The Medical System Is Misleading Women About Symptoms of Menopause | Dr. Tara Scott

Dr. Brighten: [00:00:00] Welcome back to the Dr. Brighten Show. I'm your host, Dr. Jolene Brighten. I'm board certified in naturopathic endocrinology, a nutrition scientist, a certified sex counselor, and a certified menopause specialist. As always, I'm bringing you the latest, most UpToDate information to help you take charge of your health and take back your hormones.

If you enjoy this kind of information, I invite you to visit my website, dr Brighten.com, where I have a ton of free resources for you, including a newsletter that brings you some of the best information, including updates on this podcast. Now, as always, this information is brought to you cost free, and because of that, I have to say thank you to my sponsors for making this.

Possible. It's my aim to make sure that you can have all the tools and resources in your hands and that we end the gatekeeping. And in order to do that, I do have to get support for this podcast. Thank you so much for being here. I know your time is so valuable and so important, and it's not lost on me that [00:01:00] you're sharing it with me right now.

Don't forget to subscribe, leave a comment, or share this with a friend because it helps this podcast Get out to everyone who needs it. Alright, let's dive in. Dr. Tara Scott, welcome to the Dr. Brighten Show. Thank you for having me. Yeah. I am really excited for this conversation. You teach doctors how to prescribe hormone replacement therapy, how to support women through menopause.

So we're gonna go into that. We're gonna talk about hormone replacement therapy. We are gonna talk about some of the myths around it. We will answer the cancer question because that's always the number one fear that people have. But the first place I wanna start with is why do you think medicine has taken so long to recognize that menopausal women need support?

Dr. Scott: Well, I think there's probably a lot of reasons. One, as you know, the research is mostly based on men, right? Mm-hmm. And no one ever died of a hot flash. No. So we're interested in mortality and morbidity and not necessarily, [00:02:00] uh, feeling optimal. I. So women, although you know, hot flashes are linked to an increased cardiovascular mortality and morbidity that hasn't been on anyone's radar because they're like, oh, hot flashes will stop if you gain weight.

If you don't sleep. No big deal. Right? And because medicine I think is largely driven by. The research and men. And so I really think, I don't know what you think that social media is, has really been involved in this push to get more people to understand about it. More research done. Stars have shared Halle Berry and Gwyneth Paltrow and Naomi Watts.

Everyone who's gone through menopause now have shared their story. Mm-hmm. 

Dr. Brighten: And so 

Dr. Scott: I think now there's more of a push for people to learn about it. So I think it's the patients that have really been driving it. 

Dr. Brighten: Absolutely. I love that you give patients the recognition they deserve. Because I always say medicine's not gonna change because of doctors like us going and saying we need to change medicine.

They don't listen to us. They're like, we tell you what to do. You do what you're told. It is patients who are getting educated, which social media gives us that opportunity to [00:03:00] do, who then demand better, but also start sharing their stories. I think that. Keeping us isolated and telling us like, hush, don't talk about these things.

It's not polite to talk about your hot flashes, your sleep problems, your digestive issues. If you have a miscarriage, don't tell anyone about it. Like that's, that's not something that we talk about. And in that it's never really served women. And so us sharing our stories, our experiences, I think has been a catalyst for change.

Dr. Scott: I totally agree. And when I started doing this, this, it was 20 plus years ago, and I was in a large OB GYN group, uh, 16 plus doctors. And one of 'em was like, why, why do you wanna do this? Mm-hmm. You know, like, you're, you're a reputable doctor. Why are you going down this pathway? You know? And so they would like just grill me with like the evidence and everything.

And so once I presented like study after study, they're like, okay, you know, we'll leave her alone. Yeah. But back then I was the outlier. Mm-hmm. And there wasn't as much evidence as there is now. This was [00:04:00] 2003 or 2004, right after the WHI. Yeah. So things have really, and I think you're right, I think it's the patients, I think it's social media and I think it's also maybe the younger generation of providers are more interested in optimal health wellness, listening to their patients.

Possibly. 

Dr. Brighten: Yeah. For a long time there's been many of us who are in this integrative space who've said that health is not the absence of disease. That's not the metric. And I feel like it has taken generations for that to really be adopted and to understand that like there's the, you know, I think about the RDA, right?

Dr. Scott: Yes. Which 

Dr. Brighten: is the floor of like not dying and, and doctors would be like, well this is the RDA, so you don't need to go about that. Don't worry about it. And now the understanding has shifted of like, no, that's the minimum. To do the minimum. And most of us are didn't showing up to do the minimum in life.

It's, I love that you brought up that it was 20 years ago. You know, I have been prescribing HRT more than a dozen years, and even [00:05:00] then I would get nasty letters and phone calls from doctors being like, what are you doing? You're gonna kill this patient. Like, you are a quack, you're being reckless. Like, how, how dare you give someone vaginal estrogen like they're gonna die?

And I'm like, they're what? Like actually like vaginal atrophy and, uh, plu nephritis, a kidney infection from a UTI that's more likely to make them die than vaginal estrogen. So you, you know, you've talked a bit about social media, but you brought up the Women's Health Initiative. Let's talk a bit about why, why that was so problematic and the myths that really came out of it that people are still perpetuating.

Dr. Scott: Yeah. So I was actually in practice one that, that newsline broke and it didn't make it into our scientific journals before it was on Good Morning America. Mm-hmm. So people were calling our practice and we were like, what study are you talking about? But we have to keep in mind that the reason for that study was not to see if HRT was safe.

'cause that had long been proven. I mean, this was a, a prempro conjugated, equine estrogen. And that had been [00:06:00] used since the seventies, sixties, really, probably even before that. The reason the study was done is to get another indication from the FDA to prescribe it. So the indications right now are hot flashes, something called genital urinary symptoms of menopause, as you mentioned, vaginal atrophy, prevention of bone loss, and if you have premature menopause, which is classified as before the age of 45.

Mm-hmm. So the study wasn't done to see if it was safe. The study was done to get the next indication to say, hey. This will prevent heart disease, which is the number one killer in women. And so obviously if you're a drug company and you can prevent the number one killer in women, I'm sure your prescriptions are gonna go way up, right?

Mm-hmm. So that was a reason. That was the intent. And after five years, they saw that there was an increased risk of blood clots and an increased risk of breast cancer. But what they didn't really translate to the normal finding is, first of all, 97% of people in that cohort actually had no problems.

Mm-hmm. But the issue was, is that. It's different types of hormones. And so we, what we now know is if you take estrogen transdermally, which means through a patch or a [00:07:00] cream, it's not gonna go through the liver. So it's not gonna affect the clotting risk. And the second biggest takeaway is the synthetic progestin, similar to what's in a birth control pill that showed an increased risk of breast cancer.

Mm-hmm. So when I talk to patients, I think, you know, thinking about here, if you go and have one white claw or a seltzer versus five shots of tequila, I mean, they're really not the same. Right? Yeah. And then, and somebody may be able to do fine with tequila. Somebody may have one shot and not deal with it.

Mm-hmm. So there, there's lots of things with that. So the takeaway from the WHI is that the risk of breast cancer, if you're using. What we call bioidentical, which just means is chemically, structurally to our body, which is any kind of estrogen gel or patch or cream, and a micronized progesterone, your risk of breast cancer is one in 1000.

Dr. Brighten: Mm-hmm. 

Dr. Scott: So you and I as women, 13%, one in eight is a risk of breast cancer lifetime. It goes up as you get older, but you're adding 0.01%. Mm-hmm. So your risk is now 13.01% [00:08:00] lifetime for breast cancer if you choose to take biodentical hormones. 

Dr. Brighten: Mm-hmm. Okay. So you just busted a major myth there for people. I, I, I really, uh, if you didn't catch that rewind, I want you to listen again, because this is always something you still hear perpetuated by providers.

You are going to get breast cancer. You brought up the progestin. Now we know that in the study is, it's like. Uh, we were blaming estrogen for what Progestin did, and what I find so bizarre is doctors will vilify micronize progesterone and topical estradiol and say like, oh no, that's gonna cause breast cancer instead, let's put you on the pill.

That's wild to me. So we want you to talk a bit about that, and in this discussion, talk about the difference between progestin and progesterone because. A lot of people, including scientists who are doing the research, get it wrong. Yeah, I'm really 

Dr. Scott: glad you mentioned that because that's probably one of my pet peeves, is management of perimenopausal symptoms with the birth control pill.

Dr. Brighten: Mm-hmm. 

Dr. Scott: Because as you know, the birth control pill is. Indicated to [00:09:00] prevent conception. So it does that by giving you a synthetic estrogen and a synthetic progestin, which sends a feedback back to the brain saying, Hey, we've got enough hormones we don't need to ovulate. And so you don't ovulate so you don't get pregnant.

So that's what it's used for. But as a result of that, it puts you on what's called a withdrawal bleed. So you don't have a period, you have withdrawal bleed. So in some ways, if you're having really heavy periods mm-hmm. It could regulate them and make them shorter and lighter. It might even give you some relief from some of your symptoms of hot flashes.

The dose of estrogen at what we, what we call now a 30 microgram pill, which would be a low dose pill, is equivalent to two of the highest dose patches. Yeah. Which we would never use in someone in perimenopause. We'd always start with the lowest dose patch was a, which is a quarter. So that's the dose that women are getting of estrogen.

Mm-hmm. Number one. And they're getting oral. Whenever you give oral estrogen, it also increases a binding protein. So it in it increases your thyroid binding blockin and your sex hormone binding glyn. So just by giving someone a birth control [00:10:00] pill, you're gonna decrease their free testosterone. Which is kind of like funny because it's supposed to prevent pregnancy, but it's gonna decrease your 

Dr. Brighten: libido potentially.

Right. And what is one of the top symptoms? Women with perimenopause and menopause Complaint about low sexual desire. Right? It's the only indication the FDA gives us for prescribing testosterone, which I wanna get into more. Uh, and then you're gonna hand them the pill, which the known side effect is. No libido.

Right, exactly. And low thyroid. Mm-hmm. So 

Dr. Scott: what are women in perimenopause struggling with? Weight gain. Yeah. So you're giving them a birth control pill, which is not going to help those symptoms and could possibly increase risk of breast cancer. There are studies done, small studies that show an increased risk of breast cancer with birth control pill use.

Mm-hmm. The longer you use it and cervical cancer, not even taking into consideration your HPV status, which was surprising to me. It does decrease ovarian and uterine cancer, but, mm-hmm. I, I wouldn't wanna take an additional risk of breast cancer. By taking a birth control pill. Especially [00:11:00] many of my patients at that age have had a tubal ligation, or their partners have had vasectomy, so they don't need contraception.

Mm-hmm. So that is one of my pet peeves. The breast cancer, as you mentioned, is different per what you take. So the idea is, is that if you look at the cellular level, we agree that estrogen causes growth in the breast and the uterus. Mm-hmm. And micronized progesterone, which is a form of progesterone, which our body makes after ovulation does the opposite.

It cause causes something, cause apoptosis, which is just cell cell death. Okay. So you've got growth and cell death of the uterine lining. Mm-hmm. Every month as everybody knows. But that actually happens in the breast as well. There were a couple studies that show that micronized progesterone applied to the breast, did the same thing to the breast cell.

Estrogen caused the breast cell to grow and progesterone caused it to. To have, uh, to shrink and to have cell death, right? Mm-hmm. Because we don't want overgrowth for cancer. Mm-hmm. So the issue is that the progestins do the opposite. They do, [00:12:00] especially the one which was Provera causes anti apoptosis. So you've got the premin causing growth in the Provera causing more growth.

And so that's an issue where you have an increased risk of breast cancer with that particular formulation where we're not seeing it with the micronized progesterone, but as a traditionally trained doctor, we're not taught the difference. It's in the same drug category. Mm-hmm. If you look at the label from the pharmacy, it'll say the same thing.

Dr. Brighten: Yeah. 

Dr. Scott: And so if you pulled 10 gynecologists about, and ask them, do hormones cause cancer? I'm guessing nine. Would still say yes. Mm-hmm. Well, I don't know. You should be careful. Only take the lowest dose for the shortest duration, which is an A recommendation. That was maybe 15 years ago. 

Dr. Brighten: Yeah, and I think the other thing that's important to understand is that when we look at the research on mood, we know that progestin, so again, estrogen was being implicated into why so many women reported adverse mood symptoms when they started hormonal birth control.

And as we've [00:13:00] allowed research to evolve, right? Because there's been a lot of gatekeeping on the research and saying like, this is the best thing to ever happen to women. How dare you question it, even though women are like, I feel so sad. And their doctors are like, it's you. It's not birth control. But when we look at the research, the progestin only like the IUD for example, and the younger you're given, it seems to have a very profound effect on some people's moods.

We're not in a place where we can say causation, but when we're talking about progesterone, so the, we usually do the oral micronized progesterone that gets metabolized to allopregnanolone, which then interacts with the GABA receptors, which is why we sleep and stay asleep through the night. We don't have that effect.

And so that's the other thing I think with birth control is like when you're using that. Good luck on helping her get to sleep. You're gonna probably be prescribing her something in addition to get her to sleep when we could be using progesterone for that. 

Dr. Scott: Right. They're either prescribing a sleep aid or an SSRI an antidepressant.

Mm-hmm. Which is [00:14:00] causing weight gain and low libido. And it, and it's just compounding your perimenopausal symptoms. 

Dr. Brighten: Yeah. You brought up hot flashes, which is what everyone thinks of. They're like menopause, hot flashes. What other symptoms are women experiencing and how is menopause really impacting women's life overall?

Beyond just how they feel in their body. 

Dr. Scott: I would say most of my patients aren't coming specifically for hot flashes. Mm-hmm. It seems like the mood changes, as you mentioned, it's either new onset anxiety, panic attack, or depressed mood. It's also, uh, sleep issue is a big thing and weight gain is another thing.

And, and low energy as well. Mm-hmm. I mean, a lot of people are complaining of weight, um, but then they're told to eat more, eat less, and exercise more. Mm-hmm. So some of 'em are combating by these, this excessive exercise, but those are probably the, oh, and hair. Hair loss is a big thing. Hair changes. Hair loss, yeah.

Yeah. 

Dr. Brighten: When it comes to the bioidentical hormones that you brought up, like that's a big buzz. There's talks about [00:15:00] compounding hormones. What is your take on that? And let's kind of walk through if, if this is all new to women, like what are the options available for them if they wanna start estrogen progesterone, looking at testosterone, HRT?

Dr. Scott: Yeah, so that's a great question. And so in the states we have commercially available FDA approved bioidentical hormones. Mm-hmm. So that just means that there's a patent on a specific dose that's been approved by the FDA. So we've got patches that have five different doses. We have gels now that have more and more doses.

The gels all are different in their absorption. So some of 'em have a 10 hour half-life, some of 'em have an 18 hour half-life. So those are all estradiol gels, estradiol patches. So we have a lot of options for estrogen in the us. I hear here in Mexico, they don't have as many patches. 

Dr. Brighten: Yeah. Patches are less.

Uh, common. A lot of oral estrogen prescriptions are still taking place. And that's, yeah. You know, as we brought up the, the biggest risk is clotting factors, and we [00:16:00] can actually test for this. Um, I just bring this up because people know I went through fertility treatments in Mexico. They use oral estradiol in the um.

Little side tangent. Interestingly enough, the cycle that it actually worked is when I said I didn't wanna use it unless I absolutely needed it. We didn't start it until like day 10 mm. 

Dr. Scott: Which was just 

Dr. Brighten: really interesting to let my body do its own thing for a while. But I do have a clotting disorder, so we track my clotting factors, and then I'm also on low molecular weight heparin.

Mm-hmm. Um, but yeah, they do have like topical sprays, but. As you know, that's firstly, I'm always like, how much are we actually getting out of a spray that's actually being delivered? And then how consistent is it? And then what happens when you get, you know, it's like you're on dose 35 of like a 40. Like are we still getting the same amount?

Anyhow, a little bit of a tangent, but 

Dr. Scott: yeah, I mean that's true though, because what, depending on how it's dosed, if you're pumping at the end, is it even That's true. Mm-hmm. And also, what's the absorption? So these are things that as a traditionally trained doctor, we never think [00:17:00] about. I mean, I did my training on hormones with a pharmacist, so thankfully he helped me think about like if it's an eight hour halflife or a 10 hour a half life, that means at eight hours you have half as much.

Still in your body, so by 24 hours you should be good for a second dose, but if your half-life is 18 hours mm-hmm. You still have a lot and things can accumulate, which is part of the issue with HRT also, is that not everybody responds or absorbs the same. Mm-hmm. We're not at, we don't have as many options for progesterone.

We have micronized progesterone, which it does have a brand name of Prometrium, but there is a generic form. We only have two doses. And the issue with that, and a lot of people do fine on it. It's not slow release, it's immediate release. Mm-hmm. Uh, which a lot of our medications are immediate release, but it's progesterone just isn't absorbed very well orally.

Although we do like the benefit of sleep and mood, as you mentioned, when it's given orally in the GABA receptor, but it's, it, it was initially packaged in oil, so then it's dumped. And so think about if you [00:18:00] water a plant, all the water in one, one day for the week, it's gonna only absorb so much and the rest is gonna like kind of run out.

Mm-hmm. And have a, have kind of a side effect. So some people do fine, some people don't. So what I end up tending to do in my practice is if a hundred is. Too little and 200 is too much. Even just based on symptoms, not necessarily testing levels, which is a whole nother issue, then, you know, you can pick whatever dose and have 'em slow or slow release it.

It's not really a slow release. They can slow it down. It's not like a metered release. And that would have to be compounded. Compounded just means that the medication is specifically made for you. Mm-hmm. There's no patent. It's never gonna be FDA approved because there's no patent to dose. It just means, let's just say you had a peanut allergy.

Progesterone used to be in peanut oil, which, yeah. I don't know why my kids have peanut allergies. I don't think it is anymore, but it used to, so you could go and say, I can't have this peanut oil, and someone could make it not in an oil for you. Mm-hmm. As a capsule. And so that's, that's the only difference between that and compounded.

So with [00:19:00] compounded estrogen, and we tend to give something called biased, which just means you get another form of estrogen called estriol, which is supposed to be what makes your skin so good and helps for vaginal health and has a different. Action at the receptor. So it's like kind of good cop, bad cop, not really, I don't wanna say bad cop, but you know what I mean.

Yeah. It's like a different mechanism of action. Um, maybe the more like rowdy cop. Yes. Yeah. So that you're getting a different blend of hormones. I also analogize it to money. Just think about you've got some of your short term investments in your long-term investments. They might pay off differently than you might have real estate and then you might have a savings account, right?

So you've got different types of investments that are doing different things, but it's all money. Mm-hmm. So these things act differently. And so we have less options for progesterone, um, in the United States except for the, uh, compounded kind if you wanted a different dose. Now some people choose to do it topically, uh, and I know we have over the counter topical cream mm-hmm.

For progesterone as well. I've seen it on Amazon. Again, you know, the. [00:20:00] Science is kind of like, how do you know that it's been milled correctly? And the base is good. I mean, if you go to Starbucks, you're always gonna get the same cup of coffee. If you go to a local coffee shop, it might be stronger, it might be, you know, less.

It just means there could be some variation. Mm-hmm. If it's not the same thing every time, if it's not mass produced. And so when we work with a compounded pharmacy, we always check to make sure they've been accredited since it's not gonna be FDA approved. They have a separate accreditation process that they do, but for compounded hormones, you also can use testosterone, as you mentioned.

Mm-hmm. There is no FDA approved testosterone for for women in the United States. And so the re recommendation is to use a fraction of the male dose, which is interesting because women produce about a third of a milligram of testosterone a day. Men produce about five to eight. The male doses in a topical gel are like 50 milligrams.

Yeah. So how do you even. Split that into a half a milligram, or let's say, even if you wanted to give five, I mean, it's pretty difficult to do [00:21:00] that. I know some practitioners do find a way to do it. Mm-hmm. 

Dr. Brighten: Yeah. And there are practitioners who are also using injectable testosterone, which downside you have to inject it.

Plus side, the vial lasts a really long time because you're using solo dose. So it's actually a really economical way. What do you think the problem is with practitioners medical community and even the FDA, not recognizing that women need testosterone? 

Dr. Scott: Oh, that's a whole huge, another thing, and so there was a study published in 2 20 19 that looked at the world's, the world's literature on testosterone.

And we have a lot of studies because at one time they were trying to market a 30 microgram, a 300 microgram patch. Mm-hmm. And so what they concluded is that number one, you know, your, your testosterone level doesn't always correlate with your libido. Which is fair. Mm-hmm. You could have a high testosterone or a normal testosterone, have low libido.

'cause for women, as you know, there's so many things that go into that. Yeah. It's not just testosterone and also estrogen. 

Dr. Brighten: Yes. And, and if you're on, [00:22:00] you know, a medication that raises sex hormone binding globulin, that can be another factor. 

Dr. Scott: There's a lot of things that can go into it, so it's not quite simple.

Uh, so for, for testosterone, as I mentioned, you can give it, um, I am mm-hmm. As an injection, you can, we started also giving it as a trophy. Mm-hmm. And so I think after that pub publication in 2019 came out, let, I guess I didn't finish my thought. They concluded that there was no increased risk of cardiovascular complications for women taking testosterone, and there was no increased risk of breast cancer 

Dr. Brighten: mm-hmm.

Dr. Scott: Based on the data that they saw. Now. Whoever came up with a recommendation that testosterone, I think it's the Menopause Society, I'm not really sure whose recommendation that is, that it should only be used for post-menopausal low libido. Mm-hmm. For six months now. They don't say test levels, monitor levels, and then see, they just say you can give testosterone topically for six months to see if it helps libido.

Dr. Brighten: Mm-hmm. 

Dr. Scott: But there's so many other things, as you know that testosterone can do. It's mood, it's mental clarity, it's stamina, it's muscle [00:23:00] strength. It's energy. So there's a lot of the things that testosterone can do for a woman that I think my patients respond well to. Mm-hmm. And it's not just libido. 

Dr. Brighten: Yeah.

Well, and I appreciate you bringing that up. I mean, testosterone has an integral role in our immune system. We haven't even studied extensively. What happens postmenopausally when your testosterone goes down and it doesn't for everybody. I. 'cause we still have our adrenal glands trying to work hard for us.

Give us A-D-H-E-A that goes into testosterone. But we see a lot of autoimmune disease in this age group. So what role is testosterone playing? We, I think so often in medicine, in research, it's like ovary. You were born with those. It's all about the estrogen, testes, it's all about the testosterone. And we need to rebrand these hormones.

'cause what we call them sex hormones. They do everything in every system of the body. I mean, they don't do everything, but they're out there communicating to every system of the body. And they have [00:24:00] such a bigger impact. Um, we talked about, so we talked about the different topical applications of estrogen.

Progesterone testosterone. What about vaginal estrogen? 

Dr. Scott: So vaginal, estrogen, um, is indicated for anybody who has symptoms of either vaginal dryness, burning with urination, frequent UTIs, painful intercourse, or sometimes women just have their uncomfortable just sitting there. Yeah, because they're dry. It could be an external issue, it could be an internal issue.

Right now we have some. FDA approved estrogen options. There's a tablet, there's a cream, there's a ring. Um, I think some people do well on estradiol. What I found from in my practice back to the days when I was actually looking at vaginas and doing exams is that DHEA and androgen is much, much more effective for vaginal issues.

The lower third of the vagina comes from the UroGen sinus. Embryologically, which is an androgen driven tissue, [00:25:00] and the upper two thirds come from the malaria ducts, which is more estrogen sensitive. So it makes sense if you have deep dis, you know, painful intercourse and you know, pain, uh, you know, deep then and your, your doctor's done an exam and seen that your vagina has lost its rga, then I think estrogen and estradiol could use, could help.

But the outside, the burning and the itching, when you wipe the lack of clitoral sensation, the painful intercourse on penetration. I think DHEA is more helpful now that we have one form that's FDA approved. It's one dose. I don't love the base. It's been given. It's been formulated and it's a suppository, well actually it's technically a pessary, not a suppository, but it's used vaginally.

Mm-hmm. So we would have to get that compounded if we chose to use a different strength or form. 

Dr. Brighten: I love that you brought up DHEA because, uh, that is what I have primarily offered, compounded for, you know, all, all of this time. And what I have found is it helps so much with [00:26:00] pelvic floor and I refer patients to pelvic floor physical therapists all the time, like such heroes of women's health.

I will link to a whole episode with a PT that we did where she actually goes over the pelvic floor with a model, but the PTs are like these patients. Improve faster. I'm seeing better outcomes with these patients who use the DHEA suppositories, and part of that is because of how it can support the musculature as well.

As you were talking about testosterone, so important for muscles, DHEA can be converted into estradiol and um, and the testosterone as well. But as you were saying, the topical, um, estrogen, there's a lot of doctors who are like, you have clot risk, you have a history of breast cancer. We can't give you any estrogen of any kind.

You're going through cancer treatment and your vagina is super dry and I can, none of the antibiotics are working for your UTIs, but we cannot do estrogen. What does the research actually say? There 

Dr. Scott: was one study that was [00:27:00] done on Premarin, which primarily is estro. Mm-hmm. Which is a different estrogen.

It's actually equine sulfate, which we don't have in our body. And estro sulfate. So I don't even know how many different estrogens or compounds are in Premarin. So there's a lot of things in this. After one week of using estro uh, Premarin cream for seven days, they saw an elevation in serum levels.

Mm-hmm. In that same study, the prior, uh, vaf femme, it might be called, might be generic now, was 25 micrograms. Mm-hmm. And there, there wasn't as much of an elevation, but they remarketed that now it's 10 micrograms, so you can get some systemic absorption. I remember again, when I was a, traditionally a traditional GYN and I would give Premarin and they'd be like, I had such breast tender, and I'd counter be like.

You had breast tenderness from vaginal hormones because I didn't understand. Yeah. You know, the, that yes, people can, uh, absorb it because you've got a lot of blood vessels in the pelvis, as you know, and so that can go not necessarily [00:28:00] systemic per se, so I, I don't know if that's where the fear is coming from, from that study.

Mm-hmm. Or, or that practitioners just have no idea. A vaginal is considered local. And there were other studies that were done. A lot of them were done by Dr. Libre, who was involved in marketing, the DHEA, showing that when you give DHEA, you don't see systemic, uh, effects and systemic, uh, elevations in estradiol.

So there should not be a risk for breast cancer patients to use any form of vaginal hormones. The Menopause Society guidelines that were revised in 2022 say that it's safe to use vaginal estrogen. I would still stay away from vaginal Premarin, uh, in breast cancer survivors. Even DHEA is safe to use for breast cancer survivors, but that would be my choice to use in a breast cancer patient, because in the breast there doesn't seem to be an aromatase enzyme, which is what converts, as you say, DHEA to the [00:29:00] estrogens.

Mm-hmm. It would favor DHEA to testosterone instead. So it is, it is considered not systemic, no risk of clots if you use vaginal. Mm-hmm. So I, I, I understand, and I agree with you that, that practitioners are still saying that, but I don't know of any literature that would say that vaginal estrogen would increase your risk of blood clots.

Dr. Brighten: Mm-hmm. And, you know, as you brought up Premarin. It's, I'm hard pressed to find anybody who actually prescribes Premarin or is using that these days because we do have so many other options available and you know, so there's things that insurance will cover, but you also find all these coupons online where it's like you can just put a patch on a couple of days out of the week.

I mean, you just place it and go and you're done. Like women love that, and there's economical ways to be able to access that. We've brought up a few of the reasons why you might not be a candidate for HRT. Let's go through those, like what should women be aware of, and I think this is [00:30:00] important so that you understand your own family history, you understand your own personal medical history, but also if you meet with a provider and they're like giving you a whole lot of other reasons that are outside of this, that maybe you need to get a second opinion.

Dr. Scott: Yeah. So that's interesting that you say that because I just was talking about this at the conference, is that if you look at the 2022 position statement from the Menopause Society mm-hmm. Nonhormonal options should be used first for patients with breast cancer. Mm-hmm. It doesn't ever say, don't ever give a breast cancer patient hormones.

It doesn't say if you have a first degree relative, don't give them hormones. It says, if vasomotor. Symptoms are severe. You could consider low dose hormone therapy under the discretion of your onco with the discussion with your oncologist. It never says absolute contraindication. Mm-hmm. So I'm actually not aware of any absolute contraindication that's been published.

Having said that, my personal kind of contraindication is if you're, if you're actively [00:31:00] going therapy for breast cancer, we try to wait, uh, five years. Again, it's very individual recommendation. We talk to our patients about their receptor status, their stage, their, we do a full cardiometabolic risk workup.

Do they have a higher chance of dying of a heart attack than they do of a recurrence of breast cancer? Mm-hmm. What's their bone health like? So, I won't give a blanket statement, but generally we don't give it to people with breast cancer and certainly breast cancer survivors within five years. Although I have.

With a discussion with patients. Um, and the only other hormonally sensitive cancers that I know of would be stage four, uh, endometrial cancer. Mm-hmm. That is aggressive grade. So if you've had stage one endometrial cancer, I had your uterus removed, and it's been a while. You can, you can take, uh, estrogen therapy.

I have patients with ovarian cancer that are hormone therapy. I do have patients that have had a prior history of a blood clot in their lungs, blood clot in their legs, and a blood clotting disorder, factor five Lein PI one, and that are safely [00:32:00] taking transdermal estrogen. Mm-hmm. Because we know the risks of energy, of estrogen, sorry, are related to the dose, the duration, and in the route of administration how you take it.

So if I gave you a very high dose of estrogen, like people in pregnancy have a very, uh, a much higher amount of pregnancy mm-hmm. Uh, of estrogen, sorry. Uh, the risk of blood clotting is the highest actually in the postpartum. Yeah. Pregnancy and postpartum. And so if we are giving you a lower dose. You know, it's going to depend on the dose.

So I do have patients that reach out to me on social media and say, I can't take it because I have this blood clotting disorder, whatever. Mm-hmm. I have patients with a history of severe endometriosis that take it. There used to be this recommendation in my gynecology days that six months after hysterectomy you should not give any hormones.

But a lot depends. I think where that comes from is if you still have in your pelvic floor, if you still have in your peritoneum in your pelvic side, while where endometriosis can hang out mm-hmm. They want those, [00:33:00] um, lesions to progress. And so there is sometimes a period of time to not give estrogen, but it really depends on the patient.

Other than that I, unless you previously have tried it and have not done well on it, there's no absolute contraindications to taking estrogen that I'm aware of. 

Dr. Brighten: Mm-hmm. Yeah. And you bring up the endometriosis and what we now understand from some of the research is that. In some women, it doesn't matter if you withhold that estrogen because these lesions can make their own hormones.

Yes. And so we were wrong to say that. The other thing is that you'll have a, you see a lot of women with endometriosis wrongly sometimes get a hysterectomy 'cause their doctor says, well, if you have a hysterectomy that will cure your symptoms, which we know is absolutely not true, and then because they have a hysterectomy, their doctor says, well, there's no reason to give progesterone.

Dr. Scott: Right. 

Dr. Brighten: Because you don't, you don't have a uterus. We don't have to protect that. And it's like, well hold up. If those endometrial lesions, those endometriosis lesions can be stimulated by estrogen, and as you [00:34:00] said, progesterone is gonna have the opposite effect, basically challenge that estrogen to not get too rowdy.

Right. Don't get rowdy with the tissues, then why wouldn't you give that? Because the reality is. If you have the best excision surgery with the best surgeon, it is like less than 5% chance of recurrence. But not everybody's getting that. Not every surgeon is doing imaging. They don't know whether it's lesions hiding.

So you start estrogen without challenging with progesterone. And lo and behold, now you're having trouble breathing. Your diaphragm's in pain, you're starting to have shoulder pain. You know, all these places where endometriosis can hang out. 'cause shocker to the doctors who are like, no, it's just the endometrial lining.

No, it cells that migrated, they ended up in the wrong place. And there was another interesting study showing. If you have a history of endometriomas, if you're given estrogen alone, you, you start increasing your risk of ovarian cancer. But if you give progesterone with that, there's no increased [00:35:00] risk. And so I think this is where it comes to that very nuanced discussion with the patient.

I love that you're like, okay, you have breast cancer, you have heart disease. Like what? Which one are you more likely to die from? Most providers are not doing that. We have been conditioned as a society, thank you. The month of October to think breast cancer is the most ominous thing affecting women, and yet it's heart disease.

Can you talk a little bit about the benefits of HRT for cardiovascular health? 

Dr. Scott: Yeah. So that actually has been well documented as far as, and if you think about women, while it's tragic when we hear about men in their thirties dying of a heart attack mm-hmm. We don't hear of women that often even having a heart attack, let alone a fatal mi.

Right. A few if you're a diabetic, maybe in your forties. It's very unusual. So there is some protective effect of estrogen up until the amount of menopause. And then you'll see heart disease go up as the number one killer in women after menopause higher than men [00:36:00] actually. Mm-hmm. And so the, some of, there's some old studies that they actually put in estrogen patch on women.

They saw EKG changes that were corresponding with ischemia. They gave them tetra orgen, which is. Sort of like nitro paste. And so that resolved the changes, but they gave him the estrogen patch and it did the same thing. It resolved the ischemic changes of the heart muscle. Mm-hmm. So there is some protective effect of estrogen on not only the heart muscle, but your lipids.

We see the good cholesterol, the HDL, um, at a certain level with a lower risk and your bad cholesterol. Your LDL. I've seen so many women jump up their cholesterol in menopause. Mm-hmm. And I've heard it explained that, you know, cholesterol is actually the precursor to DHGA, the, to all your hormones. And that's, and when you don't make them anymore, you have a backup.

I don't know if that's really what happens, but I see that even myself, I saw my, I've never had a cholesterol issue and it just. Jumped up. And so we know that estrogen then I see that come down for some of my patients. So [00:37:00] not only is it an anti-inflammatory, it dilates your blood vessels when you give the bioidentical form.

Mm-hmm. And it, it has a better outcome on patients with, uh, cardiovascular complications. But we can say, we can give it to prevent it. Mm-hmm. Because that WHI didn't show Yeah. That it was good for primary prevention. So we can say it's been associated with better cardiovascular. Um, health. 

Dr. Brighten: Yeah. And real talk hormones are never gonna be enough.

And so I think sometimes, you know, we're, we're so focused on the HRT conversation because it was done dirty for a long time, right? Yeah. And so now we're like talking about HRT all the time, but I have to remind people like, you have to eat your fiber, you have to exercise, like you have to limit your sugar intake.

Like just because you have HRT doesn't mean that suddenly you are. Totally protected from Alzheimer's, from cardiovascular disease, from all of these, uh, negative changes like osteoporosis. It's one tool to help you, [00:38:00] but you have to have a full arsenal in that kit to really support you. I wanna talk about the critical window.

When should women be thinking about starting HRT? 

Dr. Scott: Another great question. So according to the data that we have from the Menopause Society is within 10 years of your last period. Mm-hmm. Or between the ages of 50 and 60. Let's say you had your hi uterus removed and you don't really know when you went through menopause.

So between the ages of 50 and 60 to start HRT. So that's a confusing thing because lately I've had a lot of people question me about what if I'm 63 and I'm outside of the window? Can I start it? Some of the data that we show we have starting HRT. A lot of that was on Prempro. Mm-hmm. And showed that when you started later there was an increased risk of stroke, dementia.

But are we going back to that old data on the preparation of hormones that we don't use? There was recently a study, it was like the 7 million women study that they actually looked at Medicare patients. So a lot of those are over 65. Yeah. And they, they [00:39:00] said, actually. People. So those people were probably on Premarin because of these, this was old, uh, cohort.

And so a lot of those people had less breast cancer, less heart risk because they took hormones. Mm-hmm. And they had 7 million women in the study that they stu that they looked at. So the critical window, we still abide by that 10 year in our practice, but recently I've had a couple superfit women come in outside of that window.

Mm-hmm. So what we do is we do a full cardiometabolic workup with an advanced lipid profile. We, you know, we do their biometrics on their weight as far as visceral fat and look at their muscle mass. We look at their H-S-C-R-P, we look at their glucose insulin and fasting insulin. And if we need to, we also do a coronary, uh, calcium scan.

Mm-hmm. So I had a couple people that they. They were great. All of that looked fantastic and they wanted to start HRT. So I also would say, you know, we don't really know, I think this is based on old data, that there was an increased risk of stroke and this. So if you have any stroke symptoms, please let us know right away.

Yeah. [00:40:00] If you're having anything like this, let us know if they have no family history. So a lot of women want to start it later. Mm-hmm. So that's the critical window that you're referring to, but there is no end date. So people take this critical window and think that they have to stop it at 60. Yeah.

There's nothing that said it. There used to be a recommendation after the WSI that said five years of use, and there also used to be one that said 65 years. Mm-hmm. Both of those are no longer. Current. So there is no published year that you need to stop HRT by? 

Dr. Brighten: Yeah. Well, that's the thing that never sat well with me when they would say like, you need to stop at five years.

And it's like, so what, what? We just gave them five extra years of quality of life and then we're just supposed to withdraw it. And I want people to understand that when we're looking at HRT, uh, responsible prescribers are always looking at the lowest dose to give you the most benefit. I, I have some que more questions about HRT, but you brought up the coronary [00:41:00] calcium scan and I'm not sure everybody is familiar with the utility and the value of that.

Can you explain that to them? Sure. So, 

Dr. Scott: um, the coronary calcium score is a CAT scan that looks at calcium in your coronary artery vessels and somehow they're able to calculate it and give you a number mm-hmm. On your four main coronary arteries. And they, they tell you specifically, so if you have zero to 99, you're low risk.

If you have 100 to 400, you are. A slightly increased risk and then over 400. And I know that this has been a valuable, uh, screening tool for people who don't have symptoms for heart disease. But the other thing I have to qualify is that it's measuring hard plaque, not soft plaque. Mm-hmm. So, you know, you still could have some plaque, um, that's there, but at least it gives you some gauge if you're one.

You know that you're not 400, right? Yeah. Yeah. It gives you some gauge that of what is actually already there because plaque, the calcium is a little bit later in the whole, um, [00:42:00] timeline of plaque. Um, but I think it's still better than we've had. You could also do carotid intimal, um, thickness ultrasounds 'cause the carotid uh, arteries are so vis, um, accessible by ultrasound and they can do a measurement.

Now I don't seem to order that as much as the coronary scan. 'cause where I practice it's still free for patients. Oh, well that's fantastic. Right? 

Dr. Brighten: Yeah. When it comes to lab testing, so you've talked about labs for cardiometabolic workup. When it comes to hormones, this is still like very heated debate. Yes.

There are providers that are like, never measure, there's no reason we only chase the symptoms. But newer research is saying. Actually, we probably should be testing estrogen. So what are your thoughts about that? 

Dr. Scott: Well, it's a whole nother discussion. You're right. And um, what I would say is I do all types of testing in my practice and just as a history for those that are listening, the Endocrine Society guidelines for male hormone therapy is do best labs, give [00:43:00] testosterone, monitor testosterone?

Mm-hmm. For transgender hormone therapy, do baseline labs. Give hormones. Yep. Measure hormones for women don't measure hormones. They vary too much. They don't mean anything. Just give hormones, don't monitor. Mm-hmm. Which I have no idea how that happened. So I think part of that's coming from, to make the diagnosis of menopause, it's a clinical diagnosis.

Mm-hmm. We don't need lab testing. I suppose for androgen insufficiency for men, you need a lab test. Right. It's not a clinical diagnosis. 'cause there's no cessation of any function. Right. Yeah. So for women, I think our, my traditional counterparts get held up because like you don't need lab testing to diagnose menopause or even perimenopause.

It's a clinical diagnosis. Yes, I totally agree with that. But what we do testing for first of all is to detect imbalances. We're not trying to detect tumors. Yeah. So that's what some of our lab testing is designed for. But we do have some new research, specifically [00:44:00] just in February of 2025. Uh, Louise Newman out of the UK just published a big article that they had, I think about 1500 patients and in the UK with the national, um, health, uh, whatever it's called, the NHS, they have very strict guidelines.

Mm-hmm. So they don't routinely test hormones, but they did in these patients. And they were giving very high doses, like I said, two of the highest dose patch for pumps of ESTRO gel, which. We, we don't even give more than one generally. And so they were doing serum testing only. 

Dr. Brighten: Mm-hmm. And 

Dr. Scott: what they found is a lot of people on the patches had low levels.

Yeah. And so some of the people, they did see a correlation, which the higher the dose, the higher the level, they saw the levels go up. So they were saying, number one, yes, the blood levels do change whether it's a patch or a gel. It's very nuanced though, because when you use something topically, if you put a gel on your skin, it's gonna get through your subq tissue.

It's gonna be on your, in your capillaries, your red blood cells for about three seconds. And then it's gonna go into the tissue, but it's not gonna hop back in the vein, it's gonna [00:45:00] go in the lymphatics. Mm-hmm. So we don't always see the venous blood level go up with a topical hormone. Yeah. So with the gels that they've put testosterone in, it will spike, you'll see a little bit more, but blood can tend to underestimate topical dosing.

So that's part of the issue. So there's a difference between if you're ta, if you're checking someone's hormones in their body, versus if you're checking hormones. When they're taking it, right? 

Dr. Brighten: Mm-hmm. 

Dr. Scott: So either way, we're doing testing not to see if they're in perimenopause. Yes, we can make that diagnosis without it.

We wanna know, is their estrogen really high? There's actually some published studies that show breast cancer risk correlates. With your blood levels. Mm-hmm. And that's published in the Journal of Menopause, which is the Journal of the Menopause Society that's telling us not to do testing. 

Dr. Brighten: What about testing for estrogen metabolites?

So using something like the Dutch test, this is also highly controversial. 

Dr. Scott: Sure, yes. Um, so I was never taught how to do that. Um, and again, I would, I would echo [00:46:00] that most of our traditional counterparts are not taught at all about estrogen metabolites, but the science behind that, first of all, when you have labs, they.

Certain labs undergo something called a CLIA certification, and all that means is that their lab is valid, they've tested their assays, they know they're accurate. So it's not just someone just setting up shops somewhere. Right. Yeah. These labs are CLIA certified and some of these labs, the salivary labs have been around since, I don't know how long, 30, 40 years.

The dried urine assays changed in 2015. So prior to that, they weren't quite as accurate. Mm-hmm. And even the salivary and the blood levels are now what we called, um, liquid chromatography, mass spectography, which I don't, I'm not a lab person. I don't know what that means, but they're more accurate. Right.

I have a 

Dr. Brighten: chemistry degree. I'm like, I could break that down for you. Okay. So you, you can, you can explain, I don't really know LCMS, 

Dr. Scott: so they're different now. And even our estradiol blood assay, we have an ultrasensitive assay, so we do have some differences. So the estrogen metabolites to me, I think is extremely useful because [00:47:00] while I don't know that we can fully say the utility of it for managing.

Externally given hormones, when someone's body is making the hormones and you wanna see how they, they metabolize it. There's publish data that show if you have some alterations in the way your liver detoxifies, and those are enzymes, those are genetically coded. We can have single nucleotide polymorphisms with those labs, which make them those enzymes, which make them work faster or slower.

That's just a genetic alteration that if you have a certain type of metabolite that's a little bit higher mm-hmm. Than normal, that's associated with breast cancer. And so we have that data that shows that. And so it's a very valid test, number one for your own body's hormones. Yeah, I think where it gets a little confusing is.

How do you monitor what you're giving? Mm-hmm. So urine is gonna be, obviously whatever your veins are doing, and then it's gonna go through your kidney, into your urine. [00:48:00] So if you're doing a topical or an oral, a lot of it's gonna go in your urine, right? Almost 90% is gonna go in your urine. So if you're giving oral progesterone, you're always gonna see high levels.

The topical is gonna depend on the estrogen. Are you giving it a patch? Are you getting a gel? And then my question with that, and I'm a big user of the Dutch test too, is mm-hmm. Is it catching peripheral aromatization as far as like estradiol? Aone that's happening in the tissue. So I use this test a lot in patients to see what their own hormones are doing.

Mm-hmm. I also use it to see how their body is metabolizing the hormones I'm prescribing. So I find it helpful. It is one of many tests we do. Yeah, you do. We do a quite a bit of traditional blood testing in our practice. We also do the, the, the urine testing and we also do the saliva testing. It really just depends on what the question is that we're trying to figure out.

Mm-hmm. And the fact that the hormones do vary. Is why we're told not to check women's. But you can be very intentional about, okay, you're gonna give hormone at this [00:49:00] time. I'm gonna check the level at this time, so you can be intentional about that. And then with the dried urine test, they're measuring over four times in a 24 hour period.

Dr. Brighten: Mm-hmm. 

Dr. Scott: So if it is varying based on the time you give the hormone, they're capturing that and averaging that. 

Dr. Brighten: Yeah. You brought up a really great point in that you weren't trained in this. The majority of ob GYNs are not trained in menopause, in hormone replacement therapy. Uh, in perimenopause management.

And that is not a dis to them. It's just that I think we have to have honest conversations about the limitations of our training and not being trained in these estrogen metabolites. I see people on social media, these are doctors who have admittedly just started learning about menopause in the last three to five years, and they're like, no, there's no reason to test these metabolites.

There's no utility in it. And I'm like, okay, new kid on the block, you just arrived. Yes. So, and they're also saying 

Dr. Scott: if they say to do a Dutch test, unfollow them 

Dr. Brighten: immediately. Oh my God. I know. Like anyone who says stuff like that, I'm like, stop telling people what to do and what to think. [00:50:00] Why don't you teach people how to think critically instead?

But that's always a red flag to me. Yeah. When a provider's, like, if they go against the dogma, I'm feeding you. Yeah. You should unfollow them. And I'm like, Ooh, that's somebody with an agenda to make sure that you. Follow only their advice and just shut off your brain. Women are far too intelligent for that.

So I, I take issue with that. Like, stop telling women what to do and just start teaching them because yeah, they're smart enough to make up their own mind. But it is something that I'm like, you can admit that you did not have this training, that you do not have this expertise, that you just started gaining this expertise, but then you can't see the limitations in the fact that you don't understand the liver metabolism of estrogen.

And as you were saying, we can look at these metabolites, we can look at methylation. Everyone is unique and different. Research isn't telling us they, they haven't asked the question. Right. Research. Cherry picks a population that's most ideal to get the outcomes that they're looking for. They're not telling us like, Hey, just [00:51:00] ask these questions and you'll know if this person is going to be making more like, you know, 16 hydroxy eOne, which is gonna like push proliferation of tissue.

Like we don't have that. The only way to know is to test and to understand how your body is unique. And what's awesome about that is that there are so many ways that we can support you. Whether it's making sure you have enough magnesium coming in, if we're using sulforaphane, like, you know, making you eat broccoli sprouted, uh, daily on your salad, not making you, but asking you to.

These kinds of things are really easy interventions. And I think it's important for people to understand that. 'cause the other argument you'll hear is they just wanna run this test so then they can sell you expensive stuff. And I'm like, I'm telling you to eat two tablespoons of broccoli sprouts a day.

And I'm telling you, you could go to Home Depot, pick up a seed pack and sprout it between a wet paper towel and your window sill. I just cost you 15. No, probably 5 cents. Like, like No, 

Dr. Scott: I know. And so [00:52:00] your training as a naturopathic physician is much different than mine. Yeah. So you, you already are trained to think that way about detoxification and about how foods affect you.

We, in traditional training, no matter what your discipline is, we don't get nutrition. We don't get, I mean, we might have gone over liver physiology and detoxification in our physiology course, but we never talked about it clinically. Mm-hmm. So we might have needed to learn that just for our physiology tests.

So I think there's a little bit of a different approach for anyone who's trained traditionally, but. Going back to what you're mentioning about the interventions you gave, that's how we can see on these dried urine tests, whether it's dried urine or whatever type of urine test metabolite testing it is, you can see a difference by the interventions that you have just given.

'cause I've followed people. Yeah. And I've given those interventions, not the supplements that I'm selling, but whatever they, wherever they get them, so, and I've seen the needle move. Mm-hmm. And if you just go to PubMed and you look at estrogen detoxification, I am sure you're gonna get a plethora of articles [00:53:00] that are peer reviewed literature that are talking about it.

Even the dried urine lab has several articles that have made it into the Journal of Menopause. Um, so I think, um, I think I agree with you on your assessment of other people's, um, cautionary tale about the urine metabolite. I think you need to be trained in it. I think, you know, need to know what are you looking at and what can, what's the information you can use from 

Dr. Brighten: this 

Dr. Scott: test.

Dr. Brighten: Exactly. And that is something that I, I think sometimes people get frustrated because they're like, my doctor won't order these labs because they're like, it won't change the treatment. Mm-hmm. And I'm like, then, then it might not, and they don't wanna waste your money. Uh, but also it might not be the right provider for you as well, because they might be saying to you, you know, if you go to your PCP and you want your hormones tested.

They might not have a clue what to do with that. And so if they're saying, it's not gonna change my treatment, it doesn't mean that they're a bad provider, right? It means that like they're, they're telling you you are gonna, you can spend money on the test, but I'm not gonna interpret this and be able to do much different with it.

And [00:54:00] that's okay for them to be honest about that. And I think, you know, it's, uh, every woman out there has a bad experience with a gynecologist and it's so easy for us to jump on. Like, see, they're not even trained on that. They're the worst, dah, dah, dah, dah, dah. And yet it's like, why were you not trained in liver detoxification and nutrition?

Because dying is a really bad thing and you need to be trained on lots of worst case scenarios. And so for people to understand, like OB gyn I think is, um. It really needs to be split up because this whole, like we deliver babies and we see menopausal women is a lot for a provider to be taking on. And so when you think about the scope of practice, it's like they fit how much in four years and then a residency, like there are going to be limitations to your knowledge.

They just wanna say that because I think, um, it's not fair to always vilify a provider because they have limitations in their training. And to understand that like sometimes you have to go [00:55:00] outside of that provider. You had brought up the menopause society talking about. Well, if you have someone with breast cancer using non-hormonal therapies, there are women who are like, I just don't wanna do HRT.

So what other options do they have available when it comes to symptom management? 

Dr. Scott: Well, the biggest, uh, kind of. Overall recommendations that we give to those patients is, you know what you eat, obviously decreasing your caffeine. I'm not saying no caffeine, less caffeine, less processed sugar, less processed food, more whole foods, more cruciferous vegetables, you know, more of your greens.

All the colors of the rainbow, number one. Number two, prioritize sleep. And that can be a catch 22 because what if you can't sleep because you're having hot flashes, but many women aren't giving themselves enough time to sleep. Number three, move movement. You gotta move your body. There are studies that show both yoga and exercise can decrease hot flashes.

And so the fourth one is really stress because your adrenal gland, as you mentioned, kind of [00:56:00] takes over at menopause. So if you're super, super stressed out, your menopause symptoms are gonna be different. As far as non-hormonal management of symptoms, it really depends what the symptoms is. Are for hot flashes.

There are a few prescription, um, medications for hot flashes that rate work through your neurokinin and bradykinin, uh, brain receptors, but they're super expensive. Um, we, we like a sub, uh, supplement that has, um, uh, rhubarb extracts from it. There's a couple different companies that make that. There are some that have black Kosh in it.

Evening primrose oil, sometimes just regular fish oil can be helpful. 

Dr. Brighten: Mm-hmm. 

Dr. Scott: Um, if it's a mood issue, a lot of times we're recommending magnesium, as you mentioned. Magnesium can help be, vitamins can help back to the fish oil if it's a sleep issue. We love L-theanine, we love lemon balm. Melatonin is, it actually has some really great anti-cancer.

Yeah. Um, actions. So I think those are all safe to take for people who want non-hormonal, but we always kind of try to go back to those four [00:57:00] pillars. And kind of get patients mm-hmm. To see where could they change there and maybe their symptoms will improve. Are you using Saffron at all for mood? Not as much as I should.

Dr. Brighten: Yeah. Yeah. So I have to tell you that I did Lupron for two months. Um, after going on it myself, I'm like, nobody should ever be given Lupron. This is the absolute worst. But 'cause and people dunno, like, uh, it's, it's a chemical castration. Yes. And it puts you into menopause within two weeks or less. Um, I'm really grateful for the experience.

It gave me really good insight into like, what's coming for me. Saffron, um, literally changed, like saved my mood. Like this was during the holidays as my kids were getting the worst version of me, I was like, okay, I'm a saffron believer now. So, uh, it was like saffron, phosphatidyl choline to keep like brain fog away, but copa so I could like function.

Mm-hmm. Um, that like little cocktail. Did wonders for my brain. Yeah. So much. Um, and when you look at the [00:58:00] research of Saffron, it rivals SSRIs. Mm-hmm. And what's also interesting is that if you're on an SSRI and it's affecting your libido or you have anorgasmia, the inability to orgasm bringing in saffron can actually help with that.

And I always love something that's like, Hey, it, it might work for you. Um, and you might not have to start a medication, but if you already are on the medication, it might also be able to support you. So it's not this either or situation. 

Dr. Scott: Yeah. And I think whenever you can go back to an herb that's like a food or a spice.

Yeah. I can't say it's completely safe, but how would it not, how would it not be safe? It's not a pharmaceutical, right? Mm-hmm. It's a spice. Yeah. So I love 

Dr. Brighten: that. I know. I'm like every culture that's been using saffron. Yeah. These women were onto something. Yeah. I wanna ask you this question. I got asked this recently on a podcast and the host asked me.

Why do you think that HRT is not over the counter? It is in some countries. And is this something that we should maybe be advocating for, is [00:59:00] giving women access to HRT? Because right now most physicians are an obstacle to getting it. 

Dr. Scott: Yeah, that's a great question because it's a hard one too. It's a very hard, I'm gonna choose my words slowly here.

I think I still wish more people had access and I'm constantly surprised at the messages I get on social media that they can't find a provider and that the provider is deciding for them. Yes, don't take that. Right? And one patient said, oh my, my gynecologist said I shouldn't take, she doesn't believe in hormones.

And I said, well, she doesn't have to take them. You know? So, I mean, it's always the 

Dr. Brighten: belief for me. I'm like, we're not talking about Santa Claus. Okay, we're talking about stuff that like, is rooted in science, like has data 

Dr. Scott: as far as over the counter. That's a tough one. 'cause you know, the dose and the duration matters and more isn't always better for hormones.

So. I don't know how I feel about that. I don't want women to suffer by not being able to get it, but I worry about the [01:00:00] person that gives themselves too much estrogen. Or maybe the person that's had the hysterectomy and only thinks they need estrogen. Mm-hmm. Because that's what is the traditional recommendation.

And then they increase their risk of breast cancer by giving themselves so much estrogen. You know, estrogen, upregulates its own receptor. So if you're someone who doesn't have a uterus and you think now that you need estrogen 'cause you're in your forties having hot flashes, it could be because your estrogen's high.

Mm-hmm. But if you're giving yourself estrogen and then you're going to need more and more because it upregulates its own receptor. So I do worry about that. Uh, so I'm gonna. Kind of hedge and say, but I, I don't know how I feel about that. Supposedly birth control pills were supposed to be over the counter in some states.

Mm-hmm. And the pharmacist was gonna counsel them, I guess if they have the pharmacist, a trained pharmacist, counseling them before they're dispensing an over the counter. But I'm guessing it's gonna just be like Amazon, like, like you can get, I've seen estradiol on Amazon. 

Dr. Brighten: Oh my gosh. Okay. So I had the same answer of like countries that, um, [01:01:00] where you can, where a lot of drugs and that are, you know, behind the physician's prescription pad and patients can't access them when the countries where they're available, they have the pharmacist to counsel them.

Mm-hmm. And that's the system they have set up. And so that was my same answer is like, if we could have that where the pharmacist is counseling them, talking them through it, like that's a different situation. So it's not uncommon that, you know, in Europe, in Mexico, like you go to the pharmacist, you're discussing things with them.

They recommend a pharmaceutical too. It's, there's no prescription behind that and they talk you through everything. So that's very different. But when you brought up the Amazon thing, I'm like, of course, because. The United States is capitalism all the way. Mm-hmm. Amazon has already dipped its toes. You're like, absolutely.

Right. That's what we'd see. I mean, we already see so many, uh, mail order menopause clinics going on. Yes. Same thing happening with GLP ones. And, um, uh, I interviewed, um, Dr. Justin Human who is talking about the [01:02:00] Finasteride clinics. Mm-hmm. And how much harm those are causing when it becomes for-profit.

Things get really slight. No longer do they care about whether this is right for you. They care about are you willing to put your credit card number in and purchase this. So that's actually such a great point. I do think that women deserve access. I, I send. Literally if men had, uh, vaginal atrophy, there would be vending machines of estrogen creams.

Like it would be like everywhere. They would be in the bathrooms, just dispensing literally be not, not a thing that has like such a, you know, blockade around it. And yet I do think we have to be cautious, right? Because there are risks to this. It isn't without risk. But then at the same time I look at, well there's other countries, you know, that like you can get corticosteroids over the counter, right?

Like anything outside of like narcotics and antibiotics, like you can get over the counter. And we know those come with [01:03:00] dangerous side effects and yet we're not. Seeing that play out. And I think it comes back to like, who's dispensing it, what kind of counseling is happening? So could we emulate that in the us?

But yeah, the Amazon thing definitely gives me pause. Yes. What are the most harmful myths? Around menopause and HRT that you're still hearing, that you're like, these need to go to bed and be done. 

Dr. Scott: Well, one of the things you touched upon is my pet peeve, which may not be a popular opinion, is the use of estrogen alone.

Mm. And so regardless of whether you have a uterus or not, so just to back up the, I mentioned the study that was done with progesterone on the breast cell that estrogen causes growth and progesterone causes cell death. So many women, when they have the uterus removes are not getting their breasts removed.

So my primary concern is what is the breast cancer risk with estrogen alone? Mm-hmm. The data from the WHI, which only had 8,000 people in the treatment arm, and 8,000 people actually with the estrogen only alarm, sorry, it was 5,000 and 5,000. [01:04:00] The risk, and I might be saying the percentage is a little bit.

Wrong, but it was point 0.35% incidence of breast cancer in placebo and 0.27% in with the use of, uh, Premarin. So they were calling that a reduction in breast cancer. Mm-hmm. So that's not even a half of a percent difference. But if we look at the nurses' health study that had 122,000 people, they had the mo.

The longer you use the estrogen alone, it was 22% increased risk of breast cancer, 45%. So there's still this, a couple studies going back and forth that. L estrogen alone decreases your risk of breast cancer, which I have no idea how that even is. A physiological thing. Yeah. When what we know about growth and cell death.

So that's one of my big concerns about patients using estrogen alone. That myth, the whole myth of any type of hormone risk and cancer. There's also myths about using hormones will make you gain weight. Because I know with birth control pills, a lot of times people have water retention. Mm-hmm. [01:05:00] Again, they're not the same thing with traditional, uh, synthetic HRT patients have gained weight.

I. So that could also be an issue. So those are myths. I mean, most of our patients, if we're doing personalized dosing, we're not necessarily seeing weight gain. I mean, there's a lot of things that go into weight gain, you know, your insulin sensitivity and a lot of things, but those are the biggest ones, really.

Dr. Brighten: Yeah. Bikini medicine is such the downfall of the HRT conversation, right? Because they're like, well, you only need progesterone if, like you still have your baby container there, right? Yeah. We're always reduced to like just this reproductive capacity and the organs that still exists there, and nobody is looking at, well, what about progesterone for the brain?

Right? It's almost like they're like, what do women need to worry their pretty little heads about? What do they need brains for when we know then. You know, we talked about the GABA system, but progesterone is also involved with the myelin sheath. Like [01:06:00] how And if people don't dunno what that is, I always like to say like if you look an extension cord, that outside plastic, that's like the myelin sheath and the energy that's running there can run a straight line.

That's your neurons as well. We know that progesterone has so many benefits for the brain, also for the rest of the body. And yet it always just comes down to like, what about the uterus? What about the uterus? And it's like the uterus is one part, but we are an entire system. Let me ask you, um. People will say, whether it's doctors, it's a lot of times doctors, uh, who, who are saying this, but some women as well, menopause is natural, so why should we do anything about it?

Dr. Scott: Well, that is true, and if you had the food that is outside of our country, um, and you had less stress, you may not need hormone therapy. Mm-hmm. Because, you know, in the third world countries, they don't, they don't need it. They don't do it. They eat simpler, they eat whole foods, they're not having the processed food.

There's this whole issue with the chemicals and the endocrine disruptors that we have more of here versus somewhere else. So we [01:07:00] don't live in the same area, in the same environment that people outside of this country do. 

Dr. Brighten: Mm-hmm. 

Dr. Scott: Um, and so it is possibly not natural to take hormone therapy, but it's also not natural to have a hip replacement or a stent or any of those other things that people have no problems doing.

Yeah. When they need it. Right. And so it's a philosophical decision on your part if you want to. And what's interesting is how some people, their bodies just naturally make enough hormones. Because of whatever their issue is. Mm-hmm. You know, their adrenals are well-functioning, they make hormones, they don't need it.

And then some people who have very, very deficient hormones who do need it. 

Dr. Brighten: What are the top questions women should ask their provider when seeking HRT to know if this person's gonna be the right fit for them? 

Dr. Scott: I always tell patients to ask, what is, what is your experience on prescribing hormones? Are you in favor of it or not?

Because you still may get, I don't believe in it. Right? Mm-hmm. Do you have experience prescribing it or do you have any education? How do you feel your training has been [01:08:00] with HRT? You know, do you feel equipped to do this? And if you don't feel comfortable, who can you refer me to? And I would also ask, what's your thoughts on monitoring hormones?

I mean, do you think that we should monitor hormones? Do you get labs? Do you get baseline labs? You know, again, not every provider is getting labs and you may still be getting hormone therapy and be fine. Right. So I'm not gonna say that's a hard stop. Mm-hmm. Um, I think it's. The best clinical practice to be monitoring because you can be fooled, but I think people still, I don't want that to be a barrier.

Mm-hmm. 

Dr. Brighten: But 

Dr. Scott: those are the main things. I mean, you have to really seek out a provider. You can't assume your obs, your OB, GYN has that knowledge you. And now with Social Media Link Tree, you can look to see what are this person's credentials, you know? Yeah. There are directories. Even in the Menopause Society directory, at least those doctors have at least done a little bit more coursework.

They're not afraid to prescribe, they may not check your hormones, but at least you're gonna get a little bit more than you would get from someone who has no experience. 

Dr. Brighten: Yeah. And checking the credentials is really important on social [01:09:00] media as well. Like anybody practicing ethically and showing up ethically on social media will have their credentials.

Easy to find. And I find so often, whenever someone sends me a video of someone saying. HRT is being used too much. HRT shouldn't be used. Like there's no reason for it when I actually, and I usually have to like go through like 20 pages of clicking to find that they're not licensed to prescribe. And the person who is saying it was never trained in it.

Because if you're not licensed to prescribe, you're not trained in it. But you're also like, there's kind of this rule in medicine, you're not supposed to advise on medications that you're not licensed to prescribe. Yeah. And so that's what I always remind people of is that if someone's not licensed to prescribe, they lack the knowledge and they've been filled usually with a bias around that.

Um, you know, for whatever reason if they're taking that heart stance. Because a lot of times what they're saying fi flies in the face of the current literature, the society's position statements and what [01:10:00] clinicians are finding that actually practice this with their patients. The last question I wanna ask is women.

Will struggle to find a provider. What can they do if they're having a hard time advocating for themselves? Where can they go? I mean, obviously if they're in your area, go see you. Yeah, we'll link, uh, if you guys are like, how do I find her? Yeah, I will put it in the show notes. But how can they find a provider to work with and advocate for themselves?

So I 

Dr. Scott: normally, uh, tell patients a couple places to look. I mean, I was trained by the American Academy of Anti-Aging, regenerative and Functional Medicine. So it's the letter A, the number four, the letter m.org. I think it's org, I'm not sure it's org, but they have a provider directory and you can actually select out who's trained in BHRT.

Mm-hmm. Uh, or HRT or whatever. And you have to do a little bit more digging than that. You have to go to their website and see like, do they prescribe? Because even though I have functional training, I'm not a Lyme expert. Expert. I'm not a mold expert. Yeah. So I, you don't assume I know how to [01:11:00] treat you for that.

Right. So you have to go to their site and see do they treat, do they do that? Um, so that's one place that I would, a lot of the, like the saliva test, ZRT test and DUTCH test both have provider directories. Mm-hmm. Um, they may not be a prescriber on that directory though, because you could be a dietician to order a Dutch test.

So you could screen, uh, screen people out that way by looking for an md a do an ND or somebody who can prescribe, or you could go to the menopause menopause.org and look at their directory. They're probably not gonna test you, but at least there won't be a barrier to you receiving hormones if you need it.

Mm-hmm. 

Dr. Brighten: Yeah. And, uh, so people understand as well if you know a dietician in your area. Uses the Dutch test or they have, 'cause sometimes dieticians don't do sit for the trainings to understand it so that they can understand from the perspective of like, how do I support my patient dietarily, who's using HRT if somebody so that and, and I think dieticians, um.

Are [01:12:00] great, uh, in terms of supporting patient care overall. But if you find another provider that isn't necessarily a prescriber, you can also ask them who do you work with? Who refers to you? If a doctor refers to a dietician, odds are they're gonna be a really great doctor because they know like, nutrition is really important and I don't have the training or the time to do all of that with you.

But I think it's important for you. Right. Yeah, that's a good point. Well, thank you so much for taking the time to meet with me, for making all of this happen. I know that women are gonna really value this episode. Like I said, I'm gonna link everywhere that they can find you, but I'm just so grateful for the work that you do in this world.

Dr. Scott: Well, thank you. I know it's a lot of work during a podcast, so thank you for taking the time. So more people can hear about this. Yes. 

Dr. Brighten: I hope you enjoyed this episode. If this is the kind of content you're into, then I highly recommend checking out [01:13:00] this.