May 1 Hormone Therapy and Bone Health

May 1, 2024


Session Notes

Primary vs. Secondary Osteoporosis  

*   **Primary Osteoporosis**: Common bone health issues as people age.


*   **Secondary Osteoporosis**: Specific causes like parathyroid tumors leading to bone deterioration.  



Osteoporosis in Younger Individuals  

*   Can occur if peak bone mass is not achieved during early life.


*   Causes include inadequate nutrition, eating disorders, or absorption disorders.


*   Early screening is advocated due to increasing prevalence.  



Osteoporosis in Men  

*   Low testosterone is a significant cause.


*   Men are also affected by stressors similar to women, excluding hormonal cycling.  


HRT and Menopause  

*   Perimenopause can lead to fluctuating hormone levels and bone loss.


*   Post-menopause sees a rapid loss of bone density due to low estrogen levels.  



HRT Benefits

*   Can support hormone levels in pre, peri, and postmenopausal women.


*   In men, it can help build muscle mass, improve energy, sleep, and cognition.  



Labs for HRT  

*   For women: Estrogen, progesterone, and testosterone levels.


*   For men: Testosterone levels and prostate health indicators.  



Symptoms and Side Effects  

*   HRT can alleviate menopausal symptoms and improve mental outlook.


*   Side effects may include breast tenderness, mood changes, and androgenic effects like hair growth or loss.  



Risks of HRT  

*   Breast cancer: Estrogen alone may be protective, while progestins increase risk.


*   Cardiovascular disease: Starting HRT within 10 years of menopause can be beneficial.


*   Age considerations: Starting HRT over 20 years post-menopause may increase heart attack or stroke risk.  



Additional Benefits of HRT  

*   Improved heart health, skin appearance, and brain function.


*   Reduction in anxiety and depression.  




Skin Cancer  

*   No strong evidence linking HRT to increased skin cancer risk.  



Bone Turnover Markers (BTMs)  

*   HRT can impact BTMs quickly, potentially within weeks.  



Progesterone Alternatives  

*   Mirena IUD is not recommended as it does not impact bone health or provide systemic benefits.  



Progesterone and Testosterone  

*   They can be taken together but it's not necessary.  



Estrogen and Pain  

*   Low estrogen can exacerbate pain, including arthritic pain.  



Applying HRT Creams  

*   Rotate application sites to avoid localized hair growth.


*   Apply to areas with less hair and where skin won't be visible.


*   Allow the cream to dry before dressing and avoid washing off for at least 3 hours.  



Long-term HRT Use  

*   No concerns with long-term use if started early and continued consistently.  



Progesterone and Weight  

*   No clear physiological reason for progesterone to cause weight gain, especially abdominal.  



Cortisol Impact on Estrogen  

*   High cortisol can reduce estrogen levels due to stress on the adrenal glands.  



Study on HRT and Longevity  

*   Recent study suggests HRT after age 65 may improve overall mortality.


*   Concerns about the study's bias due to pharmaceutical funding and observational nature.


*   The study may not accurately reflect the benefits of micronized progesterone.



00:00:01.606 --> 00:00:06.775

Dr Doug: about the use of hormone therapy beyond the age of 65. So whenever that's appropriate to chat about it.


00:00:06.776 --> 00:00:07.676

Breta, MS, RDN - OHH TEAM: Awesome. Yeah.


00:00:08.044 --> 00:00:12.466

Dr Doug: Quite finished it, but I've got enough enough to talk about it.


00:00:13.366 --> 00:00:16.781

Breta, MS, RDN - OHH TEAM: Cool. We we I have that question in here, too. So.


00:00:17.066 --> 00:00:22.227

Dr Doug: Cool. I know it's been. It's been in Hs. And it's been in the slack a lot, so


00:00:22.556 --> 00:00:23.876

Dr Doug: I figured I should read it.


00:00:24.356 --> 00:00:41.595

Breta, MS, RDN - OHH TEAM: Okay, cool. Well, we will go ahead and get started. Then, since it is noon, let's I I wanna start with some basics that I want Osteo process through the life cycle. So can you give us an overview of primary Osteo process and secondary Osteo process.


00:00:41.736 --> 00:00:44.376

Dr Doug: Yeah, it's really kind of interesting


00:00:44.906 --> 00:00:52.385

Dr Doug: interesting terminology. Where the concept of the difference is essentially, there's primary osteoporosis, which is like


00:00:52.416 --> 00:01:15.146

Dr Doug: what happens to most people as they develop bone health issues. And then there's secondary osteoporosis, which are the clear reasons why someone might have developed osteoporosis. So say, for example, like the a classic example is, if someone has a parathyroid tumor, right? So like parathyroid hormone goes high because you have a tumor, and it's gonna cause your bones to just deteriorate. That's classic secondary osteoporosis.


00:01:15.146 --> 00:01:28.855

Dr Doug: But where I think this gets really confusing is that when you talk about primary osteoporosis, you're making an assumption that this is age related, or some people would say, Hormone related osteoporosis. I would argue, that's actually secondary osteoporosis, too.


00:01:28.886 --> 00:01:55.136

Dr Doug: because when you start looking at bone health, you start saying, well, the way we look at it is, why are you losing bone? In the first place, if we know that you can maintain your bone, metabolism, your bone density, and your bone strength through your twenties, thirties, and forties. Why like? Why do we accept? Then, at like 40. It starts to decline at, you know, a half a percent per year, and then 1% per year, and then 2% per year. And then it just gets worse and worse and worse.


00:01:55.176 --> 00:01:58.156

Dr Doug: I would argue, there's a secondary cause of that from the beginning.


00:01:58.497 --> 00:02:07.535

Dr Doug: And so I think that really we should just be talking about osteoporosis and not really worry about the difference between the 2. But medically, that's why they are separated.


00:02:08.616 --> 00:02:10.435

Breta, MS, RDN - OHH TEAM: Yeah. So if we.


00:02:10.516 --> 00:02:11.776

Breta, MS, RDN - OHH TEAM: I know


00:02:12.076 --> 00:02:14.816

Breta, MS, RDN - OHH TEAM: a lot of people here might be


00:02:15.246 --> 00:02:28.865

Breta, MS, RDN - OHH TEAM: Perry post menopausal going through menopause. But we do have some members that are very much like pre menopausal, so are there any common causes of osteoporosis for people in their twenties and thirties.


00:02:30.568 --> 00:02:37.826

Dr Doug: Yes. So we see this. We have patients, you know, going down into gosh, I think our youngest patient is in her twenties.


00:02:38.116 --> 00:03:03.976

Dr Doug: And so we definitely see it in younger individuals. And clearly, this is an an issue likely where a they never achieved optimal or peak bomb, mass, optimal home mass way. Like to say they never achieved peak bomb mass in the first place, and that could go potentially all the way back into adolescence and childhood, right? Like we, as as children like my kids are developing right now, and we're making sure that they're getting adequate protein. They're loading their bones or doing all the normal things


00:03:03.976 --> 00:03:11.486

Dr Doug: with the hope that they will achieve optimal or peak bone mass in their early twenties for somebody that comes to us with osteoporosis at 24.


00:03:11.486 --> 00:03:22.995

Dr Doug: They clearly never had it. In the first place, right? So they probably never got there. And there's a lot of reasons for that. So I think achieving peak bow mass is one thing, and that again is getting adequate. Nutrition


00:03:23.006 --> 00:03:51.745

Dr Doug: is staying away from challenges with eating, whether it be an eating disorder or an an absorption disorder. Getting adequate protein, eating a diet of of whole foods which is getting harder and harder to do. So I think we're gonna see more and more especially women, especially girls that are struggling with, you know the chronic dieting and and calorie malabsorption, malnutrition, all of it. I think we're gonna see bone health issues happening earlier and earlier, which is one of the reasons why I'm such an advocate for early screening


00:03:52.025 --> 00:04:10.216

Dr Doug: once you've achieved, though let's say you achieved good peak bone mass, and you have a rapid loss early in adulthood. Then that's going to be from some some kind of like an absorption issue, potentially a nutrition issue. But even that would be hard to lose bone that quickly, like there's a clear reason it could be hormonal dysfunction. Birth control can do it.


00:04:10.484 --> 00:04:24.196

Dr Doug: There's a lot of things that could potentially do it in young women, especially testosterone deficiency. And young men is becoming a bigger thing, too. So if you don't have testosterone as young man, you don't have estrogen as young man, and you'll see rapid bone loss then, as well.


00:04:25.216 --> 00:04:34.095

Breta, MS, RDN - OHH TEAM: Yeah. And so in young men, that's why we're you're mentioning that. But in men overall, are there any other common causes of Osteo process.


00:04:34.596 --> 00:04:37.125

Dr Doug: I mean, the biggest one in men is low testosterone.


00:04:37.196 --> 00:04:53.776

Dr Doug: And we see this. I mean globally. I mean, we test us. We test testosterone in all of our male patients and female patients. And we see, I can think of maybe 3 patients over the last 5 years that have had optimal testosterone. Naturally.


00:04:54.256 --> 00:05:13.375

Dr Doug: So it just is, it is just global and there's a lot of reasons for that. So that's a a big thing. And then men are also subject to all the things that women are for the most part outside of the monthly cycle cycling of hormones. But outside of that all the other stressors, adrenal dysfunction, poor sleep, etc. So all those things are true for all of us.


00:05:14.176 --> 00:05:15.125

Breta, MS, RDN - OHH TEAM: Yeah. So


00:05:15.894 --> 00:05:20.016

Breta, MS, RDN - OHH TEAM: back on our just hormones and and bone health


00:05:20.136 --> 00:05:30.796

Breta, MS, RDN - OHH TEAM: as a whole. What's happening in women as they enter menopause and like throughout as they transition into that post menopausal like phase of life. How does that impact bone health like?


00:05:30.866 --> 00:05:38.001

Breta, MS, RDN - OHH TEAM: What are we seeing at like that physiological level with like estrogen and testosterone. And all of that. How does that play a role in phone density?


00:05:38.602 --> 00:06:07.396

Dr Doug: So I think there's really there's 2 clear things that happen. So there's that that Perry Menopause window, which could be a year, could be 10 years, I think for some moment it's like, seems like it's 15 years is a really long timeframe up until the point where menopause app actually happens, which is the cessation of a cycle for 12 months. Technically, I kinda look at it as like once it stops like you're there. Let's let's figure out what to do. But that whole timeframe leading up to it. We can see


00:06:07.396 --> 00:06:30.585

Dr Doug: declining levels of estrogen. We can see back and forth. This is where it gets really challenging to to manage and also to live through. This is when you have high levels of estrogen one month, and then low levels of estrogen the next month. It's really hard to know what to do about that. But we also see consistently low levels of testosterone from adrenal dysfunction, low levels of progesterone, which then makes the estrogen up and down even more dramatic.


00:06:30.986 --> 00:06:51.676

Dr Doug: Those fluctuations and lack of the normal pulsing of the hormones can have a negative impact on bones. So we start seeing bone loss in those women. And this again is going back into your certainly into your forties, if not even into your mid thirties. And so we see that happening early, and then, once you actually lose estrogen for the most part, once your ovaries fail.


00:06:51.676 --> 00:07:02.756

Dr Doug: Then your estrogen levels went from, you know, hanging out around the like 60 80, and then pulsing up to 300 400 picogram per ml. Throughout the month to now you have essentially none.


00:07:03.116 --> 00:07:21.326

Dr Doug: When that happens you will see rapid bone loss without question. Every woman goes through this, and you'll go from that, you know, point 5 to 1% per year to on average, like 2 to 3% per year. But in those first 10 years it's even more. It's even more rapid than that. In the first 10 years it can be really rapid bone loss, depending on the situation.


00:07:22.216 --> 00:07:32.339

Breta, MS, RDN - OHH TEAM: Okay, so cool like. Obviously, I know everybody here probably knows that, like, there's a clear connection between your hormone levels and osteoporosis, and there is benefit to Hrt. But


00:07:32.686 --> 00:07:34.036

Breta, MS, RDN - OHH TEAM: what I


00:07:34.286 --> 00:07:42.775

Breta, MS, RDN - OHH TEAM: I should make sure that we're like, really, clearly defining and connecting the dots here so like what would be the value of Hrt. In someone who is Pre or Perry Menopausal.


00:07:44.032 --> 00:08:01.479

Dr Doug: So the value is depending on what's going on. You know what we can do. So for for some women they need support of all 3 hormones. And this is kind of new new newer to me to try to sort of match estrogen, cycling, and women in the premier monopause timeframe. It is possible it's just. It's more challenging, for sure.


00:08:01.776 --> 00:08:06.166

Dr Doug: But Progesterone and testosterone could certainly be supplemented. And so


00:08:06.656 --> 00:08:27.325

Dr Doug: there is value in Progesterone testosterone in in a perimenopa woman, a premenopausal woman, just like there isn't a post menopausal woman, so we can certainly provide that support and help slow down that bone loss and the the perimenopause timeframe. The the next question is, can you do it in the post menopause? Timeframe? Answer is, of course, you know, and that's where it gets really important, especially in those first 10 years.


00:08:28.317 --> 00:08:34.356

Breta, MS, RDN - OHH TEAM: And then what about for men? The value of Hrt with osteoporosis in men.


00:08:35.316 --> 00:08:54.015

Dr Doug: Yeah. So again, it's a clear driver of of bone, health and bone loss in men. So, catching it early and then preventing the bone loss, if possible, but once once it's there, and the the testosterone levels are consistently low, bringing them back up and then using that as a tool, especially in men, because we're talking about a like a hundred X


00:08:54.036 --> 00:09:08.256

Dr Doug: fall between men and women. Right? So we can use this as a tool in men to really help build muscle, mass and and bone health, and also provide all the other things like the energy, the improved sleep, better cognition, etc. So for men. It can be a really powerful tool.


00:09:08.696 --> 00:09:15.706

Breta, MS, RDN - OHH TEAM: Cool, and I think, what everybody's really been waiting for. What labs should they be looking at before starting? Hrt.


00:09:16.136 --> 00:09:35.735

Dr Doug: Yeah, it's funny. I think there was a comment. I think this was an Hsn and there was a comment about yeah, it was somebody who went to their endocrinologist and their endocrinologist said that they wouldn't test their hormone levels because they were post minute puzzle and the the person making the comment was really frustrated, and totally understand that, except that


00:09:36.449 --> 00:09:49.206

Dr Doug: as an endocrinologist or any doctor who's familiar with treating women who are postmenopausal, we know the answer right? You. You don't have estrogen. You don't have Progesterone. Now, you may or may not have testosterone. That depends on your adrenal function.


00:09:49.490 --> 00:10:10.805

Dr Doug: But so I I I understand. But that answer is actually not that inappropriate also that doctor is not interested in starting hormone therapy. So they're like, why would I test it if I'm not gonna treat it and that's fair. But if we're going to treat it, I would still want to know, like, what is your current estrogen level? Is there some weird thing happening where you have higher than expected levels?


00:10:10.886 --> 00:10:14.755

Dr Doug: What is your current progesterone level? Although this is actually


00:10:14.766 --> 00:10:35.705

Dr Doug: th. This is something we screen. We almost do it once, and we don't do it again, because it's hard to catch Progesterone and blood for a woman who's on replacement, not necessarily cycling and then testosterone levels both free testosterone and total testosterone. Those 4 things are sort of the key. And then there's some sort of peripheral labs around that from a treatment perspective. But if you wanna know your levels, that's a really good starting point.


00:10:36.336 --> 00:10:39.665

Breta, MS, RDN - OHH TEAM: And what about for men? What labs are we looking at.


00:10:39.666 --> 00:10:58.736

Dr Doug: Yeah, same, but without the without the progesterone, because we just don't catch it. And then men men have some. They just don't have much and then for men, of course we have to look at the prostate, too, and make sure that the the prostate, you know, enzyme biomarkers are not too high. And we do some peripheral labs. But again, if you wanna know your your levels, that's the starting point.


00:10:59.371 --> 00:11:04.236

Breta, MS, RDN - OHH TEAM: Is Dha important to get for Hormon replacement or not so much.


00:11:04.426 --> 00:11:12.375

Dr Doug: Yes and no. So it's good to know, I would say again, universally, postmenopausal women have low dha.


00:11:12.456 --> 00:11:29.415

Dr Doug: and I think this comes with the adrenal dysfunction that goes along with just being a post menopausal woman, and it could be improved through lifestyle. It could be improved through supplementation. And for those who don't know what dha is, it's a precursor hormone to progestrom and testosterone.


00:11:29.416 --> 00:11:49.886

Dr Doug: So again, you could have adequate dhca. It's just really common that it's low. The question is, is, would we replace it simultaneously with starting testosterone? And generally I don't. This is controversial, because some doctors would say Dhga could by itself fix the problem. I disagree with that. I think it's it's a tool, but it's not a very powerful tool.


00:11:49.886 --> 00:12:08.455

Dr Doug: So some people feel great on. Dha! Some people don't tolerate Dha, but if you add Dha and testosterone together in replacement, then you end up with multiple potential androgenic side effect, causing things. So I've pulled back from doing both together, because I want you to be successful with at least one, and testosterone is the more important one. In my opinion.


00:12:09.076 --> 00:12:16.366

Breta, MS, RDN - OHH TEAM: Yeah. And then what reference ranges should we be looking at for testosterone estrodial and progesterone.


00:12:16.866 --> 00:12:39.785

Dr Doug: So it's gonna depend on the lab. And we were talking about this with a team yesterday. So there are certain testosterone labs that are gonna show, especially from a free perspective, because there's a lot of way to either calculate or directly measure or you're using, you know, bioactive or whatever, there's so many different terms. But if we talk total, so when we're talking about estrogen, we're generally talking about totals.


00:12:39.786 --> 00:12:54.105

Dr Doug: So this is a very debatable thing. But for women. If we're talking about estrogen, we're looking specifically at estroad dial, that's the only one that we need to measure in blood. If we're looking at Estro Dial. Our current reference range is 60 to 80 pigogram per Ml.


00:12:54.146 --> 00:13:03.975

Dr Doug: which is higher than you're going to get through most of the commercial patch doses. You're not going to get anywhere near that if you're using a traditional vaginal approach


00:13:04.016 --> 00:13:13.715

Dr Doug: or Iud approach. And this is where I really differ from a lot of doctors who are prescribing estrogen because they're looking for the lowest safe dose.


00:13:13.956 --> 00:13:21.556

Dr Doug: My perspective is estrogen is not dangerous, so why are we looking for the lowest safe dose, we should be looking for the actual physiologic dose that we need.


00:13:21.726 --> 00:13:24.335

Dr Doug: But the reason why this is so controversial is that


00:13:24.645 --> 00:13:31.036

Dr Doug: when you talk about physiologic dosing, you could actually argue well, hey? We should actually drive this up to 300 picogram per mo.


00:13:31.266 --> 00:13:46.906

Dr Doug: That's where there's this gray area. There's kind of a new movement around this which is really cool. But I'm comfortable at 60 to 80, because I know that we're not seeing increased risk of side effect. There, there's plenty of studies to support those levels. So that's where we are. I don't know where I'm gonna be in a year, but that's where we are right now.


00:13:47.350 --> 00:14:02.426

Dr Doug: Testosterone levels for women is actually kind of challenging in blood, too. I definitely think we should get it in blood. We should know where your levels are. But my adjustment of dose is gonna be based a lot off of symptoms if you have them or side effects if you have them.


00:14:02.446 --> 00:14:13.646

Dr Doug: So women do really well with total testosterone levels of like 30. But some women might need total testosterone levels of like 1 50 or 200 to get enough free testosterone actually have an impact.


00:14:14.636 --> 00:14:17.766

Breta, MS, RDN - OHH TEAM: And then then what testosterone levels are we looking at.


00:14:18.366 --> 00:14:47.395

Dr Doug: Again gonna be driven a lot by symptoms. And so I would love to see, you know, on on average, men are gonna be around 800 to 1,200 total testosterone. But free testosterone varies quite a bit. And this is where, if you measure true direct, free testosterone for men, we probably want it 20 to 30. That's that's pretty hot. So that's that's men at a pretty optimized level. And then we have to look for potential side effects. There's a lot of ways to dose testosterone and men, but those are the that's the summary.


00:14:48.376 --> 00:15:03.995

Breta, MS, RDN - OHH TEAM: So I think a lot of you guys to just between Hsn and in the chat have asked about like some of your patch dosing and stuff. So I hope this answers, or gives you some guidance on like that that dosing, and what you might be getting from your ui end versus what you need to actually build bone.


00:15:04.625 --> 00:15:21.626

Breta, MS, RDN - OHH TEAM: But you've talked about how a lot of the labs won't necessarily like. I mean, the labs are helpful. They help drive our interventions, but at the same time they might not be the most clinically significant. And symptoms can be really important. So what


00:15:22.856 --> 00:15:29.456

Breta, MS, RDN - OHH TEAM: what symptoms should people be looking for, to understand if their current dose is actually working for them.


00:15:30.046 --> 00:15:36.445

Dr Doug: Yeah, it really depends on what symptoms you started with, if any. And this is where this has become such a challenging thing.


00:15:36.506 --> 00:15:42.476

Dr Doug: So for women that had symptoms especially. You know, the Vasa motor symptoms, the hot flashes, the night sweats.


00:15:42.566 --> 00:15:45.955

Dr Doug: It doesn't take much estrogen to make those go away.


00:15:46.096 --> 00:16:00.202

Dr Doug: You could also potentially make those go away with Progesterone alone. You can make those go away with testosterone alone. So the whole idea of give the lowest dose for the shortest period of time. That's sort of the the Menopause Society, the obgon perspective.


00:16:00.526 --> 00:16:13.715

Dr Doug: I struggle with that because if you do that, you're not. Gonna you're gonna be on that like that tiny dose estradile patch, and it might help you with your symptoms. But you're not gonna get enough serum levels to actually improve your your bone health and impact your heart and your brain.


00:16:13.816 --> 00:16:18.666

Dr Doug: So from a symptom perspective, if you have, as of motor symptoms, yes.


00:16:18.776 --> 00:16:23.785

Dr Doug: if you look up something. I wonder, Brett, if we could post in Hsn


00:16:23.806 --> 00:16:24.856

Dr Doug: the


00:16:25.293 --> 00:16:27.676

Dr Doug: menopause rating scale that we use for patients.


00:16:28.206 --> 00:16:30.905

Dr Doug: So what I like about this scale


00:16:31.390 --> 00:16:50.605

Dr Doug: is that we've started using it for intake for patients, and we check it every 6 months it lists all of the different areas that are suspected to be associated with the decline in sex hormones overall. Now, the people that designed the scale would say, this is all from estrogen. But if you look at it and I, this is in the book that I'm writing right now.


00:16:51.136 --> 00:17:07.176

Dr Doug: Only a couple of those areas. Specifically, the mesa motor symptoms like, I just said, but also the GU stuff. So like, you know, vaginal dryness or chronic uti, like those things are clearly astrogen related, but all of the other potential symptoms there are probably more likely testosterone related.


00:17:07.296 --> 00:17:09.035

Dr Doug: And so that's one of these


00:17:09.386 --> 00:17:23.766

Dr Doug: unknown things or not talked about things. But there's a list of, I think, 11 different sections of the menopause rating scale, and I would say 9 of them are related to testosterone deficiency. So those are also symptoms you could look for. But they're a little more vague, right? It's things like.


00:17:23.796 --> 00:17:34.906

Dr Doug: you know, higher levels of depression, anxiety, you know, muscle, loss, body, composition changes like thinner skin, cognitive deficits, you know, forgetful, like all of those things.


00:17:34.966 --> 00:17:38.736

Dr Doug: those are more likely related to testosterone deficiency or


00:17:38.746 --> 00:17:43.876

Dr Doug: estrogen deficiency. But you don't necessarily see resolution of them with low dose estrogen replacement.


00:17:44.596 --> 00:17:44.956

Breta, MS, RDN - OHH TEAM: Yeah.


00:17:45.436 --> 00:17:58.505

Breta, MS, RDN - OHH TEAM: And when it comes to like the risks that we're looking for we'll talk about some of the studies in just a second, but, like general adverse side effects that you would see


00:17:58.706 --> 00:18:03.556

Breta, MS, RDN - OHH TEAM: relatively soon from starting. Hrt. Can you outline some of those things.


00:18:03.556 --> 00:18:07.686

Dr Doug: Yeah. Here, let me go through him. Here. I'm gonna turn this light down now. I feel like I'm staring with.


00:18:08.336 --> 00:18:09.296

Breta, MS, RDN - OHH TEAM: All good.


00:18:17.786 --> 00:18:24.356

Dr Doug: That's better. So we'll just go through one by one. So estrogen.


00:18:25.116 --> 00:18:46.445

Dr Doug: And this is a challenge, because a lot of us is balanced too. But if you just talk about estrogen by itself, having quote unquote too much estrogen if you think about, you know, for women that are that are pre menopausal. When you're cycling, when you're estrogener, progesterone, or and balance particularly around, like the you know, couple of weeks before. Before you start


00:18:46.696 --> 00:19:05.438

Dr Doug: the first day of your cycle. If you get that estrogen and balance, you get some of those symptoms of you know. Pms and Pmd, whatever you wanna call it. But those are gonna be things like breast hunterness. Edema could be could be. Mood changes, you know. Moodiness is how it's described in a lot of the scales.


00:19:06.169 --> 00:19:10.276

Dr Doug: Excess bleeding for women that are still cycling. So you know.


00:19:10.406 --> 00:19:16.136

Dr Doug: bleeding for longer or bleeding more during the cycle


00:19:16.996 --> 00:19:19.846

Dr Doug: I see those in the most common now for a post menopausal woman


00:19:19.896 --> 00:19:36.666

Dr Doug: you're not gonna get unless you're truly doing physiologic cycling. You're not gonna get an increase in bleed or any bleeding hopefully, if that's the plan. But you still could get breast tenderness. That's a common complaint for people that have imbalance of estrogen. Again, it's not too much. It's just imbalance


00:19:36.939 --> 00:19:54.185

Dr Doug: but breast Internet is probably the most notable one for women that do have breakthrough bleeding again. That's a conversation around like, is that the goal? Are you? Are you trying to have a monthly cycle or are you having a balance of estrogen and progesterone. It's not too much estrogen, it's probably not enough progesterone, or the balances off


00:19:54.316 --> 00:19:55.445

Dr Doug: that makes sense.


00:19:55.776 --> 00:20:14.125

Dr Doug: So then, if you go with Progesterone. This one's kind of hard to do too much at normal doses, but for women that are sensitive to it. And assuming they've ramped up slowly over time when you have too much progesterone orally, it breaks down into a not a sedating, but like a calming


00:20:14.677 --> 00:20:35.635

Dr Doug: molecule, and so that calming molecule could still be on board when you wake up in the morning, and so you'll feel just a little groggy or hungover. So that's when you have too much progesterone on board. So women also potentially could feel like some weird like bloating and some other potential side effects of Progesterone. Again, I think that's a balance thing, progesterone and estrogen balance. Not so much just too much progesterone


00:20:35.846 --> 00:20:41.015

Dr Doug: testosterone is the one that has the most clear side effects, especially for women, although also true for men.


00:20:41.466 --> 00:20:49.515

Dr Doug: but the androgenic side effects so too much androgen and testosterone and and anabolic steroid and androgen. So


00:20:49.526 --> 00:21:09.145

Dr Doug: too much testosterone or not the right receptors for testosterone being available, can cause the things that most people think of when they think of testosterone for women and side effects which would be like growing facial hair losing hair on your head, or at least getting acne. Those things freak a lot of women out. And I totally understand that.


00:21:09.146 --> 00:21:19.656

Dr Doug: Generally it's gonna be from too big of a dose. This is why I don't like pellet application, because you get a really big dose, and you can't take it out, and if you have side effects you could lose a lot of hair in 3 months


00:21:19.656 --> 00:21:31.175

Dr Doug: from having too much testosterone, and it doesn't always grow back. And so that's why we use creams. We go, we start low, we go slow, and we see what your tolerance is, and the tolerance would generally change over time as well.


00:21:31.610 --> 00:21:55.365

Dr Doug: Those are the biggest concerns around testosterone one other caveat on that, though, when you look at the research on testosterone in women. It's really interesting that the placebo group. So the women that aren't on testosterone, the placebo group almost universally has worse side effects than the intervention group. So I think there is also a psychological component of taking testosterone and sort of anticipating some of these side effects


00:21:55.366 --> 00:22:24.456

Dr Doug: cause all of those things that I just mentioned also happen to occur with aging. And so, you know, women do lose hair for lots of reasons. Women can potentially grow hair as they age as well on their face. And then acne and oily skin are abundant and common for other reasons, too. So we I think it's real. I think the endogenic side effects are possible. But at the same time, I think there's a lot of potential looking too deep into what's actually happening. And I think a lot of women end up off of testosterone when it really wasn't the testosterone. In the first place.


00:22:26.116 --> 00:22:29.855

Breta, MS, RDN - OHH TEAM: Yeah. And would those same side effects apply to Dha as well.


00:22:30.436 --> 00:22:39.436

Dr Doug: Exactly so. All the same ones apply to Dha. And, in fact, from my perspective and clinical experience, I think Dha is more likely to cause those side effects than as testosterone.


00:22:40.446 --> 00:23:04.446

Breta, MS, RDN - OHH TEAM: Alright. I wanna transition into like more absolute like risks with Hrt, so I'll just read this question. But someone has asked if you can discuss the relative and absolute risk of Hrt. Surrounding breast cancer and cardiovascular disease on starting Hrt, so the patch and micronized Progesterone 1015, and years out of menopause.


00:23:04.898 --> 00:23:15.295

Breta, MS, RDN - OHH TEAM: if you have a positive family history of either, and do you have an age for combined? Hrt. When you feel uncomfortable prescribing.


00:23:15.296 --> 00:23:17.555

Breta, MS, RDN - OHH TEAM: so I can break that down for you, and like 3 questions. If you want me to.


00:23:17.556 --> 00:23:18.936

Dr Doug: And say, How how long do we have.


00:23:19.356 --> 00:23:27.296

Breta, MS, RDN - OHH TEAM: Yeah, I think maybe we just start with touching on breast cancer and the relative risk of breast cancer.


00:23:28.796 --> 00:23:48.413

Dr Doug: So this is such a great topic. It's a sad topic, really, but it's a great topic, because it's on most people's minds when we talk about estrogen specifically. So I I've I've explained this and I there's some new faces here, so I'll I'll go through the summary of where all of this concern came from, and then I'll talk about what's happened over the last 24 years.


00:23:48.706 --> 00:23:51.616

Dr Doug: So back in the early 2,000 s.


00:23:51.966 --> 00:24:02.395

Dr Doug: Though, there were several studies that came out that demonstrated similar findings, but the one that really blew the top off of the estrogen replacement world and hormone replacement world was the Women's Health Initiative.


00:24:02.466 --> 00:24:15.495

Dr Doug: The Women's Health Initiative was a well-meaning, I believe, and reasonably well designed study, and it was massive. So it was designed to look specifically at estrogen therapy and combined hormone replacement therapy.


00:24:15.526 --> 00:24:19.366

Dr Doug: Truly, as with cardiovascular risk, that was actually the primary outcome.


00:24:19.606 --> 00:24:29.276

Dr Doug: One of the secondary outcomes was a concern for an increased risk of cancer. So there's always been that concern that estrogen could potentially cause cancer. Excuse me.


00:24:29.576 --> 00:24:36.876

Dr Doug: And so there were 2 different groups within the Women's Health Initiative. One was on combined therapy. One was on estrogen only therapy.


00:24:36.966 --> 00:24:51.275

Dr Doug: After about 5 years the combined therapy group was stopped early because of a concern of an increased risk of both breast invasive breast cancer, but also stroke blood, clot and cardiovascular events.


00:24:51.276 --> 00:25:09.295

Dr Doug: So clearly they weren't achieving the the reduction in cardiovascular events that they were looking for. They stopped the study early, and then they published the paper in 2,002 that just exploded the world of hormone replacement, and in that paper they said that the concern for overall mortality outweighed the potential benefit of hormones.


00:25:10.966 --> 00:25:22.485

Dr Doug: 24 years later that study has been looked at over and over and over again. There's been multiple publications on all of the potential weaknesses of the study design. I mean, it has been scrutinized and scrutinized.


00:25:22.526 --> 00:25:25.436

Dr Doug: and we now have also 20 year


00:25:25.506 --> 00:25:30.126

Dr Doug: follow up data that's been published from the Women's Health Initiative. So now we know a lot.


00:25:30.266 --> 00:25:42.796

Dr Doug: but go back to 2,002. And what that study showed is that there was an increase, although not statistically significant, but an increase in diagnosis of invasive breast cancer in women that were receiving the intervention


00:25:42.876 --> 00:25:52.236

Dr Doug: there was also increased, but not statistically significant stroke, heart attack and blood clot. So those are concerning. So it's totally reasonable that they stop the study.


00:25:52.346 --> 00:25:58.676

Dr Doug: However, the takeaway from that study was estrogen causes breast cancer, which was the wrong takeaway.


00:25:59.126 --> 00:26:00.119

Dr Doug: So then


00:26:00.636 --> 00:26:03.916

Dr Doug: Millions of women ripped off a hormone replacement at the time.


00:26:04.176 --> 00:26:08.106

Dr Doug: Fast forward! 2 years! The estrogen only arm comes out.


00:26:08.136 --> 00:26:19.226

Dr Doug: and it showed some interesting findings. Now this arm was also stopped early, but it was stopped early again because they weren't achieving reduction in cardiovascular events. They were not seeing a reduction in heart attacks and deaths.


00:26:19.306 --> 00:26:20.816

Dr Doug: So they stop a study.


00:26:20.976 --> 00:26:33.346

Dr Doug: But what's interesting is that they showed that in the estrogen only group there was almost almost as significant as the increase on the other side, but a decrease in the incidence of breast cancer.


00:26:33.996 --> 00:26:37.166

Dr Doug: So estrogen was protective of breast cancer in that group.


00:26:37.246 --> 00:26:47.076

Dr Doug: And yet again the results of that study were published, and the media, you know, blah blah blah blah! And yet we still walked away with it as estrogen causes breast cancer, which is like


00:26:47.096 --> 00:26:48.116

Dr Doug: like I.


00:26:48.756 --> 00:27:01.906

Dr Doug: How did that happen, you know, like, how did? How did all of the doctors not recognize that estrogen was protected for breast cancer from that study, and it all had to do with the way that it was presented through the the groups that were sort of pushing against hormones at the time.


00:27:02.161 --> 00:27:19.565

Dr Doug: Other interesting findings there is that there was still a concern for an increased risk of stroke and blood clot. So it wasn't actually in the clear. And at the time it wasn't statistically significant. So I think people just sort of walked away from it, saying, You know what? It's too dangerous. It's too risky. I'm out. And they stop prescribing it. And that's exactly what happened.


00:27:21.056 --> 00:27:41.725

Dr Doug: now, we have 20 year data on those same studies. And so we know that 20 years out that the estrogen only group was actually, statistically, significantly protective of breast cancer. So we can clearly say that estrogen alone, even in a crappy estrogen, like they used in oral estrogen that came from horses. It was actually protective of breast cancer.


00:27:41.726 --> 00:27:53.326

Dr Doug: We also know now, because we've looked more at the progestins, the artificial progesterones that they use in the women's health initiative, that they do indeed increase the risk of breast cancer heart attack, stroke


00:27:53.376 --> 00:27:57.676

Dr Doug: all kinds of nasty stuff. Those things are still widely used.


00:27:57.686 --> 00:28:10.475

Dr Doug: even the exact same one that they used in the Women's Health Initiative Provera still out there. Mpa. Is still out there, and probably prescribed millions of times a year, and we know clearly that it increases the risk of breast cancer stroke and heart attack.


00:28:10.526 --> 00:28:31.845

Dr Doug: So the big takeaway for me now from the Women's Health initiative is that estrogen is protective of breast cancer, more likely, and progestins are devious, nobody should ever be on them, and that we really need to look at the research ourselves as providers, to understand what we should do with our patients because we cannot take the recommendations from the Menopause Society.


00:28:31.856 --> 00:28:38.006

Dr Doug: American College of Obstetricians, a gynecologist because they're all recommending information that was gleaned from that


00:28:38.236 --> 00:28:40.905

Dr Doug: wrong interpretation of the study in 2,002.


00:28:42.276 --> 00:28:43.026

Breta, MS, RDN - OHH TEAM: Yeah.


00:28:43.236 --> 00:28:45.246

Breta, MS, RDN - OHH TEAM: so on


00:28:46.456 --> 00:28:58.595

Breta, MS, RDN - OHH TEAM: the age component. I know you don't have a hard age component or like age, like, cut off but when would you be like thinking about? Potentially


00:28:58.946 --> 00:29:03.106

Breta, MS, RDN - OHH TEAM: not, or, like, you know, weighing the risks a little bit more for somebody, for.


00:29:03.106 --> 00:29:09.165

Dr Doug: Yeah, so there's excuse me, there's 2 ways to answer this. So one is, how long can you take? Hrt.


00:29:09.176 --> 00:29:18.556

Dr Doug: And that paper that that paper that just came out recently. That's been kind of all the buzz. It demonstrates that for people that never stop taking it, their mortality rate is lower.


00:29:18.646 --> 00:29:22.206

Dr Doug: So, from my perspective, there's no reason to ever stop taking HRT.


00:29:22.496 --> 00:29:32.225

Dr Doug: Now I'll talk about all the weaknesses of that paper, but that's the general perspective of the anti-aging longevity community, anyway, is like, if you want it to work, you should take it


00:29:32.936 --> 00:29:38.935

Dr Doug: so there's no reason to ever stop unless you have a medical condition that prevents you from taking it


00:29:39.076 --> 00:30:07.665

Dr Doug: as far as when to start earlier is better. So clear evidence would say that if you start. Hrt. Within 10 years of menopause. Your risk of cardiovascular disease goes down, your risk of dementia goes down. Like all all things, get better the earlier you start, but we can't go backwards in time, so let's say you are a victim of the 2,002 and 2,004 change in doctor's opinions on Hrt. And you weren't offered the conversation or prescription at the time.


00:30:07.976 --> 00:30:22.766

Dr Doug: This is a lot of our patients, right? We have this conversation every day, and it's really frustrating for patients and for me. So the challenge is, let's say you're 10 to 20 years out. Well, there's some reasonable evidence to say when you sub


00:30:22.906 --> 00:30:28.865

Dr Doug: classify the patients in the in these studies. And this is not just the Women's Health Initiative, but all studies


00:30:29.176 --> 00:30:37.086

Dr Doug: the 10 to 20 Year Group. There actually isn't an increased risk. There is just not a protective effect of starting Hrt. 10 to 20 years out.


00:30:37.136 --> 00:30:42.125

Dr Doug: It's not till you get to over 20 years out, and these are now patients, of course, in their seventies.


00:30:42.156 --> 00:31:05.465

Dr Doug: most of them for women in their seventies that are over 20 years out there is a statistically significant increased risk of having a heart attack or stroke after starting Hrt. And the physiology behind. This is pretty simple, which is just that when you withdraw estrogen, your arteries get harder, they develop plaque faster. That's why women generally will have heart attacks after menopause, not before menopause, because you lose the protective effect of estrogen.


00:31:05.846 --> 00:31:07.036

Dr Doug: So then.


00:31:07.476 --> 00:31:27.396

Dr Doug: after 20 years, your arteries are more like that of a 60 year old man, and that's when men have heart attacks, and so if we add estrogen back, then you run the risk of, you know, making those arteries more pliable, breaking off a chunk of plaque, and then having a heart attack or a stroke. Now the increased risk is not high, but it's not 0.


00:31:27.536 --> 00:31:31.135

Dr Doug: So then, if you go back and say, okay, for the 10 to 20 year group.


00:31:31.286 --> 00:31:54.246

Dr Doug: What do we do? So we like to use imaging stratification. So we'll use a corn artery calcium score. As our primary tool. And when that study, it's gonna show one of 2 things. It's gonna look at calcification of the arteries that give blood to the heart. If you have 0 calcification, I'm reasonably confident that you have not been developing plaque over the last 1020 years, because it would be classified by now, if you were for most people.


00:31:54.506 --> 00:32:17.966

Dr Doug: if it's positive and it's you know, let's say it's a little bit positive. Then we have a conversation to say, do we wanna know more information? And then we can have go down that pathway if it's wildly positive, like it's a thousand, which is a really high number. Then the answer is, you probably have significant disease. And even though you're in this age group, I think that you are probably on the riskier end of this age group. And let's just use other tools


00:32:18.646 --> 00:32:20.105

Dr Doug: because I don't think it's worth it


00:32:20.116 --> 00:32:24.866

Dr Doug: over 20 years. We kind of use the same stratification. We just get a little bit more aggressive with imaging.


00:32:26.036 --> 00:32:28.695

Breta, MS, RDN - OHH TEAM: And how do you factor family history into that.


00:32:29.176 --> 00:32:58.535

Dr Doug: It's part of it. So we don't. The imaging doesn't tell us everything now, even if we did the second test, which is a more aggressive test that looks at both soft flak and hard plaque. It gives us great information. It's just harder to get, but even that's not perfect. So if you have significant family history, it's raising another red flag. And so it just depends on how many, how many things do you have working against you? Do you have high cholesterol? Do you have diabetes? Do you have elevated inflammation? Do you have a strong family history and a positive imaging study? You're not going to start on estrogen in my practice.


00:32:58.536 --> 00:33:14.556

Dr Doug: Right? But if all those things are negative, then yeah, even if you're 75, and if your imaging looks good. You have all the other things that are negative. Why would I not offer it to you? Because I don't think that you're at high risk, so we can look at what's in the studies. But then we also have to look at the patient.


00:33:15.316 --> 00:33:34.947

Breta, MS, RDN - OHH TEAM: Yeah, one more risk that I wanna talk about and then we'll get back to the positive stuff but someone had asked about. I'm just gonna read this, but some studies show an association between hormone replacement, therapy and skin cancer in particular, melanoma


00:33:35.426 --> 00:33:46.205

Breta, MS, RDN - OHH TEAM: cara acidic carcinoma and some other studies have not found this. It's an issue of concern, because there's skin cancer in my family, and I've had a melanoma removed. Do you have any thoughts on this.


00:33:46.636 --> 00:33:53.256

Dr Doug: Yeah. So I looked at this. I remember the first time this was introduced to me. So the studies are.


00:33:53.636 --> 00:34:03.596

Dr Doug: Whenever the studies show both answers, then it's obviously not a clear association. And remember that associations also are just that their associations, not causations.


00:34:03.656 --> 00:34:21.776

Dr Doug: There's a lot of reasons why, in this recent publication on longevity is a good example of this. But there's a lot of reasons why somebody on Hrt could have a higher incidence of skin cancer diagnosis. If you think about this. So somebody who's on Hrt is obviously more engaged in their health, they're more likely to seek


00:34:21.776 --> 00:34:44.705

Dr Doug: the advice of a doctor, they're more likely to receive a diagnosis. So from an association style study, you're gonna look at people that are motivated. They're going to the doctor. They're gonna get a diagnosis skin cancer happens. I mean, globally, right? Like, I could have it, people raise their hands on this call. How many people here have have had some sort of a a basal cell, or whatever kind of cancer, and probably all of us right? So I got a little basal cell right here.


00:34:45.306 --> 00:35:11.105

Dr Doug: And so, like, I've got cancers from my testosterone. No, it's the fact that if you go to the doctor because you are proactive about your health. You're gonna get a diagnosis versus people that aren't on Hrt, that aren't pursuing healthcare. They're not gonna get a diagnosis. So from an association perspective that's obvious you're gonna see that. But you never see it in an intervention study. Now, they're also not looking. So there's that. So I don't think that the correlation is, gonna be very strong. And then, if you think about like.


00:35:11.256 --> 00:35:14.835

Dr Doug: what's the physiology behind that like, why would that even make sense?


00:35:14.956 --> 00:35:17.366

Dr Doug: If that if it made sense that


00:35:17.406 --> 00:35:24.766

Dr Doug: natural levels and physiological levels of hormones caused skin cancer. We would have skin cancer when we're young adults, not when we're older.


00:35:25.336 --> 00:35:30.046

Dr Doug: So the physiology doesn't make sense, and the evidence is not strong, so I don't think that's a concern.


00:35:30.646 --> 00:35:40.564

Breta, MS, RDN - OHH TEAM: Yeah, awesome. Alright. Now, back to the good stuff. You talked about some of the positive side effects, and like symptom reduction of Hrt. But like, what are the additional benefits of Hrt.


00:35:40.906 --> 00:35:42.696

Breta, MS, RDN - OHH TEAM: Not related to bone health?


00:35:43.406 --> 00:35:45.265

Breta, MS, RDN - OHH TEAM: What's all the good things.


00:35:45.456 --> 00:35:46.162

Dr Doug: Yeah. So


00:35:46.846 --> 00:35:51.306

Dr Doug: this is where I'm actually rewriting some sections of the book. So


00:35:52.006 --> 00:36:07.826

Dr Doug: there is evidence to support obviously, heart health. Right? So we know that especially the earlier you started as a post menopausal woman, the better the impact is going to be from a cardiovascular perspective. So decrease mortality decreased heart attack, decrease, rate of stroke, all all the things.


00:36:08.358 --> 00:36:27.395

Dr Doug: and from a a vascular perspective. So from an artery perspective, it all makes sense, because estrogen is protective of the arteries. So you're gonna have better artery function. It's gonna be better for blood pressure. It's gonna be better for the little like the arteries that that are involved in the circulation of the tissues. Just all of it. So basically, it helps everything.


00:36:27.686 --> 00:36:42.475

Dr Doug: From that perspective. Think about all the things that arteries go to right? So like your skin's gonna look better, it's gonna have better. It's gonna have better circulation. So it's gonna have better nutrition. So skin looks better. Wrinkles are better like this is why it's an anti-aging thing.


00:36:42.876 --> 00:36:48.615

Dr Doug: so the skin is going to be thicker. It's going to be fuller, it's going to heal better. So all that's true.


00:36:48.924 --> 00:37:03.915

Dr Doug: Also the brain, so that the brain is an organ that uses a lot of blood. And so micro vasculature within the brain is going to be. It's going to work better. And you're going to see improvement in brain function, particularly the more physiologic, and the younger you start estrogen therapy.


00:37:05.076 --> 00:37:09.125

Breta, MS, RDN - OHH TEAM: Awesome. And what about brain health and mental health


00:37:10.106 --> 00:37:10.886

Breta, MS, RDN - OHH TEAM: do like so.


00:37:10.886 --> 00:37:13.315

Dr Doug: Like psychiatric health or neurologic health.


00:37:13.832 --> 00:37:21.056

Breta, MS, RDN - OHH TEAM: Both. So neurologic health number one and second would be mental health.


00:37:21.306 --> 00:37:35.983

Dr Doug: Yeah, so I would say, like, neurologic health. So true, like brain nerve health, we know that estrogen is again protective of the brain. And we see this in the the dimension numbers, although it's not as impressive as you'd think. And there's some reasons for that in the studies.


00:37:36.386 --> 00:37:43.475

Dr Doug: But what I like about the trio of sex hormones is that Progesterone is very protective of nerves.


00:37:43.476 --> 00:38:08.235

Dr Doug: And so we kind of look at this from an estrogen perspective. But we really need to bring Progesterone into the picture, which is that Progesterone is gonna help to repair nerves. It's gonna help to decrease the you know the the neurofibrillary tangles. It's gonna decrease. The you know, the buildup of the plaque associated with Alzheimer. Specifically, so Progesterone might even play a bigger role here. It's just it's never studied alone. So


00:38:08.236 --> 00:38:15.745

Dr Doug: so we don't know, because it's always studied with estrogen. So we talk about estrogen a lot. But I think Progesterone plays a big role there.


00:38:15.806 --> 00:38:18.376

Dr Doug: So I think from a neural perspective.


00:38:18.456 --> 00:38:21.306

Dr Doug: it's going to be protective. I don't think there's any downside


00:38:21.754 --> 00:38:38.415

Dr Doug: from a psychiatric perspective. We clearly see reductions in anxiety and depression, symptomatic bipolar disorder, you know just the overall feeling of self worth that feeling of vitality. It's hard to measure, but all of those feelings get better on Hrt. Rather than off.


00:38:39.166 --> 00:38:45.646

Breta, MS, RDN - OHH TEAM: Yeah. So would you say that Progesterone would have a positive impact on neuropathy? Or maybe that's not totally clear.


00:38:45.676 --> 00:38:49.615

Dr Doug: Hmm! I've never seen a study on it. But again it's never studied alone.


00:38:49.908 --> 00:38:53.175

Dr Doug: I wouldn't be surprised, but I don't know the answer to that.


00:38:54.106 --> 00:39:17.626

Breta, MS, RDN - OHH TEAM: And I just wanted to share like a cool way. And this was like part of the mental health question. Then the person who asked was curious, because they're so amazed on just how Dr. Different they feel after starting their hormones in just a month. So they reported that their mental outlook and add, like all the other lifestyle, changes just got so much easier, and that starting their hormone replacement therapy was life changing for them. So


00:39:17.626 --> 00:39:30.425

Breta, MS, RDN - OHH TEAM: just a really great testimonial there. Alright, we're gonna transition into some of your questions. Oh, from the chat here. So how long does it take for Hrd. To have an impact on Btms.


00:39:32.988 --> 00:39:44.406

Dr Doug: Quick, so we don't. We don't get them more often than every 6 months, but I bet you would see if you started estrogen. I bet you would see it almost like immediately right? Cause you would think


00:39:44.606 --> 00:39:45.856

Dr Doug: we think about it


00:39:46.026 --> 00:40:02.061

Dr Doug: if you go back, you know, premin and puzzle timeframe. When you have that surge of estrogen that rises and falls in the first 2 weeks of your cycle during the follicular phase, it's pretty short, right? So like the rise and Fall peaks. Day 12 drops off, and it's gone by. Not gone. But it's like back to Baseline by day. 16.


00:40:03.176 --> 00:40:22.815

Dr Doug: It's a pretty short window, and it has an impact on osteoclast. So you get this like pulse, pull, withdrawal of of estrogen and monthly. We're during a cycle. And so it's not a reasonable to think that if you started that, you know, especially the more physiologic, those you're gonna see a bigger impact. But yeah, I think you would see an impact, probably within like a week or 2 weeks.


00:40:24.666 --> 00:40:29.580

Breta, MS, RDN - OHH TEAM: Yeah, and sorry I should have clarified Btm's as bone turnover markers. Just so. We're all in the same.


00:40:29.826 --> 00:40:31.790

Dr Doug: First a loop there for a second too.


00:40:32.318 --> 00:40:43.035

Breta, MS, RDN - OHH TEAM: It was just. I was written in the question. And then I was like, Oh, wait. Okay. And then what are your thoughts on something like the Marina iud for progesterone, instead of the micronized progesterone.


00:40:43.506 --> 00:41:02.106

Dr Doug: Yeah, this is, it's frustrating for me, cause I I do see this a lot, cause it is so easy, like as an Ogan. I get it right, or like after dial patch. Boom, marina, iud boom! I got a clinic visit. I got a procedure code, and I got like to build for them like it's just like business model makes sense totally get it.


00:41:02.206 --> 00:41:08.336

Dr Doug: But that's making the assumption, then, that Progesterone only impacts the lining of the uterus because you're not going to see Progesterone anywhere else.


00:41:08.976 --> 00:41:28.986

Dr Doug: So you're not going to get the impact of Progesterone under bones which again has never been studied independently, because we never study progesterone independently. But we know that osteoblasts have progesterone receptors, so why not leverage that it also helps improve sleep, and I can't see other than this recent study. There's never been a study on micronized Progesterone that showed any potential negatives.


00:41:30.496 --> 00:41:31.226

Breta, MS, RDN - OHH TEAM: Awesome.


00:41:31.456 --> 00:41:36.495

Breta, MS, RDN - OHH TEAM: and then the relationship between progestron and testosterone, and why you should take them together.


00:41:37.366 --> 00:41:39.616

Dr Doug: Of estrogen and testosterone.


00:41:39.616 --> 00:41:41.606

Breta, MS, RDN - OHH TEAM: And progesterone and testosterone.


00:41:41.606 --> 00:41:50.165

Dr Doug: Yeah, you don't have to take them together so often, though we find for women that are not candidates for estrogen, for whatever reason


00:41:50.256 --> 00:42:09.865

Dr Doug: that we still may have the option of using testosterone and progesterone depending on the circumstances. So if it's somebody in their seventies that's not uncommon for us to use again off label for sure. But to recommend Progesterone because we're gonna get a bone health impact of unknown measure. But it's also gonna help with sleep, which is almost universally an issue for women in their seventies.


00:42:10.209 --> 00:42:15.205

Dr Doug: And then, testosterone, you're going to get the benefits of testosterone, but you don't need to use them together.


00:42:15.926 --> 00:42:23.549

Breta, MS, RDN - OHH TEAM: Yeah. And then would low extra dial, exacerbate pain, or potentially like arthritic pain at all.


00:42:24.226 --> 00:42:25.216

Dr Doug: Absolutely.


00:42:25.666 --> 00:42:26.336

Breta, MS, RDN - OHH TEAM: Son.


00:42:26.876 --> 00:42:34.676

Breta, MS, RDN - OHH TEAM: and how can you best apply the creams? Are you supposed to alternate sites? Where do you recommend people? Apply the creams.


00:42:35.236 --> 00:42:37.276

Dr Doug: I happen to have my tube right here.


00:42:38.066 --> 00:42:51.086

Dr Doug: Just one of these things I keep on my desk after dial, though, is usually pink but so if you're using one of these things, this is how we recommend doing it. For our patients is using using a cream. Using this thing is called a copy click dispenser, so you can hear it go.


00:42:52.086 --> 00:43:02.295

Dr Doug: And so if we like, if we talk about dosing for our patients, we're usually saying, do 2 clicks, so 2 clicks would be 1, 2, and then the cream will come out the top.


00:43:02.436 --> 00:43:10.735

Dr Doug: This is full. It's probably there's probably nothing in here, but so the cream comes at the top, and people will say all the time they're like, Oh, but it's not consistent, like, I know


00:43:10.976 --> 00:43:31.586

Dr Doug: it's not perfect, but it it averages out over time. So 2 clicks is a a half of an Ml. Of of cream, and so where you apply it. I I do agree, like rotating estrogen, not as important as testosterone, but testosterone. If you apply it in the same place over and over again, you will get some increased hair growth in that area, and it's usually dark hair so


00:43:31.866 --> 00:43:59.466

Dr Doug: that can bother some people. But the actual application process is pretty simple. So if you just, you know, use you wanna use skin that doesn't have a lot of hair on it. If you're worried about the hair growth. That's a thing that you do then use skin that most people aren't gonna see. Or you could potentially even put it on somewhere that already has hair. So I was actually trained to use testosterone cream on external labia for women, because most women have hair there already, or they're not worried of hair grows there. So that's a


00:43:59.466 --> 00:44:16.785

Dr Doug: controversial topic, though. But anyway, wherever you're going to apply it generally, you want to use the actual application, and you want to put it on the skin. Not use your hand because you'll lose some that way, and then you want to just rub it in until it goes away. And so for people that have like oily skin, for example, like this can take like 2, 3 min


00:44:16.786 --> 00:44:37.452

Dr Doug: for people with dryer skin, thinner skin. It might be gone in like 30 s. And so you just wanna make sure that you're getting it in there that that actual cream like goes away. You don't need to rub your skin until your skin is like raw. Had to, I used to say, like 2 min, and that was an absolute. And then you get people there sending pictures of like their skins falling apart so like, don't don't go that long.


00:44:39.256 --> 00:44:53.615

Dr Doug: And then, once it's in, you're good, I would let it, though. Make sure you let it dry before you apply clothes, leave it on for at least 3 h before you take a shower, and then for cream, especially testosterone. True, with estrogen, though at higher doses watch for transfers to others, especially kids.


00:44:54.536 --> 00:44:55.226

Breta, MS, RDN - OHH TEAM: So.


00:44:55.966 --> 00:45:09.426

Breta, MS, RDN - OHH TEAM: And then, if somebody has had an early hysterectomy, and they've been taking Hrt for, you know, maybe 50 years. Do you see any potential concerns with that.


00:45:10.186 --> 00:45:21.245

Dr Doug: I don't, although it's such a great topic. So I think this is an interesting area. Because you look at a let's say a woman has a hysterectomy at 35, and they take her ovaries right? So she's she is menopausal at 35


00:45:22.966 --> 00:45:28.756

Dr Doug: the recommendation from every college in organization is to start Hrt.


00:45:29.776 --> 00:45:33.456

Dr Doug: but yet right, and they say, like to prevent


00:45:33.546 --> 00:45:42.756

Dr Doug: early aging cognitive dysfunction dysfunction like early heart attacks. All the things we're like. You better start Hrt. At 35, if you have a surgically induced menopause.


00:45:43.456 --> 00:45:46.836

Dr Doug: but yet at 50 like Oh, no, no! That stuff matters.


00:45:47.296 --> 00:46:08.625

Dr Doug: and I like it. It's just such a clear discrepancy. And like, I guess the expectation is, women in their sixties and seventies are gonna have heart attacks and develop cancer, anyway. So why not so? Why protect them from it? I just don't. I don't get it. But for women that have have had that or had we have. We've had some patients recently. We just had a woman in her twenties that has early ovarian failure.


00:46:08.856 --> 00:46:11.236

Dr Doug: Because she says I was like no estrogen, Mike.


00:46:11.826 --> 00:46:18.685

Dr Doug: I don't know how that happened. However, let's replace your estrogen right, and nobody's talked to her about it, because everybody's like well, I don't know why it happened.


00:46:18.766 --> 00:46:30.475

Dr Doug: but it doesn't matter. She has no estrogen, so let's replace it. And then, if it comes back fine, we can deal with that, too. But but let's actually protect her, because right now our bones are falling apart, she feels terrible. So


00:46:30.496 --> 00:46:35.436

Dr Doug: yeah, replacing it. And then again, this is a lifelong journey. So if you want it to work, you gotta keep taking it.


00:46:35.796 --> 00:46:36.516

Breta, MS, RDN - OHH TEAM: Yeah.


00:46:36.686 --> 00:46:53.396

Breta, MS, RDN - OHH TEAM: And I know a lot of people have concerns about like taking something for forever. But I would say, that's almost the case with both medications like, no matter, I mean very few times when you enter into like the traditional medical model, is there a plan to take you off of a medication. So this is at least providing you with.


00:46:53.666 --> 00:47:01.726

Dr Doug: Yeah, I mean, this isn't a reversible thing. I think, like there are some areas. And I mentioned, testosterone can be adequate. This is an area where, if a woman has


00:47:01.746 --> 00:47:04.836

Dr Doug: a really great lifestyle, I was talking to this with


00:47:04.906 --> 00:47:16.675

Dr Doug: somebody on the screen. Yeah, Don's waving her hand. So Don and I were having this conversation where you know she she doesn't want to take hormones, and that's totally fine. But what I was pointing out is that her life right now


00:47:16.816 --> 00:47:40.476

Dr Doug: has a lot of stress in it. She's doing a lot. She's like 5 jobs. So like she's doing a whole lot of stuff. She's really stressed out. She's working on her lifestyle, but she's limited in in like what she can really do. And so right now she's not. She does not have optimal testosterone levels because her adrenals are too busy making cortisol. I mean, that's just the way it is. Now, if her plans work out and she


00:47:40.496 --> 00:47:53.186

Dr Doug: retires from her jobs, and she moves to the country, and she builds this beautiful place in the middle of nowhere, and all she does is, you know, grow food and and live her life and meditate and do Yoga.


00:47:53.236 --> 00:48:01.135

Dr Doug: her testosterone levels might rebound honestly right, like her adrenal function could rebound. She could have normal testosterone, she could potentially come off that.


00:48:01.246 --> 00:48:08.705

Dr Doug: But she will not naturally make enough estrogen, and not naturally make enough progesterone. And so that's up to her. Then


00:48:08.816 --> 00:48:10.646

Dr Doug: she says, I will prove you wrong.


00:48:12.396 --> 00:48:32.745

Dr Doug: So, but that's my perspective. Other things, though, like thyroid, you know not a conversation for today, but, like thyroid, is a hormone that we often replace. That I think does potentially rebound, you know. So if you improve thyroid function, immune function that can rebound. So there, there is a potential for some of these things to go away. But as opposed when a plausible woman estrogen and progesterone, you're not gonna have adequate levels. Naturally.


00:48:33.066 --> 00:48:36.107

Breta, MS, RDN - OHH TEAM: Yeah. And then with progesterone,


00:48:36.796 --> 00:48:41.855

Breta, MS, RDN - OHH TEAM: replacement, do you ever notice abdominal weight


00:48:42.036 --> 00:48:45.015

Breta, MS, RDN - OHH TEAM: like, stick around a little bit more with Progesterone.


00:48:45.735 --> 00:48:53.245

Dr Doug: So I don't see this clinically. I hear of it, and I'm thinking that this is probably this has got to be a balance thing.


00:48:53.355 --> 00:48:56.575

Dr Doug: And so if you think about the the changes that happen


00:48:56.615 --> 00:49:23.265

Dr Doug: with post menopausal women in general. So you know, post menopausal women, their weight will go from their their thighs and their butt to their belly. And this is like very disconcerting for a lot of people. So you know, the body composition changes all of a sudden you've got belly fat, and you're like, how did this happen? I didn't change anything, my diets the same, and it's all hormonal, right? So if you think about like once you lose estrogen, you lose that drive to to keep your body composition and keep your subcutaneous fat where it is.


00:49:23.425 --> 00:49:28.295

Dr Doug: even if you replace, especially with a low dose estrogen that's not going to change.


00:49:28.395 --> 00:49:47.355

Dr Doug: And this is why, when you look at hormones for weight loss, I have this conversation from my wife's clients all the time they're like, well, if I just start on Hrt, it'll all be fine. No, it won't, because you don't have enough estrogen to even drive the impact that estrogen would have naturally, anyway, plus estrogen tends to be fat, provoking, not fat removing.


00:49:47.355 --> 00:50:06.165

Dr Doug: And so the studies on hormones for weight loss don't show significant benefit. Progesterone itself, though I can't think of any physiologic reason why it would cause weight, gain, or particularly like belly fat. I think it's just an imbalance thing overall. Estrogen does generally provoke a little bit of weight gain, but it'll stabilize and then generally come back off.


00:50:06.946 --> 00:50:14.225

Breta, MS, RDN - OHH TEAM: Yeah, awesome. And then last question, and then I'll just open it up to the group. Do you ever notice higher cortisol


00:50:14.856 --> 00:50:17.315

Breta, MS, RDN - OHH TEAM: impacting estrogen levels.


00:50:18.993 --> 00:50:38.476

Dr Doug: Yes. And so this leads to that whole adrenal hpa access dysfunction thing. So when you have adrenal dysfunction, you are at risk of having sex hormone dysfunction. And some people would say, this starts in the gut. Some people would say, it starts from stress. I don't think it matters which one is first.


00:50:38.476 --> 00:50:55.325

Dr Doug: because they both impact the other. But once one falls they're like dominoes. So once the adrenal glands are overstressed, the brain sort of turns that down the volume from the adrenal glands they kind of lose their capacity to produce. Dha, so you're going to get sex hormone dysfunction, naturally, anyway.


00:50:55.326 --> 00:51:10.315

Dr Doug: but high cortisol will also turn down the signal from the brain to the ovaries or to the testicles and men. And so that's why we see in both men and women, reduction in sex hormones from stress. So even a premenopausal woman will see a reduction in estrogen, and we see this like.


00:51:10.456 --> 00:51:20.515

Dr Doug: oh, my gosh! I see it like I was just having a conversation with all of all of my neighbors. We're talking about hormones. These are the things that happen in my house, and I swear every


00:51:20.556 --> 00:51:38.766

Dr Doug: 40 year old mom woman in my neighborhood has low estrogen, I mean, and you know, exhibits differently in each one of them. And it just like it's just global. So yes, we see low levels of estrogen from increased hormones or increased adrenal stress and and cortisol especially, and


00:51:38.816 --> 00:51:43.805

Dr Doug: I would say that Perry monopozzle time frame, because I think the system just gets a little bit more fragile.


00:51:44.636 --> 00:51:55.695

Breta, MS, RDN - OHH TEAM: Yeah, awesome. Alright. Well, I'm we'll open up the last 8 min. If anybody wants to raise their hand or just jump on, ask a question. Say a comment. Share your story. Now is the perfect time for that.


00:51:55.696 --> 00:51:59.256

Dr Doug: There's a good question from Sue, while people are deciding whether or not they wanna


00:51:59.786 --> 00:52:05.226

Dr Doug: put themselves on the spot. So Sue had a great question around shbg or sex hormone binding globulin.


00:52:05.831 --> 00:52:06.366

Dr Doug: So


00:52:06.596 --> 00:52:17.625

Dr Doug: this is one of those labs that we get in conjunction with with hormone levels, because Shpg is the the binding hormone for horming hormone for hormones, and as implied by the name, I guess.


00:52:17.626 --> 00:52:42.206

Dr Doug: But it'll bind onto the total testosterone or the estrogen, and then it has to come off. Of that the hormone has to come off of that in order for it to actually be active. So for people that have high binding globulin or high shbg their free levels especially true in testosterone, their free levels will be much, much lower. So, for example, I've seen guys that have total testosterone 6, 700, which is pretty good.


00:52:42.246 --> 00:52:53.376

Dr Doug: But if they have high Shpg they could still have single-digit free testosterone. And those are the guys that go to their doctor complaining of all the symptoms of low T, and their doctor is like dude. Your testosterone's fine. Go away. Here's an antidepressant


00:52:53.699 --> 00:53:09.826

Dr Doug: but they're free testosterone as low. And so those are guys that there's not a lot you can do with. S hg, because a lot of it's stress driven. So those are the guys. I'll potentially even replace testosterone if we've done all the lifestyle stuff. If their total testosterone is even 6 or 700, because they're symptomatic.


00:53:09.876 --> 00:53:15.165

Dr Doug: Same thing can be true in women. But again, it's we don't actually measure SH. Bg.


00:53:15.306 --> 00:53:20.326

Dr Doug: universally, because there's not a lot. There's no intervention to change. SH. Bg.


00:53:20.446 --> 00:53:39.125

Dr Doug: so we just have to know that it's one of the factors, and that you and this is another reason why you pot could potentially have high total levels of a hormone and still be symptomatic. And that's why we're not dogmatic about our levels. You know, if a woman doesn't feel good in her testosterone's at 80. She's not having side effects, but she still has signs of testosterone deficiency. We'll push it up


00:53:39.176 --> 00:53:49.385

Dr Doug: because she likely has high shbg, which we can test. But I don't really need to. And so it's definitely real. And it's definitely an issue. And most doctors aren't testing it.


00:53:52.116 --> 00:53:55.976

Breta, MS, RDN - OHH TEAM: Awesome any questions from the group here. Anybody wanna jump on.


00:53:59.256 --> 00:54:01.006

Breta, MS, RDN - OHH TEAM: Oh, you remuted yourself. There you go.


00:54:01.006 --> 00:54:02.286 Oh, sorry


00:54:02.366 --> 00:54:06.645 I did have a question since that new study came out.


00:54:07.186 --> 00:54:09.246 and it didn't make it look like


00:54:09.316 --> 00:54:10.806 suggestion.


00:54:11.446 --> 00:54:14.426 helpful or protective in some way.


00:54:14.896 --> 00:54:15.776 And


00:54:15.936 --> 00:54:21.055 so I still wanted to clarify with you, because I know you're not a fan of project.


00:54:21.606 --> 00:54:24.185 I've seen your videos on


00:54:24.991 --> 00:54:27.766 the original Women's Health initiative.


00:54:28.651 --> 00:54:31.485 What's the feeling about? Should we just


00:54:32.466 --> 00:54:35.796 about how the conflicting results? I guess.


00:54:36.036 --> 00:54:41.536

Dr Doug: Yeah, so thank you for reminding me to bring that up. So I did. I read the first half of that study this morning and


00:54:42.286 --> 00:54:52.045

Dr Doug: my, take on it is this, which is I like that. It shows that there's an improvement in an overall mortality of maintaining hormone replacement therapy after 65. I think that's great.


00:54:52.586 --> 00:55:06.733

Dr Doug: But here's the thing number one. It's observational. So there's weaknesses associated with that out of the gate. We kind of already talked about that. But number 2. I have a lot of concerns in this particular study around bias. So the Menopause Society, of which I am a member.


00:55:07.196 --> 00:55:19.045

Dr Doug: you have to understand the funding for the Menopause Society as pharmaceutical, just like the American Bone Health Society is pharmaceutical like. They're all run by pharmaceutical companies, which is absolutely should be illegal.


00:55:19.116 --> 00:55:22.736

Dr Doug: Because imagine Wyeth, who would make


00:55:22.936 --> 00:55:24.146

Dr Doug: progestins


00:55:24.556 --> 00:55:26.585

Dr Doug: funds, the Menopause Society


00:55:26.596 --> 00:55:31.985

Dr Doug: which funds the journal which gets to then editorialize an observational study.


00:55:32.176 --> 00:55:33.786

Dr Doug: How much power is that


00:55:33.926 --> 00:55:52.415

Dr Doug: to come out with this study and say, no. The micronized progesterone, which doctors have been talking about for the last 25 years since the Women's Health Initiative. No, this is actually dangerous. Here's the product that we make, which here the study shows that this is better. So. I have a lot of concerns around bias here. But if you think about, let's assume that that's not true, and there's no male efficien people there.


00:55:52.726 --> 00:55:57.226

Dr Doug: Let's just take, for example, the weakness of an observational study.


00:55:57.266 --> 00:56:03.916

Dr Doug: which is that people that are people that were studied. They were studied because they had records from Medicare.


00:56:04.106 --> 00:56:17.695

Dr Doug: and they had insurance. So I guess it'd be claims for and diagnosis of of what they were being received hormone therapy for, and then they would be getting claims for the actual, like reimbursement from insurance for the the drugs.


00:56:18.766 --> 00:56:26.486

Dr Doug: Micronized progesterone is not that commonly used commercially, much more commonly used from a compounding pharmacy.


00:56:26.646 --> 00:56:29.185

Dr Doug: None of my patients would be in this study.


00:56:29.256 --> 00:56:42.206

Dr Doug: None of my patients are on the system for Medicare or commercial system. Right? So my experience is not gonna be reflected here. And that's gonna be true for every functional doctor, integrative doctor that is outside of the insurance model.


00:56:42.346 --> 00:57:11.296

Dr Doug: So this is this study is driven by people that are within the insurance model, which is primarily gonna be driven by pharmaceutical interests. So there's just gonna be a clear bias here because you're looking at people that are using insurance. They're gonna be more likely prescribed things. And the people that are being prescribed micronized Progesterone, there might be a reason why I see the same thing with like people that are on quote unquote high dose versus low dose. That's all garbage, because these are all commercial products. There is no high dose estrogen product from a commercial pharmacy.


00:57:11.366 --> 00:57:34.836

Dr Doug: So there's a lot of issues with the way that they put it out there. And the way that they say it, they're essentially like driving the nail in the coffin of things that they wanna put to bed, and that would be micronized progesterone which I disagree with. But then it's also they talk really bad about premarin, which I do agree with, but still doing it in this way is not, I, I think, is wrong, because essentially what they're doing is they're saying


00:57:35.186 --> 00:57:43.076

Dr Doug: you shouldn't use any of these things. You should be using these synthetic progestins and a low dose estrogen. And this is what the people that live the longest we're using.


00:57:43.326 --> 00:57:50.895

Dr Doug: But if you consider, why would you know if you're let's say you're in your seventies, eighties, nineties, and you're still on Hrt. What is also true.


00:57:51.106 --> 00:57:52.726

Dr Doug: You're also healthy.


00:57:53.026 --> 00:57:54.246

Dr Doug: right? So like


00:57:54.566 --> 00:57:58.455

Dr Doug: people that are still receiving the the prescriptions still picking them up


00:57:58.506 --> 00:58:01.215

Dr Doug: are the people that haven't succumb to something else.


00:58:01.456 --> 00:58:25.086

Dr Doug: So I think I, when I see women go off of Hrt is when, like the you know, the the train cars falling apart. Right? So like things happen, you get a cancer diagnosis, you you know, like whatever it is, and you come off of your Hrt. Because you just sort of lost hope. And you're kind of in that downward spiral. A downward spiral could last 5 to 10 years sadly. But that doesn't necessarily mean that it was the Hrt's fault.


00:58:25.086 --> 00:58:33.195

Dr Doug: Right? You've just something's happened in your life, and you've decided to come off of it. I think that's what this study is actually showing. So I don't think it's really showing


00:58:33.196 --> 00:58:34.816

Dr Doug: what people want it to show.


00:58:34.816 --> 00:58:38.025

Dr Doug: So I think, unfortunately, this study is mostly garbage. Sadly.


00:58:38.736 --> 00:58:40.735 Well, I appreciate that answer.


00:58:41.616 --> 00:58:43.116 It seems like that would be


00:58:43.196 --> 00:58:47.446 exactly the case that there have a huge conflict of interest in.


00:58:49.186 --> 00:58:49.926

Dr Doug: Yeah, and.


00:58:49.926 --> 00:58:56.155 The compounding. I use the compounded testosterone, and that would never be reflected in their numbers.


00:58:56.436 --> 00:58:57.096 Nope.


00:58:58.186 --> 00:58:59.375 I do have.


00:58:59.376 --> 00:59:11.666

Dawn Aragón, PhD: On the positive note we're about to end. Jump on, Hsn. The questions that didn't get answered. I just put in the chat all of the channels. Make sure you enter all the channels, sign yourself up for all the channels.


00:59:11.986 --> 00:59:19.025

Dawn Aragón, PhD: get your questions in the categories best you can, and the categories that are there, the channels that are there, and there's one


00:59:19.056 --> 00:59:27.485

Dawn Aragón, PhD: live session follow up. So if you have more questions put them in there, and Dr. Doug will be. Do his best to get to some of them.


00:59:28.050 --> 00:59:30.106

Dawn Aragón, PhD: Maybe not all. But.


00:59:30.480 --> 00:59:31.975

Dr Doug: Thank you for that.


00:59:32.046 --> 00:59:34.965

Dr Doug: Fred is gonna remind me how to do how and when to do that later.


00:59:35.236 --> 00:59:49.790

Breta, MS, RDN - OHH TEAM: Yeah, and I will. I will add the journal article to that channel as well. And actually, I know Dr. Doug needs to run, but I will stay on for a few minutes if and I can show you guys how to make sure you're in all of those channels on slack. If you guys.


00:59:50.046 --> 00:59:52.385

Dawn Aragón, PhD: Great. Yeah, let's take a little slack break.


00:59:52.736 --> 00:59:56.097

Dr Doug: Yeah, I'm gonna I'm gonna hop off cause I got a patient. But nice to see everybody.