0:00

My new podcast series, Come Again, Sexuality

0:02

and Orgism, is now live on Dr.

0:05

Striker, dot substak, dot com. There will

0:07

be a total of 32 episodes, exploring

0:09

loss of libido, pain with sexual activity,

0:11

and postmenopause difficulty with orgasm. If you're

0:14

looking for hormonal and non-harmono solutions to

0:16

get your libido to kick in and

0:18

your literal nerve endings to wake up,

0:21

check it out. The link is in

0:23

the program notes. Today is Q&A Day,

0:25

a roundup of your questions, and

0:27

I have invited Dr. Heidi Flagg

0:29

to The Conversation. I'm Dr. Lauren

0:31

Stryker, a gynecologist, best-selling author, and

0:34

a nationally recognized menopause expert. When

0:36

it comes to menopause midlife and

0:38

what comes after, I'm betting you've

0:40

not gotten a lot of information

0:42

from your own doctor. If women

0:44

are given good information, they'll make good

0:47

choices, and I'm here to give you

0:49

the inside information. I

0:54

get lots of questions. Some are from

0:56

people who record a question on

0:58

my website, Dr. Striker.com. Some are

1:00

questions from my sub-stack subscribers. I

1:03

mean, I do ask me anything webinar

1:05

each month, but we never get to all them.

1:07

Ditto. I just finished taping a Q&A

1:09

for mentors, which is an educational platform

1:11

for midlife women that has classes taught

1:14

by the best menopause experts. And even

1:16

though I answered roughly 30 questions, I

1:18

didn't get to all them. So I

1:20

keep lists. lists and lists of questions.

1:23

And today I'm going to work my

1:25

way through as many questions as possible.

1:27

I've asked my friend and colleague, Dr.

1:29

Hattie Flag, to join me because it's

1:32

always good to get another point of

1:34

view. And Dr. Flag is above all

1:36

a clinician. She is in her office in

1:38

New York City day in and day out,

1:41

helping women navigate period menopause and

1:43

postmenopause. And unlike a lot of

1:45

people out there who are new

1:47

to the scene, Dr. Flag brings

1:49

decades of real-world experience to the

1:52

table. So welcome Dr. Flag. Thank

1:54

you so much. Dr. Stryker, it's an honor

1:56

to be here and thank you

1:58

for that lovely introduction. We actually talk

2:00

a lot, but we don't get to be

2:03

in the same room very often. In fact,

2:05

I'm pretty sure the last time we were

2:07

actually physically together was at South by Southwest

2:09

last year when we were both on menopause

2:11

panels. I think that's right, which was a

2:13

year ago, which is astounding, because I do

2:16

feel like I'm connected with you pretty constantly.

2:18

I want any one of my patients particularly

2:20

to know who might be listening to this,

2:22

to know that it's not just my brain

2:24

at work when I give them advice. I'm

2:27

talking to you. and getting advice from you

2:29

and recommendations. So, you know, there are multiple

2:31

brains helping those patients through their struggles. Yeah.

2:33

Well, you know, I think that's really true

2:35

of all the menopause experts. And every day,

2:38

all day, you know, we're kind of shooting

2:40

each other text and saying, hey, I have

2:42

this complex situation. You want to weigh in

2:44

on it because I think I know how

2:46

I want to approach it, but I'd love

2:48

to hear what you have to say. All

2:51

right, let's do this. I'm just excited

2:53

to read the recorded questions instead of

2:55

playing the recordings because quite frankly It's

2:57

it's quicker and then we can make

3:00

it through more stuff I don't know

3:02

if we're going to get through it

3:04

all But hey, why not all right?

3:06

This one came from Karen and her

3:09

question is do you need to be

3:11

12 months without a period to start

3:13

taking hormone therapy? So what's your answer

3:15

to that? That's a classic and It's

3:17

really important to understand that perimenopause starts

3:20

long before you've been without a period

3:22

for a full year, right? So we

3:24

know that menopause is when you haven't

3:26

had a period for a year, these

3:29

are basic definitions. But the preamble, and

3:31

somebody, community, and I heard just the

3:33

other day, called it the Amu's bush,

3:35

is perimenopause, which of course can last

3:37

anywhere from four to 10 or 12

3:40

years, right? So that can start in

3:42

your late 30s. and lead up to

3:44

the 51 and a half mark where

3:46

the average age of one year without

3:48

a period. So in many of those

3:51

period menopausal symptoms, the suffering happens in

3:53

period menopause as you and I both

3:55

know, right? There's early phase in the

3:57

lake phase and women suffer tremendously and

4:00

they don't quite know what's going on

4:02

and that's, it's really important. to offer

4:04

up hormone therapy and options to mitigate

4:06

and optimize how they're feeling. Totally agree,

4:08

but I mean, here's the thing. I

4:11

mean, one of the things about the

4:13

definition of menopause, which is highly problematic

4:15

in many ways, not, you know, to

4:17

mention a many ways, not, you know,

4:20

to mention a lot of them don't

4:22

even get periods because they've had a

4:24

hysterectomy. But even someone who does get

4:26

periods, this is a retrospective diagnosis. I

4:28

can't tell you how often women go

4:31

to their doctors and they're told, well,

4:33

no, you have to be 12 months

4:35

without a period before I start to

4:37

treat you. And that's just wrong. I

4:40

mean, it's just, it's not my approach.

4:42

Certainly, I don't think it's your approach.

4:44

And I'd like to hear when you

4:46

start treatment, but my approach is whenever

4:48

you're having symptoms that are bothersome to

4:51

you, even if you're still getting periods,

4:53

even if it hasn't been a filled

4:55

12 months, if you're having... things that

4:57

are really getting in the way of

5:00

your ability to function in the world,

5:02

well then it's time to start talking

5:04

hormones. We're talking about really busy women

5:06

in the middle of their life that

5:08

are working and have partners and have

5:11

young kids and aging parents and they're

5:13

not sleeping, which is a huge problem.

5:15

And it's just really important to hear

5:17

that and allow them to speak about

5:20

it and then offer up treatment. And

5:22

I offer up treatment long before the

5:24

last period for sure. Perrimanipos has had

5:26

a very inconvenient time. I mean, really,

5:28

do you really have to go through

5:31

these hormonal fluctuations at the same time

5:33

that you're dealing with the parents that

5:35

are aging and the husband that's having

5:37

the affair and the, I mean, it's

5:40

just, the timing is really. Really, right.

5:42

Really, right. So they can lead me

5:44

to the next question, which is kind

5:46

of along the same lines. This was

5:48

actually an anonymous person. She didn't give

5:51

her name. And she said, I'm getting

5:53

a period every three to four months.

5:55

So I assume I'm in period menopause.

5:57

Okay. And I'm having a lot of

5:59

symptoms. So I went to my doctor

6:02

and she suggested I go on. birth

6:04

control pills. I'm not even having sex,

6:06

so I don't need birth control. I

6:08

told you I wanted hormone therapy, but

6:11

she said no. Birth control pills would

6:13

be better. So should I see a

6:15

menopause expert? I mean the answer is

6:17

if you can find one, absolutely, right?

6:19

The drop-off in education in terms of

6:22

menopause care, we how many residents get

6:24

trained? Very few. 10% or something, right?

6:26

We, there's been no training in our

6:28

medical system. So unfortunately, to offer up

6:31

different options of actual hormone therapy, people's

6:33

doctors simply and clinicians simply don't know

6:35

how to do it. Yes, let's hear

6:37

it. I 100% agree that most doctors

6:39

are not trained in menopause and that

6:42

if your doctor doesn't seem to know

6:44

anything about it or what they're doing,

6:46

absolutely they need to get in the

6:48

hands of a menopause expert. In general,

6:51

women who are perimenopausal and still getting

6:53

periods who are told to go on

6:55

a low-dose birth control pill, that's actually

6:57

appropriate advice. You know, because a lot

6:59

of women think it's time for hormone

7:02

therapy, not understanding that birth control pills

7:04

our hormone therapy and in fact during

7:06

perimenopause it can be the best form

7:08

of hormone therapy. Why? Because your own

7:11

ovaries are confused, your estrogen levels are

7:13

up and down and all over the

7:15

place and sometimes we do give a

7:17

low-dose birth control pill to basically say

7:19

to your ovaries, hey you guys are

7:22

confused, you take a break, I'm going

7:24

to take it from here and give...

7:26

very even amounts of estrogen and progesterone

7:28

that is not only going to get

7:31

rid of these symptoms but may control

7:33

these out of you know whack periods.

7:35

I think the real issue here is

7:37

not that she wasn't offered the right

7:39

treatment but she wasn't offered a real

7:42

explanation. Exactly. You know women go to

7:44

their doctors and they're told I'll just

7:46

put on go on birth control pills

7:48

and they think that they're being dismissed

7:51

when in fact most menopause experts are

7:53

going to say that for a lot

7:55

of women in peri menopause that a

7:57

low dose birth control is actually the

7:59

best approach. You know, I agree with

8:02

that. I agree with that. You're right.

8:04

Yes, of course. Yeah. And I do

8:06

offer, in fact, I often say that

8:08

I, my favorite thing to do from

8:10

40 to 50s is put you on,

8:13

you know, I love, I haven't a

8:15

love low, low estrin, a super low

8:17

dose birth control pill just to steady

8:19

the ship so that they're getting exactly

8:22

the same estrogen progesterin every day. And

8:24

it stamps down those highs in early

8:26

premenememen. higher elevations of estrogen on certain

8:28

days. And estrogen, of course, has a

8:30

half-life of only, you know, 12, 24

8:33

hours. So then within 12, 24 hours,

8:35

you can then sink back down to

8:37

the basement, right? So that birth control

8:39

pill can tamp down those highs and

8:42

sort of fill in those lows and

8:44

give a nice steady state. Yes, they're

8:46

not being dismissed. It's actually a really

8:48

good approach. So we're not really disagreeing.

8:50

I was just saying, you know, we're

8:53

in agreement. in many cases a birth

8:55

control pill is the appropriate thing. Not

8:57

to mention, not to mention, we always

8:59

forget that while fertility is really low

9:02

during period menopause, it's not no fertility,

9:04

it's low fertility, and people do get

9:06

pregnant. And in fact, 50% of pregnancies

9:08

that occur over the age of 40

9:10

are unplanned. If you're 16, you get

9:13

pregnant, it very often will go to

9:15

viability unless you terminate the pregnancy. Whereas

9:17

if you get pregnant at 44 or

9:19

45. in most cases nature is going

9:22

to take care of it. Those are

9:24

mostly miscarriages, but still the point is

9:26

is that you cannot just assume that

9:28

contraception is is not needed. So exactly.

9:30

And then of course there's a higher

9:33

risk of twins because you're hyper ovulating,

9:35

right? So that's another. Well, no, no,

9:37

no, that's really a good point that

9:39

you make because everyone always thinks of

9:42

this as being a time when, oh,

9:44

estrogen levels are really low. And as

9:46

you pointed out, Perry menopause, it's a

9:48

roller coaster. And sometimes you get really

9:50

high estrogen levels, which is why. You

9:53

might superobulate and get a couple of

9:55

eggs there. It's why some people get

9:57

exaggeration of PMS and breast tenderness and

9:59

all that. So that's why we talk

10:02

about low-dose birth control pills because it

10:04

really does suppress what your own ovaries

10:06

are doing and basically take control of

10:08

the situation. And the other thing that's

10:10

out there that people don't understand is

10:13

they have this idea because we use

10:15

the word low-dose birth control pills. They

10:17

think that hormone therapy is higher than

10:19

birth control pills. And no, birth control

10:21

pills are obviously much, much higher than

10:24

hormone therapy is. Right, the tune of

10:26

four to four to five times the

10:28

amount of estrogen at least. But the

10:30

other way that I also start this

10:33

conversation about birth control pills during period

10:35

menopause when someone says I want hormone

10:37

therapy and I say... and I'm going

10:39

to give you hormone therapy. Birth control

10:41

calls are hormone therapy. I've heard you

10:44

say in your podcast, it's actually the

10:46

most common hormone therapy that we prescribe,

10:48

right? And you're, it's absolutely correct, right?

10:50

It's estrogen progester. Exactly. All right, next

10:53

question. Under the tool, yes. All right,

10:55

I'm 48 years old. Had a hysterectomy

10:57

five years ago because of fibroids, now

10:59

having hot flashes, brain fog, and mood

11:01

swings. So her question is, is. What

11:04

hormone levels should I check to see

11:06

if I'm ready for hormone therapy? Take

11:08

it away, Dr. Flagg. What would you

11:10

do with this patient? None. I'd offer

11:13

her transdermal patch gel, oral ester dial.

11:15

She does not have a uterus at

11:17

this point, so that does make things

11:19

somewhat easier. It doesn't mean that I

11:21

won't prescribe progesterone in that case, but

11:24

you know, we'll talk to her about

11:26

her sleep, but I would certainly just

11:28

start with some estrogen. Yeah, no, I'm

11:30

pretty much with you on this one

11:33

and when people say what hormone levels

11:35

should I check I always answer you

11:37

should get your thyroid check because so

11:39

many people have these kinds of symptoms

11:41

which are very similar to symptoms that

11:44

you might get with hypotheritism and hypotherism

11:46

is very common at this time of

11:48

life, but assuming that thyroid levels are

11:50

where they should. should be, it is

11:53

absolutely appropriate to start estrogen. It doesn't

11:55

matter. When someone's, how do I know

11:57

if on pyramenopause or postmenopause? It doesn't

11:59

matter because if you don't have a

12:01

uterus, we don't need to worry about

12:04

the progesterone or the progesterone substitute. We

12:06

can just give estrogen to get rid

12:08

of the symptoms. We can just give

12:10

estrogen to get rid of the symptoms.

12:13

So really all I care about is

12:15

the symptoms. Let's circle back to. The

12:17

whole progesterone issue, because if the purpose

12:19

of giving progesterone or a progesterone alternative

12:21

is to protect the lining of the

12:24

uterus, because if you give estrogen alone,

12:26

you can get a buildup, which over

12:28

time increases the risk of either uterine

12:30

pre-cancer or cancer. But if someone has

12:32

had a hysterectomy, if they don't have

12:35

a uterus, well then they don't need

12:37

the progesterone, yet you mentioned that you

12:39

will sometimes prescribe a progesterone. So talk

12:41

about that a little. I will and

12:44

I usually I started with sort of

12:46

a layered approach if you will in

12:48

this in this case that you just

12:50

presented obviously need a lot more information

12:52

but I would start with just the

12:55

estrogen and then I would check back

12:57

in with her follow-up is really important

12:59

when you start these hormones maybe check

13:01

in with them again in two to

13:04

three months and see how they're doing.

13:06

And there is some pretty decent data

13:08

with micronized progesterone, the biosimilar progesterone type,

13:10

that it helps in the gabber region

13:12

of the brain and helps sort of

13:15

with the... an anxiolytic if you will

13:17

and will help people with insomnia and

13:19

sleeping. So sometimes I'll add that back

13:21

in if that if that seems to

13:24

be a prevailing symptom. Which is absolutely

13:26

appropriate. My only problem with that is

13:28

as you know so often it's the

13:30

progesterone that people don't tolerate that makes

13:32

them bloated or makes them moody. So

13:35

you know I kind of feel like

13:37

all right if they're not sleeping progesterone

13:39

is not going to be my first

13:41

go to, it's going to be one

13:44

of my last, and I'm going to

13:46

look at things like, are you flashing

13:48

during the night? Do you have aches

13:50

and pains that are... you sleep apnea.

13:52

So I'm not disagreeing with you. I'm

13:55

just saying it's for me it's the

13:57

rare person that does not have a

13:59

uterus that I'm going to give progesterone

14:01

to. But I mean there are a

14:04

lot of people that their approach is

14:06

way more to like hey let's let's

14:08

add a little progesterone in. Right and

14:10

it's not and I made it sound

14:12

too simplistic you're absolutely right you have

14:15

to look at other reasons for insomnia

14:17

and some urinary frequency and needing to

14:19

go to the bathroom all those things

14:21

can be things that wake you up.

14:24

The snore in the bed next to

14:26

you there's there too. But are the

14:28

dog right? Yeah the dog right. But

14:30

I also think it's worth mentioning the

14:32

alcohol issue because we know that women

14:35

are increasingly drinking midlife menopause. Sometimes it's

14:37

just social it's you know. they're more

14:39

their lifestyle now the kids are out

14:41

of the house and they're going out

14:43

to dinner and all that more but

14:46

a lot of times women are drinking

14:48

to to help them get to sleep

14:50

and then of course they wake up

14:52

in the middle of the night and

14:55

so and of course we just had

14:57

that FDA warning right we do know

14:59

that it increases risk for multiple cancers

15:01

I think it's up to eight cancers

15:03

now or something like that yeah all

15:06

right Penny she wants to know she

15:08

wants to know she says I've been

15:10

using an estrogen estrogen patch for about

15:12

Do I need to give it more

15:15

time or do I need a higher

15:17

dose of estrogen? Right, it's a great

15:19

question. And again, this goes back to

15:21

the follow-up, right? It's important. Whenever I

15:23

start someone, I follow them up at

15:26

least in the three-month window, two to

15:28

three months, would probably just increase your

15:30

dose. Yeah, I mean, I think one

15:32

of the things that's an important point

15:35

is how long does it take for

15:37

estrogen to kick? work overnight. You know

15:39

you are certainly hopefully going to be

15:41

sleeping better and having reduction in your

15:43

hot flashes within a week or so,

15:46

but if a week or two from

15:48

now you're still not where you want

15:50

to be, it doesn't mean we change

15:52

the dose. You know what I tell

15:55

people give it a minimum of two

15:57

months before we start messing with the

15:59

dose. How about you? Yeah, exactly the

16:01

same and it's thing. You know, I

16:03

will have a small number of patients

16:06

that say they feel a difference within

16:08

48 to 72 hours. But I definitely

16:10

give them that full two months before

16:12

and I set that expectation when I

16:15

start the prescription with them. I call

16:17

it my chest moves. One of my

16:19

patients said the other day, which was

16:21

so great. She's like, you're tinkering. I'm

16:23

like, that's exactly what I'm doing. I'm

16:26

tinkering. There's two approaches. Let's say you

16:28

have someone who comes in who's really

16:30

flashing. I mean, we're talking one of

16:32

these superflashers, you know, 30 flashes a

16:35

day, she's really miserable. One school of

16:37

thought is to start on the low

16:39

side with your estrogen, whatever you're using.

16:41

It doesn't matter patch or all jaw,

16:43

whatever, and then bump it up over

16:46

time. And the other approach is to

16:48

start high and to knock out the

16:50

flashes and then maybe go down. I

16:52

take the start high and knock them

16:54

out and go down. Which approach do

16:57

you take? I do the exact same

16:59

thing when somebody's so miserable. And by

17:01

the way, I just want to point

17:03

out that if somebody really is having

17:06

severe hot flashes like that, that's an

17:08

increased risk and a red flag for

17:10

potential cardiovascular disease, right? I wonder if

17:12

they have a history preclampsia and other

17:14

sort of soft markers for cardiovascular disease.

17:17

Yeah. It's so funny that you bring

17:19

that up because I'm just writing a

17:21

sub- of cardiovascular stuff down the road,

17:23

like pre-aclamxia, gestational diabetes, and all of

17:26

that. But look, these hot flashes are

17:28

not harmless. There's a very high association

17:30

with women that have moderate to severe

17:32

persistent hot flashes and cardiovascular disease down

17:34

the road. So this isn't just about

17:37

tough it out and dress in layers.

17:39

It's we really need to do something,

17:41

whether it's hormonal or non-harmonal, to get

17:43

rid of these hot flashes. So that

17:46

you are not increasing your risk of

17:48

cardiovascular stuff down the road. But there's

17:50

another issue with this question that's interesting

17:52

with the estrogen passion. She says she's

17:54

still having half lashes. I think now

17:57

we are becoming more aware that there

17:59

are some people that just don't absorb.

18:01

transdermal estrogen very well. And I don't

18:03

know if you saw the article that

18:06

was in Menopause last month, Louise Newsom's

18:08

study, and I did a sub-stack article

18:10

on that too, where basically she looked

18:12

at women that were using transdermal

18:15

estrogen and measuring estrogen levels and

18:17

finding that about like what 20%

18:20

of them had much much lower

18:22

levels than is expected. And this is

18:24

something that I mean. anyone of us

18:26

who've been in practice for a long

18:28

time has had those patients that you're

18:31

giving them transdermal estrogen and they're still

18:33

flashing and then while we don't get

18:35

levels routinely we get a level and then it's

18:37

like lower. So what are your thoughts on that?

18:39

Does this make you feel like maybe we should

18:41

be checking levels more often in women who are

18:44

continuing to be symptomatic? Certainly and I

18:46

do that already. I mean if you somehow

18:48

just can't you know make a... one or

18:50

two adjustments, but if we just can't get

18:53

them to a happy place, I definitely check

18:55

an estradial level, right? There's so they're different

18:57

FDA approved options that we have in our

18:59

toolbox, and I think it's really important to

19:02

be flexible. And if one doesn't seem to

19:04

be working, go to a different type and

19:06

see if they're not absorbing the patch or

19:09

they don't seem to responding, go to the

19:11

doubt. The other thing I want to point

19:13

out is applying the patch properly. I

19:15

literally will demonstrate on my own. body,

19:17

I show them my patch, you know,

19:19

how to actually apply that patch properly

19:21

on a nice, flat, clean, dry surface

19:23

and, you know, rub your finger over

19:25

the top, make sure there are no

19:28

wrinkles and that it's really attached to

19:30

the skin properly so that the absorption

19:32

can be optimal. The other thing I

19:34

may want to point out too is that,

19:36

and I've noticed this more and more, but

19:38

the generic patches and some patients really do

19:40

feel a difference from one patch type to

19:43

the next. Have you seen that? by the

19:45

way, when they change their generic patches that

19:47

they all of a sudden have breakthrough symptoms

19:49

when they were fine on one type and then

19:51

they what are the different, you know, I don't

19:54

know. Yeah, well, that's funny because it's actually the

19:56

next question from someone from Anne. And this was

19:58

the question that was called in through my. website

20:00

and she wants to know if it's

20:02

okay to substitute a brand-name pass with

20:04

the generic patch and I mean you

20:07

just gave the answer sometimes it's okay

20:09

but sometimes it's not and and there

20:11

are differences you can have the exact

20:13

same active ingredient here they all have

20:16

estradiol and but the actual patch and

20:18

the what's called the vehicle that it's

20:20

in is slightly different and it may

20:22

make a difference. So yeah, if you

20:24

are switching to a generic patch and

20:26

suddenly you're not feeling the same or

20:28

you're flashing, you're not sleeping, it may

20:31

be that it's just not absorbing and

20:33

it's worth getting a level. I think

20:35

the other thing also, and you've mentioned

20:37

this, but just to emphasize, a lot

20:39

of people. If they choose to use a

20:41

transdermal product, they're just told, oh, use

20:43

the patch because those are the least

20:45

expensive and they've been around for a

20:47

long time. But we have a lot

20:49

of other transdermal options that someone might

20:51

absorb more, like, you know, the jels

20:53

and sprays and the vaginal ring. And

20:55

that's one of the problems with not seeing

20:57

a menopause expert is very often they

21:00

have like one prescription in their

21:02

toolbox. And then if you don't do well on

21:04

that, they don't really have any place to

21:06

go. personalized medicine and the art of

21:08

medicine, like you're really dealing with an

21:10

individual and all their variables and their

21:13

priorities, and then this toolbox that you

21:15

have to be really flexible with, right?

21:17

You really have to listen to what

21:19

their concerns are and what things aren't

21:21

working and what are, and then make

21:23

adjustments. It really takes a lot of...

21:25

you know, listening and so. But it

21:28

goes beyond making, it's having things in

21:30

your toolbox. I mean, I just took

21:32

a question earlier in this webinar, I

21:34

was doing that this woman said she

21:36

went to see her doctor and said

21:38

she wanted hormone therapy and the doctor

21:40

agreed and just wrote her a prescription

21:43

and she said I wasn't given any

21:45

options. I was just given this one,

21:47

should I've been given options? And I'm

21:49

like, absolutely, because first of all, you

21:51

may have had medical issues that made

21:53

one thing a better option than something

21:56

else. or you know might have been

21:58

a personal preference but there's so many

22:00

different formulations and they're all very very

22:02

different and I think one of the

22:04

things that's out there which is slightly

22:06

problematic is everyone has this idea that

22:09

everyone should be on transdermal you know

22:11

and that never should be on oral

22:13

and that's just not true there are

22:15

some people that are much better candidates

22:17

for oral than transdermal. the issue with

22:19

the transdermal versus oral as we both

22:22

know right is the clotting risk and

22:24

if you really break it down to

22:26

the absolute numbers these we're talking about

22:28

minimal risk right two and a thousand

22:30

versus three to four and a thousand

22:32

risk right I mean people here double

22:35

the risk and they panic and I'm

22:37

like okay but it's like double the

22:39

risk of getting struck by lightning if

22:41

it's only one in a million then

22:43

it's two in a million it's really

22:46

not that much when you like you

22:48

said you you got to look at

22:50

the absolute numbers. I want to go

22:52

back to the absorption thing though because

22:54

I think that this is really a

22:56

much bigger problem and when we talk

22:59

about you mentioned about making sure that

23:01

the patch is really sticking well which

23:03

is super important but there's other things

23:05

that people can do to make sure

23:07

they're they're getting maximum absorption and one

23:09

of them is if they're using a

23:12

gel or a spray if you wash

23:14

too soon after that, like within an

23:16

hour, you're not going to get the

23:18

full amount. So I don't know if

23:20

you have any tricks or tips to

23:22

make sure that you are getting the

23:25

biggest bang out of your transdermal estrogen.

23:27

after the shower when you're making your

23:29

capuccino and there's a little bit of

23:31

time put it on your pant leg

23:33

or you know you rub it on

23:35

your arm or your forearm or you're

23:38

depending on the product right right on

23:40

the product wherever you're applying and and

23:42

then you know walk around and make

23:44

make sure you're not putting clothing on

23:46

over the top I had a patient

23:49

who I just I was I showed

23:51

her how to do it. We talked

23:53

about it, and I just couldn't get

23:55

her levels up. And finally, she came

23:57

into the office and I said, show

23:59

me how you, show me how you

24:02

put it on. She lifts up her

24:04

jeans and her calf is covered with

24:06

the lint from her jeans. And she

24:08

was putting the testosterone on her calf

24:10

as a. I instructed and then throwing

24:12

her blue jeans down and she looked

24:15

at me and she goes, well, it

24:17

looks like my genes have been absorbing

24:19

all the testosterone. So they're having a

24:21

smart, I am. I mean, and we

24:23

giggled, you know, it was very flat.

24:25

Her jeans had a great libido, yeah.

24:28

So that waiting for it to absorb

24:30

properly is really important, right? To your

24:32

point, don't shower an hour afterwards. And

24:34

the other thing also, and I'm sure

24:36

you've seen this data, people that use

24:39

a gel or a spray, and then

24:41

if they have pets and they're sitting

24:43

there and cuddling their pets, not only

24:45

is their pet gonna start to grow

24:47

breasts, seriously, has been reported, but it

24:49

also means that they're losing some of

24:52

their estrogen to their pet. So people

24:54

have to be aware of. My last

24:56

period was 13 years ago. Is it

24:58

too late for me to start hormone

25:00

therapy? There's not as if some big

25:02

guillotine comes down at the age of

25:05

60. We talk about, you know, symptoms

25:07

and risks. We do know that an

25:09

early start gets you the most benefit,

25:11

right? Within that first 10 years. Is

25:13

there still some benefit at 63? It

25:15

just depends on what the... what the

25:18

patient's symptoms are, what her goals are,

25:20

what her bones look like, right? We

25:22

know that it would, it does, it

25:24

does help with the osteo class and

25:26

hippos osteo class and bone loss. Just

25:29

depends, right? I'm 100% agreement, but I

25:31

think the thing that really needs to

25:33

be stressed is why? Why does this

25:35

woman want to start hormone therapy? There's

25:37

a big difference between the woman who

25:39

says, I'm still flashing and I can't

25:42

sleep and it's not getting any better.

25:44

And the answer is, yeah, then let's

25:46

talk about this because for some women

25:48

hot flashes are 10, 12 years or

25:50

forever. So it's reasonable to talk about

25:52

it. But the one that's a little

25:55

trickier. is the woman who says, I

25:57

sleep like a baby, I don't have

25:59

any hot flashes, my bones are terrific,

26:01

I have just been seeing all of

26:03

her social media that this is going

26:05

to keep me from getting heart disease

26:08

down the road, so I want to

26:10

start hormone therapy, you know, what do

26:12

you think? And for me, the answer

26:14

is, you know... If you're not flashing

26:16

and if you're sleeping, you're probably not

26:18

going to get a whole lot out

26:21

of it. And let's really look at

26:23

what are your goals, what are your

26:25

symptoms, why are you thinking of doing

26:27

this. So it's not that I think

26:29

it's a bad idea. I don't always

26:32

think it's a necessary idea. So it

26:34

kind of depends. Yeah, and I agree

26:36

with that. And also, this was, of

26:38

course, the big flaw in the WHOI

26:40

study was that the average age of

26:42

those women was 60, and many of

26:45

them had cardiovascular disease already in place,

26:47

and then we put... you know, oral

26:49

estrogen on top of existing cardiovascular disease

26:51

and then there were problems, right? So

26:53

somebody who's 63 may in fact already

26:55

have vascular vessel disease, right? So that's

26:58

really important to make sure that that's

27:00

not the case that we won't cause

27:02

any trouble. But I agree, there has

27:04

to be, I really, I spend a

27:06

lot of time on those conversations and

27:08

really do try to figure out what

27:11

her goals are and why she wants

27:13

to do it. that too. But it

27:15

brings me back to your original point

27:17

is this is individualized medicine. This is

27:19

personalized care. You know it's not like

27:22

we can make a blanket statement that

27:24

says sure all 62 year olds should

27:26

should go on estrogen. It's really about

27:28

what is this person's goals and what's

27:30

her medical history. All right this one's

27:32

this one is actually something that is

27:35

not uncommon. This is from Miriam. And

27:37

she says that she started using local

27:39

vaginal estrogen and is loving it. Everything

27:41

is going really well. Everything is great.

27:43

But she's noticing that she's got kind

27:45

of a smugma-like accumulation under her clitoral

27:48

hood. So she wants to know how

27:50

best to clean it. So what would

27:52

you tell her? Gently, very gently, less

27:54

is always better when it comes to

27:56

the vagina. So keep it really simple.

27:58

Very gently. You know, just to retract

28:01

that literal hood. But I think really

28:03

the most important part is water, water,

28:05

do not put soap that... Do not

28:07

put those liquid soaps. Do not use

28:09

any of those so-called feminine hygiene products.

28:12

All you need is to gently, as

28:14

you said, retract the hood. And then

28:16

if you've got one of those nice

28:18

little shower heads, rinse it off, you

28:20

might get a nice lorogism while you're

28:22

doing it. I'm just saying you on

28:25

the phone, but the point is, is

28:27

that whether you get in a bathtub

28:29

or whether you use a shower head.

28:31

This is stick to water. Don't use

28:33

water. Any other products stick to water.

28:35

But, and she didn't ask this, but

28:38

the other thing is, what about the

28:40

woman who is not able to retract

28:42

her clitoral hood? Because we see this

28:44

sometimes postmenopause that someone has a hood

28:46

that doesn't just slide easily over the

28:48

clitoris. So what would you tell her?

28:51

You would need to see somebody who

28:53

can, who can, who can take a

28:55

look and see if there's some adhesions

28:57

there. And then that's something that can

28:59

be treated. fairly straightforwardly right in the

29:02

office with. If it needs to be,

29:04

yeah, let's back up because a lot

29:06

of women have a literal hood that

29:08

is not easily going to slide off

29:10

the clitoris. And if they're not having

29:12

pain, if they're not having irritation, if

29:15

they're not having problems, that's okay. That's

29:17

a normal variation. But to your point,

29:19

they need to be examined to make

29:21

sure that there's not like sclerosis or

29:23

something else going on, but not. I

29:25

just want to be clear that, yes,

29:28

there is a procedure that can be

29:30

done in the office to get rid

29:32

of any scar tissue, any adhesions, but

29:34

everybody doesn't need that. That's only if

29:36

someone is having problems. Problems and, you

29:38

know, with orgasm, right, those literal adhesions

29:41

can impair that orgasm, but yes, 100

29:43

percent, but maybe just just to start

29:45

with an exam with a gynecologist who's

29:47

going to work. sort of thing to

29:49

take a look just to see if

29:51

anything would be helpful. But yes, absolutely.

29:54

Don't need to go away. But I

29:56

think the real message is that you

29:58

need to, just like guys who aren't

30:00

circumcised, they need to pull back on

30:02

their foreskin and to clean their penis.

30:05

And you know, pizza is a big

30:07

clitoris. And so it's really very very

30:09

similar. I think the other point is

30:11

someone might be saying, well, why is

30:13

she getting all this estrogen? on her

30:15

clitoris under the literal hood? And the

30:18

answer is, and they actually have an

30:20

entire episode on this and come again,

30:22

about the idea of using a local

30:24

vaginal estrogen, not just in the vagina,

30:26

but on the vulva, including on the

30:28

clitoris, because it increases blood flow, it

30:31

increases sensitivity, it can actually help with

30:33

orgasm. So we tell women all the

30:35

time, you know, take a little estrogen

30:37

cream and put it on your clitoris,

30:39

but then you do need to be

30:41

mindful about making sure that you are...

30:44

cleansing it appropriately so that you don't

30:46

get any build up there. And every,

30:48

whenever I write a prescription for topical

30:50

estrogen cream, which is daily, multiple times

30:52

a day, I say insert into the

30:55

vagina and then a glob, pearl-sized amount

30:57

on the fingertip and that goes on

30:59

the vulva, the clitoris, all the important

31:01

parts. And then maybe a little bit

31:03

on your face while you're at it,

31:05

but that's a different topic. No, there's

31:08

a different topic, but yes. Okay, Colleen.

31:10

Colleen. Colleen wants to know. Is it

31:12

okay to put vaginal lubricant inside the

31:14

vagina? I don't see why not. I

31:16

don't have any problem with that. The

31:18

only thing I like to say about

31:21

lube is just pH compatible. Right, there's...

31:23

I'm more concerned about azimodality than pH

31:25

quite frankly. Really? Yeah, okay. So you

31:27

know, I have patients that love coconut

31:29

oil for, for example, and I don't

31:31

think that's pH compatible with the vagina

31:34

particularly, but... This is my take on

31:36

that. You know, I'm glad that she's

31:38

differentiating between using lubricant on the volva

31:40

and the opening of the vagina versus

31:42

actually putting it inside the vagina. And

31:45

we know that some things are vagina

31:47

friendly and some things are not vagina

31:49

friendly. So you mentioned coconut oil. My

31:51

take on that is if you use

31:53

it for making lunch, don't use it

31:55

for making love because it is not

31:58

pH compatible. It's oily, it can cause

32:00

an increasing bacterial vaginosis, it's fine in

32:02

a pinch, but it's not something you

32:04

should be using regularly. But, and I

32:06

don't know if everyone knows this, but

32:08

what's really interesting is these products of

32:11

course are not FDA approved, they're FDA

32:13

cleared. And in order to get FDA

32:15

clearance to put something in the vagina,

32:17

you have to test it on either

32:19

humans or animals. So usually, you know,

32:21

little rat vaginas that get the benefit

32:24

of all this. But this is how

32:26

you know. If you buy a product

32:28

and the word vagina... is on the

32:30

label. If it says vaginal lubricant, that

32:32

means it has been FDA cleared, it

32:34

has been tested, that it's not going

32:37

to cause problems in the vagina, and

32:39

you can use as much in the

32:41

vagina as you want. If it has

32:43

one of these ridiculous euphemisms like feminine

32:45

or whatever, who knows? And I wouldn't

32:48

put any of that stuff in the

32:50

vagina because you don't know what you're

32:52

getting. I mentioned osmolality. You know, most

32:54

of the water-based lubricants have a very

32:56

high osmolality, which means if you put

32:58

a lot in the vagina, you can

33:01

get all kinds of inflammation, irritation, you

33:03

can actually dry out the vagina, so

33:05

it depends. So my approach is, use

33:07

a silicone lubricant and you can put

33:09

a whole bucketful in your vagina, it's

33:11

just fine. Because it's not going to

33:14

cause any harm to the tissue, it's

33:16

not going to... cause pH problems. Some

33:18

people really want to get it inside

33:20

there. You can go to Amazon and

33:22

get one of these loop shooters, which

33:24

is just like a nice little big

33:27

plastic syringe. You can load it up

33:29

and shoot it in there. But the

33:31

point is, is... If it's truly a

33:33

vaginal lubricant that is vagina friendly and

33:35

has been tested to be okay in

33:38

the vagina, well then sure, go for

33:40

it. But I think the best delivery

33:42

system to get vaginal lubricant in the

33:44

vagina is a penis or a toy,

33:46

whatever you're using, you know, put it

33:48

on the penis and then it's going

33:51

to get in there. Exactly. Well, that.

33:53

That was excellent. I learned some things

33:55

just now. About the rest and the

33:57

vagina. Rest, yeah. What did you say

33:59

you could get the rest? What did

34:01

you say you could buy off Amazon?

34:04

Loob? It's a loop shooter. Lubricant shooter.

34:06

Yeah. You actually wrote it up? No,

34:08

and for a lot of women. who

34:10

are feeling, especially if they're in a

34:12

new relationship and they're feeling uncomfortable about

34:14

the whole that they need lubricant thing,

34:17

I mean, hopefully they communicate with their

34:19

partner and get past that, but if

34:21

they can't, you know, and you go

34:23

to the bathroom and you use your

34:25

loop shooter and you shoot it in

34:28

there and he has no idea that

34:30

it's not all you. So there's that.

34:32

I love that. All right, so this

34:34

one, this next question actually came in

34:36

from two people. Christian and Angela kind

34:38

of the same question a little bit

34:41

different version and both of these women

34:43

have a history of endometriosis and now

34:45

they're in menopause and they want to

34:47

know if they start hormone therapy is

34:49

that going to trigger a recurrence of

34:51

their endometriosis. I had somebody recently who

34:54

had big endometriosis surgery and I called

34:56

the surgeon we talked about it was

34:58

deep infiltrating and she wanted her to

35:00

kind of have a... period of time

35:02

where she had nothing and then we

35:04

started hormones maybe three months later. If

35:07

it's been a long time from their

35:09

from their last period, if they haven't

35:11

had any symptoms, and certainly using both

35:13

estrogen and progesterone, right, to suppress any

35:15

potential resurgence. I don't know. What do

35:18

you do in this situation? I tell

35:20

them that I don't think we have

35:22

a lot of data on on on

35:24

requirements, right? Well, we have some data,

35:26

and the data is really pretty reassuring.

35:28

And my take on it is twofold.

35:31

One is when you look at women

35:33

that have endometriosis, one is it's not

35:35

just the presence of estrogen, it's cycling.

35:37

You know, when someone is having natural

35:39

periods, and in fact, if they're on

35:41

birth control pills, we put on continuous

35:44

birth control pills, so they don't have

35:46

the cycle. And when we give postmenopause

35:48

hormone hormone therapy, we're giving continuous... estrogen.

35:50

But the other point is is that

35:52

we are giving it in dramatically lower

35:54

doses. That's why we don't use the

35:57

term hormone replacement therapy because we're not

35:59

replacing estrogen. We're not giving you the

36:01

same kind of levels that you had

36:03

when you were 20. We're using very

36:05

very low doses of estrogen to get

36:07

rid of symptoms. So my feeling is

36:10

if someone has a history of endotriosis

36:12

and wants to take postmenopause estrogen, go

36:14

for it. dose. We use it continuously.

36:16

Obviously we're going to monitor these people,

36:18

but I really I think it's okay

36:21

and I know that this is somewhat

36:23

controversial because we don't have as much

36:25

data as we would like, but I

36:27

will tell you that in years of

36:29

doing this It was fine. And keep

36:31

in mind also, these are often very

36:34

young women, especially if they have a

36:36

hysterectomy because of their endometriosis, and if

36:38

they have over removal, they're plunged into

36:40

a menopause at a very young age,

36:42

which puts them at the highest risk

36:44

of having long-term problems like osteoprosis and

36:47

cardiovascular disease. So my inclination is, no,

36:49

we're not going to deprive you of

36:51

estrogen for the rest of your life

36:53

just because you had endometriosis. And I

36:55

totally agree. And this patient was really

36:57

young 46, I think, that they go

37:00

through. And it holds, as you say,

37:02

all those risks with regard to brain,

37:04

bone, and heart. Despite not having a

37:06

uterus, I put both on estrogen and

37:08

pedestrian, maybe to just that continuous suppression

37:11

situation. But yes, I agree. I don't

37:13

do that, but you're not the only

37:15

person who I've heard say that is

37:17

even if they don't have a uterus,

37:19

that that that's going to suppress endometriosis

37:21

more. I'm sure we don't. People are

37:24

like, why don't people do these studies?

37:26

Well, first of all, the people that

37:28

are motivated to do studies are pharmaceutical

37:30

companies that are trying to get a

37:32

product through. So that's not the case.

37:34

And now we have complete defunding of

37:37

women's health and the NIH and on

37:39

and on and on. So I think

37:41

we are going into a very dark

37:43

period of not having anyone who's funding

37:45

these non-farma type studies. So I know

37:47

I could say, you know, this is

37:50

sort of a data free zone or

37:52

we don't have much information and patients

37:54

get really frustrated and it's always. I

37:56

always try to explain, you know, there's

37:58

no funding for it and that's always

38:01

a hard, they, they, it's hard. Yeah,

38:03

people are very frustrated. I think that's

38:05

where people like you and I come

38:07

in because we do have decades of

38:09

experience. Experience does count for something to

38:11

say I've had many, many women in

38:14

this kind of a scenario. and I've

38:16

given them estrogen with endometriosis and they

38:18

do just fine or with your experience

38:20

of giving progesterone as well so there's

38:22

something to be said for not being

38:24

new in this field. All right this

38:27

one's from Rochelle who is taking an

38:29

oral estrogen and she's curious she has

38:31

high cholesterol and I wants to know

38:33

if this is the best hormone therapy

38:35

for her in terms of her high

38:37

cholesterol or should she be using a

38:40

transdermal? So what would you tell her?

38:42

Right. Interesting. So, you know, probably need

38:44

to know a little bit more about

38:46

her lipid panel, I suppose. So oral

38:48

estrogen actually has been shown to decrease

38:50

LDL. It can increase triglycerides, right? It

38:53

can interfere there. So it can actually

38:55

have a kind of a favorable impact

38:57

on the lipid profile, maybe look into

38:59

her clotting risk potentially and just see

39:01

if there are any issues there. I

39:04

would need a little more information from

39:06

her. It's always good to have more

39:08

data, but I think overall, assuming that

39:10

she doesn't have a risk of blood

39:12

clots, we know that both oral estrogen

39:14

and transdermal estrogen are going to decrease

39:17

cholesterol. that's clear-cut, everyone agrees. It turns

39:19

out the oral estrogens decrease total cholesterol

39:21

more than the transdermal, much to some

39:23

people's surprise, but oral estrogens increase triglycerides

39:25

and transdermal decrease triglycerides. So exactly to

39:27

your point, we need to know the

39:30

whole lipid panel. But if we're just

39:32

talking... total cholesterol, then yeah, an oral

39:34

estrogen is an excellent option for her

39:36

and people generally see a significant decrease

39:38

in their total cholesterol when they go

39:40

on an oral estrogen. Yeah, and that

39:43

oral estrogen, it gets demonized a little

39:45

bit, right? Yeah, absolutely underutilized because like

39:47

I said, this is the idea that

39:49

transdermal is always better, which in some

39:51

cases it is, and it is safer.

39:54

But keep in mind that we talk

39:56

about the fact that estrogen decreases decreases

39:58

the risk of... breast cancer by around

40:00

at least 21% or more. Those studies

40:02

were all done with oral estrogen. And

40:04

while we assume that you're going to

40:07

get some of the same benefit with

40:09

transdermal, we do not have as good

40:11

data. And if people are particularly worried

40:13

about breast cancer, and I tell them

40:15

we want to put you on the

40:17

estrogen that's going to decrease your risk

40:20

the most, we're looking at. oral and

40:22

specifically a duave which is the one

40:24

that has basodoxifin which I've talked about

40:26

so many times I don't think I

40:28

need to go there again but you

40:30

know it was also going to be

40:33

breast protective okay this one is super

40:35

easy this will just take you a

40:37

second we get this question all the

40:39

time is it safe to take systemic

40:41

estrogen and local estrogen at the same

40:44

time oh my gosh yes and I

40:46

get this I'll tell you who I

40:48

get the question from um the pharmacists

40:50

With the pharmacists, they drive me crazy.

40:52

I'm like, please stop sending me messages

40:54

on the EMR. Or they block the

40:57

patient at the pharmacy. They say you

40:59

can't take both of these. So the

41:01

answer very simply is yes. Yes. So

41:03

women that are on systemic estrogen, whether

41:05

transdermal or oral, about 50% of them

41:07

will still need that topical estrogen. Oh,

41:10

I think it's higher maybe. I do

41:12

too. So yes, absolutely, you can you

41:14

can treat with both and I do

41:16

all the time. But it's funny, I

41:18

mean that's a question that comes up

41:20

all the time and it's because of

41:23

the pharmacists and the insurance company that

41:25

says your doctor made a big mistake

41:27

here. Don't do this, it's too much

41:29

estrogen and that's just not the case.

41:31

But that's why we have to keep

41:34

bringing it up because people do get

41:36

this. Okay, this is from coral. She

41:38

had a hysterectomyelmy last year because of

41:40

uterine cancer. Well, certainly topical estrogen for

41:42

her vagina, right? That's fine. We're talking

41:44

about. He's having half lashes. Can she

41:47

take us, you know, systemic? Where I

41:49

would, I definitely would get on the

41:51

call, you know, on a call with

41:53

an oncologist and have chat, right? Well,

41:55

we always have to collaborate with our

41:57

oncologist friends. In general, I can't talk.

42:00

coral what to do because I don't

42:02

know enough about her cancer, what kind

42:04

of what they found, but in general

42:06

if someone has a stage one uterine

42:08

cancer that's not a high-grade cancer, we

42:10

have very good data that shows they

42:12

are perfectly okay to take systemic estrogen.

42:14

So this is one of those

42:17

cases. This is a conversation between

42:19

the oncologists. and the gynecologist, it's a

42:21

higher grade or the more advanced cancers

42:23

that we don't have the data. It's

42:25

not that we've seen that it's bad,

42:27

it's that we just don't have the

42:29

data to know if it's safe, but

42:31

it's a great question because Euterine cancer

42:33

is the most common gynecologic cancer right

42:35

now and it's highly curable over

42:37

95% curable which is why women

42:39

should never ignore any postmenopause bleeding

42:41

but a lot of women end up with

42:43

a hysterectomy and then are told that they

42:46

can't take estrogen which is not always true.

42:48

Not always true. Let's see we had to

42:50

rush through a few more because I know

42:52

you got to you got patients you got

42:54

to get out of here but let's just

42:56

a couple more All right, taking loads of

42:58

doses of testosterone and I'm pretty sure my

43:01

voice is getting lower. My doctor said my

43:03

levels are fine. I thought that only happened

43:05

with high doses. I don't know what to

43:07

do. Should I go off and we'll go

43:09

back to how it was? Yeah, they

43:11

gave a great lecture about this at

43:13

the Menopause Society this kind of year

43:15

and I don't know that we, I

43:17

think what we've seen in the data

43:20

is that we, even at lower doses,

43:22

they can have some voice changes, which

43:24

is obviously devastating for certain people in

43:26

certain professions, right? Singers and things like

43:28

that. It's something that has to go

43:30

along with the counseling, that it is

43:32

something that can happen. And unfortunately,

43:35

the data also shows that it's irreversibleable. Exactly.

43:37

I heard that same lecture and it really

43:39

changed what I've told people because in the

43:42

past I always said you don't have to

43:44

worry about your voice getting lower as long

43:46

as we're really careful about the levels and

43:49

we keep them nice and low and this

43:51

odorangologist basically said that's not the case. She

43:53

sees women all the time who are on

43:55

appropriate dosages and particularly like you know actors

43:58

voiceover opera singers they're going to... notice

44:00

even these subtle changes. But it is

44:02

a big issue and along with the

44:04

potential for hair growth or acne, people

44:06

need to be told that you might

44:09

get some voice changes. And for some

44:11

people, that's a deal breaker. They need

44:13

to know that in advance. They need

44:15

to know that in advance. I am

44:17

45 years old, scheduled for a hysterectomy

44:19

because of fibroids. Is my sex life

44:21

going to change? Just want to make

44:23

a point, a lot of people think

44:26

that if they have a hysterectomy that

44:28

they go into menopause and you do

44:30

not. A hysterectomy is removal of the

44:32

uterus, nothing changes hormoneally. So this woman

44:34

is like, my uterus is coming out,

44:36

but not my ovaries, and I want

44:38

to know is this going to impact

44:41

my sex life? I do know though,

44:43

after hysterectomy like that, because of the

44:45

disruption of some of the blood flow,

44:47

there's all that collateral blood flow that

44:49

they can go into menopause earlier, right,

44:51

after hysterectomy. But you know, a lot

44:53

of people, like they're 50, and they

44:55

say, I'm going to keep my ovaries,

44:58

and it's like, you know, okay. And

45:00

then they go into menopause, and they

45:02

think it's because they were going to

45:04

go into menopause anyway. And I actually

45:06

just recorded a whole podcast episode on

45:08

this for Come Again about women who

45:10

have a hysterectomy and do have a

45:13

change in their sex life. It's the

45:15

exception, not the rule, most people it's

45:17

fine, but there are a lot of

45:19

things that The uterus does when it

45:21

comes to the sexual experience. I mean,

45:23

when women might have an orgasm, they're

45:25

uterus contracts. That's going to go away.

45:27

Some people's cervical stimulation will even trigger

45:30

an orgasm. So the short answer to

45:32

that excellent question is that in most

45:34

cases, no, it's not going to make

45:36

a big change, but there are women

45:38

that it will make a change. And

45:40

so, you know, as I was researching

45:42

that when I was doing this episode,

45:45

we really have a lot of really

45:47

interesting data about that. So it's a

45:49

good question, because I gotta tell you,

45:51

surgeons do not, do not bring that

45:53

up. We don't talk about it. The

45:55

one thing I would say, like, if

45:57

my patients who are miserable with their

45:59

fibres, if they're getting... hysterectomy obviously they're

46:02

terribly symptomatic and it's probably kept them

46:04

from having sex or maybe they have

46:06

pain with sex because of their fibroids

46:08

yeah oftentimes once they're treated their sex

46:10

life improves oh my god it feels

46:12

so much better from the fibroid removal

46:14

right there's really good data that shows

46:17

that women who have a hysterectomy because

46:19

of pain like endometriosis are bleeding because

46:21

of fibroids everything only gets better not

46:23

to mention the an anemia you know

46:25

if you're really anemic and tired your

46:27

sex life is going to be in

46:29

the toilet. So there's that. All right,

46:31

we got a, we're running out of

46:34

time here. But I want to ask

46:36

before we go, are there any questions

46:38

you've gotten recently that you think are

46:40

worth mentioning? Yeah, I got a message

46:42

on the portal and she said, you

46:44

know, I'm having, I'm getting a rash

46:46

in my armpit and I'm like, I'm

46:49

rationing your armpit. And she goes, does

46:51

it have anything to do with my

46:53

hormone therapy with my hormone therapy? I

46:55

don't think so, but it required a

46:57

lot of back and forth, but I

46:59

finally figured out she was putting her

47:01

patch in her armpit. That's where she

47:03

was sticking the patch. So that was

47:06

under the last question. I mean, right,

47:08

I'm not sure why or how or

47:10

where she got that idea because I

47:12

certainly never told her that. And also

47:14

we do for transdermal particularly, we don't

47:16

want that near the breast, right? They

47:18

always say that, but come on. There's

47:21

no data. I mean, that's not a

47:23

fair-mongering that if you have estrogen, it's

47:25

going to cause breast cancer. So that's

47:27

an insane, you know, we are told

47:29

that. Yes, don't put it near your

47:31

breast, but there's no medical reason why

47:33

they've been told that. And there's never

47:35

been one single study that shows if

47:38

you put your estrogen in the vicinity

47:40

of your breast, and I think it's

47:42

just really... Exactly. Once again, no data

47:44

to support it and just, there's a...

47:46

who's a menopause coach, and she sent

47:48

me a question about how do we

47:50

talk to our patients and to her

47:53

clients and all this, when they're getting

47:55

all these mixed messages from these, you

47:57

know, experts on social media. And of

47:59

course, my response to that is stop

48:01

going to. social media for your medical

48:03

care. But I've done a few podcasts

48:05

on that and it is highly problematic

48:07

because people are getting a lot of

48:10

information and then they go to their

48:12

own doctor who isn't necessarily helpful. So

48:14

I will in the program notes as

48:16

always put information about where to find

48:18

a menopause expert in the program notes.

48:20

I will also list all of the

48:22

ways that. I can get your questions

48:25

so that either on one of my

48:27

once a month ask me anything webinars

48:29

for my sub-stack subscribers or if we

48:31

do another one of these that we

48:33

can get your questions answered. So check

48:35

the program notes and I will put

48:37

all of the links and all the

48:39

information there and I want to thank

48:42

you so much. It was so nice

48:44

to have you here because I'm used

48:46

to just kind of doing this myself

48:48

and I get tired of hearing my

48:50

own voice. So it was really nice

48:52

to be able to share this with

48:54

someone else. Thank you so much. Thank

48:57

you. Thank you for having me. Thanks

48:59

for joining me and if you're looking

49:01

for more inside information, check out my

49:03

sub stack. Just go to Dr. Striker

49:05

dot sub stack dot com. And you

49:07

can also follow me on Instagram at

49:09

Dr. Strike.