Latest / Rebellious Aging Podcast / Rebellious Aging: Hormones
Transcript
- Bob Peterson: Hi, welcome back to Rebellious Aging Podcast. I'm Dr. Robert Peterson, and this is my co-host, Mina. Hi. Mina's here to keep us grounded and make sure that everything is understandable. Yes. Today we're going to be talking about hormones, and in particular we're going to be talking about the sex hormones, which is testosterone, progesterone, estrogen, and malarian hormone. We're not going to be talking about all hormones because that's too big a topic for one podcast. so this is where some people get I would say conflicting evidence about, you know, if what hormones are good and what are bad and if they should be taking hormones and some people are afraid of them and then some people think that hormones can cure every ailment they have. So can you kind of tell us what what of this is true? Yeah, this is a very complex topic and people do get conflicting advice and unfortunately Some of the reason for the conflicting advice is that there's conflicting data and we have to individualize the treatments for each patient. So the question is, should I take hormones? You know, it generally means should I take sex hormones? People aren't usually concerned and asking about should I take you know thyroid hormone or something like that. They understand that that's medically tested. But there's a lot of advertising about hormones and particularly androgens and estrogens. And so people sometimes wonder whether those hormones will be appropriate for them. And there's no simple single good answer. So that's what we're going to be delving into today to try and tease out some of the factors that would make you decide one way or the other. But the bottom line is that hormones are effective and they can make people feel better. So there's sort of two Parts of the question. One is, should I take hormones? Meaning, is there something that they're going to do for me that's going to be beneficial for my health or my longevity? And then a second question, which is a more complicated one, is can I take hormones? Will they make me feel better? And if I take them, are there risks that either I don't know about or I may say are worth the risk? Because of the way the hormones make me feel. And that's why this is so complicated. The medical indications are pretty narrow and they're pretty focused, and there are there are people who should take hormones that it's going to be beneficial for their health. And then there's a much larger group of people where whether they can and want to take hormones and whether they decide it's worth the risk is a much e you know much more complicated decision making process. And I think that's where people also forget that these aren't just lab values, right? That these hormones will actually, when administered correctly, will it affect their everything from like sleep to libido to drive to periods, fertility, everything basically comprehensively speaking under the sun, it's it's going to affect them. That's right. And and so there's a period of time in your early, you know, adult life where everything's fine. And then since this is a podcast about aging, we're going to be talking about what happens over time to those hormone levels and what the manifestations of that are. And I think people are have a pretty good sense of it. That over time in men, testosterone levels drift down. Now, some people call that andropause, but it's not really a pause. It's more like a you know, a sli a steady decrease. In women, however, the hormones will kind of go along. Pretty well through the twenties, thirties, forties, and then suddenly at menopause, there's a pause. And the the levels of estrogen will drop by like 90%. It's a crazy steep decline where it just it just suddenly goes from a very high level to a very low level over the course of a few years. And that period of transition where it goes from a very high level to a very low level is called perimenopause, and then after it stops, it's called menopause. And it's it's truly a pause. It's that the hormones have been going along and then there's a pause where the hormones stop. And that that makes a lot of changes in the body. For those of us who aren't really familiar with what menopause does to a woman, can you just really briefly explain like what people can expect when going through that premenopause or menopause? Like what does that mean? So there are a lot of different manifestations of it clinically. But what's going on inside, you know, what's happening to the hormones. Normally in women, their hormones will cycle. And there's a estrogen phase of the of the hormonal cycle at the beginning of the period, right after the period, during that early phase of the period. And during that time, the body prepares for the possibility of pregnancy. So the estrogens stimulate growth of the breast, they stimulate thickening of the uterine lining and and that's driven by the pituitary hormones LH and FSH which is glutinizing hormone and and follicular stimulating hormone but that we just call them LH and FSH. So that's what happens in the beginning of the period. And then at about the middle of the period the the ovary will release an egg or sometimes more than one and that's called ovulation. And sometimes that causes a discomfort. It's called middle schmerz because the egg is being released out from the ovary. And at that point, things are going along. The uterine lining is nice and thick and ready to host a baby and make an embryo if it needs to. and if it if it there isn't fertilization, then after a few days the body says, Okay, you know, better luck next time. At that point, the estrogen falls and progesterone levels increase. And that causes the uterine lining to shed, to to release and causes menstrual flow. And and then that sort of cycles and then resets and then the the pituitary notices that starts to produce FSH and LH again and and and then after the menstrual period the the signals from the pituitary cause the Endometrium to get thicken again. So that's what normally happens. Now at the at around perimenopause, what happens is the the hormone we talked about that people don't really think about that much called AMH, antimalarian hormone. That starts to to taper down because the antimalarian hormone is produced by the the tissue around the eggs. And it's the amount of tissue. around the eggs decreases because the number of eggs decreases from say six hundred thousand at birth down to fifty thousand, then the amount of antimalarian hormones starts to decrease. That then in turn signals the pituitary and it's sort of you've got these cycles and they start to get out of whack. And that getting out of whack makes it so that the estrogen levels change and Estrogen, one of the things that estrogen does, and it does many, many things, is that it affects the temperature senses in the hypothalamus. So that's why people get hot flashes. Right. And then it also affects the lining of the capillaries, and that's why they they get, you know, the vasomotor instability, which is first of all they feel flush because of the pituitary, but then also the blood vessels are changing, so they get flushed and they get hot. And and they literally get you know, feel hot and sweaty. so that's one thing. Of course, you know, when your body's going crazy, that causes mood changes and the estrogen affects the brain as well directly. And so you have mood changes in the brain due to first of all the estrogen changes are changing the the the brain, literally changing how the brain is operating. And and then secondarily because if you feel funny, your brain reacts to those stimuli and feels funny as well. so there's a there's a lot of things going on. And one of the things that that people don't realize is that estrogen, progesterone, testosterone, these are all sex hormones. These hormones actually are go on the surface of the cells and are taken into the nucleus of the cell. And they actually change the way that the DNA is expressed and the proteins that are produced. You know, at this other level, estrogen changes everything. Changes gene signaling, mitochondrial function, nitric oxide production, inflammatory tone, and how tissues handle glucose and fat. In the brain Falling estrogen levels can destabilize the hypothalamic temperature control networks, what we talked about with the with the hot flashes and the night sweats. It affects sleep, neurotransmitter systems, and attention. And that helps to explain the insomnia, mood shifts, and brain fogs sometimes seen during a transition. In bone, estrogen normally restrains osteoclast activity, so that's the cells that break the bone down, so it keeps them from breaking bone down. When estrogen drops, the bone resorption starts to outpace bone formation. And so that's what leads to osteoporosis and osteopenia, and the thinning of the bones and the increased risk of fracture. In blood vessels, estrogen supports endothelial function and vascular flexibility, so lower levels can contribute to worsening vascular health and cardiometabolic risk. So we're going to get back to that because that's really important about estrogen replacement therapy. postomatopausally. In skin and connective tissue, lower estrogen makes less collagen and reduce elasticity, which is why estrogen is a frequent contributor to making the skin nice and youthful and glowing and so forth. In the genitourinary tract, estrogen estrogen helps maintain the thickness, moisture, blood flow, and microbial environment of the vagina, vulva, urethra, and bladder neck. So low levels can lead to dryness, pain res, urinary urgency, and recurrent irritation. And then progesterone, it's its counterpart, also matters because it's closely linked to ovulation. When ovulation becomes inconsistent, people have irregular bleeding and and then more psycho-related mood and sleep depression. So there's a lot going on, and as I said, these things go go right to the right to the nucleus and and directly affect the amount of of protein made it affects things throughout the whole body. So estrogen is going along just fine, keeping you youthful, keeping your skin good, your you know, your your blood vessels healthy, your bones strong, and then it just phew drops off a cliff and you lose ninety percent of it at at menopause and All of those things stop having this supportive signal and start changing and in many ways for the worse. So this is the rationale for giving estrogen replacement therapy at menopause. That if the estrogen was so great earlier and problems happen when you take it away, well then wouldn't it be simple to just add estrogen back? And that would keep things fine. That's what I would think. Yeah, and that's what everybody thought. When I was in training, we learned that women should be offered estrogen replacement therapy at menopause. And then i the the standard of care at that time was for them to have estrogen replacement therapy and to continue on it for the rest of their life. now the estrogen replacement therapy was meant to mimic normal periods, so we would use 25 days of estrogen, days 1 through 25 of the month or the period or whatever, and then on days 10 to 25, we would give a progesterone so that that would cause the women to shed their uterine lining and have periods. And the the use the reason for them to have periods is that if the uterine lining is continually stimulated without shedding. It can increase the chance of endometrial cancer. So to prevent the endometrial cancer, we would have them cycle and have periods and shed the uterine lining. And then by shedding the uterine lining, any cells that were started becoming metaplastic and thinking about becoming cancer would be discarded and you would start over, you'd start fresh. So that was the standard of care up until 2002. That's fairly recent. That's fairly recent. And 2002 is a watershed year because there was a large, very well done, very well controlled study called the Women's Health Initiative, where they followed a large cohort of nurses through adulthood and menopause and on. And some of them were taking hormone replacement and some of them weren't, and they got to compare what happens with hormone replacement therapy and what happens without. So symptomatically, of course, the women on hormone replacement therapy were often doing well. They were fine. but what they found was that there was a worrisome increase in cardiovascular events, heart attacks and and and sudden death from from heart disease, and an increase in breast cancer in this cohort of women. The people that were taking the replacement hormone therapy. That's right. So in 2002, these results were published. It's called the Women's Health Initiative, the WHI, and suddenly everything changed. That from almost all women getting hormone replacement therapy, none were given hormone replacement therapy. And everybody became quite afraid of the dangers of the hormones. In particular, the worrisome one was breast cancer. because that's a very scary thing. heart disease is probably should be scarier, but it it it it wasn't as scary as it as it was to the doctors. and so from 2002 until now people have been very, very wary about giving hormone replacement therapy. Now it is recent, but in the intervening years closer analysis of the data More studies, more basic science has shown that it's more complicated than that. So it turns out that the estrogens decrease the risk of heart disease in general. So women, up until menopause, have a lower incidence of heart attacks and things than men. And we always felt that that was due to the cardioprotective effect of estrogens. To a large extent that's true. Estrogens stabilize the endothelium, they you know, they give more nitric oxide. There's a lot of good things estrogens do for the blood vessels. And they help to prevent plaque. Unfortunately, they also make it so that plaque that's already there will be softer plaque and easier to break. And in the WHI study, the Women's Health Initiative study, the women were given hormone replacement therapy often more than 10 years after menopause. So in the intervening 10 years, they've had time to build up plaque. That plaque, then when they started them on hormone replacement therapy, would become more easily to break. And the the plaque, when it breaks down, it then causes a clog in the arteries, and that's what causes the heart attacks. So the moral of the story from that is if you're gonna give hormone replacement therapy, it's really better to start it early, right by the time of menopause, continue the the vasoprotective effects of the estrogens and keep the plaques from forming, then you don't have to worry as much about the plaques that have already formed becoming what we call friable, they breakable. So that's that's one part of the story. The endometrial cancer part of the story is still true, that in general if you want to give estrogens, you should do something to prevent endometrial cancer by giving a progestin or something. Having women cycle, having them shed their uterine lining once in a while to keep it from being cancerous. If the woman has had a hysterectomy for whatever reason, then you don't have to worry about as much. Right. And and that's germane because the progestions that we use to cycle the women to cause the endometrial lining to shed also slightly increase the risk of breast cancer. So Then it's a question of balancing how high a risk, what's the relative risk, which progestin formulation should you use? And and that's a very, very tricky thing that you you know, each woman has to decide in conjunction with their prescribing physician, you know, what the risks really are, what the relative risk is, what the absolute risk is, and whether it's worth the trade off. Right. So as I said, it's a it's a very complicated situation. that has to be individualized, you know, woman by woman, as long as they understand what the risks are and the trade off. Now the other thing that happens when the estrogen falls off the cliff, remember, one of the things I talked about was that the estrogen the estrogen is suppressing the cells that eat the bone. In the bone, there's a constant balance of osteoblasts and osteoclasts. And the osteoblasts are building bone and the osteoclasts are eating it. So your your skeleton actually is changing all the time. It's remodeling. And your skeleton renews itself every ten years. You know, on average about 10% of your skeleton changes over over the year. And that allows the skeleton to remodel to make it stronger where it needs to be if you've changed your activity and and then it of course makes it stronger in some places by cannibalizing strength from other places. and that's why weight bearing exercise and and s and resistance training is so important for helping to build the the skeleton. when you suppress the the osteoclasts, I always think of them like Pac Man. They're in their you know, eating away at the bone. And then the Osteoblasts or you know Bob the Builder, you know, from the Lego movie, they're in there, you know, gild building stuff. And they're they're sort of they're building and remodeling and building and remodeling all the time. during middle adult life or early adult life, you know, the twenties, thirties, forties, women are building their skeletal mass. And the more skeleton you have, when you hit menopause the better because it starts to decrease at that point because you've lost the estrogen. So again, the thinking was very simple. You know, estrogen helps to predict you know prevent bone loss, so why not just give estrogen and that will help to preserve the bone and and it does to some extent. Now we have other things that are better at preserving bones. We have you know we have new drugs that that can reduce osteoclast activity and and stimulate the osteoblasts. So that's not as as important a factor as it once was, but it is still a consideration. And it is still very important to try to maintain bone because the bone mass does decrease over time and gets to the point of osteopenia or osteoporosis, which then predisp predisposes the fractures and the fractures can be very, very detrimental. Yes. because you know it's sort of a self-propetuating thing. If you have a fracture, that reduces your activity. Reducing your activity then causes more bone loss and makes your bones more fragile. If we were to what could you tell me about that that maybe we should know? Yeah, so it everybody knows about menopause and it has a name and stuff. And men wanted to get in on the picture too, so. Men's testosterone levels peak in their twenties and then decrease steadily about one percent per year, you know, through the remainder of their life. So that means one percent per year, you know, over fifty years, that's a significant drop. and so that drop has manifestations, you know, physically, just like in menopause does in women, but they're much more gradual. menopause in the United States typically is around age fifty one. That's that's that's sort of the the mean average for menopause. Some women it's much earlier, some women it's somewhat later. but fifty one is sort of the average. on men it's and and through the twenties and thirties it's it's sort of more or less the same. Estrogen levels are similar. the the antimalarian hormone in women will be diminishing along the that time because they're gonna be reducing the number of eggs in the ovary and the antimalarian hormone is produced by fewer eggs that are of you know potential for ovulation, you're gonna get less and less anti malarian hormone. And then the antimalarian hormone feeds back with the pituitary and the epithelial LH. But all of that is reasonably balanced through the twenties and thirties. And men, the the peak testosterone is in their twenties and then it starts a slow decline and and you know decade by decade it it gets lower and lower. And and it has similar phenotypic effects. It's similar effects on the way that the the body works. So people have a pretty good sense of what testosterone does. The testosterone increases bone mass, which is good. it increases muscle mass. Yes. as you age sarcopenia which is loss of muscle mass is a is a real problem in men as well as women and so as you age the testosterone is actually beneficial for preserving bone mass for and keeping you know you from having osteopenia osteoporosis fractures and and sarcopenia and of course you know libido and and erectile dysfunction all those things as well. the the tricky part on men for the testosterone replacement has always been concerns about the the the heart disease issue. And then prostate cancer. And so just like with the women, with the women's health initiative study and and those being you know, an issue, it was always felt that okay, men have more heart attacks than women. So estrogen seems like it's protective. If estrogen is protective, testosterone's probably non protective. You know, it probably makes things worse. And and it turns out that that's actually not that not that true. Testosterone doesn't really strongly predispose to atherosclerosis and and you know coronary artery disease and and heart attacks. so that worry is probably overblown. and in men that are hypoglenadal, which means you know that they have d decreased testosterone levels that are truly low, it is now felt to be safe to give that to to give testosterone replacement to those men. replace back up into normal levels, even if they have heart disease. The the second issue is prostate cancer. And just like the progesterone potentially stimulating an increase in breast cancer in women, testosterone, which is another another drug in a similar type of of class, could stimulate growth of early prostate cancers. And because prostate cancer is very common in men, that that is a concern. Now again the the data are starting to suggest that that giving carefully and potentially cycling in or something that that could be mitigated. and so there are a lot of men that are taking testosterone because it does it does work for building muscle mass, which guys frequently want to do, and it it helps with sexual function to some extent. Again, you know, not for everyone. And and it depends on what the problem is. If the problem is due to a low level of testosterone, then of course testosterone is going to work great. If the problem with sexual function has to do with the the innervation, that the nerves, you know, the nerves get worse with with age as well, or with microcirculation, then it's not going to be as helpful. And in fact, if somebody has erectile dysfunction, that may be the first sign. That there's a problem in their blood vessels and might merit further investigation because it might mean that they're headed for a heart attack. And you don't you don't want to mask that. You want to make sure that that's evaluated properly. Yes. So the men's testosterone is, you know, gradually decreasing. And And so you can you can replace it by giving exogenous testosterone. And there are different formulations that that can be used. and so then the the question would be okay, if you give exosterous testosterone, testosterone has a similar feedback path as the as the women's you know sex hormone feedback, that testosterone from the body then feeds back and suppresses LH and FSH in in the pituitary because they say, okay, there's enough testosterone, we don't need to stimulate it any further. If the testosterone is old, then the FSH and the LH will go up and they'll they'll push and they'll say LADIG cells, which are the cells in the testis that make the testosterone, hey, you know, guys, get get a move on, you know, start making some testosterone. And if you give exogenous testosterone, you know, you you take it by a shot or a cream or pill or whatever, pills actually don't work. then the the pituitary will say, there's enough testosterone. We'll we'll keep our LH and FSH level levels low. And guess what? That causes the testes to actually get less stimulation and they'll shrink and they'll produce less sperm. So giving taking testosterone or or or giving you know exogenous testosterone can lead to infertility because it will decrease the amount of sperm that are produced because The body isn't giving endogenous signals to say, wake up down there. We got work to do. Yeah. so that's a problem if you if you want to have kids. If you're not if you're not interested in having kids, th then that's probably less of a problem. Yes. and if you are interested in having kids and have been taking testosterone, then it it's an issue. But the other problem with exogenous testosterone is that if you give too much of it, testosterone is is a sex hormone. And the sex hormones can change back and forth from one to another and in particular, testosterone can undergo a process that's called aerotomization, which is a chemical term for changing something in the progestine testosterone category of drugs into the estrogen category of drugs. Wow. And it can turn into estradiol. And so it turns testosterone into estrogen. Okay. Then what happens? Well, some tissues in the body are sensitive to estrogen, and in particular. Breast tissue. Mm-hmm. Yes, yes. Okay. So if if the if you're taking testosterone, paradoxically, that may cause your breasts to get bigger. Growth of breast tissue. Yes. Right. And I have heard of that. In men we call that gynecomastis. and so you can be super muscular and buff and and be growing breasts. So The the bodybuilder community has figured this out and and so now what we do is if you're gonna be taking testosterone It's best to take it with an estrogen blocker. Right. So you don't get those unwanted side effects that you're not looking for. Exactly. if you take away the estrogen or if you take away the testosterone, it doesn't ungrow. It stays. It stays. Once breast tissue is grown, it stays grown. And so at that point the only way to take care of it is to remove it surgically. Mm-hmm. And you do that here at your clinic, right? Yeah we see a lot of cases that, you know, men have taken these and have developed a permanent state of gynecomastia that you've had to surgically remove. Yeah. Yeah, we see that. a substantial portion of of males during puberty have you know really, really high levels of testosterone and they'll have a transient increase in the in the estrogens. sometimes at puberty will grow a little bit or be a little sensitive. that often goes away, but not always. So sometimes men just from the surge of of the testosterone in puberty, they will get you know, some breast development at at at puberty, which then again never goes away. Wow. I didn't know that either. Yeah. So if you if you're giving exogenous testosterone and then you're suppressing the pituitary access, the LAFSH, and you stop the testosterone. You know, good question. What happens? Actually it's interesting. You can live just fine with a very low testosterone level. And more than half, the the female population and the children population does just fine without high testosterone levels. So nothing adverse happens. it's interesting because adding testosterone will make people more aggressive. Oftentimes it will change. I've heard of that. Yeah, yeah. The road rage kind of thing is is you know, I mean they call it roid rage too. Yes, roid rage. That's testosterone is a mood changer and it it makes people more aggressive. It makes them jittery sometimes. it makes them, you know, all amped. Yeah, amped. Yeah. Exactly. So people will take it because it makes them feel more I don't know, you know, agitated, confident, strong. Yeah. to some extent that's that that's a good thing for and and for some people it is. Societally it's probably not such a good thing to test boosters. I was thinking that as a woman, like wouldn't you be scared if every man on the street walking was like amped up on all these test boosters and steroids and things like that. Yeah. Well, as a man, Je probably should be scared of that 'cause they'd be more likely to get in a fight. Yes. and fights rarely benefit either party. it only takes one look and then that's it. Yeah, exactly. Yeah. So so taking the testosterone away, having it having it go away doesn't turn you back into a boy, you still have the secondary sex characteristics. So but that's one of the interesting things is that some of these things, the puberty is irreversible. you have a a surge of hormones at that time. It causes changes in the body. And then if you take the hormones away, those changes are irreversible. If you if you take away all the testosterone from a man, their voice doesn't really change. They still grow a beard. you know they're they're size is still the same. So all those changes have happened and don't unhappen if you take it away. and similarly in a woman, if you if after menopause, women don't go back to being, you know, little girls, they become adult women. and and so the there are irreversible changes and and and reversible things, you know, the the reversible things are The bone, the but vessel, the brain, the skin. The muscle. Yeah. Exactly. And in particular the the beneficial ones are the bone and the the muscle. Muscle. Mm-hmm. Mm-hmm. So Dr. P, let's talk about some common myths, right, that keep people stuck, I would say, you know, panicked or kind of in a rut over these myths and misconceptions. so myth number one is that the WHI, the Women's Health Initiative, proved hormone therapy is dangerous for women. Well, that's a tough one. so yes, the Women's Health Initiative study was a great study, it was a landmark study, and it showed that there were risks to taking hormones post-menopausally that we had not prior to that really recognized. now it that doesn't mean that the hormones are dangerous for everybody and that they should absolutely be stopped under all circumstances for every patient, which is what people did. Yeah. so I think we leapt to conclusions we probably overdid things. So now we have a much more nuanced understanding and you know it's been twenty two years, so we've got more information. And and and there were ongoing studies in Europe and and elsewhere as well that that provided a more a complete understanding. So I think it's unfair to say that hormones are unsafe for everybody. Right. I think it is safe to say that hormones have some risks that we need to recognize and be able to balance we now have a way of of looking at the the good sides and the bad sides and being able to make a an informed decision. So as we talked about earlier, the WHI did show that women are at increased risk of heart attack if they start the hormone therapy more than 10 years after menopause. The second thing that it showed is that. women that are taking a progestin do have a slightly increased chance of breast cancer. Now to put that in perspective, it's felt that that that with hormone therapy, with the progestine therapy, that approximately one in 70 women will develop breast cancer that would not have otherwise developed it. So we we're starting to get numbers that we can associate with the risk. We know that the risk is real. We know that it's Small ish, I mean one in seventy is not a really big risk of course the one in 70 is terrible if you're the one who gets breast cancer. if you're the 69 that don't, then you say, it's a it's a it's a low risk. It's worth it. So it's not that they're unsafe for everyone, but it is true that there are safety concerns that we need to balance against the very real benefits that hormone therapy can give. So this is mostly something that you should be collaborating on with your doctor and your primary healthcare position, right? To see if hormone therapy is worth it and the risks and everything are, you know, not going to be detrimental to you. That's right. Yeah. That's exactly right. Okay. That you have to look at the whole picture and say, okay, what are the problems with the hormone withdrawal, which happens naturally? you know, osteopenia, sarcopenia, and And what are your own personal risks for having breast cancer? If you're a BRACA one or two like like Angelina Jolie and have a very high risk of breast cancer, then the increased risk of breast cancer would be a significantly increased risk, and it probably wouldn't be a good idea. Not if and similarly if you're at risk for heart disease, then you may say, Well, you know what? I'm already at risk. Let me let me do everything I can for my heart. And everything for my heart will include staying away from these medicines. So yes, yeah, absolutely it's something that has to be individualized for every single patient for their complete circumstances and in conjunction with their doctor. Mm-hmm. The information also that we're putting out, I feel like, is gonna be good education for anyone who already has questions and is looking into any of these things, right? Well it's a good thing for them to know to talk about with their doctor in an informed way. Mm-hmm. And then moving on to our second myth. can you explain to me just really briefly what bioidentical means and why it's automatically safer in this myth? in the women's health initiative study they were using what we always traditionally use, which was conjugated estrogens and madroxy progesterone was the was the progesterone. Now Both of those are synthetic or semi-synthetic. They're not naturally occurring. They're they're actually different molecules that that act on the same receptors. So they have similar biological effects, but they're actually different molecules. and that's partly just because they're easier to make. They're complicated molecules. They're very difficult to make. But the you know chemistry industry has advanced and we now can make actually the same exact molecule. So now we replace things with the exact same molecules that the body makes. so bioidentical hormones are safer in that sense. the pharmaceutical industry wants to point out that the ones that they make that are FDA approved are potentially safer than ones that are bioidentical that you're buying from another another source that may not have met the same stringent criteria for manufacturing and so forth. And and the doses may be off. And so a bioidentical hormone from the FDA approved manufacturers is is almost certainly safer than the Previously manufactured ones that were not bioidentical. On the other hand, a non pharmaceutical grade product obtained from someplace else may have adulterants or something that may make it less. Exactly. Yeah. Okay. And then for another big myth that I guess a lot of people have questions on is if if you're a woman and you're struggling through menopause. To just tough it out. Like there's a lot of women who don't even consider hormone therapy, who just think that it's natural, whose mothers have told them that they went through the same thing without any kind of options. What do you think about that? Well, I think that that's been pretty much the standard of care in the United States for the last 22 years, ever since the WHI study. So a lot of women, you know, even if they were miserable and and would have certainly benefited from hormone therapy. have not been offered it because of the fears about the potential risks and the bad reputation that that hormones got. I think that now we can be a little bit more circumspect about it. We can recognize that it really is very uncomfortable and that's something that women really are struggling with and that it It isn't something that is necessary to struggle with. Right. If there is a solution that's you know up to the standard of care and it's not perfect, but it does, you know, majorly in help and increase your day-to-day life. Right. And I think it's worth worth looking into. I like we talked about at the outset, it's not a question of is this something you should take? It's a s it's a question of Is it something that you can take? Yes. That would be safe for you to take that you understand the risk, that the risks are worth the benefits and and that there are real benefits and that the benefits are going to vary from woman to woman. Some women go through menopause with very little, you know, symptomatic problems, and other women it's just they're just miserable. They they can't sleep, they they get hot flashes all the time and it really interferes with their life. And there are things that can be done to ameliorate it and and it's a it's a choice that that is off often not offered, but it's something that should be available and and thought about and discussed. Mm-hmm. Mm-hmm. I agree. And for men, I guess a common myth is that when men start to reach a certain age and they're just more tired or you know, they're not feeling the same, they should automatically consider, you know. testosterone supplementing. it's an easy conclusion to jump to and maybe too easy, that testosterone goes down, you get older, you're not as strong and aggressive and, you know, energetic as it used to be. testosterone's all in now, all these things are happening, then if I just put testosterone, it'll make me back young again alone. It's something that you might want to consider there's no medical reason why you need to, as we talked about, unless you're really ho hypochonital and and and it's really causing problems. But for most men, it's not something that is medically necessary, but on the other hand it's something that may put a you know, spring in your step and And make you more energetic and and can help you build muscle. And building muscle is is useful as you get older and can help increase your bone mass. to put more more bone in the bank for when it starts to decrease. so it's something that that should be considered. If you're taking it to improve your your sexual you know, situation, be aware that it may be masking something that's more important. Right. And that you also should be careful to check about prostate things if you're gonna do it. So again it's in the category of is it something to consider? Sure. you know, is it something you wanna try? Talk to your doctor and see if it's something that will be safe. And and then if it's something that you like and it's makes things better for you safely. Right. Then it's a then it's a choice that you can make. Right. It's about differentiating right between the like an unnecessary type of risk that you're taking versus like a clear benefit to you in your situation. So all of this I guess circles back to the fact that I guess we're encouraging these people to talk to their doctors beforehand and then consult with them to see if they would benefit from something like this. Right. And then also to evaluate if they're not benefiting why. Mm-hmm. And if there's something else going on to be investigated. Yes, exactly. And Doctor, I was actually talking to my mom before this segment to try and plan some things, maybe some questions that she had to pick your brains about the subject. and one of them was she's about 50, mid 50s. So she is going through I think what is premenopausal. So She's not quite there yet, but she's definitely feeling all of the symptoms, all of the lethargy, the weight gain, the hot flashes, the libido, everything that she thought that was gonna be a little bit more manageable. It turns out it's kind of making her life a little bit less manageable every day. So she wanted me to ask you as a woman in her situation and her age range. What can she do even just outside of hormone therapy and her daily life, her habits, to help whatever she needs to do on a day-to-day basis? Yeah, so there are two parts to the answer. And and so I'm gonna break it into things that she would want to consider that are happening at menopause that are going to impact her health later on for the rest of her life. So at menopause there's a rapid depletion of calcium from the bones. women will lose typically one percent per year, but at menopause they can lose two to five percent of the mass in their bones for that few years perimenopausally. And as we talked about, the bone mass is like a bone bank. Right. You want to put as much into that bone bank as you can prior to the, you know, eventual loss. So there are There are medications that you can take that will help preserve the bone. But things that you can do in terms of lifestyle, she should certainly consider doing a resistance exercise training where you're that that resistance causes stress on the bones. That stress causes the bones to build more bone. There's a feedback within the bones to do that. And to make sure that she has enough vitamin D. So make sure you have enough vitamin D and and adequate calcium and protein vitamin D is that not like you go out into the sun and you get that? That's a great question. Yes. You go out in the sun and you get vitamin D. And since we live in Hawaii, it's pretty easy, one would think, to get vitamin D from the sun. But vitamin D helps the bones use the calcium. I see. Vitamin D is actually a hormone. And and it's actually a steroid hormone. and so we call it vitamin, but maybe we should call it hormone D instead. so it's a hormone that helps the the bones take up the vitamin the calcium and build bone. So if you're deficient in vitamin D, you don't have enough calcium and that that then tricks the parathyroid glands into saying, we need more calcium in the in the blood. So let's let's get some calcium from the bones. That's where that's where we store it. And so it causes the body to to leach calcium out of the bones. And And those those little Pac-Man, it it stimulates them to start taking calcium out of the bones and thinning out the bones. So you know, make sure that she's trying to preserve as much bone mass as possible during that time. So that's the first thing. the second thing is that she wants to make sure that that she does you know good things for her blood vessels. So that's the aerobic exercise part of things. So diet and exercise, the usual suspects. And she might want to consider, Having a cooler room, sixty eight degrees, is considered a good sleeping best, Making sure it's dark. Yes. is really helpful. no blue light, no screens, things like that for two hours before bedtime. and then a a small dose of melatonin. Now the pharmaceutical you mean the stuff you buy is typically five to ten milligrams. actually a half a milligram to a t to a milligram. So a tenth as much as a normal pill. And so you know, a nibble a d a sliver of a pill of melatonin about an hour before bedtime can help because the pineal gland, which makes the melatonin, becomes less sensitive, and the the output of the pineal gland of melatonin drops about ninety percent over the course of of aging. So giving a little extra melatonin might help her sleep better. Okay. and so those those are things that that can help symptomatically. There's there are new drugs that have just been approved the last few years called NK receptor agonists. and there are several now that that help with the vasomotor symptoms, the hot flashes, that are non hormonal. So if if either the she's afraid to take hormones or the hormones aren't working, they she could consider those as an adjunctive therapy. then the other thing is that phytoestrogens that soy actually has estrogen like compounds in it. So tofu and you know itamame and can help as well. Okay. That's good to know. I will I will let her know. And so to bring all of this together and to kind of close out what we talked about here today, I guess our main goal is to pretty much inform, right? To make sure that there's a discussion around all of these talks about hormone therapies and treatments and what your body's going through during the aging process, I think that overall we just want to tell listeners and viewers to just make sure that everything that we say is taken with a grain of salt. Make sure that you are talking to your primary healthcare provider about all of the symptoms that you're experiencing. If you are considering hormone therapy as a type of treatment, or if you need to address any kind of underlying issues that you think that you're going through. It would be very good to talk to your doctor about anything that you're experiencing. Yeah. So just to sum up a little bit, hormone replacement therapy is a common reason why people come to you know anti-aging clinics and seeking out therapy. And if you're hoping for a fountain of youth, unfortunately it's not going to do that. So as we said earlier, who should take hormone replacement therapy? people who are having problems and have been tested and have shown to have low therapeutic levels. And in those patients, then Hormone therapy is is what's called indicated. It's FDA-approved indication. It's something that's been studied and is shown to have true benefit. that might improve their quality of life, but not in a measurable medical way, that might be interested in trying it. And those are people that should talk to their doctor about it, say, okay, what would be the potential benefits, what problems would it be meant to solve in their life, and what are the risks? And then weighing all those things carefully, then they may want to try it out and see if it's something that works, then great. if not, then there's other treatments and and there are other things that they can try. Exactly. So it's just one one tool in our armamentarium of things to try. And I think it's good to know about and it's good to have as an option in your back pocket, but it isn't a it isn't a fountain of youth, it's not going to solve everything and it's certainly not going to make you younger. Mm-hmm. Mm-hmm. Beautiful closing. So I just wanted to let everybody know too that if you are more of a visual learner or if you it's easier for you to follow along visually series. So if you folks want to go ahead and take a look at that, we'll leave a link as well. Right. Okay. Well thank you for listening and see you next time on the Revalu Saging Podcast.