yeah.
Cynthia Thurlow: [00:52:30] So, it's a shame when you think about a lot of things like parabens and things that are in products that we're putting in such a sensitive body part, it's mind blowing. And ultimately, it's done because the ingredients are likely inexpensive. But ultimately, in such a vascular sensitive body part, you don't want to have those kinds of things.
Dr. Anna Cabeca: [00:52:50] And then like Vaseline or something. That's just terrible. And you don't want to decrease sensation. You want to enhance it especially.
Cynthia Thurlow: [00:52:59] Yeah, absolutely. Absolutely. All right. Please let listeners know how to connect with you, how to purchase your books, purchase your products, find you on social media.
Dr. Anna Cabeca: [00:53:08] Yeah. So, definitely come to my website, dranna.com, and have my hormone masterclass going now, my Magic Menopause 8-week program. So, a way to work with me virtually in that program as well as on social media at @thegirlfrienddoctor. So. And let me know that you heard about me here with Cynthia.
Cynthia Thurlow: Awesome. Thank you again, my friend.
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