Hey everyone.

Today we are doing some reruns for the month of July with really popular episodes that we've had in the past two years.

So in today's episode, I get to interview and do a quick Q and A with my favorite of all time, doctor Jessica Shepherd, and she is here to answer the most common questions about menopause symptoms, treatments, and how to manage the physical and emotional changes during the stage of life.

From hot flashes and mood swings to hormonal therapy and wellness tips.

Doctor Shepherd shares her expert advice on navigating menopause with confidence and maintaining overall well being.

Whether you're currently going through menopause or preparing for it, this episode provides valuable insights and practical tips to help you fill your best I hope you enjoy this rerun with doctor Jessica Shepherd.

Hey everyone, This is Haley and I'm Lara and welcome to the Body Pod.

Welcome back to the Body Pod everyone.

Today I have the pleasure of interviewing doctor Jessica Shepherd, who is a chief medical officer at HERS.

She is a board certified lpg an a Woman's Health, Sexual Wellness and menopausal expert and the founder of synctom Med and Wellness, as well as the author of Generation M Living Well in Perimenopause and Menopause.

So today you get to join me while I have a quick Q and a rapid fire session on all things menopause enjoy.

Everyone is so excited for you.

I mean, we have like all of these questions and we gave away the Generation M book yesterday and so super excited about that.

I've loved seeing.

The progress of Generation M because you have just been like killing it on the Today Show, Good Morning America, like all of these, all of these things, which is just so incredible.

So thank you, thank you, thank you for joining us.

You know, you're my absolute favorite of all time.

You're my favorite.

And we absolutely like, I don't know why we aren't meeting, but we're meeting this year.

Yes, oh yeah, forward the end of the year.

Absolutely.

Okay, I'm going to get started on these so we can get you in and off to packing.

Wherever you're going tomorrow?

Where are you going tomorrow?

I'm going to visa Spain.

Were you just in Italy too?

Someone's got to go to these places and talk about menopause.

You know, hey, sign me up for the gig.

I mean, I'm all, I'm all for it.

So good thing that you're traveling.

It's like work slash really cool vacation place to go.

So I love it.

All right, we're going to get We're going to get right into it.

So first quest I have heard that doctors will prescribe low estrogen birth control to women in perimenopause when the woman has been suffering from some of the common perimenopause symptoms poor sleep, mood change, low energy, brain fog, lack of libido.

I also heard this is controversial because the pill is not hormone therapy and women may get better results from hormone therapy than just the pill.

If blocking the sperm is not a concern, should women in perry with these symptoms be looking at hormone therapy instead of the low estrogen pill.

Oh, I love this question.

I actually answered it yesterday.

So I was at you'n Ammonia over the weekend and I did three sessions just on HRT and that was exactly one of the questions that we got.

So I'm kind of going to back it.

Up until the perimenopathal phase and exactly what it is, and why it's actually a little bit more confusing than the menopausal phase because during perimenopause, where you have this rollercoaster fluctuation of hormones, and with that fluctuation, you have estrogen that some days are really sky high, really low, and a lot of those fluctuations cause some of the symptoms that people start to have that we would typically categorize as menopausal symptoms, so hot flashes, night sweats, irritability, obviously of your decrease in your muscle mass that starts to occur from your mid thirties.

But these symptoms usually are going to be infrequent or not as may be severe.

The problem becomes because you're still menstruating, whereas in menopause you are not menstruating, you still have estrogen and progesterone, which means that if you're still cycling and have a menstruation, you have the ability to potentially still get pregnant.

Now, is that likelihood high?

No, it decreases as you go through your forties, but there's still that likelihood.

Now Here comes the tricky part is that birth control.

Yes, it does have synthetic forms of estrogen and progesterone in it.

But what's its job to prevent pregnancy?

HRT is usually going to be more of a different form of estrogen and progesterone, but it's on a much lower level, so it does not prevent pregnancy.

So that's why in the perimenopausal phase it becomes a little bit confusing, as could I take OCPS?

Absolutely you could.

Does it take care of some of the symptoms that are what we call perimenopausal menopausal symptoms?

Yes, But the tricky part becomes do I stay on it throughout my forties into when I might be the least likely to get pregnant or a menopausal or do I start HRT.

So the way that I like to answer that question is if you're still having symptoms and for a smattering of other reasons, say you're not sexually active, say you really have infrequent periods, or you're down to maybe minute periods, and you're like, my risk of getting pregnant is really low, I would like to switch over to HRT to help with my symptoms and also booster my estrogen progesterone kind of scaffolding, which helps with longevity and bone and all of those other great things.

But there are a lot of people that are relatively younger maybe still have cycles regularly.

I have forty seven year olds.

I have fifty two year olds who have cycles regularly, and so to me, even though the likelihood is lower, they still are ovulating enough to a level to elicit a period, which means they're probably ovulating.

So they are probably people that I'll be like, you know what, you can get benefit from both, but let's prevent pregnancy should maybe be prioritized than just looking at it from an HRT perspective.

So the hormones and both of them are completely different and they do different things.

So you do have to weigh where you are in the process, what you're looking for is outcome, and then make a decision.

Oh, that was the best answer of the night right at the top.

Actually, I don't know.

I haven't read them all.

I read most of them.

Okay, So for a perimenopausal woman who is already prone to waking up around two to three am, this is me.

I didn't do this question, but this is me.

But who definitely wakes up with hunger around two to three am when in a calorie deficit, do you anticipate the adding progesterone at night might be helpful for better sleep.

Yes, so it was the hunger part part of the question or just a sleep.

I think they're saying that they also wake up if they're in a calorie deficit, but then they're waking up anyways if they're not.

Okay, so let's address it as just a pure sleep question.

Then maybe if there is more clarity on the hungry part than I can address that.

But there's multiple reasons why we have change in our sleep during the perimid apausal phase into the met possele phase and then again has to do the fluctuations.

So we'll go back to that rollercoaster ride that you're having where you don't have this great consistency in how your your hormones are starting to show up.

And so it happens, namely progesterone, which is I like to call it a comfy hormone.

It really like relaxes everything.

It makes the gi relax, it makes your sphincters relax, everything is just like so relaxed.

So in addition to that is it really does help relax you from a sleep perspective.

And so when we start to have actually a really significant drop and progesterone during the perimenopausal phase.

That's when it starts to impact not only from the comfy perspective of what it does, but also our circadian rhythm, right, And so our circadian rhythm is ever so important when we think about what it provides as far as time frames of when you're having certain when your brain is regulated to sleep be sleep versus awake, and then you're also having now this disruption in your progesterone, which is also impacting how you're able to relax in that timeframe.

So because of that fluctuation and decrease in progesterone, it is actually a good idea to consider progesterone.

And when I say that, it has to be not synthetic progestine because that is the one that actually we don't like because it does have increased risk of breast cancer in that use, but a natural progesterone which you can get from a regular pharmacy, So that can be your micronized form of progesterone in either a dose of one hundred two hundred, some people take a little bit higher, maybe three hundred, but we do see that because of that phase or that drop in the hormones, you're not going to have quite as much as the sleep that you like.

Now, the other thing that occurs too is it impacts.

So now you have estrogen starting to decrease, which doesn't take as much as a dive as progesterone throughout the perimenopausal phase.

But because estrogen decreases a lot of people then have night sweats, because that's where we get a lot of our hot flashes and night sweats is because of the decrease in estrogen.

But even if you don't notably have a night sweat, we have a lot of good data that shows that even if it's not visibly waking you up in your sweating, that people actually do experience night sweats or hot flashes at night, but it's not the typical one, but it's still enough to wake them out of their sleep.

So a good way to start, especially if someone's hesitant about going on HRT or the estrogen part of it, is actually just to start with a progesterone compound and also to start magnesium as well.

Magnesium is a beautiful way for you to kind of get that regulation back with your sleep habits.

So those are two good things.

That you can put into your routine when it comes to sleep.

Oh, I'm getting on the progesterone because my sleep is not good.

Yeah, And I do all the right things.

I try to like turn off the phone, and you know, it's it's just a doozy.

And so you're still getting kind of the awakening, right, yes, yeah every time, and then I'm just like, should I get up and work?

No, you're thirty three.

Oh, don't do it.

Eventually I go back to sleep, but it's a it's a doozy.

Can you please give possible causes of post metal pausele bleeding and suggestions on how to stop it?

Yeah.

Post menopausal bleeding is definitely one of those things as an OBGYN that really concerns or alerts us.

Okay, something that when someone says that, immediately we're like, but why why are they bleeding if they've experienced menopause.

So menopause technically means you have gone twelve months consecutively without a cycle.

Consecutively is important because some people will not have a period for ten months and then they'll have a cycle and I'm like, we have to start the clock again.

So unless it's twelve months consecutively that you have not had a cycle, then that's my pause like that is the hallmark in the start and thereafter you should not ever have.

Any more bleeding.

So if you do have bleeding after that, it is really important that you talk to your obgyn about that because we need to know why is your endometria aligning causing bleeding If your ovaries are not giving up enough estrogen to cause a cycle, so there should be no bleeding at all, so it's very important that you talk to your doctor about that.

The caveat to that is that there is if someone is on actual HRT with a form of estrogen in it, it may cause a bleed that is not a bleed you of your uterus, but the estrogen that you're on is causing the bleed.

But it's also important to still talk to your doctor about it because then we can at least put into the equation.

While she is on HRT with an estrogen component on it, could it be the estrogen that's eliciting this bleed and we can figure out, you know, through ultrasound, we can if it resolves on its own, we can decrease your level of estrogen if you're on HRT, but if you're not, then we definitely have to look into that as a reason of why.

So both of them are still very important, but two different reasons why you might be have bleeding.

End story is if you have bleeding after menopause, absolutely categorically do not hesitate and go see your obgyn.

Okay, does the next question kind of piggybacks off of that.

Can daginal estrogen cause post mental puzzle bleeding?

Is that a reason it can?

And the reason is we have estrogen receptors all over our body.

I think we do type cast to just being in the pelvis, specifically the vagina, but we have done our bone, our brain.

Our heart, our muscle.

So because it's very sensitive obviously within the pelvic region, especially the vagina, because that's what allowed the vagina to have secretions when we were younger in our kind of reproductive phase.

You know, like think about it, when you have a baby and baby gets all the way through the birth canal, it.

Comes out, it goes back down to size.

So that's the flexibility and distensibility of the actual vagina.

Estrogen has a lot to do with that.

So now when we lose our estrogen and our vagina doesn't have the ability to be distans, it becomes more fragile, the tissue becomes more fragile, and now you start vaginal estrogen.

The receptors are like, thank you, thank you so much for pouring this estrogen into the area that we really do love and and it helps the vaginal tissue thrive.

So if you have vaginal bleeding after still another reason to go to your OBGI and and get it checked out.

It doesn't necessarily mean that you have to come off.

Of your HRT or your vaginal source of estrogen.

We just want to make sure we are definitely providers or professionals that want to rule out worst case scenario.

So we will always be like, what caused the bleeding and if we can make sure that it's nothing that has to do with anything that we're concerned about, then we feel better and we can manage it that way.

That's a great answer.

Moving on to the bladder.

How does the bladder change during perimenopaus.

I feel as though it is smaller.

I need to go to the bathroom way more often, and the amount isn't as much as I used to be able to hold.

This is me all the time too, not my question, but this is me.

Yes, there is.

A lot in the pelvis that responds to estrogen, and the bladder actually is a very.

Beautiful part of the pelvis.

A lot of times it's forgotten because it doesn't seem like it's part of the uterus, vagina and ovaries, but it really does have sensitivity to both progesterone and an estrogen.

But the same type of thing that I talked about in the vagina happens with the bladder.

So as we start to age, it doesn't you know, the distensibility and the capacity for it to hold urine is not as much.

It Obviously the sphincter, so the part that closes when you're not urinating, and then that opens when you do want to urinate, it gets a little bit looser, right, so now you haven't continent issue with leaking because the door the stop clock is not there as well.

And then the other thing is that estrogen really has the ability to our control of the actual bladder, so it's smaller, it does not hold as much, and so if you think about during the night, a lot of times that's usually when you know your bladder usually will capacitate a lot more as you're in rest, and then when you get up usually after maybe eight hours or however long you sleep, then you do have to use a bathroom.

But if it can't go as big as it used to and hold as well as it used to, that again is why we start to have more issues with our bladder and having to have decrease time in the times between we need to urinate as we used to before.

The other thing that I will say is we don't typically work out our pelvis right.

So when I think of a pelbc physical therapist which helps us with our bladder and our control of our bladder, most women have never been taught how to do really good pelvic exercises to strengthen their pelvic bowl.

And so as we get older and this starts to happen, we don't know how to kind of control it and keep it to do what we would like it to do.

And then on top of that, think of what usually happens we have pregnancies.

Then you know, even whether it's C section or vagil delivery, childbirth a lot plays a lot of like trauma on the bladder, and so over time it just gets a little bit weaker.

And it is quite frankly, when I used to do a lot of surgery.

It's a kind of lazy organ.

It just likes to forget what it does.

It's like, when were we doing again?

I don't know.

So it's a little lazy.

But will I will give it some slack and that the estrogen makes it smaller.

Okay, good to know.

So I'm using estrogel for twelve days a month and a testosterone gel.

I still get mood swings despite this routine.

This is something that it can be changed with those increases.

So tell me how long they're on the estrogel twelve days?

Yes, Okay, So when we think of hormone replacement therapy, there are reasons why people can take it cyclic, which is exactly what you describe taking twelve or fourteen days, depending on how someone prescribes it, or you could just take it all the way through.

So I'm going to answer the question is if they're perimenopausal and menopausal and the perimenopausal phase, because we're doing that whole kind of rollercoaster thing.

Sometimes it is a little bit hard to figure out where your fluctuations are and if you're not on estrogen for the other remaining days, what's happening during those days as well?

You still may be having these fluctuations, and that can be contributing to the actual let's see, it can be contributing to the actual kind of frustration irritability because you don't know where you're controlling.

It's still just kind of all over the place.

Where it was a little bit more predictable earlier in our you know, teens, twenties and thirties because it followed the regiment, it followed the schedule.

Now it's just like a radic all over the place.

And then the other reason is that in a continuous fashion, sometimes it is better to try and convert to continuous fashion because then you're whatever you're on, whatever dosage you're on, can really be there to kind of buffer those fluctuations and keep the stability of the levels of hormones.

So for someone who is taking a cyclic form of the HRT in the gel form, I think it's worth a try or a shot to maybe just do it continuously to see what the outcome is, because there's no harm in taking it continuously during cyclic it's just how it was prescribed that maybe that was thought it could be done in that fashion.

But I think a good way to test you know, if you're going to have these kind of dips, is just to try and continue newest form obviously with the advice of your doctrine in what dose you're on and figuring that out and seeing if you can actually eliminate those moments and where you have the irritability.

I mean, all of this, there's so many different options that you can use for this.

I would say at the end of all of this is for everyone on here to realize that however they're taking it, or if they're not taking it, or if there's always options.

M oh I love that.

Yeah, for postmenopausal women wanting to use progesterone cream alone no estrogen for sleep benefits.

What are the FDA approved options for progesterone cream that you would recommend discussing with our healthcare provider.

Yeah, progesterone cream.

So what we have in I guess you could say in a pharmacy fashion and what pharmaceutical companies usually they will be in a pill form.

Now for a cream, usually it is a bioidentical form.

It could be compounded and so that you can actually tie trait the amounts differently because it is compounded.

What I would say is that because you're doing it in that fashion versus just estrogen alone, it is much safer.

So I said this yesterday every woman who decides if they want to take HRT, if you have a uterus, you must take progesterone if you're taking estrogen.

If you don't have a uterus, that's the only time you have the luxury of saying I would like to take estrogen alone.

And the reason is because they balance each other out, and if you only take estrogen and have a uterus, the lining in your uters will build and build and build, and it can potentially become endemetrial cancer because progesterone is not there to equal it out, and so progesterone, however, you can take alone without estrogen, but progesterone and estrogen.

If estrogen's taken, you must take progesterone if you have a uterus.

So with the cream there's usually going to be in a compounded version of how you take it, and it is very safe.

I think it's like I always say.

It's like one of the best ways to test HRT if you're a little bit hesitant about it.

It really is like the cute c type of benign or front format, you know, like for people who are just like, oh, I don't know if I should get their tea.

Progesterone really is that one that you can try in a cream form and get that compounded as well, And there's different levels of it as well, there's different dosages as well.

I hope I'm.

Answering that question in the right way.

The other thing too, is that I just as I'm thinking through the answer, there are a lot of progesterone creams that you can get over the counter, like if you go to like because it can it can be made with yams, right, So in my head, I'm thinking that's where this question may have come from, because there's ones that actually are the biogenic forms of the hormones in your body, which would be prescribed, and then those that people can try and make from wild yam so that it can replicate to some degree what progesterone can do, but it will never be as strong as what something is compounded and made in an actual pharmacy or compounding pharmacy and actually made from a chemical form.

So you may get relief from the ones over the counter, but there are some people who may try that and not get the relief they're looking for and may need to transition into more of a prescribed progesterone.

Okay, what are the most important biomarkers for an active postmenopausal woman to monitor for maintaining health at the stage in life?

Which specific blood work markers percent muscle mass or body fat percentage?

Do you have any?

Yeah?

So, yeah, when patients come into my office, to me, the menopause transition is much more than just the reproductive hormone portion of it.

That's obviously a big part of it, because the ovaries that have declined in their ability to do what they do, and so we do have our estrogen and our progesterone that we can monitor through that as well as your testosterone.

But you also have progesterone and testosterone that come from your adrenals, but most of your estrogen does come from your ovaries.

So those three obviously are ones that we're going to look at, and then we'll look at the hormones that tell those ones to release, which would be your follicle stimulating hormone which is your FSH and then your lutinizing hormone.

Are they as important?

No, but they're good to include in those to kind of see where those are as well.

I always look at thyroid and I look at a full panel of thyroid, because hormones are chemical messengers and they like to talk to each other and tell it's a symphony.

Everyone's telling everyone what to do and where to be and how to show up.

And if you basically have a portion of the symphony, you know that's playing bad notes and sounds horrible.

Everyone knows and everyone kind of like is noticing that.

So thyroid is, you know, small little gland in your neck, but it really does have a lot of responsibility.

So full thyroid panel.

In addition to the other ones I just said, I also your lipid panel.

So because estrogen is decreasing over this timeframe, it actually triggers.

Remember we said estrogen receptors are all over your body, So there are a lot of features that occur as you're starting to age with your lipids and those start to increase and sometimes do some funny things as well.

So a lipid profile is also very helpful to make sure you're not increasing some of your triglycerides or your total cholesterol.

To watch that as well.

Another test that's also important is your hemoglobin, A one C.

Your hemoglobin A one C is a lab that we draw that helps us to tell if you're going towards a pre diabetic or a diabet stage.

We know that as we age and estrogen starts to go down, our body starts to have more insulin resistance.

And one good way to make sure that we're not becoming completely insulin resistant is to make sure that our sugar is not creeping up.

And that is a better range than just taking a random sugar which can be on a lab and testing over the last three months what it's been looking like in your system.

So hemoglobin A one C.

I also recommend that women ask for maybe EKG to just see the functionality of their heart.

It's such an easy way to just look at the functionality of your heart and what's going on.

And then one more thing that I'll mention.

It's called apo B APO and then a big B and that is again a key factor in determining someone's risk and cardiovascular disease.

And basically it's a protein that kind of facilitates and transports lipids.

So if you again.

Have an issue with your APO B, that means that your lipids may not be getting to where they need to go to.

It can be kind of increasing the plaque that forms in your vessels, which may contribute to cardiovascular disease.

So again, that's another one that can be included in a blood test to kind of help because number one killer of women is heart disease.

A lot of times we think it's breast cancer or we think it's something else, but it's actually heart disease.

So we really have to take care of our hearts, especially as we start to go through menopause.

Perfect So is it What is the difference between using combined pill staying on it versus switching to MHT.

Are the hormones the same?

Oh, we talked about this, they're different.

I'm fifty two and have been on OCP since eighteen.

It was planning to just stay on it until fifty five then switch, but MHT is more appropriate.

So really that you covered that of what we should do at the first.

I would make a strong disclaimer for someone.

For me, typically it is a personal over the age of thirty five birth control pills.

I'm like, Okay, how much longer do we have to stay on this?

Can we find another way?

Even if it's for birth control I'll try to find other modalities of birth control.

We did definitely, so there's nothing wrong that was done.

We definitely have used birth control pills for decades as a form of MHT.

We now are much better educated and understanding of the different types, why it's needed, what levels are needed for us to I think get more women off of birth control.

To me, typically the latest maybe mid forties, early forties for me, even if if I can get them on another kind of birth control, but at that age, at fifty to fifty two to fifty five, I would not wait till fifty five to switch and just get off of it now and switch to MHT.

Okay, perfect, do you ever recommend hormone replacement for women?

Oh?

In perimenopause, So at what age my testosterone is super low and my doctor recommended a testosterone.

Supplement.

Something had never, something had never I'd never heard of before.

A trope.

Oh yeah, So it's a trophy.

Trophy.

It's basically like, uh, it looks like.

A pill, but you put it in your gum and it dissolved, so you get what we call like sublingual release of whatever it is.

I mean, anything can be in a troche it can be a medication, it can be a hormone.

So ask the question again, because now I forgot I.

Oh so they do you?

Okay, well, one, do you recommend HRT in perimenopause and if so, what age?

And then her testosterone is super low, but her doctor recommended a test drost on trosh, something that she had never heard before.

Okay, So back to the question about when to start.

It kind of goes back to the question of the birth control control pill in when is that time that your perimenopausal, which is usually your forties early pties for some because they still may be menstruating.

Is I need to sit and think about if I would like to stay on birth control if I'm very sexually active and there's a good possibility I could have a baby, right, because then that makes to me it prioritizes birth control over MHT.

I have frequent cycles.

In frequent cycles, which again is going to go to is it likely for me to get pregnant.

Or very very unlikely for me to get pregnant?

And I can transition over to a hormone replacement therapy, So those are like everyone's going to have a different answer, choking, So it's important to.

Know who you are and what you're looking for.

Mm hmm, I'm gonna drink the water.

Yes, drink, drink some water.

I'll get to our next question.

We didn't do the troshy one.

Oh okay, let's get let's hit that first.

So testosterone is trying to take his HRT.

I don't have a problem with taking it that way.

There there's various ways to take it.

You could take it that way, some some injection.

I'm not a fan of the injection.

You can do testosterone creams and then also testosterone pellette, so there's various ways.

Yeah, there's nothing wrong with that modality.

Okay, great, moving on to what are your thoughts on maridine live vibration plate for osteoporosis and or overall help.

Can you spell that mere.

M A R O D I N E l I V vibration plate maybe just a.

Vibration Yes, the vibration DM.

I'm doing really good on this.

So that really really what it is is to create low density vibration to help with stability, to help with flexibility.

Would I say I.

Wouldn't say it's bad, but is it evidence based as a form in a way to improve osteoporosis.

I would put it more in the in the category of a supplementary A supplementary way to improve bone mineral density.

Ways that you're going to improve your bone health from a bone mineral density is resistance training, so weight training and also increasing your protein intake, and also HRT hormone replacement therapy has been proven from the estrogen portion to improve bone mineral density.

So it's not like it's a bad thing, but maybe put it on the list of things in addition to the other thing that I mentioned, than making it maybe the only thing that you're doing, thinking it's going to just magnify your bone mineral density to the level of what you could get if you were doing those other things.

Okay, I have hashimotos and wonder about all the conflicting information I read about whether or not to do high intensity exercises.

I always think working at my best level is best.

For example, lifting the heaviest I can go with good form.

What is optimal for people with autoimmune issues?

Do you have a take on that?

So that's a multi layer question.

I think when we think of hashimotos, right, So a lot of that has to do with it's autoimmune disease, meaning that your actual thyroid is attacking its own organ right, So the goal with that is to manage how to get the thyroid levels back into a normal range, which sometimes may need medication, which is okay, But there are other ways that you can, I guess, facilitate the hashimotives, and a lot of that actually can be with diet.

And then if you think.

About it, most women will have thyroid issues after the age of forty and a lot of that has to do with starting with the fluctuations in their reproductive hormones, namely estrogen and testosterone.

Remember you're talking about the symphony, and one is out of place, and so it causes a lot of other things to be out of place as well.

So that's why when we look at thyroid, that's why I draw thyroid on the panel when I'm consulting women about perimenopause and menopause.

So a lot of times you can be correcting one and the other one starts to fall back into place.

Does that make sense?

And so a lot of women have had hashimotives or Graves disease or whatever it is.

Yes, it's an auto chronic autoimmune disease, but a lot of times it's missed by maybe if I start correcting the hormones of estrogen and progesterone slowly, we can start to see them equal out and not have as much of an issue.

So when it now comes to working out, I'm trying to answer the question as how I'm hearing it is that going overboard, will that impact the Hashimoto syroiditis or if that could be done?

Yes, I think working out always is going to decrease inflammation, and when you think about a chronic autoimmune disease, it has a lot to do with inflammation as well.

So I don't quite know where in the question where it meant like working.

Out too hard versus at your level.

I think obviously the best place to start is at your level.

Another thing to do it to being like, let me do a full review of my hormone panel and seeing if there's anything that we could do from the reaper deductive phase of the HRT that might help with a thyroid function.

And then also with your food as well.

I do think that there are very holistic ways in which people can have their food or their nutrition support an autoimmune or anti inflammatory through diet our gut.

Our gut is a big part.

As well as what lets things in and out and what things may be contributing to this autoimmune type of disease.

And so I think that there are.

A wonderful functional nutritionists out there that kind of help look at the big picture and then help from a nutritional standpoint, figure out what's going to help that issue the most.

That's great.

So for someone that is on HRT, they're fifty five, how many years, if not for my lifetime, would you recommend staying on.

Yes, this is a very controversial question because of where we are currently in.

Hormone literature.

Been for the last twenty years fixated on a study that really had us running away from hormones and thinking that they're bad, and we're now just on the other side of it in the sense of hormones are not that bad.

They're not bad at all.

They're actually very beneficial.

So there were a lot of recommendations that were made with that study twenty years ago, and one of them was stop taking HRT at ten years at the time your menopausal.

So if you stopped having periods of fifty two to fifty five, then you just add ten that's when you stop, or no longer than sixty years old, right, whichever is whichever pertains to your issue or your age.

The problem with that is that we know from literature the moment you remove estrogen, protesterone, and testosterone from your body that have been there your entire life, then your organs are also going to take a hit because they're not being substantiated by the hormones.

So we're just at this early state of research to say how.

Long should women go on.

There are a very big body of doctors that are like, from a longevity standpoint, why would I go off hormones?

Because it helps bone mineral density, decreasing rate of Alzheimer's decreasing rate, breaking your bone, improving your muscle mass.

And so it's more now as we start to age, how can I thrive while I'm aging?

And hormones have a lot to do with that.

But also we have strict recommendations based on studies that are like, well, we really shouldn't go past this point where do we think that we're going with researchers more towards I'm going to be on hormones until you desire to or until you die, and I think when you have a really good conversation with some who truly understands hormones, people should be able to make the decisions that they want to based on the information that they get.

Nowadays, we're still in that phase where they're going to be like, oh my gosh, you are sixty two and you're still on MHT.

We've got to get you off.

I have Aasians for a seventy and they're like, I feel great, I'm not coming off my hormones, and I'm like rock on.

So again, you're gonna people really need to get to the point where they're like, of all this stuff with risk and benefit, And what I'm looking for is I'm looking at my life in my sixties, seventies and eighties, nineties, what I want that to look like?

How is this helping how many I want?

As we age, age is probably the risk factor for most diseases breast cancer, heart disease, alzheimer.

So as we age anyway, things can start to not function as properly.

Disease goes up.

But if you were to think of it in a way that says, I want to be able to be exposed to hormones to give me the best benefit as I age and quality of life.

That's all another way to look at it, but no one's wrong, right You get to determine which one of those works best for you.

And I think that we're going to start to see that it is more personalized as far as a medicine form to SING.

There's going to be a risk at every point, which for you willing to take personally.

I love that.

Okay, So what do you recommend to your patients with osteopenia estrogen HRT as a prevention for further bone protection or bone loss?

And what about creating.

Back up on that question again, start with the first part.

What do you recommend to your patients with osteopenia?

Would you do HRT therapy as well to prevent further bone loss or for bone protection both?

You can see considerable amount of improvement in bone mineral density levels and scores if you're to look at it from a DEXA scan perspective when people are on estrogen.

That has been stated clearly in the literature.

So if you have osteopenia, which is a deficiency, not a deficit, then I would I would love if someone was like, you know what, let me give it my best shot of not becoming osteoporotic and go on MHT do my strength training so I can be more preventative and actually improve my bone mineral density.

Yes, and also with which with HRT for all of these like that doesn't that's never going to replace strength training, Like we have to do those hand in hand.

Yes, because they are by different different mechanisms in which they're.

Improving the bone.

So, for example, with MHT, the estrogen is improving the bone mineral density by improving the osteoclass, which is the cells that make our bone stronger.

Resistance training, what you're actually doing is it's kind of like a domino effect.

You're triggering your muscles through its fibers as it's kind of doing its twitch, to then tell the cells on the bone to improve or to become more or to build more.

Right.

So they're both different mechanisms, so you're going to get the best benefit from doing both.

But you know, I have patients who have never weight trained or they're scared to weight train.

I'm like, well, let's at least start with some estrogen or vice versa.

Right, So it's never to say that everyone's always going to have the perfect template of what they're doing, but at least being able to do one, if not both, is the best way to improve your bone?

Yes?

I love that.

Okay, what is the best non pharmaceutical intervention to protect and build bone for post metapausal women diagnosed with osteopinia?

Weight training?

It's not a medicine.

I mean, it's not a prescription.

You exercises medicine, but that one's not a drug.

Are the best way to do it?

So if someone was a little bit weird about X rays, how safe for DEXA scans in regard to radiation exposure and how often is it appropriate to get them done?

So?

And this is a good question too that I had yesterday.

So when we look at radiation radiation, when we look at it from a rad's perspective, that's how we monitor the amount that you're getting exposed to, DEXA scan is really low on that list, and even X rays, And when we think about like exposure to radiation and like the likelihood of cancer, it really is for people who are getting like significant amounts of radiation like every day for like two years, you know what I mean, A lot of the data that came out on radiation and cancer when it was done on mice, which obviously we're not big mice, but that's a good indication of what can happen.

But when you actually look at the studies, it was a significant amount of radiation.

So an everyday person's life who's like, I'm just doing this imaging occasionally with which a DEXAS scan, I'll actually let me go back to let me finish my scenements.

I'll go back to recommendations for DEXA and how often to do it.

But it really requires a lot of exposure to radiation for someone to say, oh my gosh, I got a cancer from actual right, Okay, So I want to reassure everyone with that.

The other thing about.

DEXA scans, currently the recommendations for a DEXA scan by insurance is not until the age of sixty five, which I completely hate because what do you think has happened by the age of sixty five?

Our bonds are like we were already on our way out, and and so it's not a very preventive way in the way the recommendations are written about DEXAS scan, the way that we use it, so amount of radiation is very low currently the recommendations at the age of sixty five.

To me, I'm just like, of course women are going to be They've been usually menopausal for at that point like fifteen years without any estrogen, and most of them are not taught to weight train, so of course their bones are not doing great.

So when you think of physicians, there are again a circle of physicians, not to say that it's little, but outside of the traditional setting who use dexas scan not only to look at your bones earlier, so they might recommend someone to go get it like in their latter forties early fifties, is they're going through that transition into menopause because now they're losing estrogen.

But also dexis scans are a beautiful way to look at your lean muscle mass and your actual fat capacity as well.

And the reason why that is also important is because your muscle mass two is significantly decreasing over that menopausal that perimenopause menopausal timeframe, So now your estrogen's going down.

That's what I'm saying.

Estrogen receptors are all over impacts your bone mineral density.

Your muscle mass is starting to go down as well.

But your fat cells as well, how they respond to estrogen is they just they're not as agile and shrink as well as they used to before, which is why we start to change our body composition as we start to age.

So dexa scan is actually a beautiful way to look at multiple things and to help people being a little bit more visual to what's going on internally in their body so they can start to make that the changes and the connections in their head and being like, oh my gosh, look at my muscle mass.

And so they're actually if you go find dexa scan facilities, they're actually not that expensive.

They're like one hundred and twenty five to one hundred and fifty dollars.

And if someone wanted to get a good baseline on what their body is doing internally from a muscle perspective, a bone perspective, and kind of like a fat mat or a muscle fat ratio, dexas scan's a beautiful way to see that.

It also can be preventative because now you know your bone mineral density is at a younger age, and if you wanted to, you could do it every year, you could do it every two years.

But it's a great way to see so much more than what we used it for, and much earlier is better.

Yes, okay, would you recommend somebody going on our HRT that's not having any symptoms, still has a period in perimenopause, but like doesn't have any headaches, no, no, nothing, Yes, you would recommend it.

The reason why is this is a very controversial question right now because typically we used to wait for women to be menopausal before we wuld give you MHT.

We are moving away from that and still a lot of providers and again to say that they're wrong, but this is how we were trained.

We would say, well, we'll only put you on MHT if you have a symptom, But what do we know happens when you're just declining from estrogen anyway, so many things in your body, it's not always a symptom.

So I think that there are providers who will do it.

I think that women need to think about those decisions when they sit down and think, am I having a symptom versus am I improving quality of life and longevity?

Those are two different things and actually get the benefit of both when you use MHT, and so approaching it from that way rather than I'm only going to go on MHT when I have symptoms as much.

And I really want to make a disclaimer that i'm you know, as much as an HRT advocate that I am.

It does not mean that if you're not on it, then you should be shamed because you didn't.

Go on it.

I just want everyone to have the ability to know really good, fundamental information so when they make the decision that they would like to or not, as much as I could be like, I think it's the best thing for you.

If you choose not to, then you choose not to.

Yeah, this is why I love you because I feel like your your energy and your candor is just so spot on, Like it's not harsh either way, Like, it's just here's the information.

As a physician, say you to.

Make the choice.

Say you change your mind in three years just because of the information you heard and you just gave it more thought and you had more conversations.

Right, All of this is really now to get people to then go and being like hmm, I didn't know that about.

Let me talk more about to my friends, let me bring it up to my doctor, And that's how we change the ability for us to make decisions is because we're changing our conversation.

Yeah one, Oh okay, I love it.

So I'm someone who is in the age range of perimedopause forty two but hasn't experienced any trouble except for a bit of the let's talk about the visceral fact becau.

There's a few questions here with with that, but no other symptoms.

And have heard that women should do hormone testing before menopause so that they have baseline levels of hormones to aim with HRT if they choose that route in the future.

Should I check Should I consider checking my hormones at this point anyway?

If I or wait until I have further symptoms.

If hormone testing is recommended, do you have a recommendation for the test?

You went over the test, so well cover those.

Yeah, So what your hormones are doing today at what time, Well, at my time at six fifty seven will be different than if I tested them today at two am or tomorrow morning, right, And so it's not so much a matter of if I draw it now, will it help me later.

It's good to have a baseline to see where you were, but it should not dictate what your dosage of MHT is going to be now or in the future.

It's not so much for I have to do it now so I know my dosage will later.

I think that it is good for people to get a baseline, just to have a baseline, and if we decide if you have symptoms in two years or if you're like, let me see what my hormones are in two years, you can kind of see what that difference would be.

But it doesn't necessarily mean that it should dictate your dosage.

Yeah, I want to make sure that people understand that.

Then the other thing is you asked a second part of the question.

It was about the we went over that what should be drawn on the labs, and you said something about visceral fat.

Yeah, does the visceral fat so this is the only symptom that they're having.

But then someone else had mentioned, you know, the weight gain with visceral fat, and how realistic is it for perimetalpauzle woman to achieve fat loss?

Weight loss is their hope and does HRT help with that.

Yes, So I'll answer the first question first about visceral fat.

So you have your phone.

Subcutaneous fat, which is the fat that we see, right, So it's the fat that migrates.

It used to be on your hips and your button.

Now it moves to your abdo even though you didn't ask it to go there.

And then you have visceral fat.

Visceral fat we can't see.

I have seen vistral fat because I went into someone's organs and looked at it with a laparoscope where I cut them open and was doing a surgery.

It's the fat that you see around an organ, and the fat that's around an organ is for protective reasons.

But what happens as we start to get older is that our visceral.

Fat starts to increase, okay, so that therein becomes a problem.

And that's also what you can see on a dex of scan as well, your visceral fat, which we can't see just looking at someone externally.

So the reason why visceral fat is important because you won't feel when it's increasing, you won't see when it's increasing, but it does impact your organ systems, okay, And so that's why people start to maybe have like.

Liver issues or heart issues or whatever.

That's the reason why weight loss in general will always be one of the biological features that for some people maybe more than others, but in general everyone will start to have fat weight rather increase as they age because of insulin resistance.

The main bulk of why we start to see that happen is because estrogen decreases and we start to have a shift in our muscle mass.

Right.

So, if you think of a pie chart, and for your twenties and thirties, and when you're an adolescent, really active, and your muscles are very very they're thriving, they may take up sixty five percent of the pie, and then you have organs and water weight and fat which take up the other portion.

As we start to get older, that sixty five percent of that pie starts to decrease slowly over time.

So what does that allow more space for more fat?

Right?

And so now we have decrease in estrogen, which is also not helping our muscles.

We have a decrease in testosterone, which is also not helping us build more muscle.

So hormone replacement therapy in essence, is not directly making you lose weight.

It's helping all of the things that we're there part of that symphony to kind of keep everything in check.

Increase your muscle mass through testosterone.

But then the work comes with bulking up your muscle because you're already losing it, so you need to bulk up to get that pie chart back to what it used to be.

And that's why when I see your program, it's so phenomenal, because weight training is really saving lives because muscle is the organ of longevity.

It's the thing that keeps us stable, it's the thing that keeps us strong.

It's the thing that protects a lot of our bones and also our heart.

And that is why it's important to switch to more of a weight training workout than ever.

When you're going through that phase.

We're really trying to get that sixty five percent back right, And I'm just using contrary numbers, but I'm just trying to give you a like a kind of visual of what's happening with your body.

The insistence part is also crucial because it's not anything that you can see.

It's really just this thing that's happening internally.

And when you start to have increase in insulin resistance, that means it's like a mailman.

I always say this, The insulin's like the mailman.

It distributes the sugar where it needs to go, and it's like you are fuel.

You're going to the brain, so the brain can use you.

The liver needs you, the muscle needs you, all of these things.

But as more insulin resistant, as we start to age, the mailman's like, yeah, I'm not doing the mail today, and then the male is just sitting around and the sugar is like, we have nowhere to go, and so it just sits in our blood and then we become more diabetic in a more diabetic phase.

But the reason why.

I love your program again is because the biggest utilizer of glucose is muscle.

So if we're building muscle and it's already on its way down biologically, the sugar is just going to be like, well, we'll just sit here too because we're having fun, and then it can it's to fat.

Yes.

Oh and and to answer the rest of this question, yes, you can absolutely lose fat in menopause and perimenopause.

Yeah.

And I know you have time.

I will I will go on on on brand and say is it easy?

No, can it be done?

Yes?

Yes?

Absolutely.

Okay, we're gonna rapid fire these questions because you got to get off you got you gotta a trip to pack for?

I mean, it's only a beza.

Well you please, I can't wait to watch all of your stories.

Okay.

As menopausal women not on HRT are libido decreases and orgasms may take longer to achieve.

Considering a happy, healthy sexual relationship exists.

What natural supplements or adaptogens can you recommend for this that isn't HRT?

Yes, Vitamin B twelve.

There's a medication called ad e E, a d d y E that's helpful.

Vio LESSI is also in helpful medication that helps with it.

I definitely am.

There's gosh, it's a niacin.

It's a little it's over the counter, but it's a little aal that you can put on your clitterists.

Increasing and enhancing PRP injections.

Oh shots, they do help.

I really do like those.

There's so many other ways than taking testosterone.

But when it comes to libido, all I would say is women, do not let that go.

We are entitled to pleasure.

We are entitled to having really fulfilling lives as we grow older.

Do not let that go?

Yes?

Agree?

Mic Drop Okay, would you suggest?

Okay, So we talked about if somebody was just having hot flashes, would you suggest to stay on HRT after sixty I guess that goes back to quality of life, of what you want.

Quality of life.

But I'm going to give a very big nod to yes, because I have patients who are in seventeen having hot flashes, Like I can't tell your hot flashes to stop, right, I would love there, But if they're still there, you need estrogen.

Yeah, and progestine.

Yes, yes, I learned that from tonight, so that was new to me.

Okay, what do we know about safety of oral micronized progesterone compared to progestin?

Is it associated to breast cancer or cardiovascular diseases or any other risks?

Very easy answer, progestins.

Please just don't take those.

Those are what in that study twenty years ago increased risk of breast cancer.

So those are synthetic.

Really look at your micronized progesterone and stick with that.

Yeah, okay, awesome.

What are your thoughts on estrogen products for the face?

Do they work to improve the skin and are they safe?

Yeah?

So they are safe.

It's estriol, which is a weaker form of estrogen, so it's not like it's getting absorbed in your face and it's some small amounts, it's not be getting absorbed and it's going to course, they're all throughout your body.

It does work because you have estrogen receptors on your skin as well, and so they respond to it.

They make it more plump, increase vascularity to the area.

Is it the fix all for everything?

No?

What I would say is using that.

Consider your your botox, your lasers, your micro needling.

Really like really pay attention to your skin because that's like the thing that we see and is impacted by menopause.

So start to invest more in that area.

So you just you feel great about yourself.

But estradie or estriol or estrogen creams in your face are good and they are safe.

Yes, I'm getting some that's been on my list, but I just don't have two seconds to actually even go to the dentist.

Oh right, that's me, That is me, Okay.

Any thoughts on taking adaptogens like USh gonda while also on estragel, prometrium and testosterone, feel as though the HRT doesn't help so much for mood related symptoms.

Say that one more time you put a lot in there.

And yeah, this, I'm just reading this, how how they wrote it, and any thoughts on taking adaptagens, particularly Asha Gwanda while also on estrogel, prometrium and testosterone.

But you feel like HRT doesn't help so much for the mood related symptoms.

Great, Okay, so now I get the question.

So, Yes, astragonda is an aptogen.

I think aptigens are wonderful as natural substances, and they really help balance some of the other things that are going on in life.

As much again, as much as a hormone advocate that i'm that I am, there are other things that we can be taking that can also supplement or or help them rather, So yes, as an aptagen that's completely fine to take.

The one thing that I would say about if you feel your hormone replacement therapy isn't working for you, then you need to find someone.

And if someone's not adjusting it for you in the manner in which you need it, because it's personalized, it should never just be everyone's on the same dose, so someone may need to adjust that for you.

But aptogens are a great way to kind of balance and use natural ways to create more of the substances in your body.

And the hormones to respond better.

So yes, you can take that.

At the same time, there's one the one on here that I want to answer, how do you know if you're insulin resistant when you get those labs that I talked about earlier.

Hemoglobin A one C is a good way to tell where your body is, how it's processing sugar.

I guess you could say, or glucose.

Get a fasting insulin and a fasting glucose, because then you can do insulin glucose ratio and see how your body is actually absorbing utilizing glucose.

That can give you a.

Good idea if you're going more towards insulin resistance than not.

But just in general, everyone their body biologically just starts to get more health.

Yeah, okay, fabulous.

Is there a minimum estrogen dose estrogel or estro estro dot for osteoporosis prevention?

Oh that's a good question.

There's no minimal dose.

The goal really is to get you started on it.

And the reason why I say that is how we measure bone mineral density is through like a T scorn disease score, which is arbitrary.

I don't need to know about that, but everyone kind of has a score of where they are, So a lot factors into where you are, your age, your ethnicity if you're a smoker, and also like your DNA, like you know, your your family history of what your bone structure is made up of.

So there's no minimal dose.

We're really just trying to improve who that person is and where they are based on all those things that I mentioned.

So going to help, but there's no minimum dose.

Okay, we are almost done.

How does being overweight affect symptoms of perimetopause.

I'm on HRT for improve sleep, joint relief and minimizing hot flashes and night sweats.

It works, but I've gained five to seven pounds since starting HRT a few months ago.

Is there a correlation between weight gain and worsening perimetal puzzle symptoms?

Yes, so there are some people who when they start HRT can start to have this like slight little bump with that five and seven, five to ten pounds some At most times it is transient, transient meaning that it will even out.

The other part of that is progesterone.

Again, the comfy hormone does sometimes like to absorb water, right, and so you may you may be more water retaining because of the progesterone.

So things or to offset that would be again with weight training is going to build your your muscle, increase your protein intake because that is, and your fiber intake.

If there are probably three things that I would mention in dietary to focus on.

Obviously there's a lot more vitamin D, making sure sometimes you mix it with ADK so that it's absorbed in the intestine.

Vitamin D, protein intake, and fiber.

Right.

Remember we talked a little bit about gut health, so again making sure that we're keeping our gut in the most healthy way so that we're not again losing things that we want to keep in and things are coming in that we don't want to come in.

Yes, okay, great information.

Is there a chance of inflammation and joints increasing significantly as women approach postmenopause, in particular the hand and finger joints.

Yes, inflammation.

There's a great company if you wanted to look it up.

It's called Glycanage gly c a n age.

What they're and they're not the only one who does this, but what they actually look at is from your biomarket, So they take your blood and look at your inflammation factors, because there is such great data.

As we start to decrease an estrogen, inflammation increases.

So two things cause inflammation one well, actually a lot does our diet our age.

As we start to age, we just become more inflamed.

And then also menopause contributes to that as well.

So many women start to have joint issues.

I have a lot of women who that's their presenting symptom of menopause.

We get them on HRT and their joints are not as achy.

Muscle skeletal syndrome of menopause is real.

Most people might complain of a frozen shoulder, but joints are also part of that as well, as well as lower back pain too.

Okay, what would you recommend for vaginal dryness HRT or another natural way?

Oh?

I love this because I do all of them in my office, So vaginal estrogen.

So it would be you're not going to get as much bang for your Bucklet's say if you take systemic HRT like a pill, a patch, a cream vaginally, but a vaginal estrogen cream.

Yes, there also is the laser is CO two laser that can really help restore a lot of the vaginal tissue.

And then there's also a radio frequency which can also help get to the deep layers of the tissue the vagina to help restore the vascularity and also secretions.

And then PRP injections can be We can do that for hair, we do it in face, but we can also do it I vaginally as well to kind of help restore that.

So that's like four great different ways that you can do it.

If someone wanted to do HRT and a blend of some of the other things or non hormonal and do investigate the other three.

I mean, thank goodness for this day and age right right, I know, okay, almost done.

I'm fifty one and for the last year I've been on birth control to help me with perimetopause and have very heavy periods.

I had an ultrasound prior to rule out other causes of excessive bleeding.

I've been find on birth control and the pills are controlling my periods.

But I'm wondering if I should switch to HRT.

What are the Oh, okay, so that's another over the counter So probably time to talk to her physician about possibly switching.

To HRT from what though from nothing birth control pill.

Yes, yes, yes, so she wants to, but she's unsure of what.

Yeah, she has very heavy periods, so I think that's why she's been on the pill.

She's been doing fine on the pill, but then wondering if she should switch to HRT instead if.

She has heavy bleeding, I would navigate another form of birth control because she's not going to get the control of bleeding with the HRT.

So really, I say this because I have one myself, But an IUD is a great way to control bleeding, and then you could still go on HRT.

You could also there's also medications for heavy bleeding that are just for the heavy bleeding and then you can kind of do the other stuff, which would be HRT, So I think that or small procedures so it's not a surgery, but there are small things that can actually help with heavy bleeding as well.

So that one actually.

Has like a longer cascade, I guess of list that can be done for that part while considering do I switch over to MHT.

So it's just separate categories.

The bleeding is a category that needs to be addressed with medications, non medication or non hormonal medications or procedures.

And then the other side would be do I stay on birth control or do I switch to MHT?

Two separate things.

Yeah, okay, what effect on menopause does an IUD have for women?

And for a woman in her mid forties?

Say that one again, What effect on menopause does an IUD have on a.

Woman in her mid forties?

Great birth control and no bleeding.

That's coming from a personal experience.

It really was designed to be like this really great local way to decrease bleeding.

Provide birth control that's.

Low maintenance because you don't have to take something every day, change something out, but it doesn't.

Have an impact on menopause.

It helps with the bleeding portion of someone who's perimenopausal, and also provide it's a birth control while you can still address considering MHT in the perimenopausal phase if you wanted to.

Okay, okay, we're wrapping it up.

What what are your thoughts about when this person entered metopause, she started experiencing recurring UTIs and urgency and continence.

Do you recommend a hormone therapy for women in similar situations?

Yes, because the bladder that remember we were talking about the sphincter and now it doesn't control it's not as tight as it needs to be.

So in the moments when we're trying to hold our year and it's still a little open, so urine can come out.

HRT can definitely help restore some of the tissue in the in the sphincter and in the urethra.

The other good thing and why even.

If it doesn't correct it, even if you needed a procedure or a laser or something else, you're now being preventative by using HRT, namely vaginal estrogen in this instance, because as you start to get old, it's only going to become more of a problem.

And quick statistic when you look at actual old age homes, most of the women a lot of times there usually are having issues with chronic UTIs because of either losing urine or their bladder is not working to the best capacity that it can because of the microbiome in the bladder because it's no estrogen is being provided, and that can lead to so many other mortalities and diseases and issues in older age for women.

So protect your urethra.

Consider vaginal estrogen as both helping with symptoms and also being preventive for later on in life.

Okay, fabulous.

Two more quick questions.

If a woman went through metapaus five years ago, is it possible to start HRT to treat lack of libido?

Is it too late or is it too late to start?

I always say it is never too late to try anything, because at the end of the day, if it works for one but doesn't work for another, like we still tried.

I think that testosterone is a beautiful way to restore a hormone that was already there.

Women have sposterone.

We just we're just put in this category where you know, everyone thinks that we don't have and only men have it.

But we should be just as happy to be the sexual beings that we are and that should not decrease with age.

And so I think it is always worthy of someone to consider starting testosterone therapy and in considering to increase dosage until they might feel that they do have their libido restored, and not to give up on that.

Oh I love that.

I hope this is considered general enough.

I wanted if I wondered if you could touch on how fibroids affect active women, what lifestyle changes should be we be making if we develop them.

Yeah, fibroids are actually up to seventy percent in Black women and fifty percent in women of all ethnicities have fibroids, right, So a lot of it has to do with when we think of fiveways, we think of size, amount.

And where they're located.

So most women, if you listen to those statistics, either half or most women will have fibroids, but most of us don't even know.

Right, But twenty five to thirty percent of women are symptomatic, meaning they're big and they take up size or they have heavy bleeding.

So there are really a lot of modalities that are out there to help with the symptom.

If you do have a symptom, if you don't have any symptoms and maybe on ultrasound saw that you had fibroids, typically we can be like, okay, if they're not bothering, you can kind of just monitor them are causing an issue.

So many different modalities that can help with the symptom that it's causing, because there are multiple symptoms that can cause.

But throughout the perimenopausal phase, I would say that fibroids sometimes can start to wreak havoc because our hormones are doing that roller coaster, remember how we started the roller coaster ride, And that can actually create heavy periods for people who are like I never used to have heavy periods, and all of a sudden they start to have heavy periods.

Could be a cause of the five voice that are being responsive to the hormone fluctuations, But a lot of women have five voice, they just don't have symptoms.

Jessica, I adore you, and I'm so grateful and I'm so sorry we kept you a few minutes over.

Thank you so much.

I mean so many of these questions, not only I mean I didn't have time to really read the thank you for all you do, doctor Shepherd, doctor Shepherd, so I was just like trying to get to them.

But so much love from this group of women, and so much love for what you're doing and just who.

You are as a person and a physician.

So thank you, thank you, thank you.

I can't wait to track you while you're experiencing a biza and have fun while you're there along with work.

I can't wait for us to get together.

I hope everyone who's on here thank you for investing in your health and being here.

But when you see Hayley and I together, next time she will be busting my butt and then you guys can be like, wow, she's really kicking her ass.

I'll be like, yeah, that's what she does exactly.

We're making it happen.

Yes we are, Okay, I adore you, take care and thank you so much.

All right, having a little safe bye.

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