Podcast Drop Date: 2/22/23
Amber Warren, PA-C has an in-depth conversation with internationally recognized hormone & cardiometabolic expert, Dr. Mark Holthouse, MD. In this episode Dr. Holthouse tackles the myths surrounding Hormone Replacement Therapy and separates fact from fiction.
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Transcript:
Amber Warren, PA-C: Welcome to Functional Medicine Foundations podcast, where we explore root cause medicine, engage in conversation with functional and integrative medicine experts and build community with like minded health seekers. I'm your host, Amber Warren. Let's dig deeper.
I'm your host, Amber Warren, and I'm back here with Dr. Mark Holthouse, one of my favorite people to interview. And we have a very exciting conversation really surrounding busting the myths regarding hormone replacement therapy. So I think we should just dig right in. Let's not let's not sugarcoat anything or beat around the bush. Let's go for it. So I've heard you give this talk probably like ten times now about.
Dr. Holthouse, MD: Sorry.
Amber Warren, PA-C: No, it's amazing. I'm so invigorated every time I hear it, the amount of hours. I mean, we could even probably say days, if not weeks worth of time that you have spent digging into the research really over the last year on how you as a physician that specializes in women's hormones has just changed your whole approach.
Dr. Holthouse, MD: I have. Oh, you know, it's it's humbling because you realize that when you think you've got a stance on something that you're there and that's what the ground that you defend. And in medicine, what is it, the doubling times every 18 months? It's ridiculous. So any dreams of keeping up is really just that it's a dream. You can only really delve into an area or two and be somewhat qualified to speak. What's interesting, though, is that my opinions on on hormonal therapy, you've known me for three years have have completely changed. The evolution began with looking into some of the studies, preparing for a talk that I'm doing next month. And it led me down a a course of wait a minute, that's not true. As I was hearing things and reading things and then you just go down the rabbit hole, it's it's inevitable and you have to defend. You often start trying to defend your your pet held belief. And you end up going, Oh my goodness, there's a lot of data that that really is disruptive to my my line of thinking, which was ever so comfortable. And so, yeah, the crux of of my realization has really been. Hormone therapy is very different from what we've been preaching as hormone therapy with with synthetics. And synthetics are dangerous and they cause breast cancer and heart attacks and Alzheimer's and blood clots and pulmonary pulmonary emboli versus the natural products, the actual non patentable hormones that are natural extracted from yams. And we don't see those things causing those problems. In fact, we see very positive results. And that's really what's changed.
Amber Warren, PA-C: Can you break down not to interrupt you, sorry, but what's a synthetic hormone that's out there that we could be prescribing?
Dr. Holthouse, MD: So a synthetic is something like Provera. Provera is got a big, long fancy name. And what drug companies have done is taking they take the idea of a biological molecule that's active at a receptor like natural progesterone, and they have to modify it in order to be able to patent it so that they can make profits. Everyone asks me, Well, why did they do that? Why didn't they just use the natural one that prevents these cancers and, and, and things? And it's all about money.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: So synthetics are those things that were made in the lab and that were changed from their original natural state.
Amber Warren, PA-C: Like birth control.
Dr. Holthouse, MD: Like birth control pills. Unfortunately, we don't have a bioidentical or non synthetic form of birth control. Even our IUDs with progesterone have progestins, which are synthetic progesterone. And ironically, they act completely different in human bodies than do the natural products that they're supposed to replicate. And that's really the irony.
Amber Warren, PA-C: Yeah. Yeah. It's all too often that we're seeing patients, you know, hormonal acne, hormonal headaches, you know, mood dysfunction, that's that's cyclical and related to hormones. And they're just slapped with the birth control. Exactly. And they get better. Yeah, exactly. But then no one's really talking to them about how that disrupts hormonal balance and how that just shuts down your own, you know, endogenous hormonal production. And then also what it does to gut health and a lot of other things, too.
Dr. Holthouse, MD: Right? There's a price to be paid. It seems like every time we monkey with the natural version, what seems like a great outcome often ends up later being a disaster, which was the Women's Health Initiative 20 years ago.
Amber Warren, PA-C: Yeah. So so that's really the crux of it, right? That's the fear. And even the training that a lot of us got in our training programs on why we should be so scared of prescribing hormones.
Dr. Holthouse, MD: Exactly. July 2002, Front cover of Time Magazine. Why your hormones might be killing you. And so we've had 20 years, a whole generation of women completely scared off of their hormone therapy in menopause. Why? It said the synthetics caused breast cancer. They caused heart attacks, strokes, clots, blood pressure problems, Alzheimer's disease. And the doctors during my generation, we were trained the same way. So we've all been trained based on the data on synthetics. And we don't see those findings at all with the bioidentical hormones. A lot of the studies in Europe where they didn't use Premarin and Provera don't have these outcomes. And so we're really recovering from the PTSD, if you will, over the last 20 years of misinformation and really a misallocation. Of. These synthetics causing these diseases and applying it to natural hormones, which couldn't be further from the truth. What's amazing is that in JAMA, Journal of American Medical Association 2020, group of hard core research scientists went back and looked at all this data from those clinical trials. And what they found was that when you left this toxic synthetic progesterone out, there was a significant decrease in breast cancer incidence and mortality dying from breast cancer. Versus when the progesterone was put back in. A bigger increase in incidence of breast cancer, not so much the dying from it, but the incidence of breast cancer was significantly higher. We never heard about that. That didn't make headline news. It wasn't a negative story, which often tends to be less sensationalistic. But it's out there, it's in print, and it's time to get the word out that if we use the right type of hormone, which the human body makes, that's not synthetic, we can actually help to stave off some of these diseases. We have some of our expert advisory panels that are still stuck in that kind of fear mongering from the 20 year old data.
Amber Warren, PA-C: Yeah. So unfortunate. Well, and we live in a world where it is people are still so, so heavy. So we we as practitioners, we have to be really careful. And so it is sometimes hard to step out and branch out and get outside of what majority of our colleagues are doing. So it's it's a it's a tough battle. Let's start with perimenopausal women, maybe because I'm one of them. So I'm excited to dive into this topic a little bit. But I think, again, let's go back to our training, right? We're kind of trained at hormonal, especially in functional medicine. Hormonal imbalances in menopausal women are usually due to some other issue, right? Nutrient deficiency stress, poor gut health, poor detoxification, toxins in general. And those are all true. Yes, but it's really not the whole story. It's very short sighted way of looking at premenopausal hormonal dysfunction.
Dr. Holthouse, MD: Yes, it is.
Amber Warren, PA-C: So what are you what are you using premenopausal and what are you not using?
Dr. Holthouse, MD: So it's amazing when you really understand what's happening. Before menopause, women lose their testosterone about ten years before menopause, for the most part between age 20 and 40, about 45, 50% of it's gone. And there's this rapid decline much quicker, actually, than guys who lose it much slower over many years, starting at about age 30. The next thing that goes is progesterone in pre menopause. And lastly is estrogen when you hit menopause. So knowing knowing just that, when you have someone that's come in at 35, 38 that's had a couple of kids who has no sex drive, who's tired, who's starting to put on weight, who's not sleeping well. Wouldn't it be wonderful to avoid the antidepressants? Wouldn't it be wonderful to avoid the addictive sleeping medications? Wouldn't it be wonderful for them to feel completely female again and have a libido.
Amber Warren, PA-C: And enjoy raising children and enjoy this really exciting, fun time in our lives and not feel so overwhelmingly exhausted by it all? Exactly. I'm there.
Dr. Holthouse, MD: Right. You know, so, you know, I guess I've I've after looking at the data on the safety of testosterone in women, even pre-menopausal, it's amazing when you use these things, the route of delivery, selecting the right patient and the dose is where the devil is in the in those details. Right. It can be life changing.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: And so. That's probably one of the biggest areas. Progesterone life changing in that same age group, whether it's cyclic, whether it's continuous progesterone is amazing for postpartum depression. Yeah, it's amazing for cyclic migraines, PMS, painful periods, heavy periods, cramping. You know, leave the motion in the bottle.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: So there's there's some botanicals we can use before getting to.
Amber Warren, PA-C: Are you seeing side effects in some of these premenopausal women using using progesterone.
Dr. Holthouse, MD: You know I don't. Progesterone is is just such a natural. Wonderfully women love their progesterone. It makes them sleep at night. They take it right before bed. Yeah. It's it's something that when it hits the liver, taking it orally creates this this GABA effect, which is very zen. Yeah. So it helps them get restful restorative sleep. It also helps to stimulate bone growth. Estrogen has a more passive role at bone maintenance, where testosterone and progesterone really build bone. It's great for the brain. Acute brain inflammation. We're learning so much about neuropeptides and progesterone is really at the forefront of that.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: So if you can look at migraine sufferers, PMS, dysphoria, mood issues that are occurring and these heavy periods, painful periods, clots, you know, they're just miserable. And with an oral progesterone two weeks out of the month, it can literally change their lives.
Amber Warren, PA-C: And let's we don't even have to really go the cost saving measures with health care in general if you're saving patients on some of those really expensive pharmaceuticals. Right. The antidepressants, the migraine medications and just using because it's generic progesterone, generic, it's cheap, right? You don't have to get the controlled release version. It's it's really affordable.
Dr. Holthouse, MD: It's great. You know. And the SSRIs.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: Antidepressants which are first line for PMS, where do they cause number one side effect sexual dysfunction.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: So it just adds to the problem.
Amber Warren, PA-C: Yeah, absolutely.
Dr. Holthouse, MD: They're problematic for the mitochondria.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: So it's it's been life changing for many women just drones huge premenopausal test does something newer in my.
Amber Warren, PA-C: Right.
Dr. Holthouse, MD: Armamentarium of things to try and again selecting the women the right way is is.
Amber Warren, PA-C: Key so testosterone deficiency again we're still talking about pre menopausal women. What symptoms are you seeing? You mentioned some of them, right?
Dr. Holthouse, MD: Mostly it's it's weight gain, usually increased visceral fat, which will drive down HDL cholesterol. You'll often see pre-diabetes, high insulin, you'll see glucose creeping up, diabetes. They have horrific libido issues, energy, cognitive issues. Often you'll see just brain fog. Yeah. You know, and a lot of times we focus on adrenal and we forget sometimes times that when we move away from optimal testosterone, optimal progesterone levels at 40, yeah, we start feeling it. Symptoms of androgen insufficiency start in the thirties in most women. And that's not something I was trained as a family practitioner to even talk about. Yeah, it was taboo. So lots of data showing it's safe. We need more long term studies, definitely. For sure. Most of the hormone studies on tea have been done in guys. Yeah. Historically.
Amber Warren, PA-C: Yeah. So what's your favorite mode of delivery for these women that need that need t.
Dr. Holthouse, MD: The ones that are looking at needing t that we select and we, we do the risk benefit little equation with pellets are by far my, my bias pellets have been around for 80 years. Very safe. They've never been recalled for any reason. There's no studies showing that cause clots, diabetes, stroke, breast cancer. In fact there's lots of data. Rebecca Glasser who's probably world one of the foremost world renowned surgical breast oncologists publish, has published ferociously on the effects of actually treating breast cancer with testosterone.
Amber Warren, PA-C: So cool.
Dr. Holthouse, MD: So we're not to the point where we can say we can use t to prevent breast cancer and. But it wouldn't blow my mind to see that in the next few years.
Amber Warren, PA-C: So cool.
Dr. Holthouse, MD: We saw this with men with prostate cancer. We've come full.
Amber Warren, PA-C: Circle.
Dr. Holthouse, MD: T causes prostate cancer. Now we see that the guys that are lowest in T have the higher risk of prostate cancer and they present at a higher stage when they come in with it. And they often have more cardiovascular disease as well. Completely the opposite of what we've been taught for 70 years.
Amber Warren, PA-C: Yeah. And the pellet therapy you're using isn't it. I'm not trained in pellets, but isn't it more similar physiologically to how our own, how our own hormones it.
Dr. Holthouse, MD: Is the pellets are basically compressed, natural hormone extracted from a yam.
Amber Warren, PA-C: Right.
Dr. Holthouse, MD: And the powder is compressed into four women, a rice sized pellet.
Amber Warren, PA-C: Cool.
Dr. Holthouse, MD: And we put it in the top of their glute cheek every four months. It's a very minor procedure and all natural. The pellets aren't FDA approved, but the compounding pharmacies where they're made are heavily FDA inspected.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: So very, very safe. And what's nice is exactly what you said. Instead of getting a roller coaster ride like you see with injections, you get more of a physiologic effect. There are no FDA approved testosterone preparations for women. There's one that's just come out in Australia. So we're stuck using stuff that we use for guys, which is the topical creams, gels, injectable or pellets. And my my results in the gals that come back pellets have been just amazing.
Amber Warren, PA-C: I've seen testosterone in my women work really well for depression. I've got some of my most depressed patients. They've made pretty significant turnarounds.
Dr. Holthouse, MD: One of the well, the only indication right now by the Endocrine Society for for Women is really what they call hypoactive sexual desire disorder, which is low libido. Female androgen insufficiency is easy to diagnose. It's not even based on a lab level. Everyone wants to have my level checked. Well, it's it's a symptom diagnosis, right? It's based on basically low libido and mood symptoms. And so incredibly helpful for mood. So mood, libido, weight loss, body composition, improvement, energy, cognition, sleep, bone health, bone health, huge for helping to stave off bone loss.
Amber Warren, PA-C: Yeah. Again, looking upstream right. Let's let's not keep just treating something when we're diagnosed with it let's prevent it Exactly. Don't have that diagnosis and carry that diagnosis. Right right. So that we do we did a great job with premenopausal let's move into Perry that that period of time when you've got the crazy hormonal fluctuations. Yeah what are what are you seeing there? What are you using you're finding most helpful.
Dr. Holthouse, MD: Again, testosterone for the same reasons in that age group. What's different in perimenopause? They're tricky little devils. There's a there's a very little known hormone called inhibition, which is made by the testicle and guys, ovaries and gals. And it starts to crash a little bit around that 40, 45, close to 48 on average. And its job normally when it's around is to provide negative feedback to pituitary on something called FSH, which tells the ovaries. Make more estrogen. So when you lose inhibition and you take that brake pedal off. Fs goes through the roof from the pituitary.
Amber Warren, PA-C: Because you keep trying to make. You're like, Oh my gosh. Make it, make it, make it.
Dr. Holthouse, MD: So you end up with a scenario called estrogen dominance. So estrogen dominance really rules mid thirties onto forties, fifties. So the big mistake that's tempting for providers to step in. Is to say, Oh my gosh, you're 42, you got hot flashes. It must be low estrogen. And so what do they do? They they start thinking about that when, in fact, they've got estrogen dominance, which with this wild FSH level telling the ovaries bombarding, make more, make more, make more, and they feel horrible. They go, they go nuts. So you've got to look at FSH levels and really make sure that they've come up. Should, indicating that the ovary is no longer responsive to all that excess message from the brain. To do that. So it's a real art to knowing where they are based on.
Amber Warren, PA-C: Labs.
Dr. Holthouse, MD: Coupled with symptoms. Labs are probably the least important thing premenopausal. They become very important. Not so much estrogen and progesterone, but the other things like FSH in those late forties. But yeah we it's it's a transition and every woman is different when they flip when that ovaries going on permanent strike and then often with estrogen deficiency you see the horrific hot flashes, the night sweats, the sleeplessness, you know, the cognitive issues, the vaginal dryness. The libido is completely gone.
Amber Warren, PA-C: Skin's changing. They're so upset about their skin.
Dr. Holthouse, MD: Yes. Skin skin's getting creepy and dry and saggy. And collagen is just not working in their favor anymore. Their hair is falling out. It's course. This. This is the lot. And, you know, my my position has always been very atypical where you give the smallest amounts. And this is a good segway for your next post Meadow Group. Give the smallest amounts of hormones for the shortest period of time and that's really slow and go really slow.
Amber Warren, PA-C: Very tedious about higher doses.
Dr. Holthouse, MD: And this is the ACOG, American College of OBGYN guidelines. The North American Menopause Society. Nams is much more progressive, especially in their 22 just released statement where there's much more of a shared decision making now. There they're realizing, wow, gals with low sex drive that have bone loss. This probably is the best therapy is good old hormones. But we've still got those fears based on old studies 20 years ago using synthetics that somehow these natural products are also going to cause cancers. Right. Which just isn't true. When you look at the data.
Amber Warren, PA-C: Yeah. Yeah. Okay. So we're really individualizing care based on a perimenopausal woman, based on those one, two, two, maybe three years that she's going through those changes. Exactly. Post. Post is probably one of the bigger.
Dr. Holthouse, MD: Oh, yes. Yes. So post-menopausal is interesting. Again, my change, my evolution, my metamorphosis, full transparency was if you need them because of symptoms and your hot flashes are not manageable. Oc And only for ten years like, you know, at ten age 60 arbitrarily. It's it's not a good idea based again on older studies looking looking at synthetics.
Amber Warren, PA-C: Right.
Dr. Holthouse, MD: When you look at the estrogen natural estrogens and natural progesterone studies, there really isn't data showing that we need to stop at 60 and 70. Why? Because we know that when we do that, the benefits to the brain, the breast, the cardiac diseases and the bone health. A lot of those things immediately revert back to a negative situation. Women catch up with guys within 5 to 10 years on their rates of heart disease. Right after estrogens gone. So in my mind, I'm thinking, why would I want to withhold something that has that much benefit? I don't do no harm.
Amber Warren, PA-C: Do no harm, No harm.
Dr. Holthouse, MD: And do no harm is to select my patient appropriately who doesn't have active blood clots, who doesn't have breast cancer, who doesn't have a contraindication to it, and give them the benefits of a natural product, not a synthetic where we know harms, but a natural product where we know we've got great data on reducing breast cancer mortality and risk.
Amber Warren, PA-C: And you still feel the data is really strong, that those first 0 to 5 years is when you get the most brain cardiovascular bone benefits. You still agree with that?
Dr. Holthouse, MD: I do. I think that first ten years.
Amber Warren, PA-C: Ten years.
Dr. Holthouse, MD: The sooner you can start from the onset of menopause to age 60, that is definitely the sweet spot. Nobody argues that anymore at all.
Amber Warren, PA-C: Good. Yeah.
Dr. Holthouse, MD: You know, a lot of us that are in integrative hormone therapy would argue that we shouldn't be stopping at 60, that we should be continuing to treat regardless of whether or not they've got hot flashes any longer because of the data showing that when we stop a lot of these other risks, come back up.
Amber Warren, PA-C: Yeah. Okay. Yeah. And you're using pellet therapy in these women?
Dr. Holthouse, MD: Yes, I do. I use pellet therapy. Sometimes we'll use transdermal patches with natural estrogen you get at your regular pharmacy. Yep. Yeah. And we always use oral progesterone. I don't I don't use progesterone creams.
Amber Warren, PA-C: What's the point for the oral over. Over creams on the women that are on the estrogen.
Dr. Holthouse, MD: Yeah. So the oral progesterone is where the data is on protecting the uterus from getting too much exposure to estrogen, which could be unopposed, could cause endometrial cancer. When you use creams, we have really no good data that shows your protecting that estrogen stimulation of the uterus using things like saliva, very unreliable. It's always going to overestimate your progesterone levels. Come to find out progesterone levels are really difficult to accurately assess with blood, dried urine or saliva. Treating the symptoms make sense. The data is clear that 100 to 200 milligrams of oral progesterone is giving you that great sleep, that Zen effect, and it's going to protect your uterus if you're on systemic levels of estrogen.
Amber Warren, PA-C: Yeah, yeah, yeah. Managing and following up. We actually, as a group of practitioners had a great study time today where we talked about all the ways that we manage and follow up really closely on these women to ensure that levels are are where we want them to be. Exactly.
Dr. Holthouse, MD: Doing it safely, doing a risk calculation post menopausal. You got to do, you know, what's their breast cancer risk? Do they have fibrocystic breast disease? You know, what are their leptin levels, pre diabetes, obesity, all these things drastically improve their or increase their risk of having a bad outcome. Smoking, alcohol, smoking, all these things.
Amber Warren, PA-C: Yeah. Yeah. It's really important. It's again just kind of that functional integrative approach where we cast a wide net and try to fix rebalance the body and look at biomarkers and do all the things.
Dr. Holthouse, MD: Everyone wants to just do a patch and forget about their gut.
Amber Warren, PA-C: It's easy.
Dr. Holthouse, MD: I know I can still have my Doritos and slap on a patch.
Amber Warren, PA-C: I'll feel so much better and my health will return and all the things that's so good. Any anything else that we left off? Any other anything else that's just rocked your world or kind of turned your your whole clinical approach upside down with what you're learning and what you're digging into?
Dr. Holthouse, MD: You know, I think just seeing natural hormones as a friend as opposed to a foe.
Amber Warren, PA-C: Yeah.
Dr. Holthouse, MD: Is is really the biggest epiphany. That's that's evidence based. Yeah. I think we need to stop following magazine covers emotions and media and follow the science.
Amber Warren, PA-C: But that's just the world we live in.
Dr. Holthouse, MD: Just its critical thinking is near extinction and unfortunately practitioners are not immune to that. We follow expert guidelines that are based on pharmaceutical recommendations, which is which is sad. I've seen that in my 30 year career creep in.
Amber Warren, PA-C: Yeah, I'm sure.
Dr. Holthouse, MD: That's a.
Amber Warren, PA-C: Change. Yeah.
Dr. Holthouse, MD: I was asked earlier today by these guys that are here hosting in my career, what have I really seen that's changed? And that's probably one of the biggest things that I've seen that's significant. Cool. You know, evidence based medicine is defined as randomized clinical trials. You know, who who's able to afford to fund billion dollar trials.
Amber Warren, PA-C: It's the farmers, Big Pharma. Big Pharma. So true. I'm so proud of you for saying that. Well, I. It's such an honor of mine to be with you through this pivotal moment in your career and get to learn from you and just have these conversations with you. It's truly an honor. I like to end each of my talks. You know this with with a piece of advice related to our conversation that's moved the needle the most for your patient population. What would that be in this setting?
Dr. Holthouse, MD: Educating them, empowering them with the science that says they don't have to be afraid of something their body made their whole lives.
Amber Warren, PA-C: Ever. Yeah, I love that. Mike. Drop. Boom!
Amber Warren, PA-C: Thank you for listening to the Functional Medicine Foundations podcast. For more information on topics covered today, programs offered at FMF and the highest quality of supplements and more. Go to Fun Med Foundations dot com.