During the meeting, the following key points were discussed:

1. Strontium:

  - Strontium is a natural mineral similar to calcium and can be used to increase bone mineral density (BMD).

  - Strontium ranelate, a drug once available in Europe, was taken off the market due to side effects like blood clots and DRESS syndrome.

  - Strontium citrate is now used in supplements, showing evidence of improving BMD but not definitively proven to reduce fracture risk.

  - There is no significant downside to taking strontium citrate, but it's not clear if it improves bone quality or reduces fracture risk.
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2. Hormones:

  - The discussion on hormones covered the importance of testosterone, estrogen, and progesterone in both men and women.

  - Testosterone is the primary sex hormone in women, with benefits including improved libido, muscle mass, energy, and bone density. Side effects can include oily skin, acne, and hair changes.

  - Progesterone is beneficial for sleep and bone health and is generally safe to use, with minimal side effects.

  - Estrogen therapy was once considered a panacea but faced backlash due to studies like the Women's Health Initiative, which linked it to breast cancer. However, further analysis showed that synthetic progesterone, not estrogen, was likely responsible for the increased risk.

  - Estrogen is protective against colon cancer and fractures, and when started within 10 years of menopause, it does not increase the risk of heart disease.
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3. Vitamin D and K2:

  - Vitamin D helps with calcium absorption, while vitamin K2 helps direct calcium to the bones instead of arteries.

  - There is no significant risk associated with taking vitamin K2, even with hormone replacement therapy.
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4. Hormone Replacement Therapy (HRT):

  - Topical application is preferred over oral for estrogen to avoid potential liver damage and blood clots.

  - It's important to monitor hormone levels to ensure they are within a therapeutic range.

  - Starting estrogen therapy more than 10 years after menopause may carry a risk of heart disease, so cardiac imaging like coronary artery calcium scoring is recommended before starting HRT in this population.
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5. Q&A:

  - Participants asked questions about the safety of starting and stopping strontium, the medical recognition of natural supplements versus pharmaceuticals, and the specifics of hormone levels for HRT.

  - Concerns about vitamin D and K2 interaction with blood clotting were addressed, clarifying that there is no increased risk unless on specific blood-thinning medication like Coumadin.

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Dr Doug: and I know there are infinite questions on supplements, but I thought we would take at least one

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Dr Doug: Bev. Bev wants to talk about estim. Alright. I'll talk about estrontium, but aside from that, let's take a moment to talk more about hormones. We've had just a kind of a buildup of questions on on women's hormones and men's hormones

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Dr Doug: for any men that are here, although I don't actually see any men that are here. Oh, there's one, there's 2. There's 3. Okay, we're good. So if there's questions on testosterone. Specifically, then we can talk about testosterone. Otherwise I think we can talk about most of those through the the lens of working for men. Oh, or sorry for women. There's another man day, David.

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Dr Doug: so let's chat about strontium strontium. Then out of the gate, Bev

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Dr Doug: And then, John, since you're new, and you want to talk about reclass. We can talk about reclass

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Dr Doug: so, and then we got no hormones. All right. So if you have questions, go ahead and drop them in the chat.

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Dr Doug: And let's shift after these first couple of topics to talk about hormones.

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Dr Doug: Good to see everybody today. I know, too, we have Don, who's usually here in pipes in on slack. If you're not on slack. She's been

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Dr Doug: really active on slack, and helping us out.

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Dr Doug: She is on audio. Only if she's gonna be here at all. She had a visit with a family member's doctor. She had to be their champion.

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Dr Doug: So anyway, let's talk about strontium. So strontium is a kind of an interesting natural element I actually have. I don't go upstairs.

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Dr Doug: I was just doing some some photos with some of the algae products in preparation for a launch of our affiliation that we're coming out with. So I have, like 5 bottle of strontium. So strontium is really interesting, and it is a natural mineral. So it is in the same row of the periodic table as calcium. It's very similar to calcium, and that's why you can use it

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Dr Doug: in lieu of calcium, and you will see an increase in bone marrow density. Because if you look at the periodic table, it's

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Dr Doug: heavier than calcium, but it's used in a very similar way.

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Dr Doug: So I don't know who figured this out, but at some point somebody figured out, hey, if we substitute strontium for calcium, and you build more of your bone with strontium, or then calcium, your bone and identity will go up. Which is true.

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Dr Doug: But the question is.

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Dr Doug: does it actually reduce fracture, risk, and will it improve on quality?

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Dr Doug: So there was a drug company, and I don't know what the drug company was, but this was a drug that was released in Europe called strontium ranulate. I don't know that the brand name was, but that was the generic was strontium, ranulate and and ranelic Ranelic, whatever it is, the ranolate part, I think, is renellic acid. What it was compounded with.

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Dr Doug: Is a synthetic I don't know what it is, but it's a synthetic thing that they added on to strontium. They made this drug and they ran drug trials like you would any drug. And it did improve fracture, risk in in theory, then, would improve bone quality.

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Dr Doug: The problem that I saw with this was that the drug is now off the market and strontium ranulate had some weird side effects increase in blood clots increase in this thing called dress syndrome, which is sort of weird. So too many side effects, too much risk. We took it off the market. And there's other options.

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Dr Doug: And so now in the Us. And in Europe. To a some extent, strontium citrate, which is a sip citric acid is natural. Citrate is the natural way that you can combine things, and lots of elements are combined with with citrate. So you can get

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Dr Doug: a

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Dr Doug: molecule that has those 2 things in it. Strontium citrate is then added into supplements, and strontium citrate is available for supplementation, and there is evidence through algae calzone studies which we looked at before a couple weeks ago. Through Algecow's own studies, you can see that the product of the algae based product alone

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Dr Doug: is not as good as the algae alga, based product with strontium at improving Bulmer density. But those studies were not powered enough or done in a way in which you could look at fracture risk. So we can't say that we know anything about strontium, citrate fracture, risk.

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Dr Doug: I hear often that people will say, well, but strontium ranulate, reduced fracture, risk, and likely improve bone quality. So we should say that that's the same. That's true for strontium citrate. I don't think we can say that.

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Dr Doug: So that's that's kind of a that's a frustrating thing. And I and I hear that

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Dr Doug: from a lot of people in the supplement space, they say, always just use strontium, because we know it reduces fracture risk. I don't think you can say that that's true.

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Dr Doug: I think we can say that it improves momentum density. The flip side of that is, people will say, Well.

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Dr Doug: if you use Tractium, and it increases your bone. Mineral density. Is that

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Dr Doug: is it falsely elevated? And that's sort of a concern to say, well, if I use this strontium product, my bone marrow density is going to go up more than it would with calcium. That's true.

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Dr Doug: But what does that really mean? Is it falsely elevated? And I hear that a lot is falsely elevated? I don't think it's falsely elevated. I think it is what it is. We know that it's going to improve vulnerable density faster than calcium. So just take that for what it is. I don't think there's a downside. I don't think there's any risk of taking it other than cost.

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Dr Doug: doesn't seem like it's worsening bone density or sorry worsening quality.

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Dr Doug: So I think that we're we're fair and saying that there's probably not a downside. It will improve bulity. But will it improve quality, and will it reduce fracture risk? I don't think we can actually say that. Does that make sense?

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Dr Doug: And, Bev, that was your question. So anybody else have? Any be? Have any follow-ups to that or any other questions on strontium.

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Dr Doug: Diane? Yes, ma'am.

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Dr Doug: can you unmute Diane?

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Dr Doug: Diane, do you? Wanna if you can't unmute, can you drop it in the chat? And I'll say one more thing about.

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Diane K Miller: Can you hear me?

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Dr Doug: There's there somebody's talking.

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Dr Doug: I can't hear you, Diane, because I know that you're muted.

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Dr Doug: Joanne has a question. Hi, Joanne.

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Joann Andrews: Question. I had read that if you started.

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Dr Doug: Hey, Joan, you're kind of breaking up there. But I think I got your question, which is, if you start strontium.

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Dr Doug: can you stop, strong, Tim, is it safe? And I think that the answer to that is we we really don't have good studies to to know what the answer to. That is my thought just from a function perspective is that

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Dr Doug: if we assume that there's no negative of substituting strontium for calcium, then I think you can start and stop at will, and there's going to be no negative impact.

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Dr Doug: Will you eventually lose momentary density as a result of that? Yeah, if you turn over your bone, and you then re-replace calcium for strontium.

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Dr Doug: Then probably

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Dr Doug: right. But hopefully, you're doing other things to improve your bone other than just that intervention. So I don't think that you're gonna see like a rebound and fracture risk like you would with Prolaa or anything like that. So

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Dr Doug: I don't think there's really again a negative. Does that that answer your question, Julian?

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Dr Doug: Any other questions? Hi, Diane, yeah.

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Diane’s iPad: Sorry I I froze. So I left the meeting came back.

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Diane’s iPad: So I I take strontium and yes, in 6 months my Dexa improved. I attribute that to. I tribute that improvement to to the strontium because it's too soon for anything else, and I wasn't on Hrt yet. but I have. I have quite poor

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Diane’s iPad: t scores. So but my question and I did a lot of research and thank you for speaking to this, but my, my biggest question that comes out, and I'm familiar with the rental aid versus the citrate and and and such. My question is, is, if it's medically recognized that if you take an artificial pharmaceutical which coats coats it, your bones

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Diane’s iPad: improves your dexa.

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Diane’s iPad: and and and then hence it is determined reduces your fracture risk.

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Diane’s iPad: Why isn't it medically accepted that if you take a

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Diane’s iPad: natural.

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Diane’s iPad: it does something naturally that again does the same thing goes, and I get it. That it's calcium is is, you know, where it is on the periodic table that it's not recognized that

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Diane’s iPad: it, too.

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Diane’s iPad: is valid to have the same

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Diane’s iPad: outlook as it it. If the dex is improving because of it, or potentially because of it, then why is it not recognized as also lowering your fracture, risk.

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Dr Doug: Yeah, let me let me give you an example. And and the short. The short answer is this, which is.

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Dr Doug: we don't know. If you look at the synthetic drug, we don't know which component was actually resulting in the reduced fracture risk.

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Dr Doug: Right? So what does ran allic acid, or whatever the synthetic part is, did that actually have an impact on the bones that we wouldn't recognize through strontium citrate? The only way to know is to do a a side by side comparison in a big enough study to actually look at at reduction and fracture risk. And that study is never gonna happen. Because A, we're not using the drug. And B. No one would ever pay for it. So so we we can't. We can't do that study.

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Dr Doug: I think. What could happen. And I'm encouraging Algecow to do this, since they're probably the biggest purveyor of strontium in the world is to let's design a study and let's run parallel with both of their products side by side, and then one without strontium power. It save enough people to look at fracture, risk, and then run it for long enough where you can actually see enough fractures.

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Dr Doug: Right? So that's the study that needs to be done. And and who knows? We might see that. And again, if there's really no downside, I do still use it in practice, and the way I use it in practice is for people like yourself, Diane, where, if they have a very low T score, and let's say that they've even had a fracture, it really doesn't matter, but if they have a very low T score. We're not going down the pharmaceutical pathway. We want to do everything we want to throw kitchen sink and the disposal

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Dr Doug: and the laundry room sink at it. Then? Yeah, why not? Because what's the downside other than pill fatigue and cost?

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Dr Doug: I don't think that we're going to see the risk, and we're going to see more rapid improvements in Bmd. And it very well may improve fracture risk. We just don't really know.

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Diane’s iPad: Right. And when I'm and it's not just the strontium rentally, it's it's any prescription that we're w is suggested to us. To take that will like say, reduce your fracture risk. I mean, I've been to all the special, all the doctors that's the same. It's the same thing and no that. And I get it. They're not gonna discuss the strontium. They don't even know. But but I guess for me, myself and my logical brain. It's like, Okay, if you're giving an artificial pharmaceutical, I don't care which one.

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Diane’s iPad: And you're saying that it's this, what it's gonna do. It's gonna artificially. It's gonna do something artificially inside your body

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Diane’s iPad: to reduce your fracture risk. Then why is it not equally valid that something

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Diane’s iPad: that's not a prescription? If that's having that same outcome on. Because all based around the dexa, right? It's all based around the.

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Dr Doug: Well, yes, yes and no. And then this is where we run into issues. Is that if you, if you say that it's all based around the dexa, you run into challenges because it's not. We know that fracture risk is not actually based around Dexa. Right? Cause, it's it's quality and quality.

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Dr Doug: And so this way, if you look at like estrodial studies, if you look at what's the other term?

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Dr Doug: I'm blanking on it. But there's another drug, a vista relaxaphene.

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Dr Doug: You know, if you look at those studies, they didn't really improve Dexa much, but they reduced fracture risk because they improved quality over quantity. So we can't say that it's just Dex and anything that improves Dex, it will improve fracture risk, because we also see it. If you take. We'll talk about reclass in a second. If you take reclass, which is a bisphosphonate. Ib bisphosphonate. You take that drug for, you know. 10 years. Then you're gonna have an increased risk of fracture, even though your pulmonary density is gonna be a lot better

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Dr Doug: right.

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Diane’s iPad: Understood.

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Dr Doug: So we can't say that. And let me give you one more analogy just to drive this home. And this is in a an exact analogy. But if you look at something like what's the what am I thinking of? Statins and like reduced rice? Alright? So we're all familiar with cholesterol statins. Lower cholesterol statins reduce really secondary events. But let's just say statins reduce heart attacks for ease of conversation.

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Dr Doug: Red yeast rice works through a similar mechanism, and it reduces cholesterol to some extent.

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Dr Doug: But it doesn't seem to reduce events.

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Dr Doug: Why reduce rice is natural statins or not

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Dr Doug: uses the same mechanism. Why doesn't red yeast rice reduce events? Well, maybe because it's not powerful enough, or maybe because it's something else in the statin that is causing an anti inflammatory effect, and it has nothing to do with the cholesterol, which I think is probably more true.

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Diane’s iPad: Hmm.

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Diane’s iPad: Brian.

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Dr Doug: We just don't know. And those studies have been done right reduced rice and other natural things like bergamot compared to statins. Yes, they lower cholesterol. They likely reduce risk, but they don't reduce events.

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Diane’s iPad: Understood. Thank you. I appreciate the clarification. This has been like almost a year worth of.

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Dr Doug: Well.

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Diane’s iPad: Strontium dilemma, not the dilemma, because it's important to me to take, but it's controversial.

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Dr Doug: It is controversial, and I think it's fine to take, and we do recommend it. It just doesn't usually make the cut unless somebody has a really low T score.

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Diane’s iPad: Thank you. Richard.

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Dr Doug: So alright, so for everybody that hasn't spent the last year studying that you can wipe that off your to do list.

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Dr Doug: Alright. So let's let's move on to talk about reclass for a quick second, because this is a quick answer. So John was asking, Does reclass cause bone damage remodel in the remodeling process? If so, for how long?

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Dr Doug: It's a it's a really good question. So like I said, reclast is a bisphosphonate goes by a couple of different names in different countries. But

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Dr Doug: it's essentially the best phosphosphony that you get once a year. Right?

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Dr Doug: So whenever something is

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Dr Doug: dosed once a year, you know that it has a really long half-life, meaning that the amount of time that it takes for your body to process and eliminate half of the drug.

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Dr Doug: It's gotta be probably around, you know, 6 months or potentially longer, right? Whatever the therapeutic level of that drug is. So that drug is, gonna be in your system for a really really long time. Even if you take one dose, it's probably still in your system for whatever 2, 5, 10 years even, who knows?

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Dr Doug: Would there be enough of it to actually have an impact on bone metabolism?

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Dr Doug: Probably not after like the 10 year mark, but somewhere in there the answer is, yes.

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Dr Doug: So we know that this phosphonates will reduce bone metabolism. It they poison osteoclasts, they eliminate bone turnover.

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Dr Doug: That's how they work. They also then, because Osteo class, the breakdown cells and osteo blasts, the buildup cells are are linked metabolically. When you reduce one, the other one will come down to. So when I see somebody that's been on reclass and they get their bone health labs, their bone bone biomarkers. The Ctx is very low double digits right in like low double digits when it's usually in the, you know, 200 to 500 range somewhere around there.

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Dr Doug: P. One and P. Which we would love to see, you know, 50, 80, a hundred, if possible. It's gonna be in the single digits. So they're both just extremely squashed.

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Dr Doug: And that's just really slow bone turnover. Now you have enough. P. One and P. Enough osteoblast functionality that you're going to increase bone marrow density over time a little bit, but you don't have enough breakdown to make room for new bone, and that's why those bones become more dense but fragile.

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Dr Doug: Next hinds.

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Dr Doug: Alright, so it's a kind of a vague answer to your question, John. Sorry about that.

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Dr Doug: yeah. Cheryl is asking about a supplement a NATO, and this is actually a good transition into

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Dr Doug: serms and hormones.

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Dr Doug: Yeah, so

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Dr Doug: And I don't know if I'm saying that right, Anita anato, whatever that's fermented. Soy. So

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Dr Doug: it's I don't know that I'd even call it a supplement. It's a real thing. It. I think that it probably works for bone health through a couple of mechanisms. It's fermented. It's gonna have an impact on gut health. And it is also a serm. So it is a what's the right word.

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Dr Doug: a flavonoid impacts estrogen receptors. There's a better word in there, but it has an impact on estrogen receptors, and that's why it lowers Ctx. So yes, it can do that. Some people would say that cultures that eat a lot of fermented soy are gonna have a lower fracture risk. And I think that that might be true, but might be for other reasons. Those are epidemiologic studies. Is it impactful enough to reduce fracture risk on its own? Or as a supplement. I don't know that it's ever been studied for that independently, but it works through hormone receptors.

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Dr Doug: So then oh, Hi, Edie.

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Dr Doug: so everybody. Edie is one of our new coaches.

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Dr Doug: I 80. Okay, so anyway. So

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Dr Doug: think that, let's just take us a moment and start talking about hormones. I know, David.

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Dr Doug: we can talk about. We can talk about drugs another day

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Dr Doug: and no Beth, I don't take strong team.

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Dr Doug: but I don't have osteoporosis.

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Dr Doug: Egg shells don't contain strontium.

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Dr Doug: Can you stop strong team when started? Bab? Yeah.

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Dr Doug: alright.

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Dr Doug: I'm gonna stop there. Let's talk about hormones for a minute.

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Dr Doug: And I finally, Lori or Laura said, I finally found a doctor. That will do Hrt. In my area, but she will only do pellets. I have heard that cream is better. Is that true? Let's talk about hormones. Okay, so little pivot hormone replacement. There are really 2 main components. When most women are talks to about hormones. There's estrogen and progesterone. Right? Those are the 2 dominant hormones that are discussed with Hrt.

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Dr Doug: There are 3 primary sex hormones, estrogen progesterone and testosterone, and everybody here, maybe, except for Edie, has heard me say that the dominant sex hormone and women is testosterone and that's surprising to most people when they hear for the first time. Yet, when we talk about hormone replacement, most doctors don't talk about

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Dr Doug: test, Astro.

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Dr Doug: but let's talk about each one, and we'll go through the benefits potential risks. Let's talk about testosterone, because there's less risk to talk about and more benefit.

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Dr Doug: So testosterone like I said, primary sex hormone in both women and men in men. We just replace testosterone and let it do all the work. In women. We can replace testosterone, but not all women are deficient in testosterone. So testosterone and women different from men is made about 25% in the ovaries. So therefore, post menopausal women, you can eliminate that 25%. But the other 75% is made either directly in the adrenal glands or from

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Dr Doug: precursor molecules that are also made in the adrenal glands. So 75% of a woman's testosterone is made in her adrenal glands. That's why women are so exquisitely sensitive to stress in reductions in testosterone and sex hormones as a result of stress and not living by their natural rhythm.

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Dr Doug: And so a post menopausal woman who has lifestyle dialed in may actually have way, less symptoms of menopause, because she has adequate testosterone. So many of the symptoms of menopause are not coming from estrogen deficiency. They come from combined estrogen and testosterone deficiency.

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Dr Doug: And so for women that go through. And I think this used to happen probably decades ago, right or centuries ago women would go through menopause and not be as symptomatic as they are today, because they still had adequate testosterone, adequate testosterone will still aromatize a little bit into estrogen or convert into estrogen, not at the same levels that your ovaries make, but at some extent which could potentially be enough to help alleviate the symptoms of menopause.

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Dr Doug: So, not having adequate testosterone is a really big deal. As a woman goes through that perimenopause and menopause transition.

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Dr Doug: We can add testosterone back for a a number of potential benefits. When you look at the literature, it's really mostly driven around this thing called Hsdd, or hypoactive sexual desire disorder.

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Dr Doug: And it's really unfortunate that the medical community has really only grasped on to testosterone use for women when it comes to libido and sexual function. And it does improve libido and sexual function.

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Dr Doug: But the problem with Hsdd is a diagnosis is it's a psychiatric diagnosis. Most doctors don't want to deal with that. Most doctors aren't going to diagnose the one with Hsdd. And a lot of women are. Gonna talk to their doctors about those symptoms about the loss of libido. You know. They might talk about vaginal dryness. They might talk about chronic uti, other genital, urinary stuff.

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Dr Doug: but they're they're not as likely to talk about issues with intimacy, you know, loss of libido issues with their partner, etc. So it just doesn't really get diagnosed very often. And even if you did diagnose it as a doctor. There's no commercial testosterone product to prescribe. So why would you? Why not just say that you have anxiety? You have depression, and you need an Ssri which is also gonna take your libido, by the way.

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Dr Doug: and so it's it's really underutilized. Doctors don't have a tool to use, even if they wanted to. They have to use a compounding pharmacy, and it's a controlled substance like a narcotic. So then they're also prescribing and under fear of being questioned about why they're prescribing a controlled substance to a compounding pharmacy which they've been told is not a good way to prescribe drugs for for patients. So it's this really nasty tangle of of how to manage testosterone deficiency for women.

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Dr Doug: But let's say you get testosterone, whether it be from a pellet or from a cream, or whatever. Let's say you get testosterone. What's it gonna do for you? Well, the studies very clearly show that it will improve Lapita on sexual function. That's all great. But it will also improve your ability to maintain and develop muscle mass. It'll improve body composition so that body composition change that occurs. As you know, perry menopause, menopause, hormonal changes happen. You develop. You know, visceral.

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Dr Doug: that around your belly you kind of lose the the feminine shape, and you become more like a masculine shape, because you have more of a sex hormone profile than man that will reverse, and it does reverse.

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Dr Doug: You can see improved energy. What we call like improved vitality improve. G, you know, all of those things go to make someone feel a hell of a lot better

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Dr Doug: so for women that are testosterone deficient. This is a really really big deal. And all this is true in men, too. By the way.

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Dr Doug: so testosterone specifically for bone

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Dr Doug: testosterone will indirectly impact bone through muscle. We know that the more muscle you have the better your bone quality and and quantity but it actually directly impacts bone, too. And there are not studies of women. But there are studies of men that show testosterone replacement, and men will improve bone mineral density and will reduce fracture, risk.

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Dr Doug: will, and what will directly impact bone.

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Dr Doug: So for me, this is a no-brainer.

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Dr Doug: as far as downsize. When can you not use it. And the answer is.

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Dr Doug: you know, maybe for women that have breast cancer, probably not right. If they're trying to eliminate all estrogen, then potentially testosterone is gonna not potentially, it will testosterone will aromatize into estrogen. So oncologists are not real keen on women with breast cancer or having had breast cancer. Taking testosterone. However, you can block that aromatization. So there is a pathway here where you could potentially use testosterone aromatase inhibitor.

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Dr Doug: have some of the improvements of testosterone, but block estrogen completely. But that takes a coordinated conversation with a pretty liberal oncologist.

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Dr Doug: But outside of that there's really not a reason not to use it. The cardiovascular risk has not been established in women or men. So there's not a time after menopause in which you potentially shouldn't start testosterone.

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Dr Doug: There are some potential side effects. So all the androgenic stuff, so boily skin, acne, hair, loss and hair growth is such a weird one. All those things are possible, and women respond very differently to each of them. So some women can take super high doses of testosterone and not see any side effects which makes it really easy. Some women are pretty sensitive,

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Dr Doug: oily skin, not a big deal acne plus or minus. There's ways that you can work with. That hair. Loss is a really big deal to women. I obviously don't care. But for women this becomes a really big thing.

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Dr Doug: more so than hair growth is the feedback that I get. Women don't like to lose their hair totally appreciate that. The challenge around hair loss is that

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Dr Doug: said, it's not, you know, from the testosterone. And, in fact, when you look at studies on testosterone

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Dr Doug: in women generally, you're going to see a higher impact from the placebo than the testosterone itself.

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Dr Doug: So there's gonna be more hair loss in the Placebo group than the testosterone group. I think there's something so

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Dr Doug: so I don't know. So concerning the placebo effect is so strong around testosterone so I think we do kinda see it. But I think it's also real, so we can reduce dose. We can do lots of things. There's other drugs you can potentially take. So you can men, you can limit the side effects if they occur. We find probably I don't know what percentage of women, probably 10%. So it's not big. But some percent of women will not tolerate the androgenic side effects. That's the biggest downside

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Dr Doug: any questions on testosterone.

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Dr Doug: I want to get into the pellet thing. But other than that, any questions on testosterone.

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Dr Doug: Yeah, Lorna.

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Lorna Nichols: So as far just to recap what you just said. You said 10. So of the women you've

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Lorna Nichols: worked with with testosterone.

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Lorna Nichols: 10. What percent have had hair loss to the extent that it was troublesome.

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Dr Doug: Gosh, less than 10%. So I'd say 10% are complaining about some kind of, you know, hair loss, hair growth.

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Dr Doug: And to be clear on that hair. Loss is on the head. Hair growth is on the face generally. It's unfortunate

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Dr Doug: of women that have been really

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Dr Doug: troubled by it. I mean, I can only think of maybe 2 off the top, my head.

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Dr Doug: and and there's also, you know, just not not to like poison this idea. But

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Dr Doug: the hair loss that comes, you know, we call in a temporal area of the head that hair loss in women is reported to potentially not even return. So if a woman is seeing this, then she needs to really address it aggressively.

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Dr Doug: You know. And again, there are ways to address it. I've only had one woman that I can think of discontinue testosterone because she just was. She was rapidly losing hair. She was also under a lot of stress from other things, but

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Dr Doug: she blamed the testosterone. So we stopped testosterone.

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Dr Doug: let me just mention the pellet thing real quick. So pellets are really popular for providers, because pellets you can charge for the the procedure of putting the pellet in

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Dr Doug: the problem with pellets is that you can't tick it out.

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Dr Doug: And so if a pellet goes in generally, the dose is going to be pretty high, and it's going to have a long half-life. So it's going to last for about 3 months.

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Dr Doug: And I see women that come in with testosterone levels through the roof, and they don't feel good just like a guy like, I know, guys I know body builders that take like most men are gonna be between 100 200 milligram

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Dr Doug: around a week.

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Dr Doug: I know, take grams of testosterone meaning thousands of milligrams of testosterone.

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Dr Doug: And they do it because they wanna get massive right? And it does help. But they are also they're impotent. They have erectile dysfunction, they have swelling like they don't feel good. Too much test. Astro is not a good thing in a man or in a woman.

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Dr Doug: and when you get a pellet as a woman, and it drives your testosterone well into the range that we would see for men, they don't feel good, and and you can't get it out. So you're on this roller coaster for a couple of months, and that really sucks also, if you have significant side effects like hair loss, and you have a pellet end

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Dr Doug: shoot

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Dr Doug: like you're again. You're on this ride, and you can't get it out.

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Dr Doug: so I don't like pellets for that reason. I also think that you're gonna get higher conversion. Like as you. I see this in men, too, as you get higher swings depending on how you dose it. That's why I like creams which are daily for really both men and women, although men, we think. But the reason why I like creams is that you get a kind of a daily rise and fall, rise and fall. And that's actually very natural, right? This is what our body does naturally.

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Dr Doug: lot of men will do once a week, injections or twice a week injections. And so you get a kind of a super physiologic rise, and then a super physiologic fall.

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Dr Doug: and you get symptoms with both. As you get higher. Your body's going to try to get rid of that testosterone, aromatize it faster, upregulate those enzymes. And you're actually going to see more side effects.

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Dr Doug: So I've done this even personally and myself. I've been on testosterone. For about 5 years

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Dr Doug: I burned out my adrenal glands.

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Dr Doug: From doing all the things that I do. But what I noticed is, I can go if I go down to like twice like every other day dosing I could do every day, but it's just a lot of needle sticks, but every other day dosing for me. Then I don't need anything for acne. I don't see androgenic side effects. I get still, see all the benefits of the vitality and everything else. So less free or more frequent dosing is better. And that's again, why I like creams or potentially injections even for women. But definitely. Both of those are appellates

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Dr Doug: that all makes sense.

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Dr Doug: Okay.

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Dr Doug: so let's talk about Progesterone. Just an easier one. So progesterone

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Dr Doug: traditionally is only given to women that have a uterus, and they're given estrogen because they're worried about the endometrial lining building up. And then you could potentially increase your risk of a breakthrough bleeding, which is not fun for a woman who's stopped having cycles to start having them again, but also increases your risk of endometrial cancer. So for women that have a uterus, and they're put on estrogen. They will also be given Progesterone.

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Dr Doug: Let me just take a quick moment to talk about

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Dr Doug: artificial progesterone versus natural natural ish progesterone. So this goes will lead into the conversation around estrogen. But big studies like the Women's Health Initiative. 1 million women study like all these big studies that came out in the early 2 thousands. Generally we're using an oral form of estrogen called premarin, which was made from horse, urine.

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Dr Doug: or and or and they used a synthetic progesterone, and, like the Women's Health initiative, for example, they use provera in the intervention, and provera is hydroxy progesterone acetate Mpa, really, really common progestin, which is a synthetic progesterone.

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Dr Doug: The implication there is that the progestins also they react with both progesterone receptors, but also estrogen receptors.

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Dr Doug: And so when you look at studies like the Women's health Initiative, and you start seeing these potential risks and side effects, you don't know. Is it coming from the estrogen or the progestin. I'll talk about

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Dr Doug: that in a minute. But the evidence is really clear that the natural, more natural progesterones

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Dr Doug: and we call it micronized progesterone. Promet is the commercial brand, so there is a commercial product here. The commercial micronized progesterones, or the compound and micronized progesterones do not carry the same risk as the synthetic progesterone, and that is

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Dr Doug: very clear. So progestins not the same thing as Progesterone. All right. Now, Progesterone is kind of cool because there are progesterone receptors everywhere in the body, not just in the uterus. So traditional medical model says, well, if you've had a hysterectomy. You don't have a uterus. You don't need Progesterone.

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Dr Doug: I call bullshit on that because you have progesterone receptors everywhere. There's actually studies looking at Progesterone alone. And women that are higher at higher risk for breast cancer. Don't wanna take estrogen using progesterone alone to improve symptoms of menopause. It's not quite as effective, but it does work to some extent for some women, so you can do a lot of things with progesterone. Bone also has receptors for Progesterone.

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Dr Doug: Sleep is improved by oral progesterone use. So I see a lot of women that are struggling with osteoporosis, and they have insomnia or poor quality. Sleep

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Dr Doug: progesterone again. No Brainer, what's the downside? There's almost none

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Dr Doug: right, unless you take Progesterone, and you take too much, and your dose is too high. You can feel hungover in the morning. But outside of that there's really not a downside of taking Progesterone. There's really no risk

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Dr Doug: that I'm worried about in a woman, regardless of how long she's been since she had her last cycle, and she's been into menopause. Does that make sense

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Dr Doug: so progesterone? No brainer

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Dr Doug: and then there's estrogen.

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Dr Doug: So estrogen is the more controversial, I guess, of the 2 that are most commonly used, testosterone is the most controversial overall.

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Dr Doug: so estrogen was really popular for everything under the sun. It was considered a panacea before the 1990 S. Really.

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Dr Doug: which was part of the problem because doctors were saying, oh, it extends lifespan, and it'll you know it's anti-aging, and it makes everything better, and it does make a lot of things better.

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Dr Doug: But I think the doctors were probably a little too aggressive with their recommendations. And so then there was this backlash of academic doctors who were saying, Well, that that's not true, and you can't say that. And we need to do the studies that prove it. And so then, was born

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Dr Doug: and women's study, the Women's Health Initiative, you know, all of these really big, well funded, massive trials, looking at hormone replacement therapy, and really the the biggest claim that they were pushing against was the claim about heart disease. So people talk about the Women's health Initiative and how it was. You know what it, how it was looking at breast cancer and and estrogen and hormone replacement. That's not really true.

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Dr Doug: The primary outcome of the Women's Health Initiative for the hormone replacement trial was looking at cardiovascular risk. They were looking at heart attacks.

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Dr Doug: And so

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Dr Doug: when they designed this trial and I'll I'll talk about the Women's Health Initiative because I know at the past.

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Dr Doug: But when they designed the women's health initiative. They were looking at primarily heart attack outcomes for hormone replacement.

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Dr Doug: Then all these other potential things. So they were looking at breast cancer, colon cancer fracture risk they were looking at.

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Dr Doug: What else is really relevant in there

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Dr Doug: to do? Did it to do

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Dr Doug: marrow density. There's a lot of stuff in there, but those are the bigots.

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Dr Doug: And so they looked at it and said, Okay, well, we need women that are either, you know, have a uterus or without. So there's 2 groups here. So women that had a uterus were on provera and premarin. So again, oral estrogen, synthetic and synthetic progesterone, and then another group that if they didn't have a uterus they were only on oral estrogen. So then you can remove the synthetic progesterone from that group that was really important here.

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Dr Doug: So they move forward. They do the dosing. And

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Dr Doug: really important, too, in the inclusion criteria is that they needed women that weren't symptomatic in menopause, because if they were symptomatic, they knew that if they put them on Hrt that they're gonna know if they're on the placebo, or if they're on the active drug. Right? So they said, you can't enroll if you have symptoms. So what happened? Well, they were an older population by default, because they needed women who were not symptomatic. So it's gonna push you out 5 to 10 years for most women.

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Dr Doug: right? So that'll come into play later. So most of the women were over on average over 10 years. The the oldest woman in the group, I think, was 79 years old when she started the trial.

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Dr Doug: So they go. They move forward after I think it was about 5 and a half to 6 years somewhere around there. And they're doing data every year. And these are. This is a big trial, and I forget the actual numbers. But this is, you know, tens of thousands.

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Dr Doug: I guess. I wish I had the actual numbers in front of me, but is a lot of people very well powered, in fact, maybe a little too well powered.

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Dr Doug: And so they're doing data at certain intervals. And this is all well designed. And in the combined Hrt group, so progestin and estrogen

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Dr Doug: in the combined hit group, they started to see an increase in some risks that they didn't like. One of them particularly was breast cancer.

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Dr Doug: And so they met a certain threshold, a predefined, predefined threshold of breast cancer cases, and then they terminated the study

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Dr Doug: that was then published in 2,002, and that was the study that just exploded. The hormone replacement plans and treatment options and all hormone for women really across the world. I mean, it was like a nuclear explosion that was felt all over the world.

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Dr Doug: and millions of women were taken off of their hormones. And then, really, from there, on, out. And this still persists. Today, women will often not be offered hormone replacement. They will go through a menopause without having a discussion, and they will be unnecessarily symptomatic because of this 1, 2,002 study.

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Dr Doug: So what they showed well, they showed that there was an improvement in fractureless. There was a massive reduction in colon cancer which is awesome. But there was a marginal, not statistically significant increase in invasive breast cancer cases.

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Dr Doug: and there was a

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Dr Doug: I don't think it was statistically significant increase in heart attack and stroke. So they were concerned. And that's totally fine.

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Dr Doug: I'm not saying it's wrong to stop the study because it wasn't. They met their criteria. They met their threshold they stopped the study. But what they said

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Dr Doug: in the paper is what I is, where I think this all went wrong.

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Dr Doug: And so the paper. It's funny at the paper. Actually, in their conclusion in the abstract, they didn't even really mention much about breast cancer. They mentioned it. They said there was a nominal, statistical, nominal, statistically significant increase in evasive breast cancer. That's all it said. The conclusion actually didn't say anything about it at all.

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Dr Doug: But the takeaway from that was estrogen causes breast cancer.

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Dr Doug: So okay, take that for what it is.

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Dr Doug: Then, 2 years later, they they stopped the other arm of the study. So the the estrogen only study. Now, this made big news, too. Oh, my gosh! Now they stop the estrogen study. All women on on hormones are gonna get breast cancer.

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Dr Doug: Okay? But what did it actually show? It showed a reduction in breast cancer risk.

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Dr Doug: So a reduction in invasive breast cancer for women that were on oral estrogen. Only HRT. So why they stop the study? Because there was no benefit in heart attack risk. They were not reducing the risk of heart attacks. They knew they weren't going to get to their designed outcome point. So they terminated the study.

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Dr Doug: So again, also fine.

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Dr Doug: But the takeaway from doctors was. Now we know

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Dr Doug: conclusively that the the Whi shows that estrogen causes breast cancer, but that's not what it showed. What it showed is that the combined arm with the progestin and and the estrogen had a slightly but not statistically significant increase in in evasive breast cancer cases and estrogen alone had a decrease in in breast cancer cases. So even as a layperson, you can say, this group had an increase. This group had a decrease. This group had 2 things. This group had one of those 2 things

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Dr Doug: which one was likely to cause breast cancer. It was the one in the hey. It was the one in the group that had an increased risk slightly. That wasn't in the other group. Right? And that's the progestin.

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Dr Doug: not the estrogen.

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Dr Doug: And yet that I'd be just like nobody talked about that

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Dr Doug: just mind-blowing how mistaken we were as doctors, and I was in medical school at the time. I didn't talk about it at all, because I was going into orthopedic. So I didn't care. But

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Dr Doug: I remember being trained on it. And people talking about this study

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Dr Doug: estrogen causes breast cancer? That was the answer.

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Dr Doug: So we know very clearly from that study that it's the progestin. Now, if you go forward and look at now other studies, it's been 20 plus years.

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Dr Doug: numerous studies on estrogen, big studies. And we continue to see over and over again that for the most part estrogen does not cause breast cancer. There's a small caveat in there. But for the most part estrogen does not cause breast cancer progestins, synthetic progesterones do increase your risk of evasive breast cancer absolutely clear.

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Dr Doug: So that's that.

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Dr Doug: The little signal, though the caveat to that statement is that because I looked into this, I'm writing a book on this.

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Dr Doug: And I looked at so many studies on this. And there are studies that continue to show there's a subtle little signal

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Dr Doug: of breast cancer and estrogen therapy.

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Dr Doug: It just like it kind of pisses me off actually, that it's still still there, because I would love to be able to just say, like, you know, pound my fist on the table and say, azure, June doesn't cause breast cancer.

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Dr Doug: But I don't think we can actually say that that definitively

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Dr Doug: I don't think that it causes breast cancer, but

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Dr Doug: I think if you were to develop breast cancer, it can make it grow faster, which makes sense

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Dr Doug: right. If you have a hormone sensitive cancer.

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Dr Doug: And you're on the hormone. It's gonna grow faster. That's logical. So I think what happens is if you do big enough studies. And this is where it shows up. If you do big enough studies and you have enough women and you follow them. There are going to be a certain percentage of those women that are gonna develop breast cancer because breast cancer occurs one in 7 incidents in a lifetime of woman. So

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Dr Doug: if you follow enough people for long enough. You're going to see breast cancer pop up in both groups.

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Dr Doug: But breast cancer could take months to even years to be detectable on on imaging. So of the group. Let's say you have a group on estrogen, and you have a group without the group on estrogen. Those cancers are gonna grow faster, they're gonna be identified faster. And ultimately, if the group is big enough, you're gonna see more of them just because they're identified.

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Dr Doug: And then the group that's not on estrogen. They're not going to pick them up. And then there are oftentimes not continued studies or follow up studies on these big cohort groups, because they're, you know, tens of thousands of people, hundreds of thousands of women. It's really hard to follow that up.

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Dr Doug: And so I think that's what we're seeing is that if you're if you develop breast cancer, it's going to grow faster, you're more likely to detect it. But again we see that it is an increase in cases.

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Dr Doug: not an increase in deaths.

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Dr Doug: And this is a really important point, which is that estrogen. If you again follow these women for long enough. Estrogen is actually protective of death from breast cancer. Now, I don't wish a breast cancer case on anybody, but if you're going to get breast cancer. You're actually better off to have gotten it while on Hrt. Than not.

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Dr Doug: which is also really confusing.

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Dr Doug: So what do we do? So in practice. We ask family history. The genetics really aren't that helpful? If you have bracket genetics, then that's a totally different deal. Not that common. Most women actually already know that because every woman in their family has had breast cancer. But we ask a family history. We ask a personal history

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Dr Doug: if there's one or 2 cases depending on how many women that is that we're talking about. We actually don't really consider that much of an increased reps. Because, again, that's actually the average risk.

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Dr Doug: Someone has a lot of family history. Then it's concerning. So we have that discussion. What's more important, is it the protection that estrogen provides specifically from colon cancer, from fracture risk for someone who has osteoporosis. That's a big deal.

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Dr Doug: Or are you more worried about breast cancer? And if that's the case. Then let's not use it, because we still have testosterone progesterone, which we can generally also use right? And we have a like, you know, a bajillion. Other tools that we can use. We don't have to use estrogen.

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Dr Doug: but I really encourage women to use it if they can, because it is the biggest tool that we have for reducing ctx. Without a doubt.

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Dr Doug: Does that make sense

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Dr Doug: any questions about that

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Dr Doug: can tell? I've said that before.

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Dr Doug: Yeah, they're ready.

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Loretta Kellogg: Yeah. Just had a question. Why would my doctor have tested? Not just for Esther Dial, but fsh!

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Dr Doug: Sure. So Fs, H. And LH.

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Dr Doug: And the 2 hormones that come from the brain, that tell the ovaries what to do.

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Dr Doug: and so to determine. If if a woman is in menopause, truly, then they're going to look at Fsh and lh.

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Dr Doug: and you can see like there's a ratio, and we call it the the Lh. And Fsh. Flip. And then you know that you're really in Manapos

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Dr Doug: once you're hostment of puzzle, I don't think it really does you any good

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Dr Doug: that make sense.

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Loretta Kellogg: Yeah, thank, you.

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Dr Doug: Yeah, of course.

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Dr Doug: So then, how do we? How do we do it? I like topical more than oral, I think oral does actually increase your risk of blood. Clot a little bit. It's debatable.

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Dr Doug: but I prefer topical. Again, it's easier to dose. You can manipulate the dose. You don't run the risk of potentially injuring your liver, and there's no increased risk of blood clotical can either be through a cream, which is what we use cause we prefer compounded products, or there are commercial patches. The commercial patches do work. Just make sure that they don't have a progestin in them, because the drug companies still love to use Npa, even though they know that it causes breast cancer and increased risk of heart attack.

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Dr Doug: So make sure that's just extra dial. And then you have to check your levels.

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Dr Doug: So a lot of the the dots, they are low dose estradiol.

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Dr Doug: They do not give you enough systemic estrogen to protect your bones, heart, and brain.

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Dr Doug: So this is again, why I like to use creams we use. Follow up the challenge with hormones is, you know, the creams are not cheap. I forget what our pricing are, but it's somewhere around like a hundred dollars a month. So it's not nothing.

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Dr Doug: commercial potentially could be covered by insurance. But you have to make sure that it's giving you what you think it's giving you, and that you're getting adequate levels

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Dr Doug: that make sense

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Dr Doug: progesterone, oral capsule and micronized progesterone testosterone. Again, cream. The testosterone and estrodall can be combined together.

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Dr Doug: That'll make sense.

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Dr Doug: That's me on my soapbox

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Dr Doug: you guys just had my entire book in like 15 min. That was great.

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Dr Doug: Yeah, Susan, let's do, Susan. And then Diane.

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Susan Jaye: Okay, just a quick question. So let's say you're on the estrogen. You're on, Estradile, whatever you're on the progesterone you're on the testosterone. What about vitamin d vitamin? KI get confused like K, one is one thing, K. 2 is another, and and like the blood thinning, the blood clotting. Is there anything to stay away from, or

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Susan Jaye: can you take or not take.

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Dr Doug: Yeah, it's a good question. So again, estrogen, given topically doesn't increase your risk of blood clot. So it's actually it's irrelevant. But I'll review the the case as well. So if you don't have an increased risk of blood clot, you don't need to worry about vitamin K. At all, even if it did increase risk of blood clot, which it doesn't

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Dr Doug: so then, just to to hit on that. So then, vitamin K is actually it's a really confusing vitamin. So Vitamin K comes in a couple of different, identifiable forms. You have K one, which is generally what you're gonna find in plant products. And you have K 2, which is the quote, unquote, active form or preformed form. K, 2 is gonna be found in animal products, in small doses. Not a lot and then, like aged dairy, you know, like hard cheeses, and certain other types of dairy.

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Dr Doug: It's hard to get a lot of it, though, through food. That's why it's very frequently supplemented.

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Dr Doug: And then K. 2 comes in really 2 forms, mk, 4 and mk, 7. There's more studies on Mk, 4, cause there was a group out of. I think it was Japan somewhere in Asia, and they were using like really big doses, like 50 milligram doses of of K. 2 as mk. 4, which is a massive super physiologic dose, and it does improve bone density. I forget if it reduced fracture risk, but it does improve bone density, for sure. So that's cool.

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Dr Doug: But as a short half-life. And so I think one of the reasons why they were using big dose is that if you give a lot of it, then it's as it tapers off. It's gonna last longer. But instead of using these massive super physiologic doses. You can use. Mk, 7 mk. 7. As a longer half life. So you don't have to use as much. So. Mk, 7. We're dosing 200 to 300 micrograms. Again, there's a thousand micrograms per milligram. So they were using 50,000 micrograms

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Dr Doug: of K. 2 as Mk, 4, which, again, is a really really big dose. So does that make sense?

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Dr Doug: I didn't actually answer your question, though, Susan. So none of those should increase your risk of blood clock unless you're on the drug warfare, or Coumadin.

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Dr Doug: Coumadin is a vitamin k dependent anticoagulant, meaning that it thins the blood through the vitamin K pathway. So if you're on that drug, you need very specific levels based on vitamin. K, this is why this drug is terrible, and you shouldn't really be on it.

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Dr Doug: There's such better options. The newer options that are not vitamin K dependent are not. There's no impact of K, one or K 2 or any k on those drugs whatsoever. Doctors are still really gun shy because they just I I was trained on cumin. And it's like I have like Ptsd from dosing people on cumin

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Dr Doug: most operatively. So whenever I hear Vitamin K. It still kind of makes me twinge but there's no evidence, and I've looked at this so many times in such depth. There's no evidence that any KK. One k, 2 in any form is gonna increase your risk of blood clot unless you're on Kubernet.

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Susan Jaye: Thank you.

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Dr Doug: Yeah, you're welcome. And, Diane, you had a question. Did I answer it already.

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Dr Doug: or did you fall off again?

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Dr Doug: Diane went. Bye-bye.

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Dr Doug: all right? Any other hormone questions, guys, any questions about testosterone? I just totally ignored you guys.

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Shelly’s iPad: Have a question.

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Shelly’s iPad: It's shelly.

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Dr Doug: Shelley.

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Shelly’s iPad: Hi! How soon

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Shelly’s iPad: would you see side effects with testes thrown.

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Dr Doug: Yeah, that's a good question. If you look at the studies on testosterone and women again, mostly around Hsdd.

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Dr Doug: they're not very long. And they did talk about side effects, and that was one of the main things they looked at. So you're gonna see it within, you know, a month or 2, probably pretty quickly. Hair loss could take a while. So that might be, you know, 3 months, 6 months. But you're gonna see it early on. If you're gonna see it at all.

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Shelly’s iPad: Okay. Thanks.

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Dr Doug: Yeah. And then I realized there was a big point about hormones I didn't talk about. But go ahead, David.

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David Callen: Mine's not about to soften, but it's about

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David Callen: prostate gland, and you need more saturated fats. Does that

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David Callen: Saturated fats adversely affect the size of your prostate gland.

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Dr Doug: That's a great question. So for those of us that have prostate glands. I don't have many in this call.

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Dr Doug: I don't. I don't think so. The only caveat to that would be that the prostate is going to be very sensitive to inflammation.

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Dr Doug: There's a subset of the population that responds negatively to saturated fat, and that could be tested through genetics through Apoe, 4 and other snps. If you have an inflammatory response to saturated fat, then it probably could impact your prostate.

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Dr Doug: So I

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Dr Doug: that's the only thing I can think of that would have a negative impact on the prostate. And just in case, anybody was wondering. Testosterone, if you have adequate levels.

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Dr Doug: or even if you have low levels, but they're not really low. Then adding, more testosterone does not negatively impact the prostate

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Dr Doug: urologists tend to agree with that.

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David Callen: Now, what about drinking soy milk to help your

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David Callen: prostate.

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Dr Doug: Hansu.

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David Callen: Land, help.

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Dr Doug: Soy milk. Yeah, be interesting. I haven't looked at that specifically. Urology is such an interesting controversial space. It's like, it's fascinating. The I had a patient who went to his urologist, and locally, as is Nashville okay. Told, told told his urology that he was on testosterone, and told him that he was putting that testosterone cream on his scrotum, which is actually where a lot of urologists will tell you to put it for various reasons.

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Dr Doug: And though you're all like you're all just flipped out like, blew his top, and was like screaming at the patient that whoever was prescribing him as testosterone

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Dr Doug: like should be, you know, should be sued for malpractice, and that this was the craziest thing ever you know, and I was like, I don't know. I was trained to do that by a board of urologists. So

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Dr Doug: whatever. So it's just a really an interesting controversial space start talking about prostate cancer, and what to do with testosterone, it'll make your head spin.

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Dr Doug: There was one thing I wanted to mention, Helen, before I answer your question, and I keep forgetting it. Oh, I got it.

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Dr Doug: So this is actually super important

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Dr Doug: whole chapter in the book on this.

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Dr Doug: What about the card? Excuse me, cardiovascular risk with estrogen for women that are over 10 years after menopause.

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Dr Doug: Really important point. So because of the timing of where we are now in 2024, and when this happened in the early 2 thousands, there is an entire generation and a half of women who were not offered estrogen therapy. They are now in their sixties and seventies right? And so

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Dr Doug: Most of them were not offered hormones a lot. Some some of them ended up doing it anyway. Good for you. But a lot of them didn't. So now they're 1015, 2030 years out from menopause. What do we do with those patients that the breast cancer thing is not an issue. I'm not worried about that. That doesn't matter, regardless of age.

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Dr Doug: but the heart disease risk does. So here's the physiology behind it.

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Dr Doug: When you lose estrogen as a woman or a man, it works for both. When you lose estrogen, your arteries start to get a little bit more fragile. They get a little bit more brittle. They don't move as well, because estrogen works really well with nitric oxide keeps the vessels compliant, keeps them moving. Better so brittle vessels will develop plaque faster. Alright! So, if you have been without estrogen for 10 years, and we give you estrogen back, there is in theory from the whi an increased risk of heart attack or stroke.

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Dr Doug: Why, it's because those now brittle arteries that have some developed plaque are now becoming more compliant. They're moving better, and you could break off a chunk of plaque, and it could go to your heart or your brain. Right? So that's a heart attack or stroke.

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Dr Doug: There was a study. I pulled for the book. I think it was a 2,018 or 2019 study. They went back and looked at the data from the Whi. What's interesting is you have all of those women that were on average over 10 years out for menopause. But when you break that group apart into groups of women that were either 0 to 10 years, 10 to 20 years, or 20 to 30 years. What you found is in the first 10 years

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Dr Doug: Hormon therapy was protective of breast cancer. I'm sorry, I said. Breast cancer again was protective of heart disease. So there were less events in the 0 to 10 Year Group.

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Dr Doug: There were equivocal events 10 to 20 years out, and then over 20 years. There was a slight but significant increased risk of heart attack and stroke. So that was really helpful for me to be able to say, Look okay. So for women, let's say, onsite have been deposit 50. You go out 10 years.

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Dr Doug: You're actually protected of heart disease. If you start within those 10 years, it's why it's so important to have that conversation early on.

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Dr Doug: especially if you have a significant history of heart disease yourself, a little bit of cholesterol or family history, and then 10 to 20 years, it's equivalent. So if I have a woman who's 68, and she went through menopause at 50,

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Dr Doug: the literature would support that there's no increased risk of heart attack if she were to start estrogen at 68 in.

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Dr Doug: Try getting that from any obga n

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Dr Doug: really interesting. So we still do cardiac imaging. So we'll still get a corner artery calcium score potentially a Ccta. I want to know what's going on in those arteries. But statistically, you shouldn't see an increased risk.

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Dr Doug: Does that make sense

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Dr Doug: cool? Yes, Helen.

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Helen Agarwal: That was my exact question, because I heard

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Helen Agarwal: heard you say that before I'm 15 years out from Menopause I have a very, very strong from the history of heart disease. So

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Helen Agarwal: yeah, I was presuming that

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Helen Agarwal: for me it wasn't a good

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Helen Agarwal: Lynn.

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Dr Doug: And so that's when we get we get a corn artery, calcium score. And hopefully, it's 0, meaning that there's no calcium buildup in the arteries, and then the next step would be to do to get a ccta, which is a coronary Ct. Gram. Now, if the coronary calcium score comes back, and it's really high, you know, it's hundreds or thousands.

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Dr Doug: Then we don't need to do the next step, because we know that there's significant disease. And I, personally, wouldn't start estrogen in that case, if we then go the next step when we get a ccta that looks at both hard and soft plaque, and then we can decide how much plaque there is. There's gonna be some. I've only seen 2 studies that had 0, and they were both women in their sixties that wanted to start estrogen. And that was amazing, right? It was like, Here you take it you like. You have better looking arteries than I do. The likelihood of you having an event is essentially 0.

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Dr Doug: It's not 0. So it's close to 0. So it's it's an amazing

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Dr Doug: have to be able to walk down, because then they're not worried about it

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Dr Doug: right? They're not like, Oh, my God, I'm gonna have a heart attack. Oh, my God, you know. So it's such a great pathway to go down. But after 20 years out, you know, we still get the studies, but I'm much less likely to use it.

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Dr Doug: still use testows. Remember gesture on them.

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Dr Doug: Alright, Lori.

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Dr Doug: are you there? Lori?

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Lori Riggio: There we go. Hi, I I wanted to ask specifically about vitamin D and K. 2. Should you take them together or no?

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Dr Doug: Yeah. Good question. I think that if you wanted to be a purist you could separate them because they are both fat, soluble in theory they could compete, I think realistically, it probably doesn't matter. I look at this. I always look at

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Dr Doug: you know what comes together in nature, you know. So vitamin, k and vitamin d are gonna come together in foods in nature. I don't think nature makes mistakes. I don't think our bodies make mistakes. And so if they're together in nature, we're probably gonna be able to absorb them. Just fine. If you wanna separate them. Maybe you're gonna absorb more. I don't know. We can't really measure vitamin K. But I measure vitamin D and all of our patients, and they take them together, and they have no issues getting adequate levels of vitamin d.

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Lori Riggio: Okay. I had just heard that. The K 2 helps

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Lori Riggio: to put the calcium where it needs to be rather than your arteries. Is that

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Lori Riggio: not true or.

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Dr Doug: Totally true.

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Dr Doug: Yeah. So vitamin D will help with calcium absorption.

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Dr Doug: But it doesn't really tell your calcium where to go. Vitamin K appears to have an impact on helping the calcium to go to the right place rather than the wrong place.

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Dr Doug: Still not well enough study to understand even the mechanism behind that. But it seems to be true, and I can't think of any downside to taking, you know again 100 to 300 micrograms of vitamin. K. 2 as MK. 7.

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Dr Doug: I just can't think of any negatives.

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Lori Riggio: Okay, can I ask one more question

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Lori Riggio: for like a target of your estrogen levels when they test you for a a estradial, and your progesterone like what are good target levels for that.

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Dr Doug: That's a really solid question, cause. As it was so important. I mentioned earlier that a lot of doctors don't test at all. And so if you look at the literature, if there's not great.

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Dr Doug: there's not great support for anything. But there was one study I I pulled.

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Dr Doug: and they basically suggested. Look, if you were to average

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Dr Doug: a pre-menopausal woman's estradial level, you would get somewhere between 60 and a hundred. I forget what the units are off the top of my head. It's then reasonable to aim for around 60, which would be the lower end of that with hormone replacement in the post Menopausal state.

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Dr Doug: Most again, astrodial commercial products will not give you the 60.

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Dr Doug: But if you look at again at the the rat, the the levels, and a premid apostle woman. They're gonna see that they can be in the low double digits, and they could be in the mid triple digits right? And and you get, you know, high level 3, 4, 500. So putting somebody at 60, I don't see any issues with that, but going too low. I don't think you're gonna see the benefits of it.

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Lori Riggio: How about the Progesterone.

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Dr Doug: Progesterone's hard to measure in blood.

397

00:58:01.373 --> 00:58:08.043

Dr Doug: so, because it has a short half life, you take it at night. It's worn off. By the morning you get your morning labs. It looks like you don't have any.

398

00:58:08.445 --> 00:58:22.643

Dr Doug: so I'm happy if I can see it at all. But really we're going off of symptoms of either too much meaning that you feel hungover in the morning, or too little meaning that you have symptoms of estrogen dominance which would be breast, tenderness swelling potentially breakthrough bleeding. If you still have yours.

399

00:58:23.123 --> 00:58:25.253

Lori Riggio: Okay. Great, great.

400

00:58:25.473 --> 00:58:26.533

Lori Riggio: Thank you.

401

00:58:26.713 --> 00:58:37.395

Dr Doug: Welcome and I do have to hop off on time. I have a one o'clock patient here on the east coast, so I gotta go see that patient? Nancy, if you could put your question in the chat

402

00:58:38.033 --> 00:58:41.382

Dr Doug: and then put it back in the chat when we start next week.

403

00:58:41.383 --> 00:58:42.333

Nancy Mandowa: Okay. Thank you.

404

00:58:42.663 --> 00:58:52.082

Dr Doug: And then, Susan, you had a question about when we do this meeting, we do it every Wednesday. You're gonna get an email from Breda. I think this week it's on her short list

405

00:58:52.343 --> 00:59:20.462

Dr Doug: of things to do. About. What's the best time for everyone cause you can imagine. With an international audience. We don't have the right time. And I wanna make this the most effective for the most people. So we will send that out. I don't know that we're gonna change it. There are a lot of people that are saying we should do an evening on the East Coast time, which would be better for most people. So we'll play with that and then I'll see you guys, I think. Oh, no! Next week is Carrie. Let me see, let me make sure it's true.

406

00:59:23.253 --> 00:59:24.563

Dr Doug: Next week

407

00:59:24.733 --> 00:59:33.223

Dr Doug: is me. And then the week after that is Carrie Luadi, our director of coaching. So she's gonna talk about

408

00:59:34.063 --> 00:59:34.617

Dr Doug: something.

409

00:59:36.163 --> 00:59:38.552

Dr Doug: I forget what she's gonna talk about, but it's gonna be awesome.

410

00:59:38.553 --> 00:59:39.693

Kerri Louati: Vacation.

411

00:59:40.393 --> 00:59:41.482

Dr Doug: What is it? Are you here?

412

00:59:41.483 --> 00:59:43.113

Kerri Louati: Detoxification.

413

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Dr Doug: Detoxification. Great thanks, Gary, I don't see you, but I'm sure you're here somewhere.

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