00:00:00:02 - 00:00:18:22 

Noah Reed 

Welcome back to the DUTCH podcast, where integrative medicine providers can expand their understanding of functional endocrinology and testing; and everyone, no matter who you are, can learn more about their body’s most complex communication system. I'm Noah Reed, vice president of sales and marketing for the DUTCH Test. 

 

00:00:19:04 - 00:00:33:10 

Noah Reed 

And coming up on this week's episode, Dr. Tara Scott is back for a second Ask the expert segment where she walks us through the second stage of life that women go through. We'll learn about testing during menopause and her take on aging gracefully. 

 

00:00:33:21 - 00:00:35:22 

Noah Reed 

So, now on to the show. 

 

00:00:36:18 - 00:00:50:09 

Mark Newman 

Thanks, Noah, and thanks, Tara Scott, for coming back to finish out this life cycle of females. So, we talked before about puberty and what happens after that and that phase of life where we're having babies and all of that and then that stops.

00:00:51:01 - 00:01:11:18 

Mark Newman 

So, again, your expertise is perfect to kind of guide us through this intellectually. So, can you just start from, not the beginning, but the middle towards the end and explain to us if I've got a female who's cycling regularly, like just stereotypically healthy, normal, ovulating, whatever, and then she starts to turn towards menopause 

 

00:01:12:00 - 00:01:20:08 

Mark Newman 

perimenopause like to start right in that story and tell us what's happening hormonally, what's happening to their their bodies, and we'll pick it up from there. 

 

00:01:21:16 - 00:01:40:10 

Tara Scott 

Well, first of all, I just have to say that so much of the focus is on contraception and fertility. And so, a lot of these women, you know, in the absence of needing contraception, like maybe they've had a tubal ligation, or their husbands had a vasectomy, if they're having any hormone issues, they're left with kind of nothing. 

 

00:01:40:10 - 00:01:53:05 

Tara Scott 

And so, that that's where a lot of education needs to take place, I think, to traditional providers and even functional providers, because it doesn't go straight from reproduction to menopause. There's that huge piece that you said is perimenopause 

 

00:01:53:05 - 00:02:17:15 

Tara Scott 

and by the definition, the strong classification that the North American Menopause Society endorses is that once your cycle lengthens by seven days, technically that's when you're in perimenopause. So, if you really think about that definition, that means if I have a 28-day cycle and one time have a 35-day cycle that really widens that age range 

 

00:02:17:15 - 00:02:35:16 

Tara Scott 

of perimenopause, you could be in that for ten years. So, traditionally an anecdotally, I would say most women have like once a year, like some kind of weird cycle. That doesn't necessarily mean they're in perimenopause. They might just, you know, have a late cycle or a heavy cycle or something. 

 

00:02:35:16 - 00:02:51:05 

Tara Scott 

And it's not necessarily a sign that something's wrong. And what generally happens in this age range is because they're not focused on conceiving and because maybe they don't have to worry about contraception because they've done some kind of permanent contraception. 

 

00:02:51:12 - 00:03:05:09 

Tara Scott 

They're not always thinking about their cycle. And if it's normal and what's abnormal, like we're not telling them that information isn't out there. And of course, now, as we mentioned with social media, more and more people can get this information. 

 

00:03:05:09 - 00:03:31:15 

Tara Scott 

But there are so many signs in that perimenopause that we still have our antenna up for so we can be more preventative of these hormonal related problems like breast density, breast cancer, fibroids, you know, even just, you know, mineuralgia, endometrium, hyperplasia, uterine cancer, diabetes, you know, as a result of abnormal estrogen and estrogen and balance with progesterone, 

 

00:03:31:15 - 00:03:40:06 

Tara Scott 

there's a lot of other things that can happen that we're not really taught. And we don't tell women that these are the things that need to be monitored. 

 

00:03:41:02 - 00:03:54:01 

Mark Newman 

And when you talk about monitoring what is different in that phase relative to when they were 35 and cycling? I test you when you're 35 and if you are picture perfect, I get a certain picture within a lot of normal ranges. 

00:03:54:05 - 00:04:07:14 

Mark Newman 

So, when you're when you're having a normal experience in the midst of perimenopause, but again, not yet menopausal, what does that look like in terms of your lab values and what you're seeing on a DUTCH Test and other like hormone related lab testing? 

 

00:04:08:16 - 00:04:22:10 

Tara Scott 

The biggest problem with perimenopause is we've got these poor-quality follicles, you know, and we know that if you try to get pregnant in your 40s or late 40s, you're going to have poor air quality. But nobody cares about that end quality when it talks about hormone production. 

 

00:04:22:20 - 00:04:43:22 

Tara Scott 

So, if you have varying levels of Astra dial production and we talked about that lifeguard and the FSH, it's going up and the estradiol just just swinging from high to low based on FSH stimulation. We always have this underlying descent of progesterone because these are poor quality follicles. 

 

00:04:44:08 - 00:05:02:08 

Tara Scott 

So, it's pretty common for women to be estrogen dominant, which, you know, that's a problem because we talked about estrogen causing growth and progesterone causing cell death in the uterus, in the breast. So, those are two hormonally sensitive areas that, if unregulated, could lead to cancer. 

 

00:05:03:01 - 00:05:09:01 

Tara Scott 

So, to me, you know, it's such a preventable thing, I think, if we didn't test everyone, but it's not standard of care. 

 

00:05:10:01 - 00:05:11:11 

Mark Newman 

If you did test everyone. 

 

00:05:11:18 - 00:05:27:13 

Tara Scott 

Yes, we should everyone you know, ideally, everyone should have a DUTCH Test when they're 25, 35, 45 in the absence of any problem. Right. That should be a normal right. And I think the consumers are pushing it, you know, so, they're driving it. 

 

00:05:27:14 - 00:05:43:22 

Tara Scott 

These, I guess I could say millennials, you know, they're they want to know about their body. They want to be proactive about their health, which is fantastic. My generation, which whatever generation I am, I think I'm Z. They don't want to know. If it ain't broke, don't fix it. 

 

00:05:43:22 - 00:05:47:20 

Tara Scott 

Right? So, I would much rather have someone be much more preventative. 

 

00:05:48:02 - 00:06:02:21 

Mark Newman 

Yeah, I think it's a, it's a good point to say I don't want to have a child right now. So, then you just stop thinking about like the hormonal impact of the fact that it's harder to have a child at 42 than it was at 32 means you can't have a kid, but you might not want to 

 

00:06:02:21 - 00:06:19:17 

Mark Newman 

have a kid. But then you're maybe ignoring the fact that those changes in that phase of life have some consequences, that that testing and just paying attention to what's going on then can be really helpful. So, for you, when you see those women who are going through that 

 

00:06:20:03 - 00:06:33:17 

Mark Newman 

natural experience of estrogen bouncing all over the place and the progesterone is not as robust as it used to be. What are the typical types of source solutions to the the negative consequences of that phase of life? Like what 

 

00:06:33:20 - 00:06:36:21 

Mark Newman 

what are the things you're reaching for in terms of tools for those women? 

 

00:06:38:10 - 00:06:47:14 

Tara Scott 

So, I explain it to my patients. Like, you know, when you're in your 40s, it's like you have a job on commission. You don't know each month how much you're going to get paid. You get paid a lot. 

 

00:06:47:15 - 00:07:00:00 

Tara Scott 

If you're saying your paycheck is your ovarian hormones. Right. A lot. You get paid a little. Right. And so, that's where it really ties a lot in with adrenal function, because if your ovaries are your monthly paycheck, your adrenal gland is your 401k. 

 

00:07:00:10 - 00:07:11:23 

Tara Scott 

And so, how you treat your 401k is going to be directly correlated with what kind of menopause you're going to experience. Right? I mean, if you saved up and you're not dipping into your savings account, you can retire and that's fine. 

 

00:07:12:00 - 00:07:28:18 

Tara Scott 

You live off of your savings. But if you're constantly dipping into your savings or you're not saving and you retire, you're going to have to get a part time job to bridge that gap. So, using these tools, now that we have this awareness about hormone levels, I mean, that's what we do in our practice. 

 

00:07:28:18 - 00:07:44:13 

Tara Scott 

We test people, we do all types of testing and we don't guess we want to know the objective information about what the lab ranges are. Now, symptoms generally correlate, but sometimes somebody might have really abnormal labs, but no symptoms that might happen. 

00:07:45:00 - 00:08:03:02 

Tara Scott 

Or the opposite really abnormal symptoms, but normal labs, again, that's why that's one of the reasons why traditional doctors kind of dismiss hormone testing. We say, well, hormone levels fluctuate so much they're not going to mean anything. Yes, we just walk through the cycles. 

 

00:08:03:02 - 00:08:17:18 

Tara Scott 

Of course, they fluctuate. If you get an astronaut on day three, day 14 and day 21, you're going to be a completely different levels. Right? That's the nature of the menstrual cycle. So, even though these levels fluctuate, if you're properly trained, you know when to order things. 

 

00:08:17:18 - 00:08:25:16 

Tara Scott 

And so, this is a tool, whether it's any kind of traditional blood testing or functional testing. We have those tools to test people. 

 

00:08:25:22 - 00:08:42:18 

Mark Newman 

When it sounds like what you're saying is a pretty good sales pitch for the DUTCH Test in the sense that if you don't take care of your adrenal health, which, you know, thankfully 30s and 40s are not stressful at all for women who are working and dealing with teenagers and husbands and and all sorts of things in 

 

00:08:42:18 - 00:09:03:07 

Mark Newman 

life. But that having that more comprehensive look when you are peering into your hormones can be can be helpful in terms of making sure that you're you're looking at those things of primary importance, maybe the female hormones, but also, caring for those related but different things, being the androgens and the cortisol and and all of those things 

 

00:09:03:07 - 00:09:17:23 

Mark Newman 

which may not be as relevant today as as you're mentioning, as they may be when your ovaries are supposed to be done. And then you need a little bit more support from sort of the backup team, the backup quarterback they're making making hormones with with the adrenal production. 

 

00:09:19:01 - 00:09:34:17 

Mark Newman 

So, you're talking about the natural phase of life. And people use the term like, “aging gracefully.” And I think of like, well, “aging naturally, aging gracefully.” Like for you as somebody who's no doubt walked through this with So, many women like. 

 

00:09:35:02 - 00:09:38:10 

Tara Scott 

That, you're going to ask me how old I am and I refuse to disclose that. 

 

00:09:38:17 - 00:09:52:14 

Mark Newman 

That is not a question that is coming around the corner. No, I do not care. You're going to stop. Listen, which part of your 30s you're in is no business of mine, okay? So, we're not going there. But what is that like? 

 

00:09:53:04 - 00:09:58:00 

Mark Newman 

I guess. Would you differentiate between aging naturally and aging well? 

 

00:09:59:06 - 00:10:13:04 

Tara Scott 

Well, so, let me first give you, like, how I explain hormones, too, right? Because again, it's kind of like financially you're not there yet. But what happens is you thought this FAFSA form, right? And so, some kids cannot go to college without financial aid. 

 

00:10:13:11 - 00:10:30:11 

Tara Scott 

Right? Some people like will never get financial aid. Right. They just won't qualify because their parents make too much money. So, that's kind of like hormone therapy. Some women go through menopause and they don't need hormone therapy. Their bodies are living off of their savings and their adrenals are good. 

 

00:10:30:16 - 00:10:53:21 

Tara Scott 

So, when you talk about “aging gracefully,” really the fundamentals that we knew so, many years ago before, “Big Pharma,” is, you know, prioritizing sleep movement, an exercise, a clean diet without all the processed food and the endocrine disruptors, you know, and stress management, those four pillars are imperative no matter what. 

 

00:10:53:21 - 00:11:11:13 

Tara Scott 

Right. And so, I have seen women that are able to, “age gracefully,” really concentrating on those basics and not need hormone therapy. Now, you throw in there some genomics and problems with estrogen, detox and methylation. Yeah, you may or may not need hormone therapy. 

 

00:11:11:13 - 00:11:15:22 

Tara Scott 

So, that would be like that financial aid if some people cannot go to college without financial aid. 

 

00:11:16:18 - 00:11:35:13 

Mark Newman 

It's a great answer when you think about. There's a difference between, I think, “aging gracefully,” in one sense and just flat out being able to tolerate it. So, if you have a tolerable menopausal transition such that the patient is saying, hey, my quality of life in my own brain right now, is fine. 

 

00:11:35:19 - 00:11:48:07 

Mark Newman 

So, for that patient, are you concerned about the first thing my brain thinks of is bone health, right? Is like, how do you address the patient who is like, listen, I like the uncomfortableness of menopause. I'm totally fine with. 

00:11:48:23 - 00:12:00:12 

Mark Newman 

Are you digging further to say, hey, listen. But if in that situation you have like overt deficiencies of estrogen, testosterone, whatever we got, we got to take care of your bones. Like, how do you approach people like that that can tolerate it? 

 

00:12:00:17 - 00:12:02:08 

Mark Newman 

But like, how far are you digging into that? 

 

00:12:03:16 - 00:12:16:14 

Tara Scott 

So, it's going to be 20 years since the WHI this summer in July. And so, if you think about that, you know, the WHI was the study that got all the headlines about estrogen causing breast cancer and blood clots. 

 

00:12:16:15 - 00:12:31:20 

Tara Scott 

And to this day, people still believe that. We have so many more studies since then that have swung the pendulum the other way. We have so much more data. But if you pull I bet you if you pulled 10 gynecologists, I bet you eight of them would say hormones are bad. 

 

00:12:32:04 - 00:12:47:06 

Tara Scott 

Right. And that's that's really a tragedy. If you polled 10 family practice doctors, 10 would say don't take hormones. So, that's really, really a part of our problem. Right. So, the North American Menopause Society says, you know, based on what they're looking at is all the data. 

 

00:12:47:06 - 00:13:00:07 

Tara Scott 

And even if a lot of it is on oral estrogen, synthetic progestins, the benefits outweigh the risk of hormone therapy between the ages of 50 and 60. The benefits outweigh the risks unless you personally have a history of breast cancer. 

 

00:13:00:12 - 00:13:11:22 

Tara Scott 

The number one killer in women is heart disease. Number two is stroke. Number three is lung cancer. Number four is breast cancer. If you add up to three and four, you still don't equal the number of deaths from heart disease. 

 

00:13:11:22 - 00:13:26:16 

Tara Scott 

And we know that hormone therapy is positive. If it started at or around menopause within that first those early years, early start is heart protective. So, I personally do go through all of that with every patient I see. You know, what is your heart risk? 

 

00:13:26:16 - 00:13:50:14 

Tara Scott 

What is your bone risk? The death rate two years after a hip fracture is higher than ten years after breast cancer. Yet patients fear breast cancer diagnosis. Right? So, I believe that every patient deserves to have a hormone assessment and a personal evaluation of the risks and benefits as it applies to them and their family history. 

 

00:13:50:21 - 00:14:02:21 

Tara Scott 

And then they can make an informed choice to whether they take hormones or not. But they're not based on what I'm hearing on Tik Tok, what patients are telling me, they're not getting that chance. They're not getting that evaluation. 

 

00:14:02:21 - 00:14:14:19 

Tara Scott 

They're told, I don't prescribe hormones, which I think is fine. The doctor has a prerogative to prescribe or not prescribe, but that doesn't mean you don't you can't go to somebody else who does or you don't deserve to get that evaluation. 

 

00:14:15:11 - 00:14:27:13 

Tara Scott 

Like I said, just like everyone who wants to go to college fills out that FAFSA. So, it would be great to have everyone do hormone testing and then get an evaluation because, yes, you're right, heart disease is a killer. 

 

00:14:27:21 - 00:14:45:18 

Tara Scott 

And there was another study that was done by the Women's Alzheimer's Translational Research Board, and they took over 400 women on HRT, most of them were over 65. There was a 60% reduction in Alzheimer's and neurocognitive disorders, 60% reduction in Alzheimer's. 

 

00:14:46:12 - 00:15:03:13 

Tara Scott 

So, that's a crazy reduction. And it was the reduction was greatest women over 65 that took hormone therapy for six years. And it was greatest and the people who took it in a bioidentical form. Do you think if women knew that they would want to take hormone therapy? They want their brains, you know, but that's not 

 

00:15:03:13 - 00:15:17:04 

Tara Scott 

what they're hearing now. That was not a randomized placebo-controlled trial. That was an observational study. But it's still 400,000 people and there are only about 10,050 thousand in each arm of the WHI. It was not a huge number, right? 

 

00:15:17:12 - 00:15:29:19 

Tara Scott 

So, we have a lot of data and observational studies and I think like I said, I mean, So, that's kind of why I'm out like vocal on social media trying to educate people that, you know, you need to, you know, does everyone needs a hormone therapy? 

 

00:15:29:19 - 00:15:40:05 

Tara Scott 

Not necessarily, but you need to at least know what are your risks and benefits is kind of like financial planning, right? Does everyone go to a financial planner and forecast? Okay, I want to retire when I'm 65. 

 

00:15:40:05 - 00:15:51:03 

Tara Scott 

I want to have this much money in the bank. So, let's do this, this, this, this, and let's get my, you know, my low risk or my long-range planning assessment. Not everybody does that. Right. So, your retirement is different. 

 

00:15:51:03 - 00:15:59:04 

Tara Scott 

If you do that, you're going to have a better retirement just like just like hormone therapy. So, some people are planners and some people want to be preventive. 

00:15:59:18 - 00:16:13:20 

Mark Newman 

Right. So, I think that was a yes. So, everyone gets that message and I think you have a little bit of passion for it, which is awesome. And I think I think what's so important is, you know, maybe two out of 10 you said eight out of 10, which means two out of the 10 are getting it 

 

00:16:13:20 - 00:16:27:22 

Mark Newman 

right. But I think if you I think zero out of 10 actually know the literature on that. Right. And that's where I think people like you are really, really helpful for our industry to say, listen, I'm I'm one of the odd ducks that I'm in practice, but I also, got my nose in the literature. 

 

00:16:28:11 - 00:16:44:19 

Mark Newman 

And so, you can really help, I think, guide practitioners as they try to make good decisions because people get scared, you know, it's easier to just go back to that. What you might say is a conservative position, but it doesn't end up being because it's not conserving people's lives if they, you know, don't get one sort of 

 

00:16:44:19 - 00:16:56:18 

Mark Newman 

death, but they die from the most prevalent type of death, which is, again, a risk factor. You can modify by being smart about the way that you approach that, which doesn't mean everyone needs the same treatment. That's a point of individualized medicine. 

 

00:16:57:00 - 00:17:11:19 

Mark Newman 

Right. But to to know those risks and benefits. Well, I think well done. I think that's that's great. So, speaking of knowing and not knowing. Tell me about the patient who says, hey, I cycle a couple of times a year and maybe they're in that perimenopausal phase. 

 

00:17:11:23 - 00:17:18:15 

Mark Newman 

I would wonder what those patients like. What the heck is going on? Is that do you think that's real ovulation? Like what's going on with someone who just bleeds a couple times a year? Generally. 

 

00:17:19:13 - 00:17:21:16 

Tara Scott 

Do you mean if they’re close to menopause? 

 

00:17:22:12 - 00:17:25:21 

Mark Newman 

Yeah, not quite there. You know, late forties, early fifties, something like that. 

 

00:17:25:21 - 00:17:38:14 

Tara Scott 

I think if they're not operating every month, they're just ovulating sporadically, you know. So, they're just having a cycle here and there. And I think, you know, and it gets to be the point where think about again, that lifeguard, right? 

 

00:17:38:20 - 00:17:52:16 

Tara Scott 

So, and those old men. And then you've got all those men that are standing around the block that they've stood up right then there is a lot of times a little bit of estrogen that goes up, but then nobody decides to jump in. 

 

00:17:52:17 - 00:18:09:01 

Tara Scott 

Right. So, we still see when women are not ovulating. A little surge in estrogen, but no progesterone follow-up. Right. And so, women will say, I feel like I'm still cycling, but I didn't have the period because that's essentially what's happening FSH is like, hey, come on, who's going to swim? 

 

00:18:09:08 - 00:18:22:23 

Tara Scott 

And then you'll have that little increase. No ovulation. Nobody stepped up. Yeah. I mean, I don't want to swim now, so, they leave. Right. So, then estrogen goes down, And so, hence another plug for that continuous estrogen monitor. 

 

00:18:22:23 - 00:18:25:14 

Tara Scott 

Right? So, I mean, that would be really helpful as well. 

 

00:18:25:23 - 00:18:43:03 

Mark Newman 

Right on it. So, we've talked a lot about what estrogen is doing during perimenopause, which is interesting. And then progesterone, which is is fairly predictably going to going to die off between that healthy, premenopausal and post-menopausal when the ovaries just aren't making any anymore. 

 

00:18:43:03 - 00:18:51:07 

Mark Newman 

So, I'm assuming that you're more likely to give a woman progesterone than you are estrogen in that phase of the perimenopause, is that right? 

 

00:18:51:21 - 00:18:52:15 

Tara Scott 

That's true. 

 

00:18:52:19 - 00:19:12:00 

Mark Newman 

So, then when I think of progesterone, I think of typically oral, vaginal, transdermal on the skin. So, how do you sort through what what do you do in your practice? Like what's what's typical for a woman who's, you know, maybe ovulating but has insufficient progesterone and her estrogen levels are plenty high where you need to support that 

 

00:19:12:00 - 00:19:13:02 

Mark Newman 

Like, how are you approaching that? 

 

00:19:14:05 - 00:19:28:18 

Tara Scott 

So, the most common form is going to be oral. We have FDA approved oral micronized progesterone in generic form and then name brand as well. So, we have a lot of data on it, a lot of studies that have been done that we know it's safe and we know the doses. 

 

00:19:28:18 - 00:19:42:21 

Tara Scott 

But the downside is we only have two doses on. So, that would be the most common use. And we know that there is a estrogen and progesterone receptor in every cell of the body. We know there's one in the breast because that's a normal evaluation for breast cancer. 

 

00:19:43:06 - 00:19:59:07 

Tara Scott 

So, to give it orally you're getting systemically, you're going to get it to the breast, you're going to get it into the uterus, you're going to get it to the brain, bone, everywhere because it's going to go into the system, which traditionally we think of vaginal. 

00:19:59:07 - 00:20:12:15 

Tara Scott 

And I know there are some some prescribers that use that as systemic, but vaginal is local therapy. I don't believe that we have studies, and I don't know, do we have studies that it's going to protect the brain? 

 

00:20:12:15 - 00:20:31:06 

Tara Scott 

Do we have studies that it's going to protect the bone, the heart, because it was derived for fertility support in reproductive assisted reproduction, you know, because when you do IVF, you're essentially popping a needle in the corpus luteum when you are extracting the eggs for IVF. 

 

00:20:31:06 - 00:20:49:23 

Tara Scott 

So, you have to give them IM progesterone. And then after you get vaginal progesterone because until that 13 weeks, you need progesterone support that embryo. So, that's how vaginal sources came about, is under the guise of fertility where the focus is the uterus. 

 

00:20:50:09 - 00:21:06:15 

Tara Scott 

So, again, I, I have not done the literature to see do we know that there is breast protection with vaginal progesterone? I don't know. Is there part benefits? I don't know. I mean, Dr. Saltio probably does know that data better than I do. 

 

00:21:07:09 - 00:21:28:08 

Tara Scott 

So, that's my concern. Now, when you're talking about topical, again, there aren't a lot of there isn't a lot of data because it's not funded by, “Big Pharma.” Helene Leonetti did a couple of studies on topical progesterone, which lot of first first study that was looking at markers like CRP and cardiometabolic markers, seeing that progesterone did 

 

00:21:28:08 - 00:21:44:18 

Tara Scott 

have a favorable effect. And I believe she looked at both transdermal and oral. She also, did a second study looking to see does topical progesterone really provide endometrial protection? And she did find that there was no increased risk of any endometrial hyperplasia, and they did biopsies in those patients. 

 

00:21:44:18 - 00:22:02:06 

Tara Scott 

But there was a small number, right. So, we do we have any large studies that say topical progesterone protects the endometrium from the effect of estrogen. And then again, do we know about the breast? Because I can I can pull the studies that show unopposed, even though this is not also, standard of. 

 

00:22:02:07 - 00:22:14:01 

Tara Scott 

Here. I can pull studies that show that unopposed estrogen increases the risk of breast cancer, even though the WHI in one study in 10,000 people did not show that after five years CEE increased the risk of breast cancer. 

 

00:22:14:04 - 00:22:24:10 

Tara Scott 

The nurses health study that had 122,000 people did show somewhere between a 20 to 40% increased risk in breast cancer in estrogen only besides the WHI. 

 

00:22:24:10 - 00:22:28:17 

Mark Newman 

That was conjugated equine estrogen also, or that was something different in that one. 

 

00:22:29:06 - 00:22:36:07 

Tara Scott 

In the nurses health study. I think it was not just CEE might have been others but I'm not sure but estrogen alone. 

 

00:22:36:18 - 00:22:38:23 

Mark Newman 

Right without progesterone or progestin. 

 

00:22:39:09 - 00:22:51:21 

Tara Scott 

So, the issue is that standard of care is estrogen alone after hysterectomy, which I'm vehemently opposed to. Right. Because, you know, I don't operate anymore. But when I took the uterus out, we didn't also, take the breast out. 

 

00:22:51:21 - 00:23:12:09 

Tara Scott 

And I'm pretty sure they don't do that now either. So, you're giving all those women that have breasts unopposed estrogen. Right. So, so, the dosage form that we have the most data on is also, what is accepted in my world is that once you introduce any kind of estrogen, you really ought to be giving oral progesterone because 

 

00:23:12:09 - 00:23:21:17 

Tara Scott 

we know that is going to protect the uterus. And again, I believe it's going to get to the breast. Now I don't know. You might know or there's. 

 

00:23:21:19 - 00:23:39:00 

Mark Newman 

Well, I don't I don't think outcome studies have been done with vaginal progesterone. But if you look at serum, progesterone levels will actually get higher with vaginal than with oral. So, I would say there's great promise in that, but I don't think that it's been studied and it's been studied as it relates to the endometrial. 

 

00:23:39:00 - 00:23:50:22 

Mark Newman 

Right. 40 milligrams. 100 milligrams. You put that on vaginally, meaning, you know, the top third of the vagina so, that you get that uterine first pass and the uterus is just flooded with progesterone. Then you ask the subsequent question, well, what's in the breast? 

00:23:50:23 - 00:24:03:11 

Mark Newman 

And I think the best surrogate you would have for that in that situation, I mean, based on the data we have now, would be serum, which bumps up, you know, up and over ten and 12, you know, with a normal range of 4 to 20 or whatever. 

 

00:24:03:11 - 00:24:18:02 

Mark Newman 

Like you get up into that range for a big chunk of the day with those types of doses. So, I think you could make some assumptions, but to your point, no one's actually done outcome studies that I'm aware of, and Dr. Saltio would always know better than I do, but I don't think that's been done. 

 

00:24:18:14 - 00:24:32:19 

Tara Scott 

There was a study in 1995 that Chang did in fertility and sterility. They put topical progesterone actually on the breast tissue and did biopsies. So, you know, we know that with a topical, but that's directly at the tissue that it does cause. 

 

00:24:33:01 - 00:24:44:14 

Tara Scott 

It prevents breast cell hyperplasia. So, we do know that that it that has that same effect. But the question is, is it getting there? So, if you're doing something in the vagina, you've got all that pelvic vasculature, right? 

 

00:24:44:20 - 00:24:55:10 

Tara Scott 

And so, that's going to put it into that circulation and can reflect serum levels. But does that mean that it's actually gone to the rest of the brain or does that mean it's just been picked up into that circulation? 

 

00:24:55:15 - 00:24:56:06 

Tara Scott 

I don't know. 

 

00:24:56:06 - 00:25:08:04 

Mark Newman 

Yeah. I mean, I think you could make some assumptions. And I think with Chang, if all you were worried about was the uterus and the breast, then you'd have, you know, some rationale between of maybe putting it on the breast. 

 

00:25:08:04 - 00:25:22:02 

Mark Newman 

But if you also, have benefits in the brain and elsewhere, then you do want that systemic exposure. And the most studied, as you said, is oral for getting a progestin, a progesterone effect, you know, all over the place. 

 

00:25:22:02 - 00:25:25:13 

Mark Newman 

That's a good way to go. So. Well, that's helpful. Thank you. I, I appreciate that. 

 

00:25:25:13 - 00:25:36:14 

Tara Scott 

So, and also, as an aside, as a woman, I'm not going to want to put something on your vagina, be drippy all day. I'd rather just take a capsule. Right. And so, it's just not super practical. 

 

00:25:36:20 - 00:25:53:04 

Mark Newman 

I will take your word for it, but I'm sure I mean, we we we built our testing, particularly with estrogen and testosterone, to be useful for monitoring vaginal. We actually are looking to take our vaginal estrogen data to NAMS next year. 

 

00:25:53:04 - 00:26:11:13 

Mark Newman 

That's my main target because it shows that with 0.04 (and we're getting off topic) 0.04 of estradiol, you're actually up and out of that post-menopausal range which shows little tiny doses on those mucosal membranes are getting presumably systemic exposure of stridor, which is pretty interesting. 

 

00:26:11:13 - 00:26:23:18 

Tara Scott 

Well, that's what that study when they looked at when Vagifram used to be 25 micrograms, that's why they lowered the dose because after one week with CEE and seven days, they were getting systemic levels right after seven days. 

 

00:26:23:18 - 00:26:34:15 

Tara Scott 

So, there's that that study that shows that, too. So, you're right. I mean, that's a very interesting, you know, because we traditionally don't oppose vaginal estrogen, you know. Right. 

 

00:26:34:17 - 00:26:51:10 

Mark Newman 

Well, the the term low dose, I think, is a bit of a misnomer because they did a study actually on I was just looking at on melatonin so, random. But they looked at it thoroughly enough to show that when they put it on the skin, they got about 10% in and darn close to 100% when they put 

 

00:26:51:10 - 00:27:02:21 

Mark Newman 

it on vaginally. And so, people talk about 0.2 milligrams of estradiol as if it's low and it is if you give it in other routes of administration. But if you can get it on a mucosal membrane again 

 

00:27:02:22 - 00:27:16:09 

Mark Newman 

0.04 from our study was enough to actually get it up and into a range where you might expect bone mineral density not proven, but you might expect bone mineral density to increase and and the like, meaning systemic exposure. 

 

00:27:16:09 - 00:27:33:01 

Mark Newman 

So, and that's an interesting HRT topic for another day that will will save some of those rabbit trails for that. But the the tour through perimenopause has been very helpful. So, I really appreciate your expertise and thank you for taking the time to share with us today. 

 

00:27:33:01 - 00:27:34:02 

Mark Newman 

So, we appreciate it. 

 

00:27:34:21 - 00:27:35:12 

Tara Scott 

You're welcome. 

 

00:27:36:11 - 00:27:49:20 

Noah Reed 

Dr. Scott, thank you again for joining us on part two of this two-part series. And thank you to all of our listeners who joined. Next week will be joined by Dr. Bethany Hayes to learn more about progesterone. 

Outro 

00:27:50:01 - 00:28:09:07 

Noah Reed 

You won't want to miss this high-level understanding of an important and complex hormone. If you have any questions, please send them to podcast@dutchtest.com. I know you've heard me say it before, and as a new podcast we'd really appreciate it if you liked, subscribed, and shared that you listened to us on social media by tagging 

 

00:28:09:07 - 00:28:14:19 

Noah Reed 

our Instagram account @dutchtest and let us know what you loved. I'm Noah Reed. Until next time.