Doc Discussions with Dr. Jason Edwards
THIS is the podcast you have been looking for! "Doc Discussions" are just what the title says they are: physicians from a wide range of specialties, talking about relevant, up-to-date medical topics, not to mention tips on habits to help you live your best life. Your host, Jason Edwards, MD, is a board-certified radiation oncologist with a PhD in cellular and integrative physiology at St. Luke's Hospital in St. Louis, Missouri. Dr. Edwards explores not only diseases but also suggests techniques to optimize mental and physical health for a long and good life. Real people. Real advice. Real good. This is Doc Discussions, with Dr. Jason Edwards!
Doc Discussions with Dr. Jason Edwards
Hormones and Health
Hormones control everything from your mood to your metabolism, and when they're out of balance, quality of life can suffer dramatically. In this eye-opening conversation with Dr. Julie Gould, OB-GYN, we explore the world of hormone replacement therapy and its potential to transform women's health.
Dr. Gould brings clarity to a field often clouded by misconceptions, particularly around cancer risks. She explains how the medical community has dramatically revised its understanding since the Women's Health Initiative study, with the North American Menopausal Society now stating they do not believe hormones cause cancer. For many women, this new understanding opens doors to treatment options that can address debilitating symptoms while potentially offering long-term health benefits.
Beyond just treating hot flashes (which aren't even the most common complaint), hormone therapy addresses a constellation of issues including sleep disturbances, vaginal dryness, diminished libido, joint pain, and cognitive concerns. Dr. Gould walks through the various administration methods—from patches that bypass liver metabolism to gels, pills, rings, and more—helping listeners understand which options might work best for their unique situations.
Perhaps most surprising is Dr. Gould's discussion of testosterone in women. Most people don't realize women naturally have 10 times more testosterone than estrogen in their bodies, and when those levels decline, it can lead to fatigue, brain fog, and loss of vitality. Despite this, there are no FDA-approved testosterone products specifically for women in the US, though they exist in other countries.
This conversation represents a shift toward proactive health optimization rather than just treating diseases after they develop. Whether you're currently experiencing menopausal symptoms or simply want to understand what options might be available in the future, Dr. Gould provides the knowledge needed to make informed decisions about hormonal health at every stage of life.
Ready to learn more? Call Dr. Gould's office at 314-205-6788 to schedule a consultation and discover if hormone replacement therapy might be right for you.
Hello, this is Jason Edwards and this is Doc Discussions. I'm here with my friend, dr Julie Gould. She's an OB-GYN. Julie, how are you doing today?
Speaker 2:I am fantastic, thank you.
Speaker 1:Yeah, welcome. And so tell us a little bit about yourself. Where are you from originally?
Speaker 2:Oh well, that might take your whole podcast. I'm actually from the West Coast, I'm from the Bay Area. San Jose is where I lived till I was about 13, then moved to Northern Nevada, where 13, then moved to Northern Nevada where I went to high school and undergrad and then actually residency is what brought me out to St Louis and I never thought in a million years I'd be like, yes, I want to live in St Louis. But I actually ranked it was St John's Mercy at the time. I ranked them number one for my residency and got it and then just had wonderful experience there for residency, met some great people, and then just had wonderful experience there for residency, met some great people, and then we decided to stay here.
Speaker 1:So yeah, so Mercy's residency program. It's a what they call a community program right. And but it's. It's a very highly sought after residency program, and especially these days, I think, as residents or potential residents care more about quality of life. I think it's only gotten stronger, and so it's attracted a lot of good talent to the city.
Speaker 2:Yeah. So what brought me there is? So I had the best advice I ever had from an OBGYN resident out of the University of Iowa. He said do not go to a program that has fellows.
Speaker 1:And I was like what do?
Speaker 2:you mean by that he goes because you're never going to get to operate. He goes, go to a community program. You get to assist on all the surgeries. So, and that was very true, like at a time where, like I, I got out of residency with like 107 vaginal hysterectomies. And then one of our big powerhouse residencies in town they were on probation because their, their, their residents, were only doing seven vaginal hysterectomies. So I feel very blessed that I got to operate so much as a resident over there.
Speaker 1:Yeah, actually in part of my training there was a resident in general surgery from a community program and he came in for his last year and the attendings just treated him like an attending. He got so much respect and he was treated totally differently than the residents just because he had done so many more cases and was so capable. And so, yeah, there's definitely huge benefits from a program like that.
Speaker 2:And so now you're at St Luke's yes, which I love, and I have a hard time going back to Mercy now, though, because I love the community feel of this hospital, though, too, and we know I mean, I know everybody here. I know you know who I like for general surgery and urology, and I could get you know cases on when I want to. So, I mean, I've been here, wow since 2010. And I'm very thankful and appreciative to St Luke's for helping me stay here, though, too.
Speaker 1:But a lot of OB-GYNs have privileges at other hospitals right, yes, yeah, and so you of OB-GYNs have privileges at other hospitals, right?
Speaker 2:Yes, yeah, and so you work some at Mercy, is that right? Yeah, I still deliver at Mercy and I have privileges to do just general, I mean to do GYN surgery but I hardly ever go there. Same thing with Missouri Baptist we can deliver there, but we do it more for insurance reasons or sometimes, if there's like high risk reasons that somebody has to go to a certain facility for the mom or for the baby.
Speaker 1:Yeah, and I think you probably work with my wife to a small degree from time to time.
Speaker 2:Yeah, I definitely have consulted your wife. She's fantastic too, oh thank you, thank you.
Speaker 1:And so now an OB-GYN practice can be more obstetrics or more gynecology. What's the breakup of yours?
Speaker 2:Oh well, that is changing now over the years because as I age, my population is aging with me now too. So I used to be really OB heavy. Now, like I talk about hormones quite a bit during the day, so I mean I'd probably say that I'm probably. I mean I'm actually probably 50-50 now, which is different than where I was 10 years ago, where it was probably heavier in OB.
Speaker 2:But, like I said, as all my population is aging with me, we all have the same problems, and that's the thing that we've realized, though, too that as women, we talk and we don't feel good Like we all start talking. So, you know, one of my friends talks to another one of her friends and they hear, like I do. You know hormone replacement therapy, where not all GYNs will do hormone replacement therapy, they'll farm it out to boutique practices or people that just want to do hormones all day long, but I feel like most of my new patients coming in are coming in because that's what they want, though.
Speaker 1:And so, yeah, let's get into that. So why would somebody want to have hormone replacement therapy? What are, like, the main symptoms that they're trying to address?
Speaker 2:Right. So well, this is going to surprise you. The number one complaint coming into the OBGYN office is not my cycles are irregular, or I'm having problems with my discharge, or I have hot flashes. It's I'm gaining weight in the midsection, like universally I probably hear that about 15 times a day, like I don't know why I'm gaining weight in the midsection, so, and there's a lot that goes into that, more so than just hormones. But that's the number one complaint coming in.
Speaker 2:But the other things that people will complain about, I mean, and it's like a whole myriad of potential symptoms that people have, but the most common are like hot flashes, vaginal dryness I don't have sex with my husband anymore. Can you make me have a libido? Like that's a huge, huge one though, too. And then there's other stuff that, like I hear, but not quite as frequently though, to general joint aches, dry eyes, skin changes, people always very worried about skin changes. And then there's some people that are just very proactive with their health though, too, and they've read the books and they've listened to the podcasts, and they know that, like estrogen does confer health benefits in the sense that it helps reduce cardiovascular disease.
Speaker 2:In the first five years out from menopause. It will have bone protection. It protects your vagina, protects your bladder. There's so much good that estrogen actually does that. Some people are just proactive, coming in because they're like look, I want this for longevity, I want this for, you know, for my brain health, my cognition, and that's why some people come in. But it's, you know, it's usually not one thing, it's several things at one time.
Speaker 1:And it tends to help with all of those things, correct? Yes, yeah.
Speaker 2:And different hormones will help with different things. So we just really break down what we offer them according to their health history. Do they have a uterus? What is the worst of their symptoms, and start from there.
Speaker 1:So now, some of the things that make oncologists nervous especially probably more so in the past are the risks with cancer.
Speaker 2:Right right.
Speaker 1:Can you?
Speaker 2:speak to that a little bit. They have really walked that back actually, since the Women's Health Initiative was done and that was initially the big study that was done that scared everybody off from hormones. And since that time I don't feel like, as far as clinicians go, we have caught up with what the literature actually shows. North American Menopausal Society will say that we do not think that hormones causes cancer. But would I give it to somebody that has a tremendous family history of breast cancer? Or would I give it to somebody with breast cancer? No, I wouldn't. So we do have to, you know, still do a very in-depth family history, in-depth personal history before we decide what it is that we're doing. But you know, even with the Women's Health Initiative study they did show that women that, like, received estrogen alone actually had less cases of breast cancer than women that did not have anything at all.
Speaker 2:And then the other flaw of that study was that in the estrogen and progesterone arm of that study they used a progesterone called medroxyprogesterone acetate, and so with that, once they added that progesterone to the estrogen, they did have what they thought was clinical significance of increasing breast cancer. So what I always tell my patients is if one in eight women get breast cancer in their lifetime. They thought one in 7.9 would get it if you were on those particular kinds of hormones. But what they never really went back and studied was like do we think it was the medroxyprogesterone acetate, which is Provera? Like do we think that that actually could have been the culprit? Nobody ever did the study afterwards, so nobody really uses that hormone anymore. For the progesterone aspect of their hormone replacement therapy. We all use micronized progesterone, which is Prometrium.
Speaker 1:Yeah, and so yeah, no-transcript. And if it does have an effect, it's just a fraction of those patients who would be affected by it, but you can't get it out of their mind. They say the estrogen caused this, and good luck trying to convince them otherwise, and I don't try to.
Speaker 2:When people come into my office, I do not try to talk them out of that thought. I don't either, even though statistically it's unlikely, right.
Speaker 1:You just can't. People have this anchoring bias. It's the first thing they hear or the first thing they think Right and for what it's worth. I've never had a patient who was on supplemental estrogen who had a breast cancer that ended up being anything but like a very favorable T1A or T1B, erpr positive or T2 negative, like the most favorable, most curable cancer, right, and in my estimation you know their overall quality of life, despite having a breast cancer, as horrible as that is, it was probably still better from being on the hormone and I feel like I'm probably in the minority of oncologists who would say that.
Speaker 2:I think it's starting to change though actually.
Speaker 2:I feel like there's people that want studies to be done on people, after breast cancer, using hormone replacement therapy maybe not necessarily estradiol, but being able to use estriol, because the fact of the matter is is that, for some people, when their estrogen goes away, they feel miserable, though, and their quality of life really does suffer, so they really do come in going. What else can you offer me? What can you give me in the context of safety that's going to correct my hot flashes, that make me not feel crazy, that make it so like my vagina doesn't hurt all the time? Every time I try to have relations with my husband, you know, so they are desperate, coming in and they want something else, though, too, and we do a lot I mean, I do a lot of, you know, sending messages to the oncologist saying this is what the patient would like. Do you feel comfortable with this, though, too? And most of them do feel comfortable with the basics that I'm asking for.
Speaker 2:And then there's some that you know we kind of go, we might have to get a little more creative. So you know there is estriol that can be compounded for you and that's, you know, a whole different world and some people, some people you know won't go into that world but I like to give people all the options.
Speaker 1:And the vaginal estrogen, the intravaginal estrogen. That doesn't look like there's any risk with that correct.
Speaker 2:Well, it depends on what paper you actually read though too, but overall we feel comfortable with the lack of systemic absorption. But there are some papers that say like, oh, you might absorb a little bit, and the people that have, like, serious estrogen-sensitive cancer. We tread lightly there and we know which brands that we like to use that have less systemic absorption there too.
Speaker 1:So there may be some absorption, but I've seen some pretty large studies that did not show any increase in incidence of actual cancer. Yes, yeah, and so to me and the patients that I've seen on hormone replacement therapy the women it does seem like their quality of life is better than average. Now tell me if I'm crazy. To me they look better. So I've done this more than once. I've looked at a patient and I said I bet she's on estrogen replacement therapy. To the nurse and have yeah, and have nailed it.
Speaker 2:And it's not that common yeah.
Speaker 1:And so. But to me they have like their skin looks better. Yes, I would. I dare say they look prettier Right.
Speaker 2:And I don't know if it's because these are people that are proactive with their health, though, too.
Speaker 1:Very well could be, but there are some people. I mean, I have this beautiful 79-year-old that comes in.
Speaker 2:I'm like.
Speaker 1:I want to be her when I'm 79. It's the people who are like 70s or late 70s or 80s who look really good. Those tend to be the ones I'm like.
Speaker 2:I bet they're on hormone replacement, and this lady always comes in, she's from California, gives me her list of labs that she'd like to have done, and she knows exactly what she wants when she comes in though too. But I mean, she looks fabulous though too, and she's very lively though too, and um and so yeah, so I, I agree that you could tell the people that are still on hormones, Um, and yeah, I 100% agree, yeah, I don't know if there's any research on that, but it's it's like a genesis.
Speaker 1:Yeah, but it seems kind of obvious when you see it, right yeah. And now, how can the estrogen be given? Is it a pill, an infusion? Yeah, okay.
Speaker 2:So there's a lot of different ways and I think there's like 26 different formulations of ways that you can give.
Speaker 1:Really yeah, something crazy like that. So what are the main ones, so that you can give?
Speaker 2:Really, yeah, something crazy like that.
Speaker 2:So what are the main ones?
Speaker 2:So I mean, most people's go-to or at least my go-to is probably starting with a patch, and the reason for that is because transdermal estrogen actually does have less risk than taking oral estrogen.
Speaker 2:So it bypasses the or I guess it bypasses the first pass system am I saying that right where it doesn't go through the liver, so it doesn't affect the coagulation cascade as much, and there was actually this great article that came out in the British Journal of Medicine in the last year that looked at cardiovascular risks associated with taking estrogen in different routes, and they did not show any risk in DVTs or blood clots in the arm that had transdermal estrogen. So the people that use the patch had no increased risk. So, in general, we try to use a patch. I often use gels also, though, too, but gels are just not covered as well from insurance and, knowing that there's all these different ways of giving it and different brands that are available, people always come in and they're like well, I want to use this, I'm like I'll write it for you, but it's going to cost you $300 because your insurance is not going to cover it.
Speaker 2:But they usually cover a patch to start with, and there are some people patches they just don't stick to or they don't like using the daily gel. And we will use oral though too, and oral estradiol is dirt cheap, so for some people they're like that's what fits in my life. I'm going to use an oral estradiol instead. But then there's also vaginal rings. There is actually a ring called fem ring, which I'm always learning things. Every day I'm learning new things, but there's one called fem ring that you could insert vaginally, and of course it helps with vaginal atrophy, pain with intercourse, but it is absorbed systemically, whereas a lot of the other rings are not. So you could get systemic absorption of estrogen through this ring, which is awesome, though too, is that uncomfortable.
Speaker 1:Do people see it? No, you don't.
Speaker 2:And that's also like every time somebody comes in and I show them a ring and go and there's a ring and they're like eh, I'm like it is seriously, you will not even notice it's there and it's a great vehicle for providing medication, but I think people are just afraid of it. I just want everybody to try it and be like look, you're not going to notice it and then they're afraid they can't get it out, but it is very easy to get out though too.
Speaker 2:But I mean, there's shots, there's pellets. Pellets is like its own conversation, that is its own podcast, but there's pellets that a lot of people get. But yeah, there's several different ways to give estrogen. Some are in combo patches, some are in combo pills, but, yeah, lots of different ways.
Speaker 1:Do you ever treat patients who are premenopausal?
Speaker 2:Yeah, and that's a little bit harder, though, too.
Speaker 1:With insurance or with the patient, or, harder, how?
Speaker 2:Because we're dealing with a cycle then and so and we definitely have people that are perimenopausal and you could get these symptoms, you know, five, even 10 years before your last menstrual cycle actually occurs. Yeah, because menopause is when you've gone a year without having a menstrual cycle.
Speaker 1:What's the average age for that Fifty one, fifty one.
Speaker 2:So yeah, so it could happen. It A menstrual cycle? What's the average age for that? 51. 51. So yeah, so it could happen. It's considered normal anything after 40.
Speaker 2:So I have plenty of people that are 40, 42 coming in and they're like I just feel like it's coming, like I'm getting the hot flashes, I can't sleep, sleep, and I didn't mention sleep enough, and sleep is actually probably one of the most important things to have addressed, but sleep is one the first things that go, and it's not the ability to fall asleep, but it's the ability to stay asleep, and that's what they'll mostly start coming in with is like I can't sleep, I'm really hot, I'm waking up, sweating, but they're still cycling though, too, so you can't just really put a patch on them and then say you know, use progesterone every day, because your cycle is going to become a little more wonky then. So that's where we get a little more creative. Sometimes I'll put people on progesterone for three weeks and off Using a progesterone IUD. I love when patients have a progesterone IUD place, because it makes giving the estrogen that much easier, though, too.
Speaker 2:Okay, and they don't have the cycles that are all over the place then also.
Speaker 1:That's interesting, yeah, because typically you just think postmenopausal, then you go in and get it. But but actually I was. I was discussing this with somebody before we did the podcast and they were premenopausal and they were saying what about before? And so that's cool.
Speaker 2:And sometimes we just put people on a low dose birth control pill, which is is fine. As long as people aren't smokers, as long as they don't have migraine with aura, as long as they don't have liver dysfunction, it's fine to put people on a low dose pill. I mean just what? Basically any birth control pill is considered low dose now, but you could put anybody on a birth control pill to control their symptoms though, too. Okay, and that's totally fine also, and sometimes it's easy.
Speaker 1:So so when I think of medical care, you're trying to increase the length of life or the quality of patients' lives, and it seems like a lot of these are a significant increase in their quality of life.
Speaker 2:Yeah.
Speaker 1:Is there any data on what it does to length of life at all?
Speaker 2:Yeah, I don't know. It off the top of my head. Yeah, but you're going to see it in different ways, meaning that if you're on estrogen, your risk of hip fracture is going to decrease.
Speaker 1:Yeah, and that's related to length of life.
Speaker 2:Right right. So also, if your cardiovascular system is improved, then that's going to increase your length of life. It's going to reduce your risks of dementia, though, too which I feel like a really big deal is to keep cardiovascular system in check for your brain health. More than anything else, though, too which is a really I feel like a really big deal is to keep cardiovascular system in check for your brain health. More than anything else, though, too.
Speaker 1:A hundred percent. I mean women have dementia, I think, more than men, or Alzheimer's more than men. And then you know, one thing that's to me seems totally obvious is if you have plaque in your arteries of your heart, you probably have plaque in the arteries of your brain.
Speaker 2:Yes.
Speaker 1:And a lot of dementia is vascular dementia, right, and so, and if you feel better, if you have less psychologically, you're doing better, right, physically you feel stronger, right, or probably be more active, yes, and so it's now. It's a hard study to do, uh-huh, you know, because it takes a long time to see who lives longer, right, and there's a lot of selection bias, correct, and that it would probably be a healthier person who would initially try this or, on average, a more educated person who just knows it exists.
Speaker 2:Right. There is so much room for studies to be done in the future, though, too, and the studies that have been done in the past were not fantastic, and that's part of the problem. Like a lot of times, they would say let's, let's, implement this treatment, but never follow levels on anybody. So we don't even know, like what you know, what level somebody should be at for their estradiol or their testosterone or whatever in time to come, because nobody really followed that in the past. So, like it's a huge area that is open for evaluation. So, residents, if you're listening like they could easily create studies for this, for all your senior projects.
Speaker 1:The. Now you listen to Peter Atiyah.
Speaker 2:Yeah, so you know he talks about like a brain crash on him.
Speaker 1:He talks about the old medicine where, like, you have diseases and you're trying to treat diseases and then maybe kind of like a new type of medicine, where you're trying to people don't necessarily have diseases, but you're trying to optimize their life right, and this is a little bit more of that right I mean, obviously you're treating potential future diseases and things like that, but it's more of like proactive, trying to make the quality of life and the length of life better, right, and which is kind of a cool thing, and I think all doctors wish we could, or a lot of doctors wish we could kind of address some of these things, and so it's kind of a cool, you know, very forward thinking it is.
Speaker 2:It is. Yeah. I mean, for example, I had somebody that came in yesterday and she'd had a hysterectomy, but she still had her ovaries, she and she was I think she's 52. And she's like, I mean, I don't know if I've gone through menopause, because she really doesn't have a lot of symptoms, but she's like, why would I want to be on estrogen? And so I kind of said, well, here's the health benefits of it. And so she was like, let's look. So I looked at her labs and, sure enough, I mean, she's in menopause. And so, you know, I sent her the message, and she's going to come in and talk about, you know, maybe starting on some transdermal estrogen. We'll talk about the risks associated with it, but also, like the longevity of, like what estrogen can do, though is so beneficial for her health. And so we're going to have that discussion though, too, instead of just saying, oh, you know, you don't have any symptoms.
Speaker 1:OK, bye, see you next year. So, yeah, yeah, it's, it's, it's it's kind of an exciting front, um, I I do feel like, because it's this life optimization things, uh thing you can also have, especially in men's health, with hormone replacement, it it kind of gets into this field, um, where I don't want to say quackery, but the credibility with some practices is not the same as like a doctor working in a hospital doing this, and so it kind of gets in this gray area.
Speaker 2:It's all. Everything with hormones is in a gray area, and I do feel like it is the Wild West out there, and I can't even tell is the Wild West out there, and I can't even tell you how many people come in, and they're like even for women, though, too, it's not just for men Like they'll go to these boutiques and they'll say, like I'm on this and this and this, I'm like I just kind of pause and I go, ok, and then you know, if they're feeling good and they're checking their labs and I think it's in the context of safety I just let them go, but sometimes I go. I don't really agree with this, and I'll tell them why also, though, too, and they don't even understand why they're on certain things, though too, and that's.
Speaker 2:the bothersome thing is that they don't know why they're taking this, this or that, and sometimes I'm like I don't know why you're on it.
Speaker 1:But you know, those places wouldn't exist if there weren't a market for that that is not being met, you know, with practitioners, right right, and so you know kind of looking forward. My hope is that you know reputable, you know practitioners can kind of fill in that market, right right.
Speaker 2:And it's hard though, because it's time consuming and like, unfortunately, in, you know, in in medicine these days it's very volume driven, though too Like you should be seeing this many patients each day in order to produce a profit, though, too, and it doesn't leave a lot of time to talk about all those important things, and that's where all of these other boutiques are coming in.
Speaker 1:Yeah.
Speaker 2:And that's where they're finding like, okay, people really do want this. I mean, from my standpoint for women, I mean it's a combination of GLP-1s, testosterone and then just general hormone replacement therapy. That is like a huge boom for all of these boutique practices right now Because people want, oh, and pellets. Pellets is like this other thing. That's a money, huge moneymaker for people, and so people want physicians, want easier lives and to be able to go in and charge a premium to see patients for you know, like, see a small amount of patients for a huge amount of money is very, you know, it's appealing though too.
Speaker 2:Yeah, sure, but that's you know, that's where people are. I mean, people are making it up as they go. I mean we're all kind of making it up as we go, because they don't teach this in residency and all of it's so new. We're all figuring it out together as we go and I've definitely had clinical experience with different things where I'm like, okay, I could do this and this and this, and then, you know, then I can't follow somebody's levels. Well, and people are all over the place and I decide I don't like it that way, let's do it like this. And it's talking to colleagues and seeing what they're doing. And I mean I wish we had something in town where, like, we could, you know, bounce things off of each other for what's working for them Like a consortium where you can yes, yeah and that just doesn't exist other for what's working for them Like a consortium where you can yes, yeah, and that just doesn't exist and I don't want to.
Speaker 1:You know, I don't know what goes on in any of these like a boutique. I'm sure some of them are great.
Speaker 2:Yeah.
Speaker 1:But it, but it just it does kind of you. I understand people, you know, charging more for the time and the effort, and plenty of people are are obviously happy to pay it. Yeah, um, and so it's not like anybody's being wronged, right, but, but, um, but sometimes you, you just I do think there's a credibility issue, um and it's, and it's hard to say who's kind of more legitimate or not legitimate.
Speaker 2:Right Right Without you know, throwing stones Right Right.
Speaker 1:Um, but you know, throwing stones Right, right, but, but my, my expectation is in the next 10 years, you know, some of this stuff will get sorted out.
Speaker 2:Yeah.
Speaker 1:Yeah, you know, whether it's Gregori views or whatever, yeah.
Speaker 2:And I honestly don't even know. I mean like, for I mean, how long have pellets been out? Pellets have been out forever. There's no FDA. There's no FDA checks and balance system for any of that, not for supplements, you know. So compounding pharmacies like nothing, and and and even though I use reputable compounding pharmacies, I'm still always amazed that nobody is looking into like the products are actually giving to people. And that's okay, like I mean. And I mean, the government says that that's okay, but I just don't understand it.
Speaker 2:Yeah, I just don't get it, you know.
Speaker 1:Yeah.
Speaker 2:I mean one of my, one of my friends came to see me and she's like oh, I, you know, I want to be evaluated for hormones. And I drew her labs and her testosterone was through the roof. And I'm like, are you taking testosterone? She's like no, and she's like, I mean, I'm taking this thing that I got somewhere, and I don't even know where it was. Like she got it on like YouTube or something like that, and it was like DHEA, 100 milligrams, which converts to testosterone, and her testosterone was through the roof. How about that? But she doesn't know that. She doesn't know that her testosterone is going to be super high and she might start to have like side effects from it and they could just get that over the counter.
Speaker 1:There's a lot of supplements, too, that you can buy and, to be honest, like you kind of have no idea, especially for testosterone. You know, guys lifting weights and stuff like that. And you kind of you're hoping, you know. It's like oh, it seems like it's got 10,000 Google reviews and most of them seem good because, like guys were able to bench press more or something.
Speaker 1:And like you, just go with it. It's kind of crazy and it's not like they do clinical trials on these things. They're FDA approved, meaning it's probably not going to kill you.
Speaker 2:Right.
Speaker 1:But it's not like a high standard.
Speaker 2:Right? Well, it's even worse for women, because we steal all of men's products for testosterone.
Speaker 2:We do Because they won't approve anything for women, even though men's products for testosterone we do, because they won't approve anything for women. Even though it's approved in Australia and England, they won't approve in a testosterone product for women. So we take men's and we take a fraction of what it is that men use, which is silly in itself. So, once again, like we, we kind of have to resort to like what are you doing? What are you doing? What are you doing to figure out how to actually to dose it for people, though, too?
Speaker 1:So you know for the audience. You know, everybody knows that men, you know, need testosterone or have testosterone. Why would a woman need testosterone?
Speaker 2:So we so women actually have 10 times more testosterone in their system than they do estrogen and progesterone, but nobody knows that because of how it's actually reported on labs.
Speaker 2:So like for women testosterone or for just in general testosterone, is reported in like nanograms per deciliter, and then for estrogen it's reported in picograms, so it looks on paper like these things are the same, but they're very different as far as like the amount that we have. So women produce testosterone throughout their life and then they, you know, they have their peak, you know, mid, probably like mid 30s. It starts to come down a little bit after that then, and it continues to drop. For us though also, and we feel bad when our testosterone drops also.
Speaker 1:Yeah.
Speaker 2:So our adrenal glands produce it, our ovaries produce it, but as it drops for us, then we start to feel the effects of it also, and the effects of low testosterone is a couple of different things. So, if you have fatigue and low libido is always one that people have and there's a lot of different things that contribute to that, but low libido is a big issue and then brain fog Brain fog is a huge thing, and that could be estrogen or it could be testosterone, though. So a lot of times when patients are telling me about what their symptoms are, we kind of go OK, are you interested in testosterone? These are the different ways that you can do it. Also, this is how much it will cost.
Speaker 2:If you go through compounding, if you use a gel that's prescribed by me, if you do shots, go through all that with them. Here's the side effects. You know. You can grow potentially facial hair or acne. I would say whatever you think of, like an 18 year old boy with a great libido, but acne and a lot and facial hair. That potentially could be your side effect. Um, and and my goal is not to run people super high, like I don't want to run people in the hundreds, but I usually will say somewhere between like 40 and 80 is like the sweet spot.
Speaker 1:Which is pretty low, I mean.
Speaker 2:It is. It's like where you'd be when you're 20 or 30 years old, for reference.
Speaker 1:you know a man is going to have maybe between 200 and 800 roughly, and so that's, you know you're probably very few people would grow facial hair.
Speaker 2:I would think, yeah, yeah, and if people do start, if they complain about a little bit of acne, then sometimes we'll give them spironolactone, which is what we just use in general for acne, for for hormonal acne so we just could give them a little bit of that to counteract it, though, too. But some of my patients do really really well on testosterone, though, too, and sometimes they use it alone, or sometimes they'll use it in combination with things, though, too. I think the moral of the story is there's like a million different ways to do hormones, and just trying to figure out what is right for you is, like is what we're usually shooting for, and we don't always get it right the first time, like we try this, we try this, we try this, and then we, you know, we see what sticks like what. Where do you feel good?
Speaker 1:Okay Now how often do people have to get their blood checked?
Speaker 2:typically, yeah, so I'll do it about every three months, starting out until we figure out what your happy spot is, and then and then and then I'll just usually do it. You know, for testosterone we could only refill every six months, so we should check about every six months. Refill every six months, so we should check about every six months. But there's some people that have been on the same thing forever and like, I don't even check them anymore though.
Speaker 1:Okay, Now with, I know, with like testosterone. Like in general with men, I'm against them using exogenous testosterone until they're older, maybe like 65 or 70. That's just me personally. I'm not an expert in it, because it's really hard if you have to come off of it, guys can have a really tough time and it's cycled. Where you take it every so often Is the hormones that you provide. Are they cycled where you take them so often? Then go on break, or do you go straight through?
Speaker 2:We just go straight through.
Speaker 1:Got you. And then how do people do if they have to come off, them go on break, or or or you go straight through, we just go straight through.
Speaker 2:And then how do people do if they have to come off them? Um, usually, I'm usually not part of that decision. They usually stop and then they come in a couple of months later and go I stopped my hormones. I mean, they really. It's not a conversation people ever ask me is how do I come off of it? They just decide like, well, you know what? I had this side effect, I didn't like how I felt on it, and then they just stop it.
Speaker 1:How do they do?
Speaker 2:Uh, on what testosterone?
Speaker 1:or anything, Either one. Like when they come off, do they have a tough time?
Speaker 2:Um, well, with the hot flashes, yes, yeah for sure For the hot. Probably hot flashes more than anything else, Um, and that's, I mean that's a huge problem for women, Like even I mean three times today I had women that were in their late 60s that came in, and they were like I'm having problems with hot flashes again though too. So we know that, like when you take people off of it, it could, you could, go back to that same state of like. Look, you're newly postmenopausal again though too. So so it can, it can drop.
Speaker 1:Yeah, you know I. I see patients who end up having estrogen positive breastitive breast cancer and so they have to come off the supplementation.
Speaker 2:And it's the hot flashes and the vaginal dryness seem to be like the two big ones and they do not like it.
Speaker 1:I mean, it's tough.
Speaker 2:There is Vioza, though, so I love Vioza. Now for the appropriate candidate for people that can't have estrogen anymore, and what's Vioza? Vioza is now. It's a medicine that's out, that you take orally daily.
Speaker 2:That basically resets how your body interprets heat, so you don't have the hot flashes anymore, I think it works in the hypothalamus, but it's totally non-hormonal, so that's very appealing to people and it works well. The caveat is that you have to have your liver function checked, though, too, so I go three months, six months, to make sure that it's not affecting your liver. So that scares a lot of people off, but my patients that have been on it that have always had normal liver function. It's worked really really well for them, though, too.
Speaker 1:That's great.
Speaker 2:It's definitely something.
Speaker 1:Yeah, the hot flashes are a big deal. And when?
Speaker 2:I see men for prostate cancer.
Speaker 1:If it's advanced, they have to have a testosterone blocker. And when I'm telling them, men, these are going to be the side effects of the testosterone blocker. The two main ones are hot flashes and then they have zero libido.
Speaker 2:Can men use Vioza then too?
Speaker 1:And so I don't know. I mean, it's probably worth trying, but the hot flashes are short-lived because they're usually not on the antidepressant deprivation. I mean sometimes it's six months, sometimes it's two years. Every single time you know, you feel the hot flashes aren't good we can all agree on that. Every single time I tell them they're going to have the hot flashes, their wife laughs at them.
Speaker 2:And I just feel like that's me. Welcome to my world.
Speaker 1:I think you know there's no sympathy. You would think they would have sympathy, but no, it's like they're gleeful.
Speaker 2:That's like when dads have to go get their vasectomies and they're like, oh, woe is me. I'm like, did you just see what your wife went through?
Speaker 1:Cry me a river. Well, Julie, I really appreciate you.
Speaker 2:We've had many mutual patients over the years and so thank you for coming in.
Speaker 1:I think this is going to be a really popular episode and I think a lot of people will be interested in it.
Speaker 2:Yeah, yeah. If you want anything more, if you want to talk about anything in the future, just let me know.
Speaker 1:I'll be happy to.
Speaker 2:I feel very comfortable doing this.
Speaker 1:And how would people get a hold of you? Do you have a number?
Speaker 2:Yeah, my office number is 314-205-6788. And I'm