RE-RUN - Menopause Q & A with Dr. Jessica Shepherd: Expert Advice on Symptoms, Treatments & Wellness

29:01I, for me, typically this is personal over the age of 35, I birth control pills. I'm like, okay, how much longer do we have to stay on this? Can we find another way? Even if it's for birth control, I'll try to find other modalities of birth control. we did definitely so there's nothing wrong that was done we definitely have used birth control pills for decades as a form of mht we now are much better educated and understanding of the different types why it's needed what levels are needed for us to i think get more women off of birth control to me, typically the latest, maybe mid forties, early forties for me, even if I, if I can get them on another kind of birth control.

29:48Um, but at that age at 50, 52, 55, I would not wait till 55 to switch and just get off of it now and switch to MHT. Okay. Perfect. Do you ever recommend hormone replacement for women? Oh, in perimenopause. So at what age my testosterone is super low and my doctor recommended a testosterone supplement. Something had never something had never I'd never heard of before. A troch. Oh, yeah. So it's a trochee, trochee. It's basically like it looks like a pill, but you put it in your your gum and it dissolves. So you get what we call like sublingual release of whatever it is. I mean, anything can be in a trosh.

30:35It can be a medication. It can be a hormone. So ask the question again, because now I forgot. I just, oh, so they do you. Okay. Well, one, do you recommend HRT in perimenopause? And if so, what age? And then, um, her testosterone is super low, but her doctor recommended, uh, a testosterone trosh, something that she had never heard before. Okay. So back to the question about when to start, it kind of goes back to the question of the birth control control pill in when is that time that your perimenopause which is usually your 40s early 50s for some because they still may be menstruating is i need to sit and think about if i would like to stay on birth control if i'm very sexually active and there's a good possibility i could have a baby right because then that makes to me it prioritizes birth control over mht team i have frequent cycles in frequent cycles which again is going to go to is it likely for me to get pregnant or very very unlikely for me to get pregnant and i can transition over to hormone replacement therapy so those are like everyone's going to have a different answer choking um so it's important to know who you are and what you're looking for

32:03i'm gonna drink water yes drink drink some water i'll get to our next question we didn't do the trochi one oh okay let's get let's hit that first so testosterone is is fine to take as hrt i don't have a problem with taking it that way there's various ways to take it you could take it that way some some injection i'm not a fan of the injection you can do testosterone creams and then also testosterone palate so there's various ways yeah there's nothing wrong with that modality okay great moving on to what are your thoughts on merodyne live vibration plate for osteoporosis and or overall health can you spell that um m-a-r-o-d-y-n-e-l-i-v the vibration plate maybe just a vibration yes the vibe i'm doing really good on this so that really really what it is is is to create low density vibration to help with stability to help with flexibility would i say i wouldn't say it's bad but is it evidence-based as a form in a way to improve osteoporosis i would put it more in the cat in the category of a supplementary a supplementary way to improve bone mineral density ways that you're going to improve your bone health from a bone mineral density is resistance training so weight training and also increasing your protein intake and also HRT.

33:48Hormone replacement therapy has been proven from the estrogen portion to improve bone mineral density. So it's not like it's a bad thing, but maybe put it on the list of things in addition to the other thing that I mentioned, then making it maybe the only thing that you're doing, thinking it's going to just magnify your bone mineral density to the level of what you could get if you were doing those other things. Okay. I have Hashimoto's and wonder about all the conflicting information I read about whether or not to do high intensity exercises. I always think working at my best level is best. For example, lifting the heaviest, I can go with good form.

34:27What is optimal for people with autoimmune issues? Do you have a take on that? So that's a multi-layer question. I think when we think of Hashimoto's, right? So a lot of that has to do with it's autoimmune disease meaning that your actual thyroid is attacking its own organ right so the goal with that is to manage how to get the thyroid levels back into a normal range which sometimes may need medication which is okay but there are other ways that you can I guess facilitate the Hashimoto's and a lot of that actually can be with diet and then if you think about it, most women will have thyroid issues after the age of 40.

35:12And a lot of that has to do with starting with the fluctuations in their reproductive hormones, namely estrogen and testosterone. Remember you're talking about the symphony and so one is out of place. And so it causes a lot of other things to be out of place as well. So that's why when we look at thyroid, That's why I draw thyroid on the panel when I'm consulting women about perimenopause and menopause. So a lot of times you can be correcting one and the other one starts to fall back into place. Does that make sense? And so a lot of women have had Hashimoto's or Graves disease or whatever it is.

35:54And yes, it's a chronic autoimmune disease. but a lot of times it's missed by maybe if I start correcting the hormones of estrogen and progesterone slowly we can start to see them them equal out and not have as much of an issue so when it now comes to working out I'm I'm trying to answer the question as how I'm hearing it is that going overboard will that impact the Hashimoto's thyroiditis or if that could be done yes i think working out always is going to decrease inflammation and when you think about a chronic autoimmune disease it has a lot to do with inflammation as well so i don't quite know where in the question where it meant like working out too hard versus at your level i think obviously the best place to start is at your level another thing to do it to being like let me do a full review of my hormone panel and seeing if there's anything that we could do from the reproductive phase of the uh hrt that might help with the thyroid function and then also with your food as well i do think that there are very holistic ways in which people can have their food or their nutrition support an autoimmune or anti-inflammatory through diet our gut our gut is a big part as well as what lets things in and out and what things may be contributing to this autoimmune type of disease.

37:23And so I think that there are wonderful functional nutritionists out there that kind of help look at the big picture and then help from a nutritional standpoint, figure out what's going to help that issue the most. That's great. So for someone that is on HRT, they're 55. How many years, if not for my lifetime, would you recommend staying on? yes this is a very controversial question because of where we are currently in hormone literature have been for the last 20 years fixated on a study that really had us running away from hormones and thinking that they're bad and we're now just on the other side of it in the sense of hormones are not that bad they're not bad at all they're actually very beneficial.

38:12So there were a lot of recommendations that were made with that study 20 years ago. And one of them was stop taking HRT at 10 years at the time you're menopausal. So if you stopped having periods of 52, 55, then you just add 10. That's when you stop or no longer than 60 years old, right? Whichever pertains to your issue or your age. The problem with that is that we know from literature, the moment you remove estrogen, progesterone, and testosterone from your body that have been there your entire life, then your organs are also going to take a hit because they're not being substantiated by the hormones.

38:54So we're just at this early state of research to say, how long should women go on? There are a very big body of doctors that are like, from a longevity standpoint, why would I go off hormones? Because it helps bone mineral density, decreasing rate of Alzheimer's, decreasing rate of breaking your bone, improving your muscle mass. And so it's more now as we start to age, how can I thrive while I'm aging? And hormones have a lot to do with that. But also we have strict recommendations based on studies that are like, well, we really shouldn't go past this point. Where do we think that we're going with research is more towards I'm going to be on hormones until you desire to, or until you die.

39:42Um, and I think when you have a really good conversation with someone who truly understands hormones, people get, should be able to make the decisions that they want to based on the information that they get. We're still in that phase where they're going to be like, oh my gosh, you are 62 and you're still on MHT. We've got to get you off. I have patients who are 70 and they're like, I feel great. I'm not coming off my hormones. And I'm like, rock on. So again, you're going to, people really need to get to the point where they're like, of all this stuff with risk and benefit. And what I'm looking for is I'm looking at my life in my 60s, 70s and 80s, nineties, what I want that to look like, how is this helping?

40:25How many of you want? As we age, age is probably the risk factor for most diseases, breast cancer, heart disease, Alzheimer's. So as we age anyway, things start to not function as properly, disease goes up. But if you were to think of it in a way that says, I want to be able to be exposed to hormones to give me the best benefit as I age and quality of life, that's all another way to look at it. But no one's wrong, right? You get to determine which one of those works best for you. And I think that we're going to start to see that it is more personalized as far as a medicine form to say, there's going to be a risk at every point.

41:08Which are you willing to take personally? I love that. Okay. So what do you recommend to your patients with osteopenia, estrogen, HRT, as a prevention for further bone protection or bone loss? And what about creatine? Back up on that question again, start with the first part. What do you recommend to your patients with osteopenia? Would you do HRT therapy as well to prevent further bone loss or for bone protection? Both. you can see considerable amount of improvement in bone mineral density levels and scores if you were to look at it from a DEXA scan perspective when people are on estrogen that has been stated clearly in the literature so if you have osteopenia which is a deficiency not a deficit then I would I would love if someone was like you know what let me give it my best shot of not becoming osteoporotic and go on MHT, do my strength training so I can be more preventative and actually improve my bone mineral density.

42:22Yes. And also with HRT for all of these, that's never going to replace strength training. We have to do those hand in hand. Yes, because they're by different mechanisms in which they're improving the bone. So, for example, with MHT, the estrogen is improving the bone mineral density by improving the osteoclast, which is the cells that make our bones stronger. Resistance training, what you're actually doing is it's kind of like a domino effect. you're triggering your muscles through its fibers as it's kind of doing its twitch to then tell the cells on the bone to improve or to to become more or to build more right so they're both different mechanisms so you're going to get the best benefit from doing both but you know i have patients who have never weight trained or they're scared to weight train i'm like well let's at least start with some estrogen or vice versa.

43:30Right. So it's never to say that everyone's always going to have the perfect template of what they're doing, but at least being able to do one, if not both, is the best way to improve your bone. Yes. I love that. Okay. What is the best non-pharmaceutical intervention to protect and build bone for post-menopausal women diagnosed with osteopenia? Weight training. It's not a medicine. I mean, it's not a prescription. There you go. Exercise is medicine, but that one's not a drug. Yeah. Perfect. That's probably the best way to do it. So if someone was a little bit weird about x-rays, how safe are DEXA scans in regard to radiation exposure and how often is it appropriate to get them done?

44:20so and this is a good question too that i had yesterday so when we look at radiation radiation when we look at it from a rads perspective that's how we we monitor the amount uh that you're getting exposed to dexascan is really low on that list um and and even x-rays and when we think about like exposure to radiation and like the likelihood of cancer it really is for people who are getting like significant amounts of radiation, like every day for like two years. You know what I mean? A lot of the data that came out on, on radiation and cancer, one, it was done on mice, which obviously were not big mice, but it was a good indication of what can happen.

45:03But when you actually look at the studies, it was a significant amount of radiation. So in everyday person's life, who's like, I'm just doing this imaging occasionally with which a DEXA scan. I'll actually, let me go back to, let me finish my statements. I'll go back to recommendations for DEXA and how often to do it, but it really requires a lot of exposure to radiation for someone to say, oh my gosh, I got a cancer from actual, right? Okay. So I want to reassure everyone with that. The other thing about DEXA scans, currently the recommendations for dexascan by insurance is not until the age of 65 which i completely hate because what do you think's happened by the age of 65 our bones are like we were already on our way out like and and so it's not a very preventative way in the way the recommendations are written about dexascan the way that we use it so amount of radiation is very low currently the recommendations at the age of 65 to me i'm just like of course women are going to be they've been usually menopausal for at that point like 15 years without any estrogen and most of them are not taught to weight train so of course their bones are not doing great so what when you think of physicians there again a circle of physicians not to say that's little but outside of the traditional setting who use DEXA scan, not only to look at your bones earlier.

46:35So they might recommend someone to go get it like in their latter forties, early fifties, as they're going through that transition into menopause, because now they're losing estrogen, but also DEXA scans are a beautiful way to look at your lean muscle mass and your actual fat capacity as well. And the reason why that is also important is because your muscle mass too is significantly decreasing over that menopausal, that perimenopause menopausal timeframe. So now your estrogen's going down. That's what I'm saying. Estrogen receptors all over impacts your bone mineral density. Your muscle mass is starting to go down as well, but your fat cells as well, how they respond to estrogen is they just, they're not as agile and shrink as well as they used to before, which is why we start to change our body composition as we start to age.

47:24So DEXA scan is actually a beautiful way to look at multiple things and to help people being a little bit more visual to what's going on internally in their body. So they can start to make the, the changes in the connections in their head and being like, Oh my gosh, look at my muscle mass. And so they're actually, if you go find DEXA scan facilities, they're actually not that expensive. They're like 125 to$150. And if someone wanted to get a good baseline on what their body's doing internally from a muscle perspective and bone perspective and kind of like a fat mat or a muscle fat ratio. Dexa scan is a beautiful way to see that.

48:04It also can be preventative because now, you know, your bone mineral density is at a younger age. And if you wanted to, you could do it every year, you could do it every two years, but it's a great way to see so much more than what we used it for and much earlier is better. Yes. Okay. Would you recommend somebody going on HRT that's not having any symptoms, still has a period and perimenopause, but like doesn't have any headaches? No, no, no, nothing. Yes. You would recommend it. The reason why is this is a very controversial question right now. Because typically we used to wait for women to be menopausal before we would give you MHT.

48:50We are moving away from that and still a lot of providers. And again, not to say that they're wrong, but this is how we were trained. We would say, well, we'll only put you on MHT if you have a symptom. But what do we know happens when you're just declining from estrogen anyway, so many things in your body, it's not always a symptom. So I think that there are providers who will do it. I think that women need to think about those decisions when they sit down and think, am I having a symptom versus am I improving quality of life and longevity? Those are two different things. and actually get the benefit of both when you use MHT.

49:29And so approaching it from that way, rather than I'm only going to go on MHT when I have symptoms. And I really want to make a disclaimer that I'm, you know, as much as a HRT advocate than I am, it does not mean that if you're not on it, then you should be shamed because you didn't go on it. I just want everyone to have the ability to know really good fundamental information. So when they make the decision that they would like to or not, as much as I could be like, I think it's the best thing for you. If you choose not to, then you choose not to. Yeah. This is why I love you because I feel like your energy and your candor is just so spot on.

50:08Like it's not harsh either way. Like it's just, here's the information as a physician and you get to make the choice. Say you change your mind in three years, just because of the information you heard and you just gave it more thought and you had more conversations, right? All of this is really now to get people to then go and being like, Hmm, I didn't know that about, let me talk more about to my friends. Let me bring it up to my doctor. And that's how we change the ability for us to make decisions is because we're changing our conversation. Yeah. Yeah. 100%. Oh, okay. I love it. So I'm someone who is in the age range of, of perimenopause 42, but hasn't experienced any trouble except for a bit of the, let's talk about the visceral fat, because there's a few questions here with, with that, but no other symptoms and have heard that women should do hormone testing before menopause so that they have baseline levels of hormones to aim with HRT.

51:07If they choose that route in the future, should I check, should I consider checking my hormones at this point anyway, if I, or wait until I have further symptoms. If hormone testing is recommended, do you have a recommendation for the test? You went over the test, so we'll remember those. Yeah, so what your hormones are doing today at what time, well, at my time at 6.57 will be different than if I tested them today at 2 a.m. or tomorrow morning, right? And so it's not so much a matter of if I draw it now, will it help me later? It's good to have a baseline to see where you were, but it should not dictate what your dosage of MHT is going to be now or in the future.

51:50It's not so much for, I have to do it now. So I know my dosage will be later. I think that it is good for people to get a baseline, just to have a baseline. And if we decide if you have symptoms in two years, or if you're like, let me see what my hormones are in two years, you can kind of see what that difference would be, but it doesn't necessarily mean that it should dictate your dosage. Yeah. I want to make sure that people understand that. Then the other thing is you asked a second part of the question. It was about the, we went over the, what should be drawn on the labs and you said something about visceral fat.

52:23Yeah. Does the visceral fat, so this is the only symptom that they're having, but then someone else had mentioned, you know, the weight gain with visceral fat and how realistic is it for perimenopausal women to achieve fat loss, weight loss is their hope. And does HRT help with that? yes so i'll answer the first question first about visceral fat so you have your subcutaneous fat which is the fat that we see right so it's the fat that migrates it used to be on your hips and your butt and now it moves to your your abdomen even though you didn't ask it to go there um and then you have visceral fat visceral fat we can't see i have seen visceral fat because i went into someone's organs and looked at it with a laparoscope or i cut them open and was doing a surgery, it's the fat that you see around an organ.

53:13And the fat that's around an organ is for protective reasons. But what happens as we start to get older is that our visceral fat starts to increase. Okay. So that in there and becomes a problem. And that's also what you can see on a DEXA scan as well. Your visceral fat, which we aren't, we can't see just looking at someone externally. So the reason why visceral fat is important because you won't feel when it's increasing, you won't see when it's increasing, but it does impact your organ systems. Okay. And so that's why people start to maybe have like liver issues or heart issues or whatever. That's the reason why weight loss in general will always be one of those biological features that for some people may be more than others, but in general, everyone will start to have fat weight rather increase as they age because of insulin resistance.

54:08The main bulk of why we start to see that happen is because estrogen decreases and we start to have a shift in our muscle mass, so if you have, think of a pie chart and for your 20s and 30s and when you're an adolescent really active and your muscles are very, very, they're thriving, they may take up 65 % of the pie and then you have organs and water weight and fat which take up the other portion. As we start to get older, that 65 % of that pie starts to decrease slowly over time. So what does that allow more space for? More fat, right? And so now we have decrease in estrogen, which is also not helping our muscles.

54:50We have a decrease in testosterone, which is also not helping us build more muscle. So hormone replacement therapy in essence is not directly making you lose weight. It's helping all of the things that were there, part of that symphony to kind of keep everything in check, increase your muscle mass through testosterone. But then the work comes with bulking up your muscle because you're already losing it. So you need to bulk it up to get that pie chart back to what it used to be. And that's why when I see your program, It's so phenomenal because weight training is really saving lives because muscle is the organ of longevity.

55:28It's the thing that keeps us stable. It's the thing that keeps us strong. It's the thing that protects a lot of our bones and also our heart. And that is why it's important to switch to more of a weight training workout than ever when you're going through that phase. We're really trying to get that 65 percent back. Right. And I'm just using contrary numbers, but I'm just trying to give you a, like a kind of visual of what's happening with your body. The insulin resistance part is also crucial because it's not anything that you can see. It's really just this thing that's happening internally. And when you start to have increase in insulin resistance, that means it's not, it's like a mailman.

56:09I always say this, the insulin is like the mailman. It distributes the sugar where it needs to go. And it's like, you are fuel. you're going to the brain so the brain can use you the liver needs you the muscle needs you all of these things but as insulin resistant as we start to age the mailman's like yeah i'm not doing the mail today and then the mail is just sitting around and the sugar is like we have nowhere to go and so it just sits in our blood and then we become more diabetic in a more diabetic phase but the the reason why i love your program again is because the biggest utilizer of glucose is muscle.

56:45So if we're not building muscle and it's already on its way down biologically, the sugar is just going to be like, well, we'll just sit here too, because we're having fun. And then it converts to fat. Yes. Oh, and, and, and to, to answer the rest of this question, yes, you can absolutely lose fat in menopause and perimenopause. Yeah. And I know you live time. I will, I will go on, on, on brand and say, is it easy? No. Can it be done? Yes. Yes, absolutely. Okay, we're going to rapid fire these questions because you got to get off. You got a trip to pack for. I mean, it's only Ibiza. I can't wait to watch all of your stories.

57:28Okay, as menopausal women not on HRT, our libido decreases and orgasms may take longer to achieve. Considering a happy, healthy sexual relationship exists, what natural supplements or adaptogens can you recommend for this? that isn't HRT. Yes. Vitamin B12. There's a medication called Addy E A D D Y E. That's helpful. Vilesi is also a helpful medication that helps with it. Um, I definitely am. There's a, gosh, it's a niacin. It's a little, it's over the counter, but it's a little gel that you can put on your clitoris, increasing and enhancing PRP injections. Oh, shots. They do help. I really do like those.

58:15There's so many other ways than taking testosterone, but when it comes to libido, all I would say is women do not let that go. We are entitled to pleasure. We are entitled to having really fulfilling lives as we grow older. Do not let that go. yes agree mic drop okay would you suggest um okay so we talked about if somebody was just having hot flashes would you suggest to stay on hrt um after 60 i guess that goes back to quality of life of what you want quality of life but i'm gonna give a very big nod to yes because i have patients who are in 70 and having hot flashes like i can't tell your hot flashes to stop right I would love to print there, but if they're still there, you need estrogen.

59:02Yeah. And progesterone. Yes. Yes. I learned that from tonight. So that was new to me. Okay. What do we know about safety of oral micronized progesterone compared to progestin? Is it associated to breast cancer or cardiovascular diseases or any other risks? Very easy answer. Progestins. please just don't take those. Those are what in that study 20 years ago, increased risk of breast cancer. So those are synthetic. Really look at your micronized progesterone and stick with that. Yeah. Okay. Awesome. What are your thoughts on estrogen products for the face? Do they work to improve the skin and are they safe?

59:49Yeah. So they are safe. It's estriol, which is a weaker form of estrogen. So it's not like it's getting absorbed in your face and it's in small amounts. It's not in beginning absorbed and it's going to course through all throughout your body. It does work because you have estrogen receptors on your skin as well. And so they respond to it. They make it more plump, increase vascularity to the area. Is it the fix all for everything? No. What I would say is using that consider your, your Botox, your lasers, your microneedling really like really pay attention to your skin because that's like the thing that we see and it is impacted by menopause so start to invest more in that area so you just you feel great about yourself but estradiol or estriol or estrogen creams in her face are are good and they are safe yes i'm getting some that's been on my list but i just don't have two seconds to actually even go to the dentist.

1:00:45Right. That's me. That is me. Okay. Um, any thoughts on taking adaptogens like ashwagandha while also on estrogel, um, prometrium and testosterone feel as though the HRT doesn't help so much for mood related symptoms. Say that one more time. You put a lot in there. yeah this i'm just reading this how how they wrote it and any thoughts on taking adaptogens particularly ashwagandha um while also on estrogel prometrium and testosterone but she feels like hrt doesn't help so much for the mood related symptoms great okay so now i get the question so yes ashwagandha is an aptogen i think aptogens are wonderful as natural substances and they really help balance some of the other things that are going on in life as much again as much as a hormone advocate that I'm, that I am, there are other things that we can be taking that can also, uh, supplement or, or help them rather.

1:01:47So yes, as an aptogen, that's completely fine to take. The one thing that I would say about, if you feel your hormone replacement therapy isn't working for you, then you need to find someone. And if someone's not adjusting it for you in the manner in which you need it, cause it's personalized, it should never just be everyone's on the same dose. so someone may need to adjust that for you but aptogens are a great way to kind of balance and use natural ways to create more of the substances in your body and the hormones to respond better so yes you can take that at the same time there's one the one on here that i want to answer how do you know if you're insulin resistant when you get those labs that i uh talked about earlier hemoglobin a1c is a good way to tell where your body is is how it's processing sugar i guess you could say, or glucose, get a fasting insulin and a fasting glucose, because then you can do an insulin glucose ratio and see how your body is actually absorbing, utilizing glucose.

1:02:43That can give you a good idea. If you're going more towards insulin resistance than not, but just in general, everyone, their body biologically just starts to get more. Yeah. Okay. Fabulous. Is there a minimum known estrogen dose, estrogel or estrodot for osteoporosis prevention? That's a good question. There's no minimal dose. The goal really is to get you started on it. And the reason why I say that is how we measure bone mineral density is through like a T score and a Z score, which is arbitrary. You don't need to know about that, but everyone kind of has a score of where they are. So a lot factors into where you are, your age, your ethnicity, if you're a smoker, and also like your DNA, like, you know, your family history of what your bone structure is made up of.

1:03:37So there's no minimal dose. We're really just trying to improve who that person is and where they are based on all those things that I mentioned. So estrogen is going to help, but there's no minimum dose. Okay, we are almost done. How does being overweight affect symptoms of perimenopause. I'm on HRT for improved sleep, joint relief, and minimizing hot flashes and night sweats. It works, but I've gained five to seven pounds since starting HRT a few months ago. Is there a correlation between weight gain and worsening perimenopausal symptoms? Yes. So there are some people who, when they start HRT, can start to have this like slight little bump with that five and seven, five to 10 pounds.

1:04:16Most times it is transient, transient meaning that it will even out the other part of that is progesterone again the comfy hormone does sometimes like to absorb water right and so you may you may be more water retaining because of the progesterone so things or to offset that would be again with weight training it's going to build your your muscle increase your protein intake because that is and your fiber intake. If there are probably three things that I would mention in dietary to focus on, obviously there's a lot more vitamin D making sure sometimes you mix it with ADK so that it's absorbed in the intestine, vitamin D protein intake and fiber, right?

1:05:01Remember we talked a little bit about gut health. So again, making sure that we're keeping our gut in the most healthy way so that we're not again, losing things that we want to keep in and things are coming in that we don't want to come in. Yes. Okay. Great information. Is there a chance of inflammation and joints increasing significantly as women approach post-menopause in particular, the hand and finger joints? Yes. Inflammation. There's a great company. If you wanted to look it up, it's called Glycanage, G-L-Y-C-A-N-A-G-E. And they're not the only one who does this, but what they actually look at is from your biomarker.

1:05:40So they take your blood and look at your inflammation factors because there is such great data as we start to decrease in estrogen, inflammation increases. So two things cause inflammation. One, well, actually a lot does our diet, our age, as we start to age, we just become more inflamed. And then also menopause contributes to that as well. So many women start to have joint issues. I have a lot of women who that's their presenting symptom of menopause. We get them on HRT and their joints are not as achy. Musculoskeletal syndrome of menopause is real. Most people might complain of a frozen shoulder, but joints are also part of that as well, as well as lower back pain too.

1:06:23Okay. What would you recommend for vaginal dryness? HRT or another natural way? Ooh, I love this because I do all of them in my office. So vaginal estrogen. So it would be, you're not going to get as much bang for your buck. Let's say if you take systemic HRT, like a pill, a patch, a cream vaginally, but a vaginal estrogen cream. Yes, there also is the laser, a CO2 laser that can really help restore a lot of the vaginal tissue. And then there's also radiofrequency, which can also help get to the deep layers of the tissue in the vagina to help restore the vascularity and also secretions. and then PRP, PRP injections can be, we can do that for hair.

1:07:06We do it in face, but we can also do it vaginally as well to kind of help restore that. So that's like four great different ways that you can do it. If someone wanted to do HRT and a blend of some of the other things or non hormonal and do investigate the other three. I mean, thank goodness for this day and age, right? Right. I know. Okay. Almost done. Um, I'm 51 and, and for the last year I've been on birth control to help me with perimenopause and have very heavy periods. I had an ultrasound prior to rule out other causes of excessive bleeding. I've been fine on birth control and the pills are controlling my periods, but I'm wondering if I should switch to HRT.

1:07:45What are the, oh, okay. So that's another, oh, over the counter. So probably time to talk to her physician about possibly switching. Switching? To HRT. From what though? From nothing? Birth control pills. Oh, yes, yes, yes. So she wants to, but she's unsure of what? Yeah, she has very heavy periods. So I think that's why she's been on on the pill. She's been doing fine on the pill, but then I'm wondering if she should switch to HRT instead. If she has heavy bleeding, I would navigate another form of birth control because she's not going to get the control of bleeding with the HRT. So really, and I say this because I have one myself, but IUD is a great way to control bleeding.

1:08:32And then you could still go on HRT. You could also, there's also medications for heavy bleeding that are just for the heavy bleeding. And then you can kind of do the other stuff, which would be HRT. So I think that, or small procedures. So it's not a surgery, but there are small things that can actually help with heavy bleeding as well. So that one actually has like a longer cascade, I guess, of lists that can be done for that part while considering do I switch over to MHT? So it's two separate categories. The bleeding is a category that needs to be addressed with medications, non-medication or non-hormonal medications or procedures.

1:09:08And then the other side would be, do I stay on birth control or do I switch to MHT? Two separate things. Yeah. Okay. What effect on menopause does an IUD have for women in, for a woman in her mid forties? Say that one again. What effect on menopause does an IUD have on a woman in her mid forties? Great birth control and no bleeding. That's coming from a personal experience. It really was designed to be like this really great local way to decrease bleeding, provide birth control. that's low maintenance because you don't have to take something every day, change something out. But it doesn't have an impact on menopause.

1:09:50It helps with the bleeding portion of someone who's perimenopausal and also provides birth control while you can still address considering MHT in the perimenopausal phase if you wanted to. Okay. Okay. We're wrapping it up. What are your thoughts about when this person entered menopause, she started experiencing recurring UTIs and urgency and continence. Do you recommend a hormone therapy for women in similar situations? Yes, because the bladder that member, you're talking about the sphincter and it doesn't control, it's not as tight as it needs to be. So in the moments when we're trying to hold our urine, it's still a little open.

1:10:30So urine can come out. HRT can definitely help restore some of the tissue in the sphincter and in the urethra. The other good thing in why, even if it doesn't correct it, even if you needed a procedure or a laser or something else, you're now being preventative by using HRT, namely vaginal estrogen in this instance, because as you start to get older, it's only going to become more of a problem. And a quick statistic, when you look at actual old age homes, most of the women, a lot of times they're usually are having issues with chronic UTIs because of either losing urine or their their bladder is not working to the best capacity that it can because of the microbiome in the bladder, because it's no estrogen is being provided.

1:11:26and that can lead to so many other mortalities and diseases and issues in older age for women. So protect your urethra, consider vaginal estrogen as both helping with symptoms and also being preventative for later on in life. Okay, fabulous. Two more quick questions. If a woman went through menopause five years ago, is it possible to start HRT to treat lack of libido? oh, is it too late or is it too late to start? I always say it is never too late to try anything because at the end of the day, if it works for one, but doesn't work for another, like we still tried. Testosterone is a beautiful way to restore a hormone that was already there.

1:12:10Women have testosterone. We are just put in this category where everyone thinks that we don't have it and only men have it. But we should be just as happy to be the sexual beast that we are and that should not decrease with age. And so I think it is always worthy of someone to consider starting testosterone therapy and considering to increase dosage until they might feel that they do have their libido restored and not to give up on that. Oh, I love that. I hope this is considered general enough. I wondered if you could touch on how fibroids affect active women, what lifestyle changes should we be making if we develop them?

1:12:50Yeah. Fibroids are actually up to 70 % in black women and 50 % in women of all ethnicities have fibroids, right? So a lot of it has to do with when we think of fibroids, we think of size, amount, and where they're located. So most women, if you listen to those statistics, either half or most women will have fibroids, but most of us don't even know, right? but 25 to 30 percent of women are symptomatic meaning they're big and they take up size or they have heavy bleeding so there are really a lot of modalities that are out there to help with the symptom if you do have a symptom if you don't have any symptoms and maybe on an ultrasound saw that you had fibroids typically we can being like okay if they're not bothering you can kind of just monitor them are causing an issue so many different modalities that can help with the symptom that it's causing because there are multiple symptoms that can cause but throughout the perimenopausal phase i would say that fibroids sometimes can start to wreak havoc because our hormones are doing that roller coaster remember how we started the roller coaster ride and that can actually create heavy periods for people who are like i i never used to have heavy periods and all of a sudden they start to have heavy periods could be a cause of the fibroids that are being responsive to this hormone fluctuations.

1:14:14But a lot of women have fibroids. They just don't have symptoms. Jessica, I adore you and I'm so grateful and I'm so sorry we kept you a few minutes over. Thank you so much. I mean, so many of these questions, not only, I mean, I didn't have time to really read the thank you for all you do, Dr. Shepard, Dr. Shepard. So I was just like Trying to get to them, but so much love from this group of women and so much love for what you're doing and just who you are as a person and a physician. So thank you. Thank you. Thank you. I can't wait to track you while you're experiencing Ibiza.

1:14:55Have fun while you're there, along with work. I can't wait for us to get together. I hope everyone who is on here, thank you for investing in your health and being here. But when you see Haley and I together next time, she will be busting my butt. And then you guys can be like, wow, she's really kicking her ass. I'll be like, yeah, that's what she does. Exactly. We're making it happen. Yes, we are. Okay. I adore you. Take care. And thank you so much. All right. Have a good night. Bye. Thanks for listening. If you enjoyed this episode, please consider giving us a five-star review and sharing the body pod with your friends.

1:15:35Until next time.