Welcome to today's special AMA episode, where we dive into questions from listeners regarding supplementation to support hormonal health, hormone replacement therapy, and the specific circumstances surrounding perimenopause and menopause.
We have included the relevant research links with actionable information to take to your providers. We will also happily share the provider PDF we compiled featuring experts across the United States who specialize in perimenopausal and menopausal hormone replacement therapy and links to MIDI Health, a telemedicine company I find beneficially conservative in that they can provide access to appropriate FDA-approved options to help women use their insurance to gain access to estrogen patches, oral micronized progesterone, and compounded options inexpensively.
I know you will find all the information about hormone replacement therapy, perimenopause, menopause, and targeted supplementation invaluable, and please keep on sending us your questions.
IN THIS EPISODE YOU WILL LEARN:
What are the benefits of DHEA for pre-menopausal women?
Why the keto lifestyle and cardio exercise may not be giving Mary her desired results
Amanda asks about incorporating estradiol into her hormone replacement regimen
The difference between micronized and compounded progesterone
Can Jody start HRT at 72?
The symptoms of estrogen dominance
What are the optimal estrogen and progesterone levels for brain, bone, and heart health?
The importance of cardiovascular risk assessment for women on HRT
The complex interrelationship that exists between hormones and neurotransmitters
Is HRT safe for women with a family history of cancer?
Why strength training, quality sleep, and stress management are all essential for menopausal women
“With a keto diet, you want to burn your internal body stores of fat. You don't want to be eating copious amounts of fat.”
-Cynthia Thurlow
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Transcript:
Cynthia Thurlow: [00:00:01] 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.
[00:00:29] Today, is an extra special AMA #11 really dialing in on listeners questions with regard to supplementation to support hormonal health as well as hormone replacement therapy and specific circumstances and indications in perimenopause and menopause. I was wonderfully overwhelmed with questions. I did my very best to keep this a tight 60-minute recording. I am so excited to share this with my community. We will be including relevant research links so that you will have actionable information to take to your providers. And as always, we are happy to share the provider PDF that we've compiled with experts across the United States who are working with women on perimenopausal, menopausal hormone replacement therapy as well as links to Midi Health. I have no affiliation with them but they are a telemedicine company that I believe is conservative in a good way in being able to provide access to appropriate FDA-approved options for women that you can use your insurance and you can inexpensively get access to estrogen patches, oral micronized progesterone, etc., etc., as well as compounded options if that is what you are looking for.
[00:01:51] With that being said, I don't want to delay the start of this podcast episode again all about hormone replacement therapy, perimenopause, menopause, and targeted supplementation. I know you will find this information invaluable and keep your questions coming.
[00:02:09] So the way this is going to work is I am going to read questions. I will not give the person's last name, I will just simply provide their first name. We are focused a lot tonight on questions surrounding HRT, perimenopause, menopause, things of that nature. I've got a couple of questions on thyroid, some really really good questions and then there were an intersperse of all sorts of other questions that we'll save for another episode.
[00:02:34] Okay, Allison says what are the benefits of DHEA for premenopausal women? What are the side effects? Are there women who shouldn't take it? Okay, DHEA is a hormone just like a lot of other hormones. It's chemical messenger in the body. DHEA declines with aging just like so many other things do. And so, when I think about what's upstream from DHEA, our bodies can make testosterone. And so, do I think there's value in replacing it? Yes, but here's the but, it's always thinking about what are the things that are driving it to be low to begin with. Is it chronic stress? So many of you are chronically stressed out. You are so well adapted to being chronically stressed, you don't even realize you're chronically stressed. So, when I'm looking at labs and I'm trying to figure out why a premenopausal, before going through menopause, woman has low DHEA, I start thinking about chronic stress. There's a lot of things that can contribute to that, but chronic stress is one of them. Do I think every woman needs it? Depends on the woman, depends on the patient, depends on their symptoms.
[00:03:38] So, the question is, do I personally use DHEA? Yes, I do think that there's value in using it. Does my husband take DHEA? Yes, at a very different dose. Because as a female, I don't need nearly as much as a guy does. And so, for me personally, I take 10 mg a day. My husband takes 50, so I take 20% of his dose. But I think that the question is always, are we managing? How do we redo our email for updates? Oh, Jamie's answering that, so I'm not going to comments until I'm done with questions. So, I think that, Allison, it really depends on you as an individual. What does your testing show? What are your symptoms? And then we kind of go from there.
[00:04:18] Mary said. “When postmenopausal, why is keto lifestyle and cardio exercise not giving the desired results?” Mary, this is a really good question. I can tell you that I have been knee deep in the research on the gut microbiome, and this is why many times women will say, “I did a keto diet, I gained weight, or I didn't have the results I was looking for.” It can have everything to do with the composition of your gut microbiome. So, I always look at it. Are you doing a keto diet? And I use this term the right way, meaning you want to burn your internal body stores of fat. You don't want to be eating copious amounts of fat. I think of a lot of people that do ketogenic diets think they mean they can eat five avocados a day and two sticks of butter and all the fatty meat they want. That's not really the way the ketogenic diet is meant to be done. It's meant to be done yes, you have lower carbohydrate, moderate protein, maybe you have some higher fat items, but it is not-- You get to eat all the fat and have no weight gain. So, I typically will talk to women about, what's going on in the gut microbiome and there's not one stool result I have looked at in the last eight years that does not have something abnormal that can be worked on.
[00:05:31] So, I would say stool testing, gut health testing, looking to see what's going on. Cardiovascular exercise is not an effective way to lose weight. I'm going to say that again. Cardiovascular exercise is not the reason that you do it. You do it because you enjoy it. But that's not a mechanism for weight loss. Strength training is, potentially high intensity interval training. But I would say there's something larger to look at in terms of why you are weight loss resistant because I'm assuming the desired results are body composition changes, so, there's a lot to that. These are the kinds of things that we unpack in programs. But I would say that those are things to think about. Gut health and strength training, those are going to be very, very important.
[00:06:12] Okay. Tina asked, “How many milligrams of DHEA is appropriate during menopause? When should you take the supplement? Is the keto form better than the regular DHEA?” So, I just talked a little bit about DHEA, but what I would say is typically I used to recommend taking it in the morning, but there's now some research to suggest that it helps with lowering cortisol before bed. So, there's some research to suggest it might be helpful to take it before bedtime. Especially if you're dealing with a lot of stress, that might be helpful. Generally, I'll say it's most important to take it when you can remember to take it, really, that's really what it comes down to.
[00:06:47] The keto form of DHEA. So, there's products by designs for health. It says 7 keto DHEA. The thought process is that does not run the risk of changing over from testosterone to estrogen, that aromatization, which is a fancy way of saying taking testosterone and making it into estrogen. For anyone that doesn't know that that does happen. I'm only really concerned about that if someone has like PCOS or we're really wanting to be conscientious and careful about their testosterone level. So, I frankly no longer use those products. I really just focus on regular DHEA.
[00:07:21] Amanda asks, “When is the next time to incorporate estradiol into my hormone replacement regimen, I feel I need it, but I'm still getting cycles.” What I can tell you is a woman's perimenopausal journey is as unique as she is. So, the research is now suggesting that initiating estrogen prior to menopause has benefits. The challenge is when? And so, we know that during perimenopause, we have some of the highest levels of estrogen of our entire lives. These wild fluctuations. That's what drives a lot of symptoms. The brain fog, the weight loss resistance, the breast tenderness, the bloating, etc., etc., etc., in the setting of low progesterone, because our ovaries aren't producing as much, that is what is driving this relative significant imbalance.
[00:08:13] So, the question that Amanda is asking, when's the right time to do it? I think it's when you start having symptoms. I just interviewed Esther Blum on the podcast again, which is always a pleasure, she's in her early 50s, and she said she just got to the point where she needed an adjustment in her estrogen patch. She's still cycling, but she started having trouble sleeping, a lot of vasomotor symptoms, a lot of sweating, a lot of feeling anxious. So, I think symptoms drive treatment decisions more so than labs. We go back and forth about, do we want to tailor hormone replacement therapy solely based on labs? I think the most important thing is based on symptoms. So, Amanda, the question is really a great one for your provider to ask them. When do they feel comfortable initiating estrogen. probably an estrogen patch? Maybe it's super low dose. Maybe you're wearing the patch at 0.025, which is teeny-tiny dose, but at least it's something, right? And for some people, that can make a big difference.
[00:09:14] Okay. Nikki said, “Two months ago, I started on an estrogen patch and I take progesterone, which I feel has improved my sleep quality. Over the last two months, I've gained a couple pounds and often feel bloated by day's end. I also have a GI map showing dysbiosis. GI map is a stool study, also showed H. Pylori and low secretory IgA, which is immune response. I will be starting a purification program. My question is, when would the hormones contribute to these symptoms? I think it's a lot of things. I think that most women in perimenopause are going to have a time that they're going to hit a wall, they're going to be feeling really good for a while and then they hit a wall and everything changes. And it doesn't mean that it's permanently changed. It just means that it's almost like pulling a lever to see what the response is. So, you've been on the estrogen patch and the progesterone for two months. You might need a little bit more time. You may need an adjustment in your patch dose. It could very well be that the underlying stuff that's going on in the gut might also be driving some of these symptoms.
[00:10:19] When I start seeing women dealing with weight loss resistance, it can be many, many issues. Gut health, sleep, stress management, imbalanced hormones. Sometimes it takes a period of time to get things really dialed in. And so, I think for many, many reasons. This is where I would say, you know, Nikki, I think working with your provider because she also mentioned she's in the midst of adjusting thyroid dosing-- could be many things. It may take a couple months to shake things out. And I'd say this to anyone, don't focus on the number on the scale, get body composition measurements made either with BOD pod or looking at bioimpedance scales because you want to look at fat free mass to muscle mass. That is very important because we know what starts to happen. The slippery slide of perimenopause and menopause is we start putting on more visceral fat, more fat around our bellies, we start seeing body composition changes. And so, it's very important to get a sense of what are we really dealing with. Is it just subcutaneous fat, which I know is annoying, or is it visceral fat, which is the inflammatory fat that can go on to develop insulin resistance and things we really want to avoid.
[00:11:34] So, Nikki, I think this is a very nuanced question. It's a very good question, but I think there's probably going to be multiple things that need to shift and then re-acclimate. She also mentions in here she went from standard thyroid replacement to now she's on compounded, sometimes that takes a little bit of time to figure out. I actually just did an IG story talking about how one 18-month period of time I'd been on 10 different thyroid medicines. Not kidding. Sometimes you just have to really work with someone that is nuanced and knows what they're doing, is really conscientious about it. So, give it time. Sometimes it takes a couple months to shake things out. I'm innately sensitive to that because I have been there. I know how frustrating it is, especially when you feel like your body is sort of working against you.
[00:12:18] Next is a question from Jen. She said, “If you use up all your eggs ovulating, how do you use up your eggs when you've been on birth control since your teens?” It's an interesting question. And so, Jen, I did a little bit of deep dive because I wanted to be able to give you numbers. So, at birth, women have 1 to 2 million eggs. By the time we get to puberty and they define puberty as like 11 to 12 years old, we have 300 to 500,000 eggs. Then we're really at peak fertile years, sadly, from 18 to 31. So many of us weren't ready to have babies at that time frame, but that's when our fertility is really primed. At the age of 32, we have 120,000 eggs. At 37, we have 25,000. See how our fertility really starts to take a sharp dip? At 52, we have less than 1,000. So, irrespective of whether or not your body is ovulating every month, you are losing eggs. Our eggs are as old as we are. So, I'm in menopause. I probably have some eggs hanging around, but they're not doing anything. I'm no longer fertile, but you see that precipitous drop off after the age of 30 in your fertility. That is why it's much harder for women to get pregnant as they get older.
[00:13:31] Now, some people get pregnant very easily. We know fertility rates are starting to fall. It is not just issues with women, it is also issues with men. But that was a good question. But just to give you perspective, we start with 1 to 2 million and we end in menopause with about a 1000. We just precipitously lose eggs. We're not like men, where men can replenish sperm every three days.
[00:13:51] Okay, a lot of different questions. How are you recommending dosing for micronized progesterone” This is from Jennifer Knightly, “or dosing differently in follicular phase versus luteal phase?” So, the answer is. It depends. Number one, micronized progesterone is the generic formulation that is immediate release. It is manufactured in peanut oil. So, you have a peanut allergy, you can't take that. But it works like you take it and it starts working right away. I think that if you're in perimenopause, it depends. Some women just need it the week before their menstrual cycle. Some people need it two weeks before their menstrual cycle, so that's the luteal phase. The hallmark of the beginning of perimenopause is less circulating progesterone because your ovaries are getting ready to go into retirement. Remember, I just talked about the eggs? Our egg reserve just starts to precipitate and drop off. So, when we talk about progesterone therapy, for some women, they really need progesterone therapy two weeks of their cycle. Some women need it one week of their cycle. The farther you get into perimenopause, you may need it throughout your cycle.
[00:14:57] Obviously, women in menopause benefit from taking it typically six days a week or having three to four days off a month, however you want to make that work. And that's to keep the receptors kind of sharp. But I would say that, starting with the cheap stuff, the micronized progesterone made with peanut oil, that is very inexpensive. It is immediate release. For a lot of people, that works just fine. For a lot of others, they need compounded progesterone that has sustained release so that it's a longer acting medication and that is compounded in a pharmacy. Usually, the dosing patterns are anywhere from 50 mg to 200 mg. There's someone in my Facebook group that was saying they were on 600 mg of progesterone. I'm not sure I've ever seen that. Having said that, everyone's an individual. Dr. Lindsey Berkson talks a lot about progesterone. She's actually a fan of progesterone, both intravaginally-- so placed inside the vagina as well as oral progesterone really depends on the individual.
[00:15:57] Jodi asked, “As a healthy fit woman at 72, can I take HRT if I've never taken them in earlier years? Risks and benefits.” Jodi, this is a great question, and what I would say to you is it depends. “Can you start vaginal estrogen anytime?” Yes, because it is localized to the vagina. So, if you're having a lot of genitourinary symptoms, chronic UTIs, friable skin, pelvic floor issue problems, incontinence, vaginal estrogen, you can start at any point. The other issue is how many years have you been into menopause? And I actually had a discovery call today and we talked about this. There's this opportune time to initiate hormone replacement therapy, and that has a lot to do with what starts to change internally in the blood vessels. The endothelium which is this lining of our blood vessels. We know with less and less estrogen circulating that there's more and more inflammation, oxidative stress. And so, it has to be very much a conversation about risk benefits. I think that even if you're healthy at 72, you probably have had 20 years of no exposure to estrogen, and so, you really have to do a very thorough cardiovascular workup. You really have to look closely at labs. You have to have a conversation with a provider that's willing to have that conversation.
[00:17:13] I think the longer you are in menopause, like when you get over 10 plus years, I think a lot of providers get a little hesitant. I can tell you that a lot of my colleagues and I believe this fervently vaginal estrogen, you can start that at 90. I mean, if you're having those symptoms of genitourinary symptoms of menopause, I think that we have an obligation to offer that to women because it stays localized. It's not a systemically absorbed drug, or if it is, it's very minimal. But my statement to you, Jodi, would be we would have to find a provider that would be comfortable having that conversation and also doing a very thorough cardiovascular workup to make sure there's no plaquing. We know that timing hypothesis is one that a people embrace, that there's an optimal time. A lot of us will say it's the first five years into menopause or starting prior to menopause, maybe up to the 10 years. I've had women in programs that have been told you're over the age of 60, I'm not willing to give you hormones, which I think is ridiculous. There's a lot of very healthy people, but they have to be able to provide some degree of risk assessment, and that's where a very talented, competent, conscientious provider could help you with that. The question is finding that person in your area.
[00:18:28] Jess said, I love your mission so much. I'm 40. I have estrogen dominant symptoms, which means I had extremely dense, sore breasts before my period. My DUTCH test, which is generally a urine and saliva test from a few years ago, showed that my estrogen was going down an unfavorable pathway. She mentions my liver doesn't clear toxins or estrogen well. She has a family history of breast cancer. Could she still benefit from HRT? Okay, just because your family member, your aunt died of breast cancer, that is not a contraindication to taking hormone replacement therapy. I'm going to say this again, just because your first-degree relative or second-degree-- that’s a second-degree relative died of breast cancer, that's not a contraindication. This is where having a really good discussion and having a really good history with your provider is going to help illuminate what you need to be focused on.
[00:19:23] I just interviewed Dr. Corinne Menn. She is a breast cancer survivor. She was diagnosed at 28. She is counseling women almost daily basis about the cost benefits. She is a breast cancer survivor and she is now on hormone replacement therapy. So, you really have to work with someone that understands the risks, like not just the relative risk, the absolute risk, and can properly counsel you. Jess also mentions “My progesterone is almost non-existent on my recent labs, which is common in perimenopause. When I added over the counter progesterone cream, I felt more moody, hot flashes and worse insomnia.” Okay. I'm not a fan of progesterone creams. I think that if you are taking progesterone for the purposes of replacing hormones orally is going to be superior to something transdermal. If you are in menopause, the only option is oral. If you are in perimenopause, you might be able to get away, at least initially, maybe with some cream, but if it's over the counter, we don't know. I mean, there's so many variables that can impact how it's absorbed, what formulation it is. Yeah, and especially, I think that this is where working with someone that is experienced and can walk you through the benefits of oral, even if it's just for a week or two out of the month. I think given the degree of high estrogen dominance symptoms you're experiencing, based on what you said here, you may really benefit from oral progesterone therapy, but discuss that with your provider to see what they think.
[00:20:52] Liz says, “If menopausal on HRT, what are the optimal estrogen and progesterone blood levels to help protect brain, bone and heart health? This is a great question and I'm going to go back to saying there are some providers that treat based on symptoms. There are some providers who like to look at labs. I can tell you that it is a very-- It's like the wild-wild west right now. There are certain camps that people as clinicians fall into. I think it is much more important that we are monitoring your symptoms. So, if your symptoms are quiet, does that mean that we should bump up your estrogen? Possibly, but I think there's a lot that remains to be seen. You'll see some numbers for bone and heart health greater than 50 mg/dL. Some people don't tolerate that much estrogen, number one. I see other clinicians that are using oral estrogen, which I know depending on the researcher that you follow, some researchers feel like that's the best form of estrogen to protect your heart. We can't right now measure brain estrogen levels.
[00:21:56] Dr. Lisa Mosconi and I kind of talked around this. She's doing research in this area. I'm actually part of her research study. So, I do plan on asking her more about this. But I think that the question is I think it's more important to be on some hormone replacement therapy than get obsessive about what those certain values should be. I can tell you with testosterone that a lot of providers get funny when women have-- Depending on whether it's a Lab Corp or quest, you can have free testosterone levels anywhere from 6 to 8 to 10 mg/dL, and that's where they like those numbers to be. I think people get a little more antsy around testosterone, although they think that's silly. If you're on pellet therapy, you know that you're not going to have a therapeutic number. You're going to have supratherapeutic numbers just by virtue of the pelvic as opposed to transdermal applications, oral applications of drugs.
[00:22:48] So, Liz, not to not answer your question, what I can tell you is there's a lot of consensus and I think providers are really, for the most part focused on symptom reduction and symptom amelioration, meaning getting rid of the symptoms, than they are on driving it towards a number, an empiric number. I can tell you personally that there's a ratio that we want to see ideally with progesterone and estrogen, and that can get a little bit of a sticky wicket in terms of depending on who you're talking to. So, I will just leave it at that and tell you that I've had many providers on the podcast and their opinions on this are very variable.
[00:23:31] Cavs says, “I am 45 years old and I have trouble with sleep only during the luteal phase of my cycle. Anything to help with this other than HRT?” Well, I would say, lifestyle. So, if you know that your progesterone levels are low in perimenopause, to me it makes sense to give progesterone, call me crazy. I don't think there's no other supplement that's going to mimic what progesterone does in the body. And one of the things that progesterone does is it upregulates a particular calming neurotransmitter called GABA. So, I would say during luteal phase of your cycle, take some oral progesterone, call it a day. The lifestyle stuff is important. Some people do better increasing either high quality carbohydrates. Some people do better with restorative yoga and less intense exercise. I think that a lot of it has to do with you as an individual. But oral progesterone, call it a day, make it easy.
[00:24:27] Alicia said, “I'm 49 with regular cycles, but I'm experiencing increasing perimenopause symptoms, heavy periods, increased PMS, irritability, and sensitivity. I got a prescription for 100 mg of oral progesterone to take the second half of my cycle. When I've tried it seems to give me a lot of bloating and just not quite feeling right. I'm not sure if I should continue to take it and see if I adjust it or maybe I'm just not in need of this hormone yet.”
[00:24:56] At 49, you are in perimenopause. It may be that you need a lower dose. It could very well be. I have some people that are on 50 mg. It could be that you just find it sedating. Some people need to take it earlier in the evening. I would say talk to your provider that wrote the prescription if taking 50 mg might be something worth considering. The fact that you're getting increasing symptoms tells me that you definitely have lower levels of progesterone, that's what's driving the heavy cycles, the more PMS, the irritability. For a lot of people, they've gotten so accustomed to having low progesterone levels for such a long period of time that when they start kind of adding in a little bit of progesterone therapy, sometimes it can be too much too quickly. And so maybe backing down on the dose might give you some improvement. But again, talk to your prescribing provider.
[00:25:46] This is just a first initial C. “Good morning, I have the Mirena IUD and was put on 100 mg of progesterone daily.” So, the Mirena IUD is synthetic progestin IUD. So, it's creating some synthetic progesterone and she said, “I'm put on oral progesterone as well. I was wondering why they told me not to cycle it just the last two weeks of my cycle. I'm not sure I know what the question is. Wondering why they told me not to cycle it just the last two weeks of my cycle.” So probably because in the luteal phase of your menstrual cycle, that's when progesterone used to predominate and now there's less circulating progesterone. So, some people do fine with both. I have some older patients that they have a progestin IUD put in because they don't want to deal with taking progesterone and they're using it to project the uterus. So, I think that there's a degree of experimentation. And yes, typically when you start taking oral progesterone, it's usually the week before or two weeks before your menstrual cycle starts, if you even get a cycle and if you've got an IUD and you may not be getting a cycle at all.
[00:26:48] Okay. Lynn said, “I'm 54 and postmenopausal. I haven't had a period for about 10 years. I just started HRT two months ago that includes an estrogen patch, progesterone, and testosterone. I've had breakthrough bleeding the same time month since starting it. The first time includes bad cramping, but second time was only bleeding. I've had a vaginal ultrasound.” So, these are all the things you must do. Menopausal bleeding is important to share with your prescribing provider to get evaluated and it sounds like Lynn did the right thing. She had a vaginal ultrasound, showed a normal uterus lining. “I'm scheduled for an EMB in February-- it's an endometrial ablation. Is there anything I should be concerned with or anything else to consider that might be the cause for breakthrough bleeding?” It sounds like if they're going in to do an ablation because they want to ensure that you have no further bleeding. So probably a great conversation to have with your GYN, who's going to actually do that procedure?
[00:27:45] April said, “How will you know if menopause HRT is working if you do not have symptoms and are using for heart vascular benefits?” April, it's a really great question. And in talking to the experts, the people that are at the forefront of all of the research on this, some of them are talking about oral estrogens and I know that that's not popular and it certainly would not be my first choice, but it sounds like 1 mg of oral estrogen appears to be very, very cardiovascular protective. A lot of people don't want to take oral estrogen. You get a very, very big first pass effect which means it goes directly to the liver and all of the side effects of estrogen are magnified. This is people that are greater risk. Remember I said greater risk doesn't mean it is your risk, its per se. Greater risk for blood clots, for bloating, for things like that. There are patients that do really well on 1 mg of estrogen. And so, my feeling is it's really dependent on who you follow in the research.
[00:28:47] People like Dr. Amy Killen, who's been a podcast guest before. She'll be back on. I'll actually see her in a couple weeks. She talks a lot about this on social media. That that's really what the research shows. That doesn't mean it's the right decision for everyone, right? I probably wouldn't feel great taking 1 mg of estrogen. I do a whole lot better with a patch and that works for me. I think that we're looking and trying to assess cardiovascular risk. It's looking at all of the factors. It's not just hormone replacement therapy. Do you need to have a coronary artery calcification? If there's real concern, you can get a CT angio which is going to look at-- it's going to be more detailed in terms of looking at plaquing, looking at special carotid ultrasounds called a CIMT, looking at those advanced lipid markers like I talked about with Tom Dayspring, the APoB, the LP(a), not looking at particle size, making sure your triglycerides are low, making sure your fasting insulin is normal, making sure your other types of inflammatory markers are normal, that includes high sensitivity CRP, ferritin, etc., all those things factor in. It's not just one thing. Maintaining a healthy weight, making sure you're sleeping, making sure you're managing your stress, eating anti-inflammatory diet, all of those things are important.
[00:30:03] But I know a lot of us like quantifiable information. We like to be able to look at a number and say “Check the box. My number's X. It's within that therapeutic range, therefore I'm protected.” I think there's a lot more to it than that. That's my personal feeling. And as someone who spent 16 years working in clinical cardiology, there is so much to it. We know women are more likely to develop small vessel disease. We don't per se develop big vessel disease like the left anterior descending artery, the right coronary artery, circumflex, etc., those big epicardial vessels that men have stented and men have bypassed. More often than not when women have heart attacks or myocardial infarctions, they end up in the cath lab, they don't always have vessels that can be stented or opened. Women are known for having small vessel disease. It's one of the reasons why we present differently. So, I think when it comes to us, that we have to take a nuanced approach. As Dr. Corinne Menn said today, you should be able to walk and chew gum, meaning we have to be able to think about multiple things, multiple considerations at the same time. And again, it goes back to that risk benefit, having discussion with your provider, making it very clear what your focus is and then determining what the best option is for you.
[00:31:23] Okay. Kristen said, “I know gut health is important for menopause as our diversity decreases.” That is correct. “When doing a gut stool test, do you recommend using biofilm busters a couple weeks before in order to expose pathogens that otherwise may not show up? “The answer is no, I do not do that. When I'm ordering stool testing, I'm generally letting my patients take all their normal supplements and their normal medications because I want to know what's going on. “How do you decide if you need to kill pathogens and possibly lower good bacteria or just increase good bacteria to [00:31:54] out the bad?” Kristen, that is a really good question. That is a question that a lot of it depends. When I'm looking at stool testing, which for everyone that's listening, poop testing. When I'm looking at poop testing, there's a lot that goes into it. What does the keystone bacteria look like? Do you have dysbiotic organisms which are weeds in the garden, effectively? Do you have parasites? Are you not able to break down fecal fat? Do you have a lot of inflammation going on in your colon? Are you able to mount an immune response? Are you recirculating your estrogen? There's so many factors that as a rule, I have never, ever in the last nine years of doing this, I have never given biofilm busters. Those are things like could be chlorella. I mean, there's just a lot of SerraGold. There's a lot of streptokinase things that will kind of--
[00:32:46] When we have an organism in the body, kind of like you go to the dentist, I'm going to give everyone a real-world example. Plaque on your teeth is a biofilm. What she is referring to is giving supplements that will break up the biofilm so that we can see what's underneath there. I have done this long enough that when I look at a stool test, if someone has SIBO, small intestinal bacterial overgrowth, SIFO, small intestinal fungal overgrowth, parasites, I’m already thinking, what are the patterns I'm seeing? I do not need to use that as a diagnostic tool. I think it's probably not necessary and that's not how I practice, but I know that other people do. But I do think stool testing is part of a very effective way of looking at what's going on in the gut microbiome. So, for those that don't know it, my next book is talking about the gut microbiome and the changes that go on in perimenopause and menopause. We do stool testing in the midlife pause. So, for those that are curious, interested, you want to work with a team of clinicians that have worked with hundreds and thousands different stool results. That's one of the things that we offer in that program. It's the only program where we offer testing.
[00:33:56] Okay, Kevin, this is actually from a PA, a physician's assistant. “Thank you for what you do. You've helped me to begin to help a lot of women. I've noticed some patients getting worse ADHD, so attention deficit hyperactivity symptoms when starting hormone replacement therapy, vasomotor symptoms. So that's like the hot flashes, the night sweats, sleep all improved, but more squirrely, three to four into starting treatment. Can you discuss your experience of this any. Again, I appreciate you very much and can only hope to have an impact like you someday. You're helping a lot of people.” Thank you, Kevin.
[00:34:26] Yes. So, I've talked about how I think that your experience with HRT, your experience in perimenopause and menopause is as unique as you are. Are there people that when they get started on hormone replacement therapy, do they have an uptick in symptoms? Yes, because one of the things that a lot of people forget is that these hormones have a complex interrelationship with neurotransmitters, serotonin, dopamine. Sometimes they can stimulate excitatory neurotransmitters like glutamate. So, you have GABA and glutamate. GABA is inhibitory, Glutamate is incitatory. And so, a lot of times when you're giving people hormones, you can inadvertently kind of strum up for them. You can strum up some excitatory neurotransmitters that at least transiently, may make them feel like they're a little bit wired.
[00:35:16] And same thing can happen with adding in thyroid replacement. And it happened to me personally, when I started thyroid replacement, I would go through two weeks of insomnia. That was awful, but then I felt better. But the same type of thing can happen when you're adding in hormones. We know that progesterone tends to be inhibitory. Estrogen and testosterone tend to be excitatory. So, if someone is dealing with a lot of ADHD symptoms, sometimes they need progesterone on board first to calm things down before you add in estrogen or testosterone. That's been my clinical experience. But, Kevin, thank you for the work that you do because you're helping a lot of women and that's important.
[00:35:56] Okay. A question from Chris saying, “Is it common to have breakthrough bleeding after starting hormone replacement therapy? I'm a 62-year-old female who started about six months ago on HRT.” See, you can be older and start HRT. “And have had subsequent times where there's been some breakthrough. Does not happen daily, but I'm just curious how common this is, I'm on both estrogen and progesterone.”
[00:36:16] So first things first, I was always taught the first couple months, first three months you're on HRT, very common to see a little bit of breakthrough bleeding. It should be transitory and goes away. I always encourage patients, if you have breakthrough bleeding, tell your GYN, tell your prescribing provider. So important to have that conversation just so it's documented. More than likely it is nothing. However, always best to err on the side of caution, why is that? Because we assume as clinicians, breakthrough bleeding is a problem until proven otherwise. We heard in one of the other questions that someone had a transvaginal ultrasound. They're looking is to measure the lining of the endometrium to make sure it's not too thickened. We also want to make sure that there's no sign of any malignancy or anything that sounds or looks cancerous. It sounds like Chris is just having that little bumpy ride into hormone replacement therapy. So, provided that Chris is discussing this with her treating provider and they're monitoring it closely, it's probably okay. But again, never, never, never assume. I always say assuming makes an ass of you and me, never assume, always report those symptoms. It happened to me about two years ago and my local GYN was great and we did a transvaginal ultrasound. It turned out to be totally normal. She was like, “This is what we're looking for. This is what we have to do.” She said, “I always would rather err on the side of caution,” which is the same way I feel. Report it, get it evaluated, and if it's nothing, then you have that peace of mind. And that's what I would say is, Chris, just make sure you're having a conversation with your treating provider.
[00:37:51] Amber said, “I've been on HRT for years. I've used estrogen for 28 days and break until five days after my period starts. I've used progesterone for the last 14 days of my cycle. But now my cycle is going from 28 to 30 days to around 46 to 48 days. How would you use HRT with the changes?” Amber, that's a really good question for your training provider because I don't-- You are not my patient personally, but this is common to see. You'll get periods that are spaced farther and farther out. So, you went from having like a 30-day cycle to almost a month and a half cycle. And that's what starts to happen in perimenopause. And so, I would absolutely direct your questions to your treating provider because they know you, but this pattern is very common to see. What usually goes from there is when you start getting spaced out more than two months in between cycles, then you know, you're kind of at the end. And by the end, I mean the end of perimenopause, you're probably very, very close to menopause, but I would absolutely discuss that with your treating provider.
[00:38:53] Michelle asked, “I have a question about HRT. I'm a menopausal woman in my mid-50s and I've taken estrogen and progesterone for several years. I've heard it's not safe to take estrogen orally since it has to pass through your liver.” Remember, we talked about this earlier. “But I've tried compounded estradiol cream, which I don't find very effective. I've tried several different patches, but they all gave me itchy red welts,” probably because she's sensitive to the adhesive. “And I just couldn't tolerate them. So just how risky is it to take estrogen orally. Please share your thoughts. Thanks for all the great work you do.”
[00:39:26] Michelle, this is a perfect example of, you know, you've done the transdermal creams which did not work well for me. You've done the patch, but you're sensitive to the adhesive. I think there is nothing wrong with trying in conjunction with your provider talking about oral estrogen therapy. I mean, it's interesting. I'm in a bunch of groups with physicians and this is something everyone struggles with because we've been so conditioned that oral estrogen is so terrible. And the one thing that Heather Hirsch said, she's a leading like GYN in the space, she said, “Gosh, there are just some people, that is what works best for them and we should not shame them, we should not make them feel badly.” If that's what works best for you, Michelle, that is okay, but I would absolutely entertain that conversation with your treating provider so that you, he, and she, you both can have a conversation about risk, benefits and see if it works well for you. I think that we should not be shaming women. You have to find the situation and the route and the things that work best for you and your sanity.
[00:40:31] I wish I had started using an estrogen patch earlier. I think that I went through two or three years feeling guilty about not using a compounded product and I finally just cried [audio cut] this summer and I just said, “I'm done. I'm so done. I want something easy. I want to set it and forget it.” Meaning I put a patch on twice a week, Monday and Friday. Those are my patch days. Super easy. I actually lost a couple pounds when I went on estrogen transdermal patch, probably because my body was finally absorbing some estrogen. So, I think for each one of us, we have to find what works best for us. And there's no shame, there's no blame, there's no pointing fingers. I think that you may just have to be a little more diligent about ensuring you're doing things to help support detoxification in your body, but I absolutely think that if that is what works best for you, and that is what you want to entertain, that's perfectly fine.
[00:41:26] Okay. This is from Robbie. “I'm a 57-year-old woman who's been on hormone therapy for more than a decade. My doctor, an OB/GYN who currently focuses her practice on HRT, gives me estrogen and testosterone quarterly via pellets, but has told me that I don't need progesterone because I have a Mirena IUD.” This is a long question, but it's a good question. “Recently, I persuaded her to prescribe me a compounded progesterone cream to improve my sleep quality, and that provided a significant positive impact. When I asked my doc at the next visit if I could now have my progesterone levels tested quarterly with my other lab, she told me that it wasn't necessary. She is also reluctant to prescribe oral progesterone because of unspecified risks. Note, I do not have a personal history or family history of breast, ovarian, or uterine cancer. In light of the information I've garnered from your podcast, I'm a little concerned that I'm not receiving the most accurate medical advice with regard to my HRT in general and progesterone specifically. I also wonder if she maintains my testosterone levels at a level higher than necessary. I would appreciate your thoughts and recommendations, especially as to whether the progesterone from an IUD is typically sufficient. Thank you.”
[00:42:36] This was such a great question. I wanted to get it all out. So, number one, Robbie if I told you I have 10 pieces of paper on my desk with front and back, Robbie is on a combination of pellets and she has a Mirena IUD. So, this is progestin. So, this is a synthetic progesterone. And her doc is kind of like, “Set it and forget I put pellets in. You've got an IUD. We don't need to do anything else.” But she saw a significant improvement from transdermal absorbed progesterone. Here's my thought. There is nothing wrong with asking for oral progesterone therapy. You could also say to her, if you want, you know, you don't want the IUD. And IUDs usually have about a five-year lifetime. I don't know how long your IUD has been in, but maybe the conversation is you're ready to have your ID pulled out and you want to be on oral progesterone therapy and just kind of leave it at that.
[00:43:33] I don't see a lot of people doing estrogen pellets. I see some testosterone pellet therapy. I think that one thing to remember, and this applies to everyone, is that you are in the driver's seat. This is shared decision making between you and the provider. This is based on what works best for you, what your interests are, what your comfort level of your provider is. My feeling is if you feel like you are interested in entertaining the possibility of oral progesterone therapy, that is exactly what should be done and whether or not timing for having your Mirena IUD pulled out, I don't know how long it's been in, but I would say that, you absolutely have a reasonable expectation. The other thing is, you know you can change your mind. That's the one thing I would tell everyone. You can change your mind. You don't have to do the same thing you've been doing over and over again. If you want to change your mind course correct. I think that's very, very important. So, Robbie, keep us posted.
[00:44:26] Next is Catherine. “I'm 62 and 10 years post menopause. I'm taking HRT and I have Hashimoto's. I'm dealing with 10 extra pounds, sleep issues and belly fat. She mentions here that she was doing some fasting, low-carb diet, walking training. I put ten pounds back on this past year as a result of travel. She mentions that she follows Gabrielle Lyons, Stacy Sims, Mary Claire, Mark Hyman, Jason Fung. I become extremely confused by changing recommendations regarding fasting, macronutrient consumption and Zone 2 exercise. My questions relate to my age, shape and health factors. Does it make sense to replace the Zone 2 plus hypertrophy training with short duration—"
[00:45:06] This is a great question because probably many of you have the same question. She's trying to figure out what should she focus on. I would say the most important thing is strength training. I like Zone 2 training because it keeps you moving, but if you look at the research that Dr. Vonda Wright is doing, she's an absolutely amazing clinician. She's an orthopedic surgeon. She's been a guest on the podcast. She is delightful. She talks about having some degree of HIIT, but it's short HIIT. It's like three rounds of 20 seconds all out sprint if you're even interested in doing that. I think that's certainly very important. Is there a need in place for the former for heart and body shape? I think the thing to remember is we don't want to make things too complicated, right? I think strength training two days a week is important. I don't think you have to spend three and four hours at the gym lifting weights every week. I think that being physically active, so not being particularly sedentary all day long, Zone 2 can be walking up and down in your neighborhood. It does not have to be complicated. You could increase your heart rate just by wearing a weighted vest, not a weighted vest that makes you want to fall over, but something that's thoughtfully there. When I see someone that's 62 and she's gaining belly fat, I start to think about sleep and stress management, anti-inflammatory nutrition, are you drinking alcohol? Are you eating too many sweets? Have you lost so much muscle that is driving some of the belly fat changes?
[00:46:35] The other thing is you didn't mention what you're taking for HRT, but get your testosterone check, get your thyroid checked. All of these are important. Body composition a lot of times can really be driven by low testosterone. And I think people forget this. They think they just have to slap that estrogen patch on and take that oral estrogen and that's going to fix everything, get your thyroid checked. All of which are very important. This is a really great nuanced question and one that, you know, we handle these kinds of things in our group programs. She has quite a few questions. I want to make sure that I get to some of these other ones as well.
[00:47:10] Krista said, “when you don't have a uterus, but you do have your ovaries, what are your options with HRT, with that same patient, when do you know you're a candidate?” I assume brain fog, memory issues, bloating. So, one thing to remember is that even if you still have your ovaries, and so Krista has had a partial hysterectomy, that means they went in, they took the uterus out, they left the ovaries. Even if that surgeon's really, really attuned to the ovarian arteries, the arteries that feed blood flow to the ovaries, sometimes the ovaries can still be damaged, that blood flow can still be damaged. So, I don't think you have to wait to have symptoms. I think that my feeling is depending on your age because I don't know from your question, my feeling is a little bit of progesterone goes a long way. You don't necessarily have tons and tons of symptoms.
[00:48:01] And I say this as someone who didn't have tons of symptoms in the latter part of perimenopause. I had little to no symptoms. And I personally was hospitalized in 2019. As I know many of you know, I never got another cycle because I lost 15 pounds when I was in the hospital and that shoved me off the cliff. So, my last menstrual cycle was December of 2018. So, I have been fully menopausal since December of 2019. And the reason why I share this is if I had been waiting and waiting and waiting for symptoms, I just would not have had them. So, I don't like the idea of women feeling they have to wait to suffer enough to justify the HRT when we know in perimenopause, we know that the hallmark of perimenopause is this drop in progesterone in the ovaries. So, progesterone therapy is completely reasonable. It doesn't mention here she said, “I don't have night sweats, I don't have a cycle to know, to even know about bleeding what tests do you recommend?” I think when we're talking about what tests help evaluate where you are in terms of are you in menopause, are you not in menopause? FSH, the follicular stimulating hormone and anti mullerian hormone can be helpful, but you need the FSH drawn at least twice. So just one reading above 25 is not enough because we know FSH can fluctuate, that's stimulated up in the brain. So, looking at those labs can be helpful, but again, I reiterate, don't feel like you have to wait to get symptoms to suffer “enough” to justify using HRT. I think when you think you're ready for HRT, it's time to have the conversation. It's time to have the conversation with your provider. I think that's completely reasonable.
[00:49:50] Krista also mentions I had a DUTCH that showed low hormones. Not my favorite test for looking at hormones. I like to look at that test for looking at saliva, cortisol, DHEA, looking at estrogen metabolism. I like serum labs, generally speaking for looking at just a snapshot of estrogen. Always more challenging in perimenopause because your hormone levels can change day to day, week to week versus in menopause things tend to be very consistent.
[00:50:17] One thing that I think is really important is understanding that you are in control, but you do not have to wait to suffer. Because if I had waited to suffer, I never would have gone on HRT. The only thing that really showed up for me that was magnified was the sleep piece. And progesterone helps with that enormously, as does estrogen.
[00:50:34] Okay. Lisa is 60. “She mentions menopausal weight gain of 20 pounds, pear shaped, prediabetic, cardiac calcium study score 22. Ideally, we want zero. She's osteoporotic, I eat well, exercise regularly. What can I do for weight loss and positive mental health?” And I don't say that-- I don't snicker like I'm laughing at you. I'm just saying HRT, lifestyle, lifting weights. So, getting back to Lisa, she does not have a negative coronary calcium score. So, the question is secondary workup. What are your carotids doing? Looking at APoB, looking at an Lp(a). What's your fasting insulin, fasting glucose, A1c, inflammatory markers like high sensitivity CRP, all of those need to be looked at just for osteoporosis. That in and of itself, HRT is indicated for osteoporosis prevention or progression. I would say, prediabetic with some questionable plus or minus the coronary artery calcium score, so we call it a CAC. It's a non-invasive test. But when that's not zero, you need to look deeper. If we take just the osteoporosis that in and of itself, you could have the indication for hormone replacement therapy, but you have to do a thorough evaluation for cardiac risk assessment before you can really get some hormones on board. I would say transvaginal estrogen would be completely fine because that is not systemically absorbed.
[00:52:00] Okay. A lot of questions came in around pelvic floor issues. I have an expert coming on. She's the vagina coach. I don't know if you know her on social media. I have her book. She's fantastic and delightful. We're going to talk about all things pelvic floor. I'm going to do a couple more questions because we're at 8 o'clock.
[00:52:15] Amy said, “Regarding the estrogen patch, do you think that you should stay on the very lowest dosage in order to mitigate symptoms or safe to go higher if the patient over 65 feels even better on a higher dose?” This is a fantastic question for the prescribing provider. I think that I'm of the mindset that if you feel good on a dose and you're not having any side effects, I think it is completely reasonable to see where you are. Like, are you on the lowest possible dose? Are you more comfortable on a higher dose? So, these estrogen patches usually start at like 0.025. They can go up to 0.0375, up to 0.50, up to 1 mg. So, they just kind of go up in these graduated approaches. And some people are still having hot flashes, so, we'll go up on estrogen patches. Some people are still having a lot of joint pain, so you'll go up on an estrogen patch. Some of us have no symptoms and are on a low dose, and so I'm kind of like acquiescing and just staying where I am, but I think for everyone, it's really based on how you feel. How aggressive do you want to be? When I use the term aggressive, I don't mean aggressive as in we're trying to restore estrogen levels back to where we were at 22. That is not what I'm saying. Some people just want more estrogen on board. They feel better with more estrogen on board. I think a degree of experimentation is reasonable. I have some girlfriends that when they wanted to increase their patch, they just put two patches on to see how they felt. Completely reasonable, definitely worth discussing with your treating provider.
[00:53:48] Okay. Kim said, “I recently read Estrogen Matters,” so the book why Estrogen Matters should be required reading for every perimenopausal, menopausal female. I'll just put that out there. I interviewed the authors, Dr. Avrum Bluming and Dr. Carol Tavris. They are revolutionizing the way that we think about estrogen and was surprised by a few of their findings, such as oral estrogen being mildly more beneficial than the patch for preventing cardiovascular disease and stroke. Yes, we kind of touched on that. And that vitamin D is ineffective in preventing menopausal osteoporosis or fractures because they do not affect bone resilience.
[00:54:25] Yeah, vitamin D to me is an important prohormone. It is a prohormone. It is not just a vitamin, if you will. It's a fat-soluble vitamin. It's important for insulin sensitivity, it's important for immune function. I agree with that. I don't think that that needs to be the focus for bone health. I think that we need to be really conscientious about weight bearing, exercise, putting a load on that axial skeleton. Although depending on which person I interview on the podcast, some people like weighted vests, others do not. I'm kind of the belief system that if it works for you, great, and it's not causing you any imbalances in your body, I think it's totally fine.
[00:55:05] Kim said. “This seems so contrary to so many others in the field and makes me question my use of the patch and supplemental use of vitamin D.” Vitamin D is great. If you live north of Atlanta, you very likely need vitamin D. You can hear I'm still kind of getting over this RSV junk that I had last week. I've been upping my vitamin D levels. I think this time of the year I'm all about getting vitamin D levels, vitamin C levels, getting those things up. So, Kim, it's not to suggest I still think you should continue taking vitamin D because most of us tend to be deficient. And we're so deficient that it impacts our immune function, our insulin sensitivity. I think you take the estrogen patch and then you see how you feel and you kind of monitor your bones. Getting a DEXA scan, which is like a bone x-ray, is cheap, inexpensive, and quick, and that's a good way to get a sense for what's going on with your bones and then you adjust accordingly.
[00:55:58] Okay, very last question I'm taking tonight because my voice is running out and we're a little over an hour now. This is from Luciana. “With cancer history in my family, is it possible to have HRT? Is it still safe for me to take as I'm 55 years old?” So again, this is all about risk assessment with your provider. Just having a family history of breast cancer is not a contraindication to taking hormone replacement therapy. Obviously, there are things they have to look at, genetic markers, etc. But we know that if we really look at the breadth of like what puts us at risk for breast cancer, number one is obesity, number two is an alcohol history, and then there's some genetics, right? So, if you're not at a healthy weight, that's going to put you at greater risk. If you drink regularly-- I think the statistic I read today that was on Dr. Rocio Salas Whalen’s account was saying that one drink a day increases your risk of breast cancer by 7% to 10%. So, to have some understanding that alcohol is not benign. And if you're taking hormone replacement therapy, it will push your estrogen levels up for several hours, somewhere from four to six hours after consuming alcohol. So just kind of keep that in the back of your mind.
[00:57:15] With that being said, again, I could not have gotten through all these questions in under an hour and there are still more questions. So please be reassured we will do more of these. Always love connecting with people. Does anyone have any questions while we are live together? Anything that you wanted to ask or if you had a question that didn't get submitted and you now have questions? I see there's lots and lots of people.
[00:57:43] Kelly said, “I'm 64 for post menopause, estrogen patch. My blood pressure has climbed when I have historically been in the 120/80. Can I combat this with going off of estrogen?” It's probably not the estrogen. It's very likely insulin resistance. At the basis of most chronic disease states here in the United States, it is insulin resistance. I would make sure you get a fasting insulin checked. Checking your glucose, so checking your blood sugar, knowing what your A1c is doing, making sure that you're walking, you're lifting weights. It is very likely not from the estrogen. The estrogen typically is very anti-inflammatory. I find for a lot of people that they are not per se aware that they lose insulin sensitivity as they are navigating perimenopause and menopause. I would say that, you know 145/70. If you're checking your blood pressure at home, I'd make sure you get your cuff calibrated. There's a lot of things that could be looking at that. But a really good book called Why We Get Sick by Dr. Ben Bikman. I think I've had him on the podcast four times. That's a really good resource for those kinds of things.
[00:58:47] Katherine said, “I just started HRT at 61, about 9 to 10 years post menopause because I couldn't sleep and I have one APOE4 gene. Should I consider going off HRT after 2 or 3 more years? Does HRT minimize the risk of Alzheimer's?” There's a lot of nuance to that question. I would say women can stay on HRT for the rest of their lives. The thought process that you leave patients on HRT for a couple years and you take them off, I think is cruel. If you probably stopped your HRT, you probably would resume having trouble sleeping. Yes, there are indications for hormone replacement therapy and neurocognitive effects. We know that estrogen in particular is very beneficial for neurocognition.
[00:59:30] I didn't actually get to talk to Dr. Menn about that today. We talked around a lot of other things. But you start looking at the benefits of HRT and you start looking at bone, brain, heart. Absolutely, we just buried my stepmother in November and one of the reasons why she developed Alzheimer's was that that generation of women was not given the opportunity to be on hormone replacement therapy. So, I think that when I think about the things that can help us protect our brains over time, getting good quality sleep, entertaining the possibility of estrogen. We also have progesterone and testosterone receptors in the brain. It's not just about estrogen, but estrogen in particular. Looking at Dr. Lisa Mosconi's work is very Important.
[01:00:13] Emily said, “Can you speak quickly about cycling estrogen, testosterone, progesterone and recommend a regimen for taking breaks? Thanks for all you do.” I typically say one day a week is a break that keeps those receptors sharp. “Meat supposedly raises insulin, but not one's glucose, can you explain this?” It shouldn't. Unless it's-- So it's interesting. Typically, no. Eating meat should not raise your insulin levels. For some people, you can get like a sustained elevated glucose relevant to-- if people have particularly fatty meats. Like I'm thinking about people who are already not insulin sensitive that eat like a ribeye or have a salmon steak and they can get these transiently elevated periods of time where their blood glucose is up. But nothing that should explain the fasting insulin, unless you're not already insulin sensitive, and it has really nothing to do with the food and has more to do with the lack of insulin sensitivity for those receptors. That's my prevailing philosophy.
[01:01:15] Again, we are enrolling, we're going to take 50 women into our programs. We are doing discovery calls. I highly recommend. This is the level at which we talk about things in these programs. This is not surface level information. We have the fasting program. We have midlife pause, which is 12 weeks. And here's the other thing, ladies. The one thing that I decided to do this year was that if you, whether it's, IF:45, whether it's evolved, whether it's midlife pause, you will have an entire year of support. Meaning you will go through the program and then you're in our ecosystem into our paid groups where we have monthly calls. My coaches and I are teaching in there every month and this is heading into my book launch. My book will be out in 2026. We don't have a publication date yet, but this is a very, very-- if you really enjoy this kind of discussion, this depth of discussion, you want to be in these group programs because we offer a very high-level touch. Trust me when I tell you I know what other people are doing and we do it completely differently than anyone else.
[01:02:22] And the other really cool thing is that in many instances the people that you see on my podcast, we have like quarterly group experts. I'm bringing those same very high-level people in to teach to my community. So, because of the podcast, because of the friendships that I have created and cultivated, we have super high-level people that are coming in to teach you as well as me certain specific things that you're interested in learning about. So, I hope that you are signing up for these discovery calls we've been doing. I don't know. Jamie has been keeping track of all the discovery calls we've been doing, but we've been doing quite a bit to backfill into these programs. And again, you get a whole year of support, not just during the program itself, which I think is really unique and is a really great way to be part of our ecosystem.
[01:03:08] Anyway, ladies, such a pleasure. Good to see everyone. Have a great night.
[01:03:15] If you love this podcast episode, please leave a rating in review, subscribe and tell a friend.
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