What if you had the power to manage your hormone-related symptoms, from brain fog to hot flashes, more effectively? Join us as we navigate the complex world of hormones with our medical director, Dr. Bastion. In the first part of our conversation, we take a deep look at the myriad symptoms both men and women can experience, the fluctuating nature of hormone levels, and the importance of self-care during times of stress.

Ever wondered how chronic stress and aging can disrupt your hormones? We zero in on this fascinating correlation, highlighting how it can lead to weight gain and several other health concerns. This episode also dives into the often misunderstood realm of perimenopause and menopause, debunking common misconceptions, discussing symptoms like sleep disturbances and irritability, and outlining the risks of hormone replacement therapy.

Hold tight as we scrutinize various hormone replacement options such as testosterone, HCG, and DHEA, their potential side effects and the crucial role timing plays in therapy. We shatter some myths surrounding testosterone and prostate cancer and reveal the truth about the effectiveness of bioidentical versus synthetic hormones. As we close off, we delve into the implications of hormone health and performance enhancement, delivering a comprehensive guide on fertility, sexual health, and navigating hormone replacement therapy. Listen in for a captivating conversation that empowers you to be the boss of your body.

Lisa Krzyzewski: 0:00
Hi everybody, welcome to AEON Future Health podcast. Today I’ve got our medical director, Dr. Bastian, with me and we are going to be talking about hormones. I’m going to start with what we all could be experiencing, that’s, hormone related. What are the symptoms? What are the things that keep you up at night, maybe literally and then dive into what are some of the treatment options available and especially looking at all this through the lens of longevity medicine. So stick with us. We’re going to talk about men’s hormones, women’s hormones and all things hormone. So let’s just dive right in. Yeah, let’s do it. I think there’s a lot of question around hormones. We’re definitely reaching I’m reaching that age I shouldn’t say you are, but we know hormones can go out of balance at any time for all kinds of reasons. But what are the things that people should be looking for and what are the symptoms? How do we know that hormones are not affecting us the way they should?

Dr. Jonathan Bastian, MD: 0:59
Sure, yeah. So look, it’s a very different physiologic change that men and women go through right. Women, of course we know, go through perimenopause and menopause. Men have more of the sort of gradual, stepwise decline that doesn’t always get picked up. So for men it’s really like these initial symptoms. The common things that I hear coming through are like I just don’t have enough energy, I’m feeling more irritable. Many times there’s a bit of brain fog. Now the ones that testosterone especially, are most notably for, like, I’m having weaker erections, my sex life’s not as good, I don’t have the same libido, and although you can, that’s probably what they’re primarily the treatments are primarily aimed at. There’s a whole host of other things, ranging from mood to muscle mass, to bone mass, to sleep, that often get missed under the radar.

Lisa Krzyzewski: 1:59
And that’s just men.

Dr. Jonathan Bastian, MD: 2:00
That’s just men. On the flip side, women really have like a tremendous number of symptoms and it really depends on what stage of life that you’re at, right. So we have so many women late 30s, early 40s who feel like, oh, this must just be the stresses of life. Maybe they’re having more anxiety, maybe they’re not sleeping as well, maybe they’re beginning to have hot flashes and they don’t know how to place it, when in fact, like that can easily be related to progesterone and estrogen. Similarly, as women enter into menopause, some of those symptoms get even more profound. So, you know, we talk about hot flashes or vasomotor symptoms, right? We talk about vaginal dryness. That can occur with loss of estrogen as well. And then again, like you hear, we’ve got lots of patients who have come through. They’re like look, I’m angry at my partner all the time I can’t sleep, and while that might be related to just the day to day, the wrong partner. You know I think oftentimes that can be related to back to progesterone and estrogen as well. And you know, we’ve even seen, we’ve seen patients who have, like, completely responded with HRT and I think it’s probably saved the relationship. So, yeah, it’s a topic I’m excited about and passionate about and I think there’s lots to learn and discuss.

Lisa Krzyzewski: 3:29
I literally had a girlfriend ask me this morning well, how do I know if I’m in perimenopause?

Dr. Jonathan Bastian, MD: 3:35
Yeah, yeah, well, look, it’s going to be different for everybody, but some telltale signs to watch out for is. Number one is in the second half of your cycle, you know the two weeks leading up to your period, are you finding that you’re having more irritability, more difficulty sleeping? Those are really common ones, are. Is your cycle beginning to change, where either it’s becoming less frequent or it’s becoming much heavier during the actual cycle period? Then other ones are a bit nondescript, like some of them can be related to just a general fatigue and low mood, irritability that just sort of you can’t quite place. So you know, it ends up being a bit of a bit of a science and also a bit of an art, and it’s really individualized to the patient.

Lisa Krzyzewski: 4:22
Half of us don’t even know based on our cycle anymore. You wouldn’t. You might not know how many of us out there will maybe do, but there’s so many great ways right to prevent the symptoms of monthly cycle whether it’s an IUD or just good birth control and so we don’t have a clue sometimes what’s going on. So like what do you tell those women that are like I don’t know when my cycle is?

Dr. Jonathan Bastian, MD: 4:49
Yeah, look, we see that a lot. And the other flip side of this coin is women always come in saying like, look, I want to get tested for my hormones because I know something’s wrong. And the truth is, is that just be? Whether or not you have an IUD or you’re on birth control or not, women’s hormone levels shift not just by the phase of their cycle but also just day to day. So actually finding a number that really is diagnostic of that is very difficult to do, except for some specific circumstances. So the truth is is like you really have to base it on your symptoms. There’s a little bit of trial and error with some different types of HRT that we can chat about and see if that leads to improvement. We’ve got lots of women who have sort of come in with an IUD or their cycles are just really irregular and they can’t track it and you’re like, well, let’s give it a shot. And they come back a month later and many of them feel better.

Lisa Krzyzewski: 5:56
So I love that. So starting to treat just based on symptoms instead of lab numbers exact numbers.

Dr. Jonathan Bastian, MD: 6:03
Yeah, you’re trying to treat the patient so, and that’s a great place to start.

Lisa Krzyzewski: 6:07
I don’t want to let go of this one because I think your spot on. Women work hard. We’re stressed, we’re caregivers. We kind of put ourselves last sometimes and put up with a lot of discomfort.

Dr. Jonathan Bastian, MD: 6:19
Yes.

Lisa Krzyzewski: 6:20
And so recognizing something as a problem that’s not just due to everyday life can be really hard.

Dr. Jonathan Bastian, MD: 6:27
Yeah.

Lisa Krzyzewski: 6:27
And the example that for me was. I started to have more anxiety and I thought, oh, it’s well, it’s because I started a business in the middle of COVID. Of course I’m going to have anxiety, but, as it turned out, a little bit of progesterone huge difference, right, it’s sleeping better and I wouldn’t have actually known that, except that I’m lucky enough to work in a clinic with doctors who grab me and said let’s check, yeah, so what do we do about this? When do you get checked? When should you talk to your doctor?

Dr. Jonathan Bastian, MD: 7:04
Okay. So before we dive into that, I just want to just point out that women suffering through symptoms of perimenopause and menopause is like it’s not just, oh, an individual thing we should fix this. It’s also like a systemic equality thing. So there’s this big study that came out of the UK that looked at women entering into menopause who were not treated, who had vasomotor symptoms. So hot flashes, anxiety, that whole cohort of symptoms, and 11 to 14% left their work because they couldn’t manage the symptoms. So when we talk about this, it’s not just like, hey, let’s get checked out. It’s like no, this is a big deal, because those women then end up having maybe their relationships aren’t as strong, maybe they don’t have the same financial security. It’s a big deal all the way through. So the way that I think about this if we’re backing it all the way up is women need to be aware that these symptoms exist. Perimenopause and menopause are things that should absolutely be treated, and then they need to be thoughtful of their own bodies and their own symptoms. So, for example, in the first half of your entering into perimenopause, your progesterone levels go down and the reason that you feel anxiety and you’re not sleeping well is progesterone breaks down into something called pregnatalone. Pregnatalone then breaks down into something called GABA. Gaba is a relaxing hormone that helps you to feel less anxious and also sleep better. And lo and behold, when you’re sleeping a little bit better and you’re not quite as stressed and anxious, all of a sudden, all of the other things that are always going on in many of our patients’ lives just seem a little bit more manageable. And then, as women enter into menopause and those estrogen levels begin to drop off as well, that’s when we really start to notice some of the big changes. And that’s really where you want to be aggressive in terms of reviewing whether or not hormone replacement therapy is a good place for you, because it’s not just vasomotor symptoms, it’s not just the hot flashes and the irritability. There’s a lot of morbidity that comes with menopause that we should be really aggressively treating, and it’s things like changes with your cardiovascular profile, increased risk of Alzheimer’s and dementia, increased risk of osteoporosis you know, testosterone goes down increased risk of sarcopenia or muscle loss Certainly, we just touch briefly on the mood thing, but increased symptoms of anxiety and depression. So I think all of those are big time targets that need to be evaluated, and I think it really just starts with women being aware that there’s lots of treatment options. Now. It’s not 20 years ago where we had two things that could help. It’s very individualized and you can manage your risk and it needs to be just a conversation about what symptoms are you having, what are we trying to treat, what treatment options do we have and then what’s your tolerance for risk in knowing versus not knowing. And if you can put that all together and provide women with just sort of lay that out for them, then you can. I think you can make a choice and, more importantly, I think you can make a really big difference.

Lisa Krzyzewski: 10:38
It’s just a matter of getting us to do it, because you know, you kind of feel like, oh my gosh, I just got old when you have to go on HRT. But I don’t actually think that’s the case. And one of the things that I’ve seen a ton of on Instagram lately because that’s a great source for good medical information is younger women talking about I think it’s PMDD and that’s that fluctuation, this kind of severe fluctuation in mood that happens just with a regular cycle and it sounds like it can happen at any age.

Dr. Jonathan Bastian, MD: 11:15
Is that right? Yeah, so perimenopausal depressive disorder is kind of the extreme example of what we’re referencing Right and again, like the classic treatment for that in the past has been oh you know, put them on, put them on on an antidepressant. But the truth is it’s a hormonally mediated set of symptoms and if you can replace those symptoms in a way that is both safe and effective, you can. You can improve and mitigate a lot. So I think the key is is women just need don’t tough it out, okay, don’t just assume that it’s a normal part of aging Get checked and, if appropriate for you, get treated.

Lisa Krzyzewski: 12:04
And I get the question a lot of when do you start this? And I’m always saying you start it when you feel the symptoms, like why put up with a lot of? This when you can influence it. Is that fair, or are there ages that you have to watch for? I mean, let’s myth bust a bit, because I think there’s been a fear around estrogen, especially for women.

Dr. Jonathan Bastian, MD: 12:26
Here’s what I would say. So, just touching on progesterone to start, okay, um, progesterone is typically the first hormone that women will go on when they’re having symptoms of perimenopause. Okay, but perimenopause, that can be something that starts at 49 or 50, but that can also be something that starts for many women in their early thirties, right? So, really, that’s why it’s so important to have an understanding of your symptoms and just being aware of the treatment options. Um, progesterone is incredibly safe. It’s incredibly well tolerated and if all we’re doing is balancing, bringing you back up to where you probably should have been, you know, when, in a premenopausal um state, the there’s there’s very little evidence to suggest that there’s any serious downside, downstream harm, okay, um, with the exception that you know, sometimes progesterone can also be in the same way that it helps to settle anxiety and it helps to improve sleep. Well, if you do that too much, it cannot sort of be a bit of a depressing cause. It can. It can down, regulate your whole whole system. So we’ve got to be careful of that. Now, estrogen, I think, has perhaps got the worst wrap of any of any medication or hormone that I know of, and, um, maybe we’ll save the real details for why it came to be this way, but ultimately there’s. There was an initial paper that came out early in 2003, 2004, that thought that estrogen increased your risk of breast cancer. Yeah, and the the truth is, and the headline was estrogen increases breast cancer by 24%.

Lisa Krzyzewski: 14:15
Okay, and didn’t they stop the study, even they stopped it early.

Dr. Jonathan Bastian, MD: 14:20
But the truth is is that was a relative risk ratio, so that was a that was instead of instead of being four in a thousand women that got breast cancer, it was five, so there’s a one in 1000 risk of breast cancer. That’s increased. There was no change to survival because those women were then treated and and that type of breast cancer has a tendency to be um more treatable. But, more importantly, that uh and and lastly, we don’t even use that same type of estrogen anymore. We use we use bio identical uh hormones to support that. But that one statement, that one sentence um essentially turned off an entire generation of physicians from prescribing it. Uh and led to so many women entering into menopause, not just having to deal with the symptoms of menopause, the vasomotor changes, the irritability, the brain fog, um, but also, therefore also had to have all those downstream consequences, the osteoporosis, you know the, the changes with cardiac history, the changes with dementia, et cetera. So I think the estrogens that we use now the most common one is called um estradiol. Uh, it is identical to the same type of hormone that your body absorbs and on top of that, usually it’s applied topically, either as a gel or as a patch Now, the old estrogens from 20 years ago that were made from like pregnant uh, horse, horse yeah pregnant, pregnant horse urine. Yeah yeah, that stuff was also, uh, orally ingested. And when you have an estrogen get absorbed orally, it has to go through the same um, has to go through this thing called first pass metabolism, where it gets absorbed by the liver first and filtered out. Now the trouble with that is when you do that you also sort of acted, activate these, these pro clotting proteins that increase your risk of blood clot. So, similar to what you’d expect with with women who are on birth control, there’s a small subtle increase there too. So you compare these old studies where we were using synthetic estrogen and progesterone, where we were taking them orally, um, and had a true increase, but a very, but you know, no change to the to morbidity and mortality. You compare that to what we have today, which is bio identical hormones that seem to have a much safer safety profile, Um, and are applied topically. I just don’t think the there’s no evidence that I’ve seen that suggests the risk benefit ratio particularly favors risk, unless you have a really strong history of breast cancer, both personally and within your family.

Lisa Krzyzewski: 17:20
And I want to definitely dig in with you on what we’re doing now, like what treatment looks like. But before we go there, let’s talk a bit about what causes this. You know problems.

Dr. Jonathan Bastian, MD: 17:32
Sure.

Lisa Krzyzewski: 17:33
And we can easily say, oh, you age and that causes hormonal imbalances. But that’s that’s not in fact true. I mean, there’s younger people that get hormone imbalances. There’s more profound ones that happen at, maybe during perimenopause, but it shouldn’t have been that bad. Like what are some of the things that cause hormonal disruption and hormonal Sure, yeah, yeah. Disregulation.

Dr. Jonathan Bastian, MD: 17:58
Well, look, let me. Let me start by saying this Okay, so hormonal balance is so much more than just the hormones. We’ve talked about progesterone, estrogen. We haven’t touched on women’s testosterone. But also interesting, yeah, it’s. It’s your cortisol level, it’s your thyroid and, frankly, your body was never really intended to keep producing these hormones forever. Right Up until the early 1900s. Our lifespan was roughly 50. And then, since then, with the advent of of different medications and antibiotics, things are really improved. But your body’s endocrine glands, or exocrine glands, your hormonal manufacturers, they were never really intended to last 100 years. So you end up having this very intricate play of things that happen. So your cortisol levels are high. That chronic level of stress is going to impact how your body both makes hormones and how they respond to hormones. Your, if you look at just in general, as you age, in men and women, those, those processes begin. You know the cells that physically make the hormones. They just don’t function quite as well. They don’t, they don’t read information from the other signaling processes quite as well. Sometimes they day off that kind of thing. And so you know, when we’re talking about women’s health and women’s hormones, to keep it focused, yeah, like your, your reproduction cycle slowly, slowly lose it like, goes down as your ovaries stop stimulating stop, you know, stimulating follicles to be released, your estrogen jumps up in that sort of first perimenopausal state and then, as it continues to go down, eventually the whole system sort of settles out and shuts down and you end up with decreased levels of progesterone, decreased levels of estrogen and decreased levels of testosterone. And so what? What people kind of assume to be a natural part of aging is really this you know, this organ system, this intricate system for for fertility and reproduction, slowly beginning to fail. And if we’re not going to support that and we’re not going to address it, yeah, like it, it. It’s no wonder that that women are sort of struggling along with these symptoms, because there’s a part of them that is is beginning to get downregulated. That really needs support. And if anyone has has ever had a thyroid issue, nobody bats an eye if they go on thyroid medication. Why is that any different for for our sex hormones?

Lisa Krzyzewski: 20:41
It’s so true. This is a bit, maybe chicken and egg that you can help me with. One of the symptoms that we all notice is waking, and it’s often blamed on hormonal changes, and I mean I’ve kind of wondered is it you gain weight and therefore you your hormones dysregulate, or do your hormones dysregulate and therefore you gain weight? What’s going on there?

Dr. Jonathan Bastian, MD: 21:05
The first thing is your hormones do have an impact on weight. Okay, if you are chronically stressed and your cortisol levels are high, that is going to spike your insulin and over time, that elevated insulin is going to lead to weight gain. Now there’s some common myths about sex hormones, like oh, if I go on progesterone, I’m going to gain weight. Well, kind of true, I mean. Occasionally you can initially get fluid retention, but that typically settles out and the evidence does not support the progesterone is linked to weight gain. Now, interestingly, as women begin to enter into menopause and their estrogen levels drop for sure there’s a component of that that also triggers weight gain. It’s common to gain weight and menopause, and if you catch it early enough and you’re already on transdermal estradiol, that can help prevent some of that weight gain from coming on. The flip side of this is there’s a whole variety of other things going on with your body other hormones that help to balance your hunger cues, how full you feel, how satisfied you feel after eating, and I feel like those can change regardless, and that can be through your sex hormones, but it can also be as you age, so as you enter into menopause for example, your basal metabolic rate how much food you actually need to eat might go down, but at the same time, you have these same hunger cues that are saying keep feeding me at the rate that I was at before, and that’s a common signal as to why you can see weight gain through menopause. That’s beyond just the estrogen.

Lisa Krzyzewski: 22:54
Okay, so let’s pick on guys a little bit then too on the dad bod side of things. What is dad bod all about? Is that hormone related?

Dr. Jonathan Bastian, MD: 23:03
Yes, yeah, for sure. So here’s the key thing about, about men’s health and the quote unquote dad bod. So the timelines vary, but we’ll use 40. After about age 40, you begin to lose one to two percent of your testosterone production every year. Okay, and certainly by age 50, many men have lost up to 40% of their latex cells, the cells that actually produce testosterone. And so eventually what accumulates is like if you don’t have enough testosterone, then slowly you lose muscle mass and frankly this goes for both men and women and then, because you don’t have enough muscle mass, that often gets changed into fat. What does fat do? It takes that testosterone and produces more estrogen with it, and so you end up, if you’re, if your estrogen runs really high. Now you start to see these things adipose tissue, you know, more tissue around the breast, things like that and so the typical dad bod ends up often being a testosterone dysfunction. But the flip side that I will say to that is like what else happens during those formative years. Well, often men have kids running around. Oftentimes they’ve got, you know, a full time job that they’re trying to manage. There’s a lot of responsibilities that make eating more poorly and getting to eating more poorly more common, and getting to the gym and exercising and moving like they typically did before, less common. So you take those two things, you stack them on top of testosterone and you kind of have a perfect storm. So that’s that’s. Those are kind of some of the basics that that lead into into sort of weight gain in both men and women, but it’s a really it’s a complex and intricate balance and it really needs to be based on the individual, their environment and then, yes, they’re hormones.

Lisa Krzyzewski: 24:58
Yeah, I mean, we can’t get away from the fact that there’s still an energy consumption consumption issue. If we’re gaining weight Is what about this? This might be another myth, but okay, I’m getting weight in areas that maybe I didn’t, so maybe I’m getting belly fat more now. Can that be hormone related or is it? Is it again? I mean, these are things that we like to blame on hormones.

Dr. Jonathan Bastian, MD: 25:25
Totally.

Lisa Krzyzewski: 25:26
And I is it true.

Dr. Jonathan Bastian, MD: 25:28
Yeah, yeah, I mean, I feel like every time I get asked this by a patient, the answer is always it depends, right? There is always a component that you can drag back to a one hormone testosterone estrogen as something that may be related to that shift in weight. But it’s never the whole whole story, right? Sometimes it’s chronically elevated stress. Sometimes they’re eating, but they’re they’re not eating the right things. You know they have a diet that’s too high and refined carbohydrates with with no protein. Sometimes they’re not exercising or not sleeping, like yes, hormones count, they always count, and they should never be, like, ignored, but it’s just one part of the pie, to to focus on your overall health, and so I feel like the treatment for that, the same things that we would do to improve somebody’s testosterone, which is to increase resistance training, improve their sleep, get a little bit more vitamin D really basic dietary changes those are also the same things that impact weight gain and, and what I would probably describe more is like, body habit is changes and over time you can’t improve it, but but it typically requires more than just than just treatment with a with with one thing.

Lisa Krzyzewski: 26:53
That’s fair, absolutely, and that kind of touches on treatment. And so let’s start with the less obvious stuff. I mean, what are the things that will truly impact our hormones? That maybe start with lifestyle, and then we can let’s trend towards supplements. Do they really actually help?

Dr. Jonathan Bastian, MD: 27:13
Lifestyle interventions are, I think, wildly in most cases underrepresented in in patients, in the sense that, like, if you sleep better and you’re less stressed and you eat better, you’re going to see positive impacts. Okay, so we know that you need. You know, first off, you need some fat in your diet. That’s this, that’s the steroid base for all of your sex hormones. But to have something that has got a balance of of fat and protein, relatively low carb, is going to go a long way. Anything that improves your, your stress response and your cortisol whether that be getting better sleep, going for a sauna, going for a walk, though, if you can manage your stress levels better, that allows your body to kick out of that fight or flight response improve your muscle mass, and lo and behold what happens when that happens. You have increase in growth hormone and testosterone, not to mention your your sugars get metabolized a bit better. Now, the flip side of that is, I would say that in most of the cases, for men and women, lifestyle interventions can only go so far, even though strong resistance training can certainly improve your testosterone by 10 to 14%. Is that?

Lisa Krzyzewski: 28:35
number In both men and women.

Dr. Jonathan Bastian, MD: 28:37
I think it’s only really been studied in men, Okay, but I think it’s certainly applicable to women as well and we can touch on that at any point. But really the the the coals notes are women’s testosterone is often about 50% secreted from the ovaries. As you enter into perimenopause and menopause, you can see that decline as well. While the evidence is just beginning to brew around that topic, I think the same lifestyle interventions that apply for men can apply for women.

Lisa Krzyzewski: 29:11
Okay.

Dr. Jonathan Bastian, MD: 29:12
So the flip side of that is when we’re looking at true hormone depletion, where your cells aren’t functioning well and things aren’t really really working particularly well together, there’s not really great supplements for men’s testosterone, not really. I mean you can use Testo Plus, which helps to try and stimulate your, your late egg cells and your testes to secrete more testosterone, but by and large there’s not much more that’s effective in that realm. Now women are quite different, because we have some really great supplements that help to sort of mimic the shape of estrogen, but not as a perfect estrogen balance. So, for example, women who have a history of breast cancer or are just worried about that risk ongoing will often use different sort of herbal supplements that have something called a phytoestrogen, which is like a plant-based estrogen. It interacts with the cell to still provide some support and improve some symptoms, but doesn’t actually fully connect to the cell to the point where it’s going to. It’s going to put the patient at any sort of increased risk for any of those sort of cancers that we talk about.

Lisa Krzyzewski: 30:26
And what have you seen? I mean, have you seen significant improvement with just those two interventions?

Dr. Jonathan Bastian, MD: 30:33
Yeah, I mean, I would say that the lifestyle interventions end up being a bit more of a slow burn and I would say most patients who are really suffering from hormonal imbalances want to try something else at the same time. You know, I think the really interesting thing, the thing I really like about our, our co-care model, is I was personally skeptical about, about some of the supplements that we were using for women.

Lisa Krzyzewski: 31:00
You’re probably not alone.

Dr. Jonathan Bastian, MD: 31:02
Yeah, yeah, yeah, yeah, oh my god, yeah, and and some of the supplements that one of our natural path, our lead ND, dr Lane, was prescribing and recommending totally changed one of our patients’ entire trajectory. For her, for her hormone balance, you know. It normalized her period, she felt better and all of that was without any any sort of estrogen balance at all. So I think they’re safe. I’ve looked into them much more now and I feel very comfortable recommending them and I also think in the right population they can be really effective.

Lisa Krzyzewski: 31:41
Yeah, that’s great. And then the next step after that. So it’s a great first step. If someone just wants, doesn’t have severe symptoms, but just wants to try to balance things out, they could go with. Let’s get a good supplement regime tailored to me. Let’s maybe get a bit more muscle building activity. If that’s not working, what? What’s the next line? I mean, now we’re getting into hormone replacement, right?

Dr. Jonathan Bastian, MD: 32:05
Yeah, for sure. So I think for men it ends up being typically it ends up being testosterone, either as an injection or a cream, and I would say for women it’s the same. So we’ll just talk to testosterone for a second.

Lisa Krzyzewski: 32:21
And I want to stop you because you said, oh, typically it’s testosterone. Yeah, you do, men take other hormones, cause I’ve never heard of that.

Dr. Jonathan Bastian, MD: 32:30
Yeah, I mean, look, there’s lots of testosterone is sort of the downstream product. There’s lots of things that men have been told they can take in advance of that. That can be things like HCG, that can be things like DHEA or pregnant alone. Okay, in my experience I feel like the real evidence that we’ve seen so far is for testosterone, okay, and I would say HCG is another common one. I get lots of questions about growth hormone and I would say the evidence just isn’t there yet but, like we talked about, for both men and women, their testosterone can go down substantially in early perimenopause menopause. You know, for men we used to call it andropause, but really now we just call it testosterone deficiency and it can be an excellent treatment for both. Now the interesting thing is they’ve done lots of studies. Usually it’s a once, once a week injection. They’ve done lots of studies looking at the effects of testosterone on women who are transitioning to men, right, so ultra high doses and they really have not found any substantial concerns or any substantial side effects. So when we’re looking at using it in women even though we don’t have quite the same database if we’re using it at one tenth or one twentieth of the dose of what a man would have, it can still be very effective for the treatment of libido, muscle mass, vaginal dryness. It helps with osteoporosis, and the thing that I find so fascinating about this is testosterone is the most common sex hormone women have, and yet it’s never been really studied, and only now are we beginning to see what the benefits of that might look like. Right, that’s usually as an injection or a cream. So, again, because of the risk of taking it orally and sort of going through the liver, we usually don’t provide an oral option at this point. There’s some new ones on the market that might be changing that.

Lisa Krzyzewski: 34:40
If you have too much testosterone and you’re female, you know it, like you got, you get in the chin hair going on, or something like that. But when you have too low testosterone, I don’t really think a lot of women would even know that that’s an issue that they have and so do they have to do anything about it.

Dr. Jonathan Bastian, MD: 34:58
Yeah, look, I would say that the, just like all of these things, we’re trying to balance symptoms with, again, symptoms with benefit, and what the risk and benefit of that might be for for a patient. Now, I think women in testosterone is perhaps one of the biggest areas of research that I think needs to be drawn on. Of course, if you’re not having any symptoms, my general recommendation is don’t take testosterone just to treat a number. We’re here to treat the patient as an individual, and the range of testosterone for women can be two all the way up to 35, right? So we have lots of women who come in. They have like a free testosterone of like six, but they have no libido, they’re feeling weak, they have no energy, Maybe they have some vaginal dryness and we’re like, okay, well, look, try it out. I mean the we know it’s a very safe medication. Worst case scenario is you know you’ve got a lot of people who have no energy. You’ve you’ve wasted your money on a, on a tube of testosterone. Best case scenario is like it has a really substantial improvement and if that’s the case, then continue to replace that in the same way that, in the same way that you would all these other hormone options.

Lisa Krzyzewski: 36:16
And just in case we’ve lost the man, because I know like I monopolized the conversation about women. Yeah, but women care about their husbands or their boyfriends or their brothers, and I know testosterone for men is kind of it’s gotten a bad rap, probably from the bodybuilding community, where it’s been overused and there’s roid rage and we hear all these negative things. Maybe share, just just for context, what’s a medicinal dose?

Dr. Jonathan Bastian, MD: 36:45
Sure.

Lisa Krzyzewski: 36:47
Versus when we’re hearing about roid rage and the scary things that go with testosterone. What’s? What are we talking here? And difference.

Dr. Jonathan Bastian, MD: 36:52
Yeah Right. So the first thing I would say is that the typical range is anywhere from 50 to 150 milligrams under the skin doesn’t need to be jammed into your and your and your glute or in your in your butt anymore once a week. Okay, now the other thing I would say is it’s going to be really dependent on the individual patient in terms of how much, how much testosterone they actually need. It ends up being a combination of their labs and their symptoms. We typically shoot to try and bring patients up into that upper third because we find that’s where the best evidence is for improving morbidity and mortality. And if you give it a really good shot in that upper third and you’re still feeling no change, that’s probably not the issue. Now, the flip side of that is many bodybuilders will do like three to four times that dose every week just as a baseline, not to mention all of the other hormones that they’ll be using at the same time to sort of maximize those gains. So when you’re using it at a therapeutic dose, you’re not nobody’s flipping tables. You know you’re, you’re. You might feel like you have more energy, you might feel like your, your mood is better, and that’s typically what we see, it’s not like you’re going to go to the gym and start start, you know, benching your personal max for when you were 18. We’re just here to get you back to a healthy spot where you feel, where you feel like you’re in the right spot and if we overshoot the side effects, end up might are often like I’m not quite sleeping as well, I’m feeling a little bit more irritable, let’s, you know, let’s back it off and, just like with everything that we’re talking about, this ends up being a very individualized treatment plan. So you know we’re treating the numbers and we’re treating the symptoms, and I think that’s what makes it difficult to get really quality care at for for some physicians who may not be as experienced in it, because there’s a lot of nuance to what’s going on at the individual level.

Lisa Krzyzewski: 38:54
What’s even worse is when you try to do it yourself.

Dr. Jonathan Bastian, MD: 38:56
Yes.

Lisa Krzyzewski: 38:57
Off the internet, right so and this is not unheard of right Especially with bodybuilding or some of these other communities where you have access to the drug but you don’t necessarily have medical oversight. So obviously very important to get some good support for these, these medications, essentially.

Dr. Jonathan Bastian, MD: 39:18
Yeah, for sure.

Lisa Krzyzewski: 39:19
Okay, so we’ve touched on testosterone. We’ve got progesterone.

Dr. Jonathan Bastian, MD: 39:24
Yeah.

Lisa Krzyzewski: 39:25
So there’s one you can ingest orally.

Dr. Jonathan Bastian, MD: 39:26
Yes, totally, and in fact I think that it’s important that you do, because if you don’t, if you don’t take in progesterone orally, you don’t get the benefit of it transitioning into pregnanolone and then and then GABA. So really we don’t really use transdermal unless it’s a very localized issue like around the vagina. So we’ll often do. Progesterone is usually a pill. You take one at night before you go to bed. It’s usually between 100 and 300 milligrams, and so we start at 100 and then sort of tight trade up and see how you go. Many women who are just trying it out and they’re trying to say like, look, I’m not sure if I’m having symptoms or not, they’ll often take it in just the second half of their cycle, right? So your progesterone in the first half of your cycle if you’re having a normal cycle or maybe it’s beginning to change a bit still remains fairly high. It’s really in the second half that things start to drop off and that’s where you get some of those anxiety, depression, irritability, insomnia symptoms first, and that’s a great place to start. For a lot of patients that might be the case where you see improvement in that and then shortly over time you’re like look, I want to take it for the whole time, excluding my cycle, or the whole time, even during a woman’s cycle. All of those are fine. I mean, it’s such a well tolerated medication. You really want to tight, trade it up to a position where you feel like your symptoms are well controlled. But again, trans germ is not really a great option for that.

Lisa Krzyzewski: 40:59
Okay, and I’ll come back to estrogen, but you just kind of touched on something and just made me think this could myth or not? Are you stuck on hormones for life once you get going on them?

Dr. Jonathan Bastian, MD: 41:13
So the short answer is no, I want to look at this right. No, you’re not on estrogen for life. You’re not on hormones for life, unless you want to be. So. There’s two ways of looking at this. Number one is look, I’m feeling exhausted and I’m having all these other symptoms and I’m worried about trying these hormones because I think they’re going to down, regulate the hormones that you have in your body.

Lisa Krzyzewski: 41:40
Yeah, and I won’t be able to make them myself. I won’t be able to make them.

Dr. Jonathan Bastian, MD: 41:42
It’s like no, that’s not the way it works, Certainly not up front. You can be on these hormones for a long time before your body starts making those changes. I think the best evidence is for testosterone. You can be on testosterone for six months a year, even up to two years, before you really start to see your body down regulate those hormones. Now the flip side of that is, look, if we put you on these hormones because your body is deficient in those hormones, it’s the same thing like being on a thyroid medication. Your thyroid is not making, is not making hormone the way it’s supposed to. We’re going to replace that. You’re going to have to be on that medication long term because otherwise your symptoms are going to come back, and we’ve already agreed that. That’s why you came in the first place. Same thing goes for women’s hormones. If you find that they’re going to be effective for you and you’ve maximized all these other lifestyle interventions to try and improve those which, by the way, have a huge impact on them. If you find that you’re, there’s still probably a component of that that might be those hormones getting just not being produced as well or not as much, and if you get benefit, it’s safe to be on those hormones long term in most circumstances. The one thing that I’ll caveat that with is women who start estrogen. There’s sort of this understanding that after 10 or 15 years of use we try and sort of wean you off to see if that helps. I think the research is out as to whether or not that really is the most effective tool for everybody to sort of wean off these at the end. But it really is a conversation that you need to have with your prescribing physician and, like everything we’ve talked about, it’s so individualized that it’s a conversation worth having if it ever gets to that point.

Lisa Krzyzewski: 43:36
And it is a conversation worth having. So I will bring this up now because I think we probably all will want to run to our doctors when all this is said and done. Personally, I didn’t have a lot of luck with my family doctor. I mean not that they wouldn’t do it, but I felt I really felt like I had to come in and ask hey, I want to try X. And then she was great and she’s like okay, well, we can try this. But it’s not the most comforting feeling to know that I’ve kind of directed this and I’m not really sure where it’s going and what can we expect? Like, is it fair to expect your GP to know all the stuff that you’re telling me now? And like what should my expectations be? Is it important to find a specialist? What’s? Where are we at?

Dr. Jonathan Bastian, MD: 44:24
Yeah, okay, so I think, some really great family physicians. This is absolutely a space that family physicians can be capable of treating. However, you got a couple of things working against you. Number one is we have these big studies back in 2003, 2004, increased risk of breast cancer which have, I think, essentially now being demystified a bit and I feel like that. But that same thing doesn’t just like, isn’t just perpetuated in the public eye, it’s also perpetuated by physicians. So there’s lots of physicians who are going to think the risk is greater than the benefit for lots of women and that’s gonna be a hard thing to change if it’s not something that they’re really up to date on. Number two is some of the things that we’re talking about totally, I mean, go for it. Try some progesterone, try some estrogen. Your your phytoncide, your family physician can prescribe those. But, like we talked about, this is a very intricate balance between cortisol, thyroid, testosterone, estrogen, progesterone, your diet, your supplements that you’re taking, your workout routine all of those things play a role and it’s just really unlikely that in a 15 minute interview with your family physician even if they’re really good that they’re gonna be able to hammer on all those points. So I always wanna be careful about this, because I think family physicians are very capable and I think they can, in general, do a wonderful job of managing your care, but I also feel like there’s a lot that they need to know. There’s an incredibly wide range of information that they need to follow up with and I’m just not sure if, if you’re looking for a high experience that’s very individualized, that they’re gonna have the time or the expertise to deliver it.

Lisa Krzyzewski: 46:20
Yeah, I mean that’s. That’s, I guess, our concern in general, like we have a 15 minute appointment and they do what they can, so we can’t complete this, this kind of treatment discussion, without talking about estrogen. There’s some great modalities. Tell us a bit about what there is out there.

Dr. Jonathan Bastian, MD: 46:43
Sure. So there’s lots of different ways to get estrogen. The most common, the most common, is really the transdermal approach, so through the skin. Now, for some patients that’s a cream, for other patients that’s a patch, you know, those, I’d say, are the two most common ones. Now, what I find really interesting is there’s actually some oral estrogen components that, if you don’t have a risk of blood clot, are becoming more and more common. And the thing that is really unique about some of these new medications is they actually have a blocker in the breast tissue. So, let’s say, you really are worried about about some long-term complication from a strong family history. You can go on one of these, one of these estrogen pills. It blocks the conversion of that estrogen in the breast tissue but still gives you all of the other benefits for your your cardiac health and your bone health and your brain health. Now, wow, yeah, I mean and again like just to point out, there’s options out there. Now, the other thing that I think is fascinating about that is, you know, I really feel like the timing of when you get on estrogen is perhaps, of all the things we discussed today, the most critical.

Lisa Krzyzewski: 48:00
Okay.

Dr. Jonathan Bastian, MD: 48:01
Because 10 years after you’ve entered into menopause, your body starts to down regulate those estrogen receptors there’s no estrogen floating in the system starts to settle, bring them away from the outside of the cells. So you might be giving your body if you start too late. You might be giving your body estrogen but it’s not going to, it’s not going to have an effect and therefore you end up with this risk benefit curve where you now have sort of unopposed estrogen not having a receptor. Yeah, it’s going to, it’s going to sort of increase the risk of other things that we talked about. So the key in my mind for estrogen is being really thoughtful of your body, being aware of it and then, as soon as you start to notice symptoms which frankly is most women, you know you you start early because if you can get on estrogen early, then you don’t get that down regulation of estrogen, you get all of the benefits. And because it’s a transdermal treatment, not much in terms of in terms of the side effect profile. So, look, I don’t want to say that HRT is absolutely for everyone. I think there’s. I think there’s nuance and circumstances where you want to be careful about it and have a have a clear conversation about it. But I also think it can be dramatically helpful and I think with the new options that are coming online, you know the you can shift the risk benefit curve to strongly favor benefit on an individualized scale.

Lisa Krzyzewski: 49:27
Okay, I want to make sure I’ve got this. This is new information for me and I love that. This is one of the few things where you’ve given us a timeline in terms of okay, start early with estrogen because this? This I just want to be clear, because what you’re saying is, if I start early, I keep my estrogen levels normal or higher and or or not even fluctuating the way they might as I go through aging, the receptors stay alive.

Dr. Jonathan Bastian, MD: 49:57
Exactly, they stay active. Yes, Okay, yes. And if you were out of that tenure window for some women, if they’re still having really bad side effects, we’ll have that conversation. But otherwise, for for many other women, if they have a higher risk profile, I think you’ve kind of you. You, we no longer will treat you with estrogen. The risks the risks are too high, the benefits too low.

Lisa Krzyzewski: 50:21
And those early symptoms? For, for the younger women out there, what would be some of the things they’re going to notice early?

Dr. Jonathan Bastian, MD: 50:28
Yeah, I mean so. The most common one is is a vasomotor symptoms, so hot flashes, irritability, right. Essentially you’ll stop cycling, right, so you’ll your. Your period will get fewer and farther between goes from 25 days to 60 days to 90 days. That’s the other really common one. And then there’s other. There’s other subtle, subtle signs that you’ll see skin changes. It can have a profound impact on mood, like. There’s lots of subtle things that come through, but I think Okay, that’s not subtle.

Lisa Krzyzewski: 51:02
I’ve heard that about your skin.

Dr. Jonathan Bastian, MD: 51:04
Yeah.

Lisa Krzyzewski: 51:05
That you know you can. It can really start to wrinkle and that aging process can really kick in as your estrogen drops.

Dr. Jonathan Bastian, MD: 51:12
So so that’s that’s not subtle.

Lisa Krzyzewski: 51:15
Okay, I didn’t know, I didn’t know.

Dr. Jonathan Bastian, MD: 51:16
Yeah, I feel like you know. Estrogen plays an important role in in collagen and elastin, like the things that give your skin elasticity in that sort of volume.

Lisa Krzyzewski: 51:27
Yeah.

Dr. Jonathan Bastian, MD: 51:27
And so when you enter into menopause it’s a common, really common thing to see is you begin to that begins to fade out. Now, to capture that early. I think is is an important sign. But I would say probably the most common ones patients will see will start with is some of the vasomotor symptoms.

Lisa Krzyzewski: 51:43
And I would add too, just because it’s something I’ve tried, is because most people know now that I suffer from migraines and one of the triggers will be cycle related, so fluctuations in hormones, but estrogen just a certain times of the month. You know we can, we can use to help people keep things level, and then you’re not. You’re not committed to it all the time, but you’re still helping balance out a monthly cycle.

Dr. Jonathan Bastian, MD: 52:13
Yeah, for sure. I mean, the classic thing is your, as your body in in perimenopause, as your body is trying to stimulate your, your ovaries, to release another follicle, it just ramps up the estrogen as much as it can and then when, and then on top of that you know, your estrogen or your progesterone phases out. So you end up with this real imbalance between the two, and sometimes it’s not just the progesterone falling off, it’s also that, that imbalance between the two. And again, we’ll often use things different herbals like Femgard and a few other ones to help sort of support your estrogen balance at the same time.

Lisa Krzyzewski: 52:54
I’m really curious, though, if you’re comfortable sharing just a few, even anecdotes for us what have you seen, like what are some of the things that just have stuck with you, where people have identified a problem and you’ve been able to support it by getting hormones back in balance.

Dr. Jonathan Bastian, MD: 53:11
You know, I think one of the biggest ones that I’ve seen consistently is women having really heavy cycles that they just kind of have been putting up with for like three or four years. You know they can’t go out or you know they’re not enjoying their vacations, or so we’ve had specifically a woman who’s come in with really heavy cycles. We’re able to put her on and she’s gone to her family doctor and I think it’s one of those things that sometimes doesn’t get treated as well as it could. So, you know, we treated her with some progesterone. We actually ended up giving her an iron infusion as well, which improved her energy a ton and she just returned to like incredible normalcy. And sometimes, you know, you think about that and it sounds like it is a small change in terms of a medication, but it has profound impact on how you feel and you know, a big portion of your time. So that has certainly been a win for us. We have lots of women who have tried testosterone like topically you can do it as a once a week injection or under the skin and it’s totally changed how they feel, like more energy, better sex drive, decreased vaginal dryness and for a few of our women who have come in saying you know, my husband certainly wishes that I could have you know that I’d be more interested.

Lisa Krzyzewski: 54:44
Which husband does not?

Dr. Jonathan Bastian, MD: 54:47
And look. For many women like, libido is a complex, intricate piece, but on the occasion, you land on one and you’re like, no, that’s just hormones. Yeah, so that’s been really helpful and I think certainly when you couple progesterone, estrogen and testosterone, together with some of the other things that we support here through exercise and nutrition and a focus on sleep, you can dramatically change someone’s life and we’ve seen that. So, yeah, it’s been. It’s been an awesome journey, it’s something I’m super passionate about and, yeah, we’ll just try and keep getting the word out.

Lisa Krzyzewski: 55:26
And are there any before we kind of sign off here, are there any myths that you just constantly hear of that we have not debunked today?

Dr. Jonathan Bastian, MD: 55:36
You know, on the men’s health side, I really feel like there’s there’s ongoing myth that testosterone causes prostate cancer, or testosterone yeah, we’ll start start there. Testosterone causes prostate cancer and it’s just not true. And in fact patients who have the highest level of testosterone oftentimes have the lowest rates of prostate cancer. And you would think then that if that were the case, men who have high levels of testosterone, ie younger men, would have the highest rates of prostate cancer, and of course that’s not true either. So what we now know is, after a fairly low dose of testosterone, if you think of your prostate kind of as a as a sponge, you know your prostate’s taken in as much testosterone as it’s going to have and above that level, no amount higher than that is going to influence the prostate. The prostate changes and for that reason testosterone is not going to cause prostate cancer. And in fact the Canadian Urologic Association put out a big Q&A on this about last year and they said unequivocally that that really, unless there’s very specific circumstances of like an active metastatic prostate lesion, that testosterone in the right, in the right patient population is fine to take. Good.

Lisa Krzyzewski: 57:00
Yeah, good to know. Yep, bioidenticals I hear a lot about that. Fears versus I don’t even know. Do we do we use anything other than bioidentical now? No, no.

Dr. Jonathan Bastian, MD: 57:14
So look, the bioidenticals versus synthetics is this question that we get all the time. I would say, most specifically, it’s related to progesterone. So when we were talking about that big women’s health initiative question, it’s really the synthetic progestin that caused a lot of the complications you know and tentatively increased rate with breast cancer, tentatively increased risk of blood clot, when in fact, the bioidentical versions that we have today really we haven’t. We haven’t seen anything like that at all. Okay. Similarly, with estrogen, everything we use now, whether it’s your family physician or not, is going to be typically an identical version to the, to the hormone that you’re receiving. So when we were talking about synthetic these old versions of of estrogen and progesterone- yeah those were synthetic because they weren’t the same molecule that your body was receiving. The hormones that we use to treat today progesterone and estrogens, estradiols, specifically those are identical to what your body’s receiving and so I think there’s a big of course we want to use bioidentical. I would say most of the things that are properly compounded on the market should be that way and, frankly, if you’re using like a birth control pill that’s got some synthetic components to it, you know my, my recommendation would be consider some alternatives, because I do feel like some of these synthetic versions might carry more, might confirm more risk than an identity, a bioidentical equivalent.

Lisa Krzyzewski: 58:57
Great. I mean we could probably talk another hour on this topic. I mean, I know we haven’t touched on fertility, could definitely go down the rabbit hole on all the sexual implications of hormones and performance enhancement you name it. So I think we’ve got a lot for more episodes, but I’m really happy with what you were able to cover for us today. Really appreciate you coming on. Well, thanks for listening everyone. We’re on Instagram, facebook, we have our info email and we’re happy to get questions from you on any topic, but hormones specifically. We’ll be doing another deep dive soon, thanks.