Hormone optimization, often referred to as HRT or hormone replacement therapy, has the power to transform women's lives—but despite its benefits, many women remain hesitant to pursue it due to unfounded fears. In Part II of her guest appearance on Healthy Longevity, gastroenterologist and long-COVID expert Robin Rose, MD, shares real-life case studies that reveal the tangible impact of hormone optimization. Combined with insights from Dr. Comite’s decades of endocrinology experience, these patient stories demonstrate how personalized treatment, regular monitoring, and education can make all the difference in a woman’s health journey.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
I'm so glad to see you again, Robin.
(00:02):
Join us on a two-part case study talking about various women and their issues withhormones.
Let's start by jumping right in.
And there are some cases I think we want to go over as well.
I love talking to Florence because she's so knowledgeable in this area, so I love pickingher brain.
I was saying how you almost have to, it's like pulling teeth to get these women to do thisamazing thing for them, right, to give them back these hormones.
(00:24):
For themselves.
Right.
And it's not an...
That's the other thing.
It's all they think it's all about the symptoms.
No, I'm like, it's not it's about protecting your heart protecting your brain protectingyour bones like all these things and And then you get them on it and then they're like, my
god, this is amazing Like I feel so good But then there's still this thing in the back oftheir head like my god, am I gonna get breast cancer?
(00:44):
my god, right?
Like it's really up.
It's really sad So anyway, I had this one patient a 57 year old female and she's beenfeeling amazing, you know on her on her
combination.
think she's on all three.
think she's on estrogen, progesterone, and a testosterone.
which is very rare.
lot of conventional medical doctors don't feel...
(01:05):
Yet it's such a great hormone.
Of the three, it does the most for the body.
Right, and like I get that some women can't tolerate it and that's fine, but like youshould at least try, you know to me I was like you try and see how they do, right?
think in the thousands of women I've treated in the 30 years, I've had one woman whocouldn't tolerate testosterone.
good, because I always hear other stories.
(01:26):
I mean, I'm not nearly as up in numbers as you, like we're treating, but everyone's alwayslike, you know, I hear like, this one had a problem, you know, so I just try it anyway.
so I have this female patient, and I guess I was trying to increase the progesterone andestrogen she was on like, I think maybe 200.
of progesterone and estrogen.
a micronized, progesterone micronized, progesterone 200 milligrams taken every night?
(01:50):
Yeah, she's got you know, and then the estrogen patch, you know 0.375 So her numbers likeserum wise are still very low very low So and especially the progesterone so I increased
her progesterone to three and I went up on the patch You know to the next dose.
So I guess she had some bleeding which happens sometimes and so Always I get a pelvicultrasound just to be sure right like a transvaginal ultrasound
(02:16):
And that came back, the endometrium was a little thickened, but probably having to do withher being on the hormones.
know, like whatever, was gonna show you the radiology report.
I'm not worried, it stopped.
It's all good.
And then, you know, a few weeks later, after that happened and everything was fine, shebasically calls me and she's like, I have, I have, or she sends me a picture and she has
(02:38):
almost like a cellulitic sort of like bite.
like on her right breast, the right breast.
And she thinks she has inflammatory breast cancer.
I'm like, you don't have inflammatory breast cancer, right?
I was like, that's not even where it presents.
So she's really freaking out and getting upset.
And I calmed her down and I was like, and she travels all over this patient.
(02:58):
She's like never in one place.
So I was like maybe have someone examine you, get their hands on you, just see what itlooks like because you might need an antibiotic because I didn't like the way it looked.
And it looked like a bite to me.
And then she had the cellulitis or.
So basically, she got an antibiotic.
started her...
It went away.
It started really going away within two days.
And she felt better.
So then I get a call...
(03:21):
yesterday or the day...
Yeah, yesterday or the day before, that now she's having all this breast pain and breastdiscomfort in that breast, and it's radiating to her armpit, and she's literally having a
heart attack.
let's talk about it.
So let me start, as you know, at the beginning, we are concerned when a woman has a uterusand we give them estrogen, it needs to be countered by progesterone, because
(03:43):
progesterone's the balancing hormone, right?
And we all as women make progesterone.
Usually when we're younger, in our reproductive years, until we go through menopause,we're making the progesterone after we ovulate.
As we hit our 40s, many women don't ovulate.
Sometimes they still bleed regularly,
They don't have you.
So to start with your first issue, no, I don't worry about serum levels.
(04:06):
I actually think what trumps that is how a person feels and other risk factors.
So have I used progesterone even 300, 400 milligrams every night?
Yes.
But I mainly use that in the setting of withdrawal.
So if somebody I think has unopposed estrogen, they either have a cyst, and that's notuncommon in women in their younger years.
(04:29):
40s and 50s as opposed to later on, then I might induce a menstrual cycle because I wantto shed the lining of the uterus and I would either give them an injection of
progesterone, or orally every night for two weeks and then induce a withdrawal.
Because if you get a uterine lining of greater than four, I don't find that acceptable.
(04:49):
Right, so her thickness went up to 6 millimeters.
So that's a little borderline.
You can go either way there.
Sometimes you just use progesterone and then you stop the hormones, you stop the estrogenand the progesterone, and then you have an induced bleed, and that's what you want to see.
So you don't want to keep building up that lining.
As far as the rest of it...
(05:11):
Even though she's 57 and she hasn't bled in a long time.
to, I can live with six, but four is, you know, much more.
know that is.
But what would you do with this patient?
you repeat the trans-vag ultrasound?
It depends on the timing.
So depending on when you've given her the hormones, I would take a look.
(05:32):
her.
Okay.
That's when this happened.
It's just like the timing was like
So she had the ultrasound after the increase in progesterone or before.
I increased her, she bled.
So then I ordered it.
This has happened a bunch of times.
Even with women, when I've gone to 100 to 200, this is a good conversation to have.
It's like, is this?
And it's always...
(05:53):
that it's not coincidental, it happens a lot.
And then you get the pelvic ultrasound and then you put them through a bias.
It's almost like you're incidentally finding it, but it's probably maybe a physiologicthing that's happening because they're on the hormones, right?
If you could explain that, that would be amazing.
on a positive note, if they're doing that, they actually are biologically younger becausethey have the capability of estrogen affecting the lining and building up a lining.
(06:18):
Interesting.
But the first step might be to, when somebody complains about it, or if you think thelevels are low, which is not a driver in my case, then I would get an ultrasound, I would
make sure that what it looks like, and then I might leave it alone, and I would not haveincreased to progesterone.
Well, no, I put her back down.
Right.
I put her back down, And then it was just like, they were just so, the numbers were stillin the toilet.
(06:42):
mean, you're right, you should treat the patient, not the numbers.
But then you get...
us.
So there's no question that the numbers are...
So let me tell you my bias, because it applies to all women.
First of all, each one of us is different, and we respond to different levels of hormones.
You can give two women the same hormones.
The levels can be different.
They metabolize it, they absorb it.
It's based on diet.
(07:02):
It's based on lifestyle.
There's a lot.
You know all of this.
So the first thing we do is look at risk benefit for each person.
And sometimes the levels of estrogen don't raise or progesterone too much.
But if symptomatically they feel good, you might leave
alone.
Now, you might look at other variables too, which we can go into, but
Remember, when we're of a reproductive age, the first week of our cycle, can have nearcastrate levels of estrogen and no progesterone.
(07:29):
The second week of the cycle, the estrogen starts going up.
And so by the time a woman is ready to ovulate, which is usually about two weeks beforethey have a period, it is not counted from day one of their period, it's actually
backwards because you ovulate, we ovulate 12 to 14 days before a period.
The estrogens could be as high as 100, 200, even 300.
(07:51):
There's still no progesterone.
And it's only after ovulation that you'll see progesterone rise anywhere from 1 to 20,depending on how healthy the ovulation is.
interesting because, and I think I was taught well when I was really trying to get my headaround and getting teaching around hormones, but I always do check in premenopausal women,
(08:12):
especially the hormone levels at day five, six, seven after they ovulate so that they'rein their luteal phase.
Exactly.
So you can an accurate progesterone.
that's another thing that my patients go to see their conventional.
know, doctor or gynecologist and they're not checking it based on that.
I actually had one of the brightest endocrinologists, but was not a reproductiveendocrinologist at Yale, refer me a patient, a young patient in her 30s, asking me if she
(08:39):
was menopausal.
And what happened was the bloods were drawn mid-cycle where LH is elevated.
And so I remember feeling uncomfortable because he was one of my professors.
And your protester has not.
And so because it's very important to pay attention to cycle weeks.
And some women have cycles that are every 21 days.
have them do ovulation strips even and then I have them do it like based on
(09:03):
To deal with this patient, I would likely reduce both her estrogen and her gestural.
That was a pretty low level of estrogen.
.375 is like...
back down to .375 and I went back down to 200 a pay.
Yeah, but now what we do why she's obsessing now about that.
(09:24):
Now, I told her again, she's not she's not my.
like full-time patient, like she just sees me for certain things, especially hormones.
So she has another concierge physician and I said, you really should have someone examineyou and you likely need a breast ultrasound if it's really bothering you that much.
So I told her to go back to that doctor and you know, to her concierge primary care doctorand she's going I think on Monday to examine her and I said, you likely, if it's really
(09:49):
bothering you, get a right breast ultrasound to start.
it's unilateral, one breast, not the other, not both.
It's just her right breast.
It's where she had the cell.
So it could have gotten a bite.
You don't know what happened and why she got infected.
That's exactly the path to take because you just want to be sure there's nothing elsegoing on.
And it could be an inflammatory process, but not related to cancer.
(10:13):
This is not the way it presents.
she thinks that it has to do, I'm just saying this is where women's minds go.
And that's why I just thought it was an interesting case to talk about because she thinksit's, my god, the estrogen.
And my god, you increased the estrogen for those few weeks and my, you know, like it'svery.
She has no perspective because she hasn't seen, but I've seen cases like this.
What's a possible next step, and it's really dealing with her anxiety and showing her thebefore and after, is I might stop all the hormones, let her get examined, and then she
(10:43):
won't be feeling that good when you stop the hormones.
So then I would resume it at the lower level and have her understand that there's norelationship here.
So that I've done also.
Right, to show her that even off of it, she's having maybe pain or something.
isn't due directly to the hormones.
Now the hormones can aggravate if on high doses sometimes of estrogen, which she was noton, you can get sensitivity of the breast.
(11:08):
I know you hear that all the time.
Me too.
But it's offset by progesterone and also you can use progesterone cream.
So sometimes in these cases where they're really worried,
I'm perfectly okay with saying, let's hold it for like a month or a couple of weeks.
Let's see how you feel.
And then we can resume it slowly one at a time and we can see how to do.
like that.
And then as far as her pelvic ultrasound, so physiologically it sounds like she's justresponding to the hormone.
(11:36):
She's on a good amount of progesterone to counteract.
Actually, you have her on pretty low estrogen and higher progesterone.
what I mean.
That's what I mean.
She's done plenty of producing.
So anyway, the point is, with this, like, would you repeat this or just like, what dothink we should do with that?
timing in mind, what I would do thinking it through is I would probably repeat herultrasound in a month or two.
(12:00):
I might repeat it off the hormones.
Like if she's comfortable, I would tell her this, you know, we can go in any direction.
Let's see how you do.
Stop, let's stop the hormones for now.
She might not want to, but let's assume she listens because she wants that.
long do you take them off the horn?
a minimum of two weeks, maybe a month.
(12:22):
Well, if she does it on, if she does repeats it on it and this just stays the same.
fine, she could repeat it on it because you could see what the lining looks like.
But if the lining persists or is greater than six millimeters, then I would, I might holdthe estrogen, keep her on the progesterone, and then withdraw the progesterone after two
weeks at a higher dose.
So least 200.
(12:44):
repeat the ultras down one more time like another month later.
And maybe she'll bleed again or if you don't you might not catch it, but she hopefullywill shed the lining.
and then thickening the thickness.
Okay, I like that.
All right, so you want to go to the next case?
So this patient, I wanted to show you her blood work, actually.
She's a long COVID patient, young girl.
(13:05):
In her 20s?
Now.
16.
16.
But a lot of these girls or young women after COVID or the vaccine, they developed a lotof issues with their menstrual cycles and dysmenorrhea and amenorrhea.
I've seen it a lot.
I don't know if you've seen things similar to this.
(13:26):
hold on.
I just want to tell you a little bit of her background so you know.
see where we are.
Okay, so, oh yeah, now she's 17.
She's actually 17 now.
And she came in with long COVID.
She also has SIRS.
She has a history of pandas in the past, but her main symptoms were like chronic fatiguewith post-exertional malaise, brain fog, blurry vision, insomnia, joint pain, daily
(13:51):
migraines.
She also has like lot of mast cell activation, mast cell issues.
And I'm trying to think.
where the thing is about her period.
on, let me just see, looking in my note.
Okay, so she reports bleeding.
She does menstruate every 28 days.
She'll be for about five days.
She has heavy flow the first two days.
She has some PMS symptoms, including bad headaches and cramps.
(14:14):
Okay, so that's where we were.
Now, whenever I checked her blood, you know, she looked like to me, you know, and I did ithow we just talked about the right way to do it.
During the luteo phase, she would always be hanging out at like...
Like I saw her, had an estrogen of 322 and a progesterone of 0.1.
And then...
So to me, and like you can also qualify this too, like I think about estrogen excesses twoways.
(14:39):
your estrogen is like still within range, right?
But maybe on the high end and normal, and then like you have like no progesterone.
or you have very, very elevated estrogen and the progesterone's within normal.
So like she to me was more like high normal, but like no progesterone at all.
Does she have any history of any reproductive endocrine abnormalities?
(15:02):
she any evidence of PCOS or any metabolic?
She has history with PCOS.
I lied and told you Sorry about that.
You looked at I forgot to tell you.
She's saying they are, yes.
Have she kept a calendar or one of the apps?
You can see that?
(15:23):
her history, she was able to say pretty much she's been regular every 28 days.
So you can be completely regular, you can even be completely regular just talking aboutthis, no, and be pregnant.
So I have seen all sorts of cases and presentation, because I don't think we don't knowwhat we don't know.
But in her case, just on a very low level point of view, because I don't have the numbersin front of me, it sounds like she's an ambulatory.
(15:49):
And that means she's not making an egg.
And she probably has a cyst or varian cyst that is making
enough estrogen because that level of estrogen, it's week two or three of the cycle,suggests that there's a follicle that's overgrown and is still secreting estrogen.
And that can cause not the symptoms you said, but symptoms of breast tenderness andgrowth, discomfort, sometimes there's pain in the pelvic area, right or left.
(16:16):
So I would look for an ovarian cyst in her and then I would withdraw her.
If her progesterone is low.
want to talk to you about.
So would someone like her be a good candidate for starting some progesterone?
it doesn't have to be permanent.
Like it could be something, it's used diagnostically to see if you could shed the lining.
Yeah.
Because she presumably also has a built up uterine lining.
(16:38):
There are other conditions you can look at like endometriosis and adenomyosis that couldbe contributing as well.
So I should just get the pelvic trans-vag ultrasound done.
And then how much progesterone would you start in for how long?
Minimum of 200.
Actually, my go-to levels for menopausal and perimenopausal women are really 100 because Idon't think you need to have levels of progesterone, measurable levels.
(17:05):
But in her case, she's 200.
If she's on it for like a week to two weeks, that would be the window.
Then you stop it and you see if she withdraws to that.
If you did the ultrasound, you'll also have a preview of whether there is a cyst, whethersometimes cysts have to be, you have to withdraw the fluid from the cyst for it to go
(17:27):
away.
should you do the ultrasound first and then start the progesterone?
Yes.
So you can see what she looks like.
to the baseline data first.
And I would probably repeat her values.
If she's that young, probably, you you can look mid-cycle at her LH and FSH ratio to seeif you can document that she has PCOS.
If she's never had an ultrasound before, you might, not every PCOS patient presents thisway, but you might pick up the cysts are pathognomonic or will document PCOS.
(17:56):
So when, because I know I have a lot of PCOS patients, they don't have any cysts.
That's normal.
I mean, that's a common finding.
But is that not a good time to check the FSH and LH?
Do you have to do it mid-site?
can, but you want to do it at a time that you know what the number should look like and ifthere's a reversal of the patterns you'll be able to see it more effectively.
send them twice then, like you want to send them around day, like if they're a 28 day orlike around day 14 to do LHN.
(18:23):
earlier, like where you're building up and you can see that the numbers are not compatiblewith where you need to go for ovulation.
And then you do it during ovulation to check to see what their progesterone is and ifthey're actually ovulating.
Okay, so wait, what?
So when are you checking project?
I thought.
Definitely check for progesterone during what would be presumed to be post-ovulatory.
(18:47):
You're checking estrogen then too.
I don't often do that because unless there are symptoms of pelvic pain, discomfort, and Isuspect a cyst, and she might have one because that's a pretty high estradiol level for a
young woman who's not being stimulated through IVF.
Usually you'll see estradiol levels.
(19:09):
It's not uncommon to see 150, 200, 250, but she was closer to 400.
So unless she was potentially having twins and multiple follicles were coming, it's muchmore.
likely that she has a cyst that's continuing to be active and she's not ovulatory tocounter it.
So her progesterone hasn't gone up and she's not, and she may be bleeding.
(19:29):
It could be estrogen breakdown bleeding if her estradiol has fallen.
So I would prefer to see her estradiol in the first week of the cycle because at thatpoint she should be low estradiol.
And if she's not, then she's a constant estradiol and she's just bleeding on somewhat of aregular, irregular basis because we don't really know the dates, right?
for women that do have estrogen excess, right?
(19:50):
Do you keep them on a certain amount of progesterone for a certain amount of time or no?
Let me address that in a different way, which you probably know.
I like the basics.
I really want to know the dates because a lot of times, just like we know somebody thinksthey're bleeding heavily from their mouth or a mucus membrane, we know that it's just
because it looks like that, but it really isn't.
(20:11):
The same thing is true of dates and following your cycle and symptoms.
Unless you can absolutely say, listen, I need to know the last month or two and then Iwant to follow it in the next month or two, it's very hard to make sense of it.
Once you get that health story and you see what they're doing, you can figure out, I knowyou can for sure, what is actually going on and what's the best way to proceed, where do
(20:32):
you start?
In her case, it's a little too unclear to me still what her periods were actually doing.
I'm not saying that they might not be completely regular, but I doubt it.
If she has this kind of pattern, it would be hard to...
you know, hard to trust that they're absolutely regular.
So if you're not getting the facts from her, I would ask for that.
So you're saying like for her as you should get her estradiol checked the first week ofher cycle.
(20:56):
Meaning like after day one of bleed or something.
can do day three where you can also check on NFSH and LH, right?
You do it then too, because you said mid cycle for the FSHL.
progesterone can sometimes be elevated the first two or three days of your cycle if you'veovulated and it's a good ovulation.
So I would check it at different points in the cycle, but I would start by looking, doesher estradiol fall?
(21:16):
Because that estradiol is pretty high.
And you're checking it at a time in the cycle where you can't rule out if there aremultiple, you know, eggs and follicles or she has one big cyst.
She could even have endometriosis because her long COVID symptoms could be masking otherconditions that she might have underneath.
Did she start like this with her menarche, with her first menses?
(21:38):
Because that's another good question.
When was her first menarche?
How were her periods at the beginning?
it.
It's just in the chart.
Okay.
That was like super helpful.
This was the most insane case.
she's a long COVID patient, she's 62.
And I'm looking, I keep doing her, how long was I, I did it in her first set, her totaltestosterone is 620.
(22:00):
Her estradiol's 1230.
Wait, hold on, this is insane.
I've never seen this.
the hormone by the way Quest or LabCorp?
Okay.
No, this is LabCorp.
Her progesterone was 13.
And like, what the hell is going on?
So then I...
yeah.
Okay.
Not right.
(22:20):
Yeah.
Do you know how many?
What she's
so then I repeat it.
I'm like, okay, I want to repeat this.
I was like, maybe this is a mistake.
Cause I've never, I've never seen numbers like this.
I was freaking out.
time I've ever seen that is when women are sleeping with men who are using topical
no, no, husband's not.
So then she repeats it, right?
She was 2,144.3, her estradiol.
(22:44):
It's like in the hypersteam state.
and her testosterone was 711 and her progesterone was 13.
Okay?
I mean, she has long COVID, but how can she feel good like this?
This is insane, you know?
She's nauseous all the time, nauseated 24 seven.
So then, and her sex hormone, Bidon and Glow Abulans, 211.
(23:05):
So then I repeat it, cause I'm floored by this.
I'm like, this can't be real.
So then I repeat it.
Okay, so fine.
The total testosterone now is 620.
This is better than most of my male patients coming in my door.
And her DHEA-S went, I mean, it's still high.
It's like 24.3.
Then her estradiol went from 2144 to 1230.
(23:26):
And then her sex hormone, body and globulin went up to 229.
Ready?
She's on estradiol.
Estradiol, 2.8 milligrams, estriol, 0....
And then testosterone 3, 1 gram, 1 ml per day, 1 gram.
Cream.
(23:47):
It doesn't make sense.
The numbers don't align with the treatment that she's getting.
And I repeated it.
So I stopped her.
I just took her off everything.
I was like, go off everything.
And then I had her, she was like, but I didn't want her to withdraw, like, and feel awful.
So then I took her off of it, but I did put her back on like after a while.
(24:09):
It's been like, I think it was like two weeks.
How did she feel when you stopped everything or started withdrawing?
Because you can do it slowly.
She didn't like notice anything.
Like she's been coming in to me for the IVs and stuff.
No, she was just seeing that woman for just her hormone.
Oh, okay.
is what I did, maybe I did it wrong, but I gave her just back, like I waited, I took heroff for a little bit, and then I just gave her a 0.25 patch, and I gave her 100, no,
(24:36):
0.025.
Like the lowest dose, just so she'd have a little something, because she's notcomplaining.
I haven't rechecked her.
that's unusual too What you did was fine, but whenever you're faced with abnormal numbersand you repeat them and the woman doesn't seem and the woman that you're treating doesn't
seem that symptomatic, it's always best.
(24:59):
It's like a machine that doesn't work.
Unplug it and then replug it.
Yeah, that's what I try to do.
it and let her withdraw.
I sometimes stop it slowly to not.
Like, well, there was something, I mean, I
reason why you want to stop it maybe slowly by weaning her is if she's act, if her body isadjusted to that level, she might miss it more.
And of course women don't like hot flashes and feeling uncomfortable.
(25:24):
And she already had long COVID symptoms.
So what I would do is every other day, it, well, if you're going to look at this again,maybe a more natural approach would be to say.
Every other.
Yeah, let's reduce it by half and then you go to every other day.
like go from a go to like a half a gram every other day.
And then you wean her off of it completely within like a two to three week period,depending on her comfort level.
(25:48):
Keep her off of it and then retest her hormones, because in a week or two or three, sheshould be back down to baseline.
unless there's something else going on.
And to be fair and transparent, there's nothing that I can imagine that would be behindthis besides excessive hormones in a woman who actually doesn't metabolize it very
quickly, keeps it around in her body, and she's...
(26:11):
Right.
Okay.
then, and then after you get her back to like whatever baseline or meta-plussle levels,then when.
Right, that's what I do too.
I started her on progesterone first.
I always start my patients on progesterone first.
And then I.
Do you have a reason for why you do it?
Because of the whole thing of not having unopposed estrogen and I just feel like womentolerate the progesterone better first, but that's just my...
(26:35):
a great reason because we obviously all use progesterone even when you don't have auterus.
So that's just the one reason to use it, that you have to use it.
There's one reason to do it, you know, but the other reason I like progesterone and itdepends on how a person presents is if sleep is an issue, progesterone is really useful
for sleep.
I agree.
100,000 percent and all of these women can't sleep and they're anxious.
(27:00):
So progesterone really helps.
I usually start with just 100 milligrams of micronized progesterone.
I would start low and then I would retest her in like four to six weeks.
So I usually do that.
I always start, I test it around like six weeks, know, similar to that.
But most women I would say I do usually go to 200.
I do get the...
200 is fine.
(27:21):
It depends on the patient and what you're trying to achieve.
One of the issues with progesterone is the lab varies its assays.
So we've noticed that as well where they change the assay and sometimes they'll look fornaturally secreted progesterone and sometimes they look for micronized.
So there was a long stretch of time where I then reached out to Quest because I would seeeverybody coming in and he couldn't see any progesterone and they weren't measuring
(27:43):
micronized progesterone.
So you couldn't see it.
But if a person felt well, I would leave it alone.
to that point as well, kind of thinking through this, when a woman who might be 60, 70, 80comes in and has never been on hormones, you also want to go slow and use a little.
And if sleep is not a problem, I start with testosterone, because testosterone will helpthem feel stronger, lose weight, and also it's better for sugar management and other
(28:11):
issues.
older woman you're saying like what 65 and older or something like that?
When you're giving them testosterone you're giving them a cream?
usually do you have them applied?
an applied to non and terminal hair sites, which is behind the knee and in the FASA ofthe.
How come some people use like the outer labia?
(28:32):
because they think it improves libido and it sometimes does, but I don't find thatuniversally true.
do this part of your elbow, the inner part of your elbow or behind your knee.
And sometimes I have them rotate it.
The only issue with the arm is drawing blood.
Well Robin, that was a great case, great management actually.
I love what you did.
think in looking at numbers...
(28:53):
trying.
You're doing great.
You're not just trying, you're doing it.
It's hard.
I'm very conscientious and I don't want to mess up and you just want to get it right foreverybody.
And you did it right because when you are faced with numbers that make no sense becausethe doses she's getting is not that out or not that outrageous you stop what you're doing
again and then you restart at a lower level while you're assessing how she's feeling soyou don't necessarily want to start stop overnight because she may react to it so you can
(29:22):
wean you stopped overnight and she still felt well so I what you're doing to approach itand slowly ramp up each one of the other hormones makes sense
I didn't start...
And I don't know how you feel about this too, but I usually...
Like, I do progesterone, esterone, and then I'll add testosterone.
It sounds like something...
Like, with not my older...
Like, you know, more of my newly menopause.
Hence what they're missing and what they present with.
(29:44):
So generally that's the default, but I think when someone is in amazing shape and doingeverything right and sleep is not an issue, testosterone is a good place.
When they're older, you want to make sure you're getting them to sleep if that's an issueor they need more estrogenization.
Let's say they have dyspareunia and uncomfortable sex life.
Initially I add actually an estrogen cream.
(30:06):
So there's a lot of ways to do it for the individual.
And you're fine too, like using like an estrogen, an estradiol cream with like a pack.
That's not a problem, but sometimes it's annoying and I find patches to be more annoyingeven though it could be on a basis.
mean more because if you're trying to give more like what I mean is is I I started usingboth now too because I find or I had done some reading to that the estradiol cream in
(30:32):
addition like look like will help with the pelvic and you can pelvic right muscle Right,that's what I mean.
I feel like that's awesome to get you know to give you
Yes, so I almost always, because if women come in with early symptoms but they haven'treally been treated for a while and they've been in menopause for not the perimenopausal,
because that could be subtle, then giving them some cream will hasten the recovery.
(30:56):
So we usually start it with several times a week, sometimes every night.
And then within a week or so, we reduce to two or three times a week.
And ultimately, when you get their estradiol level higher in their blood work and they seeit, their cells see it, you don't always need the
dial cream so then it becomes whenever it's necessary.
But are you getting the same effect with the pelvic musculature or pelvic muscle, thepelvic floor muscles, just giving it orally or is it, is it helped to also give it?
(31:27):
It helps when you jump start it until they get a steady state, then you're fine.
So most women don't need to continue to do it.
It's just an extra step.
So why be annoying?
Disprunia?
Well, that or like, to course or like having better intercourse.
Other reason.
are other products for that.
(31:49):
But in terms of simply making sure her body is up to speed, the usual course, if they wantto continue it, it's up to them.
you feel uncomfortable and you think it helps, you can apply it three times a week.
I'm so glad to see you again, Robin.
(00:02):
Join us on a two-part case study talking about various women and their issues withhormones.
Let's start by jumping right in.
And there are some cases I think we want to go over as well.
I love talking to Florence because she's so knowledgeable in this area, so I love pickingher brain.
I was saying how you almost have to, it's like pulling teeth to get these women to do thisamazing thing for them, right, to give them back these hormones.
(00:24):
For themselves.
Right.
And it's not an...
That's the other thing.
It's all they think it's all about the symptoms.
No, I'm like, it's not it's about protecting your heart protecting your brain protectingyour bones like all these things and And then you get them on it and then they're like, my
god, this is amazing Like I feel so good But then there's still this thing in the back oftheir head like my god, am I gonna get breast cancer?
(00:44):
my god, right?
Like it's really up.
It's really sad So anyway, I had this one patient a 57 year old female and she's beenfeeling amazing, you know on her on her
combination.
think she's on all three.
think she's on estrogen, progesterone, and a testosterone.
which is very rare.
lot of conventional medical doctors don't feel...
(01:05):
Yet it's such a great hormone.
Of the three, it does the most for the body.
Right, and like I get that some women can't tolerate it and that's fine, but like youshould at least try, you know to me I was like you try and see how they do, right?
think in the thousands of women I've treated in the 30 years, I've had one woman whocouldn't tolerate testosterone.
good, because I always hear other stories.
(01:26):
I mean, I'm not nearly as up in numbers as you, like we're treating, but everyone's alwayslike, you know, I hear like, this one had a problem, you know, so I just try it anyway.
so I have this female patient, and I guess I was trying to increase the progesterone andestrogen she was on like, I think maybe 200.
of progesterone and estrogen.
a micronized, progesterone micronized, progesterone 200 milligrams taken every night?
(01:50):
Yeah, she's got you know, and then the estrogen patch, you know 0.375 So her numbers likeserum wise are still very low very low So and especially the progesterone so I increased
her progesterone to three and I went up on the patch You know to the next dose.
So I guess she had some bleeding which happens sometimes and so Always I get a pelvicultrasound just to be sure right like a transvaginal ultrasound
(02:16):
And that came back, the endometrium was a little thickened, but probably having to do withher being on the hormones.
know, like whatever, was gonna show you the radiology report.
I'm not worried, it stopped.
It's all good.
And then, you know, a few weeks later, after that happened and everything was fine, shebasically calls me and she's like, I have, I have, or she sends me a picture and she has
(02:38):
almost like a cellulitic sort of like bite.
like on her right breast, the right breast.
And she thinks she has inflammatory breast cancer.
I'm like, you don't have inflammatory breast cancer, right?
I was like, that's not even where it presents.
So she's really freaking out and getting upset.
And I calmed her down and I was like, and she travels all over this patient.
(02:58):
She's like never in one place.
So I was like maybe have someone examine you, get their hands on you, just see what itlooks like because you might need an antibiotic because I didn't like the way it looked.
And it looked like a bite to me.
And then she had the cellulitis or.
So basically, she got an antibiotic.
started her...
It went away.
It started really going away within two days.
And she felt better.
So then I get a call...
(03:21):
yesterday or the day...
Yeah, yesterday or the day before, that now she's having all this breast pain and breastdiscomfort in that breast, and it's radiating to her armpit, and she's literally having a
heart attack.
let's talk about it.
So let me start, as you know, at the beginning, we are concerned when a woman has a uterusand we give them estrogen, it needs to be countered by progesterone, because
(03:43):
progesterone's the balancing hormone, right?
And we all as women make progesterone.
Usually when we're younger, in our reproductive years, until we go through menopause,we're making the progesterone after we ovulate.
As we hit our 40s, many women don't ovulate.
Sometimes they still bleed regularly,
They don't have you.
So to start with your first issue, no, I don't worry about serum levels.
(04:06):
I actually think what trumps that is how a person feels and other risk factors.
So have I used progesterone even 300, 400 milligrams every night?
Yes.
But I mainly use that in the setting of withdrawal.
So if somebody I think has unopposed estrogen, they either have a cyst, and that's notuncommon in women in their younger years.
(04:29):
40s and 50s as opposed to later on, then I might induce a menstrual cycle because I wantto shed the lining of the uterus and I would either give them an injection of
progesterone, or orally every night for two weeks and then induce a withdrawal.
Because if you get a uterine lining of greater than four, I don't find that acceptable.
(04:49):
Right, so her thickness went up to 6 millimeters.
So that's a little borderline.
You can go either way there.
Sometimes you just use progesterone and then you stop the hormones, you stop the estrogenand the progesterone, and then you have an induced bleed, and that's what you want to see.
So you don't want to keep building up that lining.
As far as the rest of it...
(05:11):
Even though she's 57 and she hasn't bled in a long time.
to, I can live with six, but four is, you know, much more.
know that is.
But what would you do with this patient?
you repeat the trans-vag ultrasound?
It depends on the timing.
So depending on when you've given her the hormones, I would take a look.
(05:32):
her.
Okay.
That's when this happened.
It's just like the timing was like
So she had the ultrasound after the increase in progesterone or before.
I increased her, she bled.
So then I ordered it.
This has happened a bunch of times.
Even with women, when I've gone to 100 to 200, this is a good conversation to have.
It's like, is this?
And it's always...
(05:53):
that it's not coincidental, it happens a lot.
And then you get the pelvic ultrasound and then you put them through a bias.
It's almost like you're incidentally finding it, but it's probably maybe a physiologicthing that's happening because they're on the hormones, right?
If you could explain that, that would be amazing.
on a positive note, if they're doing that, they actually are biologically younger becausethey have the capability of estrogen affecting the lining and building up a lining.
(06:18):
Interesting.
But the first step might be to, when somebody complains about it, or if you think thelevels are low, which is not a driver in my case, then I would get an ultrasound, I would
make sure that what it looks like, and then I might leave it alone, and I would not haveincreased to progesterone.
Well, no, I put her back down.
Right.
I put her back down, And then it was just like, they were just so, the numbers were stillin the toilet.
(06:42):
mean, you're right, you should treat the patient, not the numbers.
But then you get...
us.
So there's no question that the numbers are...
So let me tell you my bias, because it applies to all women.
First of all, each one of us is different, and we respond to different levels of hormones.
You can give two women the same hormones.
The levels can be different.
They metabolize it, they absorb it.
It's based on diet.
(07:02):
It's based on lifestyle.
There's a lot.
You know all of this.
So the first thing we do is look at risk benefit for each person.
And sometimes the levels of estrogen don't raise or progesterone too much.
But if symptomatically they feel good, you might leave
alone.
Now, you might look at other variables too, which we can go into, but
Remember, when we're of a reproductive age, the first week of our cycle, can have nearcastrate levels of estrogen and no progesterone.
(07:29):
The second week of the cycle, the estrogen starts going up.
And so by the time a woman is ready to ovulate, which is usually about two weeks beforethey have a period, it is not counted from day one of their period, it's actually
backwards because you ovulate, we ovulate 12 to 14 days before a period.
The estrogens could be as high as 100, 200, even 300.
(07:51):
There's still no progesterone.
And it's only after ovulation that you'll see progesterone rise anywhere from 1 to 20,depending on how healthy the ovulation is.
interesting because, and I think I was taught well when I was really trying to get my headaround and getting teaching around hormones, but I always do check in premenopausal women,
(08:12):
especially the hormone levels at day five, six, seven after they ovulate so that they'rein their luteal phase.
Exactly.
So you can an accurate progesterone.
that's another thing that my patients go to see their conventional.
know, doctor or gynecologist and they're not checking it based on that.
I actually had one of the brightest endocrinologists, but was not a reproductiveendocrinologist at Yale, refer me a patient, a young patient in her 30s, asking me if she
(08:39):
was menopausal.
And what happened was the bloods were drawn mid-cycle where LH is elevated.
And so I remember feeling uncomfortable because he was one of my professors.
And your protester has not.
And so because it's very important to pay attention to cycle weeks.
And some women have cycles that are every 21 days.
have them do ovulation strips even and then I have them do it like based on
(09:03):
To deal with this patient, I would likely reduce both her estrogen and her gestural.
That was a pretty low level of estrogen.
.375 is like...
back down to .375 and I went back down to 200 a pay.
Yeah, but now what we do why she's obsessing now about that.
(09:24):
Now, I told her again, she's not she's not my.
like full-time patient, like she just sees me for certain things, especially hormones.
So she has another concierge physician and I said, you really should have someone examineyou and you likely need a breast ultrasound if it's really bothering you that much.
So I told her to go back to that doctor and you know, to her concierge primary care doctorand she's going I think on Monday to examine her and I said, you likely, if it's really
(09:49):
bothering you, get a right breast ultrasound to start.
it's unilateral, one breast, not the other, not both.
It's just her right breast.
It's where she had the cell.
So it could have gotten a bite.
You don't know what happened and why she got infected.
That's exactly the path to take because you just want to be sure there's nothing elsegoing on.
And it could be an inflammatory process, but not related to cancer.
(10:13):
This is not the way it presents.
she thinks that it has to do, I'm just saying this is where women's minds go.
And that's why I just thought it was an interesting case to talk about because she thinksit's, my god, the estrogen.
And my god, you increased the estrogen for those few weeks and my, you know, like it'svery.
She has no perspective because she hasn't seen, but I've seen cases like this.
What's a possible next step, and it's really dealing with her anxiety and showing her thebefore and after, is I might stop all the hormones, let her get examined, and then she
(10:43):
won't be feeling that good when you stop the hormones.
So then I would resume it at the lower level and have her understand that there's norelationship here.
So that I've done also.
Right, to show her that even off of it, she's having maybe pain or something.
isn't due directly to the hormones.
Now the hormones can aggravate if on high doses sometimes of estrogen, which she was noton, you can get sensitivity of the breast.
(11:08):
I know you hear that all the time.
Me too.
But it's offset by progesterone and also you can use progesterone cream.
So sometimes in these cases where they're really worried,
I'm perfectly okay with saying, let's hold it for like a month or a couple of weeks.
Let's see how you feel.
And then we can resume it slowly one at a time and we can see how to do.
like that.
And then as far as her pelvic ultrasound, so physiologically it sounds like she's justresponding to the hormone.
(11:36):
She's on a good amount of progesterone to counteract.
Actually, you have her on pretty low estrogen and higher progesterone.
what I mean.
That's what I mean.
She's done plenty of producing.
So anyway, the point is, with this, like, would you repeat this or just like, what dothink we should do with that?
timing in mind, what I would do thinking it through is I would probably repeat herultrasound in a month or two.
(12:00):
I might repeat it off the hormones.
Like if she's comfortable, I would tell her this, you know, we can go in any direction.
Let's see how you do.
Stop, let's stop the hormones for now.
She might not want to, but let's assume she listens because she wants that.
long do you take them off the horn?
a minimum of two weeks, maybe a month.
(12:22):
Well, if she does it on, if she does repeats it on it and this just stays the same.
fine, she could repeat it on it because you could see what the lining looks like.
But if the lining persists or is greater than six millimeters, then I would, I might holdthe estrogen, keep her on the progesterone, and then withdraw the progesterone after two
weeks at a higher dose.
So least 200.
(12:44):
repeat the ultras down one more time like another month later.
And maybe she'll bleed again or if you don't you might not catch it, but she hopefullywill shed the lining.
and then thickening the thickness.
Okay, I like that.
All right, so you want to go to the next case?
So this patient, I wanted to show you her blood work, actually.
She's a long COVID patient, young girl.
(13:05):
In her 20s?
Now.
16.
16.
But a lot of these girls or young women after COVID or the vaccine, they developed a lotof issues with their menstrual cycles and dysmenorrhea and amenorrhea.
I've seen it a lot.
I don't know if you've seen things similar to this.
(13:26):
hold on.
I just want to tell you a little bit of her background so you know.
see where we are.
Okay, so, oh yeah, now she's 17.
She's actually 17 now.
And she came in with long COVID.
She also has SIRS.
She has a history of pandas in the past, but her main symptoms were like chronic fatiguewith post-exertional malaise, brain fog, blurry vision, insomnia, joint pain, daily
(13:51):
migraines.
She also has like lot of mast cell activation, mast cell issues.
And I'm trying to think.
where the thing is about her period.
on, let me just see, looking in my note.
Okay, so she reports bleeding.
She does menstruate every 28 days.
She'll be for about five days.
She has heavy flow the first two days.
She has some PMS symptoms, including bad headaches and cramps.
(14:14):
Okay, so that's where we were.
Now, whenever I checked her blood, you know, she looked like to me, you know, and I did ithow we just talked about the right way to do it.
During the luteo phase, she would always be hanging out at like...
Like I saw her, had an estrogen of 322 and a progesterone of 0.1.
And then...
So to me, and like you can also qualify this too, like I think about estrogen excesses twoways.
(14:39):
your estrogen is like still within range, right?
But maybe on the high end and normal, and then like you have like no progesterone.
or you have very, very elevated estrogen and the progesterone's within normal.
So like she to me was more like high normal, but like no progesterone at all.
Does she have any history of any reproductive endocrine abnormalities?
(15:02):
she any evidence of PCOS or any metabolic?
She has history with PCOS.
I lied and told you Sorry about that.
You looked at I forgot to tell you.
She's saying they are, yes.
Have she kept a calendar or one of the apps?
You can see that?
(15:23):
her history, she was able to say pretty much she's been regular every 28 days.
So you can be completely regular, you can even be completely regular just talking aboutthis, no, and be pregnant.
So I have seen all sorts of cases and presentation, because I don't think we don't knowwhat we don't know.
But in her case, just on a very low level point of view, because I don't have the numbersin front of me, it sounds like she's an ambulatory.
(15:49):
And that means she's not making an egg.
And she probably has a cyst or varian cyst that is making
enough estrogen because that level of estrogen, it's week two or three of the cycle,suggests that there's a follicle that's overgrown and is still secreting estrogen.
And that can cause not the symptoms you said, but symptoms of breast tenderness andgrowth, discomfort, sometimes there's pain in the pelvic area, right or left.
(16:16):
So I would look for an ovarian cyst in her and then I would withdraw her.
If her progesterone is low.
want to talk to you about.
So would someone like her be a good candidate for starting some progesterone?
it doesn't have to be permanent.
Like it could be something, it's used diagnostically to see if you could shed the lining.
Yeah.
Because she presumably also has a built up uterine lining.
(16:38):
There are other conditions you can look at like endometriosis and adenomyosis that couldbe contributing as well.
So I should just get the pelvic trans-vag ultrasound done.
And then how much progesterone would you start in for how long?
Minimum of 200.
Actually, my go-to levels for menopausal and perimenopausal women are really 100 because Idon't think you need to have levels of progesterone, measurable levels.
(17:05):
But in her case, she's 200.
If she's on it for like a week to two weeks, that would be the window.
Then you stop it and you see if she withdraws to that.
If you did the ultrasound, you'll also have a preview of whether there is a cyst, whethersometimes cysts have to be, you have to withdraw the fluid from the cyst for it to go
(17:27):
away.
should you do the ultrasound first and then start the progesterone?
Yes.
So you can see what she looks like.
to the baseline data first.
And I would probably repeat her values.
If she's that young, probably, you you can look mid-cycle at her LH and FSH ratio to seeif you can document that she has PCOS.
If she's never had an ultrasound before, you might, not every PCOS patient presents thisway, but you might pick up the cysts are pathognomonic or will document PCOS.
(17:56):
So when, because I know I have a lot of PCOS patients, they don't have any cysts.
That's normal.
I mean, that's a common finding.
But is that not a good time to check the FSH and LH?
Do you have to do it mid-site?
can, but you want to do it at a time that you know what the number should look like and ifthere's a reversal of the patterns you'll be able to see it more effectively.
send them twice then, like you want to send them around day, like if they're a 28 day orlike around day 14 to do LHN.
(18:23):
earlier, like where you're building up and you can see that the numbers are not compatiblewith where you need to go for ovulation.
And then you do it during ovulation to check to see what their progesterone is and ifthey're actually ovulating.
Okay, so wait, what?
So when are you checking project?
I thought.
Definitely check for progesterone during what would be presumed to be post-ovulatory.
(18:47):
You're checking estrogen then too.
I don't often do that because unless there are symptoms of pelvic pain, discomfort, and Isuspect a cyst, and she might have one because that's a pretty high estradiol level for a
young woman who's not being stimulated through IVF.
Usually you'll see estradiol levels.
(19:09):
It's not uncommon to see 150, 200, 250, but she was closer to 400.
So unless she was potentially having twins and multiple follicles were coming, it's muchmore.
likely that she has a cyst that's continuing to be active and she's not ovulatory tocounter it.
So her progesterone hasn't gone up and she's not, and she may be bleeding.
(19:29):
It could be estrogen breakdown bleeding if her estradiol has fallen.
So I would prefer to see her estradiol in the first week of the cycle because at thatpoint she should be low estradiol.
And if she's not, then she's a constant estradiol and she's just bleeding on somewhat of aregular, irregular basis because we don't really know the dates, right?
for women that do have estrogen excess, right?
(19:50):
Do you keep them on a certain amount of progesterone for a certain amount of time or no?
Let me address that in a different way, which you probably know.
I like the basics.
I really want to know the dates because a lot of times, just like we know somebody thinksthey're bleeding heavily from their mouth or a mucus membrane, we know that it's just
because it looks like that, but it really isn't.
(20:11):
The same thing is true of dates and following your cycle and symptoms.
Unless you can absolutely say, listen, I need to know the last month or two and then Iwant to follow it in the next month or two, it's very hard to make sense of it.
Once you get that health story and you see what they're doing, you can figure out, I knowyou can for sure, what is actually going on and what's the best way to proceed, where do
(20:32):
you start?
In her case, it's a little too unclear to me still what her periods were actually doing.
I'm not saying that they might not be completely regular, but I doubt it.
If she has this kind of pattern, it would be hard to...
you know, hard to trust that they're absolutely regular.
So if you're not getting the facts from her, I would ask for that.
So you're saying like for her as you should get her estradiol checked the first week ofher cycle.
(20:56):
Meaning like after day one of bleed or something.
can do day three where you can also check on NFSH and LH, right?
You do it then too, because you said mid cycle for the FSHL.
progesterone can sometimes be elevated the first two or three days of your cycle if you'veovulated and it's a good ovulation.
So I would check it at different points in the cycle, but I would start by looking, doesher estradiol fall?
(21:16):
Because that estradiol is pretty high.
And you're checking it at a time in the cycle where you can't rule out if there aremultiple, you know, eggs and follicles or she has one big cyst.
She could even have endometriosis because her long COVID symptoms could be masking otherconditions that she might have underneath.
Did she start like this with her menarche, with her first menses?
(21:38):
Because that's another good question.
When was her first menarche?
How were her periods at the beginning?
it.
It's just in the chart.
Okay.
That was like super helpful.
This was the most insane case.
she's a long COVID patient, she's 62.
And I'm looking, I keep doing her, how long was I, I did it in her first set, her totaltestosterone is 620.
(22:00):
Her estradiol's 1230.
Wait, hold on, this is insane.
I've never seen this.
the hormone by the way Quest or LabCorp?
Okay.
No, this is LabCorp.
Her progesterone was 13.
And like, what the hell is going on?
So then I...
yeah.
Okay.
Not right.
(22:20):
Yeah.
Do you know how many?
What she's
so then I repeat it.
I'm like, okay, I want to repeat this.
I was like, maybe this is a mistake.
Cause I've never, I've never seen numbers like this.
I was freaking out.
time I've ever seen that is when women are sleeping with men who are using topical
no, no, husband's not.
So then she repeats it, right?
She was 2,144.3, her estradiol.
(22:44):
It's like in the hypersteam state.
and her testosterone was 711 and her progesterone was 13.
Okay?
I mean, she has long COVID, but how can she feel good like this?
This is insane, you know?
She's nauseous all the time, nauseated 24 seven.
So then, and her sex hormone, Bidon and Glow Abulans, 211.
(23:05):
So then I repeat it, cause I'm floored by this.
I'm like, this can't be real.
So then I repeat it.
Okay, so fine.
The total testosterone now is 620.
This is better than most of my male patients coming in my door.
And her DHEA-S went, I mean, it's still high.
It's like 24.3.
Then her estradiol went from 2144 to 1230.
(23:26):
And then her sex hormone, body and globulin went up to 229.
Ready?
She's on estradiol.
Estradiol, 2.8 milligrams, estriol, 0....
And then testosterone 3, 1 gram, 1 ml per day, 1 gram.
Cream.
(23:47):
It doesn't make sense.
The numbers don't align with the treatment that she's getting.
And I repeated it.
So I stopped her.
I just took her off everything.
I was like, go off everything.
And then I had her, she was like, but I didn't want her to withdraw, like, and feel awful.
So then I took her off of it, but I did put her back on like after a while.
(24:09):
It's been like, I think it was like two weeks.
How did she feel when you stopped everything or started withdrawing?
Because you can do it slowly.
She didn't like notice anything.
Like she's been coming in to me for the IVs and stuff.
No, she was just seeing that woman for just her hormone.
Oh, okay.
is what I did, maybe I did it wrong, but I gave her just back, like I waited, I took heroff for a little bit, and then I just gave her a 0.25 patch, and I gave her 100, no,
(24:36):
0.025.
Like the lowest dose, just so she'd have a little something, because she's notcomplaining.
I haven't rechecked her.
that's unusual too What you did was fine, but whenever you're faced with abnormal numbersand you repeat them and the woman doesn't seem and the woman that you're treating doesn't
seem that symptomatic, it's always best.
(24:59):
It's like a machine that doesn't work.
Unplug it and then replug it.
Yeah, that's what I try to do.
it and let her withdraw.
I sometimes stop it slowly to not.
Like, well, there was something, I mean, I
reason why you want to stop it maybe slowly by weaning her is if she's act, if her body isadjusted to that level, she might miss it more.
And of course women don't like hot flashes and feeling uncomfortable.
(25:24):
And she already had long COVID symptoms.
So what I would do is every other day, it, well, if you're going to look at this again,maybe a more natural approach would be to say.
Every other.
Yeah, let's reduce it by half and then you go to every other day.
like go from a go to like a half a gram every other day.
And then you wean her off of it completely within like a two to three week period,depending on her comfort level.
(25:48):
Keep her off of it and then retest her hormones, because in a week or two or three, sheshould be back down to baseline.
unless there's something else going on.
And to be fair and transparent, there's nothing that I can imagine that would be behindthis besides excessive hormones in a woman who actually doesn't metabolize it very
quickly, keeps it around in her body, and she's...
(26:11):
Right.
Okay.
then, and then after you get her back to like whatever baseline or meta-plussle levels,then when.
Right, that's what I do too.
I started her on progesterone first.
I always start my patients on progesterone first.
And then I.
Do you have a reason for why you do it?
Because of the whole thing of not having unopposed estrogen and I just feel like womentolerate the progesterone better first, but that's just my...
(26:35):
a great reason because we obviously all use progesterone even when you don't have auterus.
So that's just the one reason to use it, that you have to use it.
There's one reason to do it, you know, but the other reason I like progesterone and itdepends on how a person presents is if sleep is an issue, progesterone is really useful
for sleep.
I agree.
100,000 percent and all of these women can't sleep and they're anxious.
(27:00):
So progesterone really helps.
I usually start with just 100 milligrams of micronized progesterone.
I would start low and then I would retest her in like four to six weeks.
So I usually do that.
I always start, I test it around like six weeks, know, similar to that.
But most women I would say I do usually go to 200.
I do get the...
200 is fine.
(27:21):
It depends on the patient and what you're trying to achieve.
One of the issues with progesterone is the lab varies its assays.
So we've noticed that as well where they change the assay and sometimes they'll look fornaturally secreted progesterone and sometimes they look for micronized.
So there was a long stretch of time where I then reached out to Quest because I would seeeverybody coming in and he couldn't see any progesterone and they weren't measuring
(27:43):
micronized progesterone.
So you couldn't see it.
But if a person felt well, I would leave it alone.
to that point as well, kind of thinking through this, when a woman who might be 60, 70, 80comes in and has never been on hormones, you also want to go slow and use a little.
And if sleep is not a problem, I start with testosterone, because testosterone will helpthem feel stronger, lose weight, and also it's better for sugar management and other
(28:11):
issues.
older woman you're saying like what 65 and older or something like that?
When you're giving them testosterone you're giving them a cream?
usually do you have them applied?
an applied to non and terminal hair sites, which is behind the knee and in the FASA ofthe.
How come some people use like the outer labia?
(28:32):
because they think it improves libido and it sometimes does, but I don't find thatuniversally true.
do this part of your elbow, the inner part of your elbow or behind your knee.
And sometimes I have them rotate it.
The only issue with the arm is drawing blood.
Well Robin, that was a great case, great management actually.
I love what you did.
think in looking at numbers...
(28:53):
trying.
You're doing great.
You're not just trying, you're doing it.
It's hard.
I'm very conscientious and I don't want to mess up and you just want to get it right foreverybody.
And you did it right because when you are faced with numbers that make no sense becausethe doses she's getting is not that out or not that outrageous you stop what you're doing
again and then you restart at a lower level while you're assessing how she's feeling soyou don't necessarily want to start stop overnight because she may react to it so you can
(29:22):
wean you stopped overnight and she still felt well so I what you're doing to approach itand slowly ramp up each one of the other hormones makes sense
I didn't start...
And I don't know how you feel about this too, but I usually...
Like, I do progesterone, esterone, and then I'll add testosterone.
It sounds like something...
Like, with not my older...
Like, you know, more of my newly menopause.
Hence what they're missing and what they present with.
(29:44):
So generally that's the default, but I think when someone is in amazing shape and doingeverything right and sleep is not an issue, testosterone is a good place.
When they're older, you want to make sure you're getting them to sleep if that's an issueor they need more estrogenization.
Let's say they have dyspareunia and uncomfortable sex life.
Initially I add actually an estrogen cream.
(30:06):
So there's a lot of ways to do it for the individual.
And you're fine too, like using like an estrogen, an estradiol cream with like a pack.
That's not a problem, but sometimes it's annoying and I find patches to be more annoyingeven though it could be on a basis.
mean more because if you're trying to give more like what I mean is is I I started usingboth now too because I find or I had done some reading to that the estradiol cream in
(30:32):
addition like look like will help with the pelvic and you can pelvic right muscle Right,that's what I mean.
I feel like that's awesome to get you know to give you
Yes, so I almost always, because if women come in with early symptoms but they haven'treally been treated for a while and they've been in menopause for not the perimenopausal,
because that could be subtle, then giving them some cream will hasten the recovery.
(30:56):
So we usually start it with several times a week, sometimes every night.
And then within a week or so, we reduce to two or three times a week.
And ultimately, when you get their estradiol level higher in their blood work and they seeit, their cells see it, you don't always need the
dial cream so then it becomes whenever it's necessary.
But are you getting the same effect with the pelvic musculature or pelvic muscle, thepelvic floor muscles, just giving it orally or is it, is it helped to also give it?
(31:27):
It helps when you jump start it until they get a steady state, then you're fine.
So most women don't need to continue to do it.
It's just an extra step.
So why be annoying?
Disprunia?
Well, that or like, to course or like having better intercourse.
Other reason.
are other products for that.
(31:49):
But in terms of simply making sure her body is up to speed, the usual course, if they wantto continue it, it's up to them.
you feel uncomfortable and you think it helps, you can apply it three times a week.
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