Bioidentical Hormones with Dr. Cynthia Watson: Rational Wellness Podcast 132
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Dr. Cynthia Watson discusses Bioidentical Hormone use in Menopause with Dr. Ben Weitz.
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4:02 During the perimenopausal period, which for women is typically in their late 30s and early 40s, their periods become irregular, either shorter or longer, or they may get heavier. Progesterone and testosterone levels tend to fall and estrogen levels tend to go up. This is because if women are not producing an egg every month, the FSH goes higher, which results in producing more estrogen. Women tend to get symptoms of irregular moodiness, irritability, more PMS, depression and their sex drive goes down.
5:55 To support women during perimenopause, we need to support the adrenal glands. The adrenal glands produce hormones. Prior to menopause, 75% of the hormones are produced by the ovaries and 25% by the adrenals, but the adrenals take over after menopause. If women are really busy, working, taking care of kids, etc. this stress weakens the adrenal glands and the hormone production tends to decrease. The adrenal glands will tend to take the progesterone to make more cortisol, so we may see progesterone levels fall. Dr. Watson likes to check the luteal phase hormone levels around day 20-24 of the cycle to see how much progesterone, estrogen, and testosterone they are producing. They may have high estrogen levels, which can cause breast tenderness, bloating, and irritability. Dr. Watson likes to use herbs and supplements to help lower estrogen and support progesterone. It may be helpful to give women some progesterone during that time in the cycle.
8:35 To help lower estrogen levels, Dr. Watson instructs her patients to avoid phytoestrogens in soy and other foods and environmental estrogens, like Bisphenol-A, and phthalates in personal care products. She will often recommend DIM, which is an extract from broccoli, which helps convert some of the estrone to a weaker form of estrone. She may also recommend calcium d-glucarate and milk thistle to help with glucuronidation and helps to pull those estrogens out.
10:35 Dr. Watson prefers to do serum testing for hormones, though she recognizes the benefits of urine testing (such as DUTCH dried urine testing) for measuring hormone metabolites. She mentioned that urine testing is not as good for progesterone, since progesterone is not seen in the urine but only it metabolites.
12:50 Dr. Watson likes to recommend Vitex (chasteberry) at a dosage of 200 mg twice per day to help with progesterone levels during perimenopause.
14:35 Some doctors feel that prescribing hormone replacement therapy for women after menopause is unsafe due to the results of the Women’s Health Initiative, published in 2002, (Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women: Principal Results From the Women’s Health Initiative Randomized Controlled Trial), which showed that taking estrogen and progesterone increases the risk of heart disease and strokes and blood clots and breast cancer. Dr. Watson explained some of the problems with this study, including that the form of estrogen used, Premarin, is conjugated estrogen from the urine of pregnant horses, and the form of progesterone used is synthetic progestins and neither of these are comparable to bioidentical estrogen and progesterone. Another issue was that most of these women did not start taking the hormones till they were 60 years of age, so they likely had already had developed heart disease and clotting from not having estrogen for 10 years. This study had 10,000 women and in women treated with conjugated equine estrogens and progestins there were 32 cases of breast cancer and in the control group there were 24 cases of breast cancer, so there were only eight more cases in the treated group but it was recorded as a third more cases. And in the arm of the study with women who had had a hysterectomy and took estrogen alone without progesterone and there was no increased risk of breast cancer. With respect to the risk of heart disease and stroke, many of the women in the study were obese and smoked, which is what accounted for most of this risk.
20:46 Dr. Watson uses bioidentical estrogen and progesterone, which are much safer than using conjugated equine estrogens and synthetic progestins. She prefers to use estradiol rather than Biest, which is a combination of estradiol and estriol, a weaker estrogen thought to be safer. Dr. Watson said that since estradiol is more effective at reversing menopausal symptoms, if you give an estriol/estradiol combination like Biest, you may end up having to give higher dosages, which can have more side effects. On the other hand, estriol is great to use topically for the vagina. Dr. Watson emphasized that she individualizes her treatments and recommendations to each patient’s needs and how their body reacts.
23:41 Dr. Watson usually prefers to use topical forms of estrogen and progesterone. She tries to avoid using oral estrogen to avoid the first pass effect that can increase clotting factors and stress the liver. If the patient will not apply the cream or some women do not absorb it very well, so sometimes she will use sublingual forms. She will more commonly use oral progesterone, since she may have trouble getting good blood levels with topical progesterone. The oral progesterone doesn’t have the same risks as the estrogen and it helps better with sleep, so Dr. Watson will use the oral progesterone frequently.
25:54 Dr. Watson typically administers hormones statically, with the same dosage throughout the month, though some doctors will use a rhythmic pattern of dosage, such as with the Wiley Protocol. And she has recommended this for a few patients. She does recommend that women with a uterus to take the progesterone regularly because it prevents the estrogen from leading to the uterine lining becoming thick. Dr. Watson will often measure the uterine lining to make sure it is not becoming thicker.
28:05 Dr. Watson explained that it is an unanswered question at this time whether hormone replacement therapy protects the heart, but she said that it is important for this purpose if women start estrogen within the first year after menopause.
31:08 If women have had a history of breast cancer but are having vaginal symptoms, Dr. Watson said that as long as she is cancer free and she is being followed by an oncologist, she may recommend the vaginal administration of estriol or DHEA or testosterone cream. Testosterone can have antidepressant effects and other benefits, but it can also cause hair loss and acne and irritability and anger in some women.
34:10 Dr. Watson will sometimes include pregnenolone in her hormone replacement program if women tests low on it and have symptoms of MS or other neurological problems, since pregnenolone can be important for brain health, but she has not seen it raise estrogen levels. She will typically prefer to start women on estrogen and progesterone alone before adding other hormones and make sure she can get the levels correct. Dr. Watson likes to use products from a good compounded pharmacy that tests every batch so that she can easily titrate up or down the dosages. If you use a patch or pellets, you are stuck with whatever dosage is there. Also, commercial brands of estrogen are often in an alcohol base and Dr. Watson prefers not to use an alcoholic base. And commercial products have various types of binders and fillers that some women can have reactions to. Commercial progesterone is often in a peanut oil. By using a compounded pharmacy, you can use an olive oil or emu oil or canola oil or even a powdered base. Dr. Watson usually does not start women on testosterone and DHEA at the same time as estrogen and progesterone till she feels that her patients are balanced. She will typically have her patients come back in a month and retest their hormone levels and see where they are at and then add in DHEA and/or testosterone if their levels are low at that point.
40:03 Dr. Watson believes that bioidentical hormones can be really beneficial for the brain. This is partially through protecting the vascular system, which allows for maximal blood flow to the brain, which is maximized by starting the hormones close to the beginning of menopause.
42:15 Adrenal function is also very important to hormonal balance and Dr. Watson will frequently test serum cortisol and in some patients she will do the 4 part salivary cortisol testing or she will do the dried urine testing for adrenals with DUTCH Labs. To support the decreased adrenal function, Dr. Watson often recommends maca root, which is a great herb that can stimulate the production of both estrogen and testosterone. She will also use licorice root to support adrenal production. For women that have a spiking of their cortisol levels, phosphatidylserine, magnolia, and ashwagandha can be beneficial.
Dr. Cynthia Watson is a primary care Medical Doctor, board certified in family medicine, and she embraces a Functional Medicine/Integrative approach to care, incorporating nutritional and herbal medicine and bioidentical hormones into her approach to health and wellness. She is still accepting patients and she can be reached through her website, WatsonWellness.org.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Dr. Weitz: This is Dr. Ben Weitz, with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness Podcast on iTunes and YouTube, and sign up for my free E-book on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness podcasters, thank you so much for joining me again today. For those of you who enjoying listening to our podcast, I would really appreciate it if you could go to Apple podcasts or your favorite podcast app and give us a review and a rating so more people can find out about it. Also, if you want to see the video version go to my YouTube page. And if you go to my website, drweitz.com, you can find a complete transcript and detailed show notes.
Our topic for today is the use of bioidentical hormones during perimenopause and menopause with Dr. Cynthia Watson. Menopause is when a woman’s body is shutting off its reproductive capabilities. A woman is technically in menopause when she has not had her period for one year. During perimenopause, the period prior to menopause, and menopause, there is a gradual but dramatic decrease in estrogen and progesterone production by the ovaries resulting in a host of symptoms including hot flashes, night sweats, brain fog, mood swings, sleep problems, depression, weight gain, vaginal dryness, hair loss and fatigue among others. Long term effects of menopause include increased risk of osteoporosis and of cardiovascular disease.
Dr. Cynthia Watson is board certified in family medicine, and she embraces a functional medicine approach to care, incorporating nutritional and herbal medicine and bioidentical hormones into her approach to health and wellness. After two years at Ohio State University, she lived on a biodynamic farm in Norway, and developed an interest in the naturopathic medicine practiced on the farm. She also worked as a nurse’s aide in a homeopathic hospital in Germany. She got her BS in chemistry from Duquesne University, and she went to the USC School of Medicine. She has had her own private practice since 1991, and she incorporates herbs, nutrition, homeopathy, intravenous vitamins and bioidentical hormones into her integrative medical approach. She wrote a number of books including Love Potions: A Guide to Aphrodisiacs and Sexual Pleasures, User’s Guide to Easing Menopause Symptoms Naturally, All About Lipoic Acid, and Better Sex in Midlife. Dr. Watson, thank you so much for joining me today.
Dr. Watson: Thanks for inviting me, Ben.
Dr. Weitz: What are hormones, and why should we care about them?
Dr. Watson: What are hormones? Well, hormones, that’s a broad definition because you’re talking about steroids hormones and other hormones. Hormones basically are defined as something that’s secreted from an organ and it has an effect on another organ. But the sex hormones are the ones that we deal with in menopause and menstruation, and also for men too. They have hormones too.
Dr. Weitz: Absolutely. What happens during the perimenopause, and how can we help women with their symptoms during this period?
Dr. Watson: In perimenopause, there are a number of changes that can happen, and it varies from woman to woman. And it also varies according to age because some women will go into what we call perimenopause in their late 30s, early 40s, and some women will not even hit that period until the mid 40s. The timing for menopause is generally between 45 and 55. But prior to that, you’ll see a number of changes. The most common changes in terms of visual changes are problems with irregular periods, where the cycles will either get shorter or the cycles will get longer. And sometimes they’ll get heavier depending on what physiologic changes there are. The most common things are that the progesterone levels fall, and the testosterone levels fall in perimenopause. And often, the estrogen levels go up. Because as women, we’re producing an egg every month, and as that gets weaker, the FSH gets higher, so the body is producing more estrogen. But the progesterone levels, and the testosterone levels tend to fall. And what that translates into is you’ll see women with either the cycles are getting shorter, where they’re having cycles every three weeks, it’s even every two weeks sometimes if they don’t produce an egg, and/or they’ll have 35, 40 day cycles. And the other thing that goes along with that is a lot of irregular mood symptoms. I’ll see irritability, more PMS, more depression, and also lower sex drive too, because the testosterone levels tend to fall.
Dr. Weitz: How can we support women during this phase?
Dr. Watson: One of the most important things that I talk to my patients about is the adrenal gland. And I wanted to really talk a lot about that in this interview because as women, our adrenal glands produce hormones. They produce hormones just like the ovary does. And as we go into menopause, the hormone production… prior to menopause, the ovary produces about 75% of the hormones. The adrenal gland about 25%, and that shifts as we go into menopause, whereas the ovaries produce less hormone and the adrenal gland takes over. What I see a lot and women in our society, especially as we’re so busy, we’re working, we’re taking care of kids, we’re doing so many things, that the adrenal glands get weaker. And so we see the hormone production cut down. And especially where that happens is with progesterone, because progesterone is used by the adrenal gland to make cortisone. So what happens is something we call it the progesterone steal phenomenon where the ovary’s making estrogen, it’s making some progesterone, but the adrenal glands want that progesterone too. So as soon as that progesterone gets produced, it gets used up by the adrenal gland to make cortisone.
For me, checking a woman’s hormones, most gynecologists, we learn to check the FSH and the estradiol on day two or three to see how … the FSH is follicle-stimulating hormone, and that’s the hormone that is stimulated when we produce an egg. And as that goes higher, then we see less fertility and we see someone moving more into perimenopause. But the other important thing to check during that time is what we call luteal phase hormones, where you want to check the estrogen and progesterone and the testosterone around day 20 to 24, depending on how long the cycle is, to see how much progesterone they’re making. And then depending on that … because I’ll see women with low progesterone, I’ll see women with super high estrogen levels, like 200, 400. I’ve even seen up to 700 and those women, they’re uncomfortable. They’re miserable. It’s like their breasts are tender, they’re bloated, they’re irritable. All of those symptoms go along with perimenopause.
Dr. Weitz: What’s … Go ahead.
Dr. Watson: What you have to do about that is you have to help to lower the estrogen levels with herbs and supplements, which work really well to do that. And then if the woman needs progesterone to give them progesterone during that time in the cycle.
Dr. Weitz: What herbs and supplements can help lower the estrogen levels?
Dr. Watson: This is an important thing because I see women in their 40s where the estrogen levels start to climb as a combination of just this hormonal cycle. And also because of the environment, because there’s a lot of the phytoestrogens and a lot of women are eating soy or they were being exposed to some of these chemicals, the xenoestrogens, which then block our ability to clear estrogen.
Dr. Weitz: Like there’s Bisphenol-A, like pesticides.
Dr. Watson: Right.
Dr. Weitz: Like phthalate in personal care products.
Dr. Watson: Exactly. So just being cautious and being aware. Those things actually clog up those cycles and make it difficult for us to metabolize the estrogens. And then there’s also genetic factors, which I’m looking at a lot of the genetic factors like certain CYP enzymes that they could have a polymorphism on. Or the COMT enzyme, if you have a polymorphism on those, then you also have reduced ability to clear the estrogen. So what can you do? You can take a supplement called DIM, diindolylmethane, which is the broccoli, the extract from cruciferous vegetables, that actually helps convert some of the estrone into a weaker estrone. You can also take calcium d-glucarate and milk thistle. Calcium d-glucarate helps with the glucuronidation of the cycle and helps pull those estrogen levels out. And it really makes a difference for some women when they’re retaining high levels of estrogen.
Dr. Weitz: Do you ever use indole-3-carbinol versus DIM?
Dr. Watson: I tend to use more DIM.
Dr. Weitz: And why is that?
Dr. Watson: Well, just from some of the research that I saw that the DIM is the downward metabolite of the indole-3-carbinol, so the DIM is actually a little more effective.
Dr. Weitz: Okay, great. You were talking about the hormone levels, the estrogen going up and the progesterone going down. What’s the best way to test or measure hormone levels? And we have serum, we have 24 hour urine, we have dried urine, we have saliva.
Dr. Watson: Yeah, there’s a lot of different testing methods. I think I’m more partial to blood. That’s what I’ve been doing for all these years, and I think it also depends on the practitioner and where their level of comfort is because I’m used to looking at blood. I know how to interpret the blood, I’m comfortable with it. If that’s something that you’re comfortable with, I think blood levels are fine. Your levels are helpful for the urine metabolites of the estrogen, so if you’ve got someone who you think is not metabolizing in the estrogen, you can get a lot of estrone metabolites, you can get the 2/16 hydroxyestrone and the 4-methoxy and 4-hydroxyestrone. So you can see if someone’s got high estrogen where you need to help them in that cycle to clear the estrogen. And so that’s really only with urine. So if I have someone where I really need that, I’ll do urine.
I think progesterone levels are not very good at urine because you’re not really measuring the actual level, you’re measuring a metabolite. I tend to use blood and I tend to check the blood depending on where the woman’s cycle is, I tend to check the blood between day 20 to 24. But if I have someone with a 21 day cycle, I’m going to do day 18, something like that.
Dr. Weitz: We’ve started using the dried urine more and one of the things that’s beneficial for that is you were talking about trying to get a woman on day 18 to 21. And a lot of times, oh, shoot, that’s a weekend. I can’t go, I have to wait till next month. So this way they can do it at home and send it in.
Dr. Watson: I’ll just adjust it based on whatever day they can do it. But yes, I sometimes do the urine as well.
Dr. Weitz: Right. What else can we do as far as the progesterone? What do you think about using herbs to support progesterone production during the perimenopause?
Dr. Watson: I love the vitex.
Dr. Weitz: Right.
Dr. Watson: Vitex is the best herb for women in perimenopausal symptoms
Dr. Weitz: A.K.A. chasteberry.
Dr. Watson: Chasteberry, yeah. Chasteberry is a great herb for that. I found a lot of my patients when you give them progesterone, they get side effects. Sometimes I’ll just go to the chase berry first, see how that works.
Dr. Weitz: What dosage do you like for the chasteberry?
Dr. Watson: I usually use about 200 milligrams twice a day.
Dr. Weitz: Okay, good.
Dr. Watson: But I don’t cycle it. I usually have them do it continuously.
Dr. Weitz: Okay, good. What happens during menopause, and why is it that some women sail through menopause with fairly manageable symptoms and other the symptoms are severe and unlivable?
Dr. Watson: I don’t also really know why some women have different symptoms because I’ve seen some women, you would think that some women who are a little more overweight, that they have more indulgence estrogen, that they wouldn’t have as many symptoms, but sometimes they do. I think some of it is genetic because I think some women if their mother had an easy menopause, that they may have an easy menopause. And again, I go back to the stress issue. Some patients, if they’ve had a lot of stress and the adrenal glands aren’t able to carry them, they are going to have less estrogen. I’ve seen some women have very low estrogen levels, and then they’re fine, so I don’t know if we know why. But certainly, there are some women that have really disabling symptoms, and those are the women that I think are good candidates for the hormone replacement.
Dr. Weitz: Now, isn’t it the case that the Women’s Health Initiative, which was published in 2002 showed that taking the estrogen and progesterone increases the risk of heart disease and stroke and blood clots and breast cancer?
Dr. Watson: That study, as you know and as reported by many doctors and even some of the doctors that even were part of the study, that the results on that study were very confusing. I think, first of all, the product that was used on that study let me start with that, is Premarin and Provera. Provera is the synthetic progesterone. So physiologically, the effects of synthetic progesterone on the body are different. And Premarin, which is the pregnant mares’ urine is mostly estrone. So because of that, it’s a different kind of estrogen and it’s metabolized in the body differently. And to add to that it is also an oral estrogen, so we tend to try to use more topical estrogens in some women when women postmenopausal.
The other problem with the study is that most of those women in the study were actually not having menopausal symptoms. And the reason for that is because they were doing placebo controlled, so they were looking for women who didn’t have menopausal symptoms. Because if they did, they would know whether or not they were on a placebo or not, so that’s the first thing. The other problem with the study was it was a prospective study. And a prospective study means that if there is a complication they need to stop the study. So it wasn’t just an observational study, it was a prospective study. And what happened-
Dr. Weitz: Aren’t prospective studies the most accurate?
Dr. Watson: Well, yes, but the way it was interpreted because there was a slightly higher statistical evidence of cancer, they had to stop the study. But the statistical evidence in that study was it was a very small group of women.
First of all on the estrogen, there was an arm of the study that was estrogen alone, they were just Premarin alone. These are women that had a hysterectomy. In that study, there was no increased risk of breast cancer. In the part of the study that had the estrogen with progesterone, those patients there were out of 10,000 women, there were 32 cases of breast cancer. In the control group there were 24 cases, so there were only eight cases more in the treated group. But because eight goes into 32 three times, it was recorded as a third more cases even though that was a very small statistical study.
Prior to that time many of the studies … First of all, there’s a wonderful book if patients want to read a little bit more about this that, I don’t know if you’re familiar with this book. It’s called Estrogen Matters, and it’s by Avrum Bluming. And he’s a wonderful gynecologist who … I mean oncologist who was in San Fernando Valley. He was one of my referrals. And he was one of the only doctors after breast cancer that would treat women with hormones and it became quite controversial. He was really in the firing line for a long time because of this. And then one day I was referring a patient when one day I found that he retired. And then a few months later, I saw this book saying Estrogen Matters, why we can give women estrogen even after breast cancer. He’s the one that did a lot of the research and he produced a lot of studies. Up until that time there were very few studies that showed that there was an increased risk of cancer. And then in the studies in Europe, they started to use bioidenticals because they tend to use more bioidenticals. They use more pure estradiol, and they use a lot of natural progesterone. There’s a very large French study that did not show an increase in cancer.
So let me address the heart disease and the stroke. Part of the problem too with that study is that many of the women in that study were obese, many of them smoked. And what they’re finding now is the risk of cancer and heart disease and stroke really has to do more with obesity, and that’s been one of the main things. There was a very large article that was written by NAMS, the National Menopause Society and the International Menopause Society showing that really, the risk of breast cancer and stroke in these women is that it’s really from the obesity that seems to be the problem.
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Now, back to our discussion.
Dr. Watson: I use all bioidenticals and primarily estradiol. I know some doctors use the Biest combination and I do use that in some of my patients, but I tend to use more of just pure estradiol.
Dr. Weitz: And why is that?
Dr. Watson: I found that some women don’t tolerate the estriol as much. And since the estradiol has the strongest effect on menopausal symptoms, what was happening is you’re giving estriol and estradiol because estriol is a weaker estrogen you were having to give higher doses of it. So there are some women especially some women, they just don’t do as well on it. Some women do, so I think it … Again, when I’m working with a patient, everything’s individualized. What I would give them would be on an individual basis, based on their body weight, their family history, whether or not it looks like they’ve had a problem clearing estrogen in the past. Because I think that’s one of the other things that I try to really pay attention to. If I have someone who has a history of fibroids, ovarian cysts, PMS symptoms, they’ve had problems, if it looks like they’ve had or they have problems metabolizing the estrogen, I’m going to want to use lower levels.
Dr. Weitz: I think a lot of the doctors who are using Biest or using estriol are using it to potentially lower the potential risk of breast cancer since estriol is a weaker estrogen.
Dr. Watson: Right. And then I have actually a couple of women who have had breast cancer and they’re on estriol. Estriol is really great for the vagina. For vaginal dryness, estriol is a wonderful product for that, just for topical application.
Dr. Weitz: Right, I know. I interviewed Dr. Gersh and she’s not really big on estriol because she explains that estriol is a dominant hormone secreted during pregnancy and it basically stimulates the estrogen beta receptors. And so you miss stimulating those estrogen alpha receptors that are so important. And overstimulating the beta receptor actually down regulates the immune system, which is maybe good for pregnancy, but not so good for fighting off infections or a cancer.
Dr. Watson: Yeah, but when you’re using estriol in hormone replacement, you’re using such small doses compared to what the body is secreting in pregnancy. In pregnancy, you’ve got super physiologic, really super high levels.
Dr. Weitz: And what form of the estrogen and progesterone? Do you like topical estrogen? Have you used pellets?
Dr. Watson: I use whatever is going to work on the patient. I have generally tried to start with some of the topical forms because the topical forms, you don’t have to deal with that first pass effect. You’re using oral estrogen long term can increase clotting factors and you can have some concern with the liver…
Dr. Weitz: By first pass, what you’re saying is when you take an estrogen orally, it goes into the-
Dr. Watson: Highest levels go into the liver.
Dr. Weitz: Right, exactly. Thank you.
Dr. Watson: But I do use sublingual forms as well for some of my patients. Some women just do not absorb the creams or they’re not going to do it. They’re just not going to do it, so if it’s better in terms of using the … if you’re going to get better compliance, and they’re going to be happier using one of the other forms, I’ll use whatever is going to work.
Dr. Weitz: Now, one of the issues with using the creams is that serum testing may not accurately reflect hormone levels if you’re using the creams. Is that right?
Dr. Watson: They do sometimes. Well, I see both. I see some women where I’m just not getting good serum levels, that’s true. And I know that salivary levels can be used for that. My problem is salivary levels is that I’m just not sure how they know standardization, how they know what is an actual good dosage. But I see women on the creams all the time and on patches all the time. They get great blood levels, so I think that’s not as much of a problem. With the progesterone though, sometimes I have trouble getting good blood levels, and I have a lot of women that sometimes I have to switch them to oral progesterone. The oral progesterone doesn’t have the same risks as the estrogen. It’s very well absorbed. It actually helps better with sleep, so a lot of my patients will do the oral progesterone instead.
Dr. Weitz: Now, when a woman’s menstruating, her progesterone levels are much higher a couple of weeks during the period and estrogen levels tend to fluctuate and spike prior to ovulation. Do you use static dosing for hormones, or do you use rhythmic dosing?
Dr. Watson: I tend to use more static dosing for hormones, although there are certain doctors that will do the rhythmic hormones and I’m learning a little bit more about that. And I have a couple of patients who have been doing that. There’s the Wiley Protocol, which was the first protocol for that. I think it just depends on the patient and what they’re going to be able to do. If you have someone who’s not going to be able to pay attention to switching off and doing a different dose every single day, then you’re not going to get good compliance. I sometimes have trouble with women even remembering to take the progesterone. I’ll say like, you got to think that progesterone, it’s really important.
Dr. Weitz: Right.
Dr. Watson: … if you have a uterus.
Dr. Weitz: Right.
Dr. Watson: And there are some women that actually don’t have a uterus that like the progesterone anyway. They actually feel better on it.
Dr. Weitz: So then the reason why the progesterone is so important for a women who has a uterus is because it stimulates the sloughing off of the increased endometrial tissue that happens from the estrogen, right?
Dr. Watson: Well, it’s not so much sloughing off. It balances the possibility of the estrogen causing the lining to get thick.
Dr. Weitz: Right.
Dr. Watson: Because in women that are doing these static dosing, we don’t usually see them bleed, so it’s not like the lining is getting thick. If they’ve got an adequate amount of estrogen and progesterone, it’s usually … and also these are low levels. We’re not doing high levels like someone does when they’re menstruating. So you won’t necessarily see the lining get thick if you’ve got the dosage, right?
Dr. Weitz: Right. Do you ever measure the uterine lining level?
Dr. Watson: All the time. All the time, yeah.
Dr. Weitz: Does hormone replacement therapy protect the heart?
Dr. Watson: Well, that’s a controversial question right now. According to the research, if you start estrogen early on, if you start it early on in menopause in the first few years … That’s one of the things that we’re encouraging right now, is that the benefits that women get in menopause starting hormone replacement early. It’s better to start it early in terms of protecting the bones, protecting the heart, protecting the brain. What happened was when they took-
Dr. Weitz: When you say starting early, you mean during perimenopause or shortly after menopause starts?
Dr. Watson: Within the first year of menopause really.
Dr. Weitz: Okay.
Dr. Watson: I tailor my hormone replacement to women based on what their comfortable with. There are a lot of women that if they’re afraid they’re going to get breast cancer and they’re doing fine, then I’m not going to push hormone replacement on them. Years ago when I first started practicing and then there were a lot of women who were trying to decide whether to do hormone replacement because the research indicated that it had such good protection on the heart, I had patients come to me and say, my gynecologist wants me to take these hormones and I don’t want to do it. Because the gynecologist were really like, “This is going to protect you and this is really important.” And then the study came out and everyone was like go off the hormones, these are bad, they’re dangerous, stop the hormones. Now we’re in a reset period, I think, where you have to really choose what is going to be best for your patient individually.
Dr. Weitz: What do you think the consensus is right now in the standard gynecological community?
Dr. Watson: Unfortunately, I think there are a lot of gynecologists out there that they’re against hormone replacement. Because I’ll have-
Dr. Weitz: They tell the patients that they’re unsafe, right?
Dr. Watson: Yeah, exactly, which I don’t believe to be true. Although, again, I think it depends on each individual person and based on their family history.
Dr. Weitz: Yeah, from what I’ve seen…
Dr. Watson: And also there are symptoms. If I have someone who comes in and they’re having no symptoms whatsoever, they’re sleeping fine, they’re doing fine, they’re not having any menopausal symptoms, I may just give them a vaginal cream because the vagina usually will need some estrogen support. But I’m not pushing hormones on someone just because. Right now, the NAMS, the National Menopause Association, they recommend using hormone replacement for menopausal symptoms, for quality of life symptoms. And so if I have someone who’s really having bad symptoms, I will encourage them to use some hormonal placement.
Dr. Weitz: What about women who have a history of breast cancer, but are having vaginal symptoms? I’ve heard some practitioners using topical testosterone and even topical DHEA for women who are really petrified about taking estrogen.
Dr. Watson: There’s two classes of things here. There’s the woman who had breast cancer. Now, I actually have some of my patients who’ve had breast cancer on hormone replacement because their cancer was a slow growing cancer. It was easily excised, it was small, it was low risk. And their symptoms are so bad in terms of depression, mood swings, hot flashes, sleep problems, that I will put them on the dose of hormones. But then if I have a woman who was menopausal, she’s had breast cancer and she’s not having any symptoms, or that she’s being followed by an oncologist who has specific like, don’t give her more most, you can use estrogen, just estradiol cream. You can use estriol cream, you can use DHEA. There’s a commercial grade suppository and then there’s an over the counter grade suppository with DHEA. Testosterone works great in these women and sometimes even helps with some of the menopausal symptoms. So all of those things are viable options for a woman that doesn’t want to do systemic hormones for just the vaginal dryness.
Dr. Weitz: So, which is your go-to? Is your first thought to use a topical estrogen rather than the testosterone or the DHEA? Or do you think they all work equally effectively?
Dr. Watson: For a woman that’s had breast cancer?
Dr. Weitz: For a woman who’s had breast cancer, but who wants help with vaginal dryness and atrophy.
Dr. Watson: Well, I’ll usually use the estradiol first just to see how they do. I check blood levels, so if someone has a low testosterone, I will. And testosterone is very well measured in the blood. And if someone’s testosterone is low, or the estrogen doesn’t work, or they’re having sexual dysfunction, where they’re having trouble with orgasm, testosterone works really well for that. It also works really well as an antidepressant. I’ve had some women even not with breast cancer, but some women. I had one woman, I gave her testosterone and she went off her antidepressant because she didn’t need it anymore. So there’s a lot of good benefits to the testosterone, but there are side effects too. You can get hair loss, you can get acne, and you can get irritability, or some women even with the lowest dose of testosterone, they’ll get rage and irritability and sharp with their partner and we don’t need that. So some women just have bad effects with testosterone. But for the woman that testosterone works for, it’s amazing.
Dr. Weitz: For your typical protocol when you have a woman … Getting away from the breast cancer thing, if you have a woman in the first year of menopause, and you’re going to put her on a program. Besides putting her on estrogen and progesterone, if testosterone levels are low, if DHEA levels are low, do you typically supplement those as well? And what about other hormones like pregnenolone?
Dr. Watson: My experience with pregnenolone is though I love it and I think it can be important for brain health and function, especially if you have someone who’s got MS or even any neurologic problem, but I’ve never seen … theoretically, it’s supposed to have a cascade effect where you would take the pregnenolone and it goes into different pathways. I’ve not really seen it actually raise estrogen levels. So I will use it if the levels are low and if someone’s having those particular symptoms. What I like to do is usually start them on estrogen and we discussed which kind to use. Like the patch, there are other issues like the controversy about compounded versus commercial brands because in the conventional medical wisdom like the OB-GYN’s group, ACOG, the American College of OB-GYN, they’re totally against compounding. They talk about compounding as being like it’s not measured, it’s not accurate, you have no way of quality control. And-
Dr. Weitz: And there’s been a movement to try to shut down the compounding pharmacies, right?
Dr. Watson: Right. And I try to use compounding pharmacies that I know that have reliability, that I know to do batch testing. They test their products, so I know that I’ve got someone who’s really paying attention. Have I seen some women get a batch and say this is not right or there’s something wrong with it, or some levels are really high? Yes, I have seen that before. Don’t forget, also even in the generic versus brand, there’s a certain percentage, like what, 20%, which doesn’t have … It has either low levels or higher levels.
Dr. Weitz: Actually, it’s a whole other topic we can get into, but there’s a huge problem with generic drugs right-
Dr. Watson: Drugs right now. Yeah, I’m seeing a lot of that with a lot of the drugs that I see. So I’ll use the patch. Again, it depends on the woman. It’s like if they don’t want to wear a patch because they’re swimmers or they take baths or exercise a lot, I’m not going to use the patch. But as someone who wants to be able to get the hormones covered by their insurance, the patch works great. And if they’re not going to take it, they’re not going to put a cream on every day. The patch works great, and it is bioidentical estrogen. It’s the pure estradiol. And then there are a couple of other-
Dr. Weitz: What are the advantages of using compounded hormones?
Dr. Watson: Well, I like them because you can titrate the dose more easily. And you can also decide, you can start with lower doses and titrate up if you have someone who you’re not sure what their dosage is going to be. It’s a little bit easier to do that. And also, if you’ve got someone who you think is going to have trouble metabolizing the estrogen, I’ll have someone, I’ll give them estrogen and it’s like, whoa, it’s way too strong. Even the lowest amount, you can have them stop for a couple of days. Once you put the patch on, you have a little bit less regularity. The other thing, some of the other commercial brands of estrogen that are available at the pharmacy, they’re in an alcohol base and I tend not to like those alcohol bases very much, but some women do fine with them.
Dr. Weitz: And sometimes women can have reactions to the binders and fillers and things like that, that they’re made with. So by going to a compounding pharmacy, you can have some control over how they’re made.
Dr. Watson: Some of my patients have the estrogen put in olive oil, which is very clean. They can just put it right on their skin. There’s a company that will make it an emu oil, and you can use hypoallergenic bases. So yeah, for especially someone who’s sensitive and going to be sensitive to chemicals, there’s a lot more options with compounded. And also, I find that the regular progesterone, the commercial grade progesterone, is in peanut oil. And some women can’t do the peanut oil, so you can have the progesterone made in a compounding pharmacy in your olive oil base or canola oil base, or even a powder base.
Dr. Weitz: And then how often do you add DHEA and testosterone as part of the mix?
Dr. Watson: Well, I usually start a woman on the hormones and then recheck their … I like to use estrogen and progesterone alone to start because then if they have a side effect or there’s anything that changes in terms of their metabolism, then I know exactly what to do, and I’m not dealing with a lot of other variables. Because with the testosterone and DHEA, those hormones also can go into the metabolic pathways and if a woman has a very strong aromatase level in her body, she will convert that DHEA and the testosterone into estrogen. And I’ve seen that happen before. I don’t want to add that in until I know what I’m dealing with, with how they’re doing with the estrogen. So I will start on estrogen and progesterone, and after about a month, I will check the levels and see where they are and then add in the DHEA and testosterone if their levels low.
Dr. Weitz: What about the benefits of bioidentical hormones for the brain?
Dr. Watson: There’s a lot of research that shows that the hormones really are beneficial for the brain. There’s certainly even in the women’s health study there, well, there’s some confusing things in that study. Because on the one hand, it did show that there’s less Alzheimer’s in women on hormones. But then there was at one point, a study that came out that showed there was increased dementia. And again, I bring up the issue is like in that study, those women were … Here’s the other benefit of starting the hormones a little bit earlier. If you start a woman on hormones later, you don’t get the benefits to the vascular system and you can get more plaque formation, more atherosclerosis. One of the few things that no one talks very much about is that estrogen and progesterone have a protective effect on lipids. I see this all the time. I have a woman who’s got low … I’m one of them because I always had a cholesterol of 180 something. My cholesterol was a non issue, and as soon as I went into menopause, even on hormone replacement, my cholesterol was a little higher. My LDL tends to be a little bit higher. So what happens in that study where they took all these women, they started a lot of these women in their 60s who could have had already vascular changes already. And then you add to that, the fact that you’re using an oral preparation, which increases clotting factors, so you’re going to increase the risk of stroke. If you look at all those statistics, you can’t make assumptions that if you start a woman in their early 50s on the bioidentical hormones, that it’s going to increase their risk of stroke because it’s like comparing apples and oranges. But it’s very clear that there’s better cognitive function in women on hormone replacement.
Dr. Weitz: Oh, I just wanted to cycle back to one thing you talked about before. You were talking about the adrenals.
Dr. Watson: Right.
Dr. Weitz: Does the adrenal function, and how do you support adrenals?
Dr. Watson: Well, first of all, you want to test. I’ll do a test, I’ll do … And part of my hormone panel is to check the cortisol levels. So I’ll look at cortisol levels.
Dr. Weitz: So you’re are talking about serum cortisol?
Dr. Watson: Serum cortisol levels, but in some of my patients, I will also do the salivary levels. Well, the spaces are 12 hours salivary test, where you do morning, noon, afternoon, evening.
Dr. Weitz: Do you include the cortisol awakening response?
Dr. Watson: Right, yeah. And so you’ll see some women who will still spike in the middle of the night, or you’ll see where they don’t really get a good cortisol … Cortisol should be higher in the morning and then go down as the afternoon goes up, but you’ll see some women that are flatline and then they go up at night. These are the women that are having trouble sleeping. And then there’s also the dried spot urine. There’s a company that does the dried spot urine, where you’re doing the four samples throughout the day.
Dr. Weitz: Right. The DUTCH testing?
Dr. Watson: Yeah, the DUTCH testing.
Dr. Weitz: Yeah, actually, one of the advantages of that is when you do the cortisol awakening response, and they have to spit into a tube as soon as they wake up, that’s always problematic.
Dr. Watson: Right, yeah.
Dr. Weitz: But The DUTCH testing, they just put a little cotton swab in their mouth, get it wet, and that’s all they have to do.
Dr. Watson: Yeah. No, it’s a good test. It’s a good test. So for adrenals, I tend to use more herbs for the adrenal gland. There’s a lot of great formulas that are out there. One of the other herbs that really is good is maca root for women, for both perimenopause and into early menopause. And even some of my women who have had breast cancer, who don’t want to use hormone replacement, maca is a great herb because it doesn’t actually have plant estrogens in it. It basically helps stimulate the production of estrogen and testosterone. So maca is a great herb. Licorice root, just the ginsengs.
Dr. Weitz: So now do you have different protocols if they’re seeing a spike in the cortisol in the evening, as opposed to when it’s just flatline the whole time?
Dr. Watson: Oh, for sure. Because for the women that have the spikes, I’m using the phosphatidylserine products. There’s a couple of products that have phosphatidylserine. Magnolia works great. There are a number of commercial products that just help to lower that cortisol level, and so you give it to them in the evening, and that really helps. So, yes, I’ll use a lot of those. Ashwagandha is another one. That’s another really good herb for women that are having that or even men, that are having that issue where they’re having trouble sleeping and we think the cortisol or the cortisol is spiking.
Dr. Weitz: Right. And then the maca and the licorice root and some of those things to help stimulate the adrenals?
Dr. Watson: Right. But again, it depends on the person. It’s like, if you’ve got someone who’s spiking cortisol you don’t want to do heavy duty adrenal stimulants. You want good adaptogens, and that’s where the ashwagandha and the maca root really help with that.
Dr. Weitz: Okay, good. I think that those are the questions that I had. Is there anything else that you want to say before we wrap up our discussion here? And then-
Dr. Watson: I know you asked me about the pellets and I didn’t really address that.
Dr. Weitz: Yeah, okay.
Dr. Watson: I know some women really benefit from the pellets and they like it because it gives them like … if they don’t have to really worry about putting something on like a cream or a patch or taking a vaginal-
Dr. Weitz: Yeah, I know some women are concerned about the cream. It’s a pain, maybe it’s –
Dr. Watson: Right.
Dr. Weitz: … they don’t want to get it on their partner. There’s a bunch of different concerns that women have about the creams.
Dr. Watson: So again, I think it’s a very individual decision. I think the issue that I have with the pellets is that I see really high levels, sometimes in women, and they get side effects from it, where they get breast tenderness because the levels are very high…
Dr. Weitz: And you can adjust it once you-
Dr. Watson: You can adjust it, yeah. So I tend to not use the pellets in my practice. But again, I had women who just love them. I had a couple of patients, it was great and they were very happy. So I think it’s again, we’re very fortunate in that we have options. We have a lot of choices for women. We get individualized therapy and I think of above everything, I think that’s the most important thing. There is no cookie cutter approach. Years ago it was take Premarin and Provera, that was the thing. There was one dose and that was it. It is not a one size-fits-all. You really have to individualize it based on each individual patient, their genetics, where they are in life, how they metabolize the hormones. Everything’s got to be individualized.
Dr. Weitz: What is the status, by the way, of compounding pharmacies? I know that there was a movement to pressure the federal government into shutting down compounding pharmacies, and I know there’s a lot of controversy about it. Where are we in terms of that situation, the political situation?
Dr. Watson: I’m afraid I’m not really up on the latest of that, except the compounding pharmacies they are still providing hormones for my patients, so…
Dr. Weitz: Right, I know. I remember signing some petitions to try to keep them from closing them down.
Dr. Watson: I don’t think they’re going to be able to close them down. I think there’s too many patients that are getting benefit out of it.
Dr. Weitz: By the way, do you have a preferred dietary approach for menopausal women?
Dr. Watson: Well, as we go into menopause, we definitely have metabolism changes. I see that, so you’re usually more into the paleo diet, into more like making sure you’re getting … It doesn’t have to be high protein, but you need to make sure you get adequate amounts of protein. I love a plant-based diet, and I think it’s really great, but it’s just not for everyone. And so some of my patients they are doing a plant-based diet, but it’s too high in carbohydrate, not enough protein. And even if they are on a plant-based diet, as long as they’re getting good amounts of protein, they’re fine. But generally, the diet that I’ve been able to maintain my way into menopause, and how I do that is I eat a lot of vegetables and salads and lean protein and just keep the carbs and sugars to a minimum.
Dr. Weitz: What about the women who are on a plant-based diet? How can they get an adequate amount of protein? How much protein is adequate, and how can they get that without consuming a lot of phytoestrogens?
Dr. Watson: The recommended dose that I use is about 40 to 60 grams of protein a day depending upon what their needs are, in terms of how much they’re exercising. Especially though-
Dr. Weitz: Your body weight and how much exercise, yeah.
Dr. Watson: Yeah, because as you know, if women are exercising a lot, they need more protein. So using the protein supplements with pea protein or rice protein powders, just working with them on trying to avoid too much soy. So use other plant-based proteins.
Dr. Weitz: What about that whole soy controversy? Because soy contains phytoestrogens and some of the data seems to show that soy is protective against breast cancer because when you…
Dr. Watson: Right, that’s weaker estrogen.
Dr. Weitz: You get the weaker estrogen, attach to the estrogen receptor sites and block the stronger estrogens. In a larger study I think, of menopausal women who consume the most amount of soy, these were women in China, who had a history of breast cancer, had the lowest risk of recurrence.
Dr. Watson: I think there’s a premenopausal issue with soy and a postmenopausal issue with soy. Because certainly, in the premenopausal period when you have women with high hormone levels taking soy, then that’s a problem because it’s too much. And I’ve actually seen some women get breast problems and heavy bleeding and fibroids eating a high soy diet. The other problem with soy is its effect on the thyroid. Soy has an anti-thyroid effect. So I’ll see some women if they’re drinking a lot of soy milk or eating a lot of soy based products, their thyroid goes off, their TSH will go up. But their thyroid is still functioning, but the TSH is up and then you get them off soy and their thyroid normalizes, so I’m not a big fan of soy because of that. Plus, it’s very difficult to digest and can cause a lot of GI bloating, gas issues. But again, postmenopausal where you’ve got women who’ve got low estrogen levels, then those women may benefit from soy, as long as it’s in moderation. In places like China and Asia, they’re eating small amounts of soy. They’re not consuming large amounts of tofu and drinking soy milk. It’s a different kind of intake. They’re not taking large amounts of processed soy, though they may be eating tofu or something like that.
Dr. Weitz: How else can these women get enough protein besides soy? You say plant-based protein powders with pea and rice?
Dr. Watson: Yeah.
Dr. Weitz: Those are the kind you like the most?
Dr. Watson: Mm-hmm (affirmative), yeah. If I see that they’re not … I have a couple of women that they’re working out quite a lot, and again, what I see in women that are doing a high plant-based diet is you have to watch their iron levels and you’ve got to watch their B12 levels to make sure they’re getting adequate amounts. And yes, various different protein forms, and there are these different processed protein. So there’s the whole thing, the Impossible Burger and Beyond Meat and all that stuff, which it’s a very-
Dr. Weitz: What’s your take on that?
Dr. Watson: Well, it’s a very highly processed product. But again, it depends on if they’re not getting protein any other way then that may be something that they might need to do. But I just try to get them to do combinations of lentils and beans and rice and things, but just keep the portions small enough so they’re not getting a high carb load. But it’s possible to do. We have people that are working out that are gaining muscle mass, and I’m sure you have them you have them too who are eating a plant-based diet. It’s definitely possible. You just have to be conscious about it. And what I tell people to watch for is watch for their sugar cravings because if you’re craving sugar, you’re not getting enough protein.
Dr. Weitz: Or you’re taking in too many carbs, yeah.
Dr. Watson: Right, yeah.
Dr. Weitz: So your preferred diet is a paleo diet that’s basically lower in carbs, and it basically does not include grains and beans like the paleo diet does.
Dr. Watson: Again, it depends on the person and how they have metabolize that, but for me, because I’m postmenopausal and I’m on hormone replacement and I’ve been able to maintain my weight all these years, that’s what’s worked for me. And that’s what has worked for me, so I’m still the same weight I was when I was in my 20s.
Dr. Weitz: Great, awesome now.
Dr. Watson: And I really don’t eat a lot of sugar. I think that’s the key. I keep that to a minimum in terms of sweets and candies and things. Not part of my diet.
Dr. Weitz: That’s good. Okay, awesome. So how can listeners and viewers get ahold of you if they want to contact you or find out about your books?
Dr. Watson: I have a website, but the books actually, unfortunately are out of print, [crosstalk 00:54:31] and I’ve been very busy in my clinic, so I haven’t really-
Dr. Weitz: When is your next book coming out?
Dr. Watson: That’s the question. Well, I am a full-time clinical practitioner, so not a lot of time to write books these days. Maybe when or if I slow down a little bit, I’ll have more time to do that. But it’s not part of my schedule right now. I’m pretty busy in the office. I’ve got a big practice, I’ve been practicing for a long time. I have people I’ve taken care of for a long time, so that’s the main focus for me. My website is watsonwellness.org, so people can check that out. There’s a lot of information on the website about me. And yes, the books definitely are something that I would like to get back out again, but it just doesn’t seem to be part of the schedule.
Dr. Weitz: Well, you can take one of those books in and just come up with a new version of it.
Dr. Watson: Right, yes, that’s on my to do list.
Dr. Weitz: And are you accepting new patients?
Dr. Watson: Yes, I am. Yes.
Dr. Weitz: Okay, awesome.
Dr. Watson: Okay.
Dr. Weitz: Thank you, Cynthia.
Dr. Watson: All right. Thanks, Ben. You have a great day.
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