Gennev Chief Medical Officer, Dr. Rebecca Dunsmoor-Su was recently interviewed by David Stewart, host of the SuperAge podcast. The podcast episode “HRT, Estrogen and Menopause, New Scientific Findings with Dr. Rebecca Dunsmoor-Su” is packed with valuable information on HRT and women’s long-term health.
In part one of five transcripts from the session, Dr. Rebecca provides a thorough view of a woman’s hormonal journey, and offers insight on why hormone testing is not always necessary. Please listen to the full podcast by visiting SuperAge.com.
David: Take me through a woman's hormonal journey.
Dr.Rebecca: Well, I think, it's good to frame how we talk about women's hormones with a background of what are they for. So, this is nota value judgment but our hormonal journey is based on reproduction. We are after all biological animals. So, the transitions that the ovary goes through is all based on reproduction and reproductive potential. When you are born, you're born with all the eggs you will ever have. In fact, they start to die off immediately. So, in utero, there are millions of eggs. By the time you're born, they're hundreds of thousands of eggs. By the time, you get to puberty, they're about 10,000 viable eggs. At puberty, you start to cycle and release those eggs one by one, and a woman will release approximately three to 500 eggs over her lifetime before they're all gone, and she starts to go through menopause.
How do hormones play into that? As you start to go through puberty, the brain starts to pulsate with pre-hormones that signal the ovary to develop eggs. Those pulsations tell the ovary to make estrogen, which makes an egg grow and mature, and then, mid-cycle when that egg is matured, and it starts to put out hormones of its own. Then the brain has a pulse of what we call luteinizing hormone, which tells you to release that egg and then, progesterone spikes. So, throughout a woman's cycling years, she's getting in the first half of her cycle or the first approximate two weeks getting a sort of a buildup of estrogen, and then, the second two weeks, a build of progesterone, and if she does not fertilize that egg and implant it then, everything drops off at the end, and we get a bleed. So, the drop of estrogen, progesterone at the end of the cycle causes a woman to menstruate.
For the first 20 years or so that a woman is cycling, those eggs are good, they're viable, they respond to the brain, the hormones are nice, and even for most women, there are conditions where they aren't. But in general, that's a nice even cycle. Then, we get to generally, woman's 40s. This can happen earlier in some women and later in others. The eggs that are being recruited just aren't discrete, as we like to say. They're a little older. They don't listen as well. So, the brain has to pulsate more.The hormone spikes have to be higher to get that egg out. What we often see int his time, which we call perimenopause is that, women are still cycling and having bleeding, but it might not happen exactly right on time. Or, she might have a lot more symptoms surrounding it because the hormone spikes are so much. bigger. And then, as we run out of eggs, once there are no more viable eggs to respond to that brain signaling, then, our hormone stopped being produced by the ovary, progesterone and estrogen that is, and our periods stop. And that's called menopause.
It'd be nice if that all just happened very smoothly. Of course, it doesn't. The last couple of years of perimenopause can be very erratic. In terms of bleeding, women can have periods every three to six months, they can be very heavy because of these huge spikes of hormone, and then we label it menopause or the end of cycling when you've been 12 months without a period or 12 months without those hormones. What I typically tell my patients is that while your estrogen and progesterone go down with menopause and you're no longer making those from the ovary, you do continue to make testosterone at the same rate. That does not go down with menopause. Both for women and for men, our testosterone slowly decreases over the course of our lifetime from a peak in our 20s until our 80s. But there's no sudden change in testosterone at menopause. If anything in fact, we see a little bit more of it as women. That's why we start to get chin hairs and acne. In the menopausal transition, we're seeing a little more of our testosterone and that's because one of the things that having circulating estrogen does is, it makes a molecule in our blood called sex hormone binding globulin go up, and that holds estrogen and testosterone bound in our blood so we can't read it. When the estrogen goes down, so does the sex hormone binding globulin, but the testosterone doesn't. So, we actually see more of our testosterone.
David: Okay, and then going forward, these levels stay the same in post menopause for the duration of one's life?
Dr.Rebecca: Yes. After menopause, basically, there's a little bit of estrogen floating around because there are other things besides the ovary that make a little bit. So, our fat cells make a little estrogen and our adrenal glands make a little estrogen. We basically have no progesterone after the menopause because there's no use for it. The whole role of progesterone in a cycling woman is to stabilize the uterine lining to inflate the pregnancy. So, that's not happening anymore. And then, like I said, the ovaries and the adrenal glands continue to make testosterone at a low level through our menopause.
David: Why would someone go into something like hormone replacement theory? Actually, let's start with what is HRT?
Dr.Rebecca: Hormone replacement therapy is the replacing of the endocrine factors, the estrogen and progesterone that have gone missing from a woman's body. What I tell all my patients is that there's a lot of chatter around hormone replacement therapy. A lot of fear mongering, a lot of only I can do this for you the right way. In reality, hormone replacement therapy can be done very safely for most women with your physician, and it should always involve FDA regulated products because that way we know exactly what dose we're giving you and can adjust appropriately.
David: Well, let's talk about dosing. So, are you doing like hormone levels and like somewhere you want to match? How do you do this?
Dr.Rebecca: The answer is no. When a woman comes to me in menopause and she's symptomatic, I don't need to do a hormone level test because I know what it is. It's very, very low. There's nothing that a blood test is going to tell me that her symptoms don't tell me. A thorough history and exam is much more cost effective than a whole bunch of lab draws that aren't going to tell me anything different. So, we treat based on symptoms. We don't titrate hormone levels to a particular lab draw because for example, in a normally cycling woman who's pre-menopausal, the normal range of estrogen is between about 12 and 200.
Dr.Rebecca: I don't know where to aim in their replacement. I don't know when she's going to feel better. Some women feel better at estrogen of 20 and some people it takes to 100. So, doing a level doesn't tell me if she's better. She tells me if she's better. And that's how we adjust hormone therapy.
David: Let’s say, for instance, I was a woman and you did a hormone draw on me at 30, and then, I come to you at 48, I'm symptomatic and would having this dot in this data point saying like, "Here, everything was happy at this level," would that be something you'd aim for?
Dr.Rebecca: No. So, here's the nifty thing because you're saying, I got a blood drawn you at 30. But did I get it in the first week of your cycle- -the second week of your cycle, the third week of your cycle, and the fourth week of your cycle? All of which have different hormone levels for women. All of those are different estrogen levels. So, we feel fine throughout it. So, women feel fine in it within a huge range of estrogen.
David: If I have a low vitamin D, I mean, I know like what my vitamin D level is, I know what it should be, and I know how to change it. I got a data point,I got a target, I know what to do. How do you do this?
Dr.Rebecca: I talk to women. I talk to them and ask them how they're feeling and we treat their symptoms. Because that's really the only marker of when we've gotten to the point where a woman feels better - the marker of us using enough estrogen.
It’s never too soon or too late to be informed about menopause symptoms and treatments. And finding a physician who specializes in menopause can help you find relief as well as identify strategies to protect your bones, brain, heart, and body.
Continue to part 2, and learn about the benefits of estrogen, and if HRT is right for you.
Listen to the full podcast episode at SuperAge.com.
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