Endo Battery

Menopause & Endometriosis: The HRT Truth You Need to Know With Vanessa Weiland

• Alanna • Episode 112

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Navigating menopause while managing endometriosis can feel like a battle with conflicting information and limited options. In this episode, we sit down with Vanessa Weiland, a primary care nurse practitioner and certified menopause specialist, to uncover the truth about menopause, hormone replacement therapy (HRT), and post-hysterectomy care.

Vanessa breaks down the gaps in traditional medical training surrounding menopause and why so many women feel unheard when seeking treatment. We explore the role of HRT in endometriosis care, how testosterone can benefit women, and the real risks associated with estrogen. Plus, we dive into natural strategies like the Mediterranean diet and phytoestrogens to support hormonal balance.

From debunking myths about the Women’s Health Initiative study to navigating medical gaslighting and post-surgical hormone options, this episode is packed with practical insights and expert-backed strategies. Whether you're in perimenopause, postmenopause, or managing surgical menopause after an endometriosis diagnosis, this conversation will leave you feeling empowered and informed.

🔎 What You’ll Learn in This Episode:
✅ How menopause impacts endometriosis and pelvic pain
✅ The truth about estrogen, progesterone, and testosterone in HRT
✅ Managing menopause symptoms naturally and through diet
✅ How to advocate for yourself in the doctor’s office
✅ The importance of community and self-care in long-term health

🎧 Hit play now and take control of your menopause journey!

Website endobattery.com

Speaker 1:

Welcome to EndoBattery, where I share my journey with endometriosis and chronic illness, while learning and growing along the way. This podcast is not a substitute for medical advice, but a supportive space to provide community and valuable information so you never have to face this journey alone. We embrace a range of perspectives that may not always align with our own. Believing that open dialogue helps us grow and gain new tools always align with our own. Believing that open dialogue helps us grow and gain new tools. Join me as I share stories of strength, resilience and hope, from personal experiences to expert insights. I'm your host, alana, and this is IndoBattery charging our lives when endometriosis drains us. Welcome back to IndoBattery. Grab your cup of coffee or your cup of tea and join me at the table.

Speaker 1:

Today we're diving into a topic that impacts so many of us but is often misunderstood or dismissed, and that's menopause and hormonal health. And to help us navigate this journey, I am thrilled to welcome Vanessa Whelan to the table. Vanessa is a primary care nurse practitioner with over a decade of experience and a menopause society certified practitioner. She created the phases framework, a course that takes a holistic approach to managing menopause symptoms, covering everything from lifestyle shifts to over the counter solutions and medical interventions. If you're in Washington state, you can even see her in person at phases clinic, where she blends hormone therapy, hypnotherapy and more to support menopause and sexual health. You can also follow her on Instagram, at phasisclinic, for insightful tips and expert guidance.

Speaker 1:

So, whether you're navigating perimenopause, postmenopause or surgical menopause, or just want to be more informed about this stage of life, vanessa is here to break it down for us. So please help me in welcoming Vanessa Whelan to the table. Thank you, vanessa, so much for joining me today at the table and taking the time to share your passion and your wisdom and your insight into hormone replacement therapy and something that's near and dear to my heart, which is surgical menopause and hormone replacement therapy. But I think, in the broader context, I love that we're talking about this topic. So thank you so much for joining me today.

Speaker 1:

Thank you so much for having me. It's a pleasure. Can you give us a background of what you do and what you're passionate about, and the things that you're striving to change in women's health care?

Speaker 2:

Thank you so much for having me.

Speaker 2:

I'm an adult gerontology primary care nurse practitioner. I've been doing that for about 12 years and in my training as a nurse practitioner I got about a one hour lecture on menopause and, for whatever reason, I didn't think twice about whether that was adequate, even though this is something that the population goes through for a large portion of our lives. So I was practicing in gerontology mostly the older adults for the last 10 years or so and then I realized, by listening to a podcast of all things, that the training I had gotten in menopause was not only so little, it was also really out of date and inaccurate and that just made me mad. So I've spent a lot of time since then learning more about menopause care and busting a lot of the myths around hormone therapy, and I've decided to dedicate my career to this now, and I own a menopause and sexual health clinic in the Seattle area and also really enjoy doing education around this for both you know, the folks going through it and also clinicians, to try to move that needle forward.

Speaker 1:

Yeah, I feel like that's probably one of the biggest challenges that we face is that there's a lot of misinformation or outdated information surrounding not only menopause, but I would say women's care in general is very outdated, and that's partly because women weren't researched for a very long time and so that's been kind of the struggle even with endometriosis is there's so much outdated information out there that really wasn't encompassing the complete picture, and I think what I like about your story is that you're looking at it from a holistic standpoint, which I think we miss. That right and in our healthcare is looking at menopause as being holistic because it's a natural thing to go through, but it's not natural to live as long as we do without the hormones that we have to function.

Speaker 2:

Yeah Well, you touched on a big debate in the menopause community about whether menopause is a evolutionary adaptation or if it's just an evolutionary accident. But regardless, we've always had women that lived until their 70s. But to have the majority of us live into our 70s and spend a third of our life in menopause, that's definitely new. So I think we need to take on that new paradigm with new solutions.

Speaker 1:

Yeah, I agree and I like that you're not afraid to speak about that. That's great for future generations. The other thing that I admire about what you're doing is you know, prior to us doing this podcast, you had put some questions out there, and I kind of just want to go over some of these questions, because these are questions that if one person has them, multiple people have them. And so one of the questions that was asked is if you've had a hysterectomy but still have ovaries, what symptoms warrant hormone replacement therapy?

Speaker 2:

Yeah, so normally menopause is a clinical diagnosis and we use periods to kind of help figure out where you are in the transition. So oftentimes early perimenopause you're still having periods, but they get longer and closer together and heavier, and then later perimenopause is when they start to get more spread out, and then the definition of menopause is one year without a period at all. So obviously all that is all out the window if you don't have a uterus. But all the other symptoms ought to be pretty similar. So a lot of people in that early perimenopause phase the reason you're having heavier and longer periods is that you have less progesterone on board, and progesterone also can make you sleepy and calmer. You know our progesterone is naturally highest when we're in that week before our period. Everyone likes talking about the luteal phase now where you just chill out and be left alone. So when you're low on that you can get anxious and have trouble sleeping. So if you start to notice that that can be a sign of early perimenopause, and then in that middle perimenopause phase where your periods are getting spaced out, that means that you're starting to lose the estrogen and so low estrogen symptoms are the stereotypical symptoms of menopause Hot flashes and night sweats and vaginal dryness.

Speaker 2:

Some common things that are less well known are heart palpitations, itchy skin, itchy inside your ears, joint pain.

Speaker 2:

A lot of people notice brain fog and forgetfulness during this time, and those symptoms tend to basically ramp up to their most extreme in that, I would say, two years, right around the last period, typically. So if things are really reaching a a point where it's almost unmanageable or is unmanageable, then hopefully you're getting toward the end of it, and then you know, two to five years past the last period, things usually start to settle down because our hormones aren't going through the roller coaster anymore. They're stable but they're low, and so for most of us the hot flashes do calm down, but some other symptoms of low estrogens stick around, like the vaginal dryness and urinary complaints and dry skin. When should you try to get treatment, which, in my opinion, is whenever you have any of those symptoms, is reasonable to pursue treatment, and it might turn out that it wasn't perimenopause. But the treatment is really quite safe and you can do a little bit of an experiment and see if you do feel better with progesterone for those anxiety and sleep symptoms early on.

Speaker 1:

Do you think that there's benefit for those who are going to have a hysterectomy and maybe not even a nephrectomy, but just like a hysterectomy and or a nephrectomy to get blood work prior to having that done, so that it gives the providers who do hormone replacement therapy a good base to go off of and track those numbers? Or is that not significant in the fact that maybe it's just better to track symptoms?

Speaker 2:

Yeah, the blood work is tricky, even when someone hasn't had a hysterectomy a lot of times in perimenopause. It just comes back normal and so a lot of people have experienced basically gaslighting from that, because they go see their provider and they say I have all these symptoms of menopause and then they go do labs and they're normal. So I'm always happy to draw labs if people are curious and if you draw them sequentially, like a lot of those over-the-counter perimenopause kits are trying to get your FSH. You know, I think it's usually several months in a row and then you might catch it if it's going into the menopause range sometimes. But if you just check it one time, odds are it'll just be normal and it's hard to interpret that.

Speaker 1:

Yeah, and I think that was something that I wasn't sure of, like when I had my hysterectomy, my oophorectomy. I wasn't sure what I should even be looking at. So I think what's important for a lot of people considering these life altering changes is what should we be looking at prior to going into surgery? I mean, we know our bodies are going to change, but how fast are they going to change when we get ovaries removed? Or even how fast are they going to change if we don't, but we cut off that blood supply potentially to the ovaries?

Speaker 2:

So I'll take that in two steps. So if you do have the oophorectomy meaning both ovaries are removed then you go into menopause overnight. That's surgical menopause, which is really well documented to be a more difficult form of menopause. I mean, it's hard enough to go through these ups and downs over the course of five to 10 years, but to do it overnight is a really it's whiplash, right. And you're not only losing the estrogen and progesterone overnight, you're also losing a significant portion of your testosterone, because that's also made in the ovaries, it's made in the adrenals too, so you're not losing all of it, but you're losing a bigger chunk than even someone going through natural menopause. So that can cause a lot of changes in mood, and one study found that almost 80% of women after surgical menopause have a change in their sexual desire because of that testosterone loss. So and I'm sure we'll talk more about it there are reasons to do the more extensive surgeries versus not, but that's definitely something to keep in mind.

Speaker 2:

And then you were also touching on if you have the hysterectomy without removing both ovaries, so you still have those hormones. In theory, you still have those hormones functioning normally. But you're right that there's been quite a few studies now showing that when you have the hysterectomy alone, it tends to lead to earlier menopause. And you know, it's not totally clear that due to the surgery or due to inflammation or due to changes in blood flow, or maybe it could be vice versa, that the people getting hysterectomies had other conditions that led to that, that might have led to earlier menopause. Anyway, we don't know that answer and there is some data that endometriosis, regardless of surgery status, can lead to earlier menopause.

Speaker 2:

So there's some validity to that too.

Speaker 1:

Yeah, I think I experienced a lot more symptoms and I think partly because of the medical management of my endometriosis. There's studies that indicate that taking GnRH agnus drugs can decrease your ovarian reserve permanently. And so you already are kind of up against the wall with medical management of that. And then when you do actually maybe have a hysterectomy and it's just your uterus and cervix and all of that, I can't imagine that. That doesn't add insult to injury, if you will, to the ovarian reserve.

Speaker 2:

We do a test called the AMH or antral follicle count, which is an imaging test, but I actually don't know if there's any studies looking at before and after hysterectomy for those things.

Speaker 1:

Yeah, it would be interesting to find that out, just because I think that there's so many of us that have gone through medical management and then later on had a hysterectomy, and I think you know I can only speak for myself, but I can tell you that having the oophorectomy for me was essential, but I know that there's other people that have had both and it is there's so much challenge and they were 32, 33, early to mid thirties when that happened and had their hysterectomy and they went into perimenopause early and so I don't know, it'd be an interesting study to have. I don't know if there's one out there, but do you find that with your patients with endometriosis, there's risk to having hormone replacement therapy for menopause symptoms?

Speaker 2:

So I did look at this and it seems that as long as you have both a progestogen which is either a natural progesterone or a synthetic progesterone along with the estrogen, that you're in good shape, it's not going to make the endometriosis grow again. It's just if you have estrogen alone that can potentially make the endometriosis grow. So the only trick about that is if you've had a hysterectomy, most providers don't think about doing estrogen plus a progestogen, because usually the standard of care is only estrogen. After hysterectomy, you don't need the progestogen to protect the uterine lining anymore, right? So you have to find a provider that's a little bit savvy about this or you know, bring the research to them yourself that there's really a good indication to add the progestogen in your case, right?

Speaker 1:

And and. For me and this is something maybe you can speak to or maybe you can't we've talked about this a little bit, but for me, having no uterus, no ovaries, I chose to skip the progesterone therapy piece of this because of my hypermobility, and so it caused a lot of issues with that. So I think for me it was important to look at the whole picture, which is why having an expert in hormone replacement therapy could be beneficial for people walking through this. Often, we have different comorbidities, we have more than one comorbidity or co-challenge, so having an expert actually looking at your whole case is, I think, so important as well, and I think that's kind of what you were speaking to is like having that expert look at whether you have all the organs or not, to look at what's best for you individually.

Speaker 2:

Another piece of the pie is the testosterone piece, particularly if you've had both ovaries removed. But I did find some interesting data that on average, women with endometriosis have lower testosterone levels. So testosterone replacement has great evidence for libido and growing evidence for mood and body symptoms and energy evidence for mood and you know body symptoms and energy. But not a lot of providers, at least in the United States, offer it for women at all, because there's no FDA-approved version of testosterone for women. So we menopause providers often use the male version and only a tenth of it, which is not ideal. Right, that's what we're working with right now.

Speaker 1:

As someone who takes it, I appreciate that they give it out in any dose. A question that was asked was can estrogen increase endometriosis pain post-excision, and have you had experience with this? I can tell you from my personal experience what it's been. But for you, what's your take on that?

Speaker 2:

All I can go is off of the data, which is that if you do the estrogen alone, you're putting yourself at risk for that. And then estrogen plus the progestogen most likely the answer is no, but I know that in your case you weren't feeling so great on the progesterone, so it's going to be case by case.

Speaker 1:

Yeah, there's a couple I think a couple studies that kind of highlight this. There's one, and the title of it is Management of Menopause in Women with History of Endometriosis. They talk a little bit about that. There's another one that looks at the review of literature on hormone replacement in women with endometriosis and really I don't think there's like a ton of research to back up one way or the other. It does highlight, I think in these research articles it highlighted that it could potentially perpetuate some of the pain, but theoretically, if it's properly excised and properly removed by an expert, you shouldn't see those symptoms by an expert. You shouldn't see those symptoms theoretically speaking, and that goes to having an approach where you're having an actual expert take that out as opposed to having it ablated. So that's just my take on it.

Speaker 1:

When I was looking into it and asking around, that was something that I found interesting. I was like I don't know if pain's going to come back. I think there's always room for pain to come back with endometriosis. It's a sneaky little monster that can reappear at any point in time and it's different for everyone and I think we can't really put every endometriosis patient into the same category. We are so individualized because the disease acts so differently for everyone and how we respond to it. So that was something that I thought was an interesting question, and one that's valid.

Speaker 2:

Yeah, yeah, I came across some interesting studies too, looking at how the skill of the surgeon really makes a big difference in endometriosis care and how one study found that if a surgeon had performed more than 30 laparoscopies for endometriosis they had much better rates for recurrence and also the fertility if that was a concern. And you know, generally speaking the remission from endometriosis is better with the radical hysterectomy where you remove the uterus and ovaries. But that's something to keep in mind if you're hoping still for, you know, to carry a baby or, you know, just prefer to keep your uterus and ovaries. Based on the rest of the conversation we've had, that really seeking out a skilled surgeon is going to be a big piece of that puzzle.

Speaker 1:

Yeah, I mean, you don't want a cardiologist working on your brain and it's similar in endometriosis you know you. You want the the right provider providing a service to you that is going to be a holistic approach to helping give you your quality of life back, or just giving it to you. In general, some of us have lived with this forever. So have you noticed a difference for those patients who have started hormone replacement therapy right after having a hysterectomy versus those who have waited? Is there risk versus benefit in doing that?

Speaker 2:

I mean there's no need to wait. I know that some surgeons are wary of estrogen because of some studies showing higher risk of blood clot Right, but actually no study has ever shown an increased risk of blood clot as long as the estrogen is delivered through your skin. So that means a patch or a gel or the vaginal ring. So that can and, in my opinion, should be given. Basically, you should wake up from surgery with that patch on so that you're not having to deal with this extreme drop in estrogen levels and progesterone. I can see where the surgeon might be, you know, feel like they want to just play it safe with that. But, as I say, there's literally no data showing a higher risk of blood clot, whether surgical or not, with the patch.

Speaker 1:

Are there risks versus benefits in doing hormone replacement therapy? Because since the Women's Health Initiative I've talked about this before but they've kind of taken that back. Can you explain the risk versus benefit of doing hormone replacement, versus maybe seeking out a more homeopathic route?

Speaker 2:

So it depends a little bit on how old you are when you go through this. So if you go through surgical menopause or natural menopause before age 45, then basically across the board, from medical society standpoint, you really should be on hormone therapy, at least until the average age of menopause, which is about 51, 52. Because when we don't do that there's a higher risk of heart disease and osteoporosis and dementia. So in that case I feel pretty strongly about it. Of course some people will still choose not to, but it's going to be a really uphill battle to not have osteoporosis if you go into surgical menopause before age 45. So if you go into surgical menopause after age 45 or natural menopause you know, maybe you have your uterus removed and you go into natural menopause, according to labs, in your 50s Then there's no international guidelines saying everybody needs to be on hormone therapy, but it still will have those same benefits as far as brain health and heart health and bone health and actually lower risk of diabetes if that's in your family, something to consider and a lower risk of colon cancer. So we've already talked a little bit about blood clot and how to avoid that risk.

Speaker 2:

And then the other thing that people worry a lot about is the risk of breast cancer, and that is meaningful in this conversation because estrogen-only hormone therapy hasn't been shown to increase the risk of breast cancer. And that is meaningful in this conversation because estrogen-only hormone therapy hasn't been shown to increase the risk of breast cancer and in fact it seems to lower the risk. But when you combine estrogen plus a progestogen, which is what we said you ought to do if you've had endometriosis, then we think it increases the risk of breast cancer. Now we're not talking about a huge risk in the that WHI study which put the fear for hormone therapy in a lot of people. Yes, it actually wasn't a statistically significant change and the change was about four women in the placebo group got breast cancer for every thousand, versus five in that combined group. So we're talking about less than one in a thousand additional risk.

Speaker 2:

But there was an additional risk. As I mentioned, the risk of colon cancer is lower. So actually the overall risk of cancer is lower. So it's all things to take into account. If you have a family history of breast cancer, maybe you're coming at this differently than someone that has a family history of colon cancer, right but so basically at this point we say that if you start hormone therapy within 10 years of menopause. So on average, if you start before age 60 or so, the benefits outweigh the risks, with all that I just said. That's the way to summarize it. So if you have symptoms as well, then you really don't need to feel like you should suffer through it because of these risks. Actually, the health benefits outweigh the risks. Plus, you can stop suffering with your symptoms.

Speaker 1:

Yeah, something that people have asked me is or and that I've heard. Actually, I've had a deep conversation with a family member about this, about is it ever? Are you ever too old to start hormone replacement therapy, and specifically testosterone and estrogen? But are you ever too old to start it? Or is there a decrease in benefit the later you start?

Speaker 2:

That's definitely the case that there's a decrease in benefit and maybe even a danger to starting it. So the Women's Health Initiative the biggest thing they were studying is whether hormone therapy could prevent heart disease. There were a lot of studies showing that in the 90s and they enrolled women anywhere from 50 to 79. So in that entire group of women they actually found a higher risk of heart disease in the women on hormone therapy.

Speaker 2:

So, that was actually the original finding that shut down the study. But when they reanalyzed the data and only those women within 10 years of menopause it was the reverse it was actually a lower risk of heart disease. So we don't totally know what that's all about. But what the theory is is estrogen is actually beneficial for your arteries and keeps them open. But if you go 10 plus years without any estrogen in your body and your arteries have gotten closed up and then all of a sudden you blast them back open again and there was a little clot forming there, then maybe that's what knocks the clot off and causes a blood clot or heart attack. And it does seem like those risks of clots are the highest in the first six months. So that kind of backs that up, I would say.

Speaker 2:

But we don't know that for sure, that's just the guess. So basically there's a window of opportunity where it's beneficial and then if you already have artery disease and you add it, then you actually might be doing more harm than good. So what some menopause specialists do is we say there's no age where you can't start it. But I want to do a little assessment to see if you already have established artery disease, in which case we're probably actually doing more harm than good. But if someone's 70 and their artery disease checkup is completely perfect, then I do think it's still safe to start. Maybe they want to improve their bone health or maybe they still have hot flashes Some people still do even 20 plus years after menopause then there might be some reasons to consider starting it later.

Speaker 1:

What about testosterone? Is that similar to estrogen or is it different? I don't think there's ever been a study looking at.

Speaker 2:

Is there a correct time to do testosterone replacement, but I'm not aware of any concerns around a window of opportunity with that. So if your main symptom is low libido or you're having a really hard time with gaining muscle mass and you're getting really tired and we check your blood levels and your testosterone is low, then we can try replacing it. If your testosterone is already normal or high normal, then we're not going to give you testosterone because we can just give you side effects like knee and chin hair and even changing your voice deeper, without improving any of those symptoms.

Speaker 1:

Let's go the reverse now, because I've had this question before from endopatients who are like I don't feel right still and they've been known to have fluctuating hormones. They've been known to have a lot of symptoms of perimenopause but aren't showing perimenopause in lab work. And they're pretty young. So we're going to say, looking at anywhere between the 25 to 35 age range, is there risks to starting hormone replacement therapy prior to what is your typical perimenopause starting age?

Speaker 2:

No, I mean we don't typically do it, partly because hormone therapy is not birth control, and so a lot of times younger women, if they're having some symptoms of hormones going up and down, we reach toward birth control because we're fixing that problem and making sure they aren't getting pregnant, assuming they still have a uterus. So if you don't have a uterus, then obviously we don't have to think about that. So I do personally think that hormone therapy is safer than birth control. We're really loose with how we prescribe birth control. We're like oh, you have acne, here's your birth control. You know you get headaches, here's your birth control, whatever the case might be.

Speaker 2:

And so I do think it's okay to experiment a little bit with hormone therapy. In the same light, I mean we shouldn't avoid ruling out other causes for your symptoms. I mean, if you have high or low thyroid, that can really mimic perimenopause, If you have vitamin deficiencies, sleep apnea, all kinds of things. So if someone is younger, I'm definitely thinking about ruling out other causes. But if that's kind of the last remaining piece, I think it's fine to do an experiment for a few months and see if you feel better.

Speaker 1:

Yeah, is that true, even still with testosterone and not just estrogen? Is it if they're feeling low libido at an earlier age and they've had maybe multiple surgeries, so things maybe don't feel the same? Is that something to consider?

Speaker 2:

Yeah, testosterone we can replace at any age, assuming it's low, and our testosterone tends to drop off even after our 20s. So a lot of my patients on testosterone are actually premenopause.

Speaker 1:

Interesting. That's really interesting because I haven't heard very much about that. I have been talking to multiple people who have been advocating for themselves to get hormone therapies and most providers say they're too young. But what they're saying is I have symptoms that I need help with and you're not hearing me. And a lot of them are saying we'll just throw birth control at you and there's risks with birth control, and I think when we were talking clotting risks, that's a huge risk in birth control, and then, on top of that, it is being processed through your liver, whereas a lot of the hormone therapies are not processed through the liver because they're transdermal. And so I think how do we shift that conversation as patients to get better care around this issue?

Speaker 2:

You know what? I do think things are changing, but most providers, like me, got very little education in menopause and what we did get was hormone therapy is bad. It causes heart disease and breast cancer. So I do think a lot more providers are kind of hearing in the ether that hormone therapy isn't so bad as they thought it was and they're willing to prescribe it. But they don't know how to prescribe it, and so I think maybe seeing a menopause specialist for a little while, just to get on the regimen that works for you, and then checking with your primary care provider, are they willing to take over on the prescribing?

Speaker 2:

I've had a lot of luck with that and maybe that's where I am in Seattle, things are a little bit more liberal, I don't know, but it seems like a lot of providers are like okay, the expert says this is okay, I'm okay with it, with the exception of testosterone. A lot of providers are really not comfortable because, as I say, it's not FDA approved for women and it's a scheduled drug, so I even have I mean, I fight with pharmacies all the time I actually give hand out what I've ordered. I went back and forth with a pharmacist yesterday because she said we can only do compounding with testosterone for women. I said that's not true and I actually sent her the menopause society guidelines specifically recommending against compounded testosterone for women and to use the male testosterone at one 10th of dose, and she said okay, I see that I still can't do it. Oh my goodness, wow.

Speaker 1:

That brings up another question With hormone replacement therapy or hormone therapies. There's multiple different versions of these things, and so can you break down what you can do for estrogen, what you can do for testosterone, because there's a lot of question. That is bioidentical hormone replacement therapies safe, are they efficacious? Are the pellets better? Are the creams better? You know, there's all these questions and there's not a lot out there, and yet there is. There's a lot of chatter around these methods, but there's not a real conclusive way to approach that that I have found.

Speaker 2:

Yes, basically, bioidentical hormone therapy. That's kind of a buzzword, it's almost a marketing term more than anything meaningful, but it means that the hormone looks exactly like what your body makes. So the three bioidentical hormones are estradiol, micronized testosterone and testosterone, and those can all be delivered with FDA approved options. Most of my patients are on bioidentical estrogen patches, estradiol patches. So that's the big misunderstanding is it has to be compounded. For some people compounding is the right choice. I mean I have patients that are allergic to peanuts and they need to be on compounded progesterone because the FDA approved option is made with peanut oil. So there's reasons that I reach for compounding.

Speaker 2:

Some people, the 10th of a male dose of the testosterone just is not realistic, is not going to work for them and we can do the compounding. But it's not considered first line because there have been some studies showing from batch to batch within the same lab or between labs, even with the same prescription, it's not quite the same dosing versus the FDA approved. You know what you're getting. Yeah, even there was one sub of cream. It was a different dose on the top versus the bottom, so I try to avoid it, but I know for a lot of people in their local area.

Speaker 2:

That's all that's being offered by providers if they do want hormone therapy, especially testosterone. So I get it. There's a vacuum of care there. I'm never mad at any woman that chooses to go with pellets if that's literally the only option and you're just trying to feel better. But I do recommend against the compounding and especially the pellets, because once it's placed we can't remove it and if the dose is too low or too high you're just stuck with it for three or even six months. I mean too low, that's not a huge deal, but too high, you know, especially testosterone. We're talking about maybe unintentionally transitioning. So that's a big deal, right.

Speaker 1:

Yeah, and that's something that I think a lot of people struggle with is knowing how to approach hormone therapies, Because in my specific area, the only providers that I've been able to find only offer the compounding. But the compounding, too that's something I want to mention is it's very expensive and insurance does not cover it. And I don't think insurance covers the testosterone, the male version for women either does it, or am I wrong in that?

Speaker 2:

Usually no. Sometimes, if you use the correct diagnosis code, they will. But honestly, since you're using the male dose at only a tenth of it, it's very affordable. A lot of times it's about $100 for 30 tubes, which for men that's a one month supply, but for women that's a 300 day supply Very manageable.

Speaker 1:

I didn't realize that. How do we approach our providers about talking about that though?

Speaker 2:

Yeah, I think so. There's a, the International Society for Sexual Health and Women, isswsh. They have a list of providers and I would say that's probably one of the best go-to sources of providers that would order testosterone without doing pellets. And then also Heather Hirsch. I actually studied how to provide hormone therapy through her course for clinicians and that's what her course recommends, and she now has a directory of providers that have taken her course. So that's another resource. I know that MIDI I think in certain states MIDI will prescribe testosterone. So, yeah, I wish there was one size fits all approach for folks, but there are some resources out there to try to find a provider.

Speaker 1:

It's hard. It's so hard as someone that's had to walk through this and I'm continuing to struggle finding providers. It's especially challenging when you've already had medical trauma because of urinometriosis. So I want to validate you in saying like it is already hard when you've experienced it with one particularly hard illness to diagnose, treat and manage. And then moving into the menopause, where again it's misunderstood, misdiagnosed and ignored. Oftentimes it can be triggering for a lot of people to try to find another provider to give them the best quality care, and so I want to just take the time to acknowledge that because it is very challenging. But I do think that there's value in finding people and having those resources available that you mentioned to look up people that really are passionate about menopause, because it makes a world of difference for your quality of life.

Speaker 2:

And something else I want to call out, which is the case for me as well, that a lot of us menopause specialists actually don't work within the insurance system, so it would be out of pocket, you know, with a super bill or something like that, and so that's adding another barrier for folks. And I get that for me personally. Every time I work with insurance I lose a piece of my soul. It was for my mental health. But I will say, you know, you've already heard through this conversation, like I know, some tricks and ways to kind of save money and help you get prescribed by your primary care provider. I think a lot of us, you know, really care about access to menopause care and we'll try to make it as affordable for you as possible. So it might be worthwhile to see a specialist for three to six months to get on that regimen and then see if your primary care is willing to take over, so that you don't have to keep paying out of pocket.

Speaker 1:

Yeah, I think that's one of the hardest things about navigating health journeys in general right now is the accessibility, because of cost and our insurance system is not built to include both provider and patient. It's a business, unfortunately, anymore, and so that does get challenging to kind of navigate, which again can add a little bit of the trauma piece to it as well. But are there ways that food and lifestyle can help in this process?

Speaker 2:

Yeah, I would say the diet that has the best overall evidence, both for helping you live longer and for menopause symptoms, is the Mediterranean diet, which is considered pretty anti-inflammatory, so it can be helpful for a lot of chronic conditions as well, and then even within that, chronic conditions as well, and then even within that, really focusing heavily on vegetables. You know, even some studies have shown a vegan diet is helpful. I don't know if it needs to be vegan, but leaning toward fatty fish and lean meats and especially a lot of soy seems to be helpful. So I know it's boring, that's what the data supports.

Speaker 1:

And it's hard too, because then we have like opposite opinions on soy for endometriosis. So it gets really tricky for that.

Speaker 1:

I know that for me and this may not be valid, so I don't really know, but there were times that I definitely in my journey, was told soy is not good for endometriosis because it is kind of like a synthetic estrogen, so to speak, and so I think it's something to talk to a specialist about if you're really concerned about that piece of it, because I don't know the answer to that unless you have any evidence that points otherwise. But I don't really know whether that's valid or not, but I do think that there's concern there.

Speaker 2:

Yeah, I have seen studies looking at the endometrial lining with soy because, yeah, that's a concern of someone using soy as a supplement for their menopause symptoms and it doesn't seem like it thickens the endometrial lining, so that's kind of a correlate to endometriosis. But I don't know of any studies specifically around endometriosis. It does seem like, even though soy acts like an estrogen, it's almost more like a CIRM, which are the medicines we use for breast cancer, for instance, where it activates estrogen receptors in some places and blocks it in other places, and it doesn't seem like soy is as active in breast tissue I know but, it does seem to be helpful in bone.

Speaker 2:

So overall it seems beneficial, but I totally understand being wary for those reasons.

Speaker 1:

Yeah, there are some people that are going to be hesitant to doing hormone replacement therapy with estrogen or testosterone. Is there a homeopathic way of managing perimenopause or menopause symptoms, and does it change if you've gone through surgical menopause, or is it really imperative that you seek out more estrogen testosterone therapies?

Speaker 2:

there are. I don't know of any homeopathies that have scientific evidence for being helpful. I'm sure that you know you could find people that have found certain things helpful, or maybe working with a provider that specializes in that, but I am aware of some supplements that are helpful, like we were just talking about. A lot of the supplements that are most effective are the ones with phytoestrogens, meaning you know a plant compound that can actually activate your estrogen receptors. Black cohosh is not a phytoestrogen, so that is one to potentially consider if you're worried about that.

Speaker 2:

There have been rare cases of liver damage. There's like no good thing without the bad side, so I think probably it was like contaminated supplements. So it's something to be aware of. If you suddenly turn yellow after you start your black cohosh supplement, you should get back off of that. Yeah, it really depends what symptoms of menopause you're trying to target, but I do think there are supplements that seem effective for hot flashes and trouble sleeping and arthritis symptoms, things like that. It kind of depends what you're trying to target. It doesn't seem like one thing is going to fix all of those.

Speaker 1:

Yeah, and that's where I think it gets challenging, because obviously we talk hormone replacement therapy as being, I would say, gold standard, but that's not what everyone is comfortable with, and so I think it's important that we address that. There are those people who aren't comfortable taking it and there are other modalities that they could potentially look at. But is this different for surgical menopause? Because I think it's hard to reproduce a hormone when you don't have the factory that does the hormones. Is that different? And what are some risks of not doing? I mean, we've talked a little bit about the risks of not having replacement therapy for after a hysterectomy. Is there benefit to not doing it and doing a more homeopathic route, or is it not beneficial at all?

Speaker 2:

I guess the main difference with surgical menopause would be the testosterone piece, and there are less. So if we're thinking about testosterone for libido, there are less supplements that seem to work really well for that. Boron seems to increase testosterone, but I actually don't know if that's working through the ovaries or through the adrenal gland, because those make testosterone as well. Yeah, I don't have a great answer for that, but I do think if you go into surgical menopause, as I mentioned before age 45, then that is really where I draw a line in the sand. I think hormone therapy is really important for your long-term health, but after that you can definitely explore, you know, whatever feels best for you.

Speaker 1:

Is there something that you wish every perimenopause menopausal or surgical menopausal person could know?

Speaker 2:

I feel like we've covered a lot of it, that you know there's so many myths around this and that we don't need to be so scared of hormone therapy. And then the other big piece is that advocacy piece just knowing when you go in to see your provider and almost like protecting your heart, that they probably don't know a ton about this and you might know more than them already by the end of this conversation. And so bringing some of the guidelines with you, like the Menopause Society Guideline on Hormone Therapy, which came out in 2022, it's available online for free. You can just print that out and bring it with you, and that's where it says really clearly that the benefits outweigh the risks if you're within that age timeline. It wouldn't talk specifically about progesterone, even after a hysterectomy, but you know, hopefully they will take your word for it on that. As far as the endometriosis history, Fortunately a lot of us are going to have to lean into the self-advocacy to get some of these things.

Speaker 1:

Yeah, I'm going to flip the switch a little bit on you. You want to try something new? Yeah, I'm going to flip the switch a little bit on you. You want to try something new. I've never done this before as a provider that isn't an endometriosis provider. What are questions that you, as a provider, would ask a patient or ask someone that has a background in endometriosis?

Speaker 2:

Oh, I love this because one of the questions we got was what can I do to prevent endometriosis coming back? I don't know. The answer to that was what can I do to prevent?

Speaker 1:

endometriosis coming back? I don't know the answer to that. Well, I don't think there's a definitive way to prevent it, and I think the reason for that is is that first of all, you need to have proper excision by a real expert. That will give you the best overall outcome and if you can do that the first time around, that's best. There's always a risk it will come back and it is different for everyone. True reoccurrence does happen for those people who are just prone to having endometriosis lesions form. So there's no definitive answer to that. But you have a better chance of not having it come back with a vengeance if it's properly excised by a true expert symptom relief.

Speaker 1:

It's not been proven to eliminate lesions or the endometriosis as a whole, but it is important to highlight the fact that having less stress in your life because it tends to be inflammatory in nature, and the way that it responds to how we eat, how we respond to stress, how we respond to life's challenges, can translate in how we feel with our endometriosis. Is it producing more flares because we are putting things in our body that respond negatively? So I mean there's a different ways to look at that True endometriosis. I don't think that there's any one very definitive way, but there's symptomatic reliefs that you can do to help alleviate some symptoms, but it won't get rid of the endometriosis. I hope that makes sense.

Speaker 2:

Are you aware of any diet that can help or other lifestyle things that can help as far as inflammation piece?

Speaker 1:

The inflammation piece. I think that's going to be varied to the specific person. That is because a lot of people in the endometriosis community will say, or the health industry that does endometriosis stuff as well, will say do gluten-free, do dairy-free, go vegan, and those can be all really good, but they can also be really bad if you don't need to, and so I think that it's very dependent on the person. So a lot of people will say I have to go gluten-free because I feel terrible, like I can feel it in my joints, my flares are significantly worse, my belly the blow is significantly worse, and I haven't experienced that. Mine is like beef and eggs. So I know that in order to prevent inflammation from happening, I have to kind of avoid those foods. But along those lines, making sure that you get plenty of water in your system, making sure that you're getting sleep, which is really hard when you are in pain and you have chronic illness A lot, of us really struggle with sleep A lot of us really do, and so there's another challenge there.

Speaker 1:

Right, but trying to get as much sleep as you can, even though you're exhausted and you can't sleep that's the other part of that, but the fatigue, fatigue part of it is hard. And then this is one thing that I am learning is balancing your boundaries, and what I mean by that is that we in society are trained to go full speed ahead, and when you have a chronic illness body.

Speaker 1:

Our bodies aren't able to do that, but we still try to push through, and so I think managing expectations of yourself and having good boundaries with what you're able to do and what your body's able to give without exceeding its limits, is important. And that's another piece that I think a lot of us in the endometriosis community struggle with is putting those boundaries without guilt, and you know, stress and guilt and all of those other things kind of play into how our bodies respond, in my experience. And so I would say, setting realistic expectations, setting those good, healthy boundaries and practicing good self-care will help with symptomatic relief, in my opinion.

Speaker 2:

I think that's very wise, that's something. I need to hear too.

Speaker 1:

I feel we all do. I mean, I was talking to someone else about this recently, about just how much pressure society puts on us to perform.

Speaker 2:

How much?

Speaker 1:

pressure we put on ourselves to do things that our bodies really struggle to do, and then what it does is it creates this stress factor and we feel guilty because we're not able to do certain things, because our bodies are in pain or tired or even our brain fog and fatigue is severe, and that tends to be pretty prevalent with endometriosis. And giving yourself the grace to say I can't today and step back and not allow others to dictate your well-being, I think is important because it is really really hard and that's not going to eliminate all the pain. It's not going to eliminate if you have pelvic pain, you need to see a pelvic for PT and there's other modalities that will help with pelvic pain as well. So just advocating for yourself in those realms is important. But when we're talking relationally whether that's family members, coworkers or whatever to dictate your wellbeing is probably where a boundary should be drawn. Our bodies respond to that in my experience. Yeah.

Speaker 2:

Now that was something we didn't talk about is that I studied hypnotherapy as well, so that can be really helpful for menopause symptoms because, like you're saying, it doesn't necessarily remove the source of what's bothersome, but it can change your relationship with it.

Speaker 1:

Yeah.

Speaker 2:

And maybe turn down the dial. Like, for instance, you know, let's say you stub your toe and then immediately go and watch an engrossing movie and you completely forget about it. Right Versus you stub your toe and then immediately take off your sock and your shoe and stare at it and prod it and it feels 10 times worse, so that it was the same injury. But how you're relating to it can really impact how it feels and hypnotherapy and other forms of therapy and mindfulness and meditation can be really helpful for changing that relationship a little bit.

Speaker 1:

Absolutely, and I think that's another thing that is helpful for patients with endometriosis because, you know, a lot of us associate pain and even after excision, this is something that is being talked about a little bit more, but probably needs to be talked about even more is the fact that our bodies are trained to respond to the pain that we have. Right, it's that connection, that neuro connection.

Speaker 1:

And so sometimes, when we've had surgery and we're still feeling pains not to invalidate your pain, but sometimes it's important to get those therapies to identify whether this is an actual pain or it's a trauma. And I think that's something that I didn't realize when I went through my surgery and have gone through this journey of learning more is that there's a huge connection between what's actually going on in your body and the trauma it's experienced, and so for me, that's something that I've had to learn along the way is therapy is not a bad thing. It's a really, really good thing and, in fact, it can help your pain management.

Speaker 2:

Yeah, I think that's very true.

Speaker 1:

I also think that community that was the other part of this that you know as providers I think something that would be helpful is to really pointing your patients into community, because when you're not feeling your best, our natural response is to be very isolated.

Speaker 1:

We isolate ourselves because we don't feel good and we don't want to do these things, and so that's something that I, for myself, have noticed. A huge difference is being in community, where people who have shared experiences can help you. I've been there, you know, and they're like oh, I went to this doctor and it's been really helpful. I experienced this symptom and they actually found that it was this and that was super helpful. So, getting in community with people who understand it or, you know, you're having a bad day and you're like I just cannot pull myself together they're going to show you more grace than those who don't or haven't experienced what you've experienced, and so, from that perspective, I think community can be a great healer and it can be really helpful for symptoms.

Speaker 1:

So those are the things that I would pass on to providers. Those are helpful for patients.

Speaker 2:

Yeah, I think that's true for menopause as well, and I think that's happening more and more.

Speaker 1:

Yeah, and I think there's more conversations happening to surrounding menopause and endometriosis. I think, as a whole, you can't ignore the chatter happening around. Patients are becoming more savvy and I think you know, as a community mostly made up of women, we are kind of tired of being ignored, and so I think conversations are happening surrounding both menopause and endometriosis, because it's been such a lackluster care until this point and because the system at large was not made for women, it was made by men for men, and that's what they researched for so long. But we're the biggest consumers of healthcare, and to have a lack of information, a lack of studies and a lack of understanding surrounding our healthcare, I think we're getting a lot more vocal about that, and I'm sure social media has done a good job at that too. So that's, I mean, that's kind of what I've noticed, and I don't know if you've noticed that a lot more with your patients coming in.

Speaker 2:

Yeah, even in this kind of micro generation between my patients in their mid fifties versus mid forties, I think a lot more are talking about it and hearing about it from their friends. So, yeah, I think Gen X is leading the charge for us.

Speaker 1:

I think they are, and I do think like there's this generational difference, right, because if you think back to the fifties, no one talked about their period, no one brought up what their ailments were if you will, you know and so I think that's shifted, even in the family dynamic that shifted. I think. I look back at you know, when I was growing up, my mom didn't really talk a lot about her period you know, and she didn't talk a lot about menopause.

Speaker 1:

But I think that's shifting and I think people are talking more in the family setting, not just in like a clinical social media setting. I think people are talking more in the family setting and I actually think if we start talking earlier on with our family members, because we know endometriosis has a genetic component, I think earlier diagnosis will be more achievable at that point.

Speaker 2:

Yeah, no, I think that's true for menopause too. Your your menopause is most likely to follow a similar path to your, your mom or your older sisters. Yeah, so you can have these conversations to know what to expect.

Speaker 1:

Yeah, talking about that though, for like the generational, would it follow more your mom and sisters or your family in general? So like your dad's side as well, do you look at that? I've?

Speaker 2:

heard that it's your mom, but I mean probably just because it's so hard to ask our dad's mother.

Speaker 1:

Right, no one's sitting there at the Thanksgiving table talking about all of that. Hopefully this past Thanksgiving they were.

Speaker 1:

Yeah, we can change that too. I'm so open. It's so funny to see the difference in generations. Now that I'm starting to talk more about my struggles with endometriosis and menopause, it's starting to open up my mom and my mother-in-law my mother-in-law and I actually had a conversation about this recently and talking about menopause and our feelings about it and our approach to hormone replacement therapies and things like that. So it actually opened up that conversation and what's interesting is she's my mother-in-law has been a big proponent of talking to people about endometriosis now that she's learning more, and so it takes just one person being out and spoken about it, and that's not true for everyone.

Speaker 1:

There is going to be those family members that don't receive that as well, but I would say that for me, the conversations are happening more because I'm willing to talk about it. I mean, it has to be an inappropriate time, it's probably not going to be around Thanksgiving table or the Christmas table, but to talk about those things I think will change the trajectory for women's health in general.

Speaker 2:

I think so, Especially at work. We need to be the squeaky wheel. Yeah, so that accommodations.

Speaker 1:

And that's an interesting thing to think about too. For your patients who are struggling through menopause symptoms. Are there ways that you help them navigate accommodations for what they need at work or in a different setting?

Speaker 2:

You know I don't have a specific way that I do that, but I definitely would recommend it for anyone. You know there's actually been studies showing that if you have a hot flash at work and you say, oh I'm sorry, I'm having a hot flash, people respond better to that than if you just don't say anything and appear kind of flustered and strange. So there actually is benefit to talking about it. And I also think, as far as getting accommodations where, like you, can work from home if needed or have more control over the temperature in the room, things like that the more people that bring it up, the more quickly we'll get change there. But there's some interesting data coming out that you know women are really taking that seriously and are willing to leave a job and find a different one for better menopause benefits. So I really think that more employers are taking it seriously too. But maybe what they think is adequate is not Right. It's probably going to take us educating them a little bit about what we need.

Speaker 1:

That's interesting that you talk about what we think is adequate versus what they think is adequate. There was a recent Stephen Colbert interview, actually, and he was talking to gosh, I don't remember I think I don't remember who it was and asked what is menopause? He's like I'm a grown man and I've seen this all my life. We've we've heard here and there but what is menopause? Grown man, and I've seen this all my life, we've, we've heard here and there, but what is menopause?

Speaker 1:

And it was interesting because that's where the education lacks as well, right, Like we're really good at educating ourselves, but I think it's important that we spread that education to those who maybe it doesn't affect directly, um, but maybe indirectly. And spreading that information because maybe we would get more accommodations, because maybe we would get more accommodations or maybe we'd get more understanding when we're having a fiery moment of perimenopause and want to scream one minute and laugh the other. You know, just that understanding piece of it.

Speaker 2:

Yeah, I think so too.

Speaker 1:

This conversation. It was interesting, you know, when you and I had talked previously offline when we talked about the correlations between the care of menopause and the care of endometriosis. They're very, very similar and they're along with a slew of other comorbidities, if you will, but they're very similar in the lack of education, the lack of understanding, the lack of treatment the lack of education, the lack of understanding, the lack of treatment. What is?

Speaker 2:

your hope moving forward for not only menopause but for women's health. Yeah, I'm really optimistic. The Menopause Society holds an annual conference and they sold out for the first time this past summer Like I mentioned, Heather Hirsch that course that I took to learn more about prescribing hormone therapy. I mean, that group is always growing and growing and growing, and more and more providers are choosing to get educated about this. So I do think it's on the upswing. I think it started with patients, so kudos to us, Right, but it's filtering into the clinician side. I can tell you from being part of that. So you know, I do think that newer providers are generally a little bit better about shared decision making too, so I think it's getting better and all we can do is keep advocating and keep helping to move that forward.

Speaker 1:

Yeah, I'm excited about all the people talking about it and it's becoming more of a talking piece across all platforms, not just women's platforms. I think that's really important. I think it's becoming more of a talking piece across all platforms, not just women's platforms. I think that's really important. I think it's true with endometriosis as well. I am hopeful that maybe we could define endometriosis more accurately more often in the future, and that's going to take a patient and provider team to make that happen as well. So I'm excited for that. But the correlations are strong and we have to understand endometriosis and menopause as they go hand in hand a lot of times. So I think this conversation has been really enlightening for that purpose alone. Any parting words of wisdom that you have for our listeners?

Speaker 2:

I gave you some good resources to find providers. The Menopause Society also has a list of providers. You can kind of know ahead of time if they have some particular interest in menopause and then, even before you make the appointment, you can ask about those questions about you know, do you offer testosterone, do you offer pellets only, or you know FDA approved options, so that you aren't wasting your time with an appointment with somebody that doesn't provide care the way you'd like. I personally work in Washington state. I do telehealth all through Washington and then, for those of you that are more interested in supplements or lifestyle pieces for all these symptoms we were talking about, like mood changes and changes in libido and trouble sleeping, I have a course actually at phasesacademycom where I go through lifestyle changes, supplements and then medical management.

Speaker 2:

That's the way I practice. That's the way I am as a patient is, when I have a medical condition, I want to know what are the few things I can do with my diet and then, if that doesn't work, okay, what supplement can I supplement? All right, who should I talk to about medical management? So that's the way I designed my courses, basically for myself. So hopefully I'm not the only one that thinks that way.

Speaker 1:

No, I don't think you are. I think a lot of us do think that way. I know I do and I think that a lot of people I talk to really appreciate that approach, because sometimes less is more, but sometimes you still need support.

Speaker 1:

So I think that's valuable information and I will make sure to put these links all in the podcast episode description so that they're easily accessible for everyone to get to. If you want more information on that, so I will happily put those in there. But, vanessa, thank you so much for taking the time to sit down with me and to go over all of this nuanced information for society. I appreciate your time and your willingness to share your expertise with all of us.

Speaker 2:

Well, thank you for sharing your expertise with me also.

Speaker 1:

Yes, that was fun. I should do that more often. I like it. Until next time, everyone continue advocating for you and for those that you love.