The Peter Attia Drive - October 16, 2023


#275 - AMA #52： Hormone replacement therapy： practical applications and the role of compounding pharmacies


Episode Stats

Length

18 minutes

Words per Minute

164.91539

Word Count

2,982

Sentence Count

11

Misogynist Sentences

6

Hate Speech Sentences

2


Summary

In this episode of the Ask Me Anything (Aa) podcast, Dr. Nick Stenson and I discuss hormone replacement therapy and testosterone replacement therapy as it relates to women. In this episode, we focus the entire conversation around HRT and TRT for women, including the practical application of these treatments in the practice with female patients.


Transcript

00:00:00.000 hey everyone welcome to a sneak peek ask me anything or ama episode of the drive podcast
00:00:16.400 i'm your host peter atia at the end of this short episode i'll explain how you can access
00:00:20.840 the ama episodes in full along with a ton of other membership benefits we've created
00:00:25.460 or you can learn more now by going to peter atia md.com forward slash subscribe so without
00:00:31.820 further delay here's today's sneak peek of the ask me anything episode
00:00:35.840 welcome to ask me anything episode number 52 i'm once again joined by my co-host nick stenson in
00:00:46.300 today's ama we focus the entire conversation around hormone replacement therapy and testosterone
00:00:51.780 replacement therapy as it relates to women we've gathered many questions that have come through
00:00:57.640 our recent podcasts with joanne manson sharon parish and the endocrine system video series that i did
00:01:03.780 on this topic these questions all focus around the practical application of hrt and trt for women
00:01:10.640 and how we do this in our practice with female patients so this ama is really centered around
00:01:17.200 answering questions with the focus of helping people put into practice what we've talked about
00:01:22.420 a lot in terms of theoretical application so we've done so much work on the theory of hrt and trt
00:01:30.720 this is kind of the how to do it wrapped up in this conversation around hrt is the topic of compounding
00:01:37.320 pharmacies as it is almost impossible to disentangle the role of hormone replacement therapy of any form
00:01:44.680 and compounding pharmacies and if you don't know what a compounding pharmacy is you're definitely
00:01:48.040 going to want to pay attention and certainly if you do know what it is i think you're going to
00:01:51.320 want to pay attention because compounding pharmacies are still a little bit the wild wild west and
00:01:56.680 there's the good the bad and the ugly associated with them even if you're not interested in hrt this
00:02:02.120 is probably an important discussion for anyone who falls within spitting distance of a compounding
00:02:06.800 pharmacy if you're a subscriber and you want to watch the full video of this podcast you can find
00:02:11.720 it on the show notes page and if you're not a subscriber you can watch a sneak peek of the video
00:02:16.440 on our youtube page so without further delay i hope you enjoy ama number 52
00:02:21.740 peter welcome to another ama how you doing doing very well we got a topic you're really excited about
00:02:33.580 i think today i am yeah i do find this topic to be simultaneously interesting and important so
00:02:40.200 glad we're doing it that's always a good overlap for today's podcast for those of you listening and
00:02:45.800 watching and what we're going to do is answer questions that have come through from subscribers
00:02:50.200 around recent topics covered on the podcast specifically questions around hormone replacement
00:02:56.440 therapy and testosterone replacement therapy as it relates to women so this is a topic that's been
00:03:02.200 talked about on the joanne manson episode sharon parish as well as the endocrine system podcast
00:03:08.280 where peter you were drawing on a whiteboard and so from those episodes we gathered a lot of questions
00:03:14.600 and these questions really focus around the practical application of hrt and trt for women and how you
00:03:22.440 use these in your practice with your female patients so the hope is this is much more of a practical
00:03:28.600 application as opposed to an educational one wrapped up in this conversation around hrt is the topic of
00:03:35.640 compounding pharmacies as many people who will need to get hrt and custom hrt prescriptions will use
00:03:42.920 compound pharmacies so even if you're not interested in hrt if you ever think about or will have to use
00:03:49.880 compound pharmacies it will be a really good discussion with all that said anything you want to add before
00:03:55.640 we get into it i think sometimes when you talk about something like sex hormones there's a potential
00:04:01.320 thinking that oh you're only speaking to half the population but of course while everything
00:04:05.400 we're going to talk about is directly applicable to women it's obviously applicable to men who sort
00:04:10.440 of know or care about women i know more about this topic than my wife and that's gonna i think help me
00:04:17.160 help her as she goes through these transitions and similarly i think if you're listening to this and
00:04:22.440 you're a guy it's worth paying a lot of attention as though we're talking about male hormones as well
00:04:27.320 which of course we spend just as much time talking about and the same argument would apply there as
00:04:31.160 well yeah and i think that kind of leads to a good first question which is even though this is a
00:04:36.600 topic we've covered somewhat extensively in the past why did you kind of feel it was important to
00:04:42.680 touch on hormone replacement therapy again as it relates to women and pull more questions around
00:04:48.040 this you know i just think that this is a very frustrating topic to me i don't tend to get as
00:04:52.600 animated about it as i used to or as angry about it i still believe the sort of mainstream medical
00:04:59.000 community has committed a gross injustice over the past 20 years in the misinterpretation of the
00:05:07.000 women's health initiative and the subsequent demonization of hormones in perimenopausal and
00:05:15.400 postmenopausal therapy for women and as a result of that many women have been significantly harmed
00:05:22.440 the sum total of lives that have been saved due to less breast cancer as a result from
00:05:30.040 the lack of hrt over the past 20 years is exactly zero i say that a bit facetiously but statistically
00:05:36.040 that is true let's be clear there were zero additional deaths due to hrt from breast cancer there were
00:05:44.120 more cases one in a thousand women increase in case but it translated to nothing in deaths and yet
00:05:50.520 i'm positive we could point to additional deaths due to hip fractures i've discussed some of those
00:05:58.200 elsewhere and that says nothing about the quality of life that has been compromised so we're not going
00:06:03.880 to rehash all of that because it's been done elsewhere and as you said the purpose of this podcast
00:06:08.120 is to talk about the logistics of how one goes about hormone replacement therapy and what all of the
00:06:14.040 options are and believe me there are a lot of options so a lot to cover today we know there's
00:06:19.080 a broad spectrum of the severity of symptoms that women will experience in menopausal transition and
00:06:25.240 because of that we see a ton of questions come through from subscribers wanting to know how would
00:06:30.920 they know if it's time for them to start considering hrt so do we know anything about what the tests are that
00:06:37.720 can be done to confirm the onset of menopause yeah so menopause is a clinical diagnosis and
00:06:44.440 technically it's really diagnosed retrospectively it requires 12 months of amenorrhea so 12 months of not
00:06:50.040 having a period without any other obvious pathologic or physiologic cause that said there are a number of
00:06:57.240 things that we can measure in the blood that tell us we're heading there or frankly if you just happen to
00:07:04.040 have difficulty or for other reasons have an inconsistent period such as the use of an iud
00:07:11.480 which can interfere with a period these blood tests can be particularly helpful really the mainstay of
00:07:17.880 looking at this is measuring follicle stimulating hormone and to a lesser extent luteinizing hormone
00:07:23.480 but it's really fsh that is perhaps the single most important hormone to look at to get a sense of
00:07:32.440 where a woman is on her trajectory towards menopause now we've covered this in great detail in the video
00:07:40.600 that i made on the subject of hormones and one of those videos people might recall was specifically
00:07:45.720 on female reproductive hormones i did one on male reproductive thyroid etc we'll link to the video
00:07:52.120 of the female reproductive hormone systems in the show notes this would be a great time to watch it if
00:07:56.280 you didn't in the first place and you'll get a sense of what fsh and lh are doing and how they're
00:08:00.760 changing throughout a cycle but i would say the gold standard is especially in the case of a woman who
00:08:07.800 is still having a period the reason i say that is there are women whose periods are very infrequent
00:08:13.720 because of iud's but they're technically not still in menopause but if you can measure fsh and lh and
00:08:20.600 estradiol just to round it out on day five day one being the day the period begins so five days in that's a
00:08:27.240 very good test and boy once that number starts to get to 20 or 25 that's really the surefire sign
00:08:35.480 that a woman is in menopause but it's important to understand that if a woman is sitting here and
00:08:40.280 she's not in menopause yet and wondering well is that it is that the diagnosis no of course again
00:08:45.640 it's the diagnosis is based on amenorrhea but for many women they're going to be having symptoms
00:08:50.280 even before they get there and i think it's safe to say that the most common symptoms that women
00:08:56.040 experience are the so-called vasomotor symptoms of hot flashes and night sweats those tend to
00:09:03.240 significantly precede other symptoms such as vaginal dryness vaginal atrophy and things of that nature
00:09:10.840 and obviously more significant issues such as loss of bone mineral density so again looking at the fsh lh
00:09:18.440 and estradiol level on that day five you'll see fsh and lh go up you'll see estradiol come down
00:09:25.400 and obviously we might start to see symptoms even before that diagnosis of menopause and we would of
00:09:31.880 course refer to those as perimenopausal symptoms yeah and that's a good transition because we also
00:09:37.400 receive questions around if there are other tests that might be indicative of perimenopause what do we
00:09:44.280 know about that so the short answer is yes there is we do not use this in our practice but i think
00:09:50.600 if you're chasing fertility you may also be looking at the anti-malarian hormone or amh so i think anybody
00:09:59.640 listening to this who has thought about fertility whether it be through ivf or other means is probably
00:10:05.800 familiar with this hormone but it's a hormone that is produced by the granulosa cells of a growing
00:10:11.800 follicle so small follicle sort of sub eight millimeter follicles are making this hormone
00:10:18.200 and the more of this hormone you have the more ovarian reserve you have now this is actually one
00:10:25.080 of those examples where a figure is sometimes worth more than the words because amh declines precipitously
00:10:33.240 before the onset of menopause and so knowing your amh level and knowing both the rate of decline
00:10:43.000 and the absolute level can also be predictive again i think this is not necessarily a valuable tool for
00:10:51.400 predicting menopause and i think the better use of this is actually around trying to get a better
00:10:57.800 handle on ovarian reserve if reproduction is still in the cards but if you pull up this figure nick you'll
00:11:05.800 get a sense of how fsh lh and amh are changing in the perimenopausal phase so for people just listening
00:11:16.600 to us unfortunately it's not as powerful but you have a graph here that on the x-axis shows you time
00:11:23.960 so time zero is the final menstrual period therefore halfway between the zero and the one would be the
00:11:31.560 definition of when you're in menopause when you enter menopause and you can see that this graph starts
00:11:37.480 on the left five years before menopause and five years before menopause you can see fsh and lh are
00:11:43.560 very low they're represented by the green line for fsh the blue line for lh by the way the dotted lines
00:11:49.560 on either side of the solid lines just show you the 95 confidence intervals this is very very tight
00:11:55.160 five years prior to menopause the anti-malarian hormone the amh is very high so the fsh and lh
00:12:01.560 concentrations are shown on the left y-axis and the right y-axis shows the amh concentration so five
00:12:08.440 years pre-menopause the amh concentration is 0.6 the units are nanograms per milliliter but
00:12:15.960 most people would just say 0.6 because those are the only units they're typically measured in
00:12:19.480 the fsh and lh are very low they're going to be somewhere between two and five and just watch what
00:12:26.200 happens as you move from basically five years prior to menopause towards menopause the amh drops very
00:12:33.880 suddenly within a period of about a year or two it goes from 0.6 to 0.1 and certainly less than that
00:12:43.720 whereas the fsh and lh rise and you'll notice that fsh lh again remember i said the fsh was the
00:12:52.200 thing i care most about you can sort of see if you look at that green curve that fsh is hitting
00:12:57.960 25 right around menopause maybe even a little bit before so there are a couple of studies and we'll link
00:13:05.080 to at least one that do look at the rate of change of amh as a predictor of menopause again we
00:13:13.560 don't do this clinically in our practice i don't think that means it's not valuable but there are
00:13:19.720 certain predictors that come out so for example if your amh is below 0.2 and you're more than 40
00:13:28.280 then the probability that you're going to go through menopause in the next five years is very high but
00:13:34.680 again the fsh is still valuable in fact it's probably necessary to determine how early or late you are
00:13:42.680 in it i think where the amh is helpful is when it's high so if your amh is above 1.5 you're likely
00:13:50.360 not perimenopausal in fact even if you're over 40 but your amh is over 1.5 menopause is probably at
00:13:57.320 least six years away so anyway i think those are kind of examples of where the amh can be helpful
00:14:04.040 again especially if you're still considering fertility peter earlier you mentioned vasomotor
00:14:10.200 symptoms and this is something that we see a lot of questions come through on from people
00:14:14.760 so maybe start with what are the underlying hormonal changes that cause menopausal symptoms
00:14:20.440 like hot flashes and then from there maybe discuss what are some hormone replacement therapies that can
00:14:26.360 be used to alleviate those symptoms thank you for listening to today's sneak peek ama episode of the
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