The Truth About Hormones: Why Every Woman Should Consider Menopause Therapy

0:00Dr. Gabrielle Lyon:You're giving your female patients testosterone? I am. Why are you giving them testosterone? There is no Wow. Not all men suffer from low testosterone. All women will go through menopause. From 1999 to 2020, menopause hormone therapy dropped almost 30%. So the Women's Health Initiative did more damage to women's health and hormones than any other single study in the history. When someone is in perimenopause, Should they wait? I hear a lot of people say, well, I want to wait. Wait for what? These things don't get better. I see a lot of providers putting patients on estrogen cream. We don't recommend it.

0:39Every female listening to this podcast needs to be taking notes and considering this no matter where they are in their life cycle.

0:46Dr. Gabrielle Lyon:All women should have vaginal estrogen. And when they're entering perimenopause, vaginal estrogen with also testosterone will prevent vaginal atrophy. women are not nearly as studied as they should be it's embarrassing it's actually embarrassing how little we know about women in relation to the science of this stuff we cannot stop menopause or perimenopause but we can get ahead of it just for the ladies out there listening we're never going to treat menopause it's happening

1:22Gabrielle, I want to talk about estrogen. What are the most common kind of signs and symptoms that a woman is low on estrogen?

1:28Dr. Gabrielle Lyon:Number one, you won't believe this, and this might be very surprising, but when a woman is going through perimenopause, one of the first signs, she will be getting hot flashes. You've heard about hot flashes. Maybe you've even seen it. Have you ever seen a hot flash? I have not. You know, we live in Texas. Yes. It's very hot here. But before moving to Texas, I was in New York, and nobody was walking around with little those handheld fans. Have you ever seen that? I know that. Yeah, the handheld fans. A sure sign and symptom that a woman is going through menopause. Okay. Yeah. No, not funny, but true.

2:03Dr. Gabrielle Lyon:One of the most common signs or even symptoms that a woman is low in estrogen, hot flashes. Also, joint pain, believe it or not, frozen shoulder. frozen shoulder yes and i learned this from uh jocelyn dr jocelyn she's an orthopedic surgeon who was recently on the show and i didn't realize that when women are going through musculoskeletal pain it's not just overtraining go figure then why aren't more women on estrogen well i've got actually some numbers here for you are you ready for this i am okay from 1999 to 2020 menopause hormone therapy dropped almost 30 percent why is that from the women's health initiative so it was 26.9 down to 4.7 holy smokes yes so the women's health initiative did more damage to women's health and hormones than probably any other single study in the history.

3:05Dr. Gabrielle Lyon:You thought castrating men was bad. The Women's Health Initiative left 20 years of women from being treated for menopause, meaning you asked me what the signs and symptoms are. Hot flashes, brain fog, mood, poor sleep. All of these things can be contributed to low estrogen, not to mention change in the lipid profile. A woman's life who is going through symptoms of menopause is, again, it is so challenging. And I've seen it and it really affects their lives. Yeah. Can you explain for the audience, the Women's Health Initiative, that was looking at the relationship between estrogen and cancer, if I remember correctly?

3:49Dr. Gabrielle Lyon:The Women's Health Initiative did a number of things. And the thing about the Women's Health Initiative is it used Prempro. It didn't use estradiol, which is what we now use. So Prempro, and then it used a synthetic progestin. They found that it increased the risk of cancer. And it was, for example, I'm looking at this here, a higher risk of thromboembolism, stroke, and breast cancer. When that happened, they created a mass hysteria and it really turned people away. Everybody. So the baby got thrown out with the bathwater. Everything got thrown out, which I think is devastating because we're seeing rates of osteoporosis and dementia, Alzheimer's dementia at rates we haven't seen before.

4:38Dr. Gabrielle Lyon:And it could have been prevented. The average age of enrollment, by the way, for the Women's Health Initiative was 63. three. That's 12 years past normal menopause. A woman typically begins perimenopause and perimenopause is a big term. It's around menopause. A woman could have these symptoms for 10 years. Wow. Yeah. Really, really bad. But the thing is, is that the Women's Health Initiative equated this PremPro and synthetic progestin with hormone replacement therapy. And it really turned people away. So just to be clear for the audience, they should not use that as a reference point. No, it dropped hormone replacement or menopause replacement therapy by 60%.

5:25Dr. Gabrielle Lyon:It left millions of women undertreated. So now that the audience has been educated and we're looking at this, what are some of the options? What are some of the delivery options for a woman who's considering going on estrogen? Well, first of all, you don't do estrogen alone. You go to your provider, you get total estrogen, estradiol, progesterone, you get FSH and LH. Typically those numbers will increase. They'll become high when you are in menopause and around perimenopause, they'll be all over the place. Testosterone. Testosterone. Yeah, free testosterone and sex hormone binding globulin, all of which are important.

6:04Dr. Gabrielle Lyon:These hormones are so important for women, not just for brain and bone and heart health, And of course, lab values, but also vaginal estrogen. One of the things that I hear all the time in my clinic and strong medical is that sex becomes painful or women are getting more UTIs. And then to top it off, they also can't train and are getting weight. Yeah, it's interesting. Not all men will suffer from low testosterone. All women will go through menopause. and yet from based on statistics a smaller percentage of them is going to get treated than men despite the fact that every woman listening to this podcast is either going to experience this or experiencing this now or it's only a matter of time yes you would definitely go if you are a woman you will definitely go through menopause and now we're seeing a resurgence of the conversation around menopause which is so important in perimenopause because there's a lot of myths out there and especially with the delivery system for fertility and for pregnancy so if a woman doesn't want to become pregnant when she's young she's typically put on birth control yes birth control will increase sex hormone binding globulin which think about it hormones are like kids so we have kids both of us we do we do and they can't go anywhere alone same with hormones Hormones don't go anywhere alone.

7:33Dr. Gabrielle Lyon:But when you increase sex hormone binding globulin, you make free hormones less available, which means from a young age, if women go on birth control, then she will likely require, for example, testosterone to have a higher dose of testosterone than she would normally to get the same result. Wow. I don't think that's discussed a lot. No. What is definitely not discussed is that birth control, while important that when you are taking an oral agent it can affect the microbiome actually we worked on a study with the legendary i'll roll my eyes andy galpin oh kristin holmes we just recently published a study on that but i saw that yeah it affects the microbiome also will irreversibly increase sex hormone binding globulin and again someone will say well isn't preventing pregnancy important yes but there are other ways to do it like an iud which is the Mirena, a non-hormonal IUD.

8:32Dr. Gabrielle Lyon:If a woman is entering perimenopause and is starting to get increased bleeding, an IUD can be very helpful if she doesn't want to take the pill, which personally I don't recommend. But again, you have to look at your blood work. No, that's great. Hormone replacement therapy isn't an option for somebody. Are there any natural treatments that women can do? For menopause? For menopause. We're never going to treat menopause. It's happening. you're never going to stop it and i was recently at this amazing event um i went to a place called newtopia which actually i came over to your house to practice this talk and it was this talk about conscious consumerism one of the things that i kept seeing was take this for hormone balancing this food for hormone balancing that's the wrong message hormones being quote balanced what what does that even mean?

9:27Dr. Gabrielle Lyon:The outcome that we're looking for probably in younger women is fertility. Polycystic ovarian syndrome is the number one cause of female infertility, which in a large part is related to the health of skeletal muscle. No amount of supplements is going to fix that, but a good diet and training regimen will help. Which again, I know that we're talking about menopause and hormone replacement therapy, estrogen and progesterone and testosterone are not used to treat body composition for menopause, which people will say, I'm going through menopause. My body is changing. Estrogen should never be given alone.

10:07Dr. Gabrielle Lyon:It should always be given with progesterone. Progesterone protects the uterus and the endometrium. Delivery systems for estrogen someone listening to this our number one delivery system that we like in the clinic is an estrogen patch now we live in texas yes which means it's hot and if you are swimming a lot and going in the sauna you might find it's not great for you then then what do you do yeah so if if you're using an estradiol patch what's what's you mentioned one mistake you avoid swimming a lot a great question actually i called dr rachel rubin i don't know if you know dr rachel Ruben, I do think she listens to this podcast.

10:46Dr. Gabrielle Lyon:Rachel, I'm looking forward to seeing you at the North American sexual medicine meeting. But she said she'll use injections. And if someone cannot tolerate a patch, then potentially an estrogen injection. I think that it's a little volatile for people. But estrogen patch is the number one way to go. People ask me all the time, what kind of protein powder I use. And in order for me to feel comfortable recommending a brand, I need to know it is clean and transparent. And that is one reason why I love one of the sponsors of the show, Peori, because every single batch of PW1 whey protein is, get this, third-party tested by the Clean Label Project for more than 200 harmful contaminants, including lead, heavy metals, and pesticides.

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12:32So for the injections, how do you do that? Is that subcutaneous or intramuscular? You can do all hormone sub-Q and you could even mix it with your testosterone. Whoa, whoa, whoa.

12:43Dr. Gabrielle Lyon:And also guys, we're not giving medical advice, but we get so many questions on hormone replacement therapy or menopause replacement therapy. And because of all the myths out there, I thought we could break down a little bit of what we do in clinical practice. No, but I want to go back to that and pump the brakes. you just said testosterone in terms of hormone replacement therapy when we're talking about the female patient yeah you're giving your female patients testosterone i am why are you giving them testosterone i don't want to say it's because it helps their husbands feel happy i'm just kidding i'm totally kidding guys um testosterone is really important for women and it's important for sex drive it's important for muscle mass there is no fda approved testosterone for women Even though we can treat hypothyroidism with thyroid hormone, we can treat menopause with estrogen, estradiol, but there is no FDA approved testosterone for women.

13:46Do you think there's just such a stigma with testosterone in women or just a lack of understanding?

13:51Dr. Gabrielle Lyon:All of it. I was shocked when I started treating women with testosterone. I was shocked at how little data is out there. And actually, we're working on a study at Baylor on safety profiles to really help move the needle for people. But in the U.S., it is not prescribed nearly as much as it should be. There is no FD approved indication. People typically give testosterone off-label for hyposexual desire disorder. Is that the only reason? I mean, not if you're in my clinic, but that is really one of the indications, which is unbelievable to me. Yeah, that seems a little sexist, right? In terms of that's the only reason people are prescribing it to a female.

14:39Dr. Gabrielle Lyon:Well, the off-label indication, but when you think about it, testosterone is important not just for men, but also for women. And there are testosterone receptors everywhere. one of the things that i always hear for from women is that they're afraid to go on testosterone because they're afraid of losing their hair getting acne voice changes that their clitoris will grow if you are being treated by a physician who is tracking your blood and you are given appropriate doses not super physiological doses you should not have a problem and then for their labs are there any values that hard and faster you're just looking at the holistic patient kind of profile every time or their their numbers that you know kind of like the males have the 300 nanograms per deciliter what does the female have tip and that's a really challenging question because we don't have great data for women the typical dosing strategy is one tenth a male dose if a man gets a hundred milligrams of testosterone a woman should get done which that would be on the high end for us the best delivery system for testosterone in my opinion is a sub-q weekly or bi-weekly injection which they could do also with their estrogen if they don't want to do the estradiol patch so it's all that they could and you're probably thinking um what would you start with yeah are you wondering what you would start i am wondering what you start with i would typically start a woman on testosterone before if she is younger and she has not gone through menopause and looking at her labs, she has low libido.

16:17Dr. Gabrielle Lyon:Why is libido important to treat? Mental health. There's a lot of other factors. Can't be landmine, Gabrielle. I know. Just setting you up there. That is also hilarious. Think about this. The relationships, having a good relationship with your spouse is everything. It means everything. You're not going to be able to live well if you are constantly at odds with your spouse. Now, I've been a doctor for well over a decade. There is two things, or there are two things that couples fight about, money and sex. I can't help someone's financial situation, but I definitely can help their sex life. And it is a couple's responsibility, a couple's disease, and I don't want to say disease.

17:01Dr. Gabrielle Lyon:But hyposexual desire disorder would be, it has to last for at least six months. and it's not just a fluctuating libido and it's not just in her head. And oftentimes it has to do with hormonal changes. Wow. No, that's great. And I'm sure very helpful for a lot of the listeners. What about, so when a female goes on testosterone, are there any like body composition changes? Are there any other things? Because you mentioned some of the masculizing effects of testosterone. What can a female who wasn't on testosterone expect once she goes on testosterone? What I have seen is that women's muscle mass can increase if they're training.

17:40Dr. Gabrielle Lyon:You'll also see her recoveries better. For a woman going on testosterone, I think it's really important to manage expectations. When women come into our clinic and they say, I'm going through menopause, my body composition has totally changed. When they start estrogen, progesterone, and testosterone, we typically don't see a change in body composition if that's all you're doing. which and i can't give you an answer as to why but as opposed to say a male we were talking about that other study you put a man on testosterone goes up muscle goes up but also the dose is so much different the dose is one tenth a male dose when she is training and her diet is together we do not necessarily see a negative change of body composition through menopause and that's probably one of the most common things that women will say i'm going through menopause let's take away hot flashes hot flashes brain fog those two listen we hear that all the time but also women really struggle with body composition changes around this time and the question is is it related to hormones probably but once you replace those hormones and her symptoms are better if she is not training, eating well, and drinking less, we won't necessarily see changes in body comp.

19:04Yeah. So you got to do it. But I mean, it makes sense because right, like estrogen is going to affect insulin sensitivity. So less estrogen, less insulin sensitive. So, I mean, it would make sense that you improve that you can improve body composition. I know we're talking about menopause, but perimenopause, like, is there like fertility? Like what's, what's that look like if a woman still wants to conceive are you guys planning on having more kids no we are not um this is a great

19:27Dr. Gabrielle Lyon:question a woman who is going through perimenopause which perimenopause is that time around menopause can happen that can last 10 years the average age of menopause is around 50 which is so disappointing it's happening and i do think just for the ladies out there listening we have to accept it and it it kind of sucks because with lower estrogen our skin changes our joints change our hair changes and how can we stop that from happening well we cannot stop menopause or perimenopause but we can get ahead of it what do i mean by getting ahead of it if a woman is having symptoms but still menstruating let's say her periods are terrible and she's not sleeping we would start with progesterone first for sleep micronized progesterone and that is given orally i see a lot of providers putting patients on estrogen cream we don't recommend it we recommend micronized progesterone the absorption is better also functions as a gaba agonist helps people sleep there is also progesterone trochies and i'm going to give you another tip postpartum some women that go through really bad postpartum depression, sometimes providers will give, say, just a shot of progesterone, 200 milligram shot.

20:50And that can help?

20:51Dr. Gabrielle Lyon:With postpartum depression. Wow. And the cream, is that just an absorption? Yeah, and also the metabolism. Cream is interesting. It's really tough for people. Now, the delivery mechanisms for hormones, let's think about what they are. Injectable, topical, and oral. injectable there's a lot of ebbs and flows because you inject it there's a peak in a trough topically you have less ability to control the delivery system here's why and i'm saying delivery system that's not the right word for example an estrogen patch and i've used estrogen patches i switched from the Vivaldot to generic. And I looked at my numbers and my numbers didn't change.

21:38Dr. Gabrielle Lyon:It was because my skin was not compatible with that patch versus a Vivaldot. And again, I have no relationship to these companies. The skin quality and the kind of skin you have plays a role. Yeah. It's thicker skin or, you know, for whatever reason. You mentioned those other delivery methods. When we were talking a little bit about testosterone, what about uh the nasal is there a nasal estrogen there is i do not use a nasal estrogen what a great question why not i don't know i i don't know because the patch works so well i don't recommend estrogen cream because think about it the patch exists have you ever seen an estrogen patch i don't think i've ever seen one in person no the patch has the designated amount as opposed to the cream the cream is it's totally messy you might do two pumps and maybe you got this time you got a bigger pump yeah i can see that but the absorption for estrogen cream i'm not a fan what i love estrogen cream for and i think all women should have vaginal estrogen and when they're entering perimenopause vaginal estrogen with also testosterone and even dhea in the cream will prevent vaginal atrophy and protect people from UTIs.

22:56Wow. Is that compounded, that combination, or is there a product out there that already does that?

23:03Dr. Gabrielle Lyon:We typically use compounded, but every woman listening to this who's going through perimenopause or someone who is suffering from UTIs, number one, do not get constipated. Constipation increases your risk of UTI. Believe it or not, it affects the anatomy. And number two, estrogen cream is really good for the flora. Wow. For the vaginal flora. Yeah. Didn't know that. Thanks to one of the sponsors. It has me asking, why go out when your pajamas feel better than most relationships? Cozy Earth's pajamas and blankets are so irresistibly soft and breathable and of course stylish. You'll find yourself planning your evenings around them.

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26:40Dr. Gabrielle Lyon:And we use anywhere from five to 10 milligrams, depending. You could even go to 20. Sometimes women will get some acne from it, but there is potential evidence for it to be supportive, DHEA use in women. Also, we were talking about hyposexual desire disorder and the genitourinary symptoms of menopause. There is an FDA approved vaginal DHEA insert, which it's 6.5 milligrams and it is called intrarosa. And it's indicated for postmenopausal women with painful sex and vulvovaginal atrophy. The DHEA versus just the estrogen, because my understanding the DHEA, it can go to estrogen or testosterone. So is that just kind of given the body, for lack of a better word, like the substrate to produce what it needs to produce in the ratio that's needed.

27:34Dr. Gabrielle Lyon:But also keep in mind, if a woman is in menopause, DHEA is separate. And that's one of the blood markers that we measure. I don't know if I mentioned that earlier. We do measure DHEA. DHEA can be important for inflammation as well. If a woman is on estrogen, progesterone, testosterone, and you measure her DHEA and it's low, definitely supplement it. But I also want to be clear in terms of expectation. a woman who is in menopause isn't going to take dhea and all of a sudden feel better as if she is on menopause replacement therapy dhea is always used in conjunction it's never like a monotherapy it can be okay it can be when you're young but again define young that's right that's such a good tricky question here um when you are young and you are making hormones you have a lot of flexibility as you get into perimenopause you'll see that sometimes cycles become irregular you will see sleep gets disturbed but if you measure your blood work the blood work you might go to the doctor and the doctor might say you're fine and you go you know what doc i'm just having brain fog i'm not feeling well and you have to be able to treat symptoms and one of the ways that we and there's various ways to measure you know you can do it very complicated there are month tests can you imagine testing urine or blood levels for a month to see what your markers are um not fun but i think that figuring out how you feel as a woman and understanding that there is a cyclical nature and starting i think progesterone which is protective uterine protective can be very helpful and our starting dose for women again we use a micronized progesterone it could be 100 to 200 milligrams women with endometriosis seem to respond really well with micronized progesterone and it's a great place to start very safe again right now we have a landscape of coming out of being afraid for the last 20 years.

29:45Yes. And so in that same vein, I have a female friend who went to their physician and asked about these things and were immediately shut down. Immediately shut. You're fine. Everything's with normative value. So I want to ask you, you know, how do you recommend that patient who maybe went out and asked their provider about these things we're talking about and they get shut down immediately to tactically push back? And then is there a point or cutoff point you would recommend they go find a new provider? Probably immediately.

30:15Dr. Gabrielle Lyon:Okay. I mean, because part of being a physician and you know this, you see, you don't see patients, but you have clients, you know, as a ranger and dietitian and, you know, taking care of high performance individuals, it's a team sport. If someone is coming in and saying, hey, I'm going to give you an example. Are you ready for this? Yes. I know a patient, she's postmenopausal, and she missed the, quote, window of opportunity for menopause treatment. There is information out there that once you are 10 years past menopause, that you cannot be treated with hormones. Well, think about all the women that missed.