November 27, 2023
In this Q&A Dr. Doug discusses:
So I didn't expect there to be too many people on this call today, but I didn't want to wait because I want to get these things moving forward and we'll build steam and momentum as we go, for sure. So we'll have probably a few more people just dropping in as we go.
One of the challenges with having a nationwide practice actually kind of worldwide audience is that time zones are nearly impossible to choose. Time zones and times are very, very challenging. So we're going to play around with some different times and see how things go. This, you know, kind of morning East Coast is really early on the West Coast, but I think we might get more attention this way.
If you guys want to if you want to, you can actually I think you're you're unmuted, too, Cathy if you guys want to, you could actually, you know, just speak up and let me know where you're calling in from. Okay. Yeah, I just got out of bed. It's in Arizona at 7 a.m.. Fantastic. Well, good morning. And Sarah, where?
I'm actually of Asheville. you are local. Okay. The backyard. Okay, Fantastic. I love that. And then, Helen, I can see that you unmuted are. Where are you? And is this a Helen that I met in Scotland? That I've just had lunch. Okay. You say you're in Scotland? Yeah. fantastic. All right, We have an international audience, all right?
For a while. So our through the desert. Okay, no problem. I'll just keep the immunity to keep the background noise down. But this will also be recorded. And so. Or it is recording. And so you guys will be able to watch this. If some of it fades out. Helen, you'll be able to watch this later. And this is how I think most people will probably end up viewing this weekly talk or interview or whatever it's going to be for the week because just the time zone issues.
So my thought today is that we would go through kind of what I see this becoming as it develops. I have some some thoughts and today I have a couple of different topics that we could talk about and I'll I'll kind of let you guys choose since you're the ones here and any that's going to be the value of being able to show up live, is that you going to be able to ask questions, You're going to be able to to interact and then sometimes you'll be able to choose actually what we talk about depending on the flexibility of the schedule.
So let me just I'm going to share my screen and just go through a couple of basic things and then and then we can stop and we can decide what we want to talk about today. So I sound reasonable. Okay, great. Since this is the first one, let me go ahead and share what I want to share so everybody gets on the same page.
All right. Can you guys see this thing that says health span nation? Yep. Okay, great. So we'll always have to have this disclaimer. And that's one of the things that we need to talk about is creating this new platform I'm very excited about because I will be able to talk to more people, will be able to spread a larger message.
But I can't give one on one recommendations unless you are actually a patient. And if you are actually a patient, then this isn't really the right format for that either. So we have to keep our answers general, and I can talk about how we treat patients and my opinions on things or the team's opinions on things, but I can't give specific recommendations and I can't treat patients through this platform.
So my thought with this weekly meeting is that we'll have a topic driven Q&A. One of the things we get so much feedback on is that there's just not enough Question Time and whether this is our patients, this is people that have come through and done our masterclass, our other interactions. People always have follow up questions and there is no opportunity to do that.
So this is the opportunity to do that, and we can do that on a weekly basis. You'll also have access to the and it should be live the community. We're using Slack right now. I don't know that we'll always use Slack. It's just what most people wanted to use when we polled people. So that's what we have now.
And you can ask questions in there too. So all the people that are in the community, a lot of them are patients, can help to answer questions as well, and that'll be monitored by our team. But I personally will not spend any time in there because that would be an unrealistic expectation. We're going to use this kind of a meeting style zoom until we get to big tonight.
And what I mean by that is the other option is to use more of a webinar style. But then I won't get to see your faces and won't have as much interaction. So we're going to try to keep it like this. And depending on how many people show up, we may have to switch. It just depends on how big it gets.
Already mentioned the general information part. We are going to do some recording for podcasts. So a topic like today, this I won't put this out as a podcast, but I will have some interviews and we'll bring some people in and do interviews on topics of interest, hopefully to you. And so those are things we'll end up going out.
So just make sure if you don't want to be on, if you don't want to be published on on YouTube, just make sure you keep your video off. And if you miss it, it'll be posted in the the website, the Health Foundation website and so you can always go back and look at these later. Okay. Any questions about any of that?
Okay. Great fantastic. All right. So my thought today is that we can either talk about one or two things. We can talk about our foundational approach to health, which is I think we should review either way. But the other thing that I thought we could do is I'm giving a talk, You know, I'll stop this for now. I'm giving a talk later this week in New York for Osteo Strong.
And what they asked me to talk about was hormones and specifically hormones for women. And I can see that we have a mostly female audience except for Brady and Brady as one of my team members. So we we could talk about that. I designed it as a 15 minute talk, but I haven't run through it yet, so I don't know actually how long it would take.
And that something that I think would be fun, too. And some of you've heard me talk about talk about hormones before, but I'm happy to to kind of dig through that talk as well. What would you prefer? Do you want to talk about help optimization in general, or you want me to run through a talk on hormones? It's mostly about women and a lot about testosterone.
Maybe health optimization, for be sure to quickly be yourself again. I'm sorry, Helen. What was that? You kind of broke up a little bit there. I'm thinking right here also position for me. Okay. Gotcha. And for me, curious about testosterone since I can't take estrogen. Yeah. Yeah, absolutely. Well, I think, honestly, we probably can get through both. And so let me start with this health optimization pyramid, and that'll actually bleed Sarah right into the hormone side.
I'm sorry, Kathy, did you have something you wanted to say? Yes. I've never taken hormones. I don't plan on taking it. Okay. Yeah, well, we'll talk about we'll go we'll go through the we'll go through the pluses and minuses with that. And my goal here is not to influence anybody to do something they don't want to do, I'll put it that way.
But it's good to know about it. So let's talk about this first then. So the health optimization pyramid is the kind of the framework that we built out when we were trying to figure out how to achieve our goals that we want to achieve when it comes to health optimization. For those of you that don't know this backstory, this company was started back in 2020 as I left Orthopedics and my wife's company for weight loss and nutrition was seeing a lot of clients who were coming through and they came out of the back end with the weight loss, which was great.
And she has a fantastic program if weight loss is the thing that you're going for. But on the back end, what happens is it exposes a lot of the the medical issues that kind of led to the weight loss in the first place. And some of them don't get better with weight loss. So things like thyroid dysfunction, sex hormone dysfunction.
And so as I started going through this functional medicine training, I wanted to pick up on how do we how do we capture the people that are coming out of that program and then help them to optimize their health. Now, that then snowballed into what we do now. So we still serve those clients, but that's actually a minority of our population and we built this framework to help those people as well as honestly, this fits everything that we do.
And that's why you see, we talk about it in the YouTube videos. And so let me just walk you through this, this pyramid of optimization and how I don't know if you can see this, so I'll just describe it as we go because some people will listen to this and not be able to see it as well. And so basically what this is, is it's a pyramid.
And the image that we have actually there's one correction that needs to be made or just in addition, rather. But basically it is a pyramid that has a foundation of of six pillars and used to have four pillars. And I divided the fourth one into three different things. And so those pillars are so critical because just like any pyramid, if you don't have the pillars, then all the other stuff isn't going to be as effective or effective at all.
And so if you take, for example, the traditional medical model and you say, well, you go to your doctor and bone health is a great example, since I'm sure that would speak to most people here. So osteoporosis is a great example. You go to your doctor, you have a T score and they are generally going to recommend a drug, right?
They might say you should lift more weights, but then they might say don't have anything heavy because you might fracture. They might say, you know, consider vitamin D and calcium, but that's about it. So I call that lifestyle lite. And then they're leaning on drugs. And that's how our our medical system works. We all know that there are a lot of downsides to that.
The other side of that would be if you go to a lot of practitioners and the help optimization or functional medicine space, they will potentially just throw hormones at you. Or if you go to a peptide practitioner and say, here, take this peptide, it's going to be the solution to all your problems. But if we don't started the foundation, then none of those things are nearly as effective and sometimes they can actually be dangerous because you haven't actually given your body what it needs from a foundational perspective.
So that's why these pillars of health are so important. So the pillars then for us are nutrition, exercise, sleep. The one correction that needs to be made here is in the connection that's sort of vague. And so that's actually supposed to mean social connection and then mindset and then spiritual connection. And the reason why we divided out those last three is that it used to say stress mitigation.
And it didn't quite it didn't quite ring true. I like to having four pillars, but six makes more sense. So the nutrition part is so key. And I talk a lot about nutrition because depending on your goals, this is going to look very, very different. If you're looking at weight loss versus looking at, you know, building bone versus looking at, you know, increasing your performance as an athlete, you're going to have very, very different nutritional needs.
And it is one of the hardest areas to find good information on as everybody here has probably gone on social media and listened to influencers and listen to doctors who have their opinions or preferences. It is one of the most confusing spaces to find any information on. So we talk a lot about nutrition. Exercise is not quite equally, but similarly confusing as far as what to do, how to do it in finding the motivation, time and resources to do it.
So that can be a big challenge, but it is arguably one of the most important things probably behind exercise as far as the impact that it'll have on your life. Sleep has to be a foundational thing, and I'm happy to talk about sleep any time so many ways that we can improve sleep easily and for free. But unfortunately not everybody has good sleep.
Social connection is one of these things, and this kind of came about as I was watching people struggle during the pandemic and people's social circle dwindled and we all saw the impact of that. So that's why I had to make a separate space and even in my own life, understanding that myself, working from home, my wife working from home, our social circles started to dwindle as well.
And so social connection is something that we we really need to continue to focus on, especially as our our society becomes more easy or more easily separated from our lives as a way to set up mindset is something that I love to talk about and I love to listen to. I can't say that I'm an expert on it, but I love listening to people who are because I see the impact that it has on my patients, how they perform and the way that we can then include all the other things into their lives.
And so a mindset is really, really important. Fortunately, most of my patients are also self-selected and have a pretty good mindset to start, but so always something to be improved upon and to be improved upon every day. And then spiritual connection is a tough one. And this is actually the only area in our program that we don't have a clear path for.
And I have I have some thoughts on how to remedy that, but I haven't figured out how to do it yet. And this doesn't have to be religious, secular people have just as much spiritual connection and even atheist have just as much spiritual connection. They call it something different too. For the people that have that in their lives, the people that do well, I think do better than the people that don't, because they seem to have this sense of a bigger purpose and a greater meaning.
And then it allows everything else to stack on top of that. So that's the foundational stuff. Any questions about that before I move on or anything that you think maybe should be included now? Okay. Is that Alan over there? Yeah. Yeah, I recognize that face. All right, so then the next step up is supplementation. So this is an area where there are so many so many products on the market, so many claims made about supplements, it's really hard to figure out what supplements do I take this is why we add supplementation at the next level, though, because I do find that it's really important, but it really has to be targeted by biomarkers.
We have to understand why we're taking what we're taking. We use blood, whatever we can function. Testing sometimes will help as well, but creating a very clear plan of supplementation so that you have a target, you have an end point, hopefully to that supplement or recognizing that some of these things may be indefinite depending on what your needs are and what your other inputs are.
So supplementation is very important, but it should be targeted and we should always know why we're taking what we're taking. And then the next level is hormone optimization, which I'll talk about in more detail next. What I see too, is that hormones when applied alone are not nearly as impactful as hormones when given on top of everything else.
And so this is why it's higher up. It's not the it's not the foundation. It is important. It's a big lever, but it's not the only lever. And then peptides, which I'm happy to talk about more in detail, probably in another another meeting, but peptides again shouldn't be used alone, they should be considered. I think the icing on the cake, yes, they can be powerful, but alone they're not going to have the impact.
Is what you have stacked up all the other stuff and then pharmaceutical, as most of you know that I don't use them very often, but we do use them. I don't think we should hide from the technology, but it shouldn't be our primary purpose. We should not just aim for pharmaceuticals because there are downsides. There's always risk. So any questions about that?
And before I move to hormones, my question is our peptides related to college and I'm not sure what they are. Yeah, yeah. I'll just give you the definition and rundown. So you are correct that you will see the words peptide when it comes to collagen. And the reason why that they do that is because a peptide is simply just a short protein.
Collagen is a protein. And so if you chop up collagen into specific shorter parts, then those are called collagen peptides. When I talk about peptides, it is true, I'm talking about short proteins, but the ones that we are using for the most part we're prescribing and we're prescribing them through compounding pharmacies because drugs don't make them, they are generally going to be fragments of hormones.
So for example, one of the ones we use commonly in osteoporosis is a peptide that's into the growth, what's called a growth hormone secreted GOG. And what that means is that actually the growth hormone pathway. But the name of that peptide is Abunimah and there's a whole bunch in this in this group, but this one you can take as a capsule.
So people prefer it. That is a fragment of a hormone that then acts on the growth hormone pathway. And so what I like about peptides is that they are kind of natural. Clearly they're made synthetically, but they are a part of a hormone that your body makes indigenously. So your body has the receptor for those peptides and there is a very clear and kind of natural mechanism that it does what it does.
So I think that the safety profile for the ones that have research behind them, the safety profile always looks good. I shouldn't say always for the ones that we use looks good. There are probably somewhere I wouldn't look at, but I think that the the benefit is going to outweigh the risk, particularly when you have something osteoporosis, because we know that we're trying hard to do the things that your body has kind of forgotten how to do.
So we're just using it to provide this strong input signal. Does that make sense? Yeah. The downside of peptides excuse me, the downside of peptides is that the research is not great. As I said, they're not made by drug companies. So the research that exists are generally going to be small in numbers. Some of the peptides that are out there and available don't even have any human research behind them.
So I think that's probably a little sketchy. I wouldn't do that. But the ones that we use has human research, but there are no big studies specifically looking at this at them for the reason why we use them. So this is why I use them, but I don't always use them. And if the FDA came through and said that's it, no more peptides, you can't prescribe them at all, they wouldn't really change my practice significantly because we're not a peptide practice.
I like them because they're fun and people like them and we see impact. But it's the icing on the cake for sure. Okay. All right. And you did ask a question about yourself. I totally get I'm in a quiet place now. Am I totally get supplementation and using biomarkers and I totally get that. But other than moving to the states, the I'm your patient.
I don't know how I'm going to do that. I'm sure because I can have well, for sure and a doctor to do really spot tests to say just start to cash and usually is good. I can get private blood tests done, but I then support more market research. But I don't know how I'm going to see right. This biomarkers.
So no, she doesn't work out. Yeah, well then what we can do, Helen, is we could maybe in the next one we do that next week, maybe the week after we could do one on biomarkers and supplementation. We actually for a while we were doing some international, we didn't call them patient, we called them coaching clients. And yeah, the challenge we ran into because we had we had a couple of patients, we had some Australia, some United Kingdom, I think one was in Amsterdam and the challenge we ran into is that the biomarkers were not always available and then the recommendations on products that we have in the U.S. are not available in many of the other countries. And so it left us sort of scratching our heads as to how to help these people. And it's possible, and I can talk about this in one of our meetings as possible to figure out what the ingredients are and then trying to find something that's available locally. You just have to do a lot more work on.
But we could do that. I'll write that down as an option. I'm actually redoing our supplement talk right now, so that's why I said maybe, maybe not next week, but maybe the week after. I'll just make a little note to myself because we can talk about the biomarkers and then how to how to actually break it down and to figure out like, what do you what do you really need to be about?
Okay, great, great. Thank you. Yeah. So then so Alan, I talked earlier about some different options for today, and I'm preparing this talk for for an astro strong media event on Friday. And so I'm actually doing this there. I just finished it. It's probably too long. It's supposed to be 15 minutes and it's going to be longer than that, but it's just kind of a new angle that I've been taking.
And so I think, Alan, you'll appreciate this and we talk a lot about women's hormones in here, but we talk about testosterone a lot. So you can kind of see the literature on that. So I'm going to run through this and we'll see how long it takes. Be a nice, nice little test run for me. So my perspective here is not to talk just about bone health.
I'll mention bone health, but really talking about hormone replacement more through the lens of health optimization. And again, with that sort of the angle on testosterone, because I feel like testosterone is something that's kind of looked down upon in men and it's not talked about at all in women. And so I shouldn't say that at all. It's talked about very little in women.
It's probably a more accurate way to say that. And I want to talk about why and why I think that is one of the biggest tragedies when it comes to the conversation of hormone replacement. And a little bit about why it's not talked about in women and something that I keep learning over and over again about the way that we manage women, particularly in middle and post-menopausal life states.
There's some really interesting concepts behind that. So you talked about this disclaimer. I talked about that already. So yeah, So when we talk about health span, one of the things that I, I got to change that top four causes of death, but there's five. One of the things that I talk about with health span is that I don't like the terms anti-aging.
I don't even like the term longevity because it brings up and conjures all of these thoughts about the next cool supplement, the technology, the thing that's going to change aging. It's going to reverse you. And I just I was just in Florida with my family over the holidays and I drove past this strip mall and there was a sign that said, stem cell.
What is it? It was like stem cell, stem cell therapy, age, reverse aging, something, something like something that at the FTC site, they would they would just explode the place. But they're so small that nobody really cares. But it brings up all these thoughts of like, what is the next cool thing that's going to reverse my aging like stem cells?
But the truth is, from most of us, probably all of us, but at least for most of us, the thing that's going to extend our health spam, which I'll define in a minute, but the thing that's going to extend our health span is not dying from the things that are usually going to kill us, right? So not dying of heart disease, which is the number one killer.
Number two is cancer. Number three is accidental deaths. This is where osteoporosis actually fits at. Number four being dementia, Number five being different forms of metabolic dysfunction, which we mostly will refer to as diabetes, but really is a spectrum of poor glucose disposal and metabolism. If you can avoid those five things, you are more likely to live a long, healthy, vibrant life.
And so this is how I look at health span and I define health span as the time in which we live in a quote unquote healthier way, with the understanding that what we typically do, our life span usually starts out with good health that declines gradually over time. And then eventually you get to the bottom of health. And then unfortunately, our our system is really good about extending that that poor health state for about a decade before we actually die.
Health span, in my opinion, should be you live as healthy as possible for as long as possible, and then literally or figuratively, you drop off a cliff, right? So you are healthy, feeling great, and then you're dead. And that's a morbid way to say it. But ultimately, that's what we actually want, is we want to live well until we're not.
And everybody agree with that. Yeah. So then avoiding these five things, I'll change this top five causes of death. Avoiding these five things is a huge, huge part of that. You guys have all heard the statistics on hip fractures. So I won't away with that. You know who I am. We just talked about that. All right. So hormones are a big part of that conversation of health span, or at least they should be.
But they're not. They're not because the various societies that deal with hormones indirectly, because none of them deal with them directly, but the American College of Obstetricians and Gynecologists, the Endocrine Society, NAMS All of these big societies that deal with hormones indirectly sort of lean on the side of taking the shortest duration of the lowest dose of hormones and that's because they're aiming at the known things like symptoms of menopause that will go away over time.
And they look at the risk and say, well, the long term use risk outweighs the benefits. And I think that's a very, very unfortunate angle and I think it's an outdated angle. And I'm going to talk about the research that drove that and you'll see why I think that's outdated. But when it comes to health span and longevity, you know, I, I don't like that word.
We have to decide as we treat people what we want to do with hormones. And so, Cathy, this is a I don't know, I don't know why you don't take hormones, and that's totally fine. But this is a perspective that I see often, which is osteoporosis and osteoporosis. Menopause is natural. We should let our body do what it's going to do.
And losing our sex hormones as a part of aging. And that's all true. And you can see that in this graph. You can see that the red line is estrogen. It goes up, it stays up. And then as you go through menopause, it drops off a cliff. And that's what causes a lot of the symptoms of menopause. And then you have essentially no estrogen for the rest of your life.
That is totally natural. And I get that in. Replacing estrogen is unnatural. And I totally understand that, too. But from a health span perspective, to live as long as possible in a good, healthy state in avoiding those five things that I said are the top five killers of adults in the United States and worldwide having adequate or optimized hormone levels will improve all of those things and decrease your risk of all of those things.
So from a health optimization perspective, from a health man perspective, hormone replacement is a reasonable thing to consider. Now, it's not right for everybody, but that's the way I look at it. For men, this is the graph for testosterone. It starts high, drops low, and then it just keeps getting lower. And this is why men struggle with a lot of the things that they struggle with.
And I actually talk about the difference between looking at sex hormones, aging and men versus sex hormones, aging and women. And they're totally different conversations. And I, I think I know why. But but it's unfortunate because women suffer from almost all of the same things, but we call them different things. But for men, when it comes to aging, we look at those things as significant.
But for women, we don't. For women, it's just part of aging and it's natural and you should just shut up and accept it. Sorry, That's that's the way it's viewed. So when I look at aging as a disease, which is how the health span, the health span physicians and the Hispanic community looks at it, is that loss of sex hormone is a symptom of aging.
It is something that we can do something about if it's appropriate. But it's just part of this bigger picture of increased inflammation. The mitochondria don't work while the cells don't work as well. And so loss of sex hormones is part of that and actually a cause of some of that. I'm going to talk briefly about men, So Alan, I'm glad you're here.
So testosterone in men is a challenge because what we're seeing is the decline of testosterone levels in men age appropriate over time, meaning that the testosterone, optimal testosterone for a male in his twenties 50 years ago is very different than it is now. So we're actually seeing this this population wide decline in testosterone for a lot of reasons, which I won't get into today.
But what I'm finding is that more and more men have low testosterone very early in their life. So that curve that I showed you really starts much earlier in the curve starts much lower. So this is why we're doing so much testosterone replacement in men. But the challenge that I see for a lot of men is that if you go to a traditional doctor, the the decision is driven around the wrong numbers.
You're looking at, for the most part, just total testosterone and you need more data. You also need to ask symptoms. What are the symptoms of low testosterone? Everybody talks about libido and erectile function, but it's so much more than that. And if you don't dig into those things, then you don't know if a patient is really suffering. If you don't have the data to say you're free.
Testosterone is in the single digits, even though your total testosterone is fine, then you're not going to have the data that you need to treat the patient. And I see this time and time and time again. That's why our approach is different. If you look at what testosterone can do in men, yes, it improves sexual function and libido, but it also improves energy.
Statistically significant improvements in quality of life, reduced depression, improved cognitive function, cardiovascular risk, metabolic function, insulin sensitive morbidity, not sensitivity, insulin sensitivity. If you notice, those last four are going to correlate with those five diseases that I just mentioned. Right. So not only can testosterone improve, Yes, the sexual stuff, but all the other stuff too. So this is why optimize optimize testosterone minutes.
So important. The challenges with the research around testosterone is that for the most part, they're looking, again, kind of this idea that they want to use the smallest dose possible, not for the shortest period of time, because we don't generally bring men off of testosterone, but still the smallest dose possible and the doses are really small. And so they might say, well, there wasn't a suggestion, never get changed.
But if you look at what they did in their blood work, they barely got their testosterone higher. You take men whose testosterone is 200 and you move them to 350. Yeah, that's a significant improvement, but it's still way too low. And so I see this in men and I definitely see it in women. When we look at those studies, there's also so much fear around doesn't testosterone cause heart attacks?
Doesn't it cause prostate cancer? Doesn't it cause blood clots? And the answer is no, no and no. And the research supports that. But this is the dogma that we're trained in as physicians. This is what I learned about testosterone. You also think, it's just all about bodybuilders and getting big. It's not. And you don't get big when you take testosterone unless you lift a lot of weights.
But all those other things have been proven not to be true. Now, there are circumstances where maybe one shouldn't take testosterone, like if they have active prostate cancer. But for the most part, those things are not true. But then we talk about women, and this is where this conversation gets crazy and it drives me insane. So when I started digging into this because I was trying to use testosterone at women, and then I realized how out of the box that is and I couldn't understand why.
And so then you go back and you look at like the Endocrine Society, for example, and what they say about using testosterone in women. And this is literally what they say we recommend against making a diagnosis of androgen deficiency. That's low testosterone in healthy women because there is a lack of a well-defined syndrome, lack of a well defined syndrome.
And we know that in women there is a well-defined syndrome of symptoms of menopause. Right. And called menopause. And that's why we get estrogen. And we'll talk about estrogen. But there is not a clearly defined testosterone syndrome except for what they mentioned here. They say we recommend against the use of testosterone for all the following things, sexual dysfunction other than hypoactive sexual desire disorder.
So there actually is a syndrome, but it's all about this sexual desire and the lack of having sexual desire as if that's the only thing that testosterone is good for. So it is an FDA approved indication for that thing, although there are no commercial products to actually treat it with. But that's a topic for another day. So there is this thing, but it is only in this very small section of what is actually relevant about testosterone deficiency in women.
And so we'll talk a little bit more about that. If you look at men, again, this isn't this this thing is called the aging males symptoms. And so aging males have these very predictable symptoms. Now, this is not just about testosterone, but I pulled the study to look at of the things that they list, how many of them are directly related to testosterone?
And it's about half, which is really interesting to think then, okay, in men, symptoms of aging are about half of them on this list are related to testosterone. But yet in women, we only talk about estrogen and progesterone. If you still have a uterus, we don't talk about testosterone at all unless you happen to complain about not having the desire to have sex and then you sort of get frowned upon and then maybe you would get recommended testosterone.
But good luck getting because there is a commercial preparation for it. Right. So you see women are stuck in this this situation where their symptoms of aging are not related to testosterone. But what I want to show you is that I think that they really are. So here's a chart that I pulled or a graph, rather, that I pulled out of a study when I was doing research for this.
And if I told you that the black line on top of the black dots is estrogen, and the black line on the bottom with white dots is testosterone for women, this would make sense, right? So these are amounts of estrogen and testosterone, respectively. Does that jive? So you have more estrogen than testosterone and that's why we call it estrogen, that the dominant sex hormone in women.
Does that make sense? Okay. But here's the truth. That top line is testosterone. It's not estrogen. Women have about five times on average, more testosterone than estrogen when adjusted for units for almost their entire life. So why don't we talk about testosterone in women? Because we can't define a disorder. Well, let's define a disorder. I look at it like this.
When women go through menopause and lose testosterone, do they have a decrease in physical activity, decrease in energy, increase in sweating that likely be from estrogen, though an increased need for naps, physical exhaustion, lack of vitality, irritability, nervousness, anxiety, depression, feelings of burnout, decreased enjoyment of life and increased forgetfulness. Do any of those ring true for a post-menopausal state?
Of course they do. In men, these are all due to testosterone, not maybe exclusively, but they are associated with testosterone in women. Why would we think that they're not associated with testosterone? What's the other explanation? If you give a woman estrogen and progesterone, some of these things do get better. That's true. But they don't feel like they did.
And I hear this the time. I feel better. I don't have symptoms of menopause. I don't have night sweats and hot flashes, but I still don't feel great until you add testosterone. And then they feel great. So I think that we are doing women such a huge disservice by not having this discussion and not labeling this a syndrome so that we could actually study it.
The thing about the Endocrine Society is that it's like they're waiting for that study to be done, but nobody's ever going to do it. So we're kind of stuck. So HRT and women without testosterone is mainly driven at symptoms of menopause. It has these other things too. And I want to point out that one on the bottom there called cancer prevention definitely is preventative for colon cancer, but breast cancer and other estrogen sense of cancers are something we should talk about.
These risks that I have listed on the right, the estrogen sensitive cancers, heart attack, stroke, blood clots. All of those can be avoided for the most part, not completely, but for the most part with the right dose and with the right route of hormone replacement. So the risk comes from a lot of studies, but this is the one that people talk about most.
And I can summarize this pretty quickly because I've done it a lot. So if you've heard about the Women's Health Initiative, it was a 1990 trial that was published in the early 2000. So this changed the face of hormone replacement up until today. And it still does and it will continue to. It was a massive trial, 160,000 women that cost $734 million.
This is why studies are not done in big format because they cost hundreds of millions of dollars to do. This was actually a well done study. But the interpretation, the outcome was, in my opinion, very mistakenly interpreted and the impact was tremendous. So the short of this is because there's a lot in the study, but the short of this is, is they looked at either combined hormone replacement, so an estrogen and progestin, a synthetic progesterone or estrogen only.
And now the estrogen that was in this was not natural bioidentical after, Jane, it was Premarin, which is a a synthetic form of estrogen and progesterone was a synthetic progesterone was implicated in to that. But this is what happened in 2002. This study came out and this, again, changed the landscape of hormone replacement forever. But what's interesting is that when you look at their conclusion, they don't say anything in here about breast cancer.
And yet the take away and I was in medical school at this time, so the take away for doctors and training doctors is that estrogen causes breast cancer and do not prescribe estrogen unless you absolutely have to. Now, I was going into orthopedics, so I didn't care. But learning about this later, it blows my mind because when you look at what actually happened, they stopped the study early for the combined arm.
I mentioned there were two arms combined in estrogen alone. The combined arm was stopped early because of a concern for an increased risk of breast cancer. Now, at that point, I think the study been running for five years. That point they almost reached nominal statistical significance. I must say that another way, which is it wasn't actually statistically significant, and yet they stopped the study anyway because of the trend.
Okay. If it's a safety thing, I get that there was also a trend for an increased risk of stroke and blood clot. But what they don't talk about is that there was a benefit of reduced risk of colon cancer, massive reduction in fracture risk, but there was a trend for these other things. And so they stopped the study early.
The impact was that in the combined group, they showed that everybody should should come off of hormone replacement, basically, which isn't true. But if you look at what the statistics showed, again, there was this almost reached nominal statistical significance and there was a relative risk increase and this is why they did it. But it's so small, I would argue not clinically relevant, not that I wish a case of breast cancer on anybody, but the impact is then that we're not getting the potential benefits and the estrogen only group was not stopped.
So now we can compare. So in 2004, the estrogen only group was actually also stopped early, but not because of risk for other reasons. But then they published on the estrogen only group, and the estrogen only group actually showed that there was a subtle increased risk of stroke and blood clot. I'll explain that in a minute. But there's a decreased risk of hip fracture and colon cancer And get this, breast cancer.
So wait a minute. So you're telling me that the Women's Health Initiative showed that there was nearly the same reduction in breast cancer risk with estrogen only as there was an increased risk in the combined group? So let's put our heads on that for a second and say, well, what was likely the cause? We don't know that. But what was likely the cause of the increased risk of breast cancer in the combined group?
That actually wasn't statistically significant. It wasn't the estrogen, it was the progestin, it was the synthetic progesterone that increased that risk. And subsequent studies have shown that if you use synthetic progesterone, these progestins there isn't increased risk of invasive breast cancer, blood clots, mood changes. and actually it causes osteoporosis, too. Oops, these things are still around. They're actually very commonly prescribed.
They're in every oral birth control that exists. They're everywhere in our medical community and they are terrible. And I say that openly because the literature so shows that they are they're not doing what we want them to do well, and they have risks associated with them. And that risk can go away. If you switched to an oral, bioidentical progesterone should not carry the same risks.
We know that it doesn't and have the blood clot risk, but there have not been studies as big as the Women's Health Initiative. Again, because this is a natural product, drug companies can't patent them. They can't make enough money to support it. Hundreds of millions of dollars study to look at this. So this is the challenge behind drugs.
So then we circle back to testosterone and we say, okay, well, what's the role here? Well, we know in men that it increases muscle mass strength, bone mineral density and improved sexual activity markers. This, again, innocent men. But in women, this is what we see increase strength, bone density, metabolic function, muscle mass memory, energy, fatality, libido, sexual function.
It's not about the sexual function. It's a nice side effect. It's about the other stuff. Why do we deny women these things? And it's very, very frustrating. I think that what's happening is that and I hear this in the kind of the what's the right way to say this in the community of postmenopausal women, particularly when you start talking about, you know, relationship, health and health, what partners is that?
We see that the patriarchal society, if you go back decades as a woman age, got into, you know, childbearing years and beyond, the men generally different societies did it differently, but generally would either take on a mistress or get a new wife. And so it was this sort of this position of for men, testosterone is important, sexual health was important.
But for women, we're just going to move on. And I've heard this over and over again, but it's it's an angle that we really need to to turn around and face directly and say, look, for women that have you know, that have had children that are perimenopausal, post-menopausal, those things all kind of happen in sequence. How we then optimize their health.
And it's not necessarily just about the sexual function, but I think this is why we don't talk about it is because it's kind of taboo, right? We don't talk about sex for women in their forties and beyond. It's just not something that we've done as a society openly. But we have to have that conversation because the deficiency of testosterone, yes, there is a sexual component, but if you don't talk about that, but you don't actually get to see the rest of it.
And so this is where I think we struggle with this thing. We're not talking about the sexual side effects of testosterone deficiency. And if we don't face that directly like we do and men, then you don't see the other side of it. And so this is why there is not a testosterone deficiency syndrome, as there should be. And we could just call it that Tbs's testosterone deficiency syndrome.
And I think it's going to we're going to see if you look at it that way, it's going to be very much in the the signs of aging or the symptoms of aging. So because there are some bone health concerns here, we do know that testosterone will increase the things that I mentioned, it'll increase muscle mass, will increase BMD.
But all of the sex hormones play a role after general increased bone marrow density, Estrogen will reduce fracture risk significantly, and then oral progesterone will actually work specifically on osteoblasts. All three of these hormones, excuse me, will play a role on bone health, but also on health optimization overall. So again, you take those five things from a heart disease perspective, you improve risk factors mostly through metabolic improvement.
But as long as the root is correct, you'll improve cholesterol and other things. Cancer risk is improved. Again, a lot of that is metabolic improvement, muscle mass, but there's also an impact on the immune system. Accidental death, again, this is osteoporosis, fractures in falls, osteoporosis is improved with it. Sarcopenia, which is muscle mass is improved with it. And then dementia also gets better.
And there are studies to demonstrate that low testosterone, particularly in man, is associated with worse cognitive function. And if you improve testosterone, that cognitive function does improve. Now, it's not a cure to Alzheimer's, but it will help with cognitive function over time. And the longer we can preserve good function, the more we should be able to stave off dementia and the metabolic dysfunction.
Again, testosterone improves insulin resistance, and that is the precursor to metabolic dysfunction which leads to diabetes. So hormones are not right for everybody, depending on how far out a woman is from menopause or if there's a high risk of estrogen cancers, that's a conversation to have. So there are risks to be considered. It is not risk free, but it's not unreasonable to consider.
And when to start is going to be different for everybody. And this is true for both men and women. I have men in their thirties. I talked to I was at a conference a couple of weeks ago and I see men in their twenties that have to be on testosterone replacement because they're just not making it and for a lot of reasons.
But same thing in women. We see the same impact in women where they're not making testosterone and I see this in young, stressed out women, especially working moms, their adrenals are shot. They're not making testosterone. They're after Jen's all over the place. They're progesterone deficient. Their hormones are a mess. So is it reasonable to start with some form of replacement or optimization in those patients?
Of course it is. But their doctors are never going to talk about that unless they say, here, take birth control, this will balance you out, which has a synthetic progesterone in it, which increases all your rest of the bad things. So challenging, challenging topic. But that's my take. And you guys already know all these things, I am sure.
So what questions do you have on that? I think we picked up a few more people I see Sheryl and our Mary talked about. So what questions do you guys have on that? So the aging. So since I haven't taken anything for 25 years since menopause, I, I don't know. What would that be a bad thing to start?
Something like that. Yeah. 25 years is a is a timeframe where we do get concerned that particularly the estrogen is going to increase risk. Now, the risk is not the cancer risk that most people think the risk is and cardiovascular risk. So what the Women's Health Initiative also showed is when you looked at women who were over ten years out from menopause that started on estrogen therapy, there was a statistically significant increased risk of heart attack and stroke.
The reason for that physiologically is when a woman loses estrogen, her vessels, her arteries start to get harder, they're more likely to develop plaque that way. And when you then give estrogen back, those harder vessels are going to start getting more compliant again. And if they develop back, the theory is that you can break off a chunk of plaque and it causes an event.
There are some issues with that group and the Women's Health Initiative, they were more likely to be obese. They're more likely to be smokers. They had other risk factors for heart disease. But I still think that physiologic really that makes sense. So our approach is we look at your risk factors for heart disease. Do you have, you know, significant increase in risk?
Do you have high cholesterol? Can we do imaging, show that you have disease or not disease? What's your family history of heart disease? I have women that are 20 years after menopause that we've started back on estrogen, but only after doing extensive testing and do identify your the pipes going to your arteries, sorry, the pipes going to your heart, your arteries are crystal clear.
They look better than mine. So I can't guarantee that they won't have an event. Hasn't happened yet. But the way I look at it is we want to treat the devil we know. And these are patients that have significant osteoporosis and sarcopenia less treat The problem that we know we have rather than worry about the thing that we don't know, understanding what the risks are.
So that's the big issue. It is possible, but at 25 years out it would be unlikely. But that doesn't mean that you can't use testosterone. It doesn't mean that you can't use progesterone in a in a rational way. But this is a very much a gray area. And there's no studies on progesterone, only therapy. That's not true. There are not many studies on progesterone, only therapy.
And as I mentioned, on testosterone therapy, there's just almost nothing for women except for on sexual desire. So you sometimes give that alone. Testosterone alone. Yep. Because the only way to get testosterone in the U.S. and in most countries is to compound it so we can prescribe it and compound it. And so in our practice, we use a cream.
You'll see a lot of women's health centers will use pellets. I don't really like pellets because that generally the dose of testosterone is too high. And what you have to be careful of and this is where most practitioners kind of like bury their hand, their head in the sand and they'll say they'll say, I'm not going to use after Jim because of the risk, but I'm going to use testosterone because it's safer.
Well, you don't know that. And the reason why you don't know that is because when you give testosterone, it goes through a process called a romanization to estrogen. So if you give enough testosterone, you'll actually get the same estrogen levels as if you get estrogen. So I don't think that's reducing your risk. I think it's just giving it to a different route and pretending that that risk doesn't exist.
But I think that's not that's not fair or true. So I use smaller doses of testosterone. You still get the benefit of increasing muscle mass, improving insulin sensitivity, improving body composition, but you monitor how much estrogen you're getting out of it. And that's why I don't like pellets, because pellets will drive your testosterone so high that you will see estrogen production.
I'd like to add something for the women. Yeah, Yeah. Alan, go ahead. Well, it's just a little story. You know, I was diagnosed with osteoporosis a year ago, and after that, my wife went and got tested. But here in her early fifties, when she was going through menopause, she had really bad symptoms, you know, night sweats, couldn't sleep, everything else.
And they put her on estrogen and it must have just forgot about it because she's 70 now and they just took her off now after 20 years. But when she went and got her bone scan, she was in the plus range and everything. Her bones were better than the 30 year old. Yeah. By a fluke of luck, she may have avoided all of this and they took her off, but she's back on it now.
But I think she's on like, maybe the bad one gram pro is that. Yeah, exactly. So that's, that's what they use in the Women's Health Initiative was Premera which is Premarin and Prober and Provera is that progestin that I was talking about. So I would get her off. Yeah. And so the way that we do hormone replacement for women is that we'll use either an estrogen cream or a patch.
And we're kind of we're looking at patches because they're commercially available. Insurance will pay for them. And we're just trying to figure out the best way to do that financially. But we either use an astro dial cream or an astro dial patch in conjunction with an oral progesterone capsule. And that's a micro nice progesterone is the bioidentical hormone.
The benefit of the progesterone capsule is that it tremendously helps with sleep. And this is something that most postmenopausal women struggle with is poor sleep and progesterone, when it's metabolized by the liver, will break down into a product that is stimulating to Gabor receptors. So you take it at night and it will significantly improve sleep. So estrogen and progesterone together.
And then, of course, I would also recommend adding testosterone. Is it like with men where like if you take testosterone, your estrogen goes up. If you're a woman and you take estrogen, does your testosterone go up a little bit? So women can aromatase as well, but not very much. And especially in Cream Pro, the dosing is so low that it's really designed for symptoms of menopause, which doesn't take a lot of estrogen.
So, Prem, you're going to get very little production of testosterone. Now, something I did want to mention, too is that I didn't show the graph, but testosterone in women does not drop at menopause like does estrogen, because your adrenal glands will make about half of the testosterone in your body. You're Ovaries, obviously stop making it because they stop doing anything.
But your adrenal glands will continue to make it unless you have adrenal dysfunction, which is so rampant and common and so this is why I see stressed out women as they go through menopause. They generally get more stressed out for various reasons. Their adrenal function gets worse. They're making more cortisol, they stop making DHEA, and therefore they stop making testosterone.
So we kind of see this like stair step decline and it's a downward spiral. And just like in me or with that testosterone by estrogen, Esther Dial was low res yesterday, which then slowed down my bone loss, correct? That's exactly right. So estrogen slows down bone loss. Testosterone will help to build bone, although it's not quite it's not quite as directly related.
But we do see that in men with increased bone mineral density with testosterone alone. But we don't know. Is that really because it's aromatase into estradiol or is it because of the testosterone itself? And ultimately, it doesn't matter because they both. Well, yes, Cheryl, you raised your hand, although I thought Kathy actually umpired. So let me have Kathy ask her question and then we'll go, you mentioned the DHEA.
I know some people take that. Yeah. So I just did a video. I don't know if it's out yet or not on YouTube. And if you guys are and if you're interested in bone health and you're not on the YouTube channel, you should definitely check that out. Just look up. Dr. Doug Lucas, us on YouTube. You'll find it.
So I just did a video on DHEA and DHEA alone will increase bone mineral density significantly. When I say that statistically it's not that significant, so I wouldn't use it alone. I think that you're going to have a tremendous impact. But the reason why it works is because it does become testosterone. Well, yeah. So DHEA will do that a little bit in India.
Any doubts, downsides to taking DHEA? Yeah. So it's it seems to be even more androgenic than testosterone in itself. What I mean by that is the symptoms of oily skin, acne and potentially hair loss, especially in postmenopausal women. I see that occasionally because when we use, we use pretty big doses. Our goal is to use the same doses they used in the research studies.
And those are big doses for women especially. So if women complain about hair loss acne, then we just pull them off of it. So I see some women don't tolerate DHEA, but those are the rest and the side effects more so there are risks. And but this testosterone is the same. But we can get better levels of testosterone without androgenic side effects than we can with DHEA.
And then, Cheryl, you had a question. Yeah, I, I am about to start the estradiol patch, the lowest amount like .25 and the naked eye is progesterone oral and at 100 and But some of my tests that I've done said that my sex hormone binding globulin was pretty high and I was wondering if that's going to interfere or if that's going to get corrected or do you, you know, like do what does that need to be corrected before I start or can it be done afterwards?
Yeah, that's a great question with a complex answer, unfortunately. But so. BG The binding globulin is very important to test, and I'm glad they tested it because most people don't. And so S-H. BG Will is the the protein that binds your sex hormones and it carries them around the body because hormones are not water soluble. And so if you have a high level of this protein, it'll bind all of your hormone and you will have a very low free hormone.
So, yes, the answer is if you have high, you will likely need higher doses, particularly of testosterone, estrogen. I'm not actually sure how that relates to Fpg in three levels because we don't measure free estrogen, but free testosterone for sure will be reduced in people that have high as BG. And I was the same way. What I can tell you is that some people their speed, you will come down with adequate dosing, but not with inadequate dosing.
And so for you, Cheryl, I would probably end up driving your testosterone pretty high to help bring down BG if it's going to come down, the mine never down. I see some people that don't have low fpg even after adequate dosing. So my dose of testosterone is pretty high. And for other people that have high BG, we would drive it pretty high and then check their free.
I'm less concerned about total at that point. I want to know about free testosterone. And so we kind of measure those things and symptoms and see how they do so it's hard to do with commercial preparations. And Sheryl, if you're on the commercial after dial at that low of a dose, you're probably not going to see adequate levels to protect bone and do some of the other things that we want extra dial to do.
But it's very variable, meaning that some women on a very low dose patch have pretty levels of estradiol. And what it's really hard to predict. Yeah, I I'm basically self managing as much as possible and then asking my doctors are finding doctors that will prescribe things for me. So all you can do I don't have any testosterone in the mix at the moment and I'm close to the end of the ten year window, so they're starting me off at the lowest dose and then I can try to get them to increase it accordingly.
But they're not they're not testing my estrogen, but I am and my testosterone levels as well as a baseline. But yeah, you can I mean, for for most postmenopausal women, their testosterone levels are going to be so low unless your adrenal glands are working really well, says the only way that that wouldn't happen. One thing I wanted to mention, too, if you look on the Health Foundation website, under resources, there is a resource that should be available.
Now it's with a company that I've partnered with called Merck Email Creek and Marik is there. They do not specialize in postmenopausal women, but I sat down with their chief medical officer, gosh, like two meetings ago or something and talked to them about what the needs of this group are and what their capacity is as an organization. So when you go on their website, you will clearly see that they're very performance driven.
You know, they're they're helping bodybuilders and, you know, they're very much in the performance space. However, their providers have the capacity to do estradiol creams. I don't know that they would do patches because they're kind of that's their business model is to do probably compounded creams. But still you can get an astro dial cream. You can actually continue on with their own patch and they'll do testosterone.
And so this is an area where for a they're not cheap, but without being a full service patient of ours, you could still potentially get testosterone from a reliable provider who is going to test you on a regular basis and you're going to get some feedback from providers that know what they're doing in the testosterone Avenue, met their providers.
They are trained in these things. So that's why I've partnered with them to give an off ramp for people that are in HSN and also potentially our self directed osteoporosis course. If you can't work with us full time, which I totally respect and understand, we don't even have that much capacity. I want to give people an off ramp for that and can do that.
Okay, great. Thanks. I had a question about the the lotion or the cream, the estradiol or any of the hormones. Are those something like. So you're do you wear a glove when you spread that? How do you not get it like on your hands. And then if you eat with your hands like not ingest it. Yeah, you could ingest it, actually.
You could eat the stick and you'd be fine because it would all break down your stomach. But the issue with the cream in your hands is actually transferring it to someone who's who's hormone sensitive like kids especially. And this is really true for testosterone so than estrogen, but actually the applicator. So they come in these little I have an example of one, but basically these little topically tubes.
And you do the click thing and the cream comes out the top and then you actually use the applicator to apply it. So you just rubbing the applicator on your skin rather than your hand. If you had to use your hand. I've some patients that like to use their hand and they rub it on that way. If you wash your hands, it, it all comes off.
It's very the cream is, is water soluble so you can wash it off with soap. So would that be a pro like the kids aside, would it be a problem for like an adult male that you have contact with. Yeah. More so the other way. So if men are using cream and they transfer that to their female partner, then that's way too much testosterone.
So that can be an issue for a woman. Transferring it to a male probably wouldn't be as big of a deal. I would recommend though, applying it at points where you're probably not going to have that much contact within the next couple of hours. After a couple of hours, it's mute because it's all absorbed. So I still would recommend doing it.
Around that time. A little bit of testosterone for a male partner. Probably not going to be an issue as long as it's not so much that you actually interfere with their own endogenous production. If they're on testosterone, then it's not enough that's going to make an impact. That's good to know. It's only for a few hours, though. Thank you.
Yeah, absolutely. With kids, I would be very careful. Yeah. All right. Well, we're a couple of minutes after the hour. If there's any burning questions, I have a few minutes. Otherwise we can wrap this one up and call it our first one. And I think it's a success. Yeah. Yeah. Okay, great. Allen, nice to see you. I'll be.
Thanks, everybody. Soon. Yeah. Okay. I look forward to it. Thank you, Cheryl. I appreciate the thumbs up. And thanks, everybody for showing up. And again, this will be available for for viewing later. Allen, nice to see you from Scotland. We'll see you next time. All right. Take care. Bye. All right. Take care. Bye bye.
