Dr. Gunther, I just love how you explain this stuff. What is hormone replacement therapy?

So menopausal hormone therapy, which is what we call it, is giving hormones to treat symptoms of menopause or to prevent complications associated with menopause, like osteoporosis.

Can you explain the different types of hormone replacement therapies, Dr. Gunther?

Yeah. So there's evidence-based FDA-approved, and then there are scams. I would think that's the best way to sort it out. So many people get I've hung up on the term bioidentical, which is really a meaningless term. It's a medically meaningless term. Whether a hormone is the same or similar to what your body makes doesn't make it safe. I could give you a high amount of epinephrine and cause harm to you, but that's something your body makes. So I can give somebody tons of estrogen and give them endometrial cancer. So whether something similar to what your body makes or not doesn't make it safe. What makes it safe is, is it studied? Is it safe? Is it effective? And is it something that can be... We know exactly how much you're getting. So one of the big problems is a lot of people are using compounded medications or pellets, and we don't know what's actually in those things from an actual amount of hormone. So if I give you an estrogen patch, I know how much is going to be absorbed. There have been studies that have been done. I know if you put it on a different body part, that's going to affect absorption because all of this has been done.

With compounded products, none of that exists. None of it. I don't know how much is getting across your skin. I don't know how much you're ingesting. I don't know how much is being absorbed. And would you want to have a broken gas gage, or would you want to have a gas gage that works? You would want to know what you're putting into your It's all about the body. I would say there are FDA-approved therapies, and there are many good ones out there. There's estradiol, which is the main hormone that the ovary makes, and we have pharmaceutical variations of those. Another big myth is that some hormones are plant-based. That, again, is a marketing jargon. Is that not true? Well, I mean, petroleum is plant-based, too, if you want to look at it that way. You take soybeans and then you expose the chemical that you extract from soybeans to a multi-step chemical process to break bonds and convert it into estradiol. So So, yeah, it's plant-based, but it's not. They used a starting chemical found in a plant and converted it into estradiol. That doesn't make it any better than if I made estradiol by assembling it from different molecules.

It's the same thing. Your body can't tell the difference. We just make it from soybeans, which is called a semi-synthesis, because it's cheaper than making it by synthesis, which is assembling the molecules itself. So it's a total marketing thing. Plant-based, it means nothing. Nobody's grinding up yams and putting them into pills and giving them to you.

How do I know that I'm doing the right thing? I listen to you and I'm like, Yes, yes, yes. I love it. Take it down. Take it down. Go, go, go. Dr. Gunther, thank God you're out there cleaning up the Internet for us. But then I'm like, Shit, what am I asking my doctor? So So if I'm going into my gynecologist and I'm interested in hormone replacement therapy, what is the proper thing to ask for so that I am in the land of research and in the land of things that we can measure versus in the fringe areas of the other stuff?

So if you're getting a prescription that doesn't have a package insert with it. What does a package insert mean? So whenever you get any prescription and there's this little folded up book and you unfold it, it's all the risks and benefits. And it's this big thing. If it doesn't have that, then it's not FDA approved.

Oh, okay. So all the things that you get from the compound pharmacy, not FDA approved? No. Because they haven't... How could they be? Because the packaging has been through clinical trial after clinical trial, and it's had to have been tested and passed through all these hoops for your safety and so that you, as a doctor, can understand what you're actually prescribing me.

Yeah. So there's this whole loophole for compounded medications, and so they They don't have to have that package insert. They don't have to tell you about risks of blood clots or risks of this. They don't have to tell you any of that. That's a big problem, and it makes people think that they're safer. Because look, if I gave you two things, one had a list that said it had a black box warning on it, and the other one didn't, you're going to automatically think the one that doesn't have the black box warning on is safer. Well, it doesn't have the black box warning because it wasn't required because it's not FDA approved.

Oh, my God. When I was going through perimenopause, I got bioidentity BIOIDENIAL hormones from a compound pharmacy, and I thought I was fancy. I thought this is high-end medicine. They have taken something for me. This is how uninformed I was. They have literally, because of the word bioidentical, I thought it meant, oh, well, somehow this is custom formulated for me to match my hormones. It is bioidentical, which sounds really fancy and trustworthy. And then I would get this packet from a compound pharmacy, and it would have these tubes in it. And there were all these warnings like, don't expose to light. Don't do this. Do that. Now, did I follow those? Of course not. Was I precise in how much I would squirt on my wrist? No. If I'm being honest. And so I thought that I was having the better result when I can see now what you're basically saying is that no, not really.

You were having the inferior. You were paying more and getting less. Because we all think when someone's customizing something for us that we're getting better, we're trustworthy, we believe people. And no menopause society recommends compounded hormones. They're not recommended by the North American or We now call them, they're now called the Menopause Society. The National Academies for Science, Medicine, and Engineering don't recommend compounded hormones. The International Menopause Society, the British Menopause Society, none of them recommend compounded hormones because it takes science and research to know how to get hormones through a skin. It takes science and research to know how to get them from your gut into your bloodstream. When you make hormones, they just get dumped into your bloodstream from your body. You're not eating them. You're not absorbing them. You're not rubbing them on your skin. You didn't evolve to get hormones that way. Now, it doesn't matter that we have modern medicine for a reason. So it doesn't mean you shouldn't take them because we didn't evolve for that. But funny thing, it takes science to figure out how to make make these molecules work for us. And so there are several issues with using compounded products.

People may be getting more of a hormone than they think they're getting. So you might be getting more estrogen than you need, which could put you at risk for endometrial cancer. You might be getting not enough progesterone, which would put you at risk for endometrial cancer, or you might not be getting enough estrogen, putting you at risk for osteoporosis. So you think that you're preventing osteoporosis, but you're not. Why would you want... So this is the analogy I use. Using FDA-approved hormones is like going to the gas station that has the gallons on it, and you can choose whichever gas you want. You fill your car and you have a working gas gage, and you're like, I know what's in there, and that's important. Go Going to a... Getting these compounded formulations or pellets is like buying gas from a dude on the side of the road who's telling you he has bespoke gas for you. And let him fill your tank. And, oh, he's going to flip that switch off so you don't know how much is in there because you trust him because he knows. That's the difference.

I am speechless. It's not very often that I don't have anything to say. And you just took a flamethrower to the entire idea of bioidentical hormones. I would never, ever try it again. And then I would add on top, by the way, you've brought the science and the research and a very compelling analogy. I'm going to add one more. As somebody who already has ADHD and has increased brain fog due to menopause, I am not that great at being consistent, at storing things the right way or using it the right way. And so I'm probably over or underdosing, even if it was made in a way that was clinically sound. And so case closed, not doing bioidentical hormones. Yeah.

And I would say, move away from using bioidentical Bioidentical and just call them compounded, because bioidentical doesn't mean anything. So bioidentical is a marketing term used to describe hormones that are plant-based, that are identical to what your body makes. But estradiol that you get from an FDA-approved company, I use an estrogen patch, it's estradiol.

I've got it on right now.

The estradiol in the patch is no different from the estradiol the compounding pharmacy is using. They're They're both buying the raw hormone from the same place. The difference is the pharmaceutical company has studied how to give that estradiol to you in a reliable dosing manner. The compounding pharmacy has not done that work. They don't have that. And because of that, they're not FDA-approved because you have to show to the FDA, and it's expensive, you have to do all those kinds. So they haven't submitted that data. They're just making things up. So you have a precise studied formulation. But the big thing is, they're not buying fancier hormones. All the raw hormone comes from the same one or two plants in the world. It's like me buying cheerios and putting them in a cheerio box or putting them in a glass jar with a ribbon around. But they're the same product. Got you. Except the delivery mechanism is different. Got you. So that's why I tell people, Every estrogen that I would prescribe you from the FDA or from an FDA-approved source, with the exception of Premrin, is bioidentical and plant-based.

So everything is the same.

To just forget that. We Let us forget that word. Okay. Yeah, because when people use the word bioidentical, it tells me that they think women are dumb.

Well, clearly, I am in this area. No. Well, no, seriously, I can own it because here's the thing. It is confusing as hell. And there's so much misinformation. And when you walk into the doctor's office and you are simultaneously erupting at your family because you're all over the place with your emotions. I'm speaking for myself here. And then next thing you know, you're sweating like Niagara Falls. And then next thing you know, your vagina feels like the Sahara Desert. And next thing you know, you can't remember where your car keys are or where you put your dog because you can't remember. And you are losing your mind. And somebody says to you, Oh, bioidentical. And I can send you. You're like, Thank you. I'll take it, whatever. And so I had no idea. And I used it for three years, and I thought I had the fancy thing. And so I want to be very clear about something, and you listen keenly to me, Dr. Gunther, to make sure I have this correct, because I'm putting my lawyer head on, and I'm feeling the association of compounding pharmacists writing us a seiths and desists letter.

And so I want to be very clear about what she has Number one, it is a fact that the Menopause Society does not recommend that you use a compound delivery formula for any hormone replacement therapy because it has not gone through FDA approval. Number two, the distinction that we're talking about is not the actual hormone. So they're using the same stuff. The reason why it is important that you understand this is because the delivery mechanism of the pharmaceutical product like Estradol has gone through FDA approval, which means the researchers and scientists and doctors know how your body is going to absorb it. They know the rate of delivery. They know that it has been tested. And so it is what the Menopause Society is recommending if you are going to do hormone replacement therapy. Did I get that right?

Yeah. And so The other important thing is when you have an FDA-approved medication, they're batch tested. So what that means is whatever, however many, one bottle in 50, one bottle in I don't know what it is, is tested to make sure it has what it claims. But when you're mixing up product after product, one at a time, there's no batch testing that can be done. You're talking about a whole different thing in quality control. So the only time we ever recommend a compounded product is if there is a true allergy. There's no pharmaceutical option because of a true allergy. And that's where we rely on compounding pharmacies for that situation. So one example might be Prometrium, oral progesterone. The brand in the United States is made with peanut oil. So if you have a peanut allergy, you can't take that product. So So the options are then to take a different pharmaceutical or to get progesterone compounded by a compounding pharmacy without peanut oil.

So Dr. Gunther, how do I know that I'm doing the right thing?

What people need to remember, the takeaway is there's really very few things you need to know about hormones. The two main estrogens that we recommend are either estradiol, and if you're stuck on the term bioidentical, that is bioidentical. Now, I'd like people to throw that away, but sometimes it's hard. So the estradiol that I would give you in a patch or a pill from a pharmaceutical company, that is bioidentical, right? So you have that. So you want to learn estradiol, and then you want to learn premrin, which is conjugated equine estrogens. And that's only actual natural estrogen because it comes from horse urine. So natural-Horse urine? Yeah. Natural means the substance exists in nature and it's being used unchanged.

How the hell did they figure out that horse urine is something that-Yeah, horse urine's got all kinds of estrogens in it.

It's a crazy thing. Those are the two things you need to learn. You need to learn estradiol and you need to learn premrin, which is the trade name for conjugated equine estrogens. And then you need to learn oral or trans vaginal or transdermal. So against the skin, through the vagina or by mouth.

Got you.

And we recommend the number one starting treatment we generally recommend is transdermal estradiol. Here, I'll show you.

I'm going to show you mine right now because I'm probably due to take it off. I have to do it every four days. Let me get down here. Okay, here it is. So this is and look, my dead skin is on it. That's disgusting. So you have a patch? Yeah. So I have a patch. I'm going to hold it up right there. I have to replace it every four days. Change my life. And so I can trust. I trust knowing that if I put this on every four days, and this is considered transdermal- That's transdermal.

It goes through the skin.

So if you were to like, I wouldn't put it here, obviously, but you just stick it to yourself.

Yeah, but you only want to put it in the place that the package insert says. Because it's been studied. They've studied it in different locations that the absorption can change. So if you put it on your belly versus putting it on your thigh or putting on your butt, you might get a different absorption of the amount of estrogen. And you don't want that. You want to know what you're getting.

Yeah, that's right. And I've also learned because I had no idea that you could also insert something into the vagina for a hormone replacement therapy. Yeah. I should probably butt my pants to finish the interview.

Yes. So there's a transvaginal ring that also has estrogen and can be absorbed that way into the body. And there's also a ring where the estrogen just stays in the vagina. And if you're having vaginal dryness, you have urinary tract infections, pain with sex, vaginal estrogen can be very effective for that. And so some people who have no other symptoms of menopause, feel great, they feel fine, but they have vaginal dryness. They don't want to take a medication that goes throughout their body. They want to just use a vaginal estrogen. So We have that. That's a great option. When you're using estrogen that goes through your body, about 50% of people will get a good level in their vagina, but some people won't. But from a take home standpoint, there is absorbing through the skin or through the vagina, and there is taking it by mouth. And we believe that absorbing it through the skin has the lower risk of blood clots. So that's why what people need to learn is the first-line therapy for menopause is transdermal estradiol.

You mentioned pellets a couple of times. What are those?

So pellets are implants that you go to a medical doctor or a nurse practitioner. And I think maybe even in some places, there's naturopaths who insert them. I don't really know because I'm not really involved with it. Maybe they don't. I'm not sure. And they can either have estrogen, they can have estrogen and testosterone, maybe they have other hormones, and they don't really know. And they're made in compounding pharmacies and they're implanted. They're not batch tested, so you don't know how much hormone you're getting. My understanding of it is it's based on a proprietary system. So you get your blood drawn, they follow your hormone levels, and then they decide when you get the next pellet based on that. But we don't recommend hormone levels for giving hormone therapy. It's not based on levels, it's based on symptoms. I don't need to know what your estrogen level is if you're 47 and starting it. I don't even need to know what your estrogen level is when you're 42. I only need to know that if I'm worried that you have premature menopause. So this system, and it's not recommended. There have also been issues with pellets, with complications and side effects not being reported to the FDA, which is also another concern.

So we don't actually know how many people have problems versus pharmaceutical companies, when they get adverse events reported, those are passed on to the FDA because there's big penalties, my understanding, for not doing that.

Is the pellet a delivery mechanism?

Yeah. It's an implant that sits in the body because I don't do it. I don't really know much about it because it's not recommended. I don't know that much about it. But what it can happen is it can produce very high levels of hormones, and then it drops off. And in some cases, you can be exposed to the levels of testosterone that we might give someone if they're transitioning. So the kind that can cause you to develop an enlarged clitoris, the kind that can cause you to develop these changes from having too high of a testosterone. We don't know when you're using those hormones, then how much progesterone to give you to protect your uterus. So there's all different kinds of issues associated with them, and they're very expensive as well. So they're just not recommended.

Do you have to have your blood drawn to have this assessed effectively? No. No.

And if you're 45 years or older, you do not need a blood test to get started on menopausal hormone therapy. If you're 11 and having a growth spurt, no one's like, Oh, why are you having a growth spurt? We should check your blood. We would expect you to have a a growth spurt at age 11. If you had a growth spurt at age three, that would be different. And that's the same thing for menopause. So if you're 45 or older and you're having hot flashes, you're having vaginal dryness, you're having irregular periods, it's not a mystery. We're expecting it to happen. The average age of menopause is 51, right? However, it's happening to you when you're 39, well, that's different. We need to know, is this an earlier menopause or is this happening for another reason? And so if you're under the age of 45, you need the bloodwork because you need to make sure that you understand why your periods have stopped. Now, if you're just having hot flashes, that's a different story. So the bloodwork is really if you've skipped periods. So say you're 42, you haven't had a period in three months, you need to have bloodwork because we should figure out why that's happened.

But if you're 45 and you're having bad hot flashes and you've had a couple of irregular periods, that's no mystery. You're starting in the menopause transition. Right if the the average age of onset for the menopause transition is 45, well, you know what? 50% of people are going to be younger than 45, and 50% of people are going to be older. So it has to be put in context. The internet wants absolutes. The internet wants, test my hormones, don't test my hormones. The internet wants this or that. But medicine is more nuanced than that. And so the only absolute I can say is if you're younger than 45 and you've skipped more than two periods, then you need to have bloodwork done because we need to know why. Is it an earlier menopause? Is it another condition that's caused your periods to stop? If you're 45 or older, it's not a mystery why you've gone two months without a period.

That makes a lot of sense.

One thing that we didn't talk about is one of the contraindications for starting estrogen is being more than 10 years from your last period or over the age of 60. And so in general, that is associated with an increased risk of dementia and an increased risk of cardiovascular disease. So We want to avoid starting it when people are older now. It doesn't mean like age 60, if you're 60 years on one day, that that's a hard stop. But I think it's just important for people to understand that there's a timing. And so if somebody, for example, their last period was 55, we might not cut them off at 60 because there might be a bit of wiggle room there. But in general, we recommend if people are going to start hormones, that it's going to be within 10 years under the age of 60. That's the ideal situation.

Everything you need to know about menopause.

Just like you went through puberty, which might have been challenging and had some symptoms, menopause is in many ways the same thing. You can think about it as puberty in reverse.