About This Episode
Welcome to Episode 013 of the PHW Podcast. In this episode, Dr. Kristen Marvin sits down with Joleen Zivnuska, APRN, PHW's women's health expert, for an honest conversation about hormone replacement therapy (HRT) and why every woman deserves to know the truth about this misunderstood treatment.
Important note: This episode was recorded before the FDA's groundbreaking announcement on November 10, 2025, removing the black box warnings from HRT products—validating exactly what Joleen discusses in this conversation about the flawed science that scared women away from treatment for over two decades.
Joleen brings decades of experience in women's health and shares her passion for helping women not just survive menopause and perimenopause, but truly thrive. She unpacks the real story behind the controversial Women's Health Initiative study that scared an entire generation away from HRT, explaining how flawed research created misconceptions that persist today.
This wide-ranging discussion covers the critical differences between bioidentical and synthetic hormones, why estrogen doesn't cause breast cancer (despite what many women have been told), and how HRT can protect your brain, bones, heart, and overall vitality. Joleen also addresses when to start HRT, the various forms available, and why some women experience symptoms as early as their 30s. Plus, they answer real listener questions about progesterone sensitivity, different delivery methods, and navigating conversations with healthcare providers.
If you're experiencing brain fog, sleep issues, joint pain, or other perimenopause symptoms—or if you care about a woman who deserves better healthcare—this episode is a must-listen!
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Episode Transcript
Auto-generated from the episode audio — may contain minor transcription errors.
And I have seen in the past a it was a cover of a journal where they had a lady it was a MRI of two different women brains one on one on hormones one not the lady on hormones her cerebral arteries looked like my pinky finger the one not it looked like a pencil and it's like that was that really was just fire in my belly about dementias you know where we see so many and and when I think of the boomers now we think we have dementia now you know the the boomer that are coming that didn't were denied hormones um or were scared, you know, to them. And and and again, at least every woman deserves that conversation about hormones. She may not she may choose not to do it, but she needs to have a good conversation of what the ramifications are of not doing that. Everybody, welcome to the PHW podcast.
Um this is episode lucky number 13. I'm the host today, Dr. Christrista Marvin, and I have the honor and pleasure of interviewing the infamous women's health expert at PHW, Jolene Znusa. And today we're going to have an exciting conversation about hormone replacement therapy. therapy. Absolutely.
Yes. And I should say should clarify since Jolene is the women's expert, women's health expert, we will not sadly this podcast be talking about men's hormone replacement therapy, but that is definitely a whole another podcast in itself that I'm sure we'll plan. So today we are solely focusing on women's hormone replacement therapy and I think probably our listeners want to hear things like you know more of the history about hormone replacement therapy and um you know there's obviously some controversial research that's happened along the way that's really changed the course and I think arguably a really bad way for a lot of women. So, I think our listeners are probably excited to hear like how we do things differently at PHW. Um, we'll talk about maybe some like misconceptions, different forms of hormones, when to start hormones, when maybe if there's not a time for hormones, um, and all those types of things.
So, if our listeners are not familiar with Jolene, which probably there's nobody out there that's not familiar with Jolene, you can refer back. We had Jolene on episode seven. Um, but Jolene, if you'll just kind of give us a little bit of your background in women's health and then we'll just dive right in. Okay. Well, I started out with in the birth rooms at Wesley and was there at the time when they were uh it was kind of changing over to a tertiary care center. So, we were getting the sickest moms and babies west of Topeka and that was an exciting time to be a part of that.
Um from there I went to working with uh high-risisk obstetrics uh exclusively and then to the um KU's OBGYn and residency program for two years. So working with medical students and residents and ladies um and then went to um the center for reproductive medicine. So reproductive endocrinology working with ladies who are trying to get pregnant. Um so stimulation cycles IVF but also endocrine disorders and then to general OB/GYN um so working with the whole lifespan of women there and then that got me to functional medicine and so uh was very excited because it was kind of in the land of OBGYn you know we got six to eight drugs and then we do surgeries and if the drugs and the surgeries don't work well then it's kind of all in your head and here's your antid-depressant and so it was delightful for me to make that transition to functional medicine and um Dr.
Amy Short and I opened Prairie um gynecology doing first trimester OB and then functional gynecology and then the rest is history as far as with the launch into Prairie Health and Wellness with Dr. Davis. That's great. That's great. Well, it seems like a big part of your practice now is definitely around hormones, right?
Mhm. So, can you maybe talk to our listeners a little bit about, you know, what HRT or hor hormone replacement therapy is, what it looks like, and let's even start kind of at the beginning of like some of the history and maybe some of those unfortunate studies that happened along the way, right? Um probably one of the you know biggest that was uh biggest study that started to try to get a randomized control trial which is the gold standard and that was the women's health initiative study. It was a large study.
It was like 27,000 women that were involved. There was a nutrition side and then the hormone side. And in the hormone side, women were randomized to two different groups of whether it was just primarin by itself, ecoin estrogens. Um, and then the other was primarin and with a synthetic proesterin pa. And there it was not like many of our trials that we've done since then as far as where there's a real strict criteria for who's invol who's entered into the studies.
Many of these women were older. they were 65, 63 I think was the average age. Um, and so beyond menopause, you know, which is for a trial looking at that, that was kind of one of the things that they looked at later that probably was not a good thing. Um, but it definitely was women who were smokers, women who were obese, you know, just everybody was into that study. It also was really interesting. I've been a FDA coordinator of many trials and this one was none like anything I'd ever heard of even um and partly because the there was some real biases um by the coordinators of it of whether hormones were helpful for women or not.
And so what had happened was that they in the prim arm so the estrogen only arm there that went on with no problems. But in 2002, and this was supposed to be like a 15-year study, but it w it was halted in 2002 because they said that there was potentially more uh breast cancers in that permanent and pa group um and heart disease. And I lived through that. I was in the general OBGYn setting at that time. And it was like a tsunami hit our office because you know physicians were and and the the problem of it was why again it was so unique was that the coordinator of the trial when they were realizing that they were going to halt the tri halt that Premier and Primro went and had a uh announced it on the Today show and basically had an interview with Matt Lowour and you don't do those kind of things with a clinical trial and so we were kind of finding out when women were calling and were and the story was that hormones were killing women. That's what they heard.
We were trying to call the prim rep and saying, "What on earth is going on? This is not what we're seeing with hormones." And she was saying, "We can't even find out anything about it." So, it was really um you know, everybody was kind of scratching their heads and how do we help these women? Because a lot of docs were very concerned and just cold turkeyed women off hormones. They were hot flashing. they were, oh my goodness, you know, they were just, please help me.
So, it really was like a tsunami from that. Um, thankfully now, this many years later, um, they have re they have looked over that data and reviewed it to say that basically it's all kind of been walked back to be not true. But because of that, you know, it was we've lost a couple decades of women being able to be offered hormone therapy or feeling comfortable enough to be it because they all they still hear is that hormones, estrogen, you know, kills women and causes breast cancer and all these other things. We've also lost lost a couple decades of physicians learning how to prescribe it. And I had a patient just not too long ago who saw a new um graduate family practice doc who told her, "I'm never going to prescribe hormone therapy." And I thought, "Oh my goodness, she she's a brand new grad." And so it's it's estimated that probably about 6 to 7% of women in the United States are on hormone therapy.
And so we have [snorts] a long way to go. And as I'm working with ladies and trying to help them understand why I think this is important and that we don't want to live the last 15 years of our life with dementia and in assisted living and of why we you know the preventative nature of being on hormone replacement. Um and then I'm asking them all please tell your friends you know please let them know that there's alternatives and they need to be asking for it. Yeah.
So, it sounds like gosh, I mean, I think any woman and any man who cares about a woman listening to that should be it should like me right now. I mean, just stop you in your tracks. But it sounds like so some of the big problems with the study was like the type of person that was selected to be in the study potentially. there were some issues there. And then the type of hormones that were used in the study could potentially be another issue. So maybe let's expand a little bit maybe on that one because I think that's something women and listeners want to hear about like what are the differences because they sometimes our own patients were will hear us talk about those things where they're like well but I I've heard bad things about like progesterone or even some of our specialists that we know and love.
They're like there's no difference. But is there a difference? Oh, there's a huge difference. So, tell us about those differences. Um, so in the Primro arm, so it's Primarin, which was really kind of one of those first estrogens that we ever had.
It's an ecoin estrogen. It's made from pregnant Mar's urine. So, it's not a biological what you would say a normal biologic hormone. It's an ecoin hormone. Um, and then but the real kicker of that because the primaran only arm actually showed that it prevented breast cancers. Okay, you don't hear too much about that, but that actually was part of the WHI.
Um, PEA is a um is a very inflammatory progesterine, a fake progesterone if you will. M and so that there's a kind of the umbrella of whether it's natural progesterones or the fake progesterones, the synthetic ones is progester is that big umbrella and then underneath there is like progesterone biioidentical you know the hot body's own progesterone and then the synthetic progesterone progesterines um and that can be pa it can be northendrone I mean there's there's other varieties now that we have but they're synthetic They're not what I would call biioidentical. They're not what the body makes. They're man-made.
And um back in the day, they felt like, you know, estrogen was a normal hormone. We can't patent it. And so, how can we, you know, make something that we can patent and go? But after the WHI, I mean, a lot of companies just walked away from making estrogens because the I mean, it it just crashed as far as um ladies not wanting to be on it. Yeah.
What are can you elaborate more on what are some of the potential negative impacts of these women? You know, we keep mentioning like you we lost this like almost whole generation or what seems like a whole generation of women that could have benefited. Can you go into like some of those things that like I mean however you want to angle it like what are the benefits or what are the potential negatives? Well, you know, one of the things that I think is a that many times people don't don't appreciate is that um when you look at men, you know, Clint Eastwood, Ed McMahon, I mean, they were fathering children at 75, okay?
So, their little swimmers were doing really pretty good. They were in good shape. But women will our hormones fall off a cliff at 50 51 usually. Um and for so for generations then the women didn't have and and actually it was probably about um 30 years ago we women were dying in their 50s or so you know I mean we just didn't but with antibiotics and sanitation we now kind of have more 30 more years maybe um and so now we want to be able to have you know to live that life well. So we have um it is one of those things that women do live longer than men usually about 3 to four years but many times we are in not in good health.
So as far as we may have a longer health span but as far as or you know have our lifespan sorry but just not necessarily health span. So how what can we do to help prevent some of those things? So what we're seeing is women usually in just a slow decline as far as their physical health. They um many times are looking at osteoporosis, hip fractures. Um 30% of those ladies will die within the year.
Rarely do they ever come back to the same mobility that they had prior. Many of them don't even make it out of the hospital because they throw huge clots. So leading cause of death in men and women is heart disease, but second for women is is hip fractures. And so how can we help with that? We also see a lot of women who may be living 10 years, 12 years, 15 in dementia. Um, and so when you look at some of these natural processes that are happening, okay, how can we help with heart disease?
How can we help with dementia? How can we help as far as keeping a keeping a stronger bone growth and uh bone density? So that's where when they were wanting to see, can we affect a change on this? can we help as far as increasing that health span? And that's what um what sparked the interest of can we add back the hormones that women have lost.
And so it's I mean and we we definitely need more studies, more random control trials. A lot of the studies looking at hormone replacement are observational as far as just seeing does it seem to be making any difference, but there's just so many factors that can go into that. And so what I'm what I tell ladies is that I just really and another reason that was a passion for me um when I first started uh working in in general OBGYn and there was we just didn't have too many options and many times I saw ladies that were um literally their vaginas had like paper cuts because for the vagina to stretch for a comfortable intercourse is an estrogen function and they were not on anything but they were trying and so looking at um back I mean that was kind of the beginning of my passion of we've got to we've got to treat women differently than this. We have to be helping. So looking at now I'm like telling women I want to really help you I want to help women in menopause and permenopause to thrive just not survive and definitely being on hormones to where um where we can um be helping as far as looking at preventing cardiovascular problems.
In fact, they first used primarin with men having a heart attack because it dilates arteries. Interesting. I don't think I knew they actually used it with them before us. Um, but that didn't work out so well in other ways.
Um, so it did it and being able to help and many times we see that the arteries themselves are more pliable and so being able to to address that cardiovascular piece with hormones and then obviously everything else that we're doing at prairie health to addressing heart health um and with the bones then we know that estrogens definitely help. So in in making bone and making bone density, we have the osteoblasts that build up bone and then the osteoclast that tear it down. Estrogen, this is my little mental imagery is that estrogen is like putting on dog leashes, if you will, on the osteoclass. So it really keeps them pretty well under control. But then after 51 you know when we if we don't have replacing that estrogen the osteoclass go wild the leashes come off and then we see this rapid decline of building of the eating up the bones basically um and not we don't have that fast there are still bone builders we see every day with our protocols that we're using that ladies densities are improving um but it's definitely having the estrogen on board and also the progesterone and testosterone can help as well with bone density, but of being a and then the having ladies um lifting weights, the weighted vest, all of that to try to increase that density.
And so that's, you know, in having ladies um just really be more active, you know, in that regard. And so when I go to like Tractor Supply and I'm getting my horse grain and all the men are wanting to help me carry it out, I'm like, "No, I need to lift those 50 lb grain sacks." And it's I try to encourage that kind of thinking into our ladies that we need to be doing those things for ourselves. We need to constantly be keeping our muscles strong which is going to keep also bone strong. Yes. Yes.
So it sounds like hormones have the potential to protect the heart, the cardiovascular system, the brain like you mentioned, bones of course and yeah kind of like you were just saying too, muscles fit into that, right? Like so often it seems like we see permenopausal women start losing muscle mass and sometimes it's really is a combination of just that loss of those hormones that help us grow and maintain muscle mass that we don't have anymore. And so when we're trying to be more active and trying to exercise and do those things, it's almost like we just don't get as much bang for our buck, right? So what other I feel like we're missing some areas. What else? I mean, hormones affect Yeah. immune system.
I mean we have estrogen receptors all over the body. Everywhere. Absolutely everywhere. And when you look at u many women that are in like an assisted living situation, then many times one of the number one killers for them is a septic UTI.
So all of those ladies should be uh and the the um the urethra actually has androgen receptors as well. So at least getting like an estradile vaginal cream, but it also and that is commercially FDA approved, but the compounders make one with testosterone as well. And so that's really is very helpful for just preventing one of those biggest killers of of ladies in that, you know, far as that time frame. Yes. Well, like you said, with the estrogen affecting the quality of the vaginal tissue, it's a huge contributor to developing a urinary tract infection, right?
And so, yeah, just learning from you in the clinic and hearing you say, you know, all women should, you know, especially at that stage in life, should be on some type of estrogen cream just for that simple type of preventative. It's something that really is pretty common, actually. Yeah. So, it is.
In fact, I was just talking to a lady this week and and um just saying that that that was one of the things that cuz I'm having women just because women don't know. So, with every patient, I'm kind of like, please help spread the word. And her own mother was in the hospital with a septic UTI and she had no clue. No, didn't hear anybody talk about it. And so it is of, you know, if anybody has somebody that's in a care home and you're probably going to have to put it on yourself because many times staff may not be willing to do that, but it's it honestly is one of the best things that we can do for them.
Yeah. Right. Right. Yeah. Um, okay.
I'm going to dip a little bit into a potential misconception because you know I think we sometimes get this question in the clinic or I'm sure ladies listening probably have either question this themselves or they've like you mentioned you know unfortunately some medical providers just aren't getting the information or the training um when we kind of sit here and say all women at that stage should consider it. What about potentially women that maybe either have a strong family history of something like a breast cancer or some other estrogen, you know, receptor positive type of cancer for the vaginal estrogen creams? Like what's our what's your response to that? Yeah, no problem whatsoever. So, one of the the travesties that happened with the women's health initiative study was that all the estrogens got a blackbox warning on them and even of using estradile face cream, it has a sticker, this is a hazardous drug. So, just recently um and this was really thankful for the menopause society, there was a hearing with the FDA trying to remove the blackbox warning on vaginal estrogens.
And it's like, you know, that's the weakest thing. I mean, it doesn't go systemic. It stays localized. Um, but it makes me hopeful that at least we're starting the conversation to remove the blacksbox warning, which we've walked back that study, which caused that.
So, you know, we need because I think that even that itself is scary to a lot of women, but having just a family history of breast cancer, you know, many times, um, you know, we're not clones of them. So, we have different medical histories. We may um we know that you know just even of how we manage stress and things like that can can radically um make a difference and and it's it's very important to because what women still and sometimes they are still being told is that estrogen causes breast cancer. It does not. So what we refer to the pillars.
So how we eat, the type of foods that we eat, how we sleep, how we manage stress, um are we having you know bowel movements routinely, are we moving, you know, all of those things is where cancer comes from. And I would also put in there trauma because I see so much of that many times when trauma has not been dealt with. That's we we may be feeling it in our anxiety, the body remembers it. So being able to realize that that's where cancer comes from.
Glucose is the biggest feeder of cancer. Second by insulin. If it is an estrogen sensitive tissue like breast, then it could be fed by estrogen or progesterone but they didn't cause it. And I think that we jump to that because we have drugs to block them. But rarely do I hear anybody talking to their oncologist about their glucose or where their insulin is, which is the bigger feeders of it.
And so that's in in fact in some places when you um get your chemotherapy, they hand out candy bars. So it it is of of one of those things of trying to realize what the truth is on that because I think that that's doing women a disservice as well. And it's um you know if there's things in medicine that if I don't know how to do it, you don't need it. Um unfortunately and so just so being able to try to make that very clear. Um if women are concerned about do I have a a a genetic risk factor, they can certainly do genetic testing to see if that may be an issue.
But even for those ladies, what I'm trying to tell them again is what causes cancer. It's the pillars that we talk about, you know, that's where cancer is at. It's not your genetics. Yeah. So to I think that's an important distinction. Um helping women understand and I think it probably really was the WHI that kind of started adding fuel to that fire that put the fear into not just women but healthc care providers like you said that you know that are still to this day telling women that that estrogen patch you're on is going to give you breast cancer.
That's right. So, I yeah, I I I love how you explained that and that's definitely how I try to help my patients learn about it, too. And there's there's great resources out there like we can definitely link them in our show notes. Um, I'm thinking in my head of these great podcasts of medical professionals discussing like a little bit more on a deeper level of like the WHI and there's books that have really good books that have been written to back up exactly what you're saying.
So, I think it's a really important distinction. What about, you know, I think the other one that sometimes gets thrown around pretty commonly are blood clots. Like, doesn't estrogen cause blood clots? So, can you maybe elaborate on that a little bit more, too? Well, one of the things that I think is it this is just kind of a backdrop with um no matter whether you know it's a cancer, it's a it's a heart issue, it's a whatever that usually the first thing that's that's going to come off is like an estradile patch.
You know, the doctor's first response usually is that we have to start hormones when actually estrogen is one of the most anti-inflammatory lifegiving hormones out there. But it's the training that would they they're still back in that WHI mentality that estrogen is is the bad guy of all of that. And so being able to um out of that came more studies of when they um we I am a big believer in hormones being transermal not being oral. And when the estradile patches came out which was like gosh like 30 years ago.
U one of the they they had many studies that they were looking at but one of them was showing that it does not increase the incidences of blood clots. So when you take things orally, when you take estrogens orally, goes through the liver, that's where you may have more of an incidence of that happening. Well, that's what's so interesting to me when I hear again even healthc care providers say statements like that where they're like, well, I'm not going to prescribe you an estrogen patch, which again, at least to this date, my awareness on that is there's no research that has been published to confirm that the transermal routes will cause a blood clot. But those same doctors will turn around, no problem, and prescribe a birth control pill. Orally, Orally, yeah, that absolutely has pretty conclusive evidence that could potentially in certain circumstances, of course, increase your risk for a blood clot.
Right. So, it's very, it just shows you what happens when something like the WHI, you know, the way that played out, right? And you know in and again of when you get into synthetic hormones and that's why it's kind of a big deal to me that I just give the real deal hormones. When I was in working with reproductive um interocinology, if we were going to give ladies some of the synthetic progesterines to make them bleed off from an anovulatory cycle, we did a pregnancy test first. Mhm.
So, I mean that that kind of gets your attention. If if this is such a an inflammatory, potentially dangerous that you want to make sure a baby never sees it, well, then what the heck are we doing, you know? I mean, it's kind of So, that's where I just stick with the the biioidentical hormones, the one that mother nature gave us. Um, and try to stay away from synthetics. There are some u there are synthetic blends out there. um that are available. But when we can when we have, you know, the real deal ones, yeah, that's it's my it's my understanding that the bio identical hormones that we're talking about that we like to use in the clinic, they still technically are made in a laboratory, but they but they start from things found in nature.
So they really are plant derived but then scientists take those substances into a lab manipulate it into a more specific controlled dose of these hormones that you're talking about. Right. So I can go to the lab and I can measure estradile. I can measure progesterone.
I can't measure northendrone. I can't measure conjugated ecoin estrogens. And so that to me is the is where the just the differences that they have in the body, right? Um, again, from being very lifegiving. Yeah.
Um, to where if we're if we're concerned about a progesterine that we need to have a pregnancy test, how do I think that that's the same as a progesterone that I give to keep a baby in the uterus? I give first trimester progesterone to help prevent miscarriages. But yet, if I needed to get a pregnancy test before I gave PA, how do we think that that's the same drug? It's a great point.
And I have had that argument with very wise physicians in the past. [gasps and laughter] Oh my gosh, I have so many thoughts that I'm just going to keep in my own head. [gasps] Oh my goodness. Okay. Well, let's let's maybe what might feel like a little bit of a rewind here and um I think our listeners would be really interested to know and maybe you know, of course, I'm sure some of them have even got to experience it working with you, but what can you kind of take us through what it might look like if a woman comes in and you're like, hey, you know, whether they're permenopausal or post-menopausal and hormones could really benefit them. Like what does that personalized individualized like approach look like for you? Okay.
So, one of the um you know, everybody that does hormone replacement kind of does it their own way. And so, some people feel that you should not give anything until ladies have not had a period for a year. I think that that is just cruel and unusual. I mean, that that is that is pretty horrific. And so, I don't want ladies to feel hot flashes.
I don't want them to go through that. So, as they are permenopausal, when they're getting into those older eggs that are more dysfunctional and you know, they they're used to having hormones every month since they were 13 probably. And now, you know, they may have hormones this month, they may not. And it it's just this up and down. And permenopause is definitely just that month-to-month variability of hormones. You just don't know what's going to happen.
And so as the as I am hearing deficits like of progesterone, so now they're they don't have enough progesterone for that ludal phase to take them out to 28 days. So they may be having 21 22 day cycles. Um or she's saying, "Oh my gosh, especially the week before uh my period. I I just want to rip everybody's head off and I'm not sleeping and this is just not me, you know, and that and so it's it's those symptoms of where you start hearing they're they're not making enough progesterone at this point." And that giving them progesterone, you would to think you just hung the moon.
I mean, they're sleeping again. They've got they're they're not um you know, the irritability is gone and they're starting to lengthen out the cycle. And you know, of course, I love Fin Balance, which helps us so much with that as well, but it is being able to. So, I add hormones back as they need it. Um, I don't wait until, you know, that longer um period of time, but and then testosterone uh leaves us unfortunately usually in our 30s.
Um, so our levels, we still have some, but it's it's pretty low. And so that's one of the trials that I was a FDA coordinator of was a um testosterone patch study. And that was just so amazing to me because these ladies were 53 years old coming in and telling me this is the best libido I've ever had in my life. Nobody ever told me that with what I was giving.
And so it was really a eye opener. And that's the fun thing about clinical trials. You get to work with stuff that's not on the market yet. Um, and so, but it was um, yeah, it was one of those things of where I knew I needed to up my game on that. I needed to start increasing levels.
But what we saw from just testosterone itself in that study was by far women have more energy. They could think faster. They felt like they were more optimistic, that they had more self-confidence, 20 25% improvement in libido, which usually means faster, stronger orgasms. So, neither one of us has to break out in a sweat to get there. And when it's more fun, then we want to do it more.
And that's part of what I'm talking about thriving in per menopause and menopause. That we don't have to kiss that goodbye as it has been maybe for our mothers or grandmothers in the past that we can still have that be a very vibrant part of our lives. Um so adding testosterone when ladies know that they are um finished with childbearing then that can be added in at any time in there. Um, and then estrogen for me is usually the last you it every lady is unique and you know I've had women who are menopausal at 28 now is an autoimmune process but definitely when women have been gaslit so much of coming in with symptoms and oh you're too young you can't be menopausal you know this type of thing so I listen to what ladies are telling me and then um and I can usually verify that with some labs but in pmenopause lab is tricky because of the monthto-month variability in hormones. So, you may think that she's menopausal with an elevated FSH this month, but next month she may have a really nice ovulation. She's just squeaked out one of those last really nice eggs.
And so, that's where the lab part of that can be a little bit more tricky for pmenopause. Yeah, that's right. So, yeah. So, we do use a combination of different labs.
And like you just said, you know, I think that's one of the more common conversations I have with patients when cuz cuz everybody likes to see data, right? I mean, it's good to see some objective evidence every now and then. Um, but yeah, the variability it's like you got to be really specific and intentional about when you test and then just know that like this month it could look bad and next month it could look great, right? And in, you know, and even in managing hormones, I mean, there are those who never draw blood. They just they go off of how women feel and I had a lady that felt amazing on her testosterone replacement and until and so I do both.
It's 50/50. I I look at what are women telling me how they feel and what are their labs saying. And this lady had a testosterone that was in the man's range. And so just of trying to figure out what was going on, her husband was giving her injections and he ended up giving her his dose.
And so but she felt great. Yeah. And I was I always said, "I'm so sorry to tell you that. We're going to have to make some changes." And that so that's kind of scares me from going off of just how are they feeling. I like to have some documentation there too of where they're at.
Yeah. Yeah, that makes sense. And I think that's where probably you and I would both agree that we look forward to hopefully the upcoming research that, you know, I think we're hearing that is going to be done and really should have been done a long time ago, right? So, okay. So, I think, you know, that's really helpful to hear.
And one thing I, you know, thought of to ask you as you were talking about, I think you mentioned, you know, with testosterone that those levels can start declining when a woman's in her 30s, are we seeing women maybe starting pmenopause what feels like earlier? Like I mean, doubt. Yeah. What are your thoughts on that? Well, it is it is come. I mean, I think that that many times is just maybe genetically where we were.
I mean, we were dying, you know, we were dying in our 50s before having babies, you know, when we were 14. And so, it's um but those are kind of some of the genetics that I think that we've we've inherited. But it is also of it's such a vital hormone that that's where um again when you when you've worked with it and you and you see what it can can happen, it's it's just sad that it's not being offered. But with the stressors that we have, I mean, our genetics was meant to be 80% of the time in rest and digest and that's not our lifestyles these days, you know, and so our genetics um we're the ones that survive the famines and so they're very good at hanging on to every calorie that we have.
But it's also of what we what we ask of ourselves, the stress levels that we have um is I think also just in in hormones, the sex hormones are what I call the non-essentials in the female body. They totally can be shut down. Like a lady who is an athlete that overtrains or a lady that's in an abusive relationship, they won't even have cycles. And many times I hear in the office, I haven't had a cycle for six years. So I know there's I don't know whether the stress was trauma.
I don't know whether I there's obviously a lot of stress there. And so it's just realizing that and that's why I work so much with cortisol, the strongest hormone in the body because it can totally shut down the the sex hormones. Right. Yeah.
Yeah. I feel like I'm definitely seeing more and more women that are, you know, typically it's like mid30s where they're starting to show some of those signs. And Yeah. Yeah, like you just mentioned, I mean, it seems like because we just continue to ask more and more of our bodies and ourselves, you know, that that cortisol piece will definitely drive where some of those sex hormones are going. So, um, can we can you expand a little bit more on the different forms?
Like when I heard you say the one trial using the testosterone patch, I was like, "Oh, that's cool." Because I don't think we have a testosterone patch. It got denied by the FDA. Of course it did. Right. So, um, yeah.
Can you can you explain to our listeners like maybe we can just you know start with estrogen move into progesterone talk about maybe then testosterone if there's any others you want to touch on but I think it'd be interesting because sometimes I'll talk to women and be like oh well we could try this form instead and they're like I didn't even know that was an option. So can you talk about as far as different hormone replacement types, different hormone replacement types, the different forms that are available and then you can maybe also share the differences of like what's commercially available and what we sometimes choose to go through compounding. Right. Right. Um, so with the and and the the FDA approved ones are um usually paid for by insurance and so I will many times go there if we can. Um, and they and like the patches are one of my favorites um because they they do, you know, but there's ladies out there that have adhesive allergies sensitivities and so it's unfortunately it's not for everybody.
Um and so if there and progesterone is definitely um commercially available and so generic and so that's cheap. The patches are generic now so that's cheaper. Um and the testosterone we've kind of gone through there there was even like an 8-year study for female testosterone. No issues.
And basically the FDA said but women have breast. And it's like well they had breast during that eight years. I mean, did did anything happen then, you know, and so it's they just kind of keep kicking the can down there. So, that I was going to ask like if you knew what the reason was for why they denied, you know, bringing it to the market. Yeah.
So, um that was that was what I was told was that the the response was for that 8-year study. Um and again looking at potential side effects all of the measuring for those you know um we were in the patch study we were looking at bone density we were doing cardiovascular labs we were we were trying to do everything that we could think of is there collateral damage here and we were not seeing it you know and that was and um so that was really frustrating to be able to to have to call the ladies that were in Witchaw that were in that trial um that it wasn't available but that was when I was just realized that, okay, I'm I I've seen this. There's no going back. So, that's when I went to the compounders.
That's when I went to Customs RX and was like, okay, we've I've seen too much. We've got to be doing stuff here. So, they had testosterone in a compounded form as far as like with bugal troies, that sort of thing. But it was then after that that they started with the injections um just to have it as a as another mechanism. Um, so when I look at if I can do things from that are FDA approved that are working well for women, they're absorbing them well, I'll I'll stay there.
But where I appreciate the compounders, and maybe I'm spoiled because I we've got really good ones in town to work with. Um, and so that is the where they can compound things that are not commercially available. And so we could have the testosterone for women be you know and it's still not approved. Um but that came up at that FDA um yes u hearing the other day that saying you've got to approve this for women. So I don't know maybe there's hope but you know we're using it off off label and and I'm very thankful that we're we can we can do that.
Um so it is of and we're now using um the compounded testosterone or we can also use like the injections that have been improved for men with a much smaller dose that's going to commercialies. So again ladies have options of um you know whether they want to put hormones in the vagina whether they want to use creams gels patches injections weekly injections. I mean that's thankfully we have options now and so for some women they they're just their first question is what's the cheapest um for others they they really want to know about different varieties available and what they feel comfortable with and so each lady then will end up with her own specific hormone replacement and um some will you know we start out usually kind of with um depending upon what the issues are but of when we've added things, you know, so many times when they're coming out of pmenopause, they're already on all three hormones. And so then it's just of whether they want to try any changes in the in the future, it we definitely will make changes in their doses. Um because as as they advance on out to not having many of their hormones with uh and pmenopause can be kind of tricky because you every now and then may get an ovulation, you know. So, I kind of give baseline doses and then we kind of go from there as they progress on into menopause and are not making those hormones then.
I love that and I love how you teach women um those signs and symptoms of like what to look for so they have that awareness and you know I think that's just a really helpful part of when like you individualize the treatment to that person. It's really helpful. Um okay, so let's summarize a little bit. Um, is there are there any like are there any things that maybe we haven't mentioned that you can think of when a woman's like questioning like is this related to hormones or lack of hormones?
Like as far as just symptoms go, is there anything sometimes that sticks out where sometimes women just don't immediately think of like, you know, hot flashes? Obviously, it's like the first thing a woman thinks of is a hormone issue, but are there other symptoms that you're like, "No, this really can be related to hormones that women's don't think women don't think about." It's huge. It's absolutely huge. So, um I had just um a adorable lady that came in for a wellwoman exam, uh university professor, and she told me that she says, "Um, my mother and my sister are my ads. I can't remember anything.
I have developed ADHD. So I said, "You know what? We're uh we're going to reschedule your will exam. We're going to talk about hormones today." And so that brain fog um feeling like you have ADHD, you know, that it's like what are the changes?
This is not me. And and again, we have estrogen receptors everywhere. And so definitely when those estrogen receptors in the brain are not being fed, then we're going to see the difference of that. And you know, one of the things too that when when you look at the the value of hormone replacement and especially with dementia, um I I look at the work of Dale, Dr. Dale Bredesen, who is rehabbing people out of dementia.
And the first thing that he does, he didn't care what age they are. The first thing that he does is he puts them back on hormones to dilate those cerebral arteries. And I have seen in the past a it was a cover of a journal where they had a lady it was a MRI of two different women brains one on one on hormones one not the lady on hormones her cerebral arteries look like my pinky finger the one not it looked like a pencil and it's like that was that really was just fire in my belly about dementias you know where we see so many and and when I think of the boomers now we think we have dementia now you know the the boomers that are coming that didn't were denied hormones um or were [snorts] scared, you know, to them and and and again, at least every woman deserves that conversation about hormones. She may not she may choose not to do it, but she needs to have a good conversation of what the ramifications are of not doing that. So, being able to to look at how our brains, our brain function, and I just had a um a conversation with a an elderly lady who has been on hormones and I don't know whe I'm not sure why, but chose to go off and and the conversation was from family members that her brain has gone to mush.
And so, it is of it's very noticeable to people around us when they see those changes happening, right? And for this young lady still in her 40s was just like what's up you know um joint pain um tonitis um we can um you know that you there's almost every function that any part of the body right that's right right and shoulder I'm so glad you said the ADHD thing because this is something I have seen over the last like 12 to 18 months that is driving me crazy in the clinic where I'm getting these 30 to 40 year old, you know, something women that come in and they're like, "Well, I saw my so and so, you know, whatever therapist, family doc, whatever." And nothing against them. I'm just saying like it's usually coming from one of those like a medical related person, right? Who took, you know, just said, "Well, your symptoms sound like you have ADHD." And so, I feel like there's been this whole push where these women then are kind of told and led to believe that, oh, you've just you just weren't diagnosed. you've probably had this your whole because ADHD kind of tends to be more of like a a condition of sorts that's like that diagnosis is given in childhood, right? And so, um, and then, you know, some of these women will say, "Well, so I went ahead and tried the medication they gave me, which was almost always a stimulant, and what do you think happened to these women? They felt terrible.
They because you I'm like, you're already stimulated. You're overstimulated." And so you're telling us that probably these 30 to 40year-old something women it's probably their hormones. It's not I think it's lack of estrogen they're starting to and they and it may be that you know cuz some of them too why they're confused is that for the last two months they had symptoms and then they get in to see me and they're like I don't know why I'm here. I'm Ry as rain and I'm like well I think I know why you're here.
And so it's it's that's that month-to-month variability again. And so they they're secondguing. They think they have a problem, but then they're not sure they have a problem. And and it it just adds to that confusion. Um but I think that when you have the ears to hear those symptoms, then you know that's where we can tell them that, you know, this is Yeah.
So it's it's amazing. And that's I I love that. That's one of the first things that I mean Indel Bredesen has been rehabbing people out of dementia for decades now. We still haven't heard about it on the nightly news but and that that is the very first thing that he does is put him back on hormones.
Amazing. Amazing. Okay, we're going to pivot a little bit and do something that I don't think we've ever done on our podcast before, but I love this idea. Um, and I think it also like brings our listeners in a little bit more. So before we sat down to record, we put out on our social media um to ask our listeners and our patients like, "Hey, we're going to talk about this topic.
What questions do you have?" So, I'm going to flip my little list here and go through some of these questions because I think a lot of them are really good questions and some of it, you know, we've kind of touched on a little bit, but maybe it'll allow us to go a little deeper. Um, so one person asked when is the best time to start hormone replacement therapy? This is a really good question. Yeah, I think it's whenever women start getting symptomatic. So there again, women are gas lit so much um because physicians well providers um don't feel that you know you're too young.
You know, it can't be possible that that's what it is. And when one of the things that I I have seen repeatedly is if women have a hyerectomy that the blood supply to the ovaries when they're being left behind um is affected. And so many times those women will go through pmenopause earlier than we would suspect it. But yet that's not something that is routinely I think thought of. And so again just listening to women they will tell us what's going on. We just uh kind of have to have the ears to hear it.
So there's not a range to me. Um, you know, like I said, I've seen it in the 20s and it's just and and I see it in, you know, the teenagers that are coming in and saying, "I haven't had a period for 3 years." So definitely something has suppressed her sex hormones, so what's going on? You know, so um just [clears throat] trying to, you know, try to help that body autocorrect again, you know. Well, I love how you've been saying in the office lately.
You're like, "My goal is that no woman ever has a hot flash." That's right. [gasps] You know, but I think you make a really good point of listening to women, the symptoms they're experiencing, and at least considering that hormones, you know, are at play, especially if we're having a hard time, you know, finding other potential causes because it can be hard sometimes, right? Where it's like there's certainly other conditions where those symptoms could mimic or overlap or something like that. So, okay. Okay. So, it sounds like the answer is technically anytime, just depending on what else is going on, what are their needs, those types of things.
So, um this kind of plays off that a little bit, you know, because it brings in a very specific age, but this person must be 68 years old cuz she asked, "What is a 68-year-old to do about an imbalance of hormones?" Yeah. So well and I and there again um I think of of you know basically all hormones as far as um cortisol is a big part part of that is too because I am a you know I tell ladies all the time that I think women take care of the world and everything else in it. Even Desmond Tutu agrees with me. He has said that if you want to invest in a country invest in its women.
Yeah. But the downside of that is um you know a lot of maybe late nights you know up with sick children or making birthday special but we have three times the amount of autoimmunity as well. So what to me it's also where are her adrenals because I really do look at cortisol that strongest hormone most inflammatory. It can totally shut down the sex hormones. I mean it it is the strongest.
Where is she at with that? because many times they may think it's their hormones but it's actually more of an adrenal issue. Mhm. Um, if she is, you know, I I would talk to her about, you know, again, symptoms. Where do I think that that may go and obviously we always need to be concerned about other things as far as hypothyroidism and everything else cuz all of those things can affect sex hormones. But if um so a lot of where I go is how she's what she's telling me is going on.
Definitely. Um many women want to, you know, see where their testosterone is. They want to see where hormones are. We'll get a a thyroid panel. We'll get a feritin. Is she, you know, anemic?
I mean, looking at just the the general labs that we get um with our our member labs, that gives me a pretty good idea of kind of an overview of of um from a lab evaluation anyway, where they're at. And so, and then from there, we kind of discuss what the possibilities are. So, it is of being able to get that background information from her of how she's feeling. Um, how is she sleeping?
I mean, is she exercising? What is her diet like? Um, what is is does she have anxiety all day long? You know, I mean, that's again, the body was never meant to be in that state. And so, what are all those other factors that that go into that?
So, hormones may be a part of that, but it's definitely not the only thing I look at. Well, that I have to give credit to one of my former patients for a quote that I feel like is hilarious, but also very fitting with what you're saying here. Um, I think if I'm remembering correctly, we had sent her to pelvic floor physical therapy. And she came back and she told me, she said, "Well, apparently I just hold the weight of the world in my vagina." So, when you say, you know, that women just like, you know, do all these amazing things.
And I told her, I said, "We definitely need to put that on a t-shirt because we could sell out on that one." That's right. That's right. It's so true. So true. It's so funny.
And yes, so true, too. So, okay. So, also in that point, like really good reminders like you're saying that sometimes it's, you know, the hormone imbalances can be coming from some of these other areas and that's why it's so important to take a whole person approach, right? Yeah. So, okay, good question so far.
Let's see. Oh, this one I definitely wanted to cover because I think it's something that definitely happens. It may not be the most common thing in the world, but we definitely see it. And that's why do some people not tolerate progesterone? Well, so and what do we do if you don't? Yeah.
So, [snorts] yeah. So, um you know, it's interesting with progesterone probably um you know, a majority of women, I would say, do I mean they they would take a bath in it if they could. They love it. It it helps to Um, it's mother nature's chill pill.
They um, some those are the women who would tell me, you know, if I w I would be pregnant if I didn't have another child to to raise because I loved how I felt when I was pregnant. Those are women who really love progesterone. Then there's women who are on progesterone because they have a uterus and I've told them they need to be on it and they're like, "Okay, well, I'll do it because you said so, but you know, I mean, they don't really notice a big difference." And then there are those, oh, bless their souls. um they they are puking usually throughout their whole pregnancies. Um progesterone is just not their friend. And if you have a uterus and we're going to give estrogen then that's where the concern comes in because we don't want that indometrial lining to grow into indometrial cancer and so of block and that's where you know just in a normal menstrual cycle we have estrogen that you know that first two weeks and then after ovulation that cor you know the follicle converts to corpusium makes progesterone the last two to um get ready for that embryo to come down and so I mean it's we're we're used to having that but those ladies do many times will have menstrual difficulties.
They they dread the last two weeks of their cycles. And so there when you when you know what to to listen for, you know, we can we can we know where they are. Bless our hearts. So there are some um some synthetic hormones that there is like the um the ecoin uh conjugated estrogens with a selective estrogen receptor modulator that um can is basically trying to halt that indometrium from u getting thicker.
But it can be a downside effect of those that sometimes we you you do need to watch Ranos because sometimes it will that indometrium will still proliferate. Mhm. Um, and it's I'm I'm kind of looking at with several ladies now of, you know, can we give them, you know, the estrogen for several months, almost like what we would do with cycling back in my day when I was using birth control pills a lot and and we for some we would just cycle like once every three months, you know. So it is something like that there or or using lower forms that don't and then the beauty too that I have is we have an ultrasound in the office. So I can others I we're working on things like that but I'm watching their indometrium as well and so because it's kind of an experiment of what can we do for them you know how can we help them um and some have chosen to have a total hyctomy so they can just do estrogen only.
That sounds pretty drastic to most women, you know, but it it has been a good fix um for some of those ladies that that went that way because then they they got the higher amount of estrogens that they wanted um and felt good without it. So it makes it a a little bit more tricky. Um obviously but the those ladies are out there and oh you talk about a group that has been gas lit. That's them because a lot of the the ducks that work with hormones they're used to hearing how wonderful progesterone is and that's true for those ladies but not for everyone. Right.
Right. And sometimes I think too um like you mentioned earlier, we're so lucky to have compoundingies and just other forms or different routes of delivery that I think sometimes can help women if you know they're maybe actually it's not the progesterone they're sensitive to, but it's something that's in the capsule for example, like the commercial um variety that's available that's inexpensive. You can get it at your localarmacies typically. Um it's in peanut oil. And while some people do fine with peanut oil, some people are either allergic to peanuts, you know, straight up, where they can't use it or they're just sensitive to it. And I think I've seen too historically that some of the different brands will sometimes have like a red food coloring, you know, it's an artificial dye.
Well, that could cause some reactions with the immune system, too. That could make women feel like, well, what the heck? Why am I reacting to this progesterone? And then I've even kind of explored like you know the compoundingarmacies are typically where we have to go for this but you know they can make different types of capsules that maybe one's more of an immediate release one's more of a delayed release and all different doses right because I think kind of the standard commercial strengths that are available are like 100 and 200 milligrams right well we can go anywhere from 25 to what you know really whatever technically that they can fit in a capsule Um, and then this kind of leads into um another question um a listener had.
They just said, "What are your thoughts on progesterone cream?" So, obviously like topicals and creams could potentially, but do you want to expand on progesterone creams? Like maybe some of the pros and cons potentially, right? It it actually kind of uh surprises me that it's it's over the counter. It technically is, you know, at a certain dose. Yeah, you're right.
Um but you know because I mean it it is a it is a hormone. Um but it so for some ladies again the the creams may be just absolutely the best place where they're at. I I think of creams usually with a lower dose but it is a more of what's in the tissues than what's systemically that we can measure in blood work. Um but for and we have many ladies who are very sensitive I think basically because they've kind of been gas lit elsewhere um but we understand their genetics and why they are very sensitive.
Um and so of being able to use those smaller doses with the creams um there's you know some of the commercially available things are just they're they're just not I can't get the dose low enough. Yeah. And so um for them that that can be very very helpful. And so it is of and that can be the beginning for some of the ladies that may have very early permenopausal symptoms that we're just starting to give them some of the ludal progesterone uh creams and that's enough to alleviate their symptoms. It won't be forever but for where they are now.
And again, that's where we're treating each one uniquely of what they need at that time. And then it changes as their hormones change. Right. Right. Yeah.
I think some of the times where you know where maybe it's more of a discussion on where it might not be enough would probably be things like pregnancy potentially or if a woman is on estrogen therapy as well. Kind of like what you're saying. Is it enough to balance out where you're not getting an abnormal growth of like that indometrial tissue? Right. So, yeah, but overall, I think it's definitely a form that's worth considering depending on where people are at and what their tolerance levels look like. For sure.
Um, one final question. We've kind of answered a little bit, but I wanted to ask it just so if there was anything else we wanted to say about it and to really just confirm what we've kind of already said about it because I think it's a really good question. But somebody asked, they were curious about the pros and cons of starting a low dose of estrogen when you're still cycling. So, kind of like what you were saying, you know, these women can have a month where they do they do get a nice level of estrogen and other hormones.
This person also mentioned they're already doing progesterone during the ludal phase and they're on a testosterone troy. So just you know reassurance or additional thoughts on or even things to potentially watch for if a woman was going to consider something like this. I think the main thing that when when they're when they're still cycling and adding it back as they need it is then to because these ladies are tracking their cycles so that they can kind of tell me what's happening. And my my thought is that I just want to give him a basement foundation, right, of a like a lowle estrogen that the testosterone I can take that, you know, as high as we need it to be. Um, but then at least they have a little bit of a safety net that they're not going to drop down to nothing, you know, because to to have like two ovulations and things are good and then now she doesn't ovulate for the next two months and then she'll ovulate again.
So if if she didn't have a safety net there, then they they just feel like they dropped off the end of the earth for those two months. And that's when they're questioning what's going on with me, you know, do I have ADHD? I mean, what's going you know, and that's where I'm trying to avoid that by giving that low dose. Um, and so, and then many times I'm kind of showing them what to do if you feel like you did have a nice ovulation.
If you get some breast tenderness, or if you're starting to feel like you maybe have higher a higher estrogen level, maybe they're seeing the spin bark at cervical mucus again, then then maybe they're not taking the extra estrogen for two weeks. So, and because you know they ladies are I I'm just want to encourage them just to get to know their body so well and they do you know and that's what's exciting is that they can tell me exactly what's going on and so of being able to just have it to where they don't feel like you know where they just fell off the cliff that's where I see the biggest benefit to that and I think that's going to serve their brains their hearts their bones you know I mean like I said we have estrogen and androgen receptors are almost everywhere too but definitely estrogen almost everywhere in the body. Right. Right. Um well gosh, I know you and I could sit here for hours on end and just keep going on this awesome topic because there's really, you know, I think you've shared so many wonderful things and there's so many more wonderful things I know you could say, but is there anything else that you can think of that you want to share with women or people who love women that are listening?
I think they, you know, especially if family members start to see some of the struggles of uh of the forget and fullness, you know, of that or if there's definitely like a a fall a strong family history maybe of dementias. Um because I think that that's kind of the the really scary one for a lot of people is that I don't want to be alive if I don't know my family. You know, I don't I don't want to be using our money for 15 years not knowing anybody. Um, and so, uh, being able to realize that, you know, if we start to replace estrogens and and it's another reason of why I measure hormones is that I want them to be in a preventive range. I want them to be high enough that we are um, now maybe not as high as Dale Bredesen has them to to rehab out of it.
Um, but, you know, to to have that range there. And so to realize these big problems that we really can prevent if we just get after them, you know, for early and that's where, you know, I I appreciate the approach that we have at Prairie Health because it's just one big prevention shop. We are always looking at how do we prevent these big programs later on versus getting to this the point where it's it's almost too late, you know? Um, and so being able to have that be available, that's great. So, very well said. Very well said.
Well, Jolene, thank you so much. You are just such a wealth of information and knowledge. And, you know, when I think about the definition of a person who is an absolute advocate for women, your picture is right next to that definition. So, we love you.
Our listeners love you. Our patients love you. So, thank you for being here with us and sharing all this wonderful information. You're welcome. My brother.
Good. Thank you. Thank you. And thank you so much for listening and tuning in to the PHW podcast.
Um, don't miss the next ones.