Perimenopause Hormone Therapy: What Women Need to Know About HRT, Progesterone & Estrogen

0:00What the hell are we doing to women's brains long term when they put them on that? If you don't want to get pregnant, and we certainly don't want to just come off of it and be like, are you ovulating? Are you not ovulating? Like we want to have a backup plan for that. Some women lose their minds with progestin. So it's all about what's true for the individual. So many of my patients, they no longer have the threat of unintended pregnancy. And they literally say, I no longer have a fear of getting pregnant. So now I'm actually in the mood. So much more. It's so much more enjoyable. Do you need to prepare or stabilize your hormones before removal?

0:32Well, at 48, no. What should women know about post-menopause that we don't talk about enough? How great sex can be. If you feel healthier, should you test hormones or start hormone support supplements proactively? It just depends on... Low energy, unfocused, foggy? You might be dehydrated. Whether it's hot yoga, over 100 degree weather, or too much sun. Gatorlite, with a specialized blend of five electrolytes, was scientifically designed to help move fluids into the body faster for rapid rehydration. Shop now at retailers nationwide. Gatorlite hydrates faster than water. Is it in you? Symptoms noted are signs of mild to moderate dehydration.

1:16Consult a healthcare professional if symptoms persist. Push your limits. Train with precision. See the results. At Equinox, that's high performance loving. Everything you need to lock in and unlock your potential at Equinox. Start today at equinox.com. Hey everyone, welcome back to another episode of the Dr. Brighton Show. And today is all about perimenopause hormones. I think menopause too, because it's all your questions that you sent in. We're doing a special Ask Me Anything, AMA for short, with my good friend and assistant, Angela. She's going to be asking me your questions. I haven't even seen them yet, so I'm very excited for this.

1:54And if you can take a quick moment, like, comment, subscribe, share, you know, do all the things that give this a little bit of juice and help it get out to the internet to all the women who need it, I would appreciate it so very much. If you don't know who you're listening to right now, I'm Dr. Jolene Brighton. I'm board certified in naturopathic endocrinology. I'm a nutrition scientist and the author of the new book, ADHD and Women, that I'm very excited about. and we're going to go right into questions that you asked. But what I need to know from you all today, do you like the AMA? Do you like the panels we do?

2:27What is giving you the most value on the Dr. Brighton show? I want you to have fun here, but I also want you to learn and get the information that you need to live a better life. We are nearing episode 200 on the Dr. Brighton show. And the only way I know how to keep showing up and serving you is if you give me your feedback. So drop it in the comments. I'm sure Angela will be perusing them too so that we can see what is it that you're into. So with that said, Angela, I will let you take it away. Okay. First question. How do you actually know what's happening with your hormones in perimenopause?

2:59You track. This is the most frustrating thing. We don't have any great tests right now for perimenopause. So I can measure what's called an FSH, follicle stimulating hormones. That's what the brain says to the ovaries to get it to make an egg, well, to recruit a bunch of follicles and get an egg ready for ovulation. If that's above 25, that's like a pretty good sign that we're going perimenopause, menopause. But one month, it might be 25. And the next month, I measure it and it's nine. And the next month, I measure it and it's 50. And the next month or the next three months, it's totally normal.

3:33And so there's no real good way to gauge it because in perimenopause, it's not a slow decline of estrogen. it's actually like a up and down spiking of estrogen dropping of estrogen brain yelling at the ovaries the ovaries sometimes deciding to work other times not so it's the same thing with the estradiol but all of that doesn't mean you don't need support and you don't need help and so why I say that is because if you track your symptoms and you're like I'm not sleeping anymore I'm completely anxious like I rage out on my partner all the time two clues um if my husband chews with his mouth open one more time?

4:08Or why does he have to breathe so loud? Like I hear this all the time from women. That's pointing to progesterone. These are interesting, interesting symptoms. This is even before a period change that we can look at optimizing progesterone or maybe bringing in progesterone. If you start having brain fog, loss of word finding, you mid sentence, you can't even remember what you're saying. You see that person, you know the person, but the brain will not give you the name of that person. You start to have those changes and it's coupled with maybe like having drier skin, itchy ears, burning mouth, cold flashes, also hot flashes, night sweats, all of that, that's pointing to estrogen.

4:43So perimenopause is a clinical diagnosis. We also have to rule out other things like hypothyroidism possibly being involved. And then the treatment is also based clinically. Once we start treatment though, for menopause hormone therapy or hormone replacement therapy, I do lab testing. Specifically, I'm looking at estrogen, testosterone, thyroid, sometimes cortisol to make sure that we're hitting the numbers where we want to be. Right. What are the best ways to tell if you're still ovulating? So if you're talking meriomenopause, that can be a little bit tricky. So we can have cycles where we don't ovulate and then we bleed.

5:20We can have cycles where we double ovulate. So it's called a loop and it's where, you know, you ovulate and then the brain and the ovaries mess up and you it again. It's just like, and this is why twins can be so common. You can be that double ovulator. Two eggs can come out at the same time. Twins are so much more common in our forties. Now, typically what we're tracking is we're tracking, how do you feel? Usually when we're going to ovulate, estrogen is going up. We're more in the mood. We're more confident. Our skin looks better. I was like about to have a photo shoot and I was like, it has to be when I'm ovulating you guys you don't understand i do remember because i was like this is probably like the last photo shoot of my 40s for like you know the whole drbrighton.com and everything so i'm like i need to like leverage that estrogen but the other things there's there's signs of ovulation fertile cervical mucus so when things get goopy downstairs right it's that really um egg white consistency it's so if you've ever broken an egg and it's on the counter and it's that like slimy, but kind of like stretchy egg white.

6:22That's what you see in your underpants. The other thing is that you'll see a temperature spike as well. So I wear, yes, I do have it on my Oura ring. So, but that's like you can see, so you ovulate and then you're going to see a subtle rise in your body temperature. And then that should sustain through the rest of the month. That's a sign of ovulation as well. So what I'm talking about here is fertility awareness method tracking. And fertility awareness method is not just about trying to get pregnant or not get pregnant, but this is also about monitoring your body. In perimenopause, it can kind of feel like if you've not been doing this your whole life, a mystery and things are all over the place.

6:58There's something we can do is if you think you ovulated, we can test five to seven days later. We can do an LH test strip. So you can pee on a test strip. And when you see that spike, then five to seven days later, we can test progesterone. And why I say that is the brain will say ovulate with LH, luteinizing hormone, but you might not. So if I test five to seven days later, I should see a progesterone level that's in the double digits. If you're like, how the heck, I want to do all of that. Go seven days before your period. So if your period's still regular, go back seven days, test your progesterone.

7:32Okay. That's a sign that we have ovulation. If your cycles are predictable, you're probably ovulating regularly. If your cycles are unpredictable, you're no longer ovulating regularly. What about if you have shorter cycles? So you shouldn't have less than 10 days of the luteal phase in your cyclical years. If you are in perimenopause, that might start happening because we ovulate and what's left behind is the corpus luteum. It's a temporary endocrine structure that produces progesterone. The temporary endocrine structure makes our progesterone. What happens sometimes in perimenopause is that that becomes weaker.

8:13And so your cycle, instead of you getting that at least 10 days of progesterone, you start to get less progesterone production because the ovary is just not as strong in producing that. Vitamin C, vitamin B6, and Vitex can help. But once the ovaries have decided they are retired, that's not going to do anything for progesterone. It'll do a whole lot for like neurotransmitters in the brain and antioxidants and, you know, other things in the body, but not so much for progesterone anymore after that. Okay. Well, I think you've answered this. How useful is hormone testing when levels fluctuate? When you ask this question, most women are asking about estrogen and progesterone.

8:53Not entirely useful, but it is nice to get a baseline, especially if we then start hormone therapy so that we can see like, okay, what are the baselines? We talk about testosterone, incredibly useful, always, always in a woman's life, incredibly useful data. We do look at symptoms. This is DEA regulated, though. So I also like to have evidence so that if the powers that be are like, why are you giving women testosterone? I'm like, look at their symptoms. Look at these labs. But with testosterone, I also want to see total testosterone. How much do you make? Free testosterone. How much is available?

9:27Sex hormone binding globulin. Are you binding it all up? And I want to see DHA sulfate. How much is coming from your adrenal glands? Because they're about 50 % of our testosterone production. And then depending on like if we think we're going to start hormone therapy or if a woman's like, I'm having like thinning hair, I'm having hirsutism, hair growth on my chin, chest, abdomen. I want to look at DHT, dihydrotestosterone as well. So I like to look at this full thyroid pan, or excuse me, testosterone panel if I can, and really understand what's going on with testosterone. Thyroid is also always pertinent.

10:02TSH, what your brain says to your thyroid, free T4, what the thyroid actually produces, free T3, what your body converts to the active hormone, and then TPO and thyroglobulin antibodies are the minimum that I'm gonna wanna see in everybody. And then sometimes we're also gonna look at cortisol. I'm always gonna look at a fasting insulin because that's when you might not have any symptoms, but your fasting insulin is elevated. And I'm like, no, no, no, I know it's coming down the pipeline. Diabetes is trying to catch you and we're not having any of that. So there's a whole lot of hormones in the body.

10:32I mean, there's even more than what I've listed here, but we want to be very clear when we talk about hormones because sometimes you go to the doctor and they're like, there's no reason to test your hormones. They're all over the place. They're only talking about estrogen progesterone. You're far more than just estrogen progesterone. And like I said, perimenopause, we don't want to just call it perimenopause. We want to make sure no concomitant hypothyroidism, no HPA access, dysregulation going on, no insulin resistance happening. What do you look at when all my labs are normal, but I still feel awful?

11:03I look at your symptoms. Labs alone mean nothing, right? Unless they're grossly off, unless like a vitamin D is like, you know, 19. And then I'm like, yeah, that's that means something all on its own. But for the most part, labs don't mean much on their own. And so this is where that naturopathic functional medicine lens comes in, is that we have to marry your symptoms with the labs. And we're looking for optimal labs, not just what's in the normal range, but we're also looking through the lens of like, what are your symptoms saying? So for example, someone might have a TSH of three. I said, I don't like to see it below 2.5.

11:37They feel totally fine. Well, okay, you feel totally fine. You're not having any symptoms. Let's just monitor it. Another person might have a TSH of three and they're like, I can't remember everything. You know, literally everything in my life is like, I can't remember it. I'm not on top of it. I'm not as mentally sharp. Maybe I'm feeling like cold. I'm having constipation. I'm having dry skin. They're having symptoms. So we always want to look at the lab in the context of the person that we're talking to and what are their symptoms? And I always believe people's symptoms over labs alone. And if the labs don't show me, there's limitations to labs, but also maybe we didn't run the right labs.

12:15Maybe we need to look elsewhere. Yeah, love that. How do you know when it's time to switch from the birth control pill to menopause or hormone therapy? The birth control pill is not menopause hormone therapy. Let me just say that. The birth control pill is way more estrogen than you need when we're talking about menopause, perimenopause. And the reason is, is because it's designed to shut down how your ovaries work and function. And so we give this big bolus of oral estrogen, which can raise clotting factors that are coming from the liver and put you at risk for a possible clot, right? We hear that.

12:50It's the same thing with pregnancy. Lots and lots of estrogen increases the risk of a clot. And so that's always like one of the concerns when women have with menopause hormone therapy, which is why we use transdermal in just about everyone. There's some emerging evidence that suggests that oral might be helpful for the cardiovascular system. But for me to do that, I want to know clotting factors in people. I want to understand like, do you have factor V Leiden or something else going on? Like I want to understand those studies. So what I will say is that if you're in perimenopause and you cannot and will not get pregnant, you're like absolutely not, then birth control bill, maybe, you know, a viable option to be using during that time because giving you estrogen progesterone bioidentical is not going to stop you from ovulating.

13:37I would say though, if you're on birth control for that reason, and maybe you're continuous, you haven't had a period, we don't really know. We don't really know when it's time to make that switch altogether because you're wanting the protection while you don't ovulate. And so it's one of those things that we typically have to have you come off and then switch you. What's really important to understand there's no progesterone in the birth control pill. Progesterone is incredibly important for GABA stimulation in the brain. Also for the myelin sheath, which is the protective layer of the neurons is important for BDNF, which is miracle grow of the brain.

14:13It's got a lot of brain benefits and we've got absence of evidence to say that it's completely safe to put someone on progestins like their entire life. And it has no impact on the brain. Like I can't say that. And I get asked that all the time where patients are like, well, what might happen to me? You know, more than 60 % of women are who get dementia. So what might happen to me if I'm on progesterone my whole life and I don't have progesterone? I don't know. I don't have a good answer for that because it's just lack long-term research, which is like really crazy to think like birth controls had like over 60 years in women and we don't have long-term studies telling us because the narrative always has to be that it's safe so that like the government doesn't try to take it away from women, right?

14:52Like that's what we're told. But I think that's a huge disservice for women. And for women who want to know, like, stay up to date on the science of birth control, Dr. Sarah Hill, I think she does a great job of like always talking about the new research coming out. But she is a researcher who really calls into question, what the hell are we doing to women's brains long term when they put them on that? Now, why I raised this is because perimenopause very vulnerable stage. And we know that these hormones, they protect against that vulnerability. And so the question of like, when do I come off birth control?

15:26It just really depends because it's, if you don't want to get pregnant, we certainly don't want to just come off of it and be like, are you ovulating? Are you not ovulating? Like, but we want to have a backup plan for that. I would also say that if you're in perimenopause and that's your concern, vasectomy. If your ADHD feels different across your cycle, postpartum or in perimenopause, ADHD and Women explains why hormones can change your brain and what you can do about it. Pre-order now and for a limited time, get the first chapter audio read by me, Dr. Jolene Brighton, for free, plus a bunch of other bonuses like a free recipe guide and a PMDD workshop.

16:04Claim your bonuses at drbrighton.com slash ADHD and women. That's D-R-B-R-I-G-H-T-E-N.com slash ADHD and women. Low energy, unfocused, foggy, you might be dehydrated. Gatorade Zero powders have been scientifically designed to help improve hydration balance in the body. With a clinically proven electrolyte blend and no artificial colors or flavors, great tasting hydration no matter where you're going. Shop now online or at retailers nationwide. Gatorade hydrates better than water. Is it in you? Symptoms noted are signs of mild to moderate dehydration. Consult a healthcare professional if symptoms persist.

16:48Vasectomy is the answer. I think that's a great answer. It should no longer be on you. I just think this burden that you've carried your entire life, it's no longer yours to carry. And we could be doing so much more for your gut health, your brain, your bones, like your entire system using hormone therapy, bioidentical hormone therapy over these synthetic contraceptives. I actually know a lot of people's partners that have had a vasectomy. I think it's great. No questions asked. I think like you got a good man. You got a good man when he's like, you've carried the torch, my friend, pass it on to me.

17:20It's now my turn. Okay. How does a Mirena IUD fit into perimenopause? Yeah. So a Mirena IUD offers protection to the uterine lining. It can also be, you know, contraceptive, like obviously, right? But if you're someone who maybe isn't tolerating progesterone and oral progesterone, you have a paradoxical effect. I have an episode I'll link on progesterone intolerance. And you're like, I tried vaginal, I tried rectal, I tried like everything, but I need estrogen. Sometimes you'll tolerate a progestin IUD. And some women do fine with progestin. Some women lose their minds with progestin. So it's all about what's true for the individual, but it can be protective for the uterine lining.

18:01The other thing, you know, we're talking about perimenopause and menopause, but the endometriosis panel, I'll link to their episodes in the show notes. They brought up with adenomyosis, this being a very good treatment for protecting fertility, like kind of being, putting the uterus in a holding state in women who have very heavy periods due to adenomyosis in perimenopause and they don't want to have a hysterectomy, which there's just a million valid reasons not to have a hysterectomy. I know someone's going to be like, I had one, why wouldn't you just do it? Because this is this person's choice and it's their body.

18:35And progestin IUD could really help with that. And it may help with that adenomyotic tissue that's in the uterus. So it all just depends. But I would say track your mood symptoms for two months. I would track everything, but mood symptoms at least for two months, have the IUD placed, track your mood symptoms for another three months. But if within the three months you're having symptoms, you have data. You have your data and you go to your doctor and you say, this is my data. This is where I'm at now. This is night and day difference. I want this thing out. Because sometimes doctors, I just think this is so patriarchal where they're like, I'm not going to take out your IUD, you bad misbehaving little girl.

19:13You don't get to make that decision I'm like it is her body and I will fight you in a dark alley so don't end up in there because you'll catch hands if you think you can tell women what to do with their bodies. I love that. Can it help with perimenopausal symptoms? So the the heavy periods yes and then if you can do the estrogen therapy with that it may help. The rage the sleepless nights the anxiety like these mental emotional symptoms that are due to declining progesterone? No. And the reason is, is because progestin is a synthetic form. It's nothing like progesterone except for its ability to dock onto the progesterone receptor.

19:51The body doesn't convert it into allopregnenolone. Progesterone gets converted into allopregnenolone. Allopregnenolone then interacts with the central nervous system. It's in the brain. It docks on the GABA receptors and it says work better with GABA, Like be besties, hang out all the time. Like you love this. So no, it can't do that. And progestin is also not going to help with the myelin sheath that I talked about. There's no evidence that progestin's raising BDNF. Like there's no evidence that the brain benefits to it. But for the uterine protection, it's definitely there. Okay. What happens when you remove it at 48?

20:27I mean, at 48, it really depends. This is where I would ask like your family history. If your mom was like, oh yeah, my mom was in menopause by like 46, odds are like we're going to be fine. Like you're probably in menopause, but it always depends too. Like did you have a phenomenal lifestyle and ate all this great stuff? Your ovaries might still be going. If you were struggling with heavy bleeding before, that's definitely going to come back when you remove that. Unless there's no longer estrogen cycling. The other thing I should warn people about the progesterone IUD, I actually talk about this in ADHD in women, is that some women will stop ovulating on it.

21:06And when you stop ovulating, you're stopping making estrogen as well. And very much in perimenopause, you'll see this like the brain fogs, the low estrogen symptoms that we talked about, which I think was this episode. Brain fog, dry skin, burning mouth, cold flashes, hot flashes, night sweats, joint pain, muscle aches, can't exercise, all these kinds of things. you could experience on the IUD because you've stopped ovulating. You're not making your estrogen. We also see these symptoms in ADHD populations because they're more sensitive. They're more hormonally sensitive to lack of estrogen, pulling on their dopamine, pulling on their acetylcholine, their serotonin.

21:40And so that's just one thing to be aware of is that sometimes we have to do add back therapy. So you have the progestin IUD, but now you're having these estrogen symptoms, slow estrogen. We've got to do add back of estrogen. So as you feel like you're not losing your mind, estrogen is also important in sleep. But yeah, it's hard to say what will happen at 48 because it depends on your history. You might take it out and everything might be just totally fine. Okay. Do you need to prepare or stabilize your hormones before removal? Well, at 48, no. At 48, I wouldn't worry about that. If you were, you know, let's say like 28, I would say why'd you start it if you say just birth control I'm like you're probably gonna be fine but if you say because I had really heavy periods painful periods like all this stuff then I'm like yes let's work you up do you have endometriosis do you have adenomyosis do you have fibroids like do you have something else going on and also how can we support your body in that transition so that when you come on or as soon as you come off you're you're not feeling like all of the symptoms are coming back.

22:46Okay. How does it fit with estrogen or testosterone therapy? Yeah, you can do progestin IUD alongside estrogen alongside testosterone. You can even do it with oral micronized progesterone. An IUD with oral micronized progesterone is a common treatment in endometriosis and adenomyosis patients. But yeah, you can, like I was saying, estrogen hormone therapy, you want to use it, you're not tolerating estrogen, we can use a progestin IUD in place, because we have to have the uterine protection. If everyone's like, why? Endometrial cancer. We don't want endometrial hyperplasia and then that turning to endometrial cancer.

23:22So this is preventative medicine. One thing I'll say, history of endometriomas, those aren't removed. You still have your ovaries. You cannot do estrogen without also doing progesterone therapy. And I'm not sure the research says progestin IUD is going to be enough. It's not localized. I need people to understand that it acts locally, but it also goes systemic, that you have to have some kind of opposition to that. Why I say I don't know if the progestin IUD is enough, because you might have to also take an oral progestin or take an oral progesterone to be protective against the development of ovarian cancer, because there is a mild increased risk with that.

24:02And then one study found estrogen alone might increase that. And so I'm just saying like, we don't have robust information for me to be like, green light, just use a progesterone IUD. And ovarian cancer, we are absolute garbage catching it. And then by the time it's caught, it's usually pretty progressed. So I'm very, very cautious with that. How should progesterone be used during the menopause transition? Is this about cyclical versus non-cyclical? Daily versus cyclic progesterone. Okay. Yes. So if you're still cycling, then we use progesterone cyclically. So you can still have regular periods and still be a candidate for progesterone.

24:37In fact, like And, you know, we sometimes will use this even in 20-somethings who just need to get that luteal phase past the 10 days. They're having a lot of symptoms and we're working on the underlying issues. So the other thing with PCOS, giving progesterone cyclically, that can help sometimes get them cycling regularly. So there is a case to be made for that. Once your periods are no longer regular, you're not ovulating regularly, we can switch over to just continuous progesterone therapy. A lot of providers will do six days on, one day off just to give a break. There is being called into question, I think it is a valid question to be asked, is that the brain's never been exposed continuously to progesterone.