Ep.62: Perimenopause and Menopause: What You Need to Know with Dr. Kelly Casperson

Episode Transcript
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Laura Bowman (00:02):
Sarah, hello everybody. Welcome back to
insights from the couch. We areso excited because we have Dr
Kelly Casperson joining ustoday, a urologist, podcast host
and author who's on a mission totransform the conversation
around sex and intimacy,especially for women at midlife

(00:23):
and beyond. She is the host ofthe top rated podcast, you are
not broken, where she dives intothe science mindset and
practical tools that help womenreclaim pleasure and confidence
in their bodies. Dr Casperson isalso the author of the
groundbreaking book, you are notbroken. Stop shoulding all over

(00:43):
your sex life, which has helped1000s of women better understand
their sexual health and rewritethe outdated narratives we've
all been fed. Her work isempowering, evidence based
refreshingly real. We are soexcited to have her here with us
today. Yay, yay. Thanks forhaving me. Thanks for being

(01:03):
here. Our community was sopumped that you were coming.

Kelly Casperson (01:07):
Oh, that's awesome. Yes,

Colette Fehr (01:09):
yeah, we've got so many questions, and it is such
an honor to have you. You'resuch a wealth of knowledge, and
you are so inspiring andempowering just your approach
and your creativity and yourhumor and your knowledge. So
let's dive right into the heartof it. Thank you. Yes,

Unknown (01:25):
you are you are seen.
You are seeing. You are seen.

So we want to dive right in and start by giving a
little bit of a definition toperimenopause, because, as
you've said, this isperimenopause is finally having
the moment that maybe menopausehad a couple of years ago, and
people are just tuning into thefact that we don't have to wait
till everything falls apart tostart addressing it. So can you

(01:50):
give our audience a littleinsight into what perimenopause
really is, what some of theearly symptoms are, that kind of
thing?

Yeah, happy to because you're right, like
menopause is now I, at least inmy bubble, it's happening. And
2025, 2026 the books arestarting to come out about
perimenopause. So that's theit's like the the younger
stepsisters like me too. Don'tforget, I'm down here. But it's
interesting, because I thinkwhat Gen X did for menopause,

(02:20):
because the oldest Gen X isturning 60 this year or next
year. That's crazy, I know.
Like, I'll pause for our headsto explode about that one,
right? Like, what, what Gen Xdid for menopause. Now the
millennials are doing even like,you know, to outdo the Gen X's
for perimenopause. Of like, weunderstand what pregnancy is
about. We understand whatpuberty is about. We go through

(02:42):
significant hormone changes inour lives, often multiple times
before we get to this stage. Andto call it midlife is actually
like a massive blessing, right?
Average age longevity for womenin America now is 82 to 84 so to
call it midlife is likeincredibly inspirational and
awesome. Of like, this isn'tdone. This is just a change

(03:05):
that, like puberty, like havinga baby, we need to understand
what our body is doing. So it'sa very empowering time to be
like, hey, things are going tochange, and women are. Women do
very well with information. Youknow, one of the one of my
stereotypes, is people are like,you're just, you just want
everybody on hormones, and I'mlike, No, hormones? I'm like,
No, I want everybody to have theinformation, then they can make

(03:27):
the right decision for them withthat information. Yeah, and like
that, I always say, spoileralert, most people want to be on
hormones then, because you butyou have to undo everything that
society told you about whatmenopause is and what hormones
are, and if they're dangerous,you have to, like, you have to
give people info so they canmake the right decisions. So
menopause is a stupiddefinition. It was created

(03:49):
centuries ago when we didn'thave we couldn't measure
hormones, and we couldn'tmeasure what ovaries did, and we
it basically was like a yearafter no natural periods,
because that was easilymeasurable in the world and but
what that is, is it's a symptomof what's actually happening,
which is a profound hormonechange, right? So today to say,

(04:11):
oh, women stop having periods,as if that's the big thing,
instead of, well, periods stopbecause of profound low
hormones, which is actually thething, right? So average age in
America of menopause 51 peopleuse that statistic to usually
tell people that they're tooyoung for X, Y and Z. I see that
all the time you're too youngfor X, Y and Z. It's like, well,

(04:32):
actually, average means 50% ofpeople go through menopause
before 51

wow, really, 50% of people go through menopause
before

51 Yeah, that's what average age of menopause
is. 51 means, right? Well,

Math has never been my spouse. Thank you for
clarifying that, right? But thatdoes blow my mind, because you
do. I have thought of it as, oh,if you're not in your 50s, it's
probably not going to happenyet. But that's not true.

47 normal, 48 normal, four. Six normal like,
that's all within one standarddeviation of 51 when you start
getting below 40, we're talkingbefore 45 is early menopause.
Before 40 is called prematuremenopause, meaning, like it gets
more rare that it happens young.
But certainly anybody who's inthe menopause and perimenopause
world, like, there are 18 yearolds whose ovaries stop working.

(05:20):
There are women in their 20s whoovaries stop working for no
apparent reason, or is there nothey haven't fully figured all
of it out yet. But just like,Hey, your thyroid stopped
working, your pancreas stoppedworking, right? She had
diabetes, diabetes in children,your pancreas stopped working
when you were seven, right? Soit's like, you know, most
pancreas is take you throughyour life, but some don't. So it

(05:40):
just what I see a lot, though,this is what I see with women.
They're either told they're tooyoung or then they're told
they're too old, and either way,it's kind of in his dismissal,
like, so you don't gettreatment, right? It's like
you're too young beforemenopause to get anything, and
then you're post menopause,you're too old to get anything.
And I'm like, oh my god, like,go to the doctor on that one

(06:02):
specific day, so you actuallyget treated. But so
perimenopause just meanssurrounding menopause, right?
The scientists will kind of pushthat past the year of no
periods, but in in the realworld, it's really the years
leading up to menopause. It's aclinical diagnosis. What that
means is, I can't X ray you. Ican't ultrasound you. I can't do

(06:22):
a lab test and tell you you'rein perimenopause. Western people
like black and white. We likethings on paper. And so, you
know, I had a woman come andshe's like, but am I in
perimenopause? And I'm like, andshe kept repeating it, but am I
in perimenopause? Right? And I'mlike, What do you mean by asking
that question, right? And whatshe meant was, can I get help?

(06:43):
Can I be treated,

right? What are those signs and symptoms that
are? I mean, I've I'm 47 I'll be48 in September. I've never had
a hot flash, but, like, my brainfeels like a piece of Swiss
cheese half the time. Yeah, Ican't, like, think of like, I
can't pull a thought out of myhead, and I feel like I have
what I just forgot, the othersymptom I have, but definitely

(07:08):
brain. There's

something else there. Maybe it's memory. I
don't remember

what is, but I'm telling you that's like, sort of
the key symptom for

me right now, the problem with hot flashes is
that's the stereotype. Yes,right? So when you don't fit the
stereotype, you get dismissedbecause you're like atypical.
But 7070, to 80% of people willhave hot flashes, not always in
perimenopause, sometimes postmenopause, and that means a good
20% of people don't have hotflashes. That's good news. Hot

(07:37):
flashes are actually associatedwith dementia and cardiovascular
disease. They're not benign. Sothe fact that you don't have
them, like probably a goodthing, right? But I can't
remember anything. Can'tremember, but at least I'm not
having hot flashes. Soperimenopause, again, clinical
diagnosis, which means a gooddoctor is going to rule out

(07:58):
other things. How's yourthyroid, how's your insulin,
how's your blood pressure? Like,they're gonna look at
everything. But what you see alot is women will come back and
they'll be like, they told me,everything was fine. They didn't
find anything wrong with me.
It's like, great. That meansit's perimenopause, right?
Because you didn't have someother huge abnormality come
back. Wonderful. It's notcancer, it's perimenopause. So
in medicine, we have a saying,common things are common. And

(08:21):
when you hear hoof beats, thinkhorses, not zebras, right? And
so we don't want to sayeverything is perimenopause,
because you're allowed to haveother issues at any age. But you
rule out the other issues andyou say, good news, we didn't
find a brain tumor. Your brainfog your word finding ability
that is a sign of ofperimenopause. So hormones that

(08:44):
are ovaries make testosteroneand estrogen work in the brain.
These are neuro hormones, neurochemicals, whatever we want to
call them. The biggest damage wedid was say, well, two things.
Number one, men. Men maketestosterone, women make
estrogen. That's oversimplified,and it's a little true, but not
fully true. Men need estradiol,women need testosterone. We all

(09:07):
have different combinations. Andthen the other thing we did is
we called them sex hormones.
That's a problem, because wedismiss sex. Sex is extra. Sex
is not you don't need it forlife. Our species isn't going to
die off if you stop havingbabies. Having babies, right? So
calling them sex hormonesdiminishes what they actually do

(09:27):
in your body, which is, theymake your brain function
incredibly important, right? So,very common in perimenopause to
have this brain fog, brain somepeople will call it cognitive
fatigue, right? It's just like,Oh man, I'm fried, uh, lower
energy. I just hit a wall at 3pmuh, sleep issues, super big.
Start kicking in andperimenopause. And again, the

(09:50):
the misnomer, or what I see alot of, is when women go in to
get help, people ask about theirperiods. That's great. Let's
learn about your periods. Buthaving a period. Doesn't dismiss
you from being treated. You canhave low hormones and still have
enough occasionally to bleedfrom your uterus. In addition, a
third of women in America don'thave periods, IUDs,

(10:13):
hysterectomies, uterineablation, ablation, yeah. So, so
your periods meaningless becauseyou don't have one, right? And
then the women who have periodsget dismissed because you're
like, but you're still havingperiods, so you're fine. Your
hormones are fine because you'rehaving periods. No. Periods are
not magical by any means. So thetrue perimenopause experts, if I

(10:34):
was to see you and I ruled outall the other things, I'd be
like, let's see what yourestrogen is doing. Let's see
what your testosterone is doing.
And women will say, I feel likemyself again. And they've
actually started to study this,this, n, f, L, M, not feeling
like myself, which in medicineis a very it's very vague. Like,
how do I measure Laura notfeeling like herself, right?

(10:55):
Like, is there a test? How doyou How do I know how you felt
two years ago? So it's notsomething in medicine that we
can test, but it's incrediblycommon. About 60% of women in
perimenopause say I don't feellike myself.

Wow. Okay, I love this term. This sounds very
therapy aligned, actually,because I do think it's
something I can see why it'shard to define, but I do think
it's powerful. If you don'tquite feel like yourself. That's
a terrible feeling, right?
What's a terrible feeling? Womensay I feel like I've lost
myself, or I'm losing myself,and so in you, correct me if
this is wrong, because I readabout this in the New York

(11:30):
Times, but in terms of why thehormone thing got dropped for a
while, what I read in thisarticle was that this study came
out until 2002 hormones weregiven regularly. Then this study
came out that showed a smallincrease in the risk of breast
cancer. And so then all of asudden, it became taboo that

(11:51):
people maybe misinterpreted theresults. I'm not even sure if
I'm reflecting that backcorrectly. But then all of a
sudden, nobody was doinghormones anymore. And now the
thought leaders in the field,even though many doctors aren't
properly trained, notnecessarily through fault of
their own, the thought leadersin the perimenopause and
menopause space are saying, youknow, with education for many

(12:14):
people, hormones really arebetter, and they're better
earlier than we might think, andperhaps not just if you're
symptomatic, because I didn'treally have any symptoms, and
theoretically it looks like Imight be through menopause, and
I really didn't even know it washappening.

Yeah, I'd say you've got that all perfect, and
my job here is done. Okay, well,signing off.

No, but I mean, so that is, that is along the right
lines. But, yeah, but help ouraudience understand then, why
are hormones potentially soimportant now for so many
people, even in perimenopause,because you talk a lot about
being proactive rather thanreactive.

Yeah. So hormones, again, they work
everywhere in our body, ears.
It's called the frozen shoulder.
Is called the 51 year oldshoulder, for a reason, right?
That's when it shows up. Whatelse happens? Average age 51
right? So, joints, muscles,bones, brain, eyes, dental,
health, certainly the pelvis,your clitoris, blood flow goes

(13:16):
up when I give you testosterone,right? Lubrication, the ability
to orgasm, decreased risk ofdiabetes, decreased risk of of
depression. We've gotrandomized, placebo, controlled
trials and perimenopause, thatif you start a woman on estrogen
versus placebo, in one year,she'll be less depressed than
her placebo. People, oh, my god,same thing with same thing with
diabetes. Like they're smallstudies, but they're there. And

(13:38):
I'm like, Dude, if a if ablockbuster drug came out and
could decrease the risk ofdiabetes by 30% they'd have they
would buy all the Super Bowlads. Yep, right, but it's like,
these are generic, oldmedications. They're not making
people a ton of money, and it iswhat it is. So you actually have
to be educated to know about it.
So what do? What are hormonesgood for? They're everywhere in
our body. Hormones preventdisease. Hormones are pretty bad

(14:00):
at treating disease, right? Sowhat does that mean? It means in
the medical paradigm, how manywomen come to me and say, My
doctor said, Come back when I'mmore sick.

That's what happens. That's what happened to
me. That's exactly what happenedto me. My doctor was like, at
50, he was like, I don't thinkyou're through menopause yet.
He's like, but we won't reallyknow unless we check your
hormones. So when you turn 51we'll check. And I had to say,
you know, I'd rather check now.
We checked I still had someestrogen and testosterone. And

(14:31):
he was like, you're fine at 51he said, let's test again. And I
had no estrogen and notestosterone,

right? Not why did, why did we wait for you to
fall off the cliff first, right?

And now I did a bone scan, and my bone density
was not good, yeah, yeah.

So

with the timing, like, I don't understand the
timing, like, where is the idealintervention spot? So

as far.
Preventing disease the earlieryou start on hormones. In this
in the menopause transition,which is a more accurate term
than, like, the day of a year ofno periods, right? It's like,
dude, Clay, you're 50 years old,like you're clearly in
perimenopause, like just by agedefinition alone, like you
wouldn't have periods, but like,you're just in perimenopause. So
some things to think about. Yourbiggest rate of bone loss is in

(15:21):
the two years prior to yourperiods ending. So I missed it
look. How do you know when yourperiods are going to end? Nobody
knows that, right? So I reallythink if we have this
conversation, 10 years from now,we are going to see more and
more people being treated inperimenopause. I'm in
perimenopause. I'm on all of thethings. And here's the other
thing that's interesting, whenyou said, like, I didn't have

(15:41):
any symptoms. Have any

symptoms, I believe you, or maybe I did, and
I didn't know,

but often you put people on hormones and
they're like, Oh my God, mysleep is so much better. I had
no idea that, right? So that is,it's not that I don't believe
people when they don't havesymptoms, but it's also like,
Hey, give yourself a little bitof hormones and see what's
better. I read a woman. I justread a woman. She was her sleep
was horrible. And she had anaura ring so she could actually
be like, my aura ring says mysleep sucks. And I knew that
anyways, so we put her on just avery low dose estrogen patch.

(16:08):
She came back and she's like, Ohmy God, it's actually recording
deep sleep and REM sleep. AndI'm like, I have a goofy
question. I'm like, Are youdreaming? And she's like, I'm
dreaming, and she wasn'tdreaming before. Yeah,

that's so interesting. I don't think I
dream as much,

no, and I have to say I because I am on an
estrogen patch now andprogesterone. And I do, I have
been noticed. I've never been agood sleeper, so it's been hard
for me to notice, but I havebeen having dreams more, and I
would not have even thought thathad to do with that. So let me
while we're here, let me ask youthis, what about testosterone?

(16:44):
Is that only if you want to haveincreased libido, or is that
really important for otherthings

too? Yeah, it's my it's my favorite topic,
because I, like, I started thisadvocacy with female sexual
education, basically, and thencame into menopause, when people
were like, Yeah, but you know,what happens to your sex life
with menopause? And I'm like, Idon't. So then I peeled back the
onions on all of that. And sojust think about it this way,
ovaries make testosterone,right? So we got to dig back.

(17:12):
Just because testosterone wasdiscovered in rooster testicles
doesn't mean that it doesn'texist in women. Women make four
times the amount of testosteronethan estrogen. The only way you
get estrogen in your bodynaturally is by converting it
via testosterone, right? So youhave to educate women about
their bodies first, becauseotherwise I'm this crazy doctor

(17:32):
who's like, I think testosteroneis awesome. And then you're
like, why do you want to turn meinto a man? Like, right? You've
got too many preconceivednotions of what testosterone is.
So ovaries make testosterone.
You make the most testosteronein your 20s, and you basically
get a linear decline after that.
There's no cliff thattestosterone falls off with
menopause. So perimenopause, alot of people have very low

(17:54):
testosterone, and I guaranteeyou had they actually checked
your testosterone years prior,it would probably be low. But,
and that's got its own host ofthings. It's actually lab values
are not perfectly accurate,because our testosterone is so
much lower than a man's, and labvalues were designed to check
men's testosterone. So labsaren't perfect, but by and

(18:15):
large, you're you're losingtestosterone production after
your 20s, and there's no bigcliff that happens when your
periods stop. So again,testosterone, like in any
gender, testosterone is vague,lethargy, maybe not sleeping.
I'm working on at the gym andnot seeing any gains. I just
can't hold on to muscle mass.
Mood, the get up and go. I justwant to get things done. The

(18:37):
mental clarity. I feel likemaths harder now.

Okay, so I feel like I need testosterone.

Yeah? Now, Laura needs design. I think I do
too, yeah. So we have multipleissues with testosterone. Number
one is just the gender bias ofit's for male bodies, and we
don't have an FDA approvedproduct yet, but I tell you
this, it is coming right now.
You have to use a compoundedproduct, or you have to micro
dose a male product, both ofthose not covered by insurance,

(19:05):
because insurance uses the FDAapproval to justify paying for
things so many, many barriers.
Again, physicians didn't geteducated on testosterone. The
other big barrier is a lot ofrecent research, we've been
giving women testosterone since1948 there's a paper published

(19:25):
in 1948 that said, at thispoint, we feel like we have
enough data and safety to saythat testosterone is essential
and useful in women 1948 Wow. Sowe've been really dragging our
heels on this. But recent datais for libido. Where is libido
in the body, the brain, brain,the brain tying back in

(19:46):
testosterone is a neurochemicalin men. Low testosterone levels
are associated with depressionand dementia in women, and the
studies are starting to comeout. Louise Newsome just
published an amazing study outof the UK that already had. Them
in on estrogen and progesterone.
They were already on thosehormones. They came in, they did
not adjust those doses, and theystarted them on testosterone,

(20:06):
significant improvements inmood, decrease in depression,
increases in energy and like,there's just more and more data,
but we are never going to getlike, a randomized, placebo,
controlled trial that's spanning20 years, that's saying this is
going to prevent dementia. We'reit's not going to happen, yeah,
but we know that when brainsfunction better, they do better,

(20:28):
right? And testosterone doesthat. And people are like, it's
only good for libido. And you'relike, okay, but where's the,
where's the square centimeter ofthe libido box in your brain,
right? Libido is complex, bodyimage, relationship, energy,
status, right? While you'resleeping, right? Like, how, how
much dopamine Are you making?

(20:48):
Guess what helps make dopamine,testosterone and estrogen,
right? So it's so yes,testosterone is helpful for
libido, not everybody in alllibido, but hormone responsive
libido, but the narrowmindedness is when people say
it's only for libido, it's like,yeah, it's not how the brain
works.

See, I'm so glad to hear you say that, because I
haven't understood and I'veheard horror stories from
people. I've heard peoplesaying, the pellets are great,
the pellets are terrible. Youknow, if you do testosterone,
you're gonna grow like, blackhair. You're gonna grow a beard,

not the black hair. Yeah,

I'm just like, so afraid. What's the best way to
do testosterone currently? Arethe pellets bad? Like, what?
What's your take on that?

There are current international
guidelines. And we always jokethe international world doesn't
agree on much, but they do agreeon testosterone. So we have
international guidelines. It'sfree online. Of dosing
testosterone for women ispriority for libido again,
because I think it's incrediblypaternalistic to be like you can
have something your ovarynaturally makes and you ran out
of because you live too long ifyou want to sleep with somebody.

(21:56):
And we have four, it's supermessed up. But we have four
countries currently that has afemale dose testosterone cream.
And that's Australia, NewZealand, UK and South Africa.
Interesting. It's calledandrofem. They have it. It's a
lovely product. And inAustralia, Australia tends I
love them. I have the biggestAustralian audience because they

(22:17):
get my sense of humor. But it'svery paternalistic, and
literally, women are deniedtestosterone at the doctor's
office because they are single.
Ooh,

Unknown (22:26):
stop, yeah, wow, that is so bad. It's

super messed up. Yeah? So, so, going back to
what you're saying, theinternational guidelines say
transdermal is the best way tostart. It's very physiologic.
It's one day at a time. You justput it on. It's very easy. I
tend to compound because I thinkmicro dosing the male product is
a little bit clunkier, but it'sa great way. They're cheap. I

(22:52):
can get my compoundedtestosterone for like 65 bucks
for three months. Same if youdose the male dose, it lasts a
very long time. It's very cheap.
You test levels six to eightweeks afterwards, make sure
you're absorbing, see how you'refeeling. Libido can take a
while. Libido can take a goodfour to six months to kind of
kick back in all the time you'relike, reading my book and seeing
the psychotherapist to figureout your relationship and how

(23:12):
you were socialized with sex andlike all the other libido
issues, right? There's not everjust testosterone, but where do
pellets come in our because ourFDA has failed to give us a
female product, and becausemainstream medicine has failed
to treat female hormonedeficiency appropriately, women
are suffering and they wantanswers, fair enough. Yeah. What

(23:34):
do they do? They go outside ofmedicine to the people who only
do pellets? Why do they only dopellets? Because that's probably
all they were trained on. Andpellets make them a lot of
money. Yeah, I don't get anymoney by prescribing a
compounded testosterone product,but if I did pellets in my
office, that's hundreds ofdollars. So there is a financial
motivation towards pellets. Andpellets tend to be, first of

(23:57):
all, it's like a little piece ofbird seed just implanted, kind
of upper buttock, usually threeto four times a year. So you'll
get a super high high, and thenit'll wear out. It tends to be a
big steroid high. Women arelike, I love it, and then it
wore off and I like, they kindof chase that high and they
can't get it again. Yeah. Soit's not good. But some people
need high doses of testosteroneto feel good. Those people do

(24:22):
incredibly well with pellets.
All right. So what's the bestway to not get the people super,
super high, but to treat theones who need it higher, right?
Start transdermal. Okay, yourway up. Okay. Then the like, the
pellet gurus will say, like, andhow I joke is, I'm like, You got
to earn your pellet. And they'relike, What do you mean by that?

(24:42):
And I'm like, Just dophysiologic, low dose
transdermal testosterone first.
Yeah, that makes sense. See ifyou like, it be like, and then
it's the women who are like, Ithink I want to try a little bit
more and do it slowly. Yeah,right. So the body doesn't care
so much. Out the level as therate of change and shocking the
body. It just like, thyroid,postpartum, yeah, you know,

(25:05):
extreme weight loss, anythingthat's a big shock to the body.
It shocks the hair follicles,and the hair hates it, right?
The hair is like, I can't handleall this massive change that
you're doing. So it's not somuch that it's a certain
testosterone level ortestosterone itself that can
cause hair loss. It's thedramatic change of, I have no
testosterone, and I threw in apellet and I got up to 350 which

(25:26):
is a man's level overnight. Hairhates that. Yeah. So it's like,
be kind to the hair. Be kind tothe body. Go slowly. Side
effects of testosterone aremasculinization. If I push you
high enough you'll start tomasculinize, which could mean,
you know, frontal hair loss,more growth in the facial hair,
but it's very, very rare atfemale dose testosterone.

Okay, okay, okay.
It is rare at female dosetestosterone. So you're saying,
like, I have an appointment withMIDI. Is that how you say it?
MIDI? MIDI, okay? And because Idid not feel like I had a good
experience in my doctor's officeon multiple accounts, including
I felt pushed onto pellets, yep,and it felt very financially

(26:12):
motivated. I can't speak forwhat that doctor's thinking, but
it didn't feel good to me, notto mention the whole way my
perimenopause menopauseexperience has been handled. So
if I'm not on testosterone now,then that could be a good thing
to talk about, starting with atransdermal product that is at a
female dose level. Andpotentially, you know, I'm about

(26:32):
to turn 52 Laura, being younger,even she could potentially
benefit from testosterone, evenif she's not in menopause or
post menopause yet,

yeah. And I'll just reiterate so it's clear for
the listeners of like, menopausemeans no periods for one year.
It means nothing about anythingelse, anything can be on
hormones or not be on hormones.
I mean, it does mean like, Hey,you're not going to get pregnant
now. Like, if you haven't hadnatural periods for your your
rate of pregnancies, like that.
Pregnancy is like nil. Butbesides that, there is

(27:05):
testosterone doesn't fall off acliff at menopause. So I think
we're going to see more and moreperimenopause women. And the
perimenopause experts will belike, dude, testosterone is low
in a lot of perimenopause women.
And there, there isn't a period.
Is a very arbitrary cut off forif you can be on these
medications or not.

Okay, so let me go back because I'm, you know, I'm
trying to piece this togetherfor clients and myself. So what
is the time, what in a perfectworld a woman would begin to get
supplemental estrogen andprogesterone at like, what point
in the journey is in your mind?

I mean, it's, it is individualized, okay? It
really is like, you know, andwhere I think the menopause
gurus will get in trouble so wedon't do it is like, everybody
needs this. Everybody needsthis. And an age like saying,
like, 48 right? Like you, you'vebeen to your high school class
reunion. Not all 45 year oldslook the same like, some are

(28:07):
looking like very, very wellpreserved, and some are looking
like they've, we don't know howmuch longer they're going to
last. What I mean by that islike to say there's an age,
yeah, it's like saying your yourlast period is meaningful. It's
not accurate, right? And so it'sreally like, do you have
symptoms? Okay, you don't havesymptoms. Are you an a healthy
person who wants to make thedecision to be on hormones for

(28:30):
preventative health, right? Andthe screening for, like, going
back to the bones, screening forosteoporosis in this country is
abysmal. It's age 65 unlessthere's risk factors, that's not
screening, that's diagnosingosteoporosis. Yeah, I thought
that was bad. And then I went toAustralia, and they're like,
Yeah, we start at 70. Oh, myGod, right. So every woman that

(28:50):
comes to see me in my clinicgets a DEXA. Dexas are cheap,
not like just cash. DEXA is 80bucks in my town. At what age do
you start that? Whenever youwant. I start. I start

everywhere than now, because I just got one, and
that was the first it was evermentioned to me. And I already
had some, not terrible, but somebone loss, and I had no idea
that I could have been payingattention to this much sooner.
Yeah, so it sounds to me likeyou're saying, hey, there's no
it is individual, but starteducating yourself and being

(29:22):
proactive now, because you couldpotentially be in perimenopause
much earlier, potentially thanpeople have thought you could be
there in your 30s, in your midto late 30s, right? It's
possible and go in, you're goingto have to probably be the
person who goes and says, Hey,can we especially if you're not
symptomatic. Hey, can we test myhormones and see what's going

(29:44):
on? Get a baseline. We reallyhave to advocate for ourselves
much more than we have been.
Yeah.

I mean, if I got to do, like, some sort of
universal, this is what I wishsort of thing like, at age 40,
you're going to get a discussionthat, Hey, you. Yeah, maybe
you're aware or not, but like,we're going to be out living our
ovaries. And what that means iswe get to make the decision of
if we want to replace thosehormones or not, right? So it's
like, get the education to knowthat it's coming. Because so

(30:13):
many women, they're like, I'manxious, I'm depressed, I'm not
sleeping, they I'm on like, fourother medications for this. Now,
do you think this could just beperimenopause? Like, that's
what's happening. Now, I want toshift that to be like, Hey,
we're running out of ovaries atsome point, and we'd like to
make it to 84 so that's 40 yearswith no hormone productions that

(30:36):
help our brain, help our bones,help our muscle, help our mood,
help our genitals, life, halfhalf of your life. And remember
when you're frail with diseasesat 76 that's not the time to
start hormones. Now the granted,the boomers are pissed. Average
age of the boomers was early 50sin 2002 when the Women's Health
Initiative came out. This is anentire generation of women who

(30:57):
were not given an option, yeah.
So they're pissed. And the thethe current myth, just to
address them, is the currentmyth is, if it's more than 10
years post menopause, you can'tbe on hormones. That's not
can't, is

that can't because I have a client right now who
went through early menopause.
She's now for my age, 47 she'sbeen postmenopausal for 10
years. She has

helped me.
She's been on hormones. She justfound out that,

like, hormones would have helped her. She's got
some cardiac issues. She's like,please ask her, Can I start

this is, this is life and death, just to be,
just to be dramatic, for a hotsecond early menopause, so
early, certainly earlier than 40definitely think in 45 early
menopause associated withsignificant increased risk of
death, heart disease, heartattack, dementia, like it is no

(31:49):
joke, and to the to the point oflike, I want to use the word
malpractice very carefully, butwe have written standard
guidelines that say hormonesshould be given till natural age
of menopause. So all these womenshould be on hormones to at
least age 5051 and then theythen we get to choose, right? So
remember, hormones are a choiceafter natural menopause, but we

(32:12):
have strong guidelines thatwomen should be offered hormones
up to natural age of menopause,and the women who aren't, it's
heartbreaking. We have the data.
It is bad for your health to nothave hormones. Could she start
at this age? Likely, yeah. Andwould that help her? Yeah?
Likely, yeah. I mean, yourquestion earlier of like, I
don't have any symptoms, shouldI start is like, can you feel

(32:33):
dementia? Can you feel

heart? Oh, I feel like I can. Yeah, you're like,
me,

yes. So you do have

symptoms, but you can have a lot happening that
you can't you can't feel Yeah,

the medicine needs to switch the conversation
to prevention of disease,maintenance of function, which
is very different than come backwhen you're sick, and we'll see
what we have for you.

Yes, prevention of disease. And actually, one of
our audience members wanted usto ask you that question that
you know, after 10 years or so,there supposedly aren't any
benefits to treatments. That'swhat she had heard. But you're
saying that's not so.

Dude with multiple studies of like women
in their 70s, you throw a lowdose estrogen patch on and their
bones improve, like hormoneswill always help your bones.
Okay, will you get the if thereis any dementia prevention, it
is starting the hormones Young.
Why? Because hormones preventdisease. Hormones don't treat
disease. So if a 73 year oldcomes in and she's like, Can I

(33:35):
start our hormones? Or will ithelp my help my dementia risk?
No, the study, the studies,don't show that, but it'll help
your bones. Yeah, right. Soimportant, heart risk, dementia,
brain risk, early menopause.
What do they mean by earlymenopause, within 10 years of
your last natural period? Butthat doesn't mean there aren't

(33:55):
benefits for older peoplestarting and then remember,
genital hormones, or what wecall local vaginal hormones. You
can start that at any age. Startyour start your demented aunt
with recurrent UTIs, who's 91she can start on vaginal
estrogen. Incredibly important,any age. Can start that. So when
people say, when people say,hormones like this big umbrella
term, yeah, I'm like, there isnothing more irritating to me,

(34:18):
because I'm like, Are youvaginal hormones, testosterone?
You can start testosterone atany age. Oral microns,
progesterone, you start that atany age. So like when people
say, I can't take hormones, thatusually means you don't know
enough about all the optionsthere are in regards to
hormones.

That's an excellent point. And I want to
ask you another question fromour audience about that that's
sort of playing off of this. Sofor women who have had breast
cancer, and I know everybody'sprobably different, but she
says, okay, most people just putbreast cancer patients to the
side as at risk. This is not thefull picture. Where do we go?

(34:51):
Who do we see for clinicallyaccurate information, and are
there studies? What doessomebody who has had breast
cancer or. Has breast cancer doto begin to unravel what's right
for them?

Great question.
Currently in America, 4 millionbreast cancer survivors. Wow.
Massive population, massivesuffering. There was just a
paper published literally thisweek looking at it was basically
a 1700 breast cancer survivorspolling them about hormones and
sexual health, and it isabysmal. Like, I know it's bad
because I'm in this world andreading that paper, I did some

(35:25):
Instagram reels on it yesterday.
I'm like, It's really bad. Wow,it's super bad. So you gotta
back up, and you gotta be like,remember, this is the best way
to do it. Food doesn't causemonsters fair enough, but
monsters eat food. Okay, so ifyou have breast cancer, get rid
of the freaking food, right?
That's hormones. Okay, so thatis a treatment for many, not

(35:49):
all, breast cancers, but manybreast cancers, it's not that
the food caused monsters. It'sthat monsters eat food. Okay,
right? And you, you have toclarify that, because what we
do, what they've done is they'vethey've used breast cancer you
can look at markers on ifthere's estrogen progesterone,
markers on breast cancer cells,and so they'll call it estrogen
positive. Progesterone positive.

(36:11):
The Lay population has takenthat, probably because the
oncologists haven't done a goodjob of explaining it. They've
taken it to say those hormonescaused that cancer. No prostate
cancer is testosterone positive.
If you stain to prostate cancercells, and we don't go around
saying, I have testosteronepositive prostate cancer, and
testosterone caused my prostatecancer. It didn't. It just
stains for it, right? So thefirst thing you have to do in

(36:33):
this population is you have toeducate them and be like
hormones are food, but fooddoesn't cause monsters. More and
more and more people who areexperts are saying, listen,
breast cancer is a tricky beast.
It does stupid things like, itcomes back eight years later. It
comes back 10 years later,right? But what's the number one

(36:53):
killer of a woman who's beencured of breast cancer heart
disease? Yeah, really. Right.
And so these women are like, Icare about my bones, I care
about my brain, I care about mysex life, and I'm not getting
any treatment. It is anindividualized risk benefit
conversation, right? Nobody isever gonna say we're fine. Now
just give all the breast cancersurvivors hormones. Nobody's

(37:14):
ever gonna say that, except forvaginal estrogen. Vaginal
estrogen is very low doseskincare for down there, pretty
much every, nearly all, I willsay that breast cancer survivors
can be on vaginal estrogen, andwe know they're horrifically
under treated. So that is lowhanging fruit again. If a breast
cancer survivor says I was toldI can never be on hormones, I'm

(37:35):
like, there's a whole bunch ofdifferent hormones, and
testosterone seems to be breastprotective, interesting. So why
we're not doing more research onthat is mind boggling to me. So
to answer the question, read thebook estrogen matters, by Dr
Avram blooming and Carol tavris.
It's a brilliant book. It breaksdown all the data for you, and
then you have to see a menopausespecialist who understands this

(37:58):
data. Dr Corinne men is anamazing advocate to follow on
Instagram. You should have heron her podcast. She's an OB GYN,
who is a survivor herself, whoknows the data like nobody else,
and is a huge advocate. So Iknow multiple breast cancer
survivors who are on hormones. Itake care of breast cancer

(38:19):
survivors on hormones. I wanteducated women. I want women to
understand I can't ever say yourbreast cancer is not going to
come back, but to the best ofour knowledge, hormones aren't
going to make it come back. More

To that end, Kelly, like is there? Are there
people that just like, fullstop. Can't do hormones because
I'll just be transparent my dog,I've had preeclampsia with all
three of my babies, my my OB,GYN was like, basically, like
you, you're not going to dohormones like your your blood
pressure, stroke risk is high.
Like, this isn't for you. Isthat

true? Does testosterone increase stroke and
breast cancer risk? I don'tknow. No. Does vaginal estrogen
increase your stroke and breastcancer risk? No, does
transdermal estrogen increaseyour breast cancer and stroke
risk? No,

when you say, is that patch? Like a patch? Patch?
What I have? I have the patch.
Yeah,

that's the most common way to get estrogen. So
this is what I advise, and thisit you have to deliver it well,
because you never want to insultsomebody by this. What is the
actual risk? Show me, right?
What's the actual risk? Where isthe where is the statement that
says I can't take hormones? Showme Hey, no, say Yeah. Say that
nicely. It might be nice if youhave already an established

(39:39):
relationship with somebody,right? But this, like the risk
is too high, is verypaternalistic, and it is meant
to shut down discussion. Yeah,you can very accurately say what
is the risk? And this is mybody. I should be able to make
an informed decision on if thatrisk is right for me or not. I.
Every single medication hasrisks. Life has risks,

Unknown (40:04):
right, right? It's cost benefit, yes.

So you need to, you need to understand what your
risk is so that you can makeyour best decision. Now we know
transdermal estradiol does notincrease the risk of stroke or
blood clots, so when they saythat that's too high of a risk
for you, you'd be like,

Unknown (40:21):
huh, based on what.
Tell me it based on what,

based on what.
And let's remember, in the 1990s40% of women in America were on
hormones. Now 5% of women inAmerica are on hormones,

right? So it's like, whole study thing. I
mentioned

it's a whole study thing. So what happened?
We have two decades ofclinicians who did not get
trained in hormones after the2002 Women's Health Initiative,
which in it's wrong. It'sinaccurate. Said estrogen
increases breast cancer risk.
That's not what that studyshows. That study, this is what
I love to tell people. Thatstudy is free online, 2002 JAMA
article, Women's HealthInitiative. It's free online,

(41:00):
everybody can read it. So

this is just the game of telephone, like, how
does this happen?

So remember, in 2002 we didn't have the internet
very much, right? So they, theydid this billion dollar study,
they said, We're going to stopthis study the progestin,
estradiol. Remember, these areoral synthetic medications we no
longer use, right? So peoplewill also argue like it's kind
of irrelevant there, but theWomen's Health Initiative did
tell us some useful things, sowe won't throw out the whole

(41:30):
baby with the bathwater, butit's medications we no longer
use. The medications we use noware much safer, but they said
we're going to stop this one armbecause it looks like breast
cancer risk might be higher, andwe want to stop it. What they
actually found out was that inthe estrogen alone arm, so these
are women without uteruses, soyou can they didn't have to take

(41:51):
the synthetic oral progestin.
Get a 30% decreased risk ofbreast cancer by taking
estrogen. That didn't make thenews. So what happened? They
said, We're going to go to themedia. And the other people in
the group said, but you haven'tpublished the study yet, so
you're going to go to the media,and nobody can read the study
now, back in 2002 journals camein the mail, right? So the news
blew up and said, estrogen studyhalted. Billion dollar study

(42:16):
halted because estrogen causesbreast cancer. The doctors sat
around having to wait a wholeweek to get in their mail the
actual study so they could readit, because he couldn't read it
online, right? And the damage.
And in that conversation in thatroom, they said, if you go to
the media and you say estrogencauses cancer, the genie will be
out of the bottle, and we'llnever be able to put the genie

(42:38):
back in the bottle. And they didit anyways, and 20 some years
later, we're still trying to putthe damn genie back in the
bottle.

Unknown (42:45):
Wow. That is just terrifying.

It's a it's egregious. It's egregious. I
mean, it is. I would say, youknow, one of the best ways to
control women is to keep themafraid. Yeah, right. And Laura
to speak to you, if, like, ifsomebody's like, Hey, your risk
is too great. It's like, No,you're allowed to be like, What
is my risk? Yeah, what exactlyis my risk? And I should be able

(43:10):
to make that decision. I mean,let's talk. Let's talk. Let's,
you know, talk about medicinefor a second. I we will put you
under anesthesia to make yourbreasts bigger,

Unknown (43:22):
which has risk, tons of risk, right? That's not gonna

make you live any longer, but it's gonna, it
might improve your body image.
That's great. We we allow it,right? But you're like, I'm
allowed to make, I'm an adult,I'm allowed to make decisions
about what I want to do with mybody. This bodily autonomy.

So let me ask you before we have to wrap up here,
because we could certainly keepyou here all day and never run
out of questions. But where doesis there anywhere any resources
you can share for where someonecan find somebody who actually
knows what they're doing?
Because I get asked thatquestion all the time, do you
have a good menopause doctor? Doyou have a good resource? Yeah,

(44:05):
so do you have any suggestions?

I mean, the best thing is so say, you know,
for the therapists who arelistening and people who take
care of midlife women, is like,find the people in your town
that do good medicine. What do Imean by that, people who sell
pellets and don't do any othertype of hormone. To me, I'm
like, that's a one trick pony.
That's one option to like, mostmenopause experts will be like,
we've got oral, we've gottransdermal, we've got vaginal,

(44:30):
we've got blah, blah, blah,we've got, like, it should be a
menu. So that's one sign to knowif, if that person's doing good
work or not. The menopausesociety, menopause.org It's a
pretty low bar. Not everybodywho's even menopause certified
knows about hormones or to stop,especially testosterone. So I

(44:51):
would say that's a pretty lowbar. The one I really like is
ish wish.org It's theInternational Society for the.
Study of women's sexual health.
Why do I like ishwish? Becausethose are people who care that
sex med is medicine. So they'recomfortable with desire, they're
comfortable with pelvic issues.
They understand the role ofhormones in sexual health, so

(45:11):
they tend to be prettyknowledgeable with testosterone
as well. So it's weird. It's aweird like sex Health niche
place, but by and large, I'mlike, nationwide, that's
probably one of the best placesto go for find a provider. The
online ones are great. Like yousaid, MIDI alloy ever now, genev
for vaginal estrogen. Interlude.

(45:37):
So there's more and more online,because it's like, if you go to
a clinic that says, I dohormones. Yeah, that's a way
more fruitful conversation thanlike, you paid for parking, you
took off work, you paid yourcopay. And they're like, Oh, the
risks are too high, right? Andthen you're like, what are the
risks? And they're like, I don'tknow. Nobody actually knew
enough to ever ask me thatbefore, so I don't actually

(45:57):
right.

Does insurance cover any of this? Yes.

Okay, yeah. FDA approved hormones have been
around for a long time. Theasterisk on that is testosterone
because we don't have an FDAapproved testosterone. The other
problem with the telemedcompanies and testosterone is
testosterone because of thedoping athletes of the 1980s I
can't make this up. Testosteroneis a schedule two medication by
the DEA. What that means is evencompanies that have multiple

(46:23):
state licenses, people don'tunderstand how physicians are
licensed, but physicians need aDEA in every state that they
have a medical license if theywant to do scheduled
medications. Scheduledmedications means like ketamine,
codeine and one hormone that ourbody naturally makes is on that
list because of the dopingsporting scandals of the 80s.
Congress passed the 1990 dopinganti doping act. Wow. Now there

(46:45):
is some movement to say forfemale dose testosterone that
should be deregulated toincrease access. Let me tell
you. Me giving a woman thetestosterone back that she had
when she was 35 is not going tomake her win gold and pole
vaulting, isn't it? That's notgonna unless she was already
that close, you know? So it's itis another barrier for women is

(47:08):
the fact that we don't have anFDA approved product for
testosterone, so that limitsinsurance coverage and then the
DEA restrictions. But

you can get transdermal testosterone, even
though it's not right, like youcan get the kind that you can
the lotion, or the ointment thatyou can put on,

you can either compound a cream, or you can use
a male product and use 1/10 ofthe dose.

So this is so much good information and so much to
think about. It is crazy howmuch people don't know or
understand. And it's our healthand our longevity and our
quality of life that's at stake?

Yeah. I mean, here's a takeaway that people
don't often think of. Soremember the 1990s 40% of women
are on hormones. Women's HealthInitiative happened a good
amount, a decent amount of womenwho were on hormones didn't
stop, right? Their doctors werelike, We know that studies
bullshit. We know that our womendo well, but sure, we'll keep
you on hormones. Those women arenow 84 years old, approximately,

(48:06):
right? Talk to them, becausewhat they say is, they say,
these are women who've been onhormones for 30 years. Here we
are like, Oh, what's this newthing? Right? It's like, this is
not new. It's just we forgot howgood it was these women in their
80s who've been on hormones eversince menopause, they say, you
will pry this out of my cold,dead hands.

There's no stopping point, like there's no
natural

and they're feeling the benefits of it, so
they don't want

Unknown (48:33):
to stop right

there. They're feeling the benefits of it, but
they're also seeing the peoplearound them age differently, and
I think that's why themillennials and Gen X are doing
this differently, because we'retaking because we're taking care
of those people, and we're like,what if it's possible that
frailty is not the only option?
Exactly. There are morehospitalizations in America
every year for hip fracture thanstroke and heart attack
combined. The elderly women areforgotten silent voices. That's

(48:56):
where the suffering is. And inorder to not be that statistic,
you've got to think about your80 year old self when you're

Unknown (49:05):
50. Yes, good point.
Oh, a we're thinking about,damn, this has

been amazing.
Amazing. It, you know what?
Thank God we're we're so luckyto be at this time when at least
people are paying attention tothis. And I think a big takeaway
for our audience is go outthere, get educated, advocate
for yourself, and don't thinkit's too early to look into
this. Yeah, right. It's betterto start now and find out what's

(49:36):
right for you.

In perimenopause, I see all the
time. I'm told I'm too young.
I'm told I'm too young. Theirsuffering gets dismissed. And we
know the rate of depressionskyrockets and perimenopause.
The rate of anxiety skyrocketsand perimenopause, women are
increasing their alcohol use andtheir drug use to I see enough
self treat untreatedperimenopause and menopause.
Exactly. The women are not.

(50:00):
Okay, and it's, you know, whenyou're feeling crappy, it's
really hard to advocate foryourself, really

hard. And they trick their own brain. They're
like, this isn't, you know, I'mfine. It's the whole like, I'll
get through this. Like, youknow, I can exercise away, or
something, diet. That's

the other myth, right? That there's a like,
there's an over it. It's like,No, honey, your hormones are low
forever, right? Yeah, there'sno, like, I'll get through it,
but you get through it till whatyour your ovaries aren't coming

back, right? And this is vital to our organs, not
just symptoms. Obviously, it'svital if you have symptoms too,
but that we need hormones forhealth. They

help our mitochondria. They help our
glial cells. Like, I oftenthink, because I read a lot of
basic science paper, right? Ioften think, like, the basic
science researchers are like,What the f are you guys doing?
Like, how much more data on howhormones work, the help cells do
you need?

Yeah. So it really shows you the psychology of
group think and how, oncesomething becomes installed our
perceptions, it can be verydifficult to override and re
narrate that even when the datadoesn't support what we think
100%

I mean, we've got so much data on that, right?
You like, you challengesomebody's ideas and they double
down on it. Well, you

are going to help so many people, just even with
this conversation today. Sothank you so much. And I know
both Laura and me are benefitingfrom this. And so

totally I can ask you, like, 50 questions. I bet
you get cornered at like, acocktail party all the time.

It's pretty fun. I mean, it just it always
speaks to like, this is a bigthis is 50% of the population,

right, right?
Right? And we matter. We matter.
We matter

matter. I mean, let alone, you know, what
percentage of divorces happen inmidlife,

right? Oh, I can speak to that from what I see in
my office.

Oh, yeah. Like, you know, I have divorced lawyer
friends who are like, untreatedmenopause is a big, big issue,
absolutely, and I never say thatto blame the woman, I say that
to say we must know what's goingon so we can make the right
decisions and advocate forourselves

exactly and that it has widespread effects,
widespread effects what we mightthink so before you go tell our
audience how they can find youand about your book and all that
good stuff,

thank you.
Thanks for having me. So I hangout on Instagram at Kelly
Casperson. MD, my website'sKelly Casperson md.com, the
first book is you are notbroken. The podcast is called
you are not broken. And then thesecond book is coming out
September 2025, and it's calledmenopause moment.

Wonderful. Thank you so thank you so much. Thanks
for having this pleasure. Havingyou. Yes, thank you. Thank you.
Applause.

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Ep.62: Perimenopause and Menopause: What You Need to Know with Dr. Kelly Casperson

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