Hormones, Health, & Happiness with Dr. Suzanne Fenske

25:45We do also have data that's showing that there might be a slight increased risk of breast cancer. You have to really break it down because kind of lumping all of these together, lumping estrogen together and not breaking it down into whether it's a bioidentical, whether it's a synthetic, whether it's transdermal, whether it's oral, you have to really understand all the nuances to hormones, even breaking down your progesterone, right? Whether it's progestins, which are synthetic, or whether it's progesterone, which is bioidentical, to understand the data that we have on it and sort of those nuances to it.

26:28Does the delivery method impact the statistics? For estrogen, we know that the increased risk of stroke and blood clot comes with oral estrogen and not with transdermal estrogen. What about for women who really just don't want to take hormones for whatever reason, but they're struggling? Is there a certain protocol that you recommend? Or for example, like my very close friend of mine had breast cancer and it's like a hormone sensitive kind And she absolutely cannot. So, but she's having lots of hot flashes. Are there other things that women can do? Definitely. I mean, there's lifestyle things.

27:06There's supplements. There's new medications that are coming out, thankfully. You know, we had the medication that just came out called Vioza. And Vioza, you can use for really hot flashes and night sweats. My patients have done so well on it, that alone. How does it work? So it works on actually the receptors in the brain. It actually works on these candy receptors in the brain where you actually have the sensation and sensing that the hot flashes and the night sweats. So it can work really well. It can be used in women who have breast cancer or breast cancer survivors. And it's non-hormonal.

27:39So we're moving. We're moving in the right direction. There's lots of options. And what about staying on, like how long do people stay on HRT? Do you stay on it forever? Do you, I've read some conflicted things. So I will die with my hormone replacement therapy. I will. I'm going to die with it on. So it used to be, you're right. It used to be, they said, you know, the shortest amount of time, lowest amount of hormones possible. Then it was five years, which was kind of arbitrary. They created this timeline. You could be on it for five years. A lot of women still think that way. I have women come in who are like, I feel miserable, but I kind of want to hold off and bank my time that I have until I'm really miserable.

28:21Well, we know now that you can be on it forever. And you might want to be on it forever because the benefits are going to go away when you go off of it. Those things that we see, those protective benefits are going to go away. And is it true that you can't go on estrogen once you're postmenopausal if you haven't been on it? You can. It's a discussion, right? So we know that if you're the data really is there for ideally starting hormones within 10 years of menopause or by the age of 60. That's the ideal, right? But we know that because if you wait too long, say it's 20 years into menopause, then there are changes that already have happened in the vasculature of the body.

29:02Have I started women far out from menopause on hormones? Yeah. If they're really miserable, we kind of have this assumption that all of those symptoms are going to go away, right? It's going to be like a two-year process of hell, and then it's all going to be fine. But I have women who come in who are 10 years past menopause, still having terrible hot flashes and night sweats. So it's a conversation. There is, you know, some studies and there's no clear cut guidelines on how to do this. Oftentimes I'll do, you know, calcium score testing to look at the plaque built up in the heart vessels, carotid artery dopplers, which you do kind of these ultrasounds on the carotid arteries in the neck to make sure that they're open and not occluded.

29:42And if a woman looks really good and she's healthy and has none of those things, then she can be on hormones. Being aware that there might be a slight increased risk of stroke or blood clot or dementia, even data has shown us too, but having that educated conversation. Wait, so it can cause dementia if you start many years after, but it prevents dementia if you start early? Yeah, we have data shown both of those things, yes. That's so interesting. And what is the kind of biomechanical purpose of hot flashes? The purpose of it besides to drive us crazy. Yeah. Like why? It's a great question. I don't know why.

30:26I think it just comes down to just not having the estrogen and estrogen receptors all over our body. Right. So we know that it impacts everything. And that's where our internal thermostats being affected. But I don't know that there's actually an evolutionary purpose to it. I mean, it's like, what the fuck? Like why I just, I'm like, if someone were like, oh, it's because, you know, your hormones are out of whack. So your body's trying to like push out excess hormone and it, so it acts like a fever. I don't know. It's like, I want to know why this is so. Oh, it's a great question. Yeah. Okay. Well, I I'd love to also know like women who, so when, after I had my son, I had some postnatal depression for like five months.

31:12Is that a hormone related condition? Is it tied to other stuff? Is it, what, what, what is that? Or what are, what is the thinking around that? Yeah. I did a deep dive one time trying to figure out some of the thought processes behind progesterone, right? The impacts of progesterone, progesterone fluctuations that happened and the linking to mood changes, because it's interesting that you see that, for example, some women in the early, early, early stages of perimenopause, when progesterone hormones declined, kind of have worsening PMS symptoms. They'll say that their moods are so much worse right before their periods.

31:51Yes. Still having regular cycles, but yep. Worsening PMS. So I kind of did a deep dive on that. And there was actually at some point, you know, a thought process behind progesterone being linked to, or the, the decrease in production of the alpha component of progesterone, the one that crosses the blood brain barrier being linked to the mood changes that we see. And even seeing that in the postpartum period as well too, you know, when you think of postpartum, what we don't realize is that it's kind of this mini menopause state. It has kind of this limited time period, but it's a menopause state.

32:23You have these high levels of hormones coursing through your body. And all of a sudden this really rapid drop-off of hormones. And when you think about it, right? Like when I look back on my postpartum period where I had hot flashes, I had night sweats, I had changes. Me too. Me too. You know, you pee yourself, right? Like I think about all the things that happened during sort of this postpartum stage. And it is this mini menopausal time period of your life. And again, that comes down to the fluctuations in hormones. I'm somebody who's, my mood is really impacted by my hormone fluctuations. And I always wondered if like, so, but are postpartum women, are they ever treated with hormone replacement to help?

33:05No, no. I mean, a lot of times they'll be started on the birth control pill, right? Which to me seems I counterintuitive. But they're never given hormone replacement therapy. The closest thing is that some women will have pain with intercourse after having a baby, right? Same thing, the decline in estrogen, mini menopause again. So even when I was doing OB in my life, which I did OB very, very short period of time, you'd give some vaginal estrogen just for those symptoms. But no, not systemic hormones. I was offered an SSRI, which I didn't do. And luckily my partum was, depression was pretty, it was pretty short lived, but I was just wondering what, what, what the other possible treatments are, are that are offered.

33:55Yeah. It's not, well, our country in general, right. We don't take care of that whole postpartum period correctly in any way. There's no postpartum pelvic PT, which in other countries is standard of care. Right. When you think about the first visit that women have, it's six weeks after they had their baby. think about those six weeks what happens in those six weeks it's crazy it's it's it's it's crazy i mean it's such a tender time it's such a momentous change i mean i it's i can't believe in this country we expect women to be back you know weeks after giving birth it seems i mean i guess that's a whole other podcast.

34:40So is there a difference between sort of aging, like normal signs of aging and symptoms, if that makes sense? Are they always conflated? Like someone might come in and say, you know, for example, my skin quality is really changing. Like, so would that be, that's aging or is that a symptom to treat, i.e. there's some kind of cream for that or it's time for HRT or some of these things around sex lives. Do you understand what I mean? Yeah. I mean, I think that the skin quality, when we talk about perimenopause and menopause, it's dramatic what you see, the difference that changes and the increase in wrinkles and dry skin and decreased in collagen production.

35:28And it's all estrogen driven, right? As estrogen levels decline, the morbid truth is that wrinkles do increase. Skin does become thinner, more dry and less collagen and less, less disability that we see in just our skin, our body, as well as the vagina too. So transdermal estrogen will help with skin quality as well. It does. Yeah, it does. How do you think, I mean, stress and I feel like also in our culture, the levels of stress are so high for everybody, you know, in lots of different ways, but for women specifically, like how does stress kind of negatively impact their gynecological health?

36:15Let's dive into that a little bit. So with stress elevated levels of cortisol is what we normally will say. And that's coming from the adrenal glands, which are these small little walnut glands sit on top of the kidneys. So when you have that elevation in cortisol levels, it has a direct impact in many things. It increases insulin resistance, right? So we'll see weight gain that happens during that time too. The stress itself will, you know, a lot of women will have hair loss associated with it as well. And directly really specific to women is that it impacts the menstrual cycle. So very often you'll see that in states of stress, the menstrual cycle is going to go away.

36:51And we see that even when we talk about, say, polycystic ovarian syndrome, right? And polycystic ovarian syndrome, which is really a hormonally mediated issue. It's kind of a misnomer for what it is. It's not really so much about having multiple cysts on the ovaries, but having sort of this hormonal state where all those quote unquote cysts that we're seeing on the ovaries are just the follicles, just the eggs that are not ovulating. And there's kind of different types of PCOS. So there is one that's more driven by the adrenals. So those high stress states are going to give elevation in cortisol and elevation in DHEA, which is an androgen that's secreted by the adrenal glands.

37:32And when you have that elevation, it affects the menstrual cycle. So you start skipping periods. It causes also that elevation in DHEA is going to cause women to have acne, hair growth in places they don't want to have hair, hair loss in places where they want to have hair. So yeah, absolutely. Stress has a direct impact on the menstrual cycle for women. I have so many friends who have PCOS, and this is something that I never had even heard of when I was kind of in my 20s and 30s. And now I have so many friends in their thirties and forties who have PCOS. What, what do you think is going on? Do you see it more?

38:12Yeah, but I think it's a combination. I think that it's been missed for so long. I think a lot of them go undiagnosed with it. I think also a lot of women were on, like when we were growing up, when we were all on birth control pills throughout their twenties and thirties, it was kind of automatic. You know, you get to a certain sexually active stage and you're just on the birth control pill, which is completely, and I'm not saying anti-birth control pill, right? I'm just saying that in that situation, you're masking. So you can't see what the menstrual cycle is. It also, you know, it decreases acne and things like that.

38:43So you don't notice those symptoms, those kind of heralding symptoms of having hormonal issues. So I think that we're seeing it more because people are, people are less drawn to the birth control pill. Now we're seeing other forms of contraception being used and less women really using the birth control pill. It's less popularity. Why do you think it's lost popularity? And what is your opinion on it? So I think that, you know, in light of the world we live in, good contraception is super important. And whatever a woman thinks is the right contraceptive choice for her should be the contraception she chooses.

39:17So I'm never going to be someone that speaks poorly about the birth control pill, because I believe in our rights to our bodies. But I will say that, you know, we've had, it used to be that the IUDs, for example, were much more popular in Europe and not so popular in our country. And we're seeing that that's become, it's become more popular in our country. So it's become more of an option. I never knew about the IUD, probably wasn't familiar with it until I went to OBGYN residency, really. So I think we're seeing other options now with the IUDs becoming more popular. And I think that women also are more drawn to kind of just knowing their menstrual cycles and understanding their fertile windows and fertile periods and focusing more on natural cycles.

39:55hmm so what are some of the kind of other approaches to treating you know so say somebody was having irregular periods and acne that those those symptoms that then they took the pill and it kind of masked the the pcos like if they weren't on the pill and they were having those symptoms what are other ways to balance is it a hormonal hormonal imbalance that causes that all of that stuff? Yeah. Yeah. So getting to the root cause, right. That's the beauty of sort of integrative and functional medicine. So when you understand sort of the root cause for what's going on, you know, I actually had an example of this.

40:33I had a patient recently in her early twenties and she had just really bad acne and she'd seen her dermatologist, traditional dermatologist who had ultimately tried multiple medications and then ultimately started her on Accutene. Incidentally, she had come to see me for something else and not about her acne, but I did a hormonal workup on her, just blood levels on her and looked at her androgens and her blood levels and her testosterone and DHEA were male range. They were so, so, so high. Wow. To the point where, you know, I ended up doing sort of a really deep dive on trying to find out what was wrong.

41:12But ultimately what kind of brought me back was that, you know, the traditional way we practice medicine in this country is that there's a problem. You give a solution in regards to medicine and you don't look. So if a dermatologist had done say just labs on her, on her sex hormones to see if there was an underlying cause for her acne, they would easily see that those elevated androgens are really the underlying cause for the acne. So that leads me to say that when I have someone and she ultimately had PCOS, just a really dramatic case of it, but PCOS. And it was a little bit missed because she actually had pretty regular menstrual cycles, which you have, you can have regular menstrual cycles and have PCOS.

41:54And kind of the old thought process really is you need to have skipping multiple menstrual cycles and say you have polycystic ovarian syndrome, which you just need kind of two or three criteria. So if you don't have that one, then you can have the other criteria. But what I do oftentimes, if I have women come and say, I don't want to be on a birth control or any hormonal sort of approach to my PCOS, I want to manage this differently. Nutrition and diet are huge when it comes to polycystic ovarian syndrome, stress management. And really, because depending on the etiology, right, if we're talking about more of that adrenally driven etiology, then navigating stress when it's with lifestyle things, as well as the right supplements, even using adaptogens or a good kind of just use of botanicals to really lower down that stress also.

42:40But you can definitely approach PCOS more naturally with supplements, lifestyle, and diet. And there's data we have on the right nutritional approaches to PCOS. So I guess this is like a good segue into asking you about Tara MD. It's kind of this amazing wellness practice that you have in New York City, and it's a very serene and beautiful space. So how does it differ from like a regular gynecological clinic? So yes, the environment's very different too. Because in general, I do, I think that there needs to change in this country, how we format and deliver medicine in all ways. I think that traditional doctor's offices are really scary, really cold.

43:26So the goal was to make it just a really warm, inviting environment for women to feel very, very comfortable. it's longer appointments it's longer visits and it's multiple different aspects right so we have nutritionists we have sex coaches in our approach to everything i do sometimes do deeper dives right with my functional background there are tests that i'll do that aren't traditionally done in a regular atmosphere but i think it's important to know that you can kind of have this integrated and functional approach to your health care without necessarily spending exorbitant amounts of money and doing, you know, so many tests, there's things kind of for each person's level, right?

44:04Economic level, however you want to categorize it to be able to approach their healthcare more in an integrative manner. So what are some examples of some of the tests that you would do that you've sort of wouldn't be routine in a normal GYN clinic? So we'll do gut testing, right? Which is different. And there is some urine hormone testing that I do like to do, which is called the Dutch test. And a lot of traditional GYNs will poo poo and put it down. It can be really, really helpful at looking at your cortisol values, your adrenal component, right? You have a lot of women come in, especially during perimenopause saying, I just feel awful.

44:43Like I have no energy. I'm so exhausted. I just want to sleep all the time. I'm taking afternoon naps. And even just using hormones alone, you're not going to know that that stress from the hormonal fluctuations of perimenopause can have a direct impact on their adrenals. So by doing say the Dutch test, I can see their adrenal functioning. I can see how they break down hormones, if they break down hormones the correct way and be able to really tailor a supplement regimen for them doing that. Why would a traditional gynecologist poo-poo that test? So they just don't think that it's kind of standardized care.

45:18It's not your blood. I mean, they're very, very traditional GYNs that also don't believe in testing blood levels of hormones, period or putting women on hormone replacement therapy, but never checking their levels, which you would never put a woman on thyroid medication and never check her thyroid levels. Right. So that's interesting.

45:42So, I mean, I think it's just so cool what you've created. Do you ever just think, oh my gosh, I'm kind of, you know, like really putting a stake in the ground around like the future of women's health care. And by taking this very integrative approach and obviously very medical and science backed approach as well. I think it's really innovative what you're what you're up to. Thank you. I mean, I hope that it's kind of the wave of the future. I hope that this is just the way that that becomes normal medicine. Right. This becomes the way that we just practice medicine. I mean, I'm observing more and more MDs taking this approach.

46:19Absolutely. I mean, you know, even like recently, you know, even being a doctor saying, you know, let's give you the gallery cancer screening test like that used to be only integrative functional test. And now, you know, I've had multiple MDs ask me if I've done that yet, for example, which I think looks for tumor markers. Is that, is that how it works? Yeah, it's for early detection of cancers. Which, you know, I think is being really driven by this. It's funny. It's almost like the idea of longevity became really on trend. And that is seems to me like what has unlocked this more holistic approach because it's like, okay, well, what are, what are the cutting edge tests that can predict, you know, genetically and otherwise where, where you might have an issue.

47:12And then the answers to those things tend to be more holistic. Yeah. Which is great. So much easier. So if someone doesn't have access to, you know, an integrative doctor, but they have a doctor that's willing to, you know, listen to them, which sometimes is still unfortunately not the case, especially with a lot of women, but what, what are sort of some routine labs that, that, that they should ask their physician to run? So I would say that, you know, you always want to check at least once a year, do vitamin D testing, B12 testing, and don't just use sort of the lab reference ranges. It's always important for women to understand where lab reference ranges come from, right?

47:57Where they just pool a bunch of people and then they do the averages and that average of what those values are is what they say is quote unquote normal, right? So there's ideal. And then there's, there's normal. So looking at your B12, for example, ideally you want it to be greater than 600. So if you're a B12, you're saying that you have low energy, you're fatigued, but your B12 levels coming back in the 300s, a lab is going to say that's normal, but it's not. So B12, vitamin D, vitamin D really want to be between 50 and 80, ideally, not just 30, 35, which is what's normal. Again, I tend to be super aggressive about insulin resistance.

48:34So I like to do fasting insulin also once a year and look for that. And obviously hemoglobin A1C. So hemoglobin A1C is that marker for diabetes, prediabetes. And the funny part is that I can't tell you how many women I've seen come to me with prediabetic levels of hemoglobin A1C drawn by their other physicians and being told that it's normal. It's a, you're fine. It's a normal value. You don't have diabetes yet. And then you ask the questions. What are you doing though? What are you doing to stop yourself from having diabetes? And there's no solution. So I would say, if you're going to advocate for yourself, you want to look at hemoglobin A1C.

49:09If it's in pre-diabetic range, you want to intervene immediately. Vitamin D, B12, fasting insulin, cholesterol, thyroid, even doing a more in-depth thyroid analysis. I tend to like to look for not just, you know, TSH, which is the screening test they do for thyroid function, but to really look at the individual thyroid hormones and to look at the antibodies. Because sometimes you can catch thyroid dysfunction way ahead, years ahead of when it actually starts to happen. Are there any areas in your field that you think something innovative and exciting is kind of coming down the pike that you're keeping a close eye on?

49:46So there's, I think that they're trying to focus more on and finding more options for pelvic pain in general, right? So what I'm seeing more and more is awareness to pelvic floor dysfunction and pelvic floor pain, which I will tell you that even back in my day when I learned how to do a gynecological examination, I did not learn how to examine the pelvic floor. I had no idea really at all about looking at a pelvic floor. So I think that that's actually great. There's new technology being used, two devices being used for pelvic pain, which is using like near infrared light, which is fascinating.

50:22So I think that that's going to be more - And you can see like the, so now you can see like the strength of the pelvic floor when you look, for example. So no, they can't, you can do actually testing of that to see kind of the strength of pelvic floor. But I now will just do an exam on everyone's pelvic floor to see whether or not it's hypotonic or hypertonic, if there's pain. A lot of times like women with concurrent pain disorders, like endometriosis will have their pelvic floor also be in dysfunction too. because it's like I say, you know, if you, if you're tensing your pelvic floor muscles all day long and some women, that's actually where they hold their attention period, right?

50:57Like I tend to raise my shoulders when I'm very tense and that's, I do this all day long at my desk and all of a sudden you realize it and you relax. Right. Right. But I have a lot of women that actually do their pelvic floor. They really hold their pelvic floor and so much tension. And if you were to walk around and flex your bicep and walk around all day long with your bicep flexed like that, it's going to hurt a lot at the end of the day. That's what's going to happen. So just bringing the awareness into the pelvic floor, which I think that most women just aren't aware of. And now we're seeing technology that's really coming to address it as well too.

51:31And finally, can you tell us a little bit about your own wellness practices? What do I do? Yeah. Yeah. So I've had a journey. I will say I, I, when I was really young, I had a lot of gut health issues too, but back then I I didn't know anything about gut health, right? That wasn't something you had the traditional gastroenterologist who would do kind of like parasite testing in your stool. And that was it. And then a lot of sleep issues in my life. And I personally have PCOS. So that was a journey for me as well, too. So my personal wellness journey is really geared around those factors. So sleep is a huge, huge focus for me.

52:07So how do you get yourself to sleep well if you're not a good sleeper? So lifestyle, right? There's a couple of... You don't have to use tools. right. But I use the right supplement approach. I have a bedtime routine, right? Just like we did for our kids when they were growing up. My kids have a bedtime routine. My kids always have a bedtime routine. They go to sleep at the same time every single day. Basically. I try to go to sleep the same time. I try to wake up the exact same time too. What's your bedtime? 10 30, which I wish was a little bit earlier than that, but 10 30. Unfortunately I wake up early.

52:37I wake up at five 30, usually between five 36. So not getting the best amount of sleep, but better. okay i use supplements i have my go-to sleep or what do you take i love magnesium yep i use magnesium if i wake in the middle of the night i'll use l-theanine actually it's a great little tool to have where you can take 100 milligrams of l-theanine you can get back to sleep and not feel drowsy in the morning so i will use that too it's kind of an anti-anxiety meds too super safe You can use it in kids too. They actually have L-theanine supplements in kids. I love, my tool that I love is, and I have no relationship with the company, but I do love Sensate.

53:19Oh, what is that? It stimulates the vagal nerve, right? Which is the parasympathetic nervous system, that rest, digest, calm nervous system. So it's an app, it connects to your phone. There's an auditory component. So I put my AirPods in at night. We're actually really funny, combo because my husband uses this face mask thing all the time when he goes to sleep and I use the Sensate. So we're just a really sexy combo, but I actually put the AirPods in and then you put this device, the Sensate it's on your chest and it vibrates. And by doing that, it's kind of making your chest and amphitheater and the vagal nerve runs along the back of your chest.

53:55So it's simulating it. And it is the most calming thing. It just, for me, it's hard to turn off my brain at night. And that's what turns off my brain at night. Someone told me about something that I haven't tried. I wonder if it's similar called heart math. I don't know. Have you ever heard of that? I haven't heard of it. I just started hearing about that. Yeah. Okay. But is that's the same kind of thing? I don't know. I have to look up heart math. I just heard about this too, actually last week. Yeah. Okay. I just, I've now heard like two people that I really trust say, so, all right, we'll, I'll check it out and I'll let you know.

54:31We'll both now check it out. Thank you so much. Thank you.

54:41Thank you so much for tuning in to today's episode of the Goop podcast. Women's health is such a deeply personal and often misunderstood journey, but conversations like these remind us how much power we have when we understand our bodies and advocate for ourselves. Your health is your power. Don't be afraid to ask questions, explore new options, and ruthlessly prioritize your well-being. This has been a presentation of Cadence 13 Studios. I hope you'll listen, follow, rate, and review all of our episodes, which are available for free on Apple Podcasts, Spotify, Odyssey, or wherever you get your podcasts.