393. Stronger in Midlife: Muscle, Hormones, and Longevity for Women

0:00This podcast is sponsored by Explore Worldwide. One of the themes that keeps coming up in my conversations is that it's okay to want more. More joy, more connection, a better experience. And thanks to our sponsor, Explore Worldwide, you can get so much more when you travel. All of Explore's adventures are 100 % human-made. Their tour leaders have actually stayed at that family-run guest house that isn't even online. They've eaten at the neighborhood restaurant the locals love and know the trail you'd never find on your own. Your vacation should feel uniquely yours, not like it was generated from the same prompt everyone else entered.

0:37That's the difference a human touch makes. Explore Worldwide's trips are created by real destination experts and led by tour leaders who actually know the places they recommend. They handle everything so you can relax, stay curious, and experience something genuinely memorable. This is your time. Demand more. Visit exploreworldwide.com and don't just travel, explore.

1:05Welcome to You Are Not Broken, the podcast that challenges everything we've been taught about midlife, hormones, and sexuality. I'm Dr. Kelly Kasperson, board-certified urologist, author, and a leading voice in women's sexual and hormone health. Enjoy the show. Hey, everybody. Welcome back to the You Are Not Broken podcast. I'm doing podcasting with friends today with Dr. Rebecca Hertel because she texted me like yesterday about podcasting. And I'm like, well, I'm getting braces on, but otherwise I'm wide open because I'm getting braces on and you need to block your schedule when you get braces on.

1:34So here we are podcasting. Welcome. Thank you. Thanks for having me. And by the way, you did leave that little tidbit out yesterday because I was like getting ready. We're celebrating my third daughter. She just turned 15. And so we had all the adults over too. And I got nothing about the braces. Well, I didn't want you to be like, well, it's fine if we don't. I'm like, I can do this. I can podcast and get braces on on the same day. Well, I don't know. True, but how it, it doesn't bother you yet. But tomorrow morning? I can do this. Tomorrow morning I'll be there. Tomorrow morning you'll be like, fucking hate.

2:06What the hell? I'm still on heavy doses of prophylactic Tylenol and NSAIDs. Okay, my biggest first question for you, because the listeners obviously need to know, Rebecca with two Bs. Yes, it is a wonderful story. Yesterday, I like flipped over it because, you know, I've been like writing a bio, which I haven't even read yet. But I'm like, oh, two Bs. Do I have this spelled wrong? So, you know, what I was hoping is I didn't reiterate to you. Yes, it's two Bs and two Cs because normally I tell everybody that. And I thought, she's going to know that I'm not spelling my name wrong when I texted her my email.

2:39She's got to know that. So I said nothing. And then I got the email. So that's why I said, got it. So I knew that you just copied and pasted it. Okay, so two B's and Rebecca is not the default spelling. My mom didn't know if it was one B or two B's. And she's like, I'm just going to go with two B's. God bless. This is before the internet, people. So like, now you can Google your kids' names and they can tell you all the good and the bad. They're like, no, don't name your child Elon Musk right now. Wait for some time to have passed. Rebecca from Stony Brook Farms. That is where she got Rebecca from and then wasn't sure how to spell it.

3:13I have a good close cousin named Rebecca with one B, which is why I know this. Otherwise, I wouldn't. Because as a child, I had to remember how to spell Rebecca's name. R-E-B-E-C-E-C-A. Yeah, with one. And then there's a K-A-A, and now it's B-B. So I'm like, two. We're in midlife. We can do hard things. Like get braces for the second effing time. I did that. So did you also, like me, not wear your retainer? Because college? Yes. It was not cool. Because it was the big, huge one. They didn't have the cool things where they put them on the inside or you only have to wear them at night. This was like, you know, after two and a half years of braces as 16, 17 year olds.

3:52You just have like a line across your face. When was the last time you saw somebody with one of those? I can't even recall. My kids didn't even have those. Jimmy Fallon doesn't even do that when he does like the girls in the basement skit. They just have braces, but he could. Okay, so you text. First of all, people need to know that we've known each other for a while. We're both involved in Ishwish and the Menopause Society and you saved my neck slash shoulder. in Austin, thank God, because I know that you are a DO instead of an MD. And I know that a lot of DOs have special magic skills that the MDs don't have.

4:28So can you share that with the world who doesn't know that? Yeah. Yeah. So we have the same training as our allopathic colleagues, but in the osteopathic world, we also learn osteopathic manipulative treatment. We are grounded in that the body heals itself and that everything is interconnected. And so we learned to use somatic powers to align the spine and the muscles. And there's so many different ways, you know, from cranial down to sacral, to muscle energy, to myofascial techniques, HVLA. There's so many different types of techniques. And I did a lot of it in medical school. I did a lot of it in residency.

5:07And as a matter of fact, with another resident colleague of mine, we opened up a clinic in residency for OMT. And in my family medicine practice, I've done OMT for almost 20 years now. So. God bless. But you did undergrad in Duluth, Minnesota. I sure did. Why is that important? Because that's where I'm from. In my brain, in my brain, because Duluth has a medical school too. Because then I was like, does Duluth have a DO school? No, they do. No, they do not. So was it Austin? Was it the Pinnacle Conference? No, where were we? We weren't in Austin? I don't think we were in Austin. Chicago. Was it Chicago?

5:45I'm like, it was either a Four Seasons. Minapalooza. In Chicago? I think it was Chicago, yes. Because we worked out. Because obviously we've worked out at multiple hotel gyms now together, which is why we can't figure this out. No, it was the Ritz-Carlton in Chicago. It was Chicago. I think Minapalooza. Okay. It feels very Austin to me. but Austin was more recent. But we did work out in that gym. No, but we worked out in the gym in Austin. Yeah. Yeah. So, okay. In Chicago then, because so that was book tour about a year ago, lots of airplane travel, full respect for people who travel for a living because good Lord, it's not kind on the body.

6:24No, it's not. You had that tech net, you know, from travel. I'm like, I do have that. Although it's a lot better since I gave up surgery. My body worker said. A lot better for a lot of things. A lot of things. Well, a lot of things were better since I don't work myself to death anymore. But yeah, so we were working in the gym and I knew you were a DO. You're in the gym and I'm like, ah, interrupt your workout. I'm an annoying person. But I think I had to go on stage and my neck was bugging me. So we literally laid down a map in the gym and you like forcefully corrected my situation. Yes. Yes. I mean, not forcefully, you know, it doesn't take a miracle, but with a little HVLA, but it was not a weak, frail person who was working on me.

7:09No, but when you get that technique, right, literally, and you have the fulcrum, right, you just have to like apply just a little bit. And you just, you went so beautifully. I didn't have to do a whole lot of anything, but it was funny because I thought the same thing. I'm on the treadmill working out and I'm like, hey Kelly and then when you work out in the gym and if you're not working out with someone you're just like do you interrupt them you don't want to interrupt them do you want to be that and but there was like a pause and enough to be like hey hi thank god um so my body worker says that people who get body work more frequently are easier to get back into alignment than a body that doesn't would you agree with that I do I absolutely agree so I've worked on my children since the day they were born with a lot of unwinding.

7:55And so their whole lives. And then they know. They know, A, they know when they're out and when they are not aligned. And it is a lot easier for me to readjust them or to adjust them. Same with patients as well. A, they know when they need a treatment. So they usually were going to come in and see you before everything, just all those muscles are just mad and tighten up around everything. And so you have just all that reciprocal change of the muscles around, you know, whatever it is that is hurting them. I love it. I think everybody, if they can have a body worker, like which, which, what do I mean by that?

8:29Like a very in tuned, more than massage therapy. It's not really a PT. It's somebody who can be like, like, I'll go to my body worker and I'll be like, oh, my left shoulder. Cause that tends to be the bugger. And she's like, oh yeah, that's because of your right glute. And I'm like, of course it is. I went to medical school and I don't know this. and never learned any of that. It is, right? You think about that. It's always like, oh, your left calf is why your chest muscle won't, yeah. Toe is why your eye is twitching. Yes, totally. And then they'll do their thing and then it'll get better. And you're like, oh, it turns out it tends to always be about the hips.

9:05It is. It's called the, or the key dysfunction is what we call it. So you may feel pain somewhere, but if that is not your key dysfunction, you can grind on that spot all you want and it's never going to get better. So yeah, it could be in the hip. Dude, more physicians need to know that though, because patients come in and they're like my shoulder and then they get injections and they get MRIs and they get all the things and it's their left glute. It's yep. Or their hip or I've had to how many patients come in and say, I have chest pain. And, you know, of course, depending on their age and if you ever put your hands on a patient, which is what us osteopaths do, even when we listen to heart and lungs, you can reproduce that pain and get them completely better by the time they walk out your door.

9:49And that is pretty cool shit. So telemed is not going to completely replace doctors? No. You're like, 92%, but not the laying on. I mean, telemed can't do pelvic exams and prostate exams yet. Yeah, that's true. I mean, I think it's a little hard to look in the ear, although they do kind of have some of those instruments that can be attached, I think, to your computer. But it makes me nervous about like, I don't know, can you move it this way? Can you move it that way? Yeah, I love it. Okay, so you texted me wanting to talk about putting on muscle in midlife. And I'm like, I can never get enough of that.

10:26No. And you know, a couple of reasons, mostly because I need five, I need, so my goal, according to my in body, I need six more pounds. Where can I buy it? How much does it cost? How fast can I get it? Who wants to be a donor? And who wants to give it to me? Who wants to give it to me? But I would say, we've been friends for a while. And from where you started to where you are now is like leap and bounds, I think from... Well, yeah, quitting your job does help. I mean, when you have time to work out, it's when you have time. I say that in a very dismissing of like all of my hard work. Right? I'm like, all you have to do is quit your job.

11:02Oh, like I'm not working now? Yeah, I wouldn't. Yeah, don't throw yourself short on that. Yeah, for anybody who's just met me, like I tend to be a little sarcastic there. I've been working hard and to know that it shows pleases me. Yes, well, and it's hard because putting on muscle now compared to 20 years ago is so different, right? I mean, you could look at a weight and put on muscle and put on a diet. I just tried to be fucking skinny from probably 14 to 45. Yes. I just tried to be skinny. Yes, because that's what we were told we were supposed to do. Kate Moss, Cindy Crawford. Yep. I'm just telling you, like the role models were lean.

11:42Yeah, very lean, very lean. It was the whole, you know, now it's what I love about my adult daughters now is strong, not skinny. And I think this, you know, 25, 24 year old age, they are starting to adopt a lot of that, which is fantastic. But women are, you know, our millennial women are Gen X women for sure. And our boomers for sure. It's still difficult. I do think our millennials are, we're probably there before our Gen Xers maybe. Let's talk about, because I interrupted you and made it about me. Let's talk about when you said putting on muscle now versus in our 20s. Is it harder? Because we just don't have, we don't have the muscle memory there.

12:25Or the body's like, oh, this is new. Or is it not harder? It's just something we've never done. So that's like... I think it takes longer to see it occur. And I'll tell you why. I'll tell you my own experience with it. As a matter of fact, it was probably age 40. Because Rebecca's very young, my friend. We'll do bicep shots at the end for y 'all. Okay. Yeah, yeah, we should. Why wait? We should do this now. Exactly. See? Here we go. For people who are on audio only, sorry. That's a good looking bicep, seriously. That's a good looking bicep. You put them both up and then you're like, whoa. I'm against a wall.

13:00Oh, and you wore a wrong shirt. I know. I'm so good. I took my shirt off at the gym today. I will have you know, I was walking around in pants and a sports bra. Yes. Own it. Why not? You have to. This is what it's all about. Okay. So tell me about your transformation. Yeah. So I was probably, it may have been right around the time before I went on hormone therapy or maybe just a little bit after. And I literally felt like I woke up and all my muscle definition was gone. And so I'm late perimenopause now. I just turned 49 last month. And so it was just like, what in the hell happened to my body?

13:35I could see inflammation. There was like, what? You know, this water, edema on my legs. And I worked really, really hard changing diet, getting better sleep, changing the way I had to work out as well, as far as, you know, I had to decrease that cardio load and And I really had to increase heavy weights heavier than I've ever done before. Where before I didn't, I didn't have to do that. I could do circuit training and I would be very toned. And then it wasn't, it just didn't work anymore. I mean, hormone therapy helped. Testosterone helped, I'm sure. Did you, you started doing all of that before you started hormones?

14:16Well, I did all that before. Then had a baby at 40. And then, yeah, that whole 40 to like 44, I was like, what in the house happening? Started hormones about 43, probably 44, 45. Peripostpartum pause. Uh-huh. Yeah, it was terrible. Way more common. Published literature on that, zero. Women's lived experiences, millions. Peripostpartum pause, for anybody who needs to break that down, that means you had a baby late-ish by what, whosoever definition you want to use. And then things never got fully back to normal. No. And you think you're losing your mind, you know? And then if you are breastfeeding, that still keeps those hormone levels low, right?

14:55So then however long you're doing that for as well. Yeah. My grandma had a baby at 48. There's no way. There's longevity in my genes. I'm like, we're double goalied over at the Casper Sun household. My grandma just turned 90 this summer. And I was like, all right, ladies, let's go. I love it. Well, I mean, like why get braces at this age? It's like, because for the next 50 years, this is preventative medicine. You know what's great? Okay, let's talk about preventative medicine and the culture of medicine. So the dentists, orthodontists, periodontists, the entire culture, and believe me, I've seen all of them.

15:28I'm just going to change my platform and talk about teeth because now I'm into it. I've seen all of them. They're all about preventative health. Yes. Don't let it get too bad. Nip it in the bud. Do what you need to do. Get them straight so you can clean them. So the blah, blah, blah, because gums and heart and blah, blah, blah, blah, blah. Right. Your gum disease leads to heart disease, all the things. Yeah, so that medical society, culture seems to be all about prevention. And then the traditional medical culture is like, longevity is a bad word. Prevention is a bad word. Don't get your DEXA before you're 65.

16:02Are you suffering enough? Are you suffering enough? This podcast is sponsored by Explore Worldwide. One of the themes that keeps coming up in my conversations is that it's okay to want more, more joy, more connection, a better experience. And thanks to our sponsor, Explore Worldwide, You can get so much more when you travel. All of Explore's adventures are 100 % human-made. Their tour leaders have actually stayed at that family-run guest house that isn't even online. They've eaten at the neighborhood restaurant the locals love and know the trail you'd never find on your own. Your vacation should feel uniquely yours, not like it was generated from the same prompt everyone else entered.

16:43That's the difference a human touch makes. Explore Worldwide's trips are created by real destination experts and led by tour leaders who actually know the places they recommend. They handle everything so you can relax, stay curious, and experience something genuinely memorable. This is your time. Demand more. Visit ExploreWorldwide.com and don't just travel, explore. This podcast is sponsored by Jones Road. I like to take care of my skin, but I don't like the whole cover-up makeup routine. I like things fast and fresh. So when I found Jones Road Beauty's Miracle Balm, it genuinely fit the bill for my lifestyle and skin.

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18:00Modern-day makeup that's clean, strategic, and multifunctional for effortless routines. For a limited time, our listeners are getting a free full-size mascara on their first purchase when they use code Y-A-N-B at checkout. Just head to jonesroadbeauty.com and use code Y-A-N-B at checkout. After you purchase, they will ask you where you heard about them. Please support our show and tell them that our show sent you. Like, what dentist is like, are you suffering enough? It makes no sense to me how even vision, I mean, let's talk about vision, right? Our screenings. And I mean, I don't know about every two years for that to be covered, but it makes no sense on the really and truly the amount of money that we would save the healthcare system by not having sick people.

18:50And the average American keeps their insurance for four years. So there is no incentive to pay up front for anything because they think it's the next generation's problem. So they think differently than you, which doesn't mean you should think that way, right? Because this is your only body you have. You've got it for the next 50 years. Insurance doesn't care about you and your AD because that's going to be bankrupt Medicare's problem. Yep. It's infuriating. I mean, we could have a whole podcast on this and get infuriated. but it makes no sense at all. And now in today's society and the way insurance is, their premiums are going up, the deductibles are going up, they're not covering anything.

19:32And so patients are just paying out of pocket somewhere else for their prevention because it's far less expensive than to use their insurance because A, it's not going to cover it. Or if it does, they're paying this astronomical fee. Yeah, totally. If you look at the economics and the market of supplements right now, which for what it's worth, if people don't know this, I am not anti-supplement at all. Supplements are good. They're not black and white. But if you look at just what the market economy is doing with supplements, Procter & Gamble just bought Thorne for$2.3 billion. It's so shocking that doctors are like, why do people do this?

20:07And it's like, because they actually don't want the paywall of the doctor. They want to be in control of their health. They want to be preventative. They think it'll help because of the way stuff is marketed. To me, I'm like, I'm not surprised at all that supplements are taking off in this world. But for people to say it's black and white are all good and bad, it's like, no, no, no. This is way too big for your simplistic black and white brain on this. No, no, it doesn't make any sense at all. And I agree with you too. You know, there's like certain stacks that I really like and brands that I think are trusted and it's definitely not black and white.

20:40None of that, none of it is, right? I just, I mean, medicine in general is so gray. None of it is black and white. I did a reel the other day because I was feisty And probably because Rebecca and I are on a feisty text. I just did a reel and it was like, does exercise help everything? No. Does sleep help everything? No. Do hormones help everything? No. Like nothing helps everything. And people will be like, well, it helped my everything. I'm like, great for you. Well, it helped you be able to do the things that also help. It helped you be able to get to the gym. It helped you be able to sleep better.

21:15or your lifestyle that you now are getting to the gym may have done helped you lose weight, which then can change the way that your hormones are. Completely. Okay, so let's talk about midlife woman. They come to see you. Maybe they're likely coming. Do you ever feel like they come to you for hormones and you're like, but wait, there's more? You know, it's like the reputation we get is like, we know hormones and hormones don't help with everything. So let's talk about that woman who you and I get frustrated because we put in the time, We know about the muscle. We care about longevity and not breaking your hip.

21:48My mother-in-law broke her hip this year. So let's talk about how you talk to women about it's not just hormones that are gonna prevent you from being frail. Oh my gosh. It's such a, it is such a long conversation. It's actually multiple conversations. So, because you have to, they're like onions, right? You have to peel the layers of the thought processes over so many years that they have thought or that they are currently thinking. And so you peel those layers and you have to say the same things over and over and over again. And to be honest, one of the main discussions that we have are the statistics of what happens to you if you fall and break a hip, because no one has told them this.

22:29Nobody. Also, how common it is, one in two, my friends. Over the age of 50, one in two people will have, one in two women over the age of 50 will have a fracture, right? But then when you go in and say 60 % of hip fractures are women and 25 to 30 % of them won't live after the first year after breaking their hip. And then these women just look at me and I'm like, I'm not making this up. Just no one has ever told us, partly because no one ever taught us that in order to teach you that. And so I really spend a lot of time just letting that sink in. And then we talk about all the things we can do.

23:04And it starts in these women's 20s and 30s. in order to help prevent this, right? So it's not just an overnight thing. Look at our athletes that stop having their periods and no one really does anything about it. So I think that's a conversation to have. So when I have these conversations with women, we talk about what estrogen can do at what levels. So do we want to prevent osteoporosis? Are we going to be building bone with your estradiol? Because those are two different conversations. They're two different things. Do you want to stop the loss that's happening or do we actually want to rebuild?

23:37That's right. That's right. And, you know, and I say, those are two different levels and that's where hormone optimizing comes in. So what are you coming to me for? I can just replace your hormones and we can hope that we can prevent it. I prefer to prevent and rebuild and that's more optimizing hormones. And so we talk about those levels. We talk about the data that we do have, you know, and not all women can, you know, especially I have found in my practice that they are multiple years post-menopause, you know, probably five or more, I have to be very gentle with how I introduce estrogen. I agree.

24:10Same. Let's talk about that. Start low, go slow. They're very sensitive to it. So sensitive. And I'll tell you what you guys, the worst thing you could do is give them a high level and sometimes even a 0.0375 patch is too much. They feel awful and they will drop it and you'll never see them again. And they will tell all of their women friends that it's horrible. Stark contrast to perimenopause. just for our listeners who might not be in America. We're using American values when we talk about labs here. But a perimenopausal woman, she might feel great at 200, 150, right? Like not until I saw women come off of their SSRIs, come off of vaping, come off of their other medications because their mental health feels better.

24:53And remember, that's normal ovulating levels. It's not crazy high. It's not pregnancy levels. It's not trans levels. No, it's not. And sometimes perimenopausal women, they just feel great on cycling progesterone and some testosterone. They're not because their E is okay, but we have to support them in the other hormones that are low right now for them. Let's talk about this a little bit more before we go back on to the older people who are sending it because you and I, we have the exact same practice. So the perimenopausal, to me, I think check the labs. And again, you guys, this is not guideline published.

25:29This is expert opinion in clinic only. see your own provider, all the asterisks. This is a fucking podcast, which you can get CME for on the Pinnacle Network, plug there. And I see my women a lot, right? They're coming to me for not once a year care. I think in perimenopause, checking an estradiol quarterly, twice a year, because I don't want to catch it below 40. Yeah. I'm making up that number. Why did I make up that number because 30 is postmenopausal, 40 or below is where we probably start seeing bone loss happen. They're like, how do I know when I need estrogen? I'm like, either you're going to feel like, hey, can I try estrogen for X, Y, and Z?

26:09Or I just don't want your hormone, if your goal is prevention, maintenance, whatever, not are you suffering enough, right? I think catching you before you hit postmenopausal levels, which happens before your periods end in people who are getting periods, I want to catch it. I've never talked to anybody about this, but that's how I think about it. Yeah. Okay. So I'll tell you also what I do. And again, for everybody else, you guys, we don't know because no one's checked labs. Yeah. You can't tell us we're wrong because nobody actually knows. No one's done this before. And so what I tell women, I'm like, listen, what's cool about what we're doing is this is where our research is going to go.

26:49They're going to ask for our charts and ask for our data and all of that. And we're going to have it because we're checking this stuff. Okay. And so what I like to do is if they are in early period menopause, meaning that they're still for everybody, they're still cycling every month. They're not going more than 60 days without a period. I will tell them to check hormones on day 21. And so that is just so I have some data. And again, not that we're necessarily going to do a whole lot with that, but they love to see those numbers. And sometimes it's just helpful to say, yeah, look at that. That's perfect.

27:22It looks great. That's exactly where your FSH should be. It's exactly where your estradiol should be. And that is also why we are cycling progesterone. Because a lot of times I'll start with cycling progesterone. That's all they really need. Sometimes as they're starting to transition out, if they're like, listen, my sleep is shit when I am off for those two weeks, fine. Let's do it every night and see what you do. Most of my people like all the time progesterone because they just like the progesterone. So either is fine in perimenopause, either is fine. Hormone replacement therapy can lighten periods, but it won't stop it.

27:57It is not birth control. How many 48-year-olds have been getting pregnant lately because they've put on hormones for perimenopause? It's a thing, you guys. Hormones do not protect you from sperm. I had a practitioner tell one of my patients that being on progesterone is like being on the mini pill. And I was like, oh my God, no, it's not. I'm like, if you have sperm in your life, You can have a baby. This is what your ovary normally makes. Follicles love testosterone. I fell over, you know? And so, and I like, and the cool thing too about what we do is that there are different ways. There are different ways that we can fine tune and optimize our patients, like where you're either cycling it or maybe you're doing it all the time.

28:37What I'll tell you when I cycle are the women. They are typically in their either late 30s or early 40s because they will oftentimes feel bloated. So I'm like, cycle it then. And let's see how you do. Go off it for that little bit of time. And sometimes you can cycle that 100, then up to 200 in that day 14 on. And that can be helpful for him too. And then testosterone. But let's say I got a post-menopausal person. She's on hormones basically 28 days out of the month. But then somebody's told her to stop for two days to give her receptors a break. Where did that come from? What's that thing? I have no idea.

29:14Yeah. I'm like, where's it? I'm like, I just want to know where it came from. So do I, because it doesn't make any sense to me, especially post-menopausal first. And even in up, I mean, how many women do we put on a sick like OCP, like constantly and stop everything until they're menopausal? I'm like, I'm like, I'm always here to learn. It doesn't make sense. Is there a book I need to get that explains that? Cause I have not. Well, let me know because I've not heard that. Okay, so that was perimenopausal. Going back to postmenopausal, start low, go slow. I start them at a 0.025 patch and it's great if they don't feel any.

29:49It's like, if you haven't felt anything, great. And sometimes I have to go lower than that if they're really sensitive. The 0.014 patch has been well-studied. It's hard to come by. See all the other podcast episodes about patch shortages right now. According to the FDA, there's no patch shortage. We should get into because in all fairness, they're like, well, declaring a patch shortage, First of all, people are worried about hoarding. I don't know who the hoarders would be who hoards. So that's one thing. They don't want to simulate hoarding behavior. The second thing is you can't actually compound a patch.

30:20So if you declare a shortage, you allow compounders to compound, but you can't compound a patch. So it's really like the general population saying shortage and the FDA saying shortage. The word shortage means something different in those two conversations. And this is just me being pedantic because I haven't done this Instagram really yet. So there can be a shortage without it being declared a shortage, but it looks like dismissal when we're using the same words differently. That's my too long didn't read on that. I also don't think that what they're putting out right now is as good as it was six months ago.

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33:06Now, when I need something, my first thought is, I wonder what Quince has. Find the fall pieces you'll reach for most at Quince. Download the Quince app for app-exclusive offers or go to quince.com. Get free shipping on your order and 365-day returns. Now available in Canada and the UK, too. And when Quince asks where you heard about them, let them know it was You Are Not Broken. It's the best way to support the show. I don't know about y 'all, but I did a reel on that and had so many practitioners feel the same and women say, yep, 100%, I don't feel like my levels are great or I've been checking levels and they are lower than they had been when they were appropriate prior.

33:48We should talk about that because I think it's very invalidating to people. And I see this, this is not pharmacist hate. This is pharmacists are on the front line and I can't imagine how awful it is sometimes. But pharmacists will say, this is the same dose, different brand. It should be the same, blah, blah, blah. No, that's not how generics are. And that's not like even how the rules are with generics. So a 0.05 and a 0.05 by two different companies can give you profoundly different absorption rates. I've experienced it myself. Oh, I'm hanging on solid to my brand of choice right now. I'm like that smoker who's like marble reds or dyes.

34:20I am a Finling all day long now, but when I was on the patch, There was 100 % differences in the two patches. And what's funny is what I preferred wasn't always what my other patients preferred. Oh, yeah. No, everybody's different. And that's the challenge of the shortage right now is like, if there's only a certain brand that works for you, then you're like, oh, honey, it gets even harder. I think my prediction, the Casper's shortage prediction, we're going to see a lot more oral estradiol used. We're going to now Femring, which used to be effing expensive at$60 a month is now cheap. I love it.

34:51Although I will say the last one I had wasn't as good. So I was wondering if it was starting to affect the time ring a little bit. The complaint is that it runs out before three months. About two weeks. Yeah, about two, two and a half weeks. Yeah. So put another one in or dabble with some gel or a patch until. Yeah. Well, I think so gels are starting to get on back order because patches, right? This, my friends, is with 5 % of eligible women on hormones. Remember the 1990s, 40 % of people were on hormones, right? We ain't out of the woods at this point. Plus, Rebecca and I aren't shutting up. So more and more people are getting educated.

35:26I had this feeling two weeks ago. I don't know what happened when I was like, oh, we're just at the very beginning of this. We're at the very beginning. And as thought leaders and people who've kind of been in this for a couple of years, sometimes we get very like, is shit ever going to change? Especially with the myths that haven't died yet. And we're like, oh my God, this so needs to die. But no, we're just at the beginning. Wait till, I can't wait to see how we think when 20 % of people are on hormones. When 30, and again, it was people like, don't you want everybody to be on hormones? I'm like, I just want to get back to the 1990s for multiple reasons.

36:04We had a balanced budget. I had perfect teeth after my braces. You know, like I didn't want to get back to the 90s for multiple reasons, but 40 % of women being on hormones is one of them. Well, you know, it's that 24 years of... It'll be interesting to see. So my daughter's a fourth year med student. So, and she did not learn a whole lot during med school about it, about hormones. So I still don't think, right? So she'll have three years of residency, four years of residency and then out. But I can see the women in her class and the students starting to get curious, hormone curious about this because it will affect them.

36:42So they're not only thinking about... I mean, clearly not enough because we have 5 % of people on hormones. But like, I feel like it's in the zeitgeist, even though I live in the fricking bubble. But like, when I was in med school, I didn't have badass mothers talking about their hormone patches like the celebrities are and Oprah and Melinda Gates. And for anybody who feels bad that you haven't found the right prescriber yet, Melinda Gates had to go to three doctors, which technically is less than the average woman. Well, average woman goes to five to seven before getting hormones. But she's Melinda effing Gates French, French Gates.

37:14Yeah. Look at Halle Berry and what she went through before she was finally hurt. Well, she had to get incorrectly diagnosed with herpes first. I'm not sharing any private info. She said that on like Capitol Hill. Yes, she did. That's public information, but still, geez Louise. Yeah. So these, you know, and so it's funny when these women, these, you know, 24, 25 year olds are watching us. And I guarantee you all, they are watching because what they're thinking is, holy shit. my mom, my mom's friends. These women are changing healthcare for women and are changing my future. God bless. Thank you for telling me that.

37:50Yep. She has said it and I'm just like, oh, thanks, sis. Oh, I love that. I mean, I can't see Gen X ever sitting down on this one. No. So let's go back to the boomers. The oldest Gen X, my friends, is turning 60, like this year, next year. and what's the longest the youngest gen x is what 45 46 i do because i tease them i go stop being a millennial you're a gen xer it's okay 47 now as somebody i was born in 1979 it depends upon if you want to call the 1980 the 1980 baby they're the elder the elder millennials yeah younger gen xers elder millennials yeah um we were born in the 1900s yes i know isn't that funny when When you're like, kids are like, what?

38:36The 1900s? I'm like the 1970s, actually. So my daughter, my daughter wanted a Walkman for her birthday. Do they even make those anymore? Yeah, they're actually very expensive. They're several hundred dollars. They're still made by Sony. But the reason she wanted a Walkman is because like one of her school textbooks had these, like that's how old the school textbook is, has this kid with the walking around with a Walkman. And she's like, what is that? And I'm like, oh, you put your music on it. You can walk around. She's like, I want a Walkman. So we actually got her a digital music player for her birthday.

39:06That's awesome. So these Walkmans don't hold cassettes though, right? Don't they hold? I don't know. I actually looked at the branded Walkman and I was like, that's too much money. You're not kidding. Sorry. I should have kept mine. It was 1999. I know. Yeah. So yeah. So these boomers, right back to that, they're really tough. You know, they're tough for a lot of reasons. First, they remember that time 24 years ago, you know, as far as hormones go, but they were even more so into like, you know, the jazzercise and the skinny. And so if we're talking, going back and talking to muscle, you know, they really, and they're also, I love them all, so stubborn when it comes to just kind of changing that mindset, you know, like, you know, and even just my mom, where I'm just like, Like you've got to resistance train.

40:01You have to resistance train. But I don't want to get bulky. Yeah, you got it. That's exactly. You know what makes me bulky? Fucking cars. Not weights. Wrong kind of bulk we're worried about, my friend. Wrong kind of bulk. And then if you put them on a GLP, that's the first time in most of their adult life that they're finally losing weight and they don't want to eat the protein and they don't want to exercise exercise and they don't want to resistance train. Let me, they don't want to exercise either, but they don't want to resistance train. That's not everyone, but I'm telling you, it is a lot of, of my population, you know, over 60.

40:39And it's really difficult to just talk to them that when you lose weight, you lose muscle, you lose fat, you lose water. Equal opportunity employer. That GLP. Yeah. And with any weight loss. Yes. And that's with any weight loss, right? If you're using a GLP-1 or not, right? Anytime you lose weight, those three things. And so we want to minimize that muscle loss because you're already losing it. You're already in sarcopenia. It's already going quicker. And the only way to slow that down is to make sure that you're eating adequate protein and making sure that you're resistance training and not pink five pound weights.

41:15Because that's what I get. I sit in my chair and I'm doing my five pound weights. I'm like, I always like to quote Vonda Wright, your mamby-pamby pink weight. Mamby-pamby pink weights. I don't know how I would be doing as good of a job as a physician without an in-body in my clinic. That in-body is a game changer. And it's a game changer for me as well. You know, looking at like me putting on the weights and then putting on muscle is like, if it's measured, you tend to pay more attention to it. Yes. And, you know, and for those of you out there that can get an InBody. They have some really great ones on Amazon that you can get, that you can get some body composition.

41:55Even a body comp Dexa at many places is$100 or less. And the home scales are pretty good. They are pretty good. And I have a home InBody and it's pretty affordable, but there's also some really affordable ones that are less than the InBody as well. And I tell you what, I put my kids on there. I put my adult kids on there. And I'm like, listen, I want to see what our composition is. Let's all get on there. Let's see what we can do. And let's see how we all can do better. Because it's not about what I see on the outside. It really matters on what's on the inside. And so agreed, when these boomers are losing weight and building muscle, they need something like that in order to see it because they're not seeing it.

42:37It's hard for us to see. Yeah. And your mind, with the decades of fuckery that your mind has had, People come in and they're like, I'm three pounds up. It's too much food. You throw them on the in-body and I'm like, yeah, it's three pounds of effing muscle. You guys have been, you have been doing the work and you put on, especially in the beginning, when, you know, we're saying putting on muscles harder. In the beginning for an untrained person, you actually can see things happen pretty quickly. Yes, yes, you can. Because a lot of times you're also losing a lot of that water if you are doing all the things, right?

43:10You're prioritizing your sleep, your protein intake, your prioritizing, your meal planning, and then of course, exercising in ways that you probably weren't before. Yep. It's so good for you. And it's the things you can't see too, like bone. That's the thing about bone is you can't feel it getting stronger. You can't feel it getting weaker. But strong bone actually weighs more than weak bone. And it's really this obsession with the scale that I see. I mean, our generation struggles with it, but the baby boomers really struggle with it? They really struggle with it. They really, really do. Cause they'll come to me and say, I used to be able to just not really eat.

43:48And I'm like, well, we can't do that. And that's just the way they did it. They just would, you know, restrict and then lose their weights or they would overexercise. And yes, student experts do it too, that scale. So a lot of times I just tell them, I don't even want you on that scale until I see you for six weeks or once a week only and you send me that number, that's it. But every day, every day is going to mess with you. And we can go up one, five pounds, right? Just from the morning to the afternoon, right? We're more swollen in the afternoon. We've eaten, all of those things. What do you, how do you talk with people?

44:27And let's pick a hormone, estrogen, progesterone, testosterone. I'm gaining weight on this. Oh my gosh, all of them, they will. They've told me that, right? All of them. Yeah, so we can see that. We can see that with all of them. by and large, the data doesn't support it. That doesn't mean individual results may vary. And I really want people to see that because on the internet, you'll hear studies don't support these hormones make you gain weight. And some people gain weight on these hormones. Yes. So both can be true. That's right. And so what I usually see, and probably as you do too, is that's where the education comes in.

45:04So when I talk about progesterone, I will say to them, this can make you retain water. It usually will even out between two to four weeks, give it a month, along with all of the other things that progesterone. In some, it can give you some food noise. So you need to retrain that brain. And over time, that will become more silent for you. And then we can always change the way that we give it, you know, orally versus different ways, you know. And then estrogen. What I find with the estradiol is going up too fast. 100%. When that estrogen is high, a lot of times I actually will just catch them in a loop cycle and that's why they're swollen and bloated.

45:40But if someone starts them on... Loop cycle for people is perimenopause when you're ovulating. So you just have a super... Or yeah, you actually didn't ovulate. So you're trying to crank out the hormones to try to ovulate. That's what a loop cycle is. So that's a time of very high estrogen in your body, which is a consequence of perimenopause and declining follicular function. Yes, yes. And you'll kind of see that a little, even in those first few years of that early menopause transition, I'll catch them. Well, you know, women will be on like a 0.025 or even a 0.0375 and we'll catch like a 150.

46:16And I'm like - Yeah, and you're like, that's not the patch. We're still at work. Nope. Yeah, and one of the ways I describe, you know, perimenopause hormones to people is I'm trying to make you not bottom out, but I can't make you not go high unless we play with birth control. but hormones won't make you not spike in perimenopause. Yes. And that, if we can take a minute on that. So I just, I tell them it's like, it's a cushion. So when you're falling, I've got the trampoline to catch you, right? You know, and you're still going to go high on your own, but you're not going to fall and hit rock bottom.

46:50And you can get pregnant on the trampoline. You can get pregnant on the trampoline when you're doing all those crazy maneuvers. Like I'm feeling so good. I'm looking good. I'm putting on muscle. Sex feels great. Don't pull the goalie. Don't pull. That's right. Don't do it. If you have sperm in your life and you do not want to get pregnant, don't mess with it. You have to have some form of something. Condoms, fine. I don't care. Yeah. Hey, if you're not playing with sperm, please disregard this last 30 seconds. Okay, let's go back to estrogen in older women. Start low, go slow. If they're feeling fine or meeting their goals.

47:26Hey, I want it to help me sleep better. I want it to help my moods. I want it to help out. Have you met your goal? And then I might check an estradiol. They might still be undetectable. And then you talk about... Because the 0.025 patch, and I'll say the 0.0375 patch, often, if you have no ovarian function, will not even get you above 30. 30 is the cutoff for post-menopause. Men live at 30 to 40. So I say, congratulations, you've possibly reached a male estradiol level, which is a great perspective, I think, for everybody. Because they're like, is this so much hormones? And I'm like, do you look at a man and say, oh, he's got tons of estrogen?

48:02Yes. I think that's so important when we counsel to say that. Your husband has more than you, or your male partner has more estrogen than you do postmenopausally or menopausally. Which he needs. Which he needs and is useful. And if you cut it out, there are consequences. I was sharing today on one of our threads that I was doing my urology research. and there's like entire people researching, publishing on the risks of dementia with androgen deprivation therapy, which some people need to do, choose to do for prostate cancer. The rate of that, so the paper we reviewed, the rate of that is 2.4%.

48:37And at 2.4 % as a side effect for androgen deprivation, we've got researchers, papers being published, and people being researched on the facts. Yes. Let's just talk about gender bias for a second. It's not wild. It's wild. We would never castrate a man and not treat that. Research the side effects of it. Yeah. And going back to when I'm like, I can't wait to see the world. We've got 30, 40 % of women on hormones. It's like, we're going to be thinking different when we get to that point. Kind of like we're thinking different now about longevity because the decade of frailty at the end of our life is overwhelming our systems.

49:15Besides the fact that we don't want to be frail. But it's like financially overwhelming our system. So we're like, hey, maybe let's try to be healthier throughout the lifespan. Bonus if you get a couple extra years. Somebody said, I don't really care if I live to 74 versus 68. Like I don't really need to do the extra things because like, who cares? It's only a couple of years. And the smart physician answered back, you don't get it. Modern medicine will keep you alive. And that quality of life might suck. That's gonna suck. So that is the impetus of like, maybe it's not about a number on your gravestone.

49:50It's how you feel on the journey. And I think, yes, and I think that's still as much as people are poo-pooing longevity, they're missing the health span point, which most longevity experts will say, yeah, it's about health span. 100 % hands down. So I don't want to live until I'm 80 or 90 as this frail person in bed, not doing anything. What I want to do is I want to be able to go up and down my stairs. I want to bring my groceries in. I want to be able to go to the bathroom myself. I want to be able to make my meal. I want to be able to kick my leg into an elevator and open up that elevator with my cane or whatever it is that you need to do.

50:36I mean, think about this. How many women are having even babies in their 40s, right? So when these children are 40 years old, I'm going to be 80 years old when my youngest child is 40. So I damn well better be doing some cool shit when I'm 80. Yeah, I totally hear that. Let's go back to mindset again, specifically with the boomers, because now maybe you've gotten a DEXA, maybe they weren't even 65 yet. So you got, I get a DEXA on everybody coming in. This is my, so when I started my clinic, I started just getting DEXAs on everybody coming in and they were all osteoporosis or osteopenia, all of them were.

51:11I got, it wasn't until my 11th DEXA that I got a normal DEXA on somebody. And I was like, oh my God, you have a normal DEXA. I figured the radiology department was broken at this point. I think it's insane. And what I think is even more insane is some of those women who have been lifters. I have patients who have lifted, started hormones in late perimenopause and are still... I was like, you need a Dexca. And it was earlier than their PCP would have done, osteopenic. And they're like, what would I have been had I not been doing those things before? Isn't that crazy? Here, I want to read something to you because maybe this doesn't irritate you as much as it irritates me.

51:50I can't handle when people say on the internet that there's no data. because oftentimes that just means you don't know the data. So I'm going to read this to you. This is a journal of the American Academy of Orthopedic Surgeons, a journal not many people are reading. Came out in February of this year, 2026. A match retrospective analysis, the relationship between testosterone replacement therapy. So we also have endogenous testosterone level data, which is also important. It's all the data that we have that gives us the signal, right? So we need like endogenous data. We need replacement therapy data, all this stuff.

52:23So a relationship between testosterone replacement therapy and the incidence of hip fractures. Sounds good. They looked at men and women. After stratifying by sex and looking at multivariable analyses, testosterone replacement therapy in male patients was associated with a decreased incidence of hip fractures with a risk reduction of 0.61. So 40 % risk reduction, statistically significant. In female patients, it was associated with a decreased incidence of hip fracture with an odds ratio of 0.49. That is a 50 % decreased reduction of hip fractures. Patients prescribed testosterone replacement therapy had a 1.9 times lower likelihood of sustaining hip fractures.

53:07That's huge. Don't tell me there's no data. I'm so fucking sick of there's no data. Yes. It's the testosterone heaters. And so what bothers me more is like there's data and nobody's doing a damn thing about it. We've got a JAMA paper looking at a randomized placebo controlled trial, looking at women in their 70s after hip fracture at six months, decreased visceral fat, second publication, 50 % decreased risk of needing Kane or Walker, which are independently associated with death and living independently. Tell me what you care about after a hip fracture, living independently. 100%. Because what?

53:4360 % don't. Go back to pre-fall function. Okay. So people are like, oh, there's no data. And I'm like, actually, we have a randomized placebo-controlled trial published in JAMA. Fast forward to the spring when my mother-in-law breaks her hip. Oh, where's her testosterone prescription? Yeah. You want more data than a randomized placebo-controlled trial published in JAMA? On the exact human that you are? It makes no sense. That's what pisses me off. It's all this like, till the cows come home, we need more research. A hundred percent. Support the research industry forever, right? And don't tell me there's no data, but you can tell me, yes, there's data and we refuse to do a damn thing about it.

54:22What are you waiting for, world? We just have to do it. And we talk with our patients about it at nauseam. They know. They know. They come into our offices asking because they know that testosterone can help with their bone. Oh, wow, we have smart patients. But they're the tip of the iceberg, right? Like it's the people who listen to these podcasts, who listen, who like are reading. Like this is, again, going back to that, we're very early. Like we're very early in this being a, I mean, how many women actually know what happens to their body in midlife? Listen, they don't because they don't know what happens to their body when they're young.

54:59So my daughter - Did you see my text today? I was like, I'm never calling this menopause again. I'm just calling it hypo. I'm just calling this hypogonadism. I'm sick of this. it's not going to change fast enough if we continue to call this menopause. Well, let me tell you, my 15-year-old and I went viral because we did a puberty and perimenopause skit with Schitt's Creek. It was so cute. And it, I mean, these young girls, so it wasn't, yeah, the moms are like, yeah, but these young girls are like, oh my gosh, this is me and my mom. Oh my gosh, this is my mom and I. This, you know, so these, these young girls and her friends follow me.

55:31So it's cute. They, they're watching this stuff. They are watching. So for all of us out there that are on social media thinking that we're only educating midlife women, we are not. We are educating young girls because they are also going through puberty and they don't understand what's happening. And so, I mean, correct me if I'm wrong. Was it not until you started really diving into menopausal healthcare and midlife healthcare for women that you truly understood hormones and the cycle, your cycle, your menstrual cycle? because we were not taught that in medical school, I think in that. Yeah, I agree with you.

56:07I mean, I think, you know, we understand the cycle, period, pregnancy. I think what we understand now that the gen pop still doesn't understand of 40 years of no hormones catches up to you. And if you don't want it to catch up to you, you have to make a decision as early as possible. Yep, absolutely. And I think we have to stop, I call it minnow shaming. or hormone shaming, partly, you know, and the reason for that is part of the reason women don't talk about how they're feeling is because they suffer in silence because they've been shamed. And it's not been something that just in midlife, they were shamed about, you know, their dark thoughts or they're not wanting to be intimate or having sex with their partners or they're not wanting to be with their children.

56:53You know, this, a lot of the times, this is happening in also in puberty. It's happening postpartum. And they're being told, I did fine and so should you. That's all over the place. I did fine and so should you. Yes, 100%. And so these girls, when they're young, they're having luteal phase mood disruptions. They don't understand why because they've been told, oh, she must be getting ready to start her period. So then they shut down. They don't say a word because they're just going to be shamed because they're being bitchy. Right? So same thing postpartum. So this is not just a midlife issue. See, this is a whole gender starting from puberty all the way up that I think this whole thing needs to change on how we view hormone health.

57:39Because if you think about men, men do the same thing, right? My boys, as teenagers, there was a time where I'm like, holy cow, their testosterone levels must be changing. Their aggression is different. Their irritability is different. But we don't shame them for that. I see a couple of pioneers on this. And then they come and they go. It's kind of like the clitoris. We discover it, we forget it. We discover it, we forget it. But the role of progesterone, not just in perimenopause, but in normally cycling women who need it, especially the week before their period. And I think like, oh my God, how long, how many more years is it going to be before that is actually studied as a thing those women are taking care of?

58:19Like this dismissal of the women in their 20s, and they're put on birth control and they're put on SSRIs, which are band-aids, but they're not solutions. They're band-aids. They're covering it up. They're trying to like mellow it out. I get it. It's not that they don't help. They're just not, when you think kind of like a scientist, you're like, is it actually solving the issue? Which I think is horrifically understudied. It is. And we're not saying that all women shouldn't be on birth control. It can be really helpful for, I have patients have told me it saved their lives. But we're saying that sometimes just a little dish of progesterone is what they're actually needing during that time.

58:59And to just blindly put all young women or teenage girls on birth control pills, is that the solution? No, it's a band-aid. Okay, let's go back to mindset and the boomers. So mindset things I see, I just can't put on muscle. I just can't. And you know, who is the famous person? Whether you think you can or you can't, you're right. Is that Einstein? I don't know. Famous person. Whether you think you can or you can't, you are right. And so I see that a lot of like, I just can't. And it's like, well, not with what you've currently been doing, but how about change? Like scientific process, my friends, you come up with a theory, work the theory, test the theory, recheck your hypothesis.

59:42Like this is not rocket science, but it does require if you want something different than what you have, you have to do something different. Yes, but it's all about change and change is scary. I didn't like putting braces on today. When they had like my mouth completely splayed open, I was like, I do not like this. It's like, that's why I get so like, I get so grumpy right in the middle of things. Like right in the middle of my colonoscopy prep, I was like, damn this colonoscopy prep. I hate it. Don't stop in the middle of it, my friends. Keep going. When the going gets rough, keep going. Let's keep going.

1:00:18It's like the middle of a pap. Yeah, yeah. Right when they've found the cervix, keep going. Yes, exactly. Or you've got one breast on the mammogram and you're ready for the second one. Turn and do it. Yes, no stop in the middle. You can't only go one boob in. You got to get the other one in too. So yeah, that would be my one is like, I just can't. And I'm like, well, that's your belief. Doctors can point out beliefs, but the only person who's capable of changing a belief or questioning a belief or awareness of a belief, this is Coaching 101, is you. So I see that. And then I also see like everything in moderation.

1:00:55I see that a lot with the boomers. Everything in moderation. I was doing this whole menopause thing naturally until you told me I could break a hip, right? And I'm like, well, naturally has given you a DEXA scan of negative three on your lumbar spine. And naturally you're going to just break walking. That's natural, my friend. Also don't wear any shoes because shoes aren't natural. But so yeah, that's the other thing is like this whole, like everything in moderation, or I just want to do it natural. There's a lot of limiting. And I mostly just want people to understand those are called beliefs.

1:01:28Those are thoughts. They're not facts. They're thoughts, which can help you or not help you, depending upon how they're causing you to have feelings and actions. That's coaching 101. It is. And that, you know, in the aging process, when that happens to, well, and another thing is they're not eating enough of the right things. if I were to have someone track, and you can use MyFitnessPal, you guys, it's a free app. You can throw it in there. There's some other ones too, but even just for one day, you put all your food in. And I guarantee if you find that they are over 30 to 40 grams of protein a day, I'd be surprised.

1:02:06Truth. The other mindset thing is, I like to eat for pleasure or I only like to eat when I'm hungry. And to eat to build, you actually have to eat for fuel. It is a very different thing and it feels different. It does. And hydration as well, because they don't like to do either of those things. And so I use like an analogy of a car, right? You don't let your car run out of gas. We keep it fueled so that it goes and it's optimal. And we do preventative oil changes. I'm kind of worried that it kind of hit me after I got the braces on today that I can't have cashews for like a year and a half. And that kind of made me sad.

1:02:41I guess cashew butter. But I'm actually very worried that I'm not going to eat enough. because I got to pop my Invisalign off. I got to brush my teeth all the freaking time. You'll do it. It's fine. You'll do it. I did it. But they're like, I feel like I already don't eat enough. And I was actually talking to my daughters about this yesterday. They're like, mom, why do you have, because sometimes I'll bring home food from work. And they're like, why do you have this food at work? And I'm like, you guys, I spent over 20 years of my life working very hard to the sacrifice of me eating and urinating.

1:03:11Yes. Right? And so I'm like, I trained myself to not eat. and so like I know I have that that I have to work against that is a mindset yes at 100 % and I will even tell patients like you need to put reminders on because you know and that's a good one when when people are on GLPs and I just tell them it is not an option you need to put reminders on and you have you know you're literally now you can't you may not be able to eat a large amount but we can eat smaller amounts more frequently and you've got to get that protein in you do not drink with your meals. You have to do your hydration in between meals.

1:03:48So you're right. That's something that for you, because you did so many years of not eating or peeing or drinking anything as a surgeon, hence again, why I'm not a surgeon. I was like, no, you guys stand for way too long. Yeah. Yeah. The people who saw surgery and they were like, nope. Yeah. I was like, this is cool, but nope. You had much more insight than others at a young age. Yes. Yeah, my daughter did too. She's like, mom, they don't eat or drink or pee. I'm like, I know that's why I'm not doing it. Yeah, exactly. So yeah, the mindset around food is very different. And I agree with you. I think the majority of women under eat proper nutrition.

1:04:34Yes, 100%. There's no doubt. And I also think you should know what your grams of protein are a day and be lifting at least twice a week before you're started on a GLP-1. That's a broad brush. Individual things may vary, but if you don't have the habits dialed in before you significantly blunt your hunger receptors, this is why GLP-1s are getting blamed for osteoporosis is because if you take a frail person and you drop their weight, the osteoporosis is a higher risk. Yes. And now remember, that is anyone who drops their weight. So, you know, the big thing is GLPs is because it happens quicker potentially if you're not doing it correctly.

1:05:15Then, yeah. So, and I do try to explain to them because I do, you know, there are people that need to be on that and it's appropriate and they're afraid of osteoporosis. And so we talk about how weight loss works and that any fast weight loss can have a detrimental effect on your bones, regardless if you're using a GLP or not, right? So if you're ill or whatever, or restricting things like that. And so... You know the other thing I hate about muscles? Besides they're sexy as hell. They're so... Muscles, there's nothing sexier on a human body. Oh, and a good tan on them are even better. Sorry, guys.

1:05:49I mean, you know, sunscreen, all the things and... A pair of pants on some muscle. Tank tops. Awesome. So, but here's the problem. It's so slow. We're Americans. I like drive-thru coffee. I like things to happen fast. I like Instacart. I like Amazon Next Day Delivery. You guys, it's slow, but the alternative doesn't look good. No, if you can't go, because I see grandparents all the time, you know, when you have kids in AAU sports, and I think your kids are in sports, so you probably understand. And these grandparents cannot go up and down the stands without scooching on their butt down the stands.

1:06:33That's a muscle issue, my friends. So it's fine. That's going to take me six. So me taking six months to put on six pounds of muscle is not a reason that I shouldn't do it, is what you're saying. Correct. Because your 67-year-old self is going to walk up and down the stands. With kettlebells. Okay. What's your favorite lift? Oh boy. Quads or arms? Oh, she pauses to catalog them. I love a good quad extension. I hate deadlifts. Only because they jack up my back a little bit if I'm not careful. And I have tight hammies, so I have to be really careful about that. I love a farmer carry. Farmer carry with kettlebells, nothing, orgasmic.

1:07:18I love it. I take off my shirt and walk around in my sports bras when I'm doing farmer carries because I just feel so good. I did that when I was putting up outdoor umbrellas and we had to like fill, you know, the weights full of water to hold the umbrella down. And so we filled them with water. And so I was carrying them and my 21 year old son's like looking at me. I go, get a video of this. It's like farmer carry. I love a farmer carry. My shoulders. I was just in LA wearing a lot of tank tops. And for all the compliments. She's like, ah, your shoulders, your arms. And I'm like, fucking farmer carry.

1:07:50I love a good this part here when it is like designed. Yeah. That whole deltoid and deltoid down into the tricep. So a nice bicep curl. I love just because I like to watch that. And then you can see like that bicep go, you know, that's my favorite. Oh yeah. I totally get an upper body pump on my upper body days. I'm like, oh, take the pictures now. Now is the time for the photo. Okay. Let's talk about age greater than 10 years post-menopause starting hormone therapy. Because it's huge. It's a huge topic. And if anybody who's listening for a full hour on our podcast, now you get the reward of us talking.

1:08:26Yes, you do. We're going to be unfiltered. Why not? Why not? That's a question. Okay. Back at you for why not? Why do they say why not? Where does it come from? Let's uncover the zombie. Right. So from the whole WHI, right, that they most bang for their buck was that 10 years within menopause. And then after that, then they have increased risk of heart attack, stroke. But they actually did it at their 18-year follow-up within the first 20 years of menopause. They didn't. Oh, and we're using transdermal now by and large. And if we are using oral, it's oral estradiol, not oral prempro, which is synthetic.

1:09:04So the too long didn't read for people because Rebecca and I are very pedantic on this. But the reason they say why not, you got to know why. And you got to know what medication they were using. and you got to know if that's actually how the world is now. So 20-year follow-up of the WHI showed no increased risk in heart disease, stroke in the 20 years past menopause. So the fact that we're saying 10 years is very conservative and the concerns that they had didn't actually even pan out with the oral synthetics 20 years later. Let's talk about two more things. We're going to talk about the United States Preventative Services Task Force.

1:09:45Do you know, I haven't been following politics. Does the United States Preventative Services Task Force exist anymore or did it get its neck chopped off recently? I don't know. I don't follow politics either. I don't know either. But the urologists already don't like it because about 20 years ago, the United States Preventative Services Task Force, which is an independent consortium which advises Medicare on what Medicare can pay for, which is why it's important because it's billions of dollars. they said don't screen for prostate cancer fast forward many years men are diagnosed at the metastatic level much more commonly now than when we screen and the whole point of screening is to catch shit early right so urologists already have a little b in our bonnet with the united states preventative services task force so when the united states preventative services task force came out and said do not use hormone therapy for prevention i already was like i don't trust you Let's go back to the data.

1:10:39So if you read it, so you read the United States Preventative Services Task Force, the most heavily weighted study is the WHI, which is an oral synthetic medication, which had very little long-term risk at 20 years follow-up, even when average age of women started on it was 63. And the risk factors involved for all of those women that were already... They already had risk factors. So when the United States Preventative Services Task sources don't use it for prevention. And then people parrot that and say, don't use HRT for prevention. They're using studies that use medications that we don't currently use in inpatient populations that might not be your 48-year-old, your 52-year-old healthy woman.

1:11:24This podcast is sponsored by Joy and Blokes. One thing I've always believed, if I'm helping one person with their sexual health, I always have to think about who's on the other side of that relationship because intimacy doesn't happen in isolation. And I've said this for years, if I'm prescribing a blue pill for a man, what about his partner? Are they dealing with pain during sex, low libido, hormonal changes? Are they both healthy enough to enjoy the relationship they're trying to build together? I see it with women and their health all the time too. She starts optimizing her hormones, more energy, better sleep, the brain fog lifts, libido comes back, and the next thing I hear is, now my husband needs help too.

1:12:02That's one of the reasons I like Joy and Blokes. They care for both women and men, connecting patients with licensed clinicians for personalized hormone optimization when it's clinically appropriate. And they publish peer-reviewed research on outcomes, real improvements in energy, mood, mental clarity, sexual function, and quality of life. Whether you're navigating perimenopause, menopause, low testosterone, or simply wondering why you don't feel like yourself anymore, the first step is understanding what's going on with your body. If you started feeling better because you've taken care of your own health, maybe it's worth asking whether your partner could benefit from doing the same.

1:12:41If you've been wondering whether your hormones could be contributing to the way you feel, visit joyandblokes.com slash notbroken and use code notbroken for 65 % off labs and 20 % off treatment. That's J-O-I-N-D-B-L-O-K-E-S dot com backslash not broken. Code not broken. Always ask why, my friend. Stay curious. It's a sign of intelligence. Staying curious is a sign of intelligence. Use it. So that's what I think about that whenever people say, and the current guidelines say do not use for dementia prevention, which when I have women in my clinic and they're staring down the barrel of family members with dementia, which is what I've been doing this entire summer visiting family is staring down the barrel of what dementia actually fucking looks like.

1:13:29Yes. Side note, I don't think we're afraid enough of this shit. But when the guidelines say do not use for prevention of dementia, I actually think that's a cruel statement. It's terrible if you've ever seen or witnessed it, or if you see the early signs of things starting to go and you know what's happening to your loved one. It's brutal. So that one specific sentence of do not use hormone replacement therapy for dementia prevention. First of all, we have no significant data that estradiol causes dementia. And if it helps you sleep, that's dementia prevention. If it helps sarcopenia and osteopenia, that's dementia prevention.

1:14:10The argument actually falls apart pretty quickly. Yeah. And let's talk about sleep with like cardiovascular prevention, right? You sleep more. Totally. Let's talk, so we talked about the United States Preventive Services Task Force and why that data does not hold up when we actually look at prevention. Let's talk about the HERS studies. I did a post. I completely get it that I don't dumb shit down for people, which is I think why they like me. But sometimes like I just made an Instagram post and I'm like, anybody who says, what did I say? I was like, anybody who says you can't use hormones after the age of 60 has never read HERS or HERS 2.

1:14:42And people's like, what does it mean? And I'm like, I'm sorry. So HERS, H-E-R-S, was published in JAMA in 1998. That was average age, mid-60s. I think it was 67, 65, 67. Known diagnosis of heart disease. So greater than 10 years post-menopause, known diagnosis of heart disease. Known diagnosis of heart disease. Some of these women had already had a heart attack. Because that's what we're telling them not to use it for. One of the reasons. I said that's important because that's one of their arguments. Exactly. So HERS was an older, greater than 10 years post-menopause with known heart disease, oral prem pro, which we don't use anymore because it's considered too high risk.

1:15:24Oral prem pro versus placebo. That average, I think the first HERS study was 4.1 years of follow-up, which is a very good follow-up for a randomized placebo-controlled trial. No increased risk of heart disease, no increased risk of death, no increased risk of cancer. basically no different than placebo after heart attack greater than 10 years post-menopause. But wait, there's more. They published the HERS too, which is an open label study for women who wanted to continue it. So now we have a follow-up of 6.1 year, and now these women average ages 73-ish. no difference versus placebo tell me again tell me again tell me again why we can't use a low dose transdermal estradiol in a healthy 73 year old it's crazy i think even the people who say like if you have a cac calcium artery score if you have a cac of a certain number you can't use hormones which has never been published published nowhere but you you could say okay any positive CAC is a quasi or proxy for heart disease.

1:16:35You could argue that. Fine. Let's argue it. Have you read the HERS data? You can still use it. Yeah. You can still use it. So I think now I'm going to send them back and probably get, you know, a coronary CTA. And hopefully, because we actually looked at the coronary calcium score, which most people aren't going to order. So we got that ordered. And we just did some prevention, my friends, because maybe they're going to, they need a cath or maybe we, you know, they're going to go see their preventative cardiologist and do more of a workup. Yes. And if you have high blood pressure for the love of God, work on it.

1:17:09Like things people are not, people, things people should be more afraid of include dementia, osteoporosis, and high blood pressure. High blood pressure is so fair. The risk of stroke in normal intensive people versus hypertensive people is night and effing day. Yes, it is. And remember, most people don't feel it. If you're feeling it, then you go to the ER because there's a name for that. But most people do not feel their blood pressure being elevated. And if you don't go and get it checked, then you're living with this for how long? Yeah. When do you think a wearable is going to do blood pressure well?

1:17:57Oh. Like pretty soon, right? Oh, it's got to. It would be really, really nice. It's a regulatory thing. Like why is that not out yet? I mean, it's very easy to buy a blood pressure cuff now and use it out even if you're not wearing it. Yep. Yep. You can use it. And if you want to make sure that it's reading right, then, you know, take it in with you your next time that someone else is manually doing your blood pressure, right? So you bring your cuff in, you can do it. Then you can have your PCP in their office. They can also check it with their manual cuff too. And it'll give you a little bit of a better idea if you're running higher or lower at home.

1:18:31So that way you know what your numbers are. If the average person only sees a doctor one time a year, is one time of your blood pressure check, maybe not even done manually, good enough? No. I love you. I love my primary care doctor friends. God, you guys know so much. No, it's not. You got to and different times of the day, my friends, right? So if I tell someone to go check their blood pressure, I'm going to say one day you're going to do it in the morning, one day you're going to do it in the afternoon, one day you're going to do it in the evening, and you're going to do that for seven days and rotating.

1:18:59I don't want five blood pressures because each one is going to be elevated because you're starting to freak out. So one time over the next seven days, it's like an ambulatory blood pressure. Different times of your day. Let's talk about one more thing before we wrap because now it's a real treat for the people are still listening to us, let's talk about physiologic testosterone replacement in women versus super physiologic testosterone replacement in women. I think it's time to start talking about this. Yes. Well, what? Because everyone thinks that anything over 45 is super physiologic? Yes. Yeah, exactly.

1:19:32Because frankly, some people who wrote the guidelines in 2019 think that anything over 45 is super physiologic. Yes. And I don't know about you, but in my clinic, most of my women are between 50 and 100. Sometimes they're a little bit higher than 100 if they don't have any side effects and they feel great. But what they see is scary because the numbers are red. The number is red. And there's a word that says, hi, next to it. For Quest Labs, my friends, I asked them, I emailed Quest Labs and I said, please send me the papers because there's a lot of new reference papers on what the women on the streets testosterone is.

1:20:09So I wanted to make sure they were including those. So I'm like, send me the reference papers for how you're designing what normal for women is. Zero. Did you get crickets or did you get... No, no. They replied and said, we don't use reference papers. We made this up in-house. Stop it. I cannot stop that. That is from Quest to me. If anybody working at Quest wants to send me something different, please do. I would love to know that because... But zero reference papers were used because I would think we should have age-adjusted. You know, maybe a 40-year-old might be different than a 60-year-old because the new papers show age-adjusted.

1:20:48No, we don't use any reference papers. We made it up in-house. So, I mean, there goes the argument of women should be treated to physiologic doses. You mean women, you're deciding how women should be treated based upon a lab that made up its own lab reference ranges? fascinating tell me more i would love to know how that came about like in a back room coffee break oh i know and how are they testosterone experts have they been taking care of women with testosterone have they been reading the papers which the majority of published testosterone papers in american values dose women into the low 100s that is our libido papers that is our step high hip fracture papers they didn't actually do because you can argue like one dose isn't the right way to do a study.

1:21:37You should do a study based upon serum levels, right? And so that's what Step High did. Good job. Good job, Step High study. They dosed women into the low 100s and they said, you can use five milligrams, 10 milligrams, whatever it takes to get women there. Yeah. Is that what that ortho paper, did they have? No, that is, I don't think they had, I don't think they have levels on this one because this is a big like, and we're talking about our 2026 match retrospective analysis, I think this was like 300 ,000 people. So I don't think they were looking at levels. Because that would be interesting. It'd be super interesting.

1:22:13And then remember for anybody else, levels are not great. They're actually not that accurate. I just had a friend check her testosterone level five times. It was three or five times at the exact same time. Meaning she was at the lab at 3.05 p.m. and just said, draw it three times. 20 % vary. Which is also why it's a full picture, right? So when we talk about getting labs, how do you feel? All of it is important. At least, you know, that's all the data. So I want to know how you're feeling. And I will get these labs. But if you're feeling like shit and your lab looks like you're supposed to feel good, guess what?

1:22:54Yeah. This is the cast percent analysis after being obsessed for many years. How do you feel? Do you have side effects that you don't like and don't want to tolerate? Because you plucking a hair is not a reason to stop your testosterone. No go for them. And for some women, it isn't. But the doctor shouldn't say stop your testosterone because you said you had a hair grow. So how do you feel? Are you meeting your goals with what you thought this was going to help with? Do you have side effects that you don't want or don't want to handle? Lab values. I think of this. Think of a plant in soil. The plant can be well watered, but the soil can be dry.

1:23:34The plant can be well watered and not drowning, but the soil can be wet. Think of the lab values as the soil. How's the plant doing? Right? Really wet soil over time might cause harm to the plant. Really dry soil over time might cause harm to the plant. But Tuesday, Thursday, different soil, plant's fine. Yes. I cannot think of a better analogy than that. No, no, it's so true. And it's, you know, that's why it's so important to take that full picture in when you're, you listen to your patients, you guys, you have to listen to them. I mean, that's what, you know. That's, I mean, at the end of the day.

1:24:17And one woman 50 can be another woman's 100 or one woman's 80 would be another woman's 120. That's the other thing. Our receptors are different. every one of you. How many keg repeats do you have on your androgen receptor? How many androgen receptors do you have? How quickly do your androgen receptors get full after dosing with... We can't study any of that. It's a black box. And people are using serum lab values as God and the law, and they are not that powerful. Yeah, we've got a long way to go on that. But I think there are, let's say there's four camps, now that I've just made four camps. Trans men camps, women who are now choosing to be trans men, who are in the 600, 800, that's high T, that's high male T ranges.

1:25:0850-year safety data, don't die more, don't have more cancer. Yes, possibly more sleep apnea, possibly more diabetes. Metabolic dysfunction can change with super physiologic testosterone. We should talk about that. But we have that data. And then we've got the guidelines data that says stay below 45. That works for some people. Getting some people between, you know, from five to 20 is fantastic, right? So we've got that camp. Okay, we've got two camps now. Now we have the 100 to 150 camp, which is kind of where all the data is. And a lot of women feel really great there. I like living at the slightly higher than physiologic range.

1:25:48Feel great. No significant side effects. Labs are flagged as high. Okay. Fourth camp. I like to live female, not trans data, female. I like to live somewhere between 250 and 450. Caution, long-term changes, you guys. Caution, long-term changes. And I just read a paper looking at, again, I was studying for urology research. And there's a paper looking at normal values of men in their 30s and 40s. It's in the 400s. Okay? So for people who are like, I'm my best self here, that might be true. Steroids are amazing. They make people feel great. Long-term changes might be happening. Caution, asterisks, live your best life, your body, your choice at the end of the day.

1:26:37But average male testosterone in 30s and 40s is in the 400s. If you're pushing and riding that high, just know that. I think there's a little bit of education that needs to happen. I agree. And do you think that really what they're feeling is just kind of what that high level of testosterone is giving them? Yeah, well, and then they love it. But I think they would need more of it. Males too, guys. We're not talking just about females. Males too, they get the same. Yes. And I don't dose people that high. I don't either. I'm just, yeah, I'm not comfortable. I do think, again, this is not in guidelines.

1:27:13This is personal practice. I do think athletes tend to feel better at a higher level, whether they're metabolizing it more, whether they need more for the muscle, whether they were just physio. If you look at athlete, meaning normal, like you just draw athletes testosterone levels, athletes tend to be at the higher end of the bell curve on normal physiologic testosterone levels, probably why they're athletes. right? So they're just born that way. So I tend to see in my practice, the athletes tend, I tend to have to give them more testosterone before they're like, there it is. And the other group I see is PCOS.

1:27:48I think they've lived at high testosterone for a long time. Now remember people, PCOS testosterone was not the driver and was never the problem. It was the outcome of functions of ovaries. But I tend to see in PCOS, people will be told you can't have testosterone, which actually doesn't really make... Yeah. But they might not be high in perimenopause or they might not be high for them where they actually liked how they felt before. I'll actually see them plummet as they transition into perimenopause, right? So it's fascinating to watch that. And there's, to my knowledge, there's no published data looking at perimenopause with athletes, perimenopause with PCOS.

1:28:28But it's interesting and it's why we do what we do. And we should. So yeah, I agree. Did we meet your goals in what you wanted to talk about today? Far exceeded. We talked about all the things, all my favorite things. They're my favorite things. These are a few of our favorite things. And if anybody's still listening, an hour and a half in, it's their favorite things too. That's right. It was your favorite thing too. And I think, you know, I think there's something to be said too that sometimes women probably can't achieve their appropriate dosing if the side effects also bother them, right? Like some women just get acne and we just struggle to titrate them up.

1:29:09I don't know if you have anything magical. Sometimes I'll have them apply it if they're different besides going slower. But I'll see acne pop up and get better. So I think there is like a, whatever you want to call that, a blush, right? A like, oh! And perimenopause, you're going to have acne right before you have a cycle too. too. So that will also get worse. Don't confuse that with testosterone acne. See, also chin hair, which happens way more in midlife, not on hormones. See, also hair loss, which 50 % of midlife women have hair loss. Hair loss in the testosterone placebo studies, so studies on testosterone in which we have a placebo, testosterone and placebo have the same amount of hair loss.

1:29:53And I believe women, when they say they have hair loss and they're on testosterone, and we need a hair loss workup, all of the things. All the things. It's kind of like hormones don't cause weight gain and women say hormones cause weight gain. And I believe all of that. Same with testosterone and placebo, no difference in hair loss. And I believe women who say they've had hair, oftentimes too high of a dose too fast. Yes, exactly. And remember, preparing menopause, stress causes hair loss, you guys. So, you know, we'll have some thinning just because of aging and the way that our hair changes as its grow and rest cycle.

1:30:28But it's also, if you're having these major hormonal fluctuations and you are sensitive to that, you may get the telogenafluvum from that. So just like postpartum, just like stress, you know, so any illness can do it to your hair as well. So a lot of times I'll... Fast weight loss slash GLP ones. 100%. Fast weight loss, illness, stress. I have seen women lose patches of hair just from grief or stress. So all of those things will also do it. And this is a transition of time where a lot of us are going through some other stressful events. So just that whole picture. Yeah. I think testosterone is a very convenient whipping boy.

1:31:07Yes. There's not enough people who understand testosterone yet, who love testosterone yet. that it's just a very convenient whipping boy for like all things that ail you, which include hair loss, weight gain, and testosterone can sometimes cause weight gain and can sometimes cause hair loss, but it's not an always thing or don't be so incurious as you're only going to blame one thing for this. That's right. And I think, you know, it's, again, like you said, be curious, ask the questions. And, you know, and if you can't, if you're not currently with someone who can answer those questions, then it's time to find someone that will answer them for you.

1:31:44Thank you for texting me and podcasting with me. Thanks for answering my texts. You know, the crazy things that go through your head on a Sunday morning. I'm like, hey, we need to talk about this. Oh, I'm like, how about tomorrow? After braces, it'll be fine. No, it was perfect because it was like the end of my day because I'm EST time. So it worked out perfect. When I can't talk tomorrow because my inner gums are swollen, I'll text you and say, but we still have fun. it was worth it. All right, my friend, until I see you again, are you going to the menopause conference this year? I didn't sign up either.

1:32:16She's whispering no. It's okay. I didn't see you either, but I'll see you at another conference. I know it. Oh, yes, we better for sure. It's a lot of fun. Thank you for helping the women. I know the people you take care of and they love you and you're very, very loved and you're also very, very intelligent and you're also very jacked. Thank you. All my love. If you found this episode funny, helpful, insightful, Please take a moment to follow, rate, and share the You Are Not Broken podcast with someone who might need this conversation too. That support is how this information reaches more people.

1:32:49And thank you. For courses, books, and my monthly membership, and the Casperson Clinic information, visit kellycaspersonmd.com. This podcast and all content from Dr. Kelly Casperson is intended for educational and informational purposes only. And this is not a substitute for individual medical, coaching, or psychological advice, diagnosis, or treatment. Always seek the guidance of your qualified healthcare professional with any questions you may have regarding your health. Never disregard or delay medical advice because of something you've heard on this or other podcasts. Thanks for being here, and remember, you are not broken.