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Breta Alstrom: Today we're going to be talking all about hormone replacement, therapy, hormone replacement therapy labs, all the good stuff. So I know a couple of you guys have submitted questions to slack, which is awesome. I'll make sure those get answered today. And then if you guys have particular questions about hormone therapy and typically like hormone therapy labs. I know we've had just a lot of conversation about that recently. Whether it's been

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Breta Alstrom: in these calls on slack in the hormone channel. Just kind of all over the place. So you guys can go ahead and drop those questions in the chat, too, and as they kind of come up in our conversation, we'll make sure that they get answered.

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Breta Alstrom: and if we don't have time for them today, we can address them in the live session. Follow up.

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Breta Alstrom: but I think we will have

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Breta Alstrom: a good bit of time to dive into Hrt. And Hrt. Labs in depth, and then, when it comes to cardiac markers, and I know there's always a conversation about our heart health, and if it's appropriate for hormone replacement therapy, we'll briefly touch on that today. But that is all. Next week we're doing a deep dive into cardiac markers next week. So if you have like specific questions for heart, health, save them for that.

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Dr Doug: Good plan. Good plan. Hi! Everybody see some new faces. Welcome.

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Breta Alstrom: Awesome, and if you make me host, I will spotlight you for everyone. Dr. Doug.

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Dr Doug: Okay, thank you. I thought you were because I joined late.

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Breta Alstrom: Somebody.

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Dr Doug: Calgary.

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Breta Alstrom: Yeah, that.

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Dr Doug: Let me see.

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Breta Alstrom: We're good.

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Dr Doug: Let me see who is. Oh, I am host.

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Dr Doug: you are

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Dr Doug: host.

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Dr Doug: Make a host.

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Breta Alstrom: Awesome.

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Dr Doug: There you go!

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Breta Alstrom: Alright. Now we're ready to dive in so we're gonna start with. Just in general. We'll we'll start with a few general things. I'm sure a lot of you guys already know, and then we'll work into more of that in depth. Nitty, gritty stuff. But let's just start with what the Hrt. Is used for.

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Dr Doug: Yes, simple answer everything.

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Dr Doug: Yeah. So this is such an interesting space.

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Dr Doug: I was just thinking how to summarize this.

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Dr Doug: So we're we are finishing a book on the topic of hormone replacement for women. And it's been such a fascinating journey, because I've just been exploring all the controversies. And the further I go, the more I realize this is that like, it's a crazy space

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Dr Doug: because of what's happened over the last really 30 years in the realm of hormone replacement for women, and how it's so different than hormone replacement for men, and how we look at women so differently in the postmenopausal timeframe than we do in Perry and Premenopausal when it comes to replacement and level. So there's

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Dr Doug: there's so much to talk about here. But a shorter answer than to your question, Brett, is, what do we use it for? I look at Hormone, either replacement or optimization, and I'll kind of explain the difference. But I look at it as a tool for

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Dr Doug: any sex hormone-related issue, which is a very, very broad category. And so this is going to go all the way back to premenopause, periminopause, and into postmenopaause, because we are seeing hormone dysfunction in our premenopausal women. Certainly we have patients in their thirties that are amenorrhagic they don't have cycles. They have dysfunctional progesterone cycles. They have no testosterone, no progesterone. So we see this happening younger and younger.

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Dr Doug: and usually they're not adequately treated by the traditional medical model. And then certainly, we're seeing this kind of big surge of discussion around perimenopause. And what's happening before in that decade of potentially even more years

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Dr Doug: before menopause and the changes that happen in hormones, and how we can support them there and then, certainly, once we lose the ovarian function, and we lose the majority of progesterone, and essentially all of the estrogen production and the ovaries, then the benefit of adding them at that point, plus or minus testosterone depending on levels and needs. So it's such a broad range of where we use hormones. And then you can get into all the specific

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Dr Doug: like, do you use them for bone health? Do you use them for cardiovascular? You just keep going and going and going, and that's what makes hormones such a challenging field to talk about. But I think in general, I'll just stop there and just say we basically use it anytime as a deficiency of sex hormones that we can't either lifestyle or supplement our way out of.

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Breta Alstrom: Yeah. And then when we'll kind of use the terms, Hrt and Vhrt, what's the difference between the 2?

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Breta Alstrom: And sometimes we just default to Hrt. Because it's fewer letters, but.

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Dr Doug: Yeah. So I tend to use the term Hrt, because that's just what's in my brain. You'll hear people talk about menopausal hormone therapy, so you'll hear mht, you'll hear just hr therapy, which makes me feel like we're talking about payroll and human resources.

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Dr Doug: You'll hear brt so bioidentical hrt, and there's an important distinction there, because most people, when they talk about Hrt, they're going to talk about commercial products. Commercial products are usually going to be Estradiol patches, some sort of synthetic progesterone called a progestin, and then unlikely testosterone. But sometimes that's in there, too.

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Dr Doug: and the big difference between Hrt. Through a commercial traditional pathway versus Brt is bioidentical hormone replacement is going to be essentially never using the synthetic progesterones. We're going to use the bioidentical version meaning, not that it was made in your body, and we're giving it back. But it's produced in a lab. So it's still synthetic to some extent. But it's the same

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Dr Doug: molecule that your body makes so Estradiol is estradiol progesterone is progesterone testosterone is testosterone. It's the same molecule that your body makes plus or minus a carrier molecule if it needs it. And so that's what bioidentical means versus say, like Medroxy progesterone acetate as progesterone. That is, traditional. Hrt, that is a synthetic progesterone, and that is not something that we recommend.

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Breta Alstrom: Yeah,

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Breta Alstrom: with that, do you? Wanna if if you guys, I just wanna take a little segue here, if you are looking for hormone replacement therapy. And you don't work with our optimal bone. Health clinic.

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Breta Alstrom: We are launching a separate company that specializes in getting you guys access into to bhrt. So I'm gonna put that in the chat here. So if you're interested just as we go along, you're more than welcome to just add your name and email there, and then, whenever we are talking about hormones, whether we say Hrt or therapy, hormone, therapy or whatever it's always bio identical hormone, replacement therapy.

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Breta Alstrom: So just know that even though we will say different things. But and then let's connect the dots real quick. How does hormone therapy impact osteoporosis.

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Dr Doug: Yes, so

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Dr Doug: benefits period. But all 3 of the sex hormones. When we talk about hormone replacement therapy, we're generally talking about the 3 sex hormones. So for postmenopausal women

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Dr Doug: always Estradiol. If candidates always progesterone, regardless of whether or not they have a uterus, and then testosterone only if they need it, which is an important talking point we can hit on later. But all 3 of those sex hormones will impact bones differently and independently. So estrogen very specifically will help to slow down bone loss. So it helps to slow down the bone breakdown cells. The osteoclasts.

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Dr Doug: progesterone and testosterone. Both will push on the osteoblasts, the cells that make bone. And so you can imagine for a premenopausal woman somebody who's cycling regularly half of the month. They have a surge of estrogen half of the month they have a surge of progesterone. It's the back and forth that keeps a woman having adequate bone, quantity and quality until she hits menopause. We actually see in women that have dysfunctional

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Dr Doug: rhythm. If they have less than 5 quote-unquote normal cycles a year, they start losing bone rapidly as if they're in menopause, and so that back and forth push, pull is really important for women to maintain bone health

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Dr Doug: which gets into the conversation of well, what if I took a birth control which we don't recommend for a lot of reasons, but that's 1 of them.

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Breta Alstrom: Yeah, awesome. So what labs are we ordering to assess hormones to recognize that deficiency.

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Dr Doug: Yeah, I've seen this a lot recently in Hsn 2. And this frustration around doctors who won't order labs. And I totally get it because we want to know and we do order labs. There are certain circumstances, though, where you almost don't need to, we still do. But if you're a postmenopausal woman, not on hormone replacement therapy. And your doctor says we don't need to order labs because we know what they are

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Dr Doug: when it comes to estrogen and Progesterone. They're right. We still order them, because I want to make sure that there's not some weird thing happening. If we're going to start you on hormones that we're going to cause something that we didn't mean to cause.

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Dr Doug: The exception to that, though, is testosterone, because postmenopausal women can make adequate testosterone through adrenal function, assuming that their adrenals are working well, which we don't see often in this group. But it's possible. So we definitely want to know what your testosterone looks like before we would replace testosterone. So when we're looking at lab values, we want to look at from an estrogen perspective. Specifically, Estradiol.

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Dr Doug: we do all of our testing, for the most part in blood, with some exceptions, and I'll explain that. But in blood Estradiol levels are important because there's evidence to support specific estradiol levels and their impact on bone. It's variable. And we can talk about numbers. But that's an important biomarker to know

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Dr Doug: Progesterone a little bit harder to measure in blood. We still do it because we want to make sure that our progesterone levels are adequate to a impact bone if that's our goal, but B to protect the uterus for a woman that still has a uterus. So if we have more estrogen, not enough progesterone, then you run the risk of increasing the thickening of the lining of the uterus, and that can expose you to the risk of uterine cancer.

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Dr Doug: And then testosterone levels. We're going to get total and free testosterone. And then there's some kind of secondary labs like Dhea Shbg, which is a binding globulin for hormones. Those are things we're going to get if we're going to replace. And we want to know kind of how we're doing and how much we need to dose. So those are sort of dosing-driven biomarkers.

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Breta Alstrom: And this is a really great, I think, segue, into Linda's question here. Any important differences between estrogen produced by ovaries as compared to estrogen produced by adrenals mentioned.

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Dr Doug: Yeah, we don't produce a lot of estrogen in the adrenal from adrenal function. Progesterone a little bit. But testosterone, certainly. So I'll kind of go through all 3 of those so estrogen is primarily produced in the ovaries, and then we see some estrogen produced at the cellular level. And this is why, for women that have had breast cancer, who were on an estrogen block or aromatase inhibitor, that's why, even if they're postmenopausal, and they didn't really have a lot of estrogen in their blood. They still feel terrible frequently because you block it at the cellular level.

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Dr Doug: So there is some estrogen production in the body, but it's very, very low compared to where a woman was preammenopausally progesterone. There's a little bit more made externally, but mostly again from ovaries, or specifically from

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Dr Doug: the follicular area coming out of the ovaries. But at postmenopausal you don't see much progesterone production either. And then testosterone is the difference. So testosterone about 25%, some people would say 30, but around somewhere a quarter to a 3rd is made in the ovaries, whereas up to 3 quarters is made from the adrenal glands or products from the adrenal glands. So this is where testosterone isn't necessarily needed for a postmenopausal woman that has good adrenal function.

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Breta Alstrom: Yeah. And since you did mention Dhea earlier let's just go ahead and scare that away. Ca, can you describe what dh is.

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Dr Doug: Yeah, I can never remember what the actual name is.

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Breta Alstrom: Yeah.

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Dr Doug: I could google it for you and pretend that I know. But it's dihydrope and Drostarin something. Anyway, it's dhea. So Dhea is a precursor hormone to progesterone and testosterone that your adrenal glands makes, and dha we see, fall in after menopause as well

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Dr Doug: with healthy adrenal function, though this is another one that it can be adequate and even optimized. Naturally, we just saw a patient yesterday that had a dhea of over 300. Naturally, so it can be really good, but frequently we see it in the low double digits, which means that even if they had the capacity to make adequate testosterone, they're not going to, because they don't have the precursors to do it.

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Breta Alstrom: Awesome, and along the lines of labs somebody had asked in slack if you could talk about the optimal serum and salivary levels of all the hormones. But

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Breta Alstrom: as far as let's just start with, the salivary levels are.

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Dr Doug: He's.

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Breta Alstrom: Those? Do you find value in that.

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Dr Doug: Yeah. So we don't use salivary at all. And the reason why is that it doesn't tell you much about what's going on in the blood. Then the people that use salivary would argue, but it tells you what's going on in your tissues. I've listened to the owner of the company. Zrt, talk about how important salivary levels are. I know great professionals that I respect, who use salivary levels. So I'm not saying it's wrong.

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Dr Doug: But what I find is that if we're using salivary levels, it's really hard to dose. I want to know what's going on in the blood. So early on in our practice we used both, and I will tell you that they were all over the place.

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Dr Doug: So I see this in practitioners a lot of times. Naturopaths will use, both because they want to use salivary and urine and blood. They're checking it everywhere. And I think actually, one of our patients is on here. And this was her experience. So they were so confused because one would look high, one would look low. They were like, Let's move it up. Oh, no, this is wrong, and you're just all over the place.

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Dr Doug: So I know that from a blood perspective, if we can hit Estradiol levels of certain thresholds, we're going to have certain impact. So I'd never use salivary, because I think it's just too all over the place.

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Dr Doug: Caveat to. That would be if you're using topical Progesterone. Some would say that you should measure that through salivary. The challenge is. Again, I just find that it's all over the place. And if you're using topical Progesterone. You're not going to see it in blood, and I think we don't use that for that reason, because you just really can't measure unless a woman is still cycling, so you can use topical if you're still cycling. That's a whole other conversation. But outside of that we don't use it for that reason, so we don't use salivary at all. Should I touch on urine? Retta.

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Breta Alstrom: Yeah, yeah.

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Dr Doug: Yeah. So then there's urine metabolites, right? So there's 3 ways to measure hormones. There's blood saliva and urine.

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Dr Doug: and we do use urine metabolites, but we use it in conjunction with blood. The reason why we use urine metabolites is because it's interesting to look at specifically, estrogen breakdown. And you can also look at cortisol breakdown really well through urine. So estrogen breakdown. We know that it can break down into different products. We can look at both detox. We can look at methylation patterns so we can kind of look at a bunch of different things through estrogen break

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Dr Doug: breakdown, and the urine metabolites will help us do that. So we find that test specifically called a Dutch test is the company we use.

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Dr Doug: We find that test to be helpful, but we don't do it across the board, because it's added expense. It doesn't necessarily change how we dose and how we treat. But it can help us to optimize for people that aren't necessarily feeling their best. I've seen a host of new posts out from, particularly the obgyn community against the Dutch tests. I don't know if you've seen this Bretta, it might just be like the ecosystem that I'm in on social media.

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Dr Doug: But so many providers who are coming out against the Dutch test and saying how crazy it is and how stupid it is, and it's not evidence-backed. So I have a whole like.

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Dr Doug: I have a series of posts that I want to do on this topic. But just know that if you've heard the negatives around it, there are a lot of people, probably, who use it inappropriately. There are people who use it for dosing. There's people who will charge $1,000 to interpret a Dutch.

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Dr Doug: I don't think that it should be used that way. It is a tool within the arsenal of tools around hormone replacement. I think it can provide us with some information, but it should always be, in my opinion, done in conjunction with blood levels.

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Breta Alstrom: And I, if anybody gets like a Dutch test through us, or something like a lot of times we're looking at the conversion. And it's like a lot of pathways and making sure that you're optimized to be able to to utilize the hormone therapy like appropriately. And you know, it's just it's more in depth than just like the dosing and along with the blood levels and using the blood levels versus the salivary levels.

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Breta Alstrom: I would say. And me, I don't know if you've

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Breta Alstrom: can comment on like what's in the research. But is it predominantly blood levels that are utilized for the research.

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Dr Doug: Oh, absolutely. This is one of the areas where I get frustrated by the people who are saying, there's no research for Dutch. There's a lot of research for Dutch, but it's all done by Dutch. It's industry funded research which that doesn't mean that it's not valid. It just means you need to take it for what it is. If you look at the medical literature on hormones, it's almost universally done with blood levels. Which is why we're comfortable using blood levels, because I know that I'm protecting myself and my patients by looking at blood levels. In addition to whatever else we want to look at.

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Breta Alstrom: Yeah. A couple of questions about what we do at obh if you've done a salivary test for us that's generally looking at cortisol. I know the package is going to say hormone, and they're gonna have details on hormone. But what we've ordered and how they're using that saliva is just measuring your cortisol levels and your stress levels that way. So not hormones. And then if they didn't have

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Breta Alstrom: a urine test through obh, we? We generally don't do that like what would be the used cases for a Dutch or getting like urine levels in addition, in addition to the blood work cause we don't normally order those.

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Dr Doug: Yeah, I mean for us, it's just looking at breakdown. And this would be for someone who's not tolerating estrogen particularly well for someone who's really concerned about breast cancer risk, which is this is kind of like a this is all a gray area, I guess. But if you look at some of the breakdown pathways. One is more strongly associated with breast cancer development. And so we would do it. In that circumstance. We used to do it in everyone. When we 1st started out we would have everybody order a Dutch at 6 weeks. But what we found is that

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Dr Doug: didn't really change what we were doing, and it gave us some interesting information. But for the cost.

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Dr Doug: you know, is it? Is it worth it? And I think not for everyone, for some people. Yeah. And that's why we do it on a case-by-case basis. Now.

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Breta Alstrom: and just to

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Breta Alstrom: touch back on the the research, too. You know, i'm sure things like salivary hormone levels, you know, yeah, you can see how much is in your is in your tissues. But if we don't know what to do with that information, because we don't have the research to connect the dots there. It's really just not that helpful and so I wanna I we have some good questions in the chat here. But I do wanna move through a couple of these questions, then we'll circle back to your questions in the chat. But

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Breta Alstrom: how do people feel? During the 1st few weeks of starting. Hrt. Generally.

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Dr Doug: Variable. This is one of the areas we've really been working on this. And we have actually some new ideas, too, because we're dealing with a population in general that is greater than 10 years out from menopause, because people are getting diagnosed with osteoporosis.

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Dr Doug: Later. Frequently it is in a population of women that did not go on. Hrt, this is part of the big picture. So we're dealing with a population a lot of times. It is over 10 years out from menopause, and some not so common circumstances, over 20 years out from menopause. So imagine your body being exposed to something, even that it had 20 years ago. But 20 years is a long time, so it can take some adjustment. And even in women who are going immediately through menopause, this can happen, too, because it's just different. What we do

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Dr Doug: in what we do and what everybody does for hormone replacement is very different than what happened before menopause. So if you think about what happened before menopause for a woman that's still cycling again, you get this rise of estrogen. Fall of estrogen. Rise of Progesterone fall of Progesterone

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Dr Doug: for the vast majority of people, women will receive what's called static dosing, meaning that you do the same dose every day.

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Dr Doug: plus or minus a vacation or holiday. Some doctors recommend that like one day, a week, or 2 days, a month, or whatever, but for the most part same dose all the time.

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Dr Doug: That's different than your body's ever experienced, and that's an argument against doing it that way. But it's certainly the easiest way to do it with the most research.

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Dr Doug: And so there is some adjustment period. So your estrogen receptors have to kind of be up regulated, especially if you haven't had them in 20 years. Same thing for progesterone receptors, and then the fact that you're getting both hormones at the same time, your body has to adjust to. So within the 1st 3 weeks you can feel Wonky. You can feel tired. You could feel over energized. You can feel bloated. You can actually put on 3 pounds 5 pounds, usually

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Dr Doug: water weight that will come off once your estrogen stabilizes sleep can either get better or get worse. And so we are working on some different protocols, particularly from the Progesterone side to ramp Progesterone up slowly. We'll start estrogen at a low dose, and then we'll ramp it up slowly. That's 1 of the reasons why I don't like pellet therapy, which I'm sure you probably have on your list of things to talk about. But in general, when go out and get pellets, even if they are estrogen, and they usually don't have progesterone in it.

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Dr Doug: Let's say it's estrogen progestin and even testosterone. You're getting these massive doses that your body hasn't seen in potentially decades. And some women do really badly. And so we don't like pellets. For that reason we like to be able to start low, go slow, get the receptors up regulated working, and then be able to adjust dosing from a daily basis. Basically.

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Breta Alstrom: Yeah, this is good. Like more of a personal question. I think we can answer it. Answer it generally. Someone had their Progesterone increase from 75 to 100, which took them from feeling great to having tender breaths, and it just wasn't agreeing with them. And so they, you know, emptied

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Breta Alstrom: like 3 fourths of the like pop goals.

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Dr Doug: And all the.

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Breta Alstrom: Like to try to get back down to their normal dose, but they haven't kind of gotten back to that normal could the reason of the side effects not be like? Is it? Does it build up her partitioners hold her to take 2 weeks off of it? What is likely happening there, or what maybe recommendations do you have for people who are having negative side effects with Hrt. Because that is, you know, it does take a little bit. The labs are important, but also how you feel is.

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Dr Doug: So important.

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Breta Alstrom: Most important, so.

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Dr Doug: Ma'am.

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Breta Alstrom: Yeah.

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Dr Doug: And this is where, like one of the reasons why we're starting a new company is specifically because we see just I mean over and over and over again women who are managed by either obgyn or even like a naturopath or a functional medicine doctor who isn't interested in their experience.

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Dr Doug: We see it just time and time again they have a 1. Size fits all approach. You're going to do this. You're going to do this, and I don't care how you feel. They don't necessarily say it like that. But that's how it feels and what our experience has been, because we're trying to get blood levels to optimize bone. Which means that we're pushing the limits on what we can do with Hrt.

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Dr Doug: We have to listen to our patients, because if we just gave them big doses of estrogen and progesterone. Our patients would hate us, and so we have to march up slowly, and then we deal with all of these symptoms, and so we, I mean breast tenderness is not uncommon, although we usually see it with estrogen, not progesterone, but again, the receptor balance. All of these things matter, and so there are infinite ways to deal with. Some of the symptoms, particularly breast pulling back and

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Dr Doug: going completely cold. Turkey off of Progesterone is probably not going to provoke symptoms. If you think about from a cycle perspective for a premenopausal woman, that's what the follicular phase is like. You have very little progesterone. So that's okay. You can kind of let the tissues calm down. My concern is, though, is that the symptoms are probably coming from estrogen, not from Progesterone. So I'd want to watch that closely, probably deal with it differently. But those are all of the things that we need

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Dr Doug: to with the providers. Say, what are you feeling? What are you experiencing? What is your current dose? How have you been taking it? How can we manipulate it? Because, like, I said, there are infinite ways to manipulate. Hrt, especially when you're using creams and capsules, because you can manipulate the dose so easily.

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Breta Alstrom: Yeah, and what would be your preferred? Like.

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Breta Alstrom: So form. That's what I'm looking for. What would be your.

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Dr Doug: The route. Yeah. So our preferred route is topical for Estradiol. And again, we use compounded creams instead of patches, so that we can have better control over the dosing. Also, again, we're going to want to achieve higher doses than the patches will usually allow you to achieve. This is extremely variable person to person.

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Dr Doug: but we use a topical cream for Estradiol. We'll use capsules for Progesterone. Usually I'm not opposed to creams, but again, we have to then deal with is a woman continuing to menstruate? Is this a premenopausal perimenopausal, or postmenopausal woman? So generally we're going to use capsules for that and then testosterone we use as a cream as well because we want to be able to manipulate the dose. And we're

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Dr Doug: less and less testosterone as we are optimizing adrenal function lifestyle, using Dhea as an androgen precursor and really focusing on the levels of azrogen and progesterone. So that's

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Dr Doug: that's sort of the approach from a route perspective.

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Breta Alstrom: And does anything change, or even just estrogen production? If somebody only has one ovary.

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Dr Doug: Yeah, I think the answer to that is, no, that's more of an over-gyn question. So if this is a premenopausal woman with one ovary. I think you can still have natural cycles, and I believe, kind of like having one kidney. You can see normal functioning levels. But I've not really looked into that research.

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Breta Alstrom: Awesome. And let's talk about testosterone a little bit. I know some things have changed versus like Overall, so I don't know if you just wanna give a little update on testosterone, how we're using it, what we're using it for, what we're.

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Dr Doug: Yeah.

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Breta Alstrom: Testosterone, so.

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Dr Doug: I would say, you know, like all things, everything is a is a journey. And so when we started using testosterone, we were getting some really great feedback. And this is like this, actually like coincides with my personal journey, like me and my family and those around me. So for those that I treat in my we'll call it my close circle.

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Dr Doug: seeing some benefits of testosterone in some, but not others. My own journey with testosterone is that I've felt a lot better on it. So we started using it more and more patients. We're getting great feedback. But as we started to expand the practice, what we were seeing is that I wouldn't say we're seeing a lot of side effects. We're seeing more people complaining about side effects.

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Dr Doug: I think that has to do a little bit with where we're using it, how much we're using. And then, also the population that we're working with. So again, from a bone health perspective. We're dealing with a lot of people who are struggling with thyroid issues already people who are undernourished already, and then adding an androgen to that, I think, can provoke things like hair loss.

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Dr Doug: And so we started looking at alternatives. What could we potentially do otherwise? And that's where, from a testosterone perspective, because natural production is possible, providing the precursors and really focusing on lifestyle. If someone's open to that, I think, is a really good option testosterone also from A.

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Dr Doug: And you're going to see this happen for those that aren't working with us as patients. Testosterone is going to get harder and harder to get. So we're also protecting our patients from the potential of not having access to it as the Dea kind of clamps down on telehealth prescribing. I think we're going to see a lot of these companies go. Either people are going to start going to jail, or they're going to shut down one of the 2. We can still prescribe

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Dr Doug: different states are doing different things. And so we're looking to protect our patients to say, Okay, how can we? If somebody really is benefiting, how can we get it to them if they don't really need it? What are the alternatives? And then this actually mirrors my own journey as well, of actually coming off of it and really focusing on lifestyle or ramping up natural production. So it's this really interesting circle of what we've been able to do during the pandemic to really experiment with this in this

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Dr Doug: population, and seeing a lot of benefit for some, but not necessarily for all.

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Breta Alstrom: Yeah, awesome. So let's get down to the nitty gritty. And I think this has to do a little bit with some of our ob protocols. But the you kinda mentioned the order of potentially starting things. But I wanna do like a little bit more of a deep dive on that

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Breta Alstrom: How do you start if you're taking all 3? What are you starting with? And then how long does it take? Generally for somebody to get on their full protocol, optimized dose.

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Dr Doug: Yeah. So I'm going to preface this by saying, for some we have. I can see some patients who are on here that have been with us for a long time. So those of you that are going to hear this are going to say like, well, he didn't do that with me. But, like I said, it's a journey we continue to learn and listen to feedback.

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Dr Doug: So where we are now is that when we start, somebody, especially a woman who's over 10 years out and definitely over 20 years out, we're going to start slow. We're going to start with one. So we're going to start with Progesterone. And we're going to start with. If our goal is, let's say our goal is on average, around 200 milligrams.

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Dr Doug: We're going to start with a 50 milligram capsule. And we're going to work our way up over the course of a week to a couple weeks, depending on how they do. We basically have them continue to march up until we find the ceiling of their ability to tolerate micronized progesterone orally.

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Dr Doug: And what we're looking for is on the backside of that. Essentially, if they wake up feeling hungover, that's sort of like the top. And then we come down one step, and so that puts most women between 150 and 300 milligrams.

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Dr Doug: Usually we don't wait until the end of that process, but we wait until at least they've been on Progesterone for a little bit. The reason for that is that when you're on Progesterone, and this is a premenopausal thing. When you have a progesterone surge. You are creating estrogen receptors. It's a little bit counterintuitive where Progesterone provokes the tissues to create estrogen receptors and vice versa.

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Dr Doug: So when we start progesterone alone. The body's gonna start creating estrogen receptors. And then we start estrogen at a low dose, and then it has somewhere to go. And our thought is, it's gonna limit some of the side effects a little too early to tell you if we've seen that globally. But certainly I think we're seeing more people tolerate it than they used to. And so we start low with estrogen. And then we start to build up. We're checking blood levels.

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Dr Doug: Now. We will do both of those before we start testosterone, because we want to optimize those before we start the androgen. And what we're seeing is some people, their androgen will rebound. And so, even if they had low testosterone, low dhea, because they feel good. Otherwise, you see the adrenal function start to rebound. So that's our approach in now how we are stepwise. Starting these 3.

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Breta Alstrom: Yeah. And I think, too, I mean, this is just a question that comes up all the time like with

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Breta Alstrom: like results. And and you know, changing perspectives on things. And I think one of the things that we do really really well is continuing to stay on top of, like all the research and what's new and what's emerging, and also looking at our patients and looking at what's working for them and what's not working from them and being willing to like change things. As we know better. So we can do a little bit better there, too. So I do think that is great, and you know our as far as the hormone and bone health side of our company. It's only

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Breta Alstrom: 2 and a half years old.

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Dr Doug: Yeah, I think the Bone health program is a little over 2 years. I don't know. Kathy. You tell me, how long have you been working with us.

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Dr Doug: You're muted, but anyway, you can use fingers 2 and a half years, probably something like that.

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kathy : I'll I'm almost to finish 3.

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Dr Doug: Yeah, there you go. So Kathy, Kathy was one of our 1st patients who jumped on board very, very quickly, right after we launched a bone health program. So yeah, so coming up on 3 years then.

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Dr Doug: And so you can imagine it takes time for us to build these protocols. But know that all of these things are different than what you're gonna get elsewhere, not as a selling point, but just saying, like your obgyn is, gonna give you micronized progesterone commercially, if you're lucky or they're gonna give you a combined product with a progestin and Estradiol. And you're gonna do it at the same time.

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Dr Doug: and then not give you testosterone. If you go to a testosterone provider that only uses testosterone, they're going to give you a pellet of testosterone, and they're going to stick it in your butt. And it's going to give you massive doses of testosterone.

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Dr Doug: I think what we're doing is certainly more tolerable than what we're seeing from other providers. But at the same time we're still learning.

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Breta Alstrom: Yeah. And we do, we get a lot of data. So we're checking in on you frequently. If things aren't, you know, going well, we know that, and we can adjust really quickly, which is excellent. Whereas a lot of places, you know, you might get something, and then you don't have a follow up for 6 months. So do you think that's another huge benefit of just having people who are available to you? But some great questions here. As you mentioned how you're recommending starting at this point is that just for perimenopausal women and ramping up, or also for postmenopausal women.

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Dr Doug: Really, mostly for postmenopausal women, permanent women is a little bit of a different approach. So permanent women that are still cycling. We're not going to add estrogen in that mix yet, unless they clearly demonstrate need for it, because adding estrogen to estrogen can provoke a lot of side effects.

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Dr Doug: But if we're doing Progesterone, we're typically going to do it in a cyclic pattern. So we're going to do it. For the second 2 weeks of the cycle, depending on the length of the cycle and at a static dose. But we would probably start low and then increase that dose sequentially, depending on how things are going with menstruation and with the bleed and with symptoms, etc. So permanent pause is tough because we do. We'll see some months

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Dr Doug: with estrogen levels that are great, and then we'll see some months with estrogen levels that aren't great. And so then we're really chasing those symptoms until they balance out in menopause.

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Breta Alstrom: Yeah,

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Breta Alstrom: a quick

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Breta Alstrom: segue here. But if somebody starts extra dial and progesterone, how fast can they expect to see changes in bone density, and I know we probably we're not measuring bone density that often. But maybe the bone turnover markers, how fast are we seeing a change.

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Dr Doug: Yeah. So I talk about this in the imaging sections, I think rems is faster than Dexa. I don't have hard evidence to support that it just seems like people that do rems every 6 months continue to see improvement. So we are seeing changes in rems at 6 months. I wouldn't expect to see much of a change in Dexa at 6 months, although we just had a patient. Did you see that Greta? Almost not even 6 months.

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Dr Doug: dexa, and had a 10% jump in her spine or hips, one of the 2 so apparently.

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Breta Alstrom: How do you test for that in our share your success panel in slack. So you guys go check that out and also share your story.

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Dr Doug: Yeah, so apparently it can happen. But I don't usually recommend. People get dexas every 6 months because a there's some radiation, and I'm not expecting to see a change, so we haven't really pushed that. But, rems, there's very little downside, because other than cost. As long as you have a couple of 100 bucks to spend. Then there's no downside other than the money, so I think 6 months is probably the earliest reasonable timeframe in which you're going to see change in imaging.

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Breta Alstrom: Yeah, awesome. Okay. I have one other kind of big question here. And then I think we might do some rapid fire audience questions. Are there any other hormones other than progesterone estrogen and testosterone that have a role in bone health, positive or negative?

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Dr Doug: Oh, well, yeah, I mean, but you're talking about like parathyroid hormone, like you're talking about the endogenous things that we're not going to replace so other than those things that we're not going to replace.

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Dr Doug: No, I mean cortisol. Yes. But again, that's kind of a different picture.

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Dr Doug: Yeah. Other hormones like insulin will play a role. But we're not going to replace that unless you're diabetic. So other than the from a sex hormone perspective, it's those 3.

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Breta Alstrom: Okay? And then on. We've got a couple of questions about how to naturally increase testosterone. If we're not replacing it in everyone.

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Dr Doug: Yeah. So it's all about lifestyle. So in supporting adrenal function, we can do that through adaptogens. But for the most part it's about lifestyle. So one of the things that we see so consistently in the osteoprosis population is this underlying feeling of anxiety, stress.

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Dr Doug: poor sleep

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Dr Doug: leading to adrenal dysfunction. I mean, it's like predictable. So everybody here is shaking their head right? They're like, yep, that's me. So I think this chronically elevated cortisol as a result of the impact of our lifestyle is going to play a role in developing osteoporosis over time.

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Dr Doug: Women that fit that category generally on biomarkers. We're going to see deficient progesterone. If they're premenopausal, we're going to see deficient testosterone. We see it in our non-bone health patients, of which we don't have that many. Anymore. But in our non-bone health patients, women that are in their thirties and forties that fit that same profile. They have no testosterone. They have no progesterone, and they're at risk for osteoporosis.

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Dr Doug: So focusing on the lifestyle and supporting the adrenal function is priority number one. When it comes to naturally improving testosterone

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Dr Doug: them.

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Breta Alstrom: Alright transition into some quick fire. Audience chat questions here. How would you change any of this like

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Breta Alstrom: or these recommendations, or just how would you classify someone who maybe

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Breta Alstrom: like very young, had a hysterectomy and goes on Hrt, and pretty much stays on Hrt. And they were never technically characterized as postmenopausal, even well, into their eighties.

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Dr Doug: That's a long time. Yeah. So it's this really interesting divergence in the literature here. So for a woman that goes under, you know, basically a surgical menopause, right? So she'll have her ovaries taken out generally with the uterus. And then she is essentially menopausal, right?

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Dr Doug: That woman is almost universally put on Hrt. Hormone replacement therapy, and the doctors will say to protect your heart, your brain, your skin, your vaginal mucosa, your urinary tract, like all of those things

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Dr Doug: they will tell a forty-year-old who goes through a surgical menopause. But yet when a woman naturally does it a decade later, they're like there's no change in lifestyle like you don't need it. I just don't understand it. And it's so very clear in the literature. When you read the literature from

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Dr Doug: like oncology surgeons who are doing these surgeries or obgyn, who are doing these surgeries. And they're such advocates for Hrt and these patients. And then you take a different population of women 10 years later, and they're like, Oh, no, it's a totally different situation.

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Dr Doug: Why, I don't understand it. So, anyway, to get back to your question.

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Dr Doug: The same things apply. So you want to start Hrt right away, because a woman's going to go through menopause, and it happens rapidly right. So you remove the ovaries, and you went from like way up here, and you're just going to crash down into the floor. And so we know that women feel terrible for the most part, when that happens.

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Dr Doug: Going through menopause naturally is a little bit different, because you see this up and down and perimenopause, and it's sort of like dood we call it hormones dropping off a cliff. But that's not actually what happens in most women. It's sort of like this up and down, up and down, up and down, and then it's finally gone. That transition is easier, although not for everybody. But I would imagine easier than going through a surgical menopause.

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Dr Doug: So

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Dr Doug: we do the same thing in those patients. I think the error is, so many of those women are not given adequate levels of hormones.

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Dr Doug: and so they'll say, I want to protect your brain, your heart. But here is a low dose, Estradiol patch with a progestin, and let me know if this covers your hot flashes, and there's a big disconnect there, too, because the amount of estrogen needed to protect a woman from hot flashes and night sweats is different than the amount of estrogen she needs to be protected from her bone, her heart, and her brain.

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Dr Doug: But that's harder to measure and obgyn's don't seem to be too concerned about that.

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Dr Doug: Yeah.

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Breta Alstrom: Next question is.

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Breta Alstrom: Beth is 70. She started Hrt. With some trepidation, and she's concerned that if she comes off of estrogen, even though she's not planning to that. Her bone loss would plummet more so than if she had never started estrogen. In the 1st place.

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Dr Doug: I love this line of thinking.

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Dr Doug: So I

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Dr Doug: I understand where you're coming from from this perspective. But I also look at this. This is like a self-defeating mindset. Right? You're like, I don't want to do the thing that's going to help my bones, because if I ever stop doing the thing that's going to help my bones. My bones might get worse.

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Dr Doug: but your bones are already worse.

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Dr Doug: So let's do the thing that's going to help your bones, and then, if you ever need to come off of it, for whatever reason deal with it then. But you're going to have better bones then. So it's going to be a different situation. And then if you had to potentially use other tools.

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Dr Doug: So I think we just have to watch for that mindset click. And that's why mindset is in our the foundational pillars of the Oh pyramid is because that is a clear mindset issue where you're basically self defeating your potential progress by worrying about something that might happen in the future.

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Breta Alstrom: Yeah.

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Breta Alstrom: And this next one, I think, will touch on a few different questions. Are older women like 70 plus more or less likely to receive. Hrt.

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Dr Doug: Less.

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Breta Alstrom: And with that, with all this, is a big topic in slack, too. We had a couple of people with the same question in the the slack channel on. How do you talk to your doctor about the benefits of Hrt. For them to advocate for themselves? Whether it's for all the other benefits that you've mentioned, or just for bone, health.

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Dr Doug: Yeah, good luck. So you can.

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Breta Alstrom: Well, at least for Pemma again.

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Dr Doug: Yeah, exactly. So I will say it's possible. And I've had people tell me that. Hey? I went to my doctor and I took these studies, and they were open to listening to me. And that's awesome. But that is not common. So most doctors, especially around hormone replacement. They have their set opinion.

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Dr Doug: If they do it, they have their protocol. If they don't do it, they're not going to do it. So trying to convince a doctor to change. The way that they think about something is

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Dr Doug: unlikely unless you have a concierge doctor, and you're basically paying them for their time. And you're going to sit them down and educate them. But doctors don't usually take very well to that approach.

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Dr Doug: So I would say, in general, you're going to go get a consult. You're going to hear what it is that they want to do. And then, if you don't agree with that, or you don't think that's right for you, then you need to find another way to do it would be generally my recommendation. There are some people who don't have that opportunity. They don't have

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Dr Doug: like wherever their insurance they can't go to another doctor, or they don't have anybody else in town or whatever. So there are some circumstances where maybe you do need to try to convince them otherwise. But it's really really tough to do with the doctor mindset. But that's why, again, we're creating a company where, if you're not getting what you need, just go elsewhere.

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Breta Alstrom: And then the another question is, if somebody comes like has to take a 2 week break of their progesterone. Is that enough time for their uterus. Lining does or does like start thickening.

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Dr Doug: I mean.

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Dr Doug: yeah, if you think about a natural cycle, it's a two-week break from Progesterone. So yes, would it actually happen at the levels that you're receiving in Hrt, it's different. So if you look at the natural levels of Progesterone endogenously during a cycle, you're averaging somewhere 300 400 picogram per ml.

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Dr Doug: If we look at what we're giving women, it's hard to measure in blood when you take it orally, you're not getting the same stimulus as you are. Naturally I wouldn't expect it to. But again, if this is the same situation in patient from before, I would probably recommend taking a break from estrogen. First, st I can't tell you what to do.

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Dr Doug: but estrogen is generally the more proliferative of the 2. I know that this happened in conjunction with a progesterone increase in dose. So we'd have to learn more. But generally it's not progesterone, although it's not impossible.

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Breta Alstrom: Alright. This is a great question. Kind of really bridges the gap on all of different, a aspects of bone health. But if someone is on one of the bone. Health medications like Avini for a time. Once treatment is complete, will Hrt. And lifestyle be enough to keep Ctx and pt, p, 1 np, at proper levels.

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Dr Doug: We are in the process of proving this right now.

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Dr Doug: So I will say. What we've seen so far is, I don't know of any.

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Dr Doug: We have patients who are coming off of avinity. I can't think of anybody off the top of my head who we've been watching. But basically, if someone's coming off of avinidity off of Bisphosphonates off of proleia.

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Dr Doug: We're following their labs. We're getting repeat p. 1, and P. And Ctx. And we're seeing I haven't seen anybody whose ctx is shot through the roof coming off of any of those drugs.

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Dr Doug: So I think that when you look at the literature and you see this rebound effect, especially with prolia.

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Dr Doug: I think that you're just dealing with a population that isn't doing anything else.

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Dr Doug: So all they were doing for their osteoporosis was taking Perlea. And then when they come off of Perlea, they're not doing anything for their osteoporosis. And so I think we're dealing with a different group. Our patient population are people who are doing all the things they're eating the right food. They're working on the lifestyle. They're potentially doing. Hrt, they're taking the supplements. They're doing all the stuff.

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Dr Doug: I think your body's going to naturally combat that rise in Ctx because I can't think of anybody again. We have a number of patients, especially coming out for Proleea. I don't think anybody's seen a dramatic rise in Ctx.

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Breta Alstrom: What would you consider like some a ctx that's through the roof.

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Dr Doug: Over a thousand, but but I would be like

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Dr Doug: I would be worried. So it takes somebody who's on. It doesn't matter. Actually, all 3 are kind of the same. So affinity after 12 months it looks more like an anti-resorptive drug. So Ctx is very low.

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Dr Doug: So all 3 drugs. Your Ctx. Is going to be like a hundred or below.

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Dr Doug: I would be worried if we saw this g(040) 050-0800. I wouldn't wait until it gets to 1,000 before we sound alarmed.

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Dr Doug: But I don't think we've even seen that. I think it looks natural. It looks physiologic, and it depends on the p. 1 and P. Because we also want the p. 1 and P. To rise. That's why we follow that ratio, and if the ratio looks good, even if their ctx is, let's call it 800. But their p. 1, and P. Is 150. I don't care. That's great. That means we're just chomping up old bone, but we're making new bone in the process.

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Dr Doug: So we just have to watch it closely.

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Breta Alstrom: And on the topic of the Ctx. To p. 1 and P. Ratios. We've had a couple of questions about this in slack, too. If somebody has a ratio over 700,

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Breta Alstrom: what do we think about.

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Dr Doug: I know. So we see this occasionally. I just saw somebody with that earlier this week

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Dr Doug: can't be. Today's well, I don't know. Whatever my days are blurred.

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Dr Doug: It was naturally over 600. It was crazy high, but this was a scenario where I think that it's actually real, where I think it's not real is when both numbers are really low.

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Dr Doug: I don't really know what that threshold is yet, but if you look at somebody who's on, let's say Perla, for example, their ctx. Is whatever. 50, but their p. 1 MP. Is

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Dr Doug: 28.

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Dr Doug: The ratio is going to look good, but it's not good, so I don't know what the bottom is of what I would consider to be physiologic and natural. But when you see these really elevated ratios. Then you have to look at the absolute numbers and say, Well, is it really low? Is it really high? Is there some weird thing going on here, but if they're kind of mid-range, then I think it just means that at that point in time you were making a lot of bone.

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Breta Alstrom: Yeah.

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Breta Alstrom: pen.

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Breta Alstrom: But I'm just trying to pick some good questions.

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Dr Doug: While you're thinking I'm gonna turn off my fan freezing.

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Breta Alstrom: Okay.

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Breta Alstrom: we've got time. We'll do one. Well, I have 2 more questions. That I'll do. And then if anybody wants to jump on and ask their questions. Live! You are welcome to do that. But if s0me1 0, my gosh! I just I literally just lost it.

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Breta Alstrom: I

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Breta Alstrom: struggle. If somebody had a hysterectomy at like 43 and then they did start Hrt. But are there any other hormones they should be worried about up like with their ovaries being removed? Or is it pretty much just like the basics.

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Dr Doug: Well, I mean, the ovaries are essentially producing to some extent estrogen and progesterone. Right? So those are the 2 big ones. I would also want to know what's happening from testosterone perspective at that point. But I would definitely focus on those 2 the 2 primary sex hormones.

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Breta Alstrom: Awesome, and

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Breta Alstrom: last one

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Breta Alstrom: is the Hrt protocol for secondary osteoporosis from ongoing low-dose quote unquote steroids, or anything else the same as primary osteoporosis. And what are your thoughts on concurrent treatment?

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Dr Doug: Yeah, the answer is, basically, it's the same. So if you think about our framework for primary osteoprosis, and I've talked about this. It's been a while. So you guys probably haven't heard me say this. I almost feel like, for the most part, primary and secondary. Osteoporosis aren't really great terms, because if you think about the way we look at primary osteop primary osteoporosis for me, we still want to look at what is the underlying cause. What is the reason why you're losing bone

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Dr Doug: from that perspective. Primary osteoporosis looks a whole lot like secondary osteoporosis. So really it is the same, except in a true secondary osteoporosis, meaning like you have a parathyroid tumor. You're taking 100 milligrams of

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Dr Doug: cortisone every day. Those are clear, obvious reasons, but it still fits in the same paradigm. The question is, can you stop that thing? So if you have a parathyroid tumor, are you a surgical candidate? If you're taking a steroid. Why are you taking a steroid? Is it something that you can come off of? Or is this something that we have to try to work around? So the treatment is essentially the same. But we have to take a hard look at the thing that's causing it. And then, seeing if we can stop that

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Dr Doug: is it something like a PPI that you're on? That is increasing your risk of fracture. You can't digest protein, but you have Barrett's esophagus, and you have a hiatal hernia, and you're not a surgical candidate to fix it. That's a different scenario than somebody that has. Gerr. That's on a PPI. Let's fix your gut. Let's get you off the PPI. So we kind of have to figure out what that thing is, and then tackle that thing the best that we can.

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Dr Doug: Yeah.

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Breta Alstrom: Awesome. Alright. I'm gonna open the floor to anybody who wants to maybe raise their hand using the raise their hand feature. Or, oh, David, go ahead! I see your hand can unmute.

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David Callen: Yes, you brought it up so I've gotta ask it. What is a good ctx. p. 1 NP. Rain ratio range? You know where you see the ratios telling you that you're building bone rather than subtracting both.

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Dr Doug: Yeah, we are definitely still in the process of figuring this out. But I'll tell you that we're collecting a lot of data. We're looking at numbers. We're looking at improvements. But because Dexa takes so long I don't know when we're going to have a definitive answer to this. But right now we're using a threshold of 150. Let me just run you through. How to do that again? Because I've seen this question asked recently. So the p. 1, and P. Over ctx.

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Dr Doug: So p. 1, and P. Building over Ctx. Adjusted for units. So p. 1. And P. Is usually going to be a 2 digit number. I'd love for it to be 100, but generally it's going to be a 2 digit number. So let's call it 80, and then you want to match ctx to those units. And the way that you do that is, by moving the decimal point 3 places. So let's say your Ctx is 400, so your number then would be 80, divided by 0 point 4 0, which is going to give you a 3 digit number. I don't know if that is off the top of my head.

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Dr Doug: Yeah, does that make sense.

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David Callen: Yeah, yeah, this looked like you looked at my numbers. How'd you guess that.

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Dr Doug: I feel you, I feel you.

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David Callen: So there. So I understand that I'm a data guy, too, and it drives me nuts being able to not see the numbers grow and develop as you get to. So.

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Dr Doug: Yeah, I would love to. I mean, we have. Of course, we have hundreds of people. Now, we're collecting all this data. But because the dexa stuff just takes so long and repeat imaging. I mean, some people are even afraid to do it, which is why we were like, I don't really rely on

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Dr Doug: Dexa to tell me that we're succeeding, either. So we have some people where actually, now we're reaching out to people and be like, Hey, did you ever repeat your Dexa? Because I would love to know what that is. So some people they don't even want to repeat it. I'm like no, no, no, it's important. We need to know. And so we are collecting in, and we'll have a better answer. I don't know when, but we'll continue to be able to refine that. I sort of see that 150 threshold, though as for people that aren't.

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Dr Doug: they'll kind of come into their follow up, and they're not able to do much, or they're just not doing much, for whatever reason we tend to see it stay below that. So that's why I'm using that 150 threshold for now, because when I feel like people are doing stuff and they're active, and they're doing all the things I feel like we see it breach that 150, and go upwards of 200.

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David Callen: And I

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David Callen: thank you.

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David Callen: Great question.

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Dr Doug: Great question.

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Breta Alstrom: And then, Nancy, you can go ahead and ask your question.

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nancy m: Hi! I'm I'm not sure if I heard this wrong.

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nancy m: The difference between measuring in the blood the compounded Progesterone and the Oral progesterone. I thought, Doctor Doug said, that one of them wasn't as good as far as measuring. I started out with compound progesterone, and then later switched to oral, and the levels are the same. So I'm a little confused. There.

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Dr Doug: Yeah, let me just clarify terms a little bit. I think this will help clarify this for you, so compounded could mean both topical as in a cream, but it could also mean oral

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Dr Doug: as a capsule, so there is compounded, and commercial and compounded can be either commercial is, I think, only going to be. I've never seen a cream, so it'd be oral. So when I talk about testing, generally, we're going to test in blood, and if you take it orally, either compounded or commercial, but orally, you're going to be able to see it in blood easier than if you use it. A topical

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Dr Doug: topical. You're pretty much never going to see in blood, because it doesn't circulate there. But even if you're taking it orally, you might still not see it in blood. Because if you're taking an immediate release, especially so like the normal formulation, immediate release, and you take it at night by the time you get your blood drawn in the morning, it very well might be gone. And so this is why Progesterone can be challenging to measure. We still want to see it in blood, but sometimes we have to go off of symptoms as well.

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sjcsr: We can clean.

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nancy m: So.

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nancy m: I'm I guess I'm still confused because I'm taking twice as much progesterone orally as I was compounded.

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nancy m: and and the levels are the same.

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Dr Doug: And Nancy, when you say compounded, are you referring to a cream that was topical.

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nancy m: And cream. Yeah. Got gotcha.

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Dr Doug: Well, so you can't relate. The dosing from a cream to oral is not apples to apples.

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Dr Doug: So if you were taking, let's say you were taking a 200 milligram per whatever Ml, cream, and you go to a 200 milligram capsule. That's not the same thing.

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Dr Doug: And so, because the way that you absorb it's going to be different. But remember, too, if you were taking a cream, you're unlikely to see it in blood. So how are you measuring it before.

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nancy m: With blood.

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Dr Doug: And you saw.

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nancy m: And you.

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Dr Doug: Saw it in blood.

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nancy m: Yeah, that's what's confusing to me. It was very low in both cases, very low, I mean.

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Dr Doug: I wonder if it was even? Was that even endogenous production? Because if you're using it as a cream you shouldn't see it in blood.

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nancy m: Wow!

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Dr Doug: Which is which is confusing. Yeah.

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nancy m: Yeah.

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Breta Alstrom: Alright, and one last question on our last few minutes, Lorna, you can go ahead.

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Lorna Nichols: Okay, I

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Lorna Nichols: I've been starting back on the Bhrt protocol. And it's going really, really, really? Well, I'm so happy no symptoms.

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Lorna Nichols: And but I, but I'm on testosterone. I can do my little clicker here. And with what you've said today, I'm thinking, oh, gosh! Maybe I don't need that. Maybe I should not

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Lorna Nichols: not worry about it and concentrate on the adrenal.

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Lorna Nichols: Granted, I am the stressed up

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Lorna Nichols: to the Max. All right. But I also have a lot of hair loss which

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Lorna Nichols: can be

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Lorna Nichols: made worse, maybe, by testosterone. But I but if there's extra benefits to testosterone, then I'm wanting at all. So

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Lorna Nichols: your opinion on that.

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Dr Doug: Yeah, well, we're breaching hipaa a little bit here. But clearly you said it, not me

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Dr Doug: for you specifically, I would recommend staying on it, because, as you said, you are, if you describe yourself as like the typical patient with anxiety and stress, I would say you are. You are more than that.

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Dr Doug: You just have a lot of fear. And that's okay. And that's not uncommon. But definitely, I think your path to adrenal health is going to require your T. Score to be better a lot of things for you to be better than worry about whether or not you should be on testosterone. Let's just stay on testosterone and worry about the things that we can get you to worry less about.

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Dr Doug: So let's just use it. It's at a low dose. Let's let it do its thing, and then, if you ever want to come off of it, you certainly can. It's not like estrogen. Where, if you come off of it. You don't have any. You can taper off of testosterone really at any point, honestly, and just continue to function on adrenal health. But let's use it for now, because it is a tool that we have.

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Lorna Nichols: Thank you so much. Thank you.

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Dr Doug: And welcome.

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Breta Alstrom: Awesome. Okay? Great question. Stay. I feel like this was very informative, successful. Hopefully, you guys have more clarity. Doctor Doug has to jump off and go see patients. But I have about 10 min. If you guys have any tech questions and I'm gonna give you guys a little slack update, too. But thanks, Doctor Doug. We'll see one.

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Dr Doug: Yeah, thanks everybody. Great questions. I really appreciate all of your thought into these questions. So love these topics. Thanks. See ya.

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Lorna Nichols: Thank you.

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sjcsr: Greta, this is Sue. JI didn't get an answer to my question. I'm concerned because when you read the question to him, you didn't read the poll question, and what I want to know is if the slow release Progesterone builds up as opposed to the regular progesterone.

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sjcsr: because the doctor that I'm going to put me on. I'm on slow release. And he and I went in there this week because he bumped up my progesterone, and it made me very, very uncomfortable, and he told me not to take any progesterone for 2 weeks now. Doctor Doug just answered a question for somebody over there, saying he wouldn't advise that.

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sjcsr: So, my! I don't even know what Progesterone that woman was on. But my doctor saying, if you take slow release which helps you sleep at night

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sjcsr: that it's it's builds up in your system. Would you happen to know anything about that?

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Breta Alstrom: So that's gonna be out of my scope. But that was the end of your question. So yes, but you're gonna have to work that out with your doctor, though, because we don't know what other things you're taking

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sjcsr: Wait.

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Breta Alstrom: Level, for Friday.

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sjcsr: No, no, no, that was a very simple question to get an answer to. I'm taking estrogen. I'm taking testosterone. I'm taking Progesterone. I was doing great on 75 Mgs. Of Progesterone, and he bumped it up to 100. It made me very uncomfortable. I had a lot of side effects. This, doctor I'm seeing, says that

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sjcsr: slow release Progesterone builds up.

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sjcsr: And that's the problem. And I just wanted to know from Dr. Doug, if that's the case because there's 2 types of Progesterone, you know, the slow release and the regular progesterone.

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sjcsr: So

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sjcsr: you know, if you have trouble sleeping, you gravitate to the slow release. But the question is, does the slow release build up in your body, as opposed to the other progesterone that you take at night to go to sleep? I mean, it's pretty basic.

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Breta Alstrom: Yeah, I do believe, Dr. Doug answered, that

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sjcsr: No, he didn't cause you didn't. No, he didn't, because you didn't, you, because you did not say slow release. You just said Progesterone. Micronize Progesterone. You didn't. You didn't make the distinction. That's why I put it in there. Please ask him, and when you read it you read it so fast. You left that part out.

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Breta Alstrom: You can always post this in the live session, follow up in slack, and then we can have Doctor Doug comment on it.

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sjcsr: Okay, I'll do that. Thank you.

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Breta Alstrom: Awesome. So just a couple of slack updates for you guys. You're now gonna see these things called slack canvases that are gonna have a bunch of quick links in there for you. So it's just some really easy access tools. And so some of the posts that had previously been pinned. I went ahead and moved those into the canvases, and you'll see those on the side and each of the different channels. Haven't added them to every single channel yet, but I did add them to some. So if there's other things that you want as like a quick reference, please let me know, and I can add those to the appropriate canvas for you.

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Breta Alstrom: Nancy, did you have another question.

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nancy m: Yeah, I'm sorry I've never heard of slow release, for just on is there a brand name or something? I just never heard of that I I mean, I know Prometrium, and then there's generic Prometrium.

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nancy m: and then.

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sjcsr: No, not all, not all compounding pharmacies use it. But it is. It's very nice. It helps you. If you have anxiety or hard to sleep it. It's a slow release, but you have to ask for it specifically, and not all pharmacies do it.

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nancy m: Oh, so it's only in compounded.

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sjcsr: Yeah.

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nancy m: I think.

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sjcsr: It's very nice, but the thing that concerns me is, my doctor told me with these symptoms to go off of it for 2 weeks. And someone in this group asked him about the thickening of the uterine lining. If you stop

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sjcsr: and you don't take it for 2 weeks. And he said, yes, that could cause a problem. So I wanted to ask him about the buildup of the slow release. Is that true? Because I'll go against my doctor's advice. I won't do it because I'm 72. I'm not going to take a chance. I have a uterus.

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sjcsr: so

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sjcsr: you know I was double checking, because what I'm gonna do is I'm not listening to my doctor. I'm just gonna cut it back a little bit, but I'm not gonna take it away completely.

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sjcsr: Cause? You know.

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sjcsr: But alright! That's what happened. I'm I'm sorry.

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nancy m: Interject, but the progesterone reduces the lining of the of the

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nancy m: endometrium.

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nancy m: It's the estrogen that builds it up.

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sjcsr: Right, but if you have, but if you have a uterus, you have to take Progesterone in order to protect your uterus, and if you don't take the progesterone, then I believe that it can someone in this group. He even answered it. Today, he said. If you stop the progesterone, it can thicken the lining of the uterus. I listen very carefully to that. He did say that.

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nancy m: I I see I'm sorry. See what chat.

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sjcsr: That's alright. That's okay. I mean, look, I could be wrong. But I listen very intently, and I thought, that's what I heard him say.

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Breta Alstrom: Post questions in the women's hormones, too, and then can crowdsource some info there as well? Stephanie, you had a question.

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Stephanie Mandel: Yeah, I I know. Can you explain the whole slack thing? I haven't gone on that before.

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Breta Alstrom: Yes. Did you create an account.

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Stephanie Mandel: Now.

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Breta Alstrom: Okay, so let me,

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Breta Alstrom: is send.

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Breta Alstrom: Well, if you're not on slack, okay, can you do me a favor and send an email to Hsn support

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Breta Alstrom: at ohmd.com.

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Breta Alstrom: and

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Breta Alstrom: we will get you squared away and make sure you have access to that. There's just a link. It just depends on kind of if you're an ovh platinum patient, if you're just Hsn. Only there's just a few things to navigate there, and it'll be super clear and straightforward if we just help you one on one.

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Stephanie Mandel: Okay, that was Hsn support at.

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Breta Alstrom: ohmd.com.

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Stephanie Mandel: Okay? And that has additional information having to do with Hsn.

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Breta Alstrom: Yeah, so you'll be emailing Julie, who may or may not still be on this call. But she will help. Just help you navigate all the systems and make sure you're set up with all the things that you need. And I put that email. That's just all our Hsn tech questions and everything. I put that in the chat so you can grab that. And yeah, she's still here. So send her an email, and she'll make sure you have the right links. So you can get into that. And then I am just as another little update. I'm updating our slack tutorial

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Breta Alstrom: and our Hsn platform tutorials, since those things are new. So I'll have those in hopefully by today. But maybe tomorrow in those canvases as well. And then over the next, probably next week. Everybody. If you're in Hsn, you're gonna get an onboarding email from Dr. Doug for Hsn. But we're just gonna resend those out, since all our platforms are different.

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Breta Alstrom: and then

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Breta Alstrom: it's just the onboarding. All new members will get from from here on out. But if you get, you know, an email that's like I, I've been an Hsn member for a year. Now. It's just so we send out a little update and refresh. So you guys have access to everything. So

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Breta Alstrom: yeah, any other questions, tech questions.

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Breta Alstrom: Yeah. And then I also have one other favor in Hsn. On the announcements channel, I posted a link for positive feedback and constructive criticism as well. If you guys will go and select that link and just share what you're liking about, Hsn. And any things you wish that you could have through Hsn or things you wanna see and submit that that would be amazing cause when people ask us about our program

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Breta Alstrom: and you know, if people like it, then we have some some positive things to share with them, and then we could also help improve the processes or get you guys more resources to make sure you're getting the most value out of Hsn. Too. So just let us know what you need, and you can always send me a direct message in slack I will try to get to those as fast as possible. And just yeah, keep you. I think the the community in slack is really flourishing right now, and I hope you guys are enjoying connecting with each other.

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Breta Alstrom: But yeah, have a great 4th of July. If you celebrate and we'll see you guys next week where we'll be talking about cardiac markers.

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