Latest / Alabama The Beautiful: The Eastern Shore Cosmetic Surgery Podcast / Bioidentical Hormone Replacement: You, But Way Better
Transcript
- Announcer (00:02): You are listening to Alabama the Beautiful with cosmetic surgeon Dr. James Koehler and Kirstin Jarvis. Kirstin (00:08): Hey, Dr. Koehler. Dr. Koehler (00:10): Hey, Kirstin. Kirstin (00:12): You want to know what we're talking about today? Dr. Koehler (00:13): Yes. Please tell me. Kirstin (00:15): We are introducing Mary Emma Pitman, our new nurse practitioner at the office. Dr. Koehler (00:22): Who's she? Kirstin (00:25): Who are you, Mary Emma? Mary Emma (00:26): What do you want to know about me? Kirstin (00:28): Let's first hear what you do here. Mary Emma (00:31): Okay, so here at Eastern Shore Cosmetic Surgery, I am in charge of the hormone aspect of the practice. So all things bioidentical hormones. Before we get into it, I am 27. I'm from Fairhope, Alabama, so born and raised here and I'm married and have a dog. Kirstin (00:55): Awesome. How did you come to our practice? How did you meet Dr. Koehler? Mary Emma (01:00): When I was working in the NICU at USA Children's and Women's Hospital, I knew that I didn't want to do the night shift for the rest of my life, and so I was kind of looking for somewhere else to go, somewhere that really made me feel good as a nurse. And I came upon Eastern Shore Cosmetic Surgery, started working as an RN for I think it was about two years before I graduated nurse practitioner school. So I was working here the whole time I was in school and still worked full time. And the whole time I was in school, Dr. Koehler and I were discussing how beneficial hormones would be for the patients that are already in our practice. And one thing led to another and now we're here. Dr. Koehler (01:45): Yeah, we're glad you're here because I mean, this is something that we're really excited to add to the practice. Kirstin (01:51): Mary Emma, how do you help patients in our practice? Mary Emma (01:54): So a lot of patients, whether they are teenagers to women that are menopausal to postmenopausal or even men, most people have some aspect of hormone imbalance. And so what I do is I evaluate our patients for all of these different hormone irregularities that can occur and then treat them and through treatment, their energy increases, their mood, their overall wellbeing, and relieve a lot of their symptoms and get them to feeling better and on the right path to take on life. Dr. Koehler (02:35): Yeah, I think it's important though when we talk about this, that is very true and I think that's the hormone part is what we're offering, but it's really, I think it's part of an overall plan of general health. I think people want a quick fix and hormones are not that. They are something that will help people if their hormones are depleted and they need help in that area, we can bring that to them, but they still need to address other parts of their life. So that's the one thing I think that's really important as we're dealing with these patients. It's like is there nutrition on point? Are they doing some kind of physical activity and exercise? Are they getting enough sleep? And sometimes these things are connected, so it's like a big puzzle. So I think that's the important thing for people to really understand is that Mary Emma is really working on identifying people that may have deficiencies or areas that can be optimized, but it's not a magic bullet. Mary Emma (03:37): I do think that also that's what sets us apart is we're not just giving a magic cream or giving a magic pill, we are looking at the whole patient. So all of the lifestyle factors come into play and yes, diet, exercise and hormone treatment is also based on the patient. One may be great for one person and not for the other, and it's due to lifestyle and all those other factors. Dr. Koehler (04:06): So Mary Emma, why don't you tell us about some of the things that you're doing in the office here? Sort of explain maybe to the people who are listening, what the whole process is and what you're doing. Mary Emma (04:19): So when someone reaches out about hormones, I have a talk with them on the phone first just to see if they're overall a good patient for the program. And then to get started, what we do is draw a very, very large panel of labs. And a lot of times this is not labs that a patient has had drawn at their primary care or even by their OB/GYN. These are a little more extensive. And after I receive all those labs, I bring the patient in the office and have a very in-depth consultation with them. Now the consultation includes me going over all of their lab work and looking at all of those lifestyle factors. I do a full medical history exam and give my recommendations based on all of their symptoms, everything. And then once they decide they want to move forward with treatment, they join our program and I begin treatment. Dr. Koehler (05:17): So the people that you're seeing, what are you telling them in terms of expectations? I think some people are like, "well, how quickly am I going to see a difference or am I going to see a difference?" Mary Emma (05:28): So I like to remind patients that hormone imbalance is not an overnight fix. So for example, it took a while for your body to be depleted of hormones. That didn't happen overnight. Now if you had a hysterectomy or something of that nature, it may have been a little bit faster, but that hormone depletion didn't occur overnight. That being said, it's going to take a little bit for those hormones to build back up. Now, typically when someone joins, I tell them the first three months, let's just see how this goes. It's going to be a little bit, I remind them that they're not going to have a tremendous improvement in one week. They may have some of their symptoms go away, that sort of thing. But talking about the longevity and there's long-term markers, those are not going to increase overnight. Kirstin (06:18): What sorts of things have you learned from listening to the patients that you've seen already? Mary Emma (06:23): A lot of times they feel like they have not been heard for a long time, and that's how they end up in our door anyways. And so they've been to other places and they just want someone to listen. And yeah, they may want to talk about their own personal life and things that are going on in their life and how they feel hormones could benefit them. It's not just decreasing hot flashes. It's way more than that. And so one, being a big patient advocate and listening to the patients and making them feel heard is huge. Dr. Koehler (06:58): Well, I have to say one of the quotes that I heard in regards to hormone replacement therapy is that one of the goals for hormone replacement is to add life to years and not years to life. And I thought that is a pretty profound thing. Yes, we talk about anti-aging medicine and wanting to live longer and all that, but what good is it to live longer if you feel terrible, that's not beneficial. So we want to feel better and enjoy the years we have right now. I think the thing is we want to feel like we did when we were younger and people talk about brain fog and fatigue and all of these types of symptoms. And yes, some of those are age related, but what part of that aging process? And a lot of times it's the fact that there are certain hormones and things that get our bodies in that state, and when we're depleted of those hormones or over time, the receptors may not be as sensitive to those hormones and we're not seeing the effects that we used to see. I think that's a pretty profound thing. I think that's the biggest benefit I think that we hope to see with the hormone replacement therapy is yes, we'd love to see it improve your longevity, but really we want to see it improve the quality of your life. Mary Emma (08:16): Correct. The biggest thing is a lot of times I have women that are experiencing the horrible symptoms of perimenopause, and a lot of them have been told they're not in full menopause yet so it's just part of the process. And yes, aging is normal and going through menopause is normal, but do we have to suffer? No. I mean, we have a treatment and a solution for those horrible symptoms and how patients are feeling, so why not them? Kirstin (08:52): What does a typical visit look like when patients come see you for the first time? Mary Emma (08:59): So along with the things I said, including full evaluation, medical history and lifestyle factor exam, I want patients to understand that why we're treating, what we're treating, what we should see from treatment, what they should get out of treatment. Dr. Koehler (09:17): Mary Emma, why don't you tell us a little bit about some of the patients that you've seen recently and how you've been able to help them? Mary Emma (09:23): I would love to say most of my patients look like this, but they're all different. And so every patient that comes in the door has their own treatment plan that's completely different from others. So for example, I had a patient come in the other day, one of her biggest symptoms, which she didn't even realize was related to her hormones was her lack of sleep. And then that affected her energy the next day and everything else. And I put her on progesterone and she's sleeping like a baby. She also feels calmer. So progesterone works on the area of your brain called the GABA receptors, which helps to calm you and is one of the biggest things it does. And so when you start progesterone, it kind of helps decrease that anxiety and depression and other symptoms that may be occurring. And so for this patient in particular, not only did it improve her sleep, but it improved her anxiety. She didn't have anything specific going on in her life, but she just felt anxious all the time. And she mentioned that it improved her quality of life because she just felt like she could handle her children and handle her husband and not be ready to snap back at them, that she just was able to handle things. Dr. Koehler (10:36): Oh, there's no drug that fixes that. I can tell you that right now. Kirstin (10:39): I was just about to say, "can I take a whole tube a day? Anxiety? Sleep? Snapping?" Mary Emma (10:44): Well, so there's a lot of different symptoms that each hormone treats, but for progesterone, sleep, anxiety, depression, overall calmness. Now the estradiol, that one treats more of the symptoms that you typically hear about when someone's in menopause. So the hot flashes, the night sweats, all of those symptoms. That's going to target that. Now testosterone, this is one that a lot of people don't really know about for women especially. So for men, that's the main treatment typically. But for men, it helps improve endurance strength, build muscle mass, help with energy and increase libido. And then for women, it's actually very, very important that women have testosterone as well. It's just a female hormone as much as it is a male hormone. So things also like energy, libido. Libido is huge for testosterone overall strength and energy, testosterone is one of the big treatments for that. Kirstin (11:56): Awesome. Give me some of that too. I want all the testosterone and all the progesterone if it's going to help me sleep and be happy and not anxious and get my libido going. Mary Emma (12:09): Yep. Kirstin (12:11): Is there a certain group or are there certain things that you look for in people that makes them not a candidate? Mary Emma (12:18): So based on literature, actually most people are a candidate for hormone replacement therapy. Now, there are some factors that I like to address. I want to make sure that someone does not need a cardiac evaluation first or need to have an updated mammogram or there's a lot of different things that I do look at their history of blood clots or cancer. Dr. Koehler (12:43): My thoughts on the issue are the people who really aren't good candidates for hormone replacement therapy, if you have active cancer, you're not a good patient for hormone therapy, you need to be seen by your oncologist. And hormones during cancer therapy is, that's not a good time to be getting hormone replacement therapy. After you've had cancer, like women after breast cancer, that is a bit of a controversial subject matter as far as what should be done in terms of hormone replacement. And again, this is kind of one of these subjects that in this setting it's maybe not, there's a lot to discuss and unpack there. But I just suffice it to say that there's definitely some ongoing studies looking at this. Definitely things like testosterone have been shown to be beneficial in preventing the recurrence of cancers, but even there are some thoughts that, well, we shouldn't be giving estrogen to women who've had breast cancer because it might come back. Dr. Koehler (13:44): But the reality is, is that's probably not true. And actually estrogen supplementation can be done with estradiol, not some of the conjugated estrogens. But again, it's a complex issue. So anyhow, I'd say cancer patients, active cancer, whether it be breast cancer or prostate cancer, you shouldn't be on hormones. And then those that have really severe cardiovascular disease, history of stroke, blood clots, stuff like that, we may want to stay away from treatment in those patients as well. So it's not, again, every case is looked at individually, but it is important to realize that not everybody is a candidate. But I guess one of the things that we really need to touch on and we haven't talked about is how bioidentical hormones are different from what a lot of the studies that referenced the problems with hormones. There was the Women's Health Initiative, which is a study that we talk about quite frequently, which started in the nineties and actually was stopped prematurely back in 2002. Dr. Koehler (14:53): And the study results were released. The study was supposed to go for I think eight and a half years, and it was cut short. It only went five and a half years or something like that. And in that study, they stopped the study because the incidence of breast cancer and things like stroke, cardiovascular events was so high that they said, we got to stop the study. So then the media got ahold of that and they said, "Hey, women shouldn't be on estrogen because it's causing strokes and breast cancer." So now all these women, postmenopausal, perimenopausal women who would've benefited from hormone replacement therapy were basically told, "well, you shouldn't get it." And this is where it gets all sticky and we get stuck in the terminology. But that particular study, they weren't using the hormones that your body produces. And so what is being shown now is that actually the estrogen really wasn't the problem. Dr. Koehler (15:54): The main problem in that study, it really had more to do with the synthetic progestin that was used, which was causing the issues with breast cancer because in the estrogen only arm of the study, those patients didn't have an increased risk for breast cancer. It was only in the arm that concluded the progestin with it. So anyhow, since that time, there's been more evidence to show that when we use the actual bioidentical hormone, which is estradiol, and that's the one that we're supplementing in our treatment plans here and progesterone, that's different than the estrogen and progestin that was used in those studies. And so this sounds very confusing. It is. It's a very confusing, it's very confusing amongst healthcare professionals. If you say estrogen, for a lot of physicians, that means estradiol and they mean the same thing to people. But in these clinical studies, it's very different. They are different. One is a synthetic drug. Well, progestin is a synthetic drug, but the conjugated estrogens used is not the estrogen that your body produces. It's not the bioidentical. And so you're not comparing apples to apples. And that's what replacing your hormones with identical, the identical hormone that your body produces. Now, all of these studies are having to be looked at very closely because the data is different. Mary Emma (17:27): Correct. And I feel like a lot of times they get grouped together. They don't just, like you said, apples to apples. They're looking at these two medications like they're the same and they're completely different. They act completely different in the body. I mean, it has never made sense to replace hormones that are not bioidentical to the body. Dr. Koehler (17:46): It's an interesting thing because I'm sure you've come across this where people ask you, they're like, well, okay, let's say you just say a patient should be on estradiol and progesterone, and they go, "well, will my insurance pay for that?" And the answer is no, it won't. Mary Emma (18:02): What I explain to patients is that we're doing a program cash pay program because how insurance wants me to treat their hormones is not how I want to treat their hormones. And so that is the biggest reason for why we don't accept insurance. Even labs, insurance gets involved in lab work and everything, and how they treat hormones and what numbers they like to see and what medications they like to use are not what we like to use. So. Dr. Koehler (18:31): Yeah, I thought it was interesting from the male perspective on hormones where they talk about testosterone levels and how they came up with this number, "Well, if your testosterone is under 300, then you potentially could have that covered by insurance." But how did they come up with that number? And how they came up with that number is insurance companies basically looked and said, well, look, that's this small percentage of the male population that we'd actually have to cover if they were symptomatic and they were under this level, because most men are going to be above that. But just because you're above 300, let's say you're 350, you could absolutely be completely symptomatic. But because you don't reach that number, which again is sort of an arbitrary number, symptoms don't always correlate with the actual value of the lab. There's people that could be symptomatic at 500 or symptomatic at 600. So I think you're right, Mary Emma, that's the thing that gets very sticky. So that's where doing these programs where we are like, look, we're not going to be dictated to by the insurance company as far as what we consider to be optimized. We're going to get you to where we can hopefully get your symptoms under control. And that's the goal of therapy and not to treat to a number. Mary Emma (19:45): Correct. And normal is different for every patient. One person may feel great at one number and then another patient may be horribly symptomatic at that number. So normal and optimal are not the same for each patient. So we like to take that into account. Kirstin (20:00): Well, I am curious to learn about the different forms of hormones that you use, because I know some people may prefer one method over another, or you may prefer one method over another, or people's lifestyles may dictate that they need to use something versus something else. So can you tell us what you offer? Mary Emma (20:23): Yeah, so my offer hormones in various different forms. And so I have creams, I have troches, I have oral dissolving medications, I have oral pills, we have injectables, and we have pellets. Kirstin (20:40): All the things. Mary Emma (20:41): All the things. And too we get into, let's say you want or need metformin and you have symptoms with the oral medication. Well, with the compounding pharmacy, I have the ability to do it subcutaneously or through the skin as a cream. So for example, testosterone's a great medication, but if you can't remember to put it on every day, then it's not a great medication because it's not doing anything. So that patient may benefit from a pellet that they only have to remember every three months to come into the office and get a pellet with progesterone. Some women may experience some daytime sleepiness if they have to take progesterone during the daytime. And so doing one of those troches or rapid dissolving medications, they won't experience those symptoms. So with estradiol, we can do that one in a pill, in a pellet or in a cream. I typically recommend oral medications for estradiol or the pellet pellet. Typically for convenience, there's more protective factors over taking estradiol orally, progesterone I'll never do in the pellet, I do it orally. It just works because of the mechanism of the drug. That's how it works best. Kirstin (21:58): Do pellets hurt? Mary Emma (22:01): So no, every patient that I have done pellets on, the majority of the pain that they experience is a little pinch, and that's just from that first initial injection of numbing. So a lot of times patients get very nervous about doing pellets because they're worried that it's going to hurt or worried that they're going to have pain from it. But I make sure to numb the patient completely, and after that they don't experience any pain. And the patients that do pellets really love pellets because of the convenience factor. Kirstin (22:40): You don't have to remember to do it every day or take it every day. Mary Emma (22:43): Correct. Dr. Koehler (22:44): Yeah. And you have to be careful with some medications that are done topically. Like, I don't know if you mentioned the testosterone for instance, if you're putting that on, whether it's a male or a female patient and you're putting that on, and if you're not good about washing your hands, if you've got young children, you can actually get transference where the kids are absorbing testosterone, and that can be detrimental to a young child. So sometimes choosing the right form is important. If you're not going to be good about making sure you're not getting it onto your kids or whatever, then you may be better off with an injection or a pellet, something like that. So there are things to take into consideration when choosing the form. Mary Emma (23:26): So when I see a patient, I ask all of these questions to see initially what may work best for them. And then we do a trial run of a month to see if they were able to remember to take the medication every day or put the cream on, or if they had trouble with letting the cream dry for four hours before touching anything or anyone. So all those factors are looked at and then we adjust based on how well they did. Kirstin (23:52): I think it's important to note that you both have attended the same courses. You have a lot of the same education for this hormone replacement therapy and bioidentical hormones. So it's important for patients to know this is a physician-led program, but Mary Emma, you also have as great of an education with this hormone stuff as Dr. Koehler does. So patients are going to be in great hands that everything's monitored by the doctor, but also you have a fantastic education on these hormones and their side effects and their effects, and I think that's great. Mary Emma (24:27): Yeah, so whenever I was in nurse practitioner school, the topic of hormones was avoided. And even in clinicals, other nurse practitioners didn't know how to handle the patients that were experiencing symptoms of hormone depletion. And in school, it definitely was something that whenever I learned it, I knew the difference in synthetic and bioidenticals and they were just grouped together. And so for me to receive the proper training to be able to do this, Dr. Koehler and I have both attended all of these extensive courses to learn all of our information. Kirstin (25:03): I know that you both had mentioned this is not going to be an overnight cure for people, but is there a timeline that you tell people like, "okay, you're going to feel better in two weeks, darling," or is it just dependent on each person's body? Dr. Koehler (25:20): Well, I think a lot of people are going to start to notice a change within three to six weeks probably. I mean, it may not be a couple of weeks, but you should start noticing some differences. It's probably going to take up to six months to really notice the optimal change. And again, as Mary Emma said, it may be dose related. So sometimes if somebody is not seeing a change in three, four weeks, that's when we need to reevaluate the dose. We may have to check some levels and we may have to bump it up because we're not going to know what level, we're not going to go to the highest dose. We're going to go to a dose that's appropriate based on your lab results and based on your symptoms. And then we're going to slowly increase it until we get you to that point where you're feeling great. So yeah, if you don't feel great in 3, 4, 6 weeks, I wouldn't stress about it because that's the whole point. I mean, that's why you're in this program. I mean, we're going to be monitoring you throughout and depending on your circumstances, you're going to have to be seen several times throughout the year. And once you're stabilized, then it may only be a couple times a year that we check some spot labs and see where you're at. But at first it may be a little more frequent in terms of getting those doses just right. Mary Emma (26:30): I think it's important to note that I evaluate a lot of different vitamins because there's so many people with vitamin deficiencies and that's impacting their overall wellbeing as well. I mean, I have tested so many vitamin D levels and you would be amazed at the amount of people, including myself that have a vitamin D deficiency. And yeah, I'm out in the sun all the time. I eat a great diet. But there's still factors that come into play. And every person for prevention of so many different things, including osteoporosis, need to have an adequate vitamin D level in their body. And I work with a great company that provides really good supplements. I get really great levels from the supplements that I'm giving. When you just go to Walmart or Costco and get a vitamin D, you're not taking enough. And those supplements are not FDA regulated or monitored, and so they really don't have to disclose the correct amount that's in there. I mean, a one milligram of my melatonin is probably equivalent to you taking three of those 10 milligram gummies that you get from Walmart. It's completely different. And so I'm making sure that patients are on the right supplements in addition to treating their hormones. Kirstin (27:49): Mary Emma, have you ever heard of any side effects from these bioidentical hormones or hormone replacement therapy? Mary Emma (27:55): Yes, I have had patients experience side effects, and my best method to prevent, I'll get into all of them, but my best method to prevent them is to start low and go slow. Progesterone, like I talked about, is very important for sleep and for anxiety. But a lot of times, if you've been deficient of progesterone for a long time, and like I said, it works on those GABA receptors in your brain, if I were to just start a patient on a high dose of progesterone, they're going to feel sleepy. And that's just because it's working on that calming area. And yet you may feel calmed where you're sleepy during the day. So starting at a lower dose and working the patient up, yes, they need the higher dose. A lot of these patients come in, and I would love to be able to put them on a high dose, but starting low and going slow helps to prevent those symptoms. Mary Emma (28:49): Nipple tenderness, breast tenderness, those can occur with testosterone. Some localized swelling can occur. And again, starting with a low cream and building up, a lot of times I don't, if someone has never had testosterone before as in testosterone replacement, I don't want to go ahead and pellet a high dose testosterone because then they may experience those symptoms. So typically I would start a patient on a cream, work, build those numbers up a little bit, and then they could switch to a pellet. So there's a method to my madness on how I like to go about doing the different hormones to prevent those side effects. But no major side effects like the synthetic ones cause. Dr. Koehler (29:30): Well, first of all, I would just like to say everything has side effects. Water has side effects. You drink too much water, you're going to pee a lot. You can actually die from water, taking in too much water. So anything in excess can have side effects and problems. But when it comes to, for instance, with testosterone replacement, I mean for men, we're not going to typically treat men unless they're at least age 40. We're typically treating older men. And the main reason is is that it can decrease your sperm production. So if you're in your forties and you're like, I just want to get back out in the dating scene and I want to build some muscle and I want to look good and all that kind of stuff, well, that's great, but if you're still maybe planning on having more kids, we got to think this through. And the other thing is it can cause testicular atrophy, your balls are going to get smaller because your body's not making it anymore unless you're a surgeon. They don't shrink them, they stay the same time, they actually get bigger. But those are important things that people do need to know. And we go through that in the process. And we talked about testosterone for women, and one of the things that I've heard a million times like, "well, I don't want to take testosterone. I don't want my clitoris to get huge" and all this stuff. And I'm like, yes. I mean, obviously those things can happen, but typically those are in much higher doses, but that's not typical. But again, side effects, there can be some, yes. Mary Emma (31:04): Sometimes we have a treatment for those side effects. So whether someone is experiencing facial acne or hair growth, I can put them on spironolactone and that fixes all their problems. So side effects are very minimal, and usually the benefits far outweigh the side effects. Kirstin (31:23): So what is my first step if I do a little research or see an ad or look you up on social media and I see that hormone replacement therapy might be right for me, what do I do? Mary Emma (31:38): So it's hard for a patient to determine whether hormone replacement therapy is right for them, but that's kind of our job. And so when someone is thinking, "maybe I may have some of these symptoms, I didn't realize that my sleep was related to my hormones and things like that," they can just call the office. So call the office, send a message to me, I'll give the patients a call, talk with them about all their symptoms and what they expect to see improvement on, and then we'll go from there. Dr. Koehler (32:09): Well, what would you say for, let's just not talk about the polycystic ovarian syndrome patients, but our typical menopausal patients and even some of our male patients, older male patients. What are the common symptoms that we're seeing that we may see that are related to hormones? What should people be looking for if they go like, "oh, I've got these symptoms. Could it be related to my hormones?" What would you say the top five or 10 symptoms would be? Mary Emma (32:43): So for both men and women, top five symptoms would probably be fatigue, decreased libido, hot flashes, or just temperature. Irregulation in general. I mean, I feel like those are my biggest. Weight gain. Dr. Koehler (32:57): Weight gain, insomnia. Mary Emma (32:59): Yeah, midsection weight gain and then sleep, insomnia. Dr. Koehler (33:02): I mean, I think those are some of the big ones. Weight gain, problems sleeping, depression, anxiety, fatigue, mental fog, maybe temperature regulations, things. And then with women, hot flashes. But I think one of the reasons, and the one we touched on earlier is the issue with weight regulation. And again, I would just like to emphasize something that every person that has a weight problem doesn't have a hormone problem. But there are certainly patients that have weight problems that do have hormone problems. And so again, as Mary Emma said, it's part of our job to try to help find out what areas we can help people with, especially the things that they can't, don't necessarily have any control over. You can maybe modify your diet and you can modify exercise, but you can't change. You can't go, "Hey, body, produce more of this hormone that I need to be able to decrease the amount of visceral fat that I'm storing in my abdomen." Dr. Koehler (34:03): And so again, I think the understanding of what going into this is like, yes, we're going to assess you. We're going to see what your symptoms are. We're going to run a very extensive panel of labs to hopefully see if any of these things are out of whack or that we can optimize. Sometimes the lab value can be normal, but as Mary Emma said before, it's normal for an average person, but it might not be normal for you. So if we try by increasing your levels, does that improve your symptoms? I think that's really where we are really hoping to make the biggest change in people, is to go, alright, provided you're doing other things that we're going to counsel you on that this is all part of a big puzzle and this is one piece of it, which is the hormones, and that's what we're going to try to at least make sure that's in the optimal range. Kirstin (34:54): Tell us about yourself. I know you said you're from Fairhope. What do you and Clay like to do for fun? Or do you have family here? How does that look? Mary Emma (35:07): Yes. So I was born and raised in Fairhope, born at Thomas Hospital, and I went to Fairhope schools my whole life. So this is my hometown. All of my family is from here. So both sides of my family, my husband's entire family is from here. So I'm very blessed to have so many wonderful people around me. And I do feel like it's good that I know a lot of these patients already walking in the door because I've grown up in this town and have seen them forever. On the weekends, me and Clay like to go on the boat. We're down at the beach and hanging out with friends. I'm in a wedding almost every weekend right now, so that consumes a lot of my life. Kirstin (35:43): Do you have a burning question for Dr. Koehler or me or Mary Emma? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler. Mary Emma (35:57): Thanks, Dr. Koehler and Kirstin. Kirstin (36:00): Go back to making Alabama beautiful. Announcer (36:02): Got a question for Dr. Koehler? Leave us a voicemail at alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at @easternshorecosmeticsurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.