1 00:00:00,320 --> 00:00:03,919 Speaker 1: The content of this podcast is provided for general informational 2 00:00:03,960 --> 00:00:07,000 purposes only and is not intended as nor should it 3 00:00:07,040 --> 00:00:21,800 be considered a substitute for professional medical advice. Hello, this 4 00:00:21,920 --> 00:00:25,160 is Karen Nicol, family nurse practitioner, and you are listening 5 00:00:25,160 --> 00:00:27,719 to Itchy and BITCHI a podcast that provides answers to 6 00:00:27,760 --> 00:00:32,119 your many unanswered health questions. As I mentioned in the 7 00:00:32,200 --> 00:00:36,560 last two episodes, after nine years of hosting Itchy and Bitchy, 8 00:00:37,320 --> 00:00:40,759 it is time for the podcast to grow and evolve 9 00:00:40,880 --> 00:00:45,280 with new hosts in a slightly different format. And remember 10 00:00:45,560 --> 00:00:49,719 that growth and change is a good thing. My dear friends, 11 00:00:49,719 --> 00:00:53,679 Stephen Miller and Keith Millica will be the future hosts 12 00:00:53,840 --> 00:00:56,320 of Itchy and Bitchy. As hosts, they will have a 13 00:00:56,359 --> 00:01:01,479 comprehensive approach to wellness with a focus on connection human health, 14 00:01:01,520 --> 00:01:06,359 animal health, and environmental health. To provide a transition period 15 00:01:06,400 --> 00:01:09,480 for you, for me, and for Stephen and Keith, we 16 00:01:09,599 --> 00:01:12,519 have a series of four episodes plans. This is the 17 00:01:12,560 --> 00:01:16,200 third of the four episodes during which I will be 18 00:01:16,319 --> 00:01:20,319 interviewing both Stephen and Keith. Doctor Stephen Miller is an 19 00:01:20,359 --> 00:01:23,640 acute care nurse practitioner known for his expertise in diagnosing 20 00:01:23,640 --> 00:01:27,239 and treating cardiovascular disease, and Doctor Keith Nillica is a 21 00:01:27,319 --> 00:01:31,560 veterinarian and Board certified veterinary dermatologist who has been in 22 00:01:31,640 --> 00:01:36,319 practice for thirty years. To learn more details about them 23 00:01:36,359 --> 00:01:39,879 and their expertise, make sure to listen to the episode's 24 00:01:39,959 --> 00:01:43,079 date at April fourth and April eleventh, twenty twenty six. 25 00:01:43,760 --> 00:01:50,359 We are going to surprise talk about hormones today, specifically 26 00:01:50,400 --> 00:01:54,439 about estradile, which is the most potent form of estrogen 27 00:01:54,519 --> 00:01:58,400 in a woman's body. Menopause occurs when the ovary stops 28 00:01:58,400 --> 00:02:04,200 secreting estradile or when the ovaries have been surgically removed. Recently, 29 00:02:04,760 --> 00:02:09,719 the black box warning on HRT was removed, and this 30 00:02:09,759 --> 00:02:13,199 is a big deal. I've talked about black box warnings before, 31 00:02:13,240 --> 00:02:17,599 but as a refresher, this is a bold, black bordered 32 00:02:17,719 --> 00:02:21,879 warning that is placed at the top of a medications labeling. 33 00:02:22,360 --> 00:02:27,240 It alerts healthcare providers and patients to serious, life threatening 34 00:02:27,479 --> 00:02:33,280 or permanently disabling adverse risks. The FDA announced the removal 35 00:02:33,599 --> 00:02:38,840 of the black box warning from most menopausal hormone therapy 36 00:02:38,919 --> 00:02:43,800 products on November tenth, twenty twenty five. This serious warning 37 00:02:43,919 --> 00:02:47,560 was placed on HRT in two thousand and two when 38 00:02:47,599 --> 00:02:51,840 the Women's Health Initiative Study WHI study, which by the way, 39 00:02:52,240 --> 00:02:56,080 was a poorly designed study with misinterpreted data that led 40 00:02:56,120 --> 00:03:00,560 practitioners to stop prescribing HRT for their patients. So now, 41 00:03:00,960 --> 00:03:05,280 twenty four years later, the FDA finally took the step 42 00:03:05,439 --> 00:03:11,199 to right this wrong. But it took twenty four years. 43 00:03:11,840 --> 00:03:15,840 I've said it before, this culture is very tolerant of 44 00:03:15,879 --> 00:03:20,560 women's suffering. Probably in light of recent studies touting all 45 00:03:20,639 --> 00:03:24,639 the benefits of starting HRT early in menopause, the FDA 46 00:03:24,759 --> 00:03:28,599 determined that the WHI study warnings of risks like breast 47 00:03:28,639 --> 00:03:34,520 cancer and cardiovascara disease were overstated. The new and improved 48 00:03:34,599 --> 00:03:39,199 labels highlight the benefits for women under sixty and within 49 00:03:39,400 --> 00:03:43,800 ten years of menopause. Well hello. As soon as the 50 00:03:43,879 --> 00:03:48,719 black box warning was removed, all of a sudden, practitioners 51 00:03:48,719 --> 00:03:53,479 felt more comfortable with prescribing HRT. This after women were 52 00:03:53,479 --> 00:03:57,560 frequently told by their practitioners that it's just part of life, 53 00:03:57,840 --> 00:03:59,199 something you'll have to get through. 54 00:04:00,080 --> 00:04:00,639 Speaker 2: Buck up. 55 00:04:01,280 --> 00:04:05,159 Speaker 1: This surge in prescribing led to shortages of estra dial 56 00:04:05,280 --> 00:04:10,280 patches in the pharmacy. Keith, what are your thoughts on 57 00:04:10,439 --> 00:04:14,159 comments on the history I just shared and the consequences 58 00:04:14,199 --> 00:04:16,639 of how HRT has been handled for the last quarter 59 00:04:16,680 --> 00:04:17,480 of a century. 60 00:04:17,800 --> 00:04:22,879 Speaker 2: All right, so I'm you go. I'm Keith Milica, doctor Milica. 61 00:04:23,079 --> 00:04:26,680 Just a veterinarian, so real, no pony in this race. 62 00:04:27,279 --> 00:04:30,720 But I was listening to one of my favorite news 63 00:04:30,759 --> 00:04:34,839 episode podcasts and the story came to light, and I 64 00:04:34,959 --> 00:04:38,199 just thought, what is going on in the medical world. 65 00:04:38,199 --> 00:04:41,000 A black box warning is basically a death nail for 66 00:04:41,079 --> 00:04:44,480 a drug. So and a lot of drugs that actually 67 00:04:44,600 --> 00:04:48,800 have pretty good efficacy and even a few side effects 68 00:04:48,879 --> 00:04:51,879 can get a black box warning for a variety of reasons. 69 00:04:52,199 --> 00:04:55,639 Oftentimes because there's a serious concern in side effects. It 70 00:04:55,759 --> 00:05:00,639 dramatically communicates to the providers that this can kill your patients, 71 00:05:00,680 --> 00:05:03,720 and so they stopped using the drug for twenty four years. 72 00:05:03,759 --> 00:05:07,399 This drug had a black box warning. So they reviewed 73 00:05:07,399 --> 00:05:10,360 the literature, which is good. Always progress, and we're going 74 00:05:10,399 --> 00:05:11,600 to do some menta analysis. 75 00:05:11,680 --> 00:05:12,399 Speaker 3: Reading is good. 76 00:05:12,560 --> 00:05:15,959 Speaker 2: How big was the review of this study? It was big. 77 00:05:16,000 --> 00:05:19,199 We talked before on the last interview that in dogs, 78 00:05:19,240 --> 00:05:22,079 a lot of our studies are like twelve dogs, dogs. 79 00:05:22,360 --> 00:05:26,639 This was like thousands of patients, right, So they decide 80 00:05:26,680 --> 00:05:30,879 that it's actually pretty good for you. Hrt is is 81 00:05:30,959 --> 00:05:34,879 maybe a good thing. But then now that it's a 82 00:05:34,879 --> 00:05:37,759 good thing, women can't get it, and if you can 83 00:05:37,920 --> 00:05:40,759 get it, it's three times the cost. And it's like, 84 00:05:40,879 --> 00:05:44,160 what the freak is going on here? So I'm not 85 00:05:44,279 --> 00:05:48,920 a big conspiracy theorist, but if I was, this would 86 00:05:48,959 --> 00:05:49,480 fit the bill. 87 00:05:49,839 --> 00:05:54,319 Speaker 4: So there, I'll give just the slightest Yeah, so this 88 00:05:54,399 --> 00:05:55,120 is this. 89 00:05:55,079 --> 00:05:58,600 Speaker 3: Is steven step which I appreciate. 90 00:05:58,720 --> 00:06:02,680 Speaker 4: From there, again from the male perspective, but from the 91 00:06:02,680 --> 00:06:05,399 gay mail perspective, so it could be different. But the 92 00:06:05,600 --> 00:06:10,600 daughters with daughters, yes, so a little pushback in that. 93 00:06:11,480 --> 00:06:14,600 So they come up with a statement basically saying they 94 00:06:14,600 --> 00:06:17,439 do a comprehensive review of the scientific data. Right, And 95 00:06:17,480 --> 00:06:22,000 so the issue came down to divergent outcomes and looking 96 00:06:22,040 --> 00:06:27,920 at divergency between estrogen alone versus estrogen plus progestion. Truly, 97 00:06:28,000 --> 00:06:31,519 I think that is deserving of some adjudication. I'm not 98 00:06:31,560 --> 00:06:34,759 sure twenty four years of adjudication, but so that's one 99 00:06:35,160 --> 00:06:37,920 point that I think needs to be considered. The other 100 00:06:38,519 --> 00:06:43,279 point is that reviewing and looking at the timing hypothesis, 101 00:06:43,279 --> 00:06:46,879 which we really didn't deal with before. So the timing 102 00:06:47,199 --> 00:06:52,319 of treatment either in pre sixty year old women and 103 00:06:52,720 --> 00:06:56,680 favorable risk benefit profile. Again, I'm not sure twenty four 104 00:06:56,800 --> 00:07:01,199 years was. That's a really long time, but certainly I 105 00:07:01,279 --> 00:07:02,560 think that's worthy of mention. 106 00:07:02,839 --> 00:07:06,519 Speaker 2: So sub dividing the population into are you a thirty 107 00:07:06,600 --> 00:07:09,000 year old person, a sixty year old person, a ninety 108 00:07:09,040 --> 00:07:11,399 year old person? Is that what you're talking about? 109 00:07:11,519 --> 00:07:14,800 Speaker 4: Yes, okay, you mean in the study or yes. So 110 00:07:15,000 --> 00:07:18,800 in the retrospective review of this analysis comparing the Women's 111 00:07:18,800 --> 00:07:24,319 Health Initiative with more recent evidence, the timing hypothesis evolved, right, 112 00:07:24,680 --> 00:07:27,800 because before then it was just estrogen for everyone. 113 00:07:28,600 --> 00:07:31,079 Speaker 1: Well, but in the WHI study, this is one of 114 00:07:31,120 --> 00:07:35,160 the faulty pieces of the design, is that they started 115 00:07:35,240 --> 00:07:39,639 women who had never been on HRT. They started them 116 00:07:39,680 --> 00:07:44,759 on premarin anywhere from age sixty eight to seventy three. 117 00:07:44,959 --> 00:07:50,480 And we don't typically do new starts of HRT on 118 00:07:50,560 --> 00:07:54,199 a seventy three year old woman, not typically, right, So 119 00:07:54,439 --> 00:07:55,560 it was a bad setup. 120 00:07:55,639 --> 00:07:58,199 Speaker 4: It's a bad setup, and I totally agree with that, 121 00:07:58,240 --> 00:07:58,560 thank you. 122 00:07:59,240 --> 00:08:03,360 Speaker 2: The twenty four years is a long time. 123 00:08:03,360 --> 00:08:07,839 Speaker 4: So almost a quarter of a century women have had 124 00:08:07,879 --> 00:08:12,000 to deal with being taken hormones away and with the 125 00:08:12,040 --> 00:08:17,240 fear of cardiovascular implications. So then there was the third 126 00:08:17,439 --> 00:08:20,839 panel point, which was that they need an expert panel 127 00:08:20,959 --> 00:08:24,800 deliberation and a sixty day public comment, And I get 128 00:08:24,839 --> 00:08:29,000 it because there are a lot of different bodies of 129 00:08:29,639 --> 00:08:32,919 expertise that needed to weigh in on this. And then 130 00:08:33,000 --> 00:08:39,759 fourthly acknowledging that warnings were based on incomplete data. And 131 00:08:39,799 --> 00:08:41,879 this is the point with the Women's Health Initiative. It 132 00:08:41,919 --> 00:08:45,399 was incomplete data set, so they were looking at putative 133 00:08:45,480 --> 00:08:50,080 harm and secondary outcomes, and they weren't looking at primary outcomes. 134 00:08:50,080 --> 00:08:54,639 In this we're talking about WAWHI yes, and so they 135 00:08:54,639 --> 00:08:59,600 were inappropriately extrapolated those outcomes. I think that's a really 136 00:08:59,720 --> 00:09:02,480 key thing that I think if I were a listener, 137 00:09:02,519 --> 00:09:06,639 I would want to know about clinical trials across the board. 138 00:09:07,159 --> 00:09:12,039 Is inappropriate extrapolation of data across populations really becomes a 139 00:09:12,039 --> 00:09:14,720 big deal, And it doesn't matter if it's hormone or whatever. 140 00:09:15,080 --> 00:09:18,039 But in this situation, we're talking about HRT. So that 141 00:09:18,240 --> 00:09:20,360 was my little bit of pushback in that there were 142 00:09:20,399 --> 00:09:25,159 some valid points, but twenty four years is a really long. 143 00:09:24,960 --> 00:09:30,679 Speaker 1: Time, WHI was on conjugated horse estrogen, and they did 144 00:09:30,759 --> 00:09:34,200 do some of the study on prim pro which has 145 00:09:34,360 --> 00:09:41,279 conjugated estrogens and progestin, and a lot of providers mistakenly 146 00:09:41,840 --> 00:09:49,159 is progestin and progesterone synonymously, and progestin is a synthetic 147 00:09:49,240 --> 00:09:52,799 version of our progesterone and has a bunch of risk factors, 148 00:09:52,879 --> 00:09:58,879 especially clotting. Our own natural, bioidentical progesterone does not have 149 00:09:59,000 --> 00:10:03,159 the same risks that progestin holds. So I just want 150 00:10:03,200 --> 00:10:06,840 to make it clear to our listeners that progestin is 151 00:10:06,879 --> 00:10:09,879 a very different thing, and don't let anybody tell you otherwise, 152 00:10:10,200 --> 00:10:12,720 because there are a lot of providers who still don't 153 00:10:12,759 --> 00:10:15,679 know the difference, believe it or not, a lot of 154 00:10:15,720 --> 00:10:19,759 GYNs who don't know the difference between a progestine and progesterone. 155 00:10:20,039 --> 00:10:23,279 Speaker 2: And hormones are complex. I mean, they really are a 156 00:10:23,440 --> 00:10:27,240 very complex, metabolic, interactive kind of system. I want to 157 00:10:27,279 --> 00:10:29,840 go back to my outrage. There you go, Okay, so 158 00:10:30,399 --> 00:10:33,919 sixty days I've worked for pharmaceutical companies, and in sixty 159 00:10:33,960 --> 00:10:37,519 days they could easily have ramped up production knowing that 160 00:10:37,559 --> 00:10:39,919 the FDA was probably going to open up and release 161 00:10:40,000 --> 00:10:45,799 this black box nightmare limitation warning. And so what is 162 00:10:45,879 --> 00:10:48,440 up with not being able to get these patches? Right? 163 00:10:48,480 --> 00:10:51,960 The patch is one of the leading ideal fewest side 164 00:10:51,960 --> 00:10:54,279 effects type therapies. And I want to ask you about 165 00:10:54,279 --> 00:10:57,480 side effects in a second, But why why didn't the 166 00:10:57,480 --> 00:11:02,480 pharmaceutical companies ramp up? And look what's up with that? Well, Karrot, 167 00:11:02,480 --> 00:11:04,080 you're supposed to have the answers here. 168 00:11:03,879 --> 00:11:09,399 Speaker 1: Well, yes I do, but they're usually not angry capitalisms. 169 00:11:09,480 --> 00:11:13,159 It's capitalists answers. Well, I think we don't think ahead 170 00:11:13,200 --> 00:11:17,799 in these things. I think they didn't expect. I'm sure 171 00:11:18,000 --> 00:11:21,919 that practitioners would start writing them like it's handing out 172 00:11:21,919 --> 00:11:23,120 candy on the street corner. 173 00:11:23,200 --> 00:11:26,120 Speaker 2: I mean, so along those lines that now the prescription 174 00:11:26,279 --> 00:11:33,240 rate for esters and patches is skyrocketing because it's now safer, 175 00:11:33,360 --> 00:11:38,080 we understand the limitations, and so women now have access 176 00:11:38,720 --> 00:11:40,080 if they can find the product. 177 00:11:40,519 --> 00:11:42,600 Speaker 4: And I think too, I think for the audience, I 178 00:11:42,600 --> 00:11:47,080 think it's important to state that the transdermal patches are 179 00:11:47,120 --> 00:11:50,240 preferred over oral formulations right here. 180 00:11:50,200 --> 00:11:52,759 Speaker 2: Yes, you're the expert care, and so tell us what's 181 00:11:52,759 --> 00:11:55,639 what with the modality of administration? 182 00:11:55,720 --> 00:12:00,759 Speaker 1: So there are multiple benefits of topical estra dial over oral. 183 00:12:01,240 --> 00:12:05,440 Number one, when you use a topical estradl whether it's 184 00:12:05,480 --> 00:12:10,519 a patch or a cream or a gel or intravaginal estradl, 185 00:12:11,679 --> 00:12:15,279 it does not have a first pass through the liver. 186 00:12:15,879 --> 00:12:19,759 And during that first pass what would happen And this 187 00:12:19,799 --> 00:12:23,399 is what happens with oral estrogen. When it passes through 188 00:12:23,399 --> 00:12:29,000 the livers, we produce more fibrinogen. And when we have 189 00:12:29,159 --> 00:12:33,279 higher levels of fibrinogen in our blood, we have increased 190 00:12:33,399 --> 00:12:38,320 risk for clot. So by doing it transdermally on the 191 00:12:38,360 --> 00:12:45,039 skin in the vagina, then we reduce significantly reduce clot 192 00:12:45,120 --> 00:12:49,759 risk because we do not increase fibrinogen levels with topical estradioline. 193 00:12:49,879 --> 00:12:54,279 Speaker 2: What topicals are you talking about? So you have a patch, creamream. 194 00:12:53,960 --> 00:12:58,759 Speaker 1: Gels, intravaginal like if you did a vaginal cream, that 195 00:12:59,000 --> 00:12:59,879 would be compounded. 196 00:13:00,120 --> 00:13:03,000 Speaker 3: We have vaginal rings that. 197 00:13:02,960 --> 00:13:05,960 Speaker 1: Have estradile and like a slow release yeaw, you even 198 00:13:06,039 --> 00:13:09,080 started vaginally and it releases for three months. And so 199 00:13:09,200 --> 00:13:13,840 anything that is not directly going into the digestive system. 200 00:13:14,240 --> 00:13:16,080 Speaker 2: Then Doctor Miller side effects. 201 00:13:16,320 --> 00:13:19,519 Speaker 4: The biggest scary thing is the increased risk for benus thrombosis. 202 00:13:20,279 --> 00:13:25,720 And then the historical fear was moderate cardiovascular risk associated 203 00:13:25,720 --> 00:13:29,879 with oral formulations. But then there's also with that transdermal avoiding. 204 00:13:29,879 --> 00:13:34,440 The hepatic first pass is the issue related to elevated lipids, 205 00:13:34,440 --> 00:13:37,320 so you don't have to worry about hyperdruglis rhodemia when 206 00:13:37,360 --> 00:13:41,679 you do the transdermal formulation. So there are differences, and 207 00:13:41,759 --> 00:13:45,080 I do think historically when we go back to the 208 00:13:45,120 --> 00:13:51,200 Women's Health Initiative, that evidence was poorly understood, you know, 209 00:13:51,360 --> 00:13:54,360 and so there has been some really positive things to 210 00:13:54,399 --> 00:13:57,200 come out of this period of time that we've waited, 211 00:13:57,279 --> 00:13:58,480 not twenty four years. 212 00:13:58,480 --> 00:14:01,440 Speaker 5: It don't so would you he's watching me glare out 213 00:14:01,440 --> 00:14:05,480 of it, would you say oral is more risky and 214 00:14:05,600 --> 00:14:10,879 bad and topical trans epidermal is better. 215 00:14:11,279 --> 00:14:13,480 Speaker 2: Fewer side effects absolutely well. 216 00:14:13,679 --> 00:14:16,240 Speaker 1: First of all, if you're using something like a patch 217 00:14:16,360 --> 00:14:20,000 or the vaginal estradyle ring, or even creams or gels, 218 00:14:20,039 --> 00:14:23,720 but especially a patch or the vaginal ring, it's a 219 00:14:23,799 --> 00:14:28,720 slow even release, so you're going to have fewer breakthrough 220 00:14:29,080 --> 00:14:32,039 symptoms like hot flashes and night sweats because you get 221 00:14:32,080 --> 00:14:36,759 a more steady estradile state that's going into your bloodstream 222 00:14:37,440 --> 00:14:41,799 and then into your tissues. So that's a big advantage too, 223 00:14:41,840 --> 00:14:45,120 because we have a natural fall off of levels when 224 00:14:45,120 --> 00:14:48,600 we use something orally, because it has to go through 225 00:14:48,799 --> 00:14:51,600 our digestive system, it breaks down a lot of it. 226 00:14:52,080 --> 00:14:54,799 And as a matter of fact, because of that, we 227 00:14:54,840 --> 00:14:58,039 also have to use much higher doses, so we get 228 00:14:58,039 --> 00:15:00,320 the same effect after we lose a bunch of in 229 00:15:00,360 --> 00:15:04,440 our gut. For instance, if I were compounding of estradile 230 00:15:04,919 --> 00:15:08,879 cream and someone was on a tablet or you know, 231 00:15:09,000 --> 00:15:12,720 some form of oral estrogen, we would cut that dose 232 00:15:12,799 --> 00:15:16,360 in half when we convert it to a transdermal form. 233 00:15:16,600 --> 00:15:18,679 Speaker 2: How often do they have to put on the cream 234 00:15:19,000 --> 00:15:19,960 or a patch. 235 00:15:19,720 --> 00:15:22,360 Speaker 1: Well, the cream, the cream or gel is usually once 236 00:15:22,480 --> 00:15:26,000 or twice a day. The patch is once or twice 237 00:15:26,039 --> 00:15:29,279 a week. We have patches that are twice weekly that 238 00:15:29,320 --> 00:15:34,240 are quite small, which is nice. The once weekly is 239 00:15:34,279 --> 00:15:38,200 easier for people. But that thing at the highest dose 240 00:15:38,519 --> 00:15:41,039 is about as big as this coaster that's on the table. 241 00:15:40,759 --> 00:15:44,480 Speaker 3: Next to me. Four it's a big it's a big thing. 242 00:15:45,159 --> 00:15:45,360 You know. 243 00:15:45,440 --> 00:15:48,480 Speaker 1: Typically people like the twice weekly dosing because it's a 244 00:15:48,559 --> 00:15:52,279 much much smaller patch and it's clear that once weekly 245 00:15:52,360 --> 00:15:55,440 is usually a flesh colored and that's fine if you're 246 00:15:55,600 --> 00:15:59,879 a white person because it's that color. Yeah, but maybe 247 00:16:00,080 --> 00:16:03,000 not so much again capitalism or a person of color. 248 00:16:03,840 --> 00:16:07,840 Speaker 2: So what I've heard that the availability of the patches 249 00:16:08,200 --> 00:16:13,279 is very difficult now because of the demand, and I 250 00:16:13,320 --> 00:16:16,679 think they come in different milligram doses, and then I've 251 00:16:16,720 --> 00:16:20,360 heard of people cutting them in half. It just desperation 252 00:16:20,799 --> 00:16:22,879 to what do you think about that? 253 00:16:23,039 --> 00:16:27,879 Speaker 1: Yes, you can cut patches in half. Absolutely, you might 254 00:16:28,000 --> 00:16:32,720 have a little more difficulty getting it to stay in place. 255 00:16:33,440 --> 00:16:36,559 But personally, I cut my patch in half. 256 00:16:36,679 --> 00:16:39,279 Speaker 2: So you would go up a milligram dose and then 257 00:16:39,519 --> 00:16:40,000 cut Yeah. 258 00:16:40,039 --> 00:16:44,159 Speaker 1: So for instance, I'm getting super personal, but I have 259 00:16:44,200 --> 00:16:48,159 a prescription for a zero point zero five milligram patch 260 00:16:48,200 --> 00:16:50,399 and I cut it in half, so I have a 261 00:16:50,559 --> 00:16:53,840 zero point zero two five zero point zero two five 262 00:16:54,000 --> 00:16:57,559 milligram patch is the lowest dose we have, and then 263 00:16:57,559 --> 00:17:00,000 it goes up to point one. 264 00:17:00,600 --> 00:17:04,119 Speaker 2: And this I assume at least my patient's veterinary side. 265 00:17:04,119 --> 00:17:06,359 I would want them to consult me and talk to 266 00:17:06,400 --> 00:17:08,640 the provider about exactly what you're doing. 267 00:17:08,680 --> 00:17:10,599 Speaker 3: Oh, yes, yes, don't just. 268 00:17:10,519 --> 00:17:11,960 Speaker 2: Go willy nilly cutting your. 269 00:17:11,839 --> 00:17:16,799 Speaker 1: Patches willy nilly whatever. But I often would tell my 270 00:17:16,920 --> 00:17:20,480 patients that if they were having financial difficulty getting their patch, 271 00:17:20,720 --> 00:17:23,319 you know, so I would say, let's if they were 272 00:17:23,359 --> 00:17:25,200 on a point oh five, let's do a point one, 273 00:17:25,279 --> 00:17:27,720 we'll cut it in half. So we're going to take 274 00:17:27,799 --> 00:17:32,079 a little break right now and calm our nurse, and 275 00:17:32,119 --> 00:17:36,599 we'll be right back with lots more information. So stay 276 00:17:36,640 --> 00:17:54,480 with me, welcome back. We're going to continue this discussion, 277 00:17:54,599 --> 00:17:56,640 and it's good. It's gonna be good. 278 00:17:57,359 --> 00:18:01,559 Speaker 2: So the other thing, Doctor Miller and Karen that y'all 279 00:18:01,559 --> 00:18:05,440 were talking to me, I'm just the ignorant veterinarian sever 280 00:18:05,519 --> 00:18:10,599 about these things. Ever, they were running through the benefits 281 00:18:10,640 --> 00:18:16,680 of HRT and in veterinary medicine. If we see five 282 00:18:16,880 --> 00:18:22,079 percent improvement, that's pretty good, Like we like that, and 283 00:18:22,160 --> 00:18:25,680 anything above five percent ten percent, we're doing really good. 284 00:18:25,720 --> 00:18:27,920 Like that's a treatment that we're going to focus on 285 00:18:28,359 --> 00:18:32,559 that can help our patients. So what kind of improvements 286 00:18:32,599 --> 00:18:34,599 do you see with HRT now? 287 00:18:35,400 --> 00:18:37,000 Speaker 3: Well, as a person who. 288 00:18:38,720 --> 00:18:42,440 Speaker 1: Is an expert in that area, my goal always is 289 00:18:42,480 --> 00:18:45,839 to have them one hundred percent relieved of their symptoms. 290 00:18:46,319 --> 00:18:49,119 A lot of that involves some really good listening and 291 00:18:49,359 --> 00:18:52,440 knowing how to dose different products. In a way to 292 00:18:52,680 --> 00:18:55,599 try to make that happen. I would say, though I 293 00:18:55,720 --> 00:19:00,079 typically could get people to feel eighty to ninety, is 294 00:19:00,200 --> 00:19:04,880 it better, which is big, But that was also because 295 00:19:04,920 --> 00:19:08,079 I worked hard to do that. I mean, I learned 296 00:19:08,240 --> 00:19:10,960 a lot over the years. I studied. Over the years, 297 00:19:11,079 --> 00:19:15,519 I listened to patients and people's symptoms and what makes 298 00:19:15,519 --> 00:19:18,079 them better, what makes them worse, Rather than worrying just 299 00:19:18,160 --> 00:19:22,359 about labs, far more successful. When you start treating labs, 300 00:19:22,759 --> 00:19:25,000 you're in trouble. You're in trouble. You got to listen 301 00:19:25,000 --> 00:19:27,400 to people. When it comes to hormones, treat the patient, 302 00:19:27,559 --> 00:19:31,279 not the paper. It's exactly, especially with hormones, because the 303 00:19:31,400 --> 00:19:35,640 range of normal is huge, and where you feel great 304 00:19:36,000 --> 00:19:38,759 is not where the person next to you feels great. 305 00:19:39,079 --> 00:19:44,400 Even with patches estradial patches, which we have several doses, 306 00:19:45,079 --> 00:19:48,319 and you think, well, that's great. But if I told 307 00:19:48,319 --> 00:19:51,519 the women of the world that there are seven bras 308 00:19:51,680 --> 00:19:54,640 sizes and you've got to find one that fits you 309 00:19:55,000 --> 00:19:58,720 as close as possible, people would be burning mattresses in the. 310 00:19:58,680 --> 00:20:03,359 Speaker 3: Street or broad or broad something. They've been burning something. 311 00:20:03,839 --> 00:20:06,599 Speaker 1: We accept that there are only these few doses for 312 00:20:06,759 --> 00:20:11,440 women and for men to replace hormones. And that's one 313 00:20:11,440 --> 00:20:14,480 of the many reasons I got into compounding, because there 314 00:20:14,480 --> 00:20:17,440 are infinite number of doses with compounding. 315 00:20:18,079 --> 00:20:20,839 Speaker 2: Right. And then doctor Miller, can you give us some 316 00:20:20,960 --> 00:20:24,559 statistics on cardiac disease benefits? 317 00:20:25,000 --> 00:20:27,759 Speaker 4: Well, I think as we were talking, the thing that 318 00:20:27,880 --> 00:20:29,519 sort of was sticking out with me is sort of 319 00:20:29,559 --> 00:20:34,720 the American College of Cardiology did that twenty nineteen systematic 320 00:20:34,759 --> 00:20:38,759 review based some evidence on that and basically came out 321 00:20:38,799 --> 00:20:41,799 with a statement that said, if your cardiovascular risk was 322 00:20:42,279 --> 00:20:47,240 less than five percent, then consider transdermal therapy. If your 323 00:20:47,319 --> 00:20:53,599 cardiovascular risk was five to ten percent, consider transdermal estrogen, 324 00:20:54,319 --> 00:20:58,200 and those with greater than ten percent should consider no 325 00:20:58,240 --> 00:21:05,079 hormonal option at all. Tell me, Kire, Yeah, not for law. 326 00:21:05,440 --> 00:21:10,279 Tell me your perspective, because people of that take care 327 00:21:10,319 --> 00:21:13,319 of HRT, send people for me to say yes or no. 328 00:21:13,400 --> 00:21:19,920 And there have been people historically, who usually men in cardiology, 329 00:21:20,119 --> 00:21:25,400 who have made commentary about no HRT based upon the 330 00:21:25,519 --> 00:21:29,559 WHI data, And so I guess I would be interested 331 00:21:29,599 --> 00:21:32,880 in your thoughts about that perspective. 332 00:21:33,039 --> 00:21:37,680 Speaker 1: And point, well, think about what estradile does for our body. 333 00:21:38,200 --> 00:21:45,319 It makes things stretchy and flexible, including arteries. So we 334 00:21:45,799 --> 00:21:49,440 you know, if we have less arterial stiffness, our arteries 335 00:21:49,480 --> 00:21:54,119 function better. If our heart muscle is more flexible, it 336 00:21:54,279 --> 00:21:59,119 functions better. So it's not just about the flexibility, which 337 00:21:59,279 --> 00:22:02,359 is a bit big deal. Our cholesterol numbers go up 338 00:22:02,440 --> 00:22:05,559 when we don't have hormones, because our hormones are made 339 00:22:05,839 --> 00:22:11,559 from cholesterol. So when we don't have hormones, our brain goes, oh, 340 00:22:11,680 --> 00:22:15,039 what the heck, she has no hormones. She must not 341 00:22:15,119 --> 00:22:18,079 have goop to make hormones. Well, let's make some more 342 00:22:18,119 --> 00:22:21,319 goop and then she can make hormones. Levels naturally go up, 343 00:22:21,319 --> 00:22:24,440 which increases your risk for cardiovascular disease. I mean, we 344 00:22:24,599 --> 00:22:29,880 have studies now that show that estra dial is heart protective. 345 00:22:30,799 --> 00:22:33,440 Speaker 4: Yeah, and so I think, but I think my point 346 00:22:33,640 --> 00:22:38,680 to asking that is this whole delineation between should I 347 00:22:38,720 --> 00:22:45,079 do oral or transdermal or just transdermal or not at all? Okay, 348 00:22:45,079 --> 00:22:48,640 And I think again, that's what people are asking me 349 00:22:48,880 --> 00:22:52,240 as a cardiovascular exp They're wanting me to say to them, 350 00:22:52,720 --> 00:22:55,759 you should not do oral therapy because you have preexisting 351 00:22:55,880 --> 00:23:00,559 cornary artery disease and stints. You should only do transdermal. Now, 352 00:23:00,839 --> 00:23:07,880 I would be somewhat reluctant to tell any female person 353 00:23:08,640 --> 00:23:13,480 that no therapy at all would be okay. Right, So 354 00:23:14,240 --> 00:23:16,480 it puts me in a bit of a position number one, 355 00:23:16,519 --> 00:23:20,880 number two the risk calculator for that how many people 356 00:23:21,200 --> 00:23:26,000 actually on these women who need HRT are running the 357 00:23:26,079 --> 00:23:29,839 risk calculator and putting it in their documentation to say, well, 358 00:23:30,119 --> 00:23:35,319 I've calculated your risk based upon these variables, and for HRT, 359 00:23:35,559 --> 00:23:36,720 this is where you resign. 360 00:23:36,920 --> 00:23:39,839 Speaker 1: Here's what I would say about those things. Definitely, if 361 00:23:39,839 --> 00:23:42,680 I had someone and I did, if I had people 362 00:23:42,720 --> 00:23:48,119 who had heart disease or personal clot history or family 363 00:23:48,200 --> 00:23:52,480 history of clot, I would never put them on oral estradial. 364 00:23:52,920 --> 00:23:57,799 I always used topical and as a way to not 365 00:23:57,839 --> 00:24:00,440 saying to protect yourself as a practitioner, but just to 366 00:24:00,559 --> 00:24:06,480 monitor what risks are happening. If you're on transdermal estradile, 367 00:24:06,839 --> 00:24:09,440 just draw a fibrintagen level, it's not that big a deal. 368 00:24:09,759 --> 00:24:14,839 I would monitor fibrintage and levels and those people. Now, also, 369 00:24:14,960 --> 00:24:18,880 it's so individual. If somebody came into you with new 370 00:24:18,960 --> 00:24:22,559 diagnoses of heart disease and they're already on some kind 371 00:24:22,599 --> 00:24:26,519 of hormone replacement. I would say, okay, you're on oral 372 00:24:26,880 --> 00:24:30,799 form of estrogen. I know there are benefits, cardiac benefits 373 00:24:30,880 --> 00:24:34,640 for women being on hormones, but we need to reduce 374 00:24:34,799 --> 00:24:38,240 your clot risk, and we can do so by giving 375 00:24:38,279 --> 00:24:43,359 you a transdermal version of estradile. If somebody came in 376 00:24:43,400 --> 00:24:46,400 to you and they were just diagnosed with heart disease, 377 00:24:47,039 --> 00:24:49,240 or you've just diagnosed them with heart disease and they're 378 00:24:49,319 --> 00:24:52,519 seventy three years old and never been on hormone replacement therapy, 379 00:24:52,599 --> 00:24:55,240 or they were on hormone replacement therapy from age fifty 380 00:24:55,279 --> 00:24:57,839 one to fifty eight, and they said, you know, can 381 00:24:57,880 --> 00:25:00,359 I do hormone replacement therapy? 382 00:25:00,400 --> 00:25:04,039 Speaker 3: I heard it would be good for me. I'd be like, what. 383 00:25:04,079 --> 00:25:07,119 Speaker 1: Symptoms you have and why you know, why would we 384 00:25:07,119 --> 00:25:09,960 want to start that at this point based on the age, 385 00:25:10,160 --> 00:25:13,119 based on and not being on hormones all this time, 386 00:25:13,640 --> 00:25:17,759 we see the most benefit in terms of hormone replacement 387 00:25:17,920 --> 00:25:23,799 therapy if women are on HRT, specifically estra dial in 388 00:25:23,839 --> 00:25:29,079 the first five years of menopause, and now we're even 389 00:25:29,119 --> 00:25:32,640 seeing that it's more beneficial to start it in perimenopause, 390 00:25:33,079 --> 00:25:36,000 just before you go into menopause, not to say that 391 00:25:36,119 --> 00:25:38,799 you don't get any benefit after five years, but the 392 00:25:39,000 --> 00:25:42,640 really meat of it, the meat of the benefit is 393 00:25:42,680 --> 00:25:46,240 in those first five years during the transition. So would 394 00:25:46,240 --> 00:25:48,720 you ever, well, once they get into menopause, would you 395 00:25:48,799 --> 00:25:52,759 ever use oral hormone replacement? Or we started saying that 396 00:25:52,799 --> 00:25:55,400 the patches and the topicals are the way to go, 397 00:25:55,480 --> 00:25:59,440 and then doctor Miller brought up oral and heart disease 398 00:25:59,480 --> 00:26:02,079 and their high risks with oral. So would you, as 399 00:26:02,119 --> 00:26:06,200 a practitioner, where would you put in an oral It 400 00:26:06,279 --> 00:26:08,279 sounded to me like you would always use topical. 401 00:26:08,440 --> 00:26:11,480 Speaker 4: So I want to chime in a bit. This plays 402 00:26:11,519 --> 00:26:16,559 in to the underrepresentation of women with cardiovascular disease and 403 00:26:16,599 --> 00:26:19,240 the number of studies have been done. And so you 404 00:26:19,240 --> 00:26:22,599 look at the subpopulation of women who have cornery disease 405 00:26:22,720 --> 00:26:26,880 and stints and they're on aspirin, they may be on plavix, 406 00:26:27,039 --> 00:26:30,519 they may be on anticoagulation therapy, and what does that 407 00:26:30,559 --> 00:26:34,680 subgroup analysis look like? We really don't know. And so 408 00:26:34,839 --> 00:26:40,759 then risk benefit. So then the addition of anticoagulation or 409 00:26:40,759 --> 00:26:45,680 antiplatelet therapy to that group of women may alter treatment. 410 00:26:45,720 --> 00:26:49,359 Speaker 1: Right, I mean, if you're saying look, we're already anti coagulating. 411 00:26:49,920 --> 00:26:54,720 Adding on topical estradisle isn't going to increase your right risk. 412 00:26:54,799 --> 00:26:58,839 You're already treated here, You're already treated. And I would 413 00:26:58,880 --> 00:27:02,240 also as you mentioned symptoms, I also would look at 414 00:27:03,039 --> 00:27:05,960 you know, is this person miserable with night sweats and 415 00:27:06,039 --> 00:27:11,079 hot flashes? And cardiologists don't want women who have heart 416 00:27:11,079 --> 00:27:15,680 disease to have high stress hormone levels. And if you 417 00:27:15,759 --> 00:27:19,680 want to see high stress hormone levels in a body, 418 00:27:20,200 --> 00:27:22,880 check it out. And a woman who's having hot flashes 419 00:27:22,920 --> 00:27:27,119 and night sweats and anxiety and fearfulness and you know, 420 00:27:27,160 --> 00:27:30,200 on and on and on, you're better off to make 421 00:27:30,279 --> 00:27:34,400 that woman comfortable and happy because that plays into their 422 00:27:34,480 --> 00:27:36,279 cardiovascular healthy as well. 423 00:27:36,400 --> 00:27:40,599 Speaker 4: Yeah, I get a ton of women who come with 424 00:27:41,079 --> 00:27:45,680 vasomotor symptoms those flashes and night sweat say thank you, 425 00:27:46,079 --> 00:27:48,839 and then they think they're having a heart attack or 426 00:27:48,839 --> 00:27:53,119 they're dying because those symptoms are severe sometimes. And so 427 00:27:53,200 --> 00:27:59,559 I think that balance of treating vasomotor symptoms appropriately and 428 00:27:59,599 --> 00:28:04,680 doing appropriate cardiovascular risk assessment in those patients really becomes 429 00:28:04,680 --> 00:28:06,759 a balance that we have to meet well. 430 00:28:07,079 --> 00:28:11,839 Speaker 1: And I think that if cardiologists are just afraid to 431 00:28:11,880 --> 00:28:17,680 prescribe hormone replacement therapy because they're not knowledgeable. Then they 432 00:28:17,680 --> 00:28:21,000 either need to get knowledgeable or refer on to someone 433 00:28:21,400 --> 00:28:25,599 who is. Because the one thing I really don't want 434 00:28:25,599 --> 00:28:28,680 to hear is a patient coming back and saying, oh, 435 00:28:28,799 --> 00:28:31,400 I saw my cardiologists and this has happened to me. 436 00:28:32,200 --> 00:28:35,200 I've seen my cardiologists and they said I shouldn't be 437 00:28:35,240 --> 00:28:36,000 on hormones. 438 00:28:36,839 --> 00:28:41,680 Speaker 4: Well, and was there a risk calculator run? So did 439 00:28:41,720 --> 00:28:47,440 we look within the evidence and balance that out with risk? 440 00:28:47,599 --> 00:28:49,960 Speaker 2: You're talking about a risk calculator? Is this something I 441 00:28:50,000 --> 00:28:52,240 can pull out of my pocket and type in numbers 442 00:28:52,359 --> 00:28:53,279 or what are you talking about? 443 00:28:53,440 --> 00:28:56,440 Speaker 4: So many? Yeah, in general, there are a lot of 444 00:28:56,559 --> 00:29:00,440 risk calculators out there. For cardiovascular risk. It's a it's 445 00:29:00,480 --> 00:29:03,079 an app, okay, and so most people can pull those 446 00:29:03,119 --> 00:29:07,319 out pretty quickly. Medcalk is one of the apps where 447 00:29:07,319 --> 00:29:09,880 you can find most of the risk calculators, and I'm 448 00:29:09,880 --> 00:29:12,839 sure on some of the women's health websites there's probably 449 00:29:12,839 --> 00:29:16,960 a cardiovascular risk calculator. I think that's important that if 450 00:29:16,960 --> 00:29:21,079 someone has risk and wants to be treated, needs to 451 00:29:21,119 --> 00:29:26,599 be treated, that the risk calculator calculation be done and 452 00:29:26,640 --> 00:29:29,119 that that be discussed with the person and then we 453 00:29:29,119 --> 00:29:32,000 weigh risk benefit as we do with anything, right. But 454 00:29:32,119 --> 00:29:36,880 I think that's one piece of the problem solving. And 455 00:29:36,960 --> 00:29:41,200 anybody who does that and says, oh, you are seeing 456 00:29:41,200 --> 00:29:45,039 it too high risk because you're one point over, you 457 00:29:45,039 --> 00:29:46,799 don't get hormones. 458 00:29:46,400 --> 00:29:46,960 Speaker 2: Tough it out. 459 00:29:47,079 --> 00:29:50,680 Speaker 1: They're not, Yeah, and get dismissed and told they can 460 00:29:50,799 --> 00:29:53,960 just buck up and deal with it. Yeah, nobody wants 461 00:29:53,960 --> 00:29:58,680 to be treated based on one calculator number. We're going 462 00:29:58,759 --> 00:30:01,200 to take a little break right now and we'll be 463 00:30:01,359 --> 00:30:03,160 right back, so stay with me. 464 00:30:12,519 --> 00:30:13,359 Speaker 3: Welcome back. 465 00:30:13,880 --> 00:30:17,839 Speaker 4: So this leans into one thing I wanted to ask 466 00:30:17,839 --> 00:30:20,880 you which we haven't discussed yet, which is the timing 467 00:30:21,000 --> 00:30:25,319 of therapy, because that became an issue with this most 468 00:30:25,359 --> 00:30:30,279 recent analysis of the data. And so you know current 469 00:30:30,319 --> 00:30:33,799 recommendations on how long do we take this and what 470 00:30:34,039 --> 00:30:35,839 when do we stop it? Or do we stop it? 471 00:30:36,039 --> 00:30:39,559 Speaker 2: Or so can I jump in? So a few sentences 472 00:30:39,599 --> 00:30:44,480 before we went down doctor Miller's calculator rabbit hole, so 473 00:30:44,519 --> 00:30:47,720 I was saying that five to ten percent benefit in 474 00:30:48,000 --> 00:30:51,880 morbidity of various diseases is really impressive. And before we 475 00:30:51,920 --> 00:30:54,920 got on here, Karen, you gave me a list. It 476 00:30:54,960 --> 00:31:01,680 blew my mind of the level of diseases, morbidity rates, 477 00:31:01,799 --> 00:31:05,119 the change with HRT. Can you run through that list? 478 00:31:05,279 --> 00:31:09,480 Speaker 1: This is in response directly actually to how long should 479 00:31:09,519 --> 00:31:13,079 we be on hormones? Because the other thing that happened 480 00:31:13,079 --> 00:31:17,200 with WHI is you should be on hormones for five 481 00:31:17,319 --> 00:31:18,400 years and then come off. 482 00:31:18,519 --> 00:31:21,559 Speaker 4: That's correct, which is that that's what I was. 483 00:31:22,079 --> 00:31:25,039 Speaker 1: I told my patience when they ever asked me this, 484 00:31:25,400 --> 00:31:31,599 I'd say, look, let's treat you. Let's treat you if 485 00:31:32,480 --> 00:31:36,559 risk factors change, if your benefits change, or at some 486 00:31:36,599 --> 00:31:38,599 point you want to go off of it, and we 487 00:31:38,839 --> 00:31:43,400 ty trate you off and you're doing great. Great. I 488 00:31:43,440 --> 00:31:46,680 am not going to tell you you're coming off of 489 00:31:46,720 --> 00:31:48,880 this in X amount of time. I'm not going to 490 00:31:48,960 --> 00:31:52,480 do it because I'm not cookie cutter. I'm not a factory. 491 00:31:53,000 --> 00:31:56,559 I treat people as individuals and I've always believed this, 492 00:31:56,640 --> 00:31:58,839 and I listen. I had women in their eighties that 493 00:31:58,880 --> 00:32:03,960 if I took them off there dial patch, they were sweaty, angry. 494 00:32:04,559 --> 00:32:06,119 Speaker 4: Messes, sweaty and pissed. 495 00:32:06,240 --> 00:32:10,559 Speaker 1: They were sweaty and pissed for sure, and I would 496 00:32:10,599 --> 00:32:12,160 just put them back on look's fine. 497 00:32:12,440 --> 00:32:12,839 Speaker 3: I don't care. 498 00:32:12,880 --> 00:32:15,000 Speaker 1: I mean, you know, so, why in your eighties, if 499 00:32:15,039 --> 00:32:18,400 you're miserable because you don't have your esther dial patch, 500 00:32:18,759 --> 00:32:20,599 Why are you doing that to an eighty three year 501 00:32:20,640 --> 00:32:22,000 old woman? I mean so. 502 00:32:22,079 --> 00:32:25,160 Speaker 2: One of the things you've taught me, Karen, and the 503 00:32:25,240 --> 00:32:28,880 years that we've known each other is I've been very 504 00:32:28,920 --> 00:32:33,079 much trained in epidemiology, so herd health, big populations, and 505 00:32:33,160 --> 00:32:36,160 all of these studies look at ten thousand people, you know, 506 00:32:36,200 --> 00:32:39,680 five hundred thousand people, and what's best for a population 507 00:32:39,880 --> 00:32:42,839 of America. One of the things I've been very impressed 508 00:32:42,880 --> 00:32:46,240 with you is what's optimal for the individual patient that's 509 00:32:46,240 --> 00:32:48,240 in your exam room. And that's kind of what you're 510 00:32:48,240 --> 00:32:50,759 referring to now, is that you know, the studies say this, 511 00:32:50,839 --> 00:32:53,519 and we're going to take that into account, but what 512 00:32:53,680 --> 00:32:56,759 are you feeling day to day and what's best for 513 00:32:56,880 --> 00:33:02,039 you may not be necessarily what the demiological studies say. 514 00:33:02,279 --> 00:33:04,599 They give me the list of the benefits, because I 515 00:33:04,960 --> 00:33:05,680 that blew my mind. 516 00:33:05,759 --> 00:33:05,960 Speaker 3: Yeah. 517 00:33:06,000 --> 00:33:09,039 Speaker 1: So this is specifically a study that came out in 518 00:33:09,079 --> 00:33:13,279 May of twenty twenty four in the journal Menopause. 519 00:33:13,799 --> 00:33:15,839 Speaker 3: It was looking at. 520 00:33:15,640 --> 00:33:21,319 Speaker 1: Women over sixty five and they looked at ten million 521 00:33:22,480 --> 00:33:26,519 senior Medicare women. That's a lot focus and they looked 522 00:33:26,559 --> 00:33:31,720 at it based on the prescriptions used and the visit records. 523 00:33:31,920 --> 00:33:34,559 So they were looking at chart review. They're looking at 524 00:33:34,559 --> 00:33:38,359 the chart and they looked at the effects of different 525 00:33:38,400 --> 00:33:44,920 preparations of menopausal hormonal therapy on all cause mortality, five cancers, 526 00:33:45,400 --> 00:33:50,240 six cardiovascar diseases, and dementia. So they examined those areas 527 00:33:50,839 --> 00:33:56,440 compared with those women who never used or discontinued menopausal 528 00:33:56,480 --> 00:34:00,839 hormonal therapy after age sixty five years. The use of 529 00:34:01,000 --> 00:34:05,720 estrogen monotherapy, so we're talking about just using estradil beyond 530 00:34:06,000 --> 00:34:10,519 the age of sixty five years, was associated with significant 531 00:34:11,320 --> 00:34:13,519 risk reductions. And I know this is a lot of 532 00:34:13,519 --> 00:34:17,800 your patient population, Stephen sixty five years in older mortality 533 00:34:17,960 --> 00:34:22,519 risk reduction was reduced by nineteen percent. 534 00:34:22,320 --> 00:34:28,039 Speaker 2: Plus death death nineteen percent five and ten is impressive, nineteen. 535 00:34:28,639 --> 00:34:32,760 Speaker 1: Breast cancer by sixteen percent, this is all risk reduction, 536 00:34:33,480 --> 00:34:38,519 Lung cancer by thirteen percent, colorectal cancer by twelve percent, 537 00:34:39,039 --> 00:34:43,360 congestive heart failure by five percent, clots in the veins 538 00:34:43,760 --> 00:34:48,639 three percent, atrial fibrillation by four percent, heart attack by 539 00:34:48,639 --> 00:34:54,199 eleven percent and dementia by two percent, and among senior 540 00:34:54,280 --> 00:34:58,559 medicare women in general, risk reductions appear to be greater 541 00:34:59,079 --> 00:35:02,679 with low rather than medium or high doses of estradyle 542 00:35:03,280 --> 00:35:07,760 and by using either vaginal or transdermal rather than oral HRT, 543 00:35:08,360 --> 00:35:14,800 and using bioidentical estradle rather than conjugated estrogen, which again 544 00:35:15,239 --> 00:35:18,480 that's what was in the WHI study was so. 545 00:35:19,039 --> 00:35:24,559 Speaker 4: This is a retrospective cohort study, and so of ten 546 00:35:24,599 --> 00:35:29,320 million women, which is a huge population, and so I 547 00:35:29,360 --> 00:35:33,760 guess really be interested in subpopulation analysis on that group 548 00:35:33,800 --> 00:35:34,239 of people. 549 00:35:34,880 --> 00:35:38,119 Speaker 2: You can ask them ten million, that's a lot of questions. 550 00:35:39,400 --> 00:35:42,199 Speaker 4: Carrie just gave me a look like Stephenovan as string. 551 00:35:41,800 --> 00:35:46,440 Speaker 1: You want to microphone or superrand. 552 00:35:46,559 --> 00:35:50,039 Speaker 4: I think it the scientist in me right now. I'm 553 00:35:50,079 --> 00:35:55,079 not living with the issue of lack of estrogen and 554 00:35:55,159 --> 00:35:59,519 basomotor symptoms. I'm not living that, but just the scientific 555 00:35:59,639 --> 00:36:02,880 brain of me wants to know, among the ten million 556 00:36:03,000 --> 00:36:07,119 women who had those benefits, how did that break out? 557 00:36:07,440 --> 00:36:11,320 How many had cardiovascular disease pre existing? And I know 558 00:36:11,360 --> 00:36:13,199 I'm going down a rabbit at a bit, but I 559 00:36:13,239 --> 00:36:17,559 think on this side of fairness, I do think that 560 00:36:18,880 --> 00:36:24,119 it's important to say and preface this with this group 561 00:36:24,159 --> 00:36:27,119 of women included these people. 562 00:36:27,239 --> 00:36:29,599 Speaker 1: Well, and I'll send you the whole study. I try 563 00:36:29,639 --> 00:36:33,360 to for the listeners. I try to share the conclusion, yes, 564 00:36:33,599 --> 00:36:37,760 because I don't know that people are tuning in to 565 00:36:38,159 --> 00:36:41,639 hear every last detail of a study, but there are 566 00:36:41,639 --> 00:36:42,639 all those things in there. 567 00:36:42,760 --> 00:36:45,679 Speaker 4: Yeah, no, no doubt, Like in that group of women 568 00:36:45,719 --> 00:36:50,840 at that age, I know that the subpopulation analysis includes 569 00:36:50,840 --> 00:36:54,639 a fib and athoscrite disease and this and that. I think, 570 00:36:55,039 --> 00:36:57,760 and this might be a nice follow up for the 571 00:36:57,800 --> 00:37:02,719 podcast to look at that, and just because I might 572 00:37:02,840 --> 00:37:08,239 dare say there might be some increased benefit in those subpopulations, right. 573 00:37:08,039 --> 00:37:10,239 Speaker 1: Well, you mean the risk reduction numbers would be better 574 00:37:10,440 --> 00:37:14,320 right in certain populaces. Yeah, I get that, and I 575 00:37:14,360 --> 00:37:17,679 guess I bring this up, especially with you, Stephen, who 576 00:37:17,719 --> 00:37:21,639 works in cardiology, to know that if there is somebody 577 00:37:21,679 --> 00:37:25,920 who comes in to see you, a cardiologist, any cardiologist 578 00:37:27,239 --> 00:37:31,039 who's sixty five, sixty eight, and they've been on hormone 579 00:37:31,280 --> 00:37:34,400 replacement therapy and they're still on hormone replacement therapy, they're 580 00:37:34,440 --> 00:37:38,000 on an estradial patch, I hope that nobody's ripping them 581 00:37:38,039 --> 00:37:41,960 off that right, and especially with this study because they 582 00:37:42,000 --> 00:37:44,280 don't they haven't seen as many as ten million women. 583 00:37:44,320 --> 00:37:48,239 Speaker 4: I can tell you that much, right, I will tell 584 00:37:48,280 --> 00:37:51,760 you it is not a comfortable consolet for someone to 585 00:37:51,760 --> 00:37:55,280 send you and say should I continue the therapy? Much 586 00:37:55,320 --> 00:37:57,880 of my job is not comfortable. But if you do 587 00:37:58,239 --> 00:38:03,400 due diligence, especially in light of the new FDA labeling 588 00:38:03,519 --> 00:38:07,440 and with retraction of the old information, it is now 589 00:38:08,000 --> 00:38:11,400 worthy of having the conversation and going in and looking 590 00:38:11,440 --> 00:38:14,400 yourself at the data set and the subpopulation and saying 591 00:38:14,400 --> 00:38:18,000 to the person, you've got athersk right disease. I ran 592 00:38:18,440 --> 00:38:22,360 the risk calculator, which is the a SCBD risk calculator 593 00:38:22,360 --> 00:38:24,719 that's put out by the American College of Cardiology and 594 00:38:24,719 --> 00:38:29,360 American Heart Association, readily available, and if your risk is 595 00:38:29,400 --> 00:38:32,440 this or this or this, this is what's recommended. I'm 596 00:38:32,440 --> 00:38:35,519 not a hormone expert, don't claim to be, you know, 597 00:38:35,840 --> 00:38:39,000 but this is on the cardiology side, what's fair and reasonable. 598 00:38:39,320 --> 00:38:42,000 Speaker 1: Right, But I would say, if you want to have 599 00:38:42,039 --> 00:38:45,400 a little bit of a CYA again, I would just 600 00:38:45,480 --> 00:38:48,400 draw off fibriantage and level on them. Yeah, I agree, 601 00:38:48,519 --> 00:38:51,760 that's the clot risk period. That's the clot risk is 602 00:38:51,840 --> 00:38:53,639 if fibriantage and levels go up. 603 00:38:53,840 --> 00:38:55,880 Speaker 3: I've checked these levels. 604 00:38:56,000 --> 00:38:58,599 Speaker 1: Many, many, many many times over the years on patients 605 00:38:58,639 --> 00:39:03,119 who are higher risk and who were on transdermal therapy 606 00:39:03,159 --> 00:39:07,039 because of their risk, and I have never, not once 607 00:39:07,800 --> 00:39:11,400 had a fibridsion level that bumped up and was always normal, 608 00:39:11,400 --> 00:39:14,800 but never bumped up, never even moved transien. Yeah. 609 00:39:14,840 --> 00:39:19,320 Speaker 4: Yeah, I think in this time where newer and clearly, 610 00:39:19,480 --> 00:39:23,199 to God, after twenty four years of belaboring this, we 611 00:39:23,280 --> 00:39:28,760 have really good evidence to say that risk with transdermal 612 00:39:28,840 --> 00:39:30,400 therapy is pretty low. 613 00:39:30,519 --> 00:39:34,679 Speaker 1: Yeah, believe me, I was doing this twenty four years ago. 614 00:39:34,960 --> 00:39:38,599 That's how I started doing compounded hormone therapy because I 615 00:39:38,639 --> 00:39:40,800 had all these women who got yanked off of their 616 00:39:40,880 --> 00:39:44,840 hormones and they were miserable RECs. I thought there's got 617 00:39:44,840 --> 00:39:47,599 to be another way, and all we're looking at is 618 00:39:47,599 --> 00:39:50,599 permar and I have never written a permiram prescription in 619 00:39:50,679 --> 00:39:53,840 my career, not one. And that's how I started. That 620 00:39:53,960 --> 00:39:57,400 whole thing was wh I should be thankful for WHI 621 00:39:57,639 --> 00:40:00,280 I'm not, but I should be thankful full. 622 00:40:00,320 --> 00:40:03,039 Speaker 2: But maybe twenty two years earlier. 623 00:40:04,239 --> 00:40:07,239 Speaker 1: I mean it led me to look at what other 624 00:40:07,280 --> 00:40:11,760 options we have because no one was writing anything any 625 00:40:11,800 --> 00:40:13,440 hormone therapy at that time. 626 00:40:13,840 --> 00:40:17,440 Speaker 4: And I think if you're not seeing someone who's interested 627 00:40:17,559 --> 00:40:23,519 in hormone related issues right then across providers, it's a 628 00:40:23,599 --> 00:40:28,719 challenging population that requires a focused evaluation. If that person 629 00:40:28,920 --> 00:40:32,920 hasn't had the expertise in that focused area, then clearly 630 00:40:33,000 --> 00:40:37,440 there's a broad space for people who care about helping women. 631 00:40:38,440 --> 00:40:42,760 The vasomotor symptoms are debilitating. 632 00:40:42,280 --> 00:40:45,199 Speaker 1: Hot flashes and night sweats. Yeah, they're terrible, but that's 633 00:40:45,320 --> 00:40:48,360 the tip of the iceberg. I mean, so many women 634 00:40:48,400 --> 00:40:52,239 get put on antidepressants because all of the symptoms in 635 00:40:52,320 --> 00:40:59,039 perimenopause and menopause are almost identical to depression symptoms. Tired, 636 00:40:59,280 --> 00:41:02,440 gain way, we have no interest in anything. We have 637 00:41:02,559 --> 00:41:06,400 low sex drive, we're fatigued all the time, we have 638 00:41:06,519 --> 00:41:10,400 brain fog, we have poor mood, we have anxiety. When 639 00:41:10,440 --> 00:41:12,679 you give them that list to a provider, they're like, oh, 640 00:41:12,719 --> 00:41:13,840 let's put you on lexapro. 641 00:41:14,480 --> 00:41:17,519 Speaker 4: They're like, do I have my magic Wand today I 642 00:41:17,599 --> 00:41:19,679 do have a magic wand it shoots blanks, but I 643 00:41:19,719 --> 00:41:21,039 do have one. 644 00:41:21,280 --> 00:41:23,320 Speaker 3: But you know what, the easy fix is just to 645 00:41:23,400 --> 00:41:24,920 put you on this one pill a day. 646 00:41:25,519 --> 00:41:27,760 Speaker 4: But then you're just shoving pills at people, right. 647 00:41:27,760 --> 00:41:30,960 Speaker 1: Well, and you're not addressing the problem. Right, The problem 648 00:41:31,039 --> 00:41:34,559 is perimenopause or menopause. And I'm not saying you can't 649 00:41:35,000 --> 00:41:39,559 also need an antidepressant, but don't use that as a 650 00:41:39,719 --> 00:41:45,840 fix all for women's hormonal symptoms. That's not right, And 651 00:41:45,840 --> 00:41:48,519 that's why I was so busy for all those years. 652 00:41:48,559 --> 00:41:52,119 Speaker 4: Clearly, I don't think it's treating root cause well no, right, 653 00:41:52,239 --> 00:41:56,639 So again, you might need depression medicine for a period 654 00:41:56,639 --> 00:41:58,400 of time to get through some of the symptoms. So 655 00:41:58,960 --> 00:42:02,960 not under estimating the impact of treatment of depression, but 656 00:42:03,599 --> 00:42:07,000 more about focusing on root calls and solutions. 657 00:42:07,079 --> 00:42:11,119 Speaker 1: Well, oftentimes new patients I would probably say at least 658 00:42:11,679 --> 00:42:13,840 sixty or seventy percent of the time when I saw 659 00:42:13,840 --> 00:42:16,639 a new patient, they were already on an antidepressant that 660 00:42:16,679 --> 00:42:19,760 they'd never been on antipressant their entire life, but that 661 00:42:19,920 --> 00:42:23,679 minute they hit like forty eight, then they needed an antidepressant, 662 00:42:24,280 --> 00:42:27,840 and so I would say to them, look, I think 663 00:42:27,920 --> 00:42:32,920 you're antidepressant was started to address your pyramidopousm menopostal symptoms. 664 00:42:33,880 --> 00:42:38,519 We're going to work on fixing the menopausal perimenopausal symptoms, 665 00:42:38,840 --> 00:42:41,239 but we are not taking out your safety net from 666 00:42:41,280 --> 00:42:45,800 under you're I'm leaving this antidepressant on board, and when 667 00:42:45,880 --> 00:42:49,519 we're ready, we will look to discontinue and see how 668 00:42:49,559 --> 00:42:49,800 you do. 669 00:42:50,079 --> 00:42:52,000 Speaker 2: So how much of that was the harm of the 670 00:42:52,039 --> 00:42:55,960 black box? The warning that if you were a provider, 671 00:42:56,480 --> 00:42:59,360 the antidepressant didn't have a black box, so you weren't 672 00:42:59,360 --> 00:43:02,679 going to get into trouble prescribing that. Where if you 673 00:43:02,840 --> 00:43:06,400 prescribed something with a black box, then suddenly. 674 00:43:06,519 --> 00:43:09,480 Speaker 1: I think that's a piece of it. I think it's multifactorial. 675 00:43:09,519 --> 00:43:12,960 I think it's lazy practitioners, to be honest with you, 676 00:43:13,280 --> 00:43:16,119 I think it's lazy care. Look, I have a passion 677 00:43:16,159 --> 00:43:19,440 for this and I always did, and you sort of 678 00:43:19,480 --> 00:43:23,119 have to have that. To help menopausal paerimenopausal women. You 679 00:43:23,199 --> 00:43:26,199 need a passion, and most people don't have the passion. 680 00:43:26,679 --> 00:43:29,280 They don't want to take all the extra training. 681 00:43:28,960 --> 00:43:29,519 Speaker 3: That I did. 682 00:43:29,960 --> 00:43:34,519 Speaker 5: And hormans are complex and they're so complex and nobody 683 00:43:34,880 --> 00:43:37,440 has the time anymore because it's just a business. 684 00:43:37,480 --> 00:43:40,719 Speaker 1: Now. Medicine is a business. You know, if you can't 685 00:43:40,719 --> 00:43:44,039 get somebody in and out the appointment within fifteen minutes, 686 00:43:44,320 --> 00:43:47,639 you're losing money. So you have to want to spend 687 00:43:47,679 --> 00:43:50,719 time with people and that you have a passion to help. 688 00:43:50,559 --> 00:43:52,920 Speaker 2: Them treat the patient, not the paper. 689 00:43:53,000 --> 00:43:56,960 Speaker 1: That's right. That's right, the long and short of it. 690 00:43:57,239 --> 00:43:59,440 That's sort of the long of it right now. I 691 00:43:59,440 --> 00:44:01,119 do want to wrap this up, but we didn't get 692 00:44:01,159 --> 00:44:04,199 into the other things that are so important for in 693 00:44:04,280 --> 00:44:07,320 terms of having estradyle as we go into menopause is 694 00:44:07,400 --> 00:44:11,079 brain health and bone health. And I've talked about both 695 00:44:11,079 --> 00:44:14,320 of those things on previous episodes, so you can always 696 00:44:14,400 --> 00:44:19,000 look that up as a listener. But brain health is huge. 697 00:44:19,039 --> 00:44:23,840 There is a reason that Alzheimer's hits more women the men, 698 00:44:24,119 --> 00:44:27,360 way more women than men. Not that lack of estrogen 699 00:44:27,719 --> 00:44:32,199 causes Alzheimer's or dementia, but we are much more susceptible 700 00:44:32,280 --> 00:44:36,199 because our brains don't work very well without estrogen, and 701 00:44:36,239 --> 00:44:38,920 so that's why we get brain fog and then word 702 00:44:39,000 --> 00:44:44,639 recall problems, and then dementia or mild cognitive impairment whatever. 703 00:44:44,960 --> 00:44:45,880 Speaker 3: There are a lot of. 704 00:44:45,960 --> 00:44:51,599 Speaker 1: Pieces of the puzzle that estradile. Just reminding everybody that 705 00:44:51,639 --> 00:44:55,320 if you have a uterus, you can't just do estradiyle alone. 706 00:44:55,360 --> 00:44:59,920 You have to have progesterone too. Having hormones is key 707 00:45:01,000 --> 00:45:05,639 in terms of your overall health in menopause, and now 708 00:45:05,679 --> 00:45:09,639 we have studies showing that even after age sixty five, 709 00:45:09,840 --> 00:45:11,320 it's super important. 710 00:45:11,679 --> 00:45:16,960 Speaker 2: And hopefully this outrage that started this whole conversation, yes, 711 00:45:17,320 --> 00:45:21,599 will be resolved and all of the people in need 712 00:45:21,599 --> 00:45:25,440 will have access, and providers will step up, and the 713 00:45:25,480 --> 00:45:30,519 pharmaceutical companies will start producing and the insurance companies will 714 00:45:30,559 --> 00:45:34,840 stop protesting and life for everyone can get better. 715 00:45:35,920 --> 00:45:38,840 Speaker 1: I think the production is better. I think people are 716 00:45:39,239 --> 00:45:42,559 able to get their estradial patches more easily. 717 00:45:42,920 --> 00:45:43,719 Speaker 3: So that's good. 718 00:45:43,920 --> 00:45:44,719 Speaker 2: That's good. Good. 719 00:45:45,239 --> 00:45:47,280 Speaker 3: Yeah, do you have any last comments? 720 00:45:47,440 --> 00:45:50,559 Speaker 4: Steven, I was trying to fund that subgroup and els 721 00:45:50,639 --> 00:45:53,320 I wanted to have a little wrap on the Oh. 722 00:45:53,199 --> 00:45:55,840 Speaker 1: Well, we can do an addendum on the next podcast. 723 00:45:56,039 --> 00:45:58,280 We'll do that next time, I promising. 724 00:45:58,800 --> 00:45:59,039 Speaker 3: So. 725 00:45:59,440 --> 00:46:03,800 Speaker 1: I want to thank Keith and Steven so much. This 726 00:46:03,880 --> 00:46:08,119 has actually been fun and lively conversation. I really appreciate it, 727 00:46:08,320 --> 00:46:11,280 and many thanks to all of you for listening. Wherever 728 00:46:11,320 --> 00:46:14,000 you listen to this podcast, please leave a review and 729 00:46:14,119 --> 00:46:18,239 rate the podcast. Your reviews and ratings matter. Also, make 730 00:46:18,280 --> 00:46:20,199 sure you follow the show so that it will be 731 00:46:20,280 --> 00:46:24,119 automatically downloaded. That really matters. I encourage you to visit 732 00:46:24,159 --> 00:46:26,599 our Facebook page imb Podcast, where you can give us 733 00:46:26,599 --> 00:46:30,360 a like and leave comments or questions for me. Our 734 00:46:30,360 --> 00:46:34,039 website is itchymbitchi dot com, where there are blogs with 735 00:46:34,119 --> 00:46:37,559 some of our subjects available for you to read. Thank 736 00:46:37,599 --> 00:46:41,440 you to Forrest Winsl, my son, our producer and composer 737 00:46:41,480 --> 00:46:43,559 of our theme music and the person who does all 738 00:46:43,599 --> 00:46:46,559 the behind the scenes work to make this podcast possible. 739 00:46:46,639 --> 00:46:51,000 And Forest will be sharing his producing knowledge and expertise 740 00:46:51,199 --> 00:46:54,239 with Stephen and Keith to help with the transition. 741 00:46:54,920 --> 00:46:57,639 Speaker 2: Thank you for one of your son. 742 00:46:57,800 --> 00:47:02,480 Speaker 3: Thank you for help. You guys are fast learners. 743 00:47:02,519 --> 00:47:02,960 Speaker 2: You'll begin. 744 00:47:03,880 --> 00:47:07,159 Speaker 1: Forest continues to thrive at Peabody Music Conservatory and is 745 00:47:07,239 --> 00:47:11,880 finishing up his final final semester of the Master's program. 746 00:47:12,360 --> 00:47:14,880 Forest was recently informed that he was admitted to the 747 00:47:14,920 --> 00:47:19,320 Peabody Doctoral Program to receive a Doctor of Musical Arts 748 00:47:19,360 --> 00:47:23,480 in Composition. His dad and I are so happy for him. 749 00:47:23,639 --> 00:47:27,880 It is fun to see his immense musical talents being recognized. 750 00:47:28,119 --> 00:47:29,880 If you want to listen to what he is creating, 751 00:47:29,920 --> 00:47:34,320 You can go to his website Forrestwinsl dot com and 752 00:47:34,639 --> 00:47:49,639 always remember that your health is in your hands.