May 21, 2025 • 36 mins
Hormones control everything from your mood to your metabolism, and when they're out of balance, quality of life can suffer dramatically. In this eye-opening conversation with Dr. Julie Gould, OB-GYN, we explore the world of hormone replacement therapy and its potential to transform women's health.
Dr. Gould brings clarity to a field often clouded by misconceptions, particularly around cancer risks. She explains how the medical community has dramatically revised its understanding since the Women's Health Initiative study, with the North American Menopausal Society now stating they do not believe hormones cause cancer. For many women, this new understanding opens doors to treatment options that can address debilitating symptoms while potentially offering long-term health benefits.
Beyond just treating hot flashes (which aren't even the most common complaint), hormone therapy addresses a constellation of issues including sleep disturbances, vaginal dryness, diminished libido, joint pain, and cognitive concerns. Dr. Gould walks through the various administration methods—from patches that bypass liver metabolism to gels, pills, rings, and more—helping listeners understand which options might work best for their unique situations.
Perhaps most surprising is Dr. Gould's discussion of testosterone in women. Most people don't realize women naturally have 10 times more testosterone than estrogen in their bodies, and when those levels decline, it can lead to fatigue, brain fog, and loss of vitality. Despite this, there are no FDA-approved testosterone products specifically for women in the US, though they exist in other countries.
This conversation represents a shift toward proactive health optimization rather than just treating diseases after they develop. Whether you're currently experiencing menopausal symptoms or simply want to understand what options might be available in the future, Dr. Gould provides the knowledge needed to make informed decisions about hormonal health at every stage of life.
Ready to learn more? Call Dr. Gould's office at 314-205-6788 to schedule a consultation and discover if hormone replacement therapy might be right for you.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello, this is Jason Edwards and this is Doc
Discussions.
I'm here with my friend, drJulie Gould.
She's an OB-GYN.
Julie, how are you doing today?
Speaker 2 (00:07):
I am fantastic, thank you.
Speaker 1 (00:08):
Yeah, welcome.
And so tell us a little bitabout yourself.
Where are you from originally?
Speaker 2 (00:13):
Oh well, that might take your whole podcast.
I'm actually from the WestCoast, I'm from the Bay Area.
San Jose is where I lived tillI was about 13, then moved to
Northern Nevada, where 13, thenmoved to Northern Nevada where I
went to high school andundergrad and then actually
residency is what brought me outto St Louis and I never thought
in a million years I'd be like,yes, I want to live in St Louis
.
But I actually ranked it was StJohn's Mercy at the time.
(00:37):
I ranked them number one for myresidency and got it and then
just had wonderful experiencethere for residency, met some
great people, and then just hadwonderful experience there for
residency, met some great people, and then we decided to stay
here.
Speaker 1 (00:48):
So yeah, so Mercy's residency program.
It's a what they call acommunity program right.
And but it's.
It's a very highly sought afterresidency program, and
especially these days, I think,as residents or potential
residents care more aboutquality of life.
I think it's only gottenstronger, and so it's attracted
(01:08):
a lot of good talent to the city.
Speaker 2 (01:09):
Yeah.
So what brought me there is?
So I had the best advice I everhad from an OBGYN resident out
of the University of Iowa.
He said do not go to a programthat has fellows.
Speaker 1 (01:21):
And I was like what do?
Speaker 2 (01:22):
you mean by that he goes because you're never going
to get to operate.
He goes, go to a communityprogram.
You get to assist on all thesurgeries.
So, and that was very true,like at a time where, like I, I
got out of residency with like107 vaginal hysterectomies.
And then one of our bigpowerhouse residencies in town
they were on probation becausetheir, their, their residents,
were only doing seven vaginalhysterectomies.
(01:43):
So I feel very blessed that Igot to operate so much as a
resident over there.
Speaker 1 (01:47):
Yeah, actually in part of my training there was a
resident in general surgery froma community program and he came
in for his last year and theattendings just treated him like
an attending.
He got so much respect and hewas treated totally differently
than the residents just becausehe had done so many more cases
and was so capable.
And so, yeah, there'sdefinitely huge benefits from a
(02:11):
program like that.
Speaker 2 (02:12):
And so now you're at St Luke's yes, which I love, and
I have a hard time going backto Mercy now, though, because I
love the community feel of thishospital, though, too, and we
know I mean, I know everybodyhere.
I know you know who I like forgeneral surgery and urology, and
I could get you know cases onwhen I want to.
So, I mean, I've been here, wowsince 2010.
(02:33):
And I'm very thankful andappreciative to St Luke's for
helping me stay here, though,too.
Speaker 1 (02:41):
But a lot of OB-GYNs have privileges at other
hospitals right, yes, yeah, andso you of OB-GYNs have
privileges at other hospitals,right?
Speaker 2 (02:48):
Yes, yeah, and so you work some at Mercy, is that
right?
Yeah, I still deliver at Mercyand I have privileges to do just
general, I mean to do GYNsurgery but I hardly ever go
there.
Same thing with MissouriBaptist we can deliver there,
but we do it more for insurancereasons or sometimes, if there's
like high risk reasons thatsomebody has to go to a certain
facility for the mom or for thebaby.
Speaker 1 (03:07):
Yeah, and I think you probably work with my wife to a
small degree from time to time.
Speaker 2 (03:12):
Yeah, I definitely have consulted your wife.
She's fantastic too, oh thankyou, thank you.
Speaker 1 (03:18):
And so now an OB-GYN practice can be more obstetrics
or more gynecology.
What's the breakup of yours?
Speaker 2 (03:27):
Oh well, that is changing now over the years
because as I age, my populationis aging with me now too.
So I used to be really OB heavy.
Now, like I talk about hormonesquite a bit during the day, so
I mean I'd probably say that I'mprobably.
I mean I'm actually probably50-50 now, which is different
than where I was 10 years ago,where it was probably heavier in
(03:49):
OB.
But, like I said, as all mypopulation is aging with me, we
all have the same problems, andthat's the thing that we've
realized, though, too that aswomen, we talk and we don't feel
good Like we all start talking.
So, you know, one of my friendstalks to another one of her
friends and they hear, like I do.
You know hormone replacementtherapy, where not all GYNs will
do hormone replacement therapy,they'll farm it out to boutique
(04:11):
practices or people that justwant to do hormones all day long
, but I feel like most of my newpatients coming in are coming
in because that's what they want, though.
Speaker 1 (04:21):
And so, yeah, let's get into that.
So why would somebody want tohave hormone replacement therapy
?
What are, like, the mainsymptoms that they're trying to
address?
Speaker 2 (04:28):
Right.
So well, this is going tosurprise you.
The number one complaint cominginto the OBGYN office is not my
cycles are irregular, or I'mhaving problems with my
discharge, or I have hot flashes.
It's I'm gaining weight in themidsection, like universally I
probably hear that about 15times a day, like I don't know
why I'm gaining weight in themidsection, so, and there's a
lot that goes into that, more sothan just hormones.
(04:49):
But that's the number onecomplaint coming in.
But the other things that peoplewill complain about, I mean,
and it's like a whole myriad ofpotential symptoms that people
have, but the most common arelike hot flashes, vaginal
dryness I don't have sex with myhusband anymore.
Can you make me have a libido?
Like that's a huge, huge onethough, too.
(05:10):
And then there's other stuffthat, like I hear, but not quite
as frequently though, togeneral joint aches, dry eyes,
skin changes, people always veryworried about skin changes.
And then there's some peoplethat are just very proactive
with their health though, too,and they've read the books and
they've listened to the podcasts, and they know that, like
(05:30):
estrogen does confer healthbenefits in the sense that it
helps reduce cardiovasculardisease.
In the first five years out frommenopause.
It will have bone protection.
It protects your vagina,protects your bladder.
There's so much good thatestrogen actually does that.
Some people are just proactive,coming in because they're like
look, I want this for longevity,I want this for, you know, for
(05:54):
my brain health, my cognition,and that's why some people come
in.
But it's, you know, it'susually not one thing, it's
several things at one time.
Speaker 1 (06:03):
And it tends to help with all of those things,
correct?
Yes, yeah.
Speaker 2 (06:07):
And different hormones will help with
different things.
So we just really break downwhat we offer them according to
their health history.
Do they have a uterus?
What is the worst of theirsymptoms, and start from there.
Speaker 1 (06:19):
So now, some of the things that make oncologists
nervous especially probably moreso in the past are the risks
with cancer.
Speaker 2 (06:30):
Right right.
Speaker 1 (06:31):
Can you?
Speaker 2 (06:31):
speak to that a little bit.
They have really walked thatback actually, since the Women's
Health Initiative was done andthat was initially the big study
that was done that scaredeverybody off from hormones.
And since that time I don'tfeel like, as far as clinicians
go, we have caught up with whatthe literature actually shows.
North American MenopausalSociety will say that we do not
(06:53):
think that hormones causescancer.
But would I give it to somebodythat has a tremendous family
history of breast cancer?
Or would I give it to somebodywith breast cancer?
No, I wouldn't.
So we do have to, you know,still do a very in-depth family
history, in-depth personalhistory before we decide what it
is that we're doing.
(07:14):
But you know, even with theWomen's Health Initiative study
they did show that women that,like, received estrogen alone
actually had less cases ofbreast cancer than women that
did not have anything at all.
And then the other flaw of thatstudy was that in the estrogen
and progesterone arm of thatstudy they used a progesterone
(07:37):
called medroxyprogesteroneacetate, and so with that, once
they added that progesterone tothe estrogen, they did have what
they thought was clinicalsignificance of increasing
breast cancer.
So what I always tell mypatients is if one in eight
women get breast cancer in theirlifetime.
They thought one in 7.9 wouldget it if you were on those
(07:58):
particular kinds of hormones.
But what they never really wentback and studied was like do we
think it was themedroxyprogesterone acetate,
which is Provera?
Like do we think that thatactually could have been the
culprit?
Nobody ever did the studyafterwards, so nobody really
uses that hormone anymore.
For the progesterone aspect oftheir hormone replacement
therapy.
We all use micronizedprogesterone, which is
(08:20):
Prometrium.
Speaker 1 (08:21):
Yeah, and so yeah, no-transcript.
(08:48):
And if it does have an effect,it's just a fraction of those
patients who would be affectedby it, but you can't get it out
of their mind.
They say the estrogen causedthis, and good luck trying to
convince them otherwise, and Idon't try to.
Speaker 2 (09:03):
When people come into my office, I do not try to talk
them out of that thought.
I don't either, even thoughstatistically it's unlikely,
right.
Speaker 1 (09:09):
You just can't.
People have this anchoring bias.
It's the first thing they hearor the first thing they think
Right and for what it's worth.
I've never had a patient whowas on supplemental estrogen who
had a breast cancer that endedup being anything but like a
very favorable T1A or T1B, erprpositive or T2 negative, like
the most favorable, most curablecancer, right, and in my
(09:31):
estimation you know theiroverall quality of life, despite
having a breast cancer, ashorrible as that is, it was
probably still better from beingon the hormone and I feel like
I'm probably in the minority ofoncologists who would say that.
Speaker 2 (09:46):
I think it's starting to change though actually.
I feel like there's people thatwant studies to be done on
people, after breast cancer,using hormone replacement
therapy maybe not necessarilyestradiol, but being able to use
estriol, because the fact ofthe matter is is that, for some
people, when their estrogen goesaway, they feel miserable,
though, and their quality oflife really does suffer, so they
(10:07):
really do come in going.
What else can you offer me?
What can you give me in thecontext of safety that's going
to correct my hot flashes, thatmake me not feel crazy, that
make it so like my vaginadoesn't hurt all the time?
Every time I try to haverelations with my husband, you
know, so they are desperate,coming in and they want
something else, though, too, andwe do a lot I mean, I do a lot
(10:28):
of, you know, sending messagesto the oncologist saying this is
what the patient would like.
Do you feel comfortable withthis, though, too?
And most of them do feelcomfortable with the basics that
I'm asking for.
And then there's some that youknow we kind of go, we might
have to get a little morecreative.
So you know there is estriolthat can be compounded for you
(10:51):
and that's, you know, a wholedifferent world and some people,
some people you know won't gointo that world but I like to
give people all the options.
Speaker 1 (10:58):
And the vaginal estrogen, the intravaginal
estrogen.
That doesn't look like there'sany risk with that correct.
Speaker 2 (11:03):
Well, it depends on what paper you actually read
though too, but overall we feelcomfortable with the lack of
systemic absorption.
But there are some papers thatsay like, oh, you might absorb a
little bit, and the people thathave, like, serious
estrogen-sensitive cancer.
We tread lightly there and weknow which brands that we like
(11:25):
to use that have less systemicabsorption there too.
Speaker 1 (11:30):
So there may be some absorption, but I've seen some
pretty large studies that didnot show any increase in
incidence of actual cancer.
Yes, yeah, and so to me and thepatients that I've seen on
hormone replacement therapy thewomen it does seem like their
quality of life is better thanaverage.
Now tell me if I'm crazy.
To me they look better.
(11:51):
So I've done this more thanonce.
I've looked at a patient and Isaid I bet she's on estrogen
replacement therapy.
To the nurse and have yeah, andhave nailed it.
Speaker 2 (12:05):
And it's not that common yeah.
Speaker 1 (12:07):
And so.
But to me they have like theirskin looks better.
Yes, I would.
I dare say they look prettierRight.
Speaker 2 (12:14):
And I don't know if it's because these are people
that are proactive with theirhealth, though, too.
Speaker 1 (12:19):
Very well could be, but there are some people.
I mean, I have this beautiful79-year-old that comes in.
Speaker 2 (12:30):
I'm like.
Speaker 1 (12:30):
I want to be her when I'm 79.
It's the people who are like70s or late 70s or 80s who look
really good.
Those tend to be the ones I'mlike.
Speaker 2 (12:35):
I bet they're on hormone replacement, and this
lady always comes in, she's fromCalifornia, gives me her list
of labs that she'd like to havedone, and she knows exactly what
she wants when she comes inthough too.
But I mean, she looks fabulousthough too, and she's very
lively though too, and um and soyeah, so I, I agree that you
could tell the people that arestill on hormones, Um, and yeah,
(12:56):
I 100% agree, yeah, I don'tknow if there's any research on
that, but it's it's like agenesis.
Speaker 1 (13:02):
Yeah, but it seems kind of obvious when you see it,
right yeah.
And now, how can the estrogenbe given?
Is it a pill, an infusion?
Yeah, okay.
Speaker 2 (13:14):
So there's a lot of different ways and I think
there's like 26 differentformulations of ways that you
can give.
Speaker 1 (13:21):
Really yeah, something crazy like that.
So what are the main ones, sothat you can give?
Speaker 2 (13:23):
Really, yeah, something crazy like that.
So what are the main ones?
So I mean, most people's go-toor at least my go-to is probably
starting with a patch, and thereason for that is because
transdermal estrogen actuallydoes have less risk than taking
oral estrogen.
So it bypasses the or I guess itbypasses the first pass system
am I saying that right where itdoesn't go through the liver, so
(13:48):
it doesn't affect thecoagulation cascade as much, and
there was actually this greatarticle that came out in the
British Journal of Medicine inthe last year that looked at
cardiovascular risks associatedwith taking estrogen in
different routes, and they didnot show any risk in DVTs or
blood clots in the arm that hadtransdermal estrogen.
So the people that use thepatch had no increased risk.
So, in general, we try to use apatch.
I often use gels also, though,too, but gels are just not
(14:11):
covered as well from insuranceand, knowing that there's all
these different ways of givingit and different brands that are
available, people always comein and they're like well, I want
to use this, I'm like I'llwrite it for you, but it's going
to cost you $300 because yourinsurance is not going to cover
it.
But they usually cover a patchto start with, and there are
some people patches they justdon't stick to or they don't
(14:31):
like using the daily gel.
And we will use oral though too, and oral estradiol is dirt
cheap, so for some peoplethey're like that's what fits in
my life.
I'm going to use an oralestradiol instead.
But then there's also vaginalrings.
There is actually a ring calledfem ring, which I'm always
learning things.
Every day I'm learning newthings, but there's one called
(14:54):
fem ring that you could insertvaginally, and of course it
helps with vaginal atrophy, painwith intercourse, but it is
absorbed systemically, whereas alot of the other rings are not.
So you could get systemicabsorption of estrogen through
this ring, which is awesome,though too, is that
uncomfortable.
Speaker 1 (15:09):
Do people see it?
No, you don't.
Speaker 2 (15:11):
And that's also like every time somebody comes in and
I show them a ring and go andthere's a ring and they're like
eh, I'm like it is seriously,you will not even notice it's
there and it's a great vehiclefor providing medication, but I
think people are just afraid ofit.
I just want everybody to try itand be like look, you're not
going to notice it and thenthey're afraid they can't get it
(15:34):
out, but it is very easy to getout though too.
But I mean, there's shots,there's pellets.
Pellets is like its ownconversation, that is its own
podcast, but there's pelletsthat a lot of people get.
But yeah, there's severaldifferent ways to give estrogen.
Some are in combo patches, someare in combo pills, but, yeah,
lots of different ways.
Speaker 1 (15:54):
Do you ever treat patients who are premenopausal?
Speaker 2 (15:57):
Yeah, and that's a little bit harder, though, too.
Speaker 1 (16:01):
With insurance or with the patient, or, harder,
how?
Speaker 2 (16:05):
Because we're dealing with a cycle then and so and we
definitely have people that areperimenopausal and you could
get these symptoms, you know,five, even 10 years before your
last menstrual cycle actuallyoccurs.
Yeah, because menopause is whenyou've gone a year without
having a menstrual cycle.
Speaker 1 (16:21):
What's the average age for that Fifty one, fifty
one.
Speaker 2 (16:23):
So yeah, so it could happen.
It A menstrual cycle?
What's the average age for that?
51.
51.
So yeah, so it could happen.
It's considered normal anythingafter 40.
So I have plenty of people thatare 40, 42 coming in and they're
like I just feel like it'scoming, like I'm getting the hot
flashes, I can't sleep, sleep,and I didn't mention sleep
enough, and sleep is actuallyprobably one of the most
important things to haveaddressed, but sleep is one the
(16:46):
first things that go, and it'snot the ability to fall asleep,
but it's the ability to stayasleep, and that's what they'll
mostly start coming in with islike I can't sleep, I'm really
hot, I'm waking up, sweating,but they're still cycling though
, too, so you can't just reallyput a patch on them and then say
you know, use progesteroneevery day, because your cycle is
going to become a little morewonky then.
So that's where we get a littlemore creative.
Sometimes I'll put people onprogesterone for three weeks and
(17:07):
off Using a progesterone IUD.
I love when patients have aprogesterone IUD place, because
it makes giving the estrogenthat much easier, though, too.
Okay, and they don't have thecycles that are all over the
place then also.
Speaker 1 (17:21):
That's interesting, yeah, because typically you just
think postmenopausal, then yougo in and get it.
But but actually I was.
I was discussing this withsomebody before we did the
podcast and they werepremenopausal and they were
saying what about before?
And so that's cool.
Speaker 2 (17:34):
And sometimes we just put people on a low dose birth
control pill, which is is fine.
As long as people aren'tsmokers, as long as they don't
have migraine with aura, as longas they don't have liver
dysfunction, it's fine to putpeople on a low dose pill.
I mean just what?
Basically any birth controlpill is considered low dose now,
but you could put anybody on abirth control pill to control
their symptoms though, too.
Okay, and that's totally finealso, and sometimes it's easy.
Speaker 1 (17:54):
So so when I think of medical care, you're trying to
increase the length of life orthe quality of patients' lives,
and it seems like a lot of theseare a significant increase in
their quality of life.
Speaker 2 (18:06):
Yeah.
Speaker 1 (18:07):
Is there any data on what it does to length of life
at all?
Speaker 2 (18:10):
Yeah, I don't know.
It off the top of my head.
Yeah, but you're going to seeit in different ways, meaning
that if you're on estrogen, yourrisk of hip fracture is going
to decrease.
Speaker 1 (18:23):
Yeah, and that's related to length of life.
Speaker 2 (18:25):
Right right.
So also, if your cardiovascularsystem is improved, then that's
going to increase your lengthof life.
It's going to reduce your risksof dementia, though, too which
I feel like a really big deal isto keep cardiovascular system
in check for your brain health.
More than anything else, though, too which is a really I feel
like a really big deal is tokeep cardiovascular system in
check for your brain health.
More than anything else, though, too.
Speaker 1 (18:43):
A hundred percent.
I mean women have dementia, Ithink, more than men, or
Alzheimer's more than men.
And then you know, one thingthat's to me seems totally
obvious is if you have plaque inyour arteries of your heart,
you probably have plaque in thearteries of your brain.
Speaker 2 (19:00):
Yes.
Speaker 1 (19:01):
And a lot of dementia is vascular dementia, right,
and so, and if you feel better,if you have less psychologically
, you're doing better, right,physically you feel stronger,
right, or probably be moreactive, yes, and so it's now.
It's a hard study to do, uh-huh, you know, because it takes a
long time to see who liveslonger, right, and there's a lot
of selection bias, correct, andthat it would probably be a
(19:24):
healthier person who wouldinitially try this or, on
average, a more educated personwho just knows it exists.
Speaker 2 (19:31):
Right.
There is so much room forstudies to be done in the future
, though, too, and the studiesthat have been done in the past
were not fantastic, and that'spart of the problem.
Like a lot of times, they wouldsay let's, let's, implement
this treatment, but never followlevels on anybody.
So we don't even know, likewhat you know, what level
somebody should be at for theirestradiol or their testosterone
(19:52):
or whatever in time to come,because nobody really followed
that in the past.
So, like it's a huge area thatis open for evaluation.
So, residents, if you'relistening like they could easily
create studies for this, forall your senior projects.
Speaker 1 (20:09):
The.
Now you listen to Peter Atiyah.
Speaker 2 (20:11):
Yeah, so you know he talks about like a brain crash
on him.
Speaker 1 (20:16):
He talks about the old medicine where, like, you
have diseases and you're tryingto treat diseases and then maybe
kind of like a new type ofmedicine, where you're trying to
people don't necessarily havediseases, but you're trying to
optimize their life right, andthis is a little bit more of
that right I mean, obviouslyyou're treating potential future
diseases and things like that,but it's more of like proactive,
(20:36):
trying to make the quality oflife and the length of life
better, right, and which is kindof a cool thing, and I think
all doctors wish we could, or alot of doctors wish we could
kind of address some of thesethings, and so it's kind of a
cool, you know, very forwardthinking it is.
Speaker 2 (20:53):
It is.
Yeah.
I mean, for example, I hadsomebody that came in yesterday
and she'd had a hysterectomy,but she still had her ovaries,
she and she was I think she's 52.
And she's like, I mean, I don'tknow if I've gone through
menopause, because she reallydoesn't have a lot of symptoms,
but she's like, why would I wantto be on estrogen?
And so I kind of said, well,here's the health benefits of it
.
And so she was like, let's look.
(21:13):
So I looked at her labs and,sure enough, I mean, she's in
menopause.
And so, you know, I sent herthe message, and she's going to
come in and talk about, you know, maybe starting on some
transdermal estrogen.
We'll talk about the risksassociated with it, but also,
like the longevity of, like whatestrogen can do, though is so
beneficial for her health.
And so we're going to have thatdiscussion though, too, instead
(21:34):
of just saying, oh, you know,you don't have any symptoms.
Speaker 1 (21:46):
OK, bye, see you next year.
So, yeah, yeah, it's, it's,it's it's kind of an exciting
front, um, I I do feel like,because it's this life
optimization things, uh thingyou can also have, especially in
men's health, with hormonereplacement, it it kind of gets
into this field, um, where Idon't want to say quackery, but
the credibility with somepractices is not the same as
(22:07):
like a doctor working in ahospital doing this, and so it
kind of gets in this gray area.
Speaker 2 (22:14):
It's all.
Everything with hormones is ina gray area, and I do feel like
it is the Wild West out there,and I can't even tell is the
Wild West out there, and I can'teven tell you how many people
come in, and they're like evenfor women, though, too, it's not
just for men Like they'll go tothese boutiques and they'll say
, like I'm on this and this andthis, I'm like I just kind of
pause and I go, ok, and then youknow, if they're feeling good
(22:35):
and they're checking their labsand I think it's in the context
of safety I just let them go,but sometimes I go.
I don't really agree with this,and I'll tell them why also,
though, too, and they don't evenunderstand why they're on
certain things, though too, andthat's.
the bothersome thing is thatthey don't know why they're
taking this, this or that, andsometimes I'm like I don't know
why you're on it.
Speaker 1 (22:55):
But you know, those places wouldn't exist if there
weren't a market for that thatis not being met, you know, with
practitioners, right right, andso you know kind of looking
forward.
My hope is that you knowreputable, you know
practitioners can kind of fillin that market, right right.
Speaker 2 (23:19):
And it's hard though, because it's time consuming and
like, unfortunately, in, youknow, in in medicine these days
it's very volume driven, thoughtoo Like you should be seeing
this many patients each day inorder to produce a profit,
though, too, and it doesn'tleave a lot of time to talk
about all those important things, and that's where all of these
other boutiques are coming in.
Speaker 1 (23:39):
Yeah.
Speaker 2 (23:39):
And that's where they're finding like, okay,
people really do want this.
I mean, from my standpoint forwomen, I mean it's a combination
of GLP-1s, testosterone andthen just general hormone
replacement therapy.
That is like a huge boom forall of these boutique practices
right now Because people want,oh, and pellets.
Pellets is like this otherthing.
(24:00):
That's a money, huge moneymakerfor people, and so people want
physicians, want easier livesand to be able to go in and
charge a premium to see patientsfor you know, like, see a small
amount of patients for a hugeamount of money is very, you
know, it's appealing though too.
Yeah, sure, but that's you know,that's where people are.
(24:21):
I mean, people are making it upas they go.
I mean we're all kind of makingit up as we go, because they
don't teach this in residencyand all of it's so new.
We're all figuring it outtogether as we go and I've
definitely had clinicalexperience with different things
where I'm like, okay, I coulddo this and this and this, and
(24:41):
then, you know, then I can'tfollow somebody's levels.
Well, and people are all overthe place and I decide I don't
like it that way, let's do itlike this.
And it's talking to colleaguesand seeing what they're doing.
And I mean I wish we hadsomething in town where, like,
we could, you know, bouncethings off of each other for
what's working for them Like aconsortium where you can yes,
yeah and that just doesn't existother for what's working for
them Like a consortium where youcan yes, yeah, and that just
doesn't exist and I don't wantto.
Speaker 1 (25:02):
You know, I don't know what goes on in any of
these like a boutique.
I'm sure some of them are great.
Speaker 2 (25:07):
Yeah.
Speaker 1 (25:14):
But it, but it just it does kind of you.
I understand people, you know,charging more for the time and
the effort, and plenty of peopleare are obviously happy to pay
it.
Yeah, um, and so it's not likeanybody's being wronged, right,
but, but, um, but sometimes you,you just I do think there's a
credibility issue, um and it's,and it's hard to say who's kind
of more legitimate or notlegitimate.
Speaker 2 (25:36):
Right Right Without you know, throwing stones Right
Right.
Speaker 1 (25:40):
Um, but you know, throwing stones Right, right,
but, but my, my expectation isin the next 10 years, you know,
some of this stuff will getsorted out.
Speaker 2 (25:45):
Yeah.
Speaker 1 (25:46):
Yeah, you know, whether it's Gregori views or
whatever, yeah.
Speaker 2 (25:49):
And I honestly don't even know.
I mean like, for I mean, howlong have pellets been out?
Pellets have been out forever.
There's no FDA.
There's no FDA checks andbalance system for any of that,
not for supplements, you know.
So compounding pharmacies likenothing, and and and even though
I use reputable compoundingpharmacies, I'm still always
(26:10):
amazed that nobody is lookinginto like the products are
actually giving to people.
And that's okay, like I mean.
And I mean, the government saysthat that's okay, but I just
don't understand it.
Yeah, I just don't get it, youknow.
Speaker 1 (26:23):
Yeah.
Speaker 2 (26:23):
I mean one of my, one of my friends came to see me
and she's like oh, I, you know,I want to be evaluated for
hormones.
And I drew her labs and hertestosterone was through the
roof.
And I'm like, are you takingtestosterone?
She's like no, and she's like,I mean, I'm taking this thing
that I got somewhere, and Idon't even know where it was.
Like she got it on like YouTubeor something like that, and it
was like DHEA, 100 milligrams,which converts to testosterone,
(26:46):
and her testosterone was throughthe roof.
How about that?
But she doesn't know that.
She doesn't know that hertestosterone is going to be
super high and she might startto have like side effects from
it and they could just get thatover the counter.
Speaker 1 (26:58):
There's a lot of supplements, too, that you can
buy and, to be honest, like youkind of have no idea, especially
for testosterone.
You know, guys lifting weightsand stuff like that.
And you kind of you're hoping,you know.
It's like oh, it seems likeit's got 10,000 Google reviews
and most of them seem goodbecause, like guys were able to
bench press more or something.
(27:19):
And like you, just go with it.
It's kind of crazy and it's notlike they do clinical trials on
these things.
They're FDA approved, meaningit's probably not going to kill
you.
Speaker 2 (27:31):
Right.
Speaker 1 (27:32):
But it's not like a high standard.
Speaker 2 (27:34):
Right?
Well, it's even worse for women, because we steal all of men's
products for testosterone.
We do Because they won't approveanything for women, even though
men's products for testosteronewe do, because they won't
approve anything for women.
Even though it's approved inAustralia and England, they
won't approve in a testosteroneproduct for women.
So we take men's and we take afraction of what it is that men
use, which is silly in itself.
(27:55):
So, once again, like we, wekind of have to resort to like
what are you doing?
What are you doing?
What are you doing to figureout how to actually to dose it
for people, though, too?
Speaker 1 (28:08):
So you know for the audience.
You know, everybody knows thatmen, you know, need testosterone
or have testosterone.
Why would a woman needtestosterone?
Speaker 2 (28:16):
So we so women actually have 10 times more
testosterone in their systemthan they do estrogen and
progesterone, but nobody knowsthat because of how it's
actually reported on labs.
So like for women testosteroneor for just in general
testosterone, is reported inlike nanograms per deciliter,
and then for estrogen it'sreported in picograms, so it
(28:38):
looks on paper like these thingsare the same, but they're very
different as far as like theamount that we have.
So women produce testosteronethroughout their life and then
they, you know, they have theirpeak, you know, mid, probably
like mid 30s.
It starts to come down a littlebit after that then, and it
continues to drop.
For us though also, and we feelbad when our testosterone drops
also.
Speaker 1 (28:57):
Yeah.
Speaker 2 (28:57):
So our adrenal glands produce it, our ovaries produce
it, but as it drops for us,then we start to feel the
effects of it also, and theeffects of low testosterone is a
couple of different things.
So, if you have fatigue and lowlibido is always one that
people have and there's a lot ofdifferent things that
contribute to that, but lowlibido is a big issue and then
(29:21):
brain fog Brain fog is a hugething, and that could be
estrogen or it could betestosterone, though.
So a lot of times when patientsare telling me about what their
symptoms are, we kind of go OK,are you interested in
testosterone?
These are the different waysthat you can do it.
Also, this is how much it willcost.
If you go through compounding,if you use a gel that's
(29:42):
prescribed by me, if you doshots, go through all that with
them.
Here's the side effects.
You know.
You can grow potentially facialhair or acne.
I would say whatever you thinkof, like an 18 year old boy with
a great libido, but acne and alot and facial hair.
That potentially could be yourside effect.
Um, and and my goal is not torun people super high, like I
don't want to run people in thehundreds, but I usually will say
(30:04):
somewhere between like 40 and80 is like the sweet spot.
Speaker 1 (30:07):
Which is pretty low, I mean.
Speaker 2 (30:08):
It is.
It's like where you'd be whenyou're 20 or 30 years old, for
reference.
Speaker 1 (30:12):
you know a man is going to have maybe between 200
and 800 roughly, and so that's,you know you're probably very
few people would grow facialhair.
Speaker 2 (30:26):
I would think, yeah, yeah, and if people do start, if
they complain about a littlebit of acne, then sometimes
we'll give them spironolactone,which is what we just use in
general for acne, for forhormonal acne so we just could
give them a little bit of thatto counteract it, though, too.
But some of my patients doreally really well on
testosterone, though, too, andsometimes they use it alone, or
sometimes they'll use it incombination with things, though,
too.
I think the moral of the storyis there's like a million
different ways to do hormones,and just trying to figure out
(30:48):
what is right for you is, likeis what we're usually shooting
for, and we don't always get itright the first time, like we
try this, we try this, we trythis, and then we, you know, we
see what sticks like what.
Where do you feel good?
Speaker 1 (31:03):
Okay Now how often do people have to get their blood
checked?
Speaker 2 (31:06):
typically, yeah, so I'll do it about every three
months, starting out until wefigure out what your happy spot
is, and then and then and thenI'll just usually do it.
You know, for testosterone wecould only refill every six
months, so we should check aboutevery six months.
Refill every six months, so weshould check about every six
months.
But there's some people thathave been on the same thing
forever and like, I don't evencheck them anymore though.
Speaker 1 (31:22):
Okay, Now with, I know, with like testosterone.
Like in general with men, I'magainst them using exogenous
testosterone until they're older, maybe like 65 or 70.
That's just me personally.
I'm not an expert in it,because it's really hard if you
(31:47):
have to come off of it, guys canhave a really tough time and
it's cycled.
Where you take it every sooften Is the hormones that you
provide.
Are they cycled where you takethem so often?
Then go on break, or do you gostraight through?
Speaker 2 (31:58):
We just go straight through.
Speaker 1 (32:00):
Got you.
And then how do people do ifthey have to come off, them go
on break, or or or you gostraight through, we just go
straight through.
Speaker 2 (32:05):
And then how do people do if they have to come
off them?
Um, usually, I'm usually notpart of that decision.
They usually stop and then theycome in a couple of months
later and go I stopped myhormones.
I mean, they really.
It's not a conversation peopleever ask me is how do I come off
of it?
They just decide like, well,you know what?
I had this side effect, Ididn't like how I felt on it,
and then they just stop it.
Speaker 1 (32:19):
How do they do?
Speaker 2 (32:21):
Uh, on what testosterone?
Speaker 1 (32:23):
or anything, Either one.
Like when they come off, dothey have a tough time?
Speaker 2 (32:32):
Um, well, with the hot flashes, yes, yeah for sure
For the hot.
Probably hot flashes more thananything else, Um, and that's, I
mean that's a huge problem forwomen, Like even I mean three
times today I had women thatwere in their late 60s that came
in, and they were like I'mhaving problems with hot flashes
again though too.
So we know that, like when youtake people off of it, it could,
you could, go back to that samestate of like.
Look, you're newlypostmenopausal again though too.
So so it can, it can drop.
Speaker 1 (32:54):
Yeah, you know I.
I see patients who end uphaving estrogen positive
breastitive breast cancer and sothey have to come off the
supplementation.
Speaker 2 (33:00):
And it's the hot flashes and the vaginal dryness
seem to be like the two big onesand they do not like it.
Speaker 1 (33:06):
I mean, it's tough.
Speaker 2 (33:08):
There is Vioza, though, so I love Vioza.
Now for the appropriatecandidate for people that can't
have estrogen anymore, andwhat's Vioza?
Vioza is now.
It's a medicine that's out,that you take orally daily.
That basically resets how yourbody interprets heat, so you
don't have the hot flashesanymore, I think it works in the
hypothalamus, but it's totallynon-hormonal, so that's very
(33:29):
appealing to people and it workswell.
The caveat is that you have tohave your liver function checked
, though, too, so I go threemonths, six months, to make sure
that it's not affecting yourliver.
So that scares a lot of peopleoff, but my patients that have
been on it that have always hadnormal liver function.
It's worked really really wellfor them, though, too.
Speaker 1 (33:49):
That's great.
Speaker 2 (33:49):
It's definitely something.
Speaker 1 (33:50):
Yeah, the hot flashes are a big deal.
And when?
Speaker 2 (33:58):
I see men for prostate cancer.
Speaker 1 (33:58):
If it's advanced, they have to have a testosterone
blocker.
And when I'm telling them, men,these are going to be the side
effects of the testosteroneblocker.
The two main ones are hotflashes and then they have zero
libido.
Speaker 2 (34:08):
Can men use Vioza then too?
Speaker 1 (34:10):
And so I don't know.
I mean, it's probably worthtrying, but the hot flashes are
short-lived because they'reusually not on the
antidepressant deprivation.
I mean sometimes it's sixmonths, sometimes it's two years
.
Every single time you know, youfeel the hot flashes aren't
good we can all agree on that.
Every single time I tell themthey're going to have the hot
flashes, their wife laughs atthem.
Speaker 2 (34:29):
And I just feel like that's me.
Welcome to my world.
Speaker 1 (34:32):
I think you know there's no sympathy.
You would think they would havesympathy, but no, it's like
they're gleeful.
Speaker 2 (34:39):
That's like when dads have to go get their
vasectomies and they're like, oh, woe is me.
I'm like, did you just see whatyour wife went through?
Speaker 1 (34:47):
Cry me a river.
Well, Julie, I reallyappreciate you.
Speaker 2 (34:52):
We've had many mutual patients over the years and so
thank you for coming in.
Speaker 1 (34:57):
I think this is going to be a really popular episode
and I think a lot of people willbe interested in it.
Speaker 2 (35:00):
Yeah, yeah.
If you want anything more, ifyou want to talk about anything
in the future, just let me know.
Speaker 1 (35:04):
I'll be happy to.
Speaker 2 (35:06):
I feel very comfortable doing this.
Speaker 1 (35:07):
And how would people get a hold of you?
Do you have a number?
Speaker 2 (35:10):
Yeah, my office number is 314-205-6788.
And I'm
Hello, this is Jason Edwards and this is Doc
Discussions.
I'm here with my friend, drJulie Gould.
She's an OB-GYN.
Julie, how are you doing today?
Speaker 2 (00:07):
I am fantastic, thank you.
Speaker 1 (00:08):
Yeah, welcome.
And so tell us a little bitabout yourself.
Where are you from originally?
Speaker 2 (00:13):
Oh well, that might take your whole podcast.
I'm actually from the WestCoast, I'm from the Bay Area.
San Jose is where I lived tillI was about 13, then moved to
Northern Nevada, where 13, thenmoved to Northern Nevada where I
went to high school andundergrad and then actually
residency is what brought me outto St Louis and I never thought
in a million years I'd be like,yes, I want to live in St Louis
.
But I actually ranked it was StJohn's Mercy at the time.
(00:37):
I ranked them number one for myresidency and got it and then
just had wonderful experiencethere for residency, met some
great people, and then just hadwonderful experience there for
residency, met some great people, and then we decided to stay
here.
Speaker 1 (00:48):
So yeah, so Mercy's residency program.
It's a what they call acommunity program right.
And but it's.
It's a very highly sought afterresidency program, and
especially these days, I think,as residents or potential
residents care more aboutquality of life.
I think it's only gottenstronger, and so it's attracted
(01:08):
a lot of good talent to the city.
Speaker 2 (01:09):
Yeah.
So what brought me there is?
So I had the best advice I everhad from an OBGYN resident out
of the University of Iowa.
He said do not go to a programthat has fellows.
Speaker 1 (01:21):
And I was like what do?
Speaker 2 (01:22):
you mean by that he goes because you're never going
to get to operate.
He goes, go to a communityprogram.
You get to assist on all thesurgeries.
So, and that was very true,like at a time where, like I, I
got out of residency with like107 vaginal hysterectomies.
And then one of our bigpowerhouse residencies in town
they were on probation becausetheir, their, their residents,
were only doing seven vaginalhysterectomies.
(01:43):
So I feel very blessed that Igot to operate so much as a
resident over there.
Speaker 1 (01:47):
Yeah, actually in part of my training there was a
resident in general surgery froma community program and he came
in for his last year and theattendings just treated him like
an attending.
He got so much respect and hewas treated totally differently
than the residents just becausehe had done so many more cases
and was so capable.
And so, yeah, there'sdefinitely huge benefits from a
(02:11):
program like that.
Speaker 2 (02:12):
And so now you're at St Luke's yes, which I love, and
I have a hard time going backto Mercy now, though, because I
love the community feel of thishospital, though, too, and we
know I mean, I know everybodyhere.
I know you know who I like forgeneral surgery and urology, and
I could get you know cases onwhen I want to.
So, I mean, I've been here, wowsince 2010.
(02:33):
And I'm very thankful andappreciative to St Luke's for
helping me stay here, though,too.
Speaker 1 (02:41):
But a lot of OB-GYNs have privileges at other
hospitals right, yes, yeah, andso you of OB-GYNs have
privileges at other hospitals,right?
Speaker 2 (02:48):
Yes, yeah, and so you work some at Mercy, is that
right?
Yeah, I still deliver at Mercyand I have privileges to do just
general, I mean to do GYNsurgery but I hardly ever go
there.
Same thing with MissouriBaptist we can deliver there,
but we do it more for insurancereasons or sometimes, if there's
like high risk reasons thatsomebody has to go to a certain
facility for the mom or for thebaby.
Speaker 1 (03:07):
Yeah, and I think you probably work with my wife to a
small degree from time to time.
Speaker 2 (03:12):
Yeah, I definitely have consulted your wife.
She's fantastic too, oh thankyou, thank you.
Speaker 1 (03:18):
And so now an OB-GYN practice can be more obstetrics
or more gynecology.
What's the breakup of yours?
Speaker 2 (03:27):
Oh well, that is changing now over the years
because as I age, my populationis aging with me now too.
So I used to be really OB heavy.
Now, like I talk about hormonesquite a bit during the day, so
I mean I'd probably say that I'mprobably.
I mean I'm actually probably50-50 now, which is different
than where I was 10 years ago,where it was probably heavier in
(03:49):
OB.
But, like I said, as all mypopulation is aging with me, we
all have the same problems, andthat's the thing that we've
realized, though, too that aswomen, we talk and we don't feel
good Like we all start talking.
So, you know, one of my friendstalks to another one of her
friends and they hear, like I do.
You know hormone replacementtherapy, where not all GYNs will
do hormone replacement therapy,they'll farm it out to boutique
(04:11):
practices or people that justwant to do hormones all day long
, but I feel like most of my newpatients coming in are coming
in because that's what they want, though.
Speaker 1 (04:21):
And so, yeah, let's get into that.
So why would somebody want tohave hormone replacement therapy
?
What are, like, the mainsymptoms that they're trying to
address?
Speaker 2 (04:28):
Right.
So well, this is going tosurprise you.
The number one complaint cominginto the OBGYN office is not my
cycles are irregular, or I'mhaving problems with my
discharge, or I have hot flashes.
It's I'm gaining weight in themidsection, like universally I
probably hear that about 15times a day, like I don't know
why I'm gaining weight in themidsection, so, and there's a
lot that goes into that, more sothan just hormones.
(04:49):
But that's the number onecomplaint coming in.
But the other things that peoplewill complain about, I mean,
and it's like a whole myriad ofpotential symptoms that people
have, but the most common arelike hot flashes, vaginal
dryness I don't have sex with myhusband anymore.
Can you make me have a libido?
Like that's a huge, huge onethough, too.
(05:10):
And then there's other stuffthat, like I hear, but not quite
as frequently though, togeneral joint aches, dry eyes,
skin changes, people always veryworried about skin changes.
And then there's some peoplethat are just very proactive
with their health though, too,and they've read the books and
they've listened to the podcasts, and they know that, like
(05:30):
estrogen does confer healthbenefits in the sense that it
helps reduce cardiovasculardisease.
In the first five years out frommenopause.
It will have bone protection.
It protects your vagina,protects your bladder.
There's so much good thatestrogen actually does that.
Some people are just proactive,coming in because they're like
look, I want this for longevity,I want this for, you know, for
(05:54):
my brain health, my cognition,and that's why some people come
in.
But it's, you know, it'susually not one thing, it's
several things at one time.
Speaker 1 (06:03):
And it tends to help with all of those things,
correct?
Yes, yeah.
Speaker 2 (06:07):
And different hormones will help with
different things.
So we just really break downwhat we offer them according to
their health history.
Do they have a uterus?
What is the worst of theirsymptoms, and start from there.
Speaker 1 (06:19):
So now, some of the things that make oncologists
nervous especially probably moreso in the past are the risks
with cancer.
Speaker 2 (06:30):
Right right.
Speaker 1 (06:31):
Can you?
Speaker 2 (06:31):
speak to that a little bit.
They have really walked thatback actually, since the Women's
Health Initiative was done andthat was initially the big study
that was done that scaredeverybody off from hormones.
And since that time I don'tfeel like, as far as clinicians
go, we have caught up with whatthe literature actually shows.
North American MenopausalSociety will say that we do not
(06:53):
think that hormones causescancer.
But would I give it to somebodythat has a tremendous family
history of breast cancer?
Or would I give it to somebodywith breast cancer?
No, I wouldn't.
So we do have to, you know,still do a very in-depth family
history, in-depth personalhistory before we decide what it
is that we're doing.
(07:14):
But you know, even with theWomen's Health Initiative study
they did show that women that,like, received estrogen alone
actually had less cases ofbreast cancer than women that
did not have anything at all.
And then the other flaw of thatstudy was that in the estrogen
and progesterone arm of thatstudy they used a progesterone
(07:37):
called medroxyprogesteroneacetate, and so with that, once
they added that progesterone tothe estrogen, they did have what
they thought was clinicalsignificance of increasing
breast cancer.
So what I always tell mypatients is if one in eight
women get breast cancer in theirlifetime.
They thought one in 7.9 wouldget it if you were on those
(07:58):
particular kinds of hormones.
But what they never really wentback and studied was like do we
think it was themedroxyprogesterone acetate,
which is Provera?
Like do we think that thatactually could have been the
culprit?
Nobody ever did the studyafterwards, so nobody really
uses that hormone anymore.
For the progesterone aspect oftheir hormone replacement
therapy.
We all use micronizedprogesterone, which is
(08:20):
Prometrium.
Speaker 1 (08:21):
Yeah, and so yeah, no-transcript.
(08:48):
And if it does have an effect,it's just a fraction of those
patients who would be affectedby it, but you can't get it out
of their mind.
They say the estrogen causedthis, and good luck trying to
convince them otherwise, and Idon't try to.
Speaker 2 (09:03):
When people come into my office, I do not try to talk
them out of that thought.
I don't either, even thoughstatistically it's unlikely,
right.
Speaker 1 (09:09):
You just can't.
People have this anchoring bias.
It's the first thing they hearor the first thing they think
Right and for what it's worth.
I've never had a patient whowas on supplemental estrogen who
had a breast cancer that endedup being anything but like a
very favorable T1A or T1B, erprpositive or T2 negative, like
the most favorable, most curablecancer, right, and in my
(09:31):
estimation you know theiroverall quality of life, despite
having a breast cancer, ashorrible as that is, it was
probably still better from beingon the hormone and I feel like
I'm probably in the minority ofoncologists who would say that.
Speaker 2 (09:46):
I think it's starting to change though actually.
I feel like there's people thatwant studies to be done on
people, after breast cancer,using hormone replacement
therapy maybe not necessarilyestradiol, but being able to use
estriol, because the fact ofthe matter is is that, for some
people, when their estrogen goesaway, they feel miserable,
though, and their quality oflife really does suffer, so they
(10:07):
really do come in going.
What else can you offer me?
What can you give me in thecontext of safety that's going
to correct my hot flashes, thatmake me not feel crazy, that
make it so like my vaginadoesn't hurt all the time?
Every time I try to haverelations with my husband, you
know, so they are desperate,coming in and they want
something else, though, too, andwe do a lot I mean, I do a lot
(10:28):
of, you know, sending messagesto the oncologist saying this is
what the patient would like.
Do you feel comfortable withthis, though, too?
And most of them do feelcomfortable with the basics that
I'm asking for.
And then there's some that youknow we kind of go, we might
have to get a little morecreative.
So you know there is estriolthat can be compounded for you
(10:51):
and that's, you know, a wholedifferent world and some people,
some people you know won't gointo that world but I like to
give people all the options.
Speaker 1 (10:58):
And the vaginal estrogen, the intravaginal
estrogen.
That doesn't look like there'sany risk with that correct.
Speaker 2 (11:03):
Well, it depends on what paper you actually read
though too, but overall we feelcomfortable with the lack of
systemic absorption.
But there are some papers thatsay like, oh, you might absorb a
little bit, and the people thathave, like, serious
estrogen-sensitive cancer.
We tread lightly there and weknow which brands that we like
(11:25):
to use that have less systemicabsorption there too.
Speaker 1 (11:30):
So there may be some absorption, but I've seen some
pretty large studies that didnot show any increase in
incidence of actual cancer.
Yes, yeah, and so to me and thepatients that I've seen on
hormone replacement therapy thewomen it does seem like their
quality of life is better thanaverage.
Now tell me if I'm crazy.
To me they look better.
(11:51):
So I've done this more thanonce.
I've looked at a patient and Isaid I bet she's on estrogen
replacement therapy.
To the nurse and have yeah, andhave nailed it.
Speaker 2 (12:05):
And it's not that common yeah.
Speaker 1 (12:07):
And so.
But to me they have like theirskin looks better.
Yes, I would.
I dare say they look prettierRight.
Speaker 2 (12:14):
And I don't know if it's because these are people
that are proactive with theirhealth, though, too.
Speaker 1 (12:19):
Very well could be, but there are some people.
I mean, I have this beautiful79-year-old that comes in.
Speaker 2 (12:30):
I'm like.
Speaker 1 (12:30):
I want to be her when I'm 79.
It's the people who are like70s or late 70s or 80s who look
really good.
Those tend to be the ones I'mlike.
Speaker 2 (12:35):
I bet they're on hormone replacement, and this
lady always comes in, she's fromCalifornia, gives me her list
of labs that she'd like to havedone, and she knows exactly what
she wants when she comes inthough too.
But I mean, she looks fabulousthough too, and she's very
lively though too, and um and soyeah, so I, I agree that you
could tell the people that arestill on hormones, Um, and yeah,
(12:56):
I 100% agree, yeah, I don'tknow if there's any research on
that, but it's it's like agenesis.
Speaker 1 (13:02):
Yeah, but it seems kind of obvious when you see it,
right yeah.
And now, how can the estrogenbe given?
Is it a pill, an infusion?
Yeah, okay.
Speaker 2 (13:14):
So there's a lot of different ways and I think
there's like 26 differentformulations of ways that you
can give.
Speaker 1 (13:21):
Really yeah, something crazy like that.
So what are the main ones, sothat you can give?
Speaker 2 (13:23):
Really, yeah, something crazy like that.
So what are the main ones?
So I mean, most people's go-toor at least my go-to is probably
starting with a patch, and thereason for that is because
transdermal estrogen actuallydoes have less risk than taking
oral estrogen.
So it bypasses the or I guess itbypasses the first pass system
am I saying that right where itdoesn't go through the liver, so
(13:48):
it doesn't affect thecoagulation cascade as much, and
there was actually this greatarticle that came out in the
British Journal of Medicine inthe last year that looked at
cardiovascular risks associatedwith taking estrogen in
different routes, and they didnot show any risk in DVTs or
blood clots in the arm that hadtransdermal estrogen.
So the people that use thepatch had no increased risk.
So, in general, we try to use apatch.
I often use gels also, though,too, but gels are just not
(14:11):
covered as well from insuranceand, knowing that there's all
these different ways of givingit and different brands that are
available, people always comein and they're like well, I want
to use this, I'm like I'llwrite it for you, but it's going
to cost you $300 because yourinsurance is not going to cover
it.
But they usually cover a patchto start with, and there are
some people patches they justdon't stick to or they don't
(14:31):
like using the daily gel.
And we will use oral though too, and oral estradiol is dirt
cheap, so for some peoplethey're like that's what fits in
my life.
I'm going to use an oralestradiol instead.
But then there's also vaginalrings.
There is actually a ring calledfem ring, which I'm always
learning things.
Every day I'm learning newthings, but there's one called
(14:54):
fem ring that you could insertvaginally, and of course it
helps with vaginal atrophy, painwith intercourse, but it is
absorbed systemically, whereas alot of the other rings are not.
So you could get systemicabsorption of estrogen through
this ring, which is awesome,though too, is that
uncomfortable.
Speaker 1 (15:09):
Do people see it?
No, you don't.
Speaker 2 (15:11):
And that's also like every time somebody comes in and
I show them a ring and go andthere's a ring and they're like
eh, I'm like it is seriously,you will not even notice it's
there and it's a great vehiclefor providing medication, but I
think people are just afraid ofit.
I just want everybody to try itand be like look, you're not
going to notice it and thenthey're afraid they can't get it
(15:34):
out, but it is very easy to getout though too.
But I mean, there's shots,there's pellets.
Pellets is like its ownconversation, that is its own
podcast, but there's pelletsthat a lot of people get.
But yeah, there's severaldifferent ways to give estrogen.
Some are in combo patches, someare in combo pills, but, yeah,
lots of different ways.
Speaker 1 (15:54):
Do you ever treat patients who are premenopausal?
Speaker 2 (15:57):
Yeah, and that's a little bit harder, though, too.
Speaker 1 (16:01):
With insurance or with the patient, or, harder,
how?
Speaker 2 (16:05):
Because we're dealing with a cycle then and so and we
definitely have people that areperimenopausal and you could
get these symptoms, you know,five, even 10 years before your
last menstrual cycle actuallyoccurs.
Yeah, because menopause is whenyou've gone a year without
having a menstrual cycle.
Speaker 1 (16:21):
What's the average age for that Fifty one, fifty
one.
Speaker 2 (16:23):
So yeah, so it could happen.
It A menstrual cycle?
What's the average age for that?
51.
51.
So yeah, so it could happen.
It's considered normal anythingafter 40.
So I have plenty of people thatare 40, 42 coming in and they're
like I just feel like it'scoming, like I'm getting the hot
flashes, I can't sleep, sleep,and I didn't mention sleep
enough, and sleep is actuallyprobably one of the most
important things to haveaddressed, but sleep is one the
(16:46):
first things that go, and it'snot the ability to fall asleep,
but it's the ability to stayasleep, and that's what they'll
mostly start coming in with islike I can't sleep, I'm really
hot, I'm waking up, sweating,but they're still cycling though
, too, so you can't just reallyput a patch on them and then say
you know, use progesteroneevery day, because your cycle is
going to become a little morewonky then.
So that's where we get a littlemore creative.
Sometimes I'll put people onprogesterone for three weeks and
(17:07):
off Using a progesterone IUD.
I love when patients have aprogesterone IUD place, because
it makes giving the estrogenthat much easier, though, too.
Okay, and they don't have thecycles that are all over the
place then also.
Speaker 1 (17:21):
That's interesting, yeah, because typically you just
think postmenopausal, then yougo in and get it.
But but actually I was.
I was discussing this withsomebody before we did the
podcast and they werepremenopausal and they were
saying what about before?
And so that's cool.
Speaker 2 (17:34):
And sometimes we just put people on a low dose birth
control pill, which is is fine.
As long as people aren'tsmokers, as long as they don't
have migraine with aura, as longas they don't have liver
dysfunction, it's fine to putpeople on a low dose pill.
I mean just what?
Basically any birth controlpill is considered low dose now,
but you could put anybody on abirth control pill to control
their symptoms though, too.
Okay, and that's totally finealso, and sometimes it's easy.
Speaker 1 (17:54):
So so when I think of medical care, you're trying to
increase the length of life orthe quality of patients' lives,
and it seems like a lot of theseare a significant increase in
their quality of life.
Speaker 2 (18:06):
Yeah.
Speaker 1 (18:07):
Is there any data on what it does to length of life
at all?
Speaker 2 (18:10):
Yeah, I don't know.
It off the top of my head.
Yeah, but you're going to seeit in different ways, meaning
that if you're on estrogen, yourrisk of hip fracture is going
to decrease.
Speaker 1 (18:23):
Yeah, and that's related to length of life.
Speaker 2 (18:25):
Right right.
So also, if your cardiovascularsystem is improved, then that's
going to increase your lengthof life.
It's going to reduce your risksof dementia, though, too which
I feel like a really big deal isto keep cardiovascular system
in check for your brain health.
More than anything else, though, too which is a really I feel
like a really big deal is tokeep cardiovascular system in
check for your brain health.
More than anything else, though, too.
Speaker 1 (18:43):
A hundred percent.
I mean women have dementia, Ithink, more than men, or
Alzheimer's more than men.
And then you know, one thingthat's to me seems totally
obvious is if you have plaque inyour arteries of your heart,
you probably have plaque in thearteries of your brain.
Speaker 2 (19:00):
Yes.
Speaker 1 (19:01):
And a lot of dementia is vascular dementia, right,
and so, and if you feel better,if you have less psychologically
, you're doing better, right,physically you feel stronger,
right, or probably be moreactive, yes, and so it's now.
It's a hard study to do, uh-huh, you know, because it takes a
long time to see who liveslonger, right, and there's a lot
of selection bias, correct, andthat it would probably be a
(19:24):
healthier person who wouldinitially try this or, on
average, a more educated personwho just knows it exists.
Speaker 2 (19:31):
Right.
There is so much room forstudies to be done in the future
, though, too, and the studiesthat have been done in the past
were not fantastic, and that'spart of the problem.
Like a lot of times, they wouldsay let's, let's, implement
this treatment, but never followlevels on anybody.
So we don't even know, likewhat you know, what level
somebody should be at for theirestradiol or their testosterone
(19:52):
or whatever in time to come,because nobody really followed
that in the past.
So, like it's a huge area thatis open for evaluation.
So, residents, if you'relistening like they could easily
create studies for this, forall your senior projects.
Speaker 1 (20:09):
The.
Now you listen to Peter Atiyah.
Speaker 2 (20:11):
Yeah, so you know he talks about like a brain crash
on him.
Speaker 1 (20:16):
He talks about the old medicine where, like, you
have diseases and you're tryingto treat diseases and then maybe
kind of like a new type ofmedicine, where you're trying to
people don't necessarily havediseases, but you're trying to
optimize their life right, andthis is a little bit more of
that right I mean, obviouslyyou're treating potential future
diseases and things like that,but it's more of like proactive,
(20:36):
trying to make the quality oflife and the length of life
better, right, and which is kindof a cool thing, and I think
all doctors wish we could, or alot of doctors wish we could
kind of address some of thesethings, and so it's kind of a
cool, you know, very forwardthinking it is.
Speaker 2 (20:53):
It is.
Yeah.
I mean, for example, I hadsomebody that came in yesterday
and she'd had a hysterectomy,but she still had her ovaries,
she and she was I think she's 52.
And she's like, I mean, I don'tknow if I've gone through
menopause, because she reallydoesn't have a lot of symptoms,
but she's like, why would I wantto be on estrogen?
And so I kind of said, well,here's the health benefits of it
.
And so she was like, let's look.
(21:13):
So I looked at her labs and,sure enough, I mean, she's in
menopause.
And so, you know, I sent herthe message, and she's going to
come in and talk about, you know, maybe starting on some
transdermal estrogen.
We'll talk about the risksassociated with it, but also,
like the longevity of, like whatestrogen can do, though is so
beneficial for her health.
And so we're going to have thatdiscussion though, too, instead
(21:34):
of just saying, oh, you know,you don't have any symptoms.
Speaker 1 (21:46):
OK, bye, see you next year.
So, yeah, yeah, it's, it's,it's it's kind of an exciting
front, um, I I do feel like,because it's this life
optimization things, uh thingyou can also have, especially in
men's health, with hormonereplacement, it it kind of gets
into this field, um, where Idon't want to say quackery, but
the credibility with somepractices is not the same as
(22:07):
like a doctor working in ahospital doing this, and so it
kind of gets in this gray area.
Speaker 2 (22:14):
It's all.
Everything with hormones is ina gray area, and I do feel like
it is the Wild West out there,and I can't even tell is the
Wild West out there, and I can'teven tell you how many people
come in, and they're like evenfor women, though, too, it's not
just for men Like they'll go tothese boutiques and they'll say
, like I'm on this and this andthis, I'm like I just kind of
pause and I go, ok, and then youknow, if they're feeling good
(22:35):
and they're checking their labsand I think it's in the context
of safety I just let them go,but sometimes I go.
I don't really agree with this,and I'll tell them why also,
though, too, and they don't evenunderstand why they're on
certain things, though too, andthat's.
the bothersome thing is thatthey don't know why they're
taking this, this or that, andsometimes I'm like I don't know
why you're on it.
Speaker 1 (22:55):
But you know, those places wouldn't exist if there
weren't a market for that thatis not being met, you know, with
practitioners, right right, andso you know kind of looking
forward.
My hope is that you knowreputable, you know
practitioners can kind of fillin that market, right right.
Speaker 2 (23:19):
And it's hard though, because it's time consuming and
like, unfortunately, in, youknow, in in medicine these days
it's very volume driven, thoughtoo Like you should be seeing
this many patients each day inorder to produce a profit,
though, too, and it doesn'tleave a lot of time to talk
about all those important things, and that's where all of these
other boutiques are coming in.
Speaker 1 (23:39):
Yeah.
Speaker 2 (23:39):
And that's where they're finding like, okay,
people really do want this.
I mean, from my standpoint forwomen, I mean it's a combination
of GLP-1s, testosterone andthen just general hormone
replacement therapy.
That is like a huge boom forall of these boutique practices
right now Because people want,oh, and pellets.
Pellets is like this otherthing.
(24:00):
That's a money, huge moneymakerfor people, and so people want
physicians, want easier livesand to be able to go in and
charge a premium to see patientsfor you know, like, see a small
amount of patients for a hugeamount of money is very, you
know, it's appealing though too.
Yeah, sure, but that's you know,that's where people are.
(24:21):
I mean, people are making it upas they go.
I mean we're all kind of makingit up as we go, because they
don't teach this in residencyand all of it's so new.
We're all figuring it outtogether as we go and I've
definitely had clinicalexperience with different things
where I'm like, okay, I coulddo this and this and this, and
(24:41):
then, you know, then I can'tfollow somebody's levels.
Well, and people are all overthe place and I decide I don't
like it that way, let's do itlike this.
And it's talking to colleaguesand seeing what they're doing.
And I mean I wish we hadsomething in town where, like,
we could, you know, bouncethings off of each other for
what's working for them Like aconsortium where you can yes,
yeah and that just doesn't existother for what's working for
them Like a consortium where youcan yes, yeah, and that just
doesn't exist and I don't wantto.
Speaker 1 (25:02):
You know, I don't know what goes on in any of
these like a boutique.
I'm sure some of them are great.
Speaker 2 (25:07):
Yeah.
Speaker 1 (25:14):
But it, but it just it does kind of you.
I understand people, you know,charging more for the time and
the effort, and plenty of peopleare are obviously happy to pay
it.
Yeah, um, and so it's not likeanybody's being wronged, right,
but, but, um, but sometimes you,you just I do think there's a
credibility issue, um and it's,and it's hard to say who's kind
of more legitimate or notlegitimate.
Speaker 2 (25:36):
Right Right Without you know, throwing stones Right
Right.
Speaker 1 (25:40):
Um, but you know, throwing stones Right, right,
but, but my, my expectation isin the next 10 years, you know,
some of this stuff will getsorted out.
Speaker 2 (25:45):
Yeah.
Speaker 1 (25:46):
Yeah, you know, whether it's Gregori views or
whatever, yeah.
Speaker 2 (25:49):
And I honestly don't even know.
I mean like, for I mean, howlong have pellets been out?
Pellets have been out forever.
There's no FDA.
There's no FDA checks andbalance system for any of that,
not for supplements, you know.
So compounding pharmacies likenothing, and and and even though
I use reputable compoundingpharmacies, I'm still always
(26:10):
amazed that nobody is lookinginto like the products are
actually giving to people.
And that's okay, like I mean.
And I mean, the government saysthat that's okay, but I just
don't understand it.
Yeah, I just don't get it, youknow.
Speaker 1 (26:23):
Yeah.
Speaker 2 (26:23):
I mean one of my, one of my friends came to see me
and she's like oh, I, you know,I want to be evaluated for
hormones.
And I drew her labs and hertestosterone was through the
roof.
And I'm like, are you takingtestosterone?
She's like no, and she's like,I mean, I'm taking this thing
that I got somewhere, and Idon't even know where it was.
Like she got it on like YouTubeor something like that, and it
was like DHEA, 100 milligrams,which converts to testosterone,
(26:46):
and her testosterone was throughthe roof.
How about that?
But she doesn't know that.
She doesn't know that hertestosterone is going to be
super high and she might startto have like side effects from
it and they could just get thatover the counter.
Speaker 1 (26:58):
There's a lot of supplements, too, that you can
buy and, to be honest, like youkind of have no idea, especially
for testosterone.
You know, guys lifting weightsand stuff like that.
And you kind of you're hoping,you know.
It's like oh, it seems likeit's got 10,000 Google reviews
and most of them seem goodbecause, like guys were able to
bench press more or something.
(27:19):
And like you, just go with it.
It's kind of crazy and it's notlike they do clinical trials on
these things.
They're FDA approved, meaningit's probably not going to kill
you.
Speaker 2 (27:31):
Right.
Speaker 1 (27:32):
But it's not like a high standard.
Speaker 2 (27:34):
Right?
Well, it's even worse for women, because we steal all of men's
products for testosterone.
We do Because they won't approveanything for women, even though
men's products for testosteronewe do, because they won't
approve anything for women.
Even though it's approved inAustralia and England, they
won't approve in a testosteroneproduct for women.
So we take men's and we take afraction of what it is that men
use, which is silly in itself.
(27:55):
So, once again, like we, wekind of have to resort to like
what are you doing?
What are you doing?
What are you doing to figureout how to actually to dose it
for people, though, too?
Speaker 1 (28:08):
So you know for the audience.
You know, everybody knows thatmen, you know, need testosterone
or have testosterone.
Why would a woman needtestosterone?
Speaker 2 (28:16):
So we so women actually have 10 times more
testosterone in their systemthan they do estrogen and
progesterone, but nobody knowsthat because of how it's
actually reported on labs.
So like for women testosteroneor for just in general
testosterone, is reported inlike nanograms per deciliter,
and then for estrogen it'sreported in picograms, so it
(28:38):
looks on paper like these thingsare the same, but they're very
different as far as like theamount that we have.
So women produce testosteronethroughout their life and then
they, you know, they have theirpeak, you know, mid, probably
like mid 30s.
It starts to come down a littlebit after that then, and it
continues to drop.
For us though also, and we feelbad when our testosterone drops
also.
Speaker 1 (28:57):
Yeah.
Speaker 2 (28:57):
So our adrenal glands produce it, our ovaries produce
it, but as it drops for us,then we start to feel the
effects of it also, and theeffects of low testosterone is a
couple of different things.
So, if you have fatigue and lowlibido is always one that
people have and there's a lot ofdifferent things that
contribute to that, but lowlibido is a big issue and then
(29:21):
brain fog Brain fog is a hugething, and that could be
estrogen or it could betestosterone, though.
So a lot of times when patientsare telling me about what their
symptoms are, we kind of go OK,are you interested in
testosterone?
These are the different waysthat you can do it.
Also, this is how much it willcost.
If you go through compounding,if you use a gel that's
(29:42):
prescribed by me, if you doshots, go through all that with
them.
Here's the side effects.
You know.
You can grow potentially facialhair or acne.
I would say whatever you thinkof, like an 18 year old boy with
a great libido, but acne and alot and facial hair.
That potentially could be yourside effect.
Um, and and my goal is not torun people super high, like I
don't want to run people in thehundreds, but I usually will say
(30:04):
somewhere between like 40 and80 is like the sweet spot.
Speaker 1 (30:07):
Which is pretty low, I mean.
Speaker 2 (30:08):
It is.
It's like where you'd be whenyou're 20 or 30 years old, for
reference.
Speaker 1 (30:12):
you know a man is going to have maybe between 200
and 800 roughly, and so that's,you know you're probably very
few people would grow facialhair.
Speaker 2 (30:26):
I would think, yeah, yeah, and if people do start, if
they complain about a littlebit of acne, then sometimes
we'll give them spironolactone,which is what we just use in
general for acne, for forhormonal acne so we just could
give them a little bit of thatto counteract it, though, too.
But some of my patients doreally really well on
testosterone, though, too, andsometimes they use it alone, or
sometimes they'll use it incombination with things, though,
too.
I think the moral of the storyis there's like a million
different ways to do hormones,and just trying to figure out
(30:48):
what is right for you is, likeis what we're usually shooting
for, and we don't always get itright the first time, like we
try this, we try this, we trythis, and then we, you know, we
see what sticks like what.
Where do you feel good?
Speaker 1 (31:03):
Okay Now how often do people have to get their blood
checked?
Speaker 2 (31:06):
typically, yeah, so I'll do it about every three
months, starting out until wefigure out what your happy spot
is, and then and then and thenI'll just usually do it.
You know, for testosterone wecould only refill every six
months, so we should check aboutevery six months.
Refill every six months, so weshould check about every six
months.
But there's some people thathave been on the same thing
forever and like, I don't evencheck them anymore though.
Speaker 1 (31:22):
Okay, Now with, I know, with like testosterone.
Like in general with men, I'magainst them using exogenous
testosterone until they're older, maybe like 65 or 70.
That's just me personally.
I'm not an expert in it,because it's really hard if you
(31:47):
have to come off of it, guys canhave a really tough time and
it's cycled.
Where you take it every sooften Is the hormones that you
provide.
Are they cycled where you takethem so often?
Then go on break, or do you gostraight through?
Speaker 2 (31:58):
We just go straight through.
Speaker 1 (32:00):
Got you.
And then how do people do ifthey have to come off, them go
on break, or or or you gostraight through, we just go
straight through.
Speaker 2 (32:05):
And then how do people do if they have to come
off them?
Um, usually, I'm usually notpart of that decision.
They usually stop and then theycome in a couple of months
later and go I stopped myhormones.
I mean, they really.
It's not a conversation peopleever ask me is how do I come off
of it?
They just decide like, well,you know what?
I had this side effect, Ididn't like how I felt on it,
and then they just stop it.
Speaker 1 (32:19):
How do they do?
Speaker 2 (32:21):
Uh, on what testosterone?
Speaker 1 (32:23):
or anything, Either one.
Like when they come off, dothey have a tough time?
Speaker 2 (32:32):
Um, well, with the hot flashes, yes, yeah for sure
For the hot.
Probably hot flashes more thananything else, Um, and that's, I
mean that's a huge problem forwomen, Like even I mean three
times today I had women thatwere in their late 60s that came
in, and they were like I'mhaving problems with hot flashes
again though too.
So we know that, like when youtake people off of it, it could,
you could, go back to that samestate of like.
Look, you're newlypostmenopausal again though too.
So so it can, it can drop.
Speaker 1 (32:54):
Yeah, you know I.
I see patients who end uphaving estrogen positive
breastitive breast cancer and sothey have to come off the
supplementation.
Speaker 2 (33:00):
And it's the hot flashes and the vaginal dryness
seem to be like the two big onesand they do not like it.
Speaker 1 (33:06):
I mean, it's tough.
Speaker 2 (33:08):
There is Vioza, though, so I love Vioza.
Now for the appropriatecandidate for people that can't
have estrogen anymore, andwhat's Vioza?
Vioza is now.
It's a medicine that's out,that you take orally daily.
That basically resets how yourbody interprets heat, so you
don't have the hot flashesanymore, I think it works in the
hypothalamus, but it's totallynon-hormonal, so that's very
(33:29):
appealing to people and it workswell.
The caveat is that you have tohave your liver function checked
, though, too, so I go threemonths, six months, to make sure
that it's not affecting yourliver.
So that scares a lot of peopleoff, but my patients that have
been on it that have always hadnormal liver function.
It's worked really really wellfor them, though, too.
Speaker 1 (33:49):
That's great.
Speaker 2 (33:49):
It's definitely something.
Speaker 1 (33:50):
Yeah, the hot flashes are a big deal.
And when?
Speaker 2 (33:58):
I see men for prostate cancer.
Speaker 1 (33:58):
If it's advanced, they have to have a testosterone
blocker.
And when I'm telling them, men,these are going to be the side
effects of the testosteroneblocker.
The two main ones are hotflashes and then they have zero
libido.
Speaker 2 (34:08):
Can men use Vioza then too?
Speaker 1 (34:10):
And so I don't know.
I mean, it's probably worthtrying, but the hot flashes are
short-lived because they'reusually not on the
antidepressant deprivation.
I mean sometimes it's sixmonths, sometimes it's two years
.
Every single time you know, youfeel the hot flashes aren't
good we can all agree on that.
Every single time I tell themthey're going to have the hot
flashes, their wife laughs atthem.
Speaker 2 (34:29):
And I just feel like that's me.
Welcome to my world.
Speaker 1 (34:32):
I think you know there's no sympathy.
You would think they would havesympathy, but no, it's like
they're gleeful.
Speaker 2 (34:39):
That's like when dads have to go get their
vasectomies and they're like, oh, woe is me.
I'm like, did you just see whatyour wife went through?
Speaker 1 (34:47):
Cry me a river.
Well, Julie, I reallyappreciate you.
Speaker 2 (34:52):
We've had many mutual patients over the years and so
thank you for coming in.
Speaker 1 (34:57):
I think this is going to be a really popular episode
and I think a lot of people willbe interested in it.
Speaker 2 (35:00):
Yeah, yeah.
If you want anything more, ifyou want to talk about anything
in the future, just let me know.
Speaker 1 (35:04):
I'll be happy to.
Speaker 2 (35:06):
I feel very comfortable doing this.
Speaker 1 (35:07):
And how would people get a hold of you?
Do you have a number?
Speaker 2 (35:10):
Yeah, my office number is 314-205-6788.
And I'm
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