Jaclyn (00:01)

So Dr. Scott, thank you so much for being on the Dutch podcast. Again, it's always so nice to get the chance to talk with you.

Tara Scott, Hormone Guru (00:07)

You're welcome and thank you for continuing to get the important information out there.

Jaclyn (00:11)

Absolutely. So today we're going to talk about a lot of different elements of HRT, particularly around breast cancer, because it is breast cancer month. But I'd love to start by just sharing, if you can just remind listeners or people who are maybe new to this because of a breast cancer history they've stumbled upon this talk or breast cancer risk, can you just share a little bit about what is HRT? And really, what are you seeing doctors utilize in the health care space?

Tara Scott, Hormone Guru (00:39)

Well certainly it's interesting how HRT is in the news lately because Gwyneth Paltrow and Halle Berry and Drew Barrymore and all these celebrities that are going through menopause or have gone through menopause so it's definitely getting the media attention. And you know 20 years ago there was a study that was probably the wrong study and the wrong patient in the wrong cohort with the wrong medication and medications we don't really use right now and really scared a lot of people from using hormone therapy. And I think if you pulled 10 family practice doctors, 10 of them would tell you not to take hormones. And I think actually probably nine OBGYNs would probably tell you not to take hormones.

So hormone therapy is any replacement therapy and they don't even want to say replacement anymore. They want to say hormone therapy is supposed to be a duplication of what your body produces. So your ovary produces estradiol and progesterone, a little bit of testosterone, and traditionally a form of estrogen and a form of progesterone had been given. Now in the past, they were more similar to birth control pills because those are synthetic and the whole point of birth control pills is to prevent pregnancy. So when they were trying to get, hormones way back in the 1940s, they didn't really know how to make progesterone in its natural state. So they made a synthetic version of it.

Nowadays, we have many, many FDA approved what we call bioidentical hormone therapy. And the word bioidentical, all that means is that it's chemically, structurally the same to our bodies. So for example, we have sugar and we have Splenda and sucralose and saccharin. We have all these artificial sweeteners that all they do is sweeten your coffee. But if you're a diabetic with a low blood sugar and you took one of those like Splenda, it wouldn't raise your blood sugar. It would do nothing. It just sweetens your coffee without any calories. So that's kind of how I explain to my patients the difference between bioidentical is chemically the same as what our bodies produce. There still are synthetic hormones available and the bioidentical hormone doesn't mean they can't be synthesized in a lab. When I was a resident we used to give beef and pork insulin to diabetics. So some people would have like allergic reactions to beef or the pork, right?

Well, now someone figured out in the lab how to make human insulin. So we give patients human insulin. We don't get insulin from other donors and make it. Someone makes it in a lab. So it's the same as hormones. so bioidentical hormones just means that it's the same as our bodies.

Jaclyn (03:16)

So it is interesting that you bring up the whole like hormone therapy versus hormone replacement therapy and that was emphasized actually really recently, NAMS, the North American Metapod Society, released a statement because they had an event and at the event there was so much chatter amongst the attendees that there is a tremendous amount of misinformation circulating online. So they released a statement really to re-emphasize the points that they've always made. But I think it's worth kind of talking about those. That first one that's so interesting feels probably the most controversial to me, which is that we've always called it hormone replacement therapy and they did too for a long time, but now they are calling it hormone therapy for the following FDA approved indications saying replacement is not necessary in menopause. So let's start with that comment. How did that land for you when you read that?

Tara Scott, Hormone Guru (04:05)

Right, I know. So the first thing, it's so interesting because, you know, we don't get the same guidelines about men's hormones, right? And so for men's testosterone therapy, there's much broader indications to use it. For women for hormone therapy, the first point that the menopause society made was that it's not necessary to do it, right? And so I think because of social media, maybe there are some influencers or maybe there are some even just people who are normal people that ended up being influencers because of their experience that they've shared on social media. There may be interpreted that you have to take it.

And so I believe 100 % of women should be told of the risks and benefits. They should have their own personal history and situation assessed and they should have the opportunity to choose to take it. But I don't, I wouldn't go so far to say that every single person needs to take hormone therapy. I just think everybody needs the opportunity to be evaluated and know of the personal risks and benefits of hormone therapy. So it was pretty clear by that statement that we can all that they were advising hormone therapy as indicated by the FDA for four indications. The first is what they say, moderate to severe vasomotor symptoms. So that I don't know how you define that if they've actually said, you know, 20 hot flashes or 10 hot flashes, but moderate to severe to me means that your hot flashes are disruptive, right? Two is prevention of osteoporosis. You can't say treatment, prevention of osteoporosis. And I think they even, correct me if I'm wrong, Jacqueline, they might've had a qualifying age for that. Cause I know they designate premature menopause as the third indication. So it's menopause before the age of 45.

Jaclyn (05:53)

Yes.

Tara Scott, Hormone Guru (05:59)

Primary ovarian insufficiency is now called, it used to be premature ovarian failure, primary ovarian insufficiency is before 40 and premature menopause is before 45. Natural age of menopause is 52. So the recommendation from the Menopause Society based on their 2022 position statement is that if you're somebody who has had your ovaries removed before the age of 45, it actually, there's more benefits for you taking hormone therapy at least until the age of natural menopause because of the markedly increased risk of heart disease. Now we're not allowed to say it's going to prevent heart disease. And the fourth indication is genitourinary symptoms of menopause, which is vaginal dryness, painful intercourse, painful urination, frequent UTIs, pain with sex. So any of those vaginal complaints, that would be an indication for hormone therapy according to the FDA.

And so there are other benefits of taking it, but we can't say.

Jaclyn (06:52)

Now they.

Yeah, it was interesting because they really kind of debunked. I thought they were a little overly strong actually in that section of their statement, which is like, we should not be discussing hormones for the following reasons. And it really listed a lot of the symptoms that women come to their provider with around menopause and really want relief from. More fatigue, brain fog. I can't remember everything that was on the list. I don't have it in front of me. OK. cognition.

Tara Scott, Hormone Guru (07:21)

mean, was cardiovascular health. mean, even though there are studies that show, right, it was definitely fatigue and brain fog. And I think there are many studies that show it does help cardiovascular prevention, but this WHI, which was done in 2002, failed to show for the FDA that their product, which was...a synthetic version called Premrin and Provera, it failed to show that it was prevention of heart disease. And that's what that's based on. There have been a lot of observational trials, right? But for the FDA to put their stamp on it and say that, it does prevent heart disease, they want a randomized placebo control trial. And this WHI, everyone says it's the largest one we've had, but if you actually look at the number, it was only 8,000 people who got the drug and 8,000 got the placebo. To me, 16,000, it sounds like a decent study, but we have studies of 80,000 people, but they're observational, right? So that's the difference.

Jaclyn (08:24)

Yeah, it's so interesting because I think in a way when I read that, absolutely it's true. It's only FDA approved for certain indications. However, I think clinically providers that prescribe...hormone therapy really see women experience relief of other symptoms as well. it's a matter of, like you said, that we need to clarify. These are not FDA approved indications. However, there are trials that exist that show the following in order to tell that whole story when you're helping a woman consider whether or not that's right for her.

Tara Scott, Hormone Guru (08:56)

And if you actually look back to their 2022 position statement, mean, they have verbiage in there that shows observational studies show that there's a 19 % reduction in diabetes in patients who choose to take hormone therapy. And we all see weight gain at menopause, people's women's cholesterol just jump up. I mean, I've never had a problem with my cholesterol. Boom, it just went up, you know, and not just HG, we're not talking about HDL, we're talking about LDL.

Jaclyn (09:08)

Hmm. Interesting.

Tara Scott, Hormone Guru (09:23)

not triglycerides, but like for no reason. And we're talking about diabetes, weight gain. So that's well been documented. And in the studies they did out of the University of Colorado, and again, I'm guessing these were observational studies. They showed that basal metabolic rate did change with menopause and exercise did not improve that, but estradiol patches did. Again, observational data. And I don't remember how big this was.

Jaclyn (09:26)

Mm-hmm.

Yeah. Now the last thing that was on that that I wanted to get your thoughts on was the use of testosterone in women. They really clarify that it's a very narrow indication for testosterone, yet we see testosterone prescribed much more broadly. In fact, there is even schools of thought in integrative medicine and some providers who start with testosterone therapy, which I think is a pretty controversial approach instead of an estrogen and progesterone approach. And I can see why they're wanting to reemphasize their position statement really, which is what they did in this. But what are your thoughts about that, that narrow window for testosterone? And of course, that's...

Tara Scott, Hormone Guru (10:28)

So it's interesting because the Endocrine Society guidelines on male testosterone replacements says you can replace male testosterone hormones for testosterone levels at the low end of normal. Doesn't even have to be abnormal. Low end of normal for erectile dysfunction, low libido, fatigue, low mood, low stamina. Okay. And for females, the Endocrine Society says there is no condition of hypoandrogen that exists for women. The lab ranges are not I can't remember the verbiage, but they're not accurate because we have free testosterone levels that are 0 to 2.2 are a normal range. So 0 somehow is a normal, included in the normal range. And it says that you can't correlate symptomatology with blood results. So don't do the blood results. And it also says it's only indicated for postmenopausal women with hypoactive sexual desire disorder, which is now called female arousal disorder.

So it used to be HSDD. So low libido basically in postmenopausal. And so there's quite a dichotomy as far as male hormone therapy and female. Now, having said that, there was the global consensus on testosterone that was published in September of 2019 where they looked at the world's data on testosterone. There's quite a bit of data because they were trying to market a testosterone patch at one time.

Jaclyn (11:42)

Yeah.

Tara Scott, Hormone Guru (11:59)

And it didn't come to market because there were safety concerns or efficacy concerns. They said they didn't have enough data. But if you look at the studies on testosterone gel for men, they had similar amounts of data. nothing was concerning. And I think from a marketing perspective or maybe a business perspective, nobody decided to push it through. So it's not available in the United States. I think at one time it was available in Europe. I don't know if it's still available.

So with that narrow indication, know, that global consensus said, you know, those things, but the last line said it does not increase cardiovascular risk in women. And two, it does not increase breast cancer.

And so that's in the global consensus on testosterone. And so, you know, a lot of people are concerned about that. Having said that though, like you said, it's very liberally prescribed. There are some schools of thought that believe in driving the levels, what we call super physiologically. So for an example, if your normal testosterone level is 16 to 55, they're aiming for women to have a level of 150. Again, it's another approach. I don't really practice that way, but that is another approach they're using higher doses in a form called pellet, which is a super compressed hormones that's surgically implanted into your hip. And then it has to degrade over a couple of months. and you know, and some women are feeling really good. Now, again, you know, I can't say that's without risk because we, those, those hormones aren't often monitored as to how they're metabolized, which is one of the key things that the Dutch test looks at, right? Is how is it metabolized? And when I see people being prescribed estrogen, sorry testosterone, they're almost never looking at estrone, which is a key metabolite of, you know, where testosterone can go in men or women. So it's interesting.

Jaclyn (13:56)

Mm-hmm. Yeah, that downstream metabolism is critical to take a look at to make sure because one of the routes of elimination for testosterone is through estrogen and then estrogen detoxification, aromatization to estrogen, and then estrogen detoxification. absolutely, we agree both looking at androgen metabolites as well as looking at estrogen metabolites are really critical for anyone on testosterone therapy. And you are subtly pointing out over and over a couple of times here just the differences in the grade of literature required to make a recommendation, particularly around these quality of life concerns like fatigue and libido. There were a couple other that you mentioned that jumped to mind where there is a different approach taken for men and for women. I actually didn't know that the normal range for free testosterone went down to zero. That seems mind boggling.

Tara Scott, Hormone Guru (14:49)

And it might be just, it must be just, it depends on the lab, but it's not very far from zero. It might be 0.1. I mean, it's ridiculous, you know, and that's for free. Yes.

Jaclyn (14:53)

Right.

Mm-hmm. That's crazy. That is crazy, because we do know testosterone plays a critical role, even in cycling females. It's really important. It's so important. So.

Tara Scott, Hormone Guru (15:08)

Yeah, it's not really just actually there's it's not really just libido and it's not hair and skin and nails. There's actually studies of women who had lower levels of testosterone and they extrapolate out for diabetes heart disease and they still had higher levels of death mortality rates. There's studies where they gave testosterone to elderly women with heart failure.

Jaclyn (15:13)

No.

Mm-hmm.

Tara Scott, Hormone Guru (15:30)

And it improved their injection fraction. Because if you think about it, testosterone helps your muscles and the heart is a muscle. So I think there's just so much misunderstanding and it just goes down to your approach with anything. Right. Because I could sit here and say, only if you're feeling terrible, I'll give you hormones, which that's not really my approach either. Or I could be like, hey, let's juice you up. And you know, there's hormone.

Jaclyn (15:34)

Hmm, right.

Mm-hmm.

Tara Scott, Hormone Guru (15:53)

people who think you should have a period till you're 80. Let's give you enough estrogen so you have a withdrawal bleed and let's give you this level of testosterone. And it exists in any space. Look at our weight loss space now that there's people taking injectables for five pounds, whatever it is, you know what I mean.

Jaclyn (16:05)

Right.

Mm-hmm. So one thing that I think is interesting and will be interesting to follow is that particularly around safety data and testosterone is that now we have this whole body of literature coming out for trans males, which are individuals who were born biologically female, assigned female at birth, and go through a hormone replacement therapy process.

Tara Scott, Hormone Guru (16:21)

Yes.

Jaclyn (16:29)

to become a trans male, and that is incredibly high doses, much higher than we'd ever use for a menopausal female because the intent is to produce male-like symptoms, different patterns of hair growth, muscle growth, et cetera. So that literature is really starting to grow around safety and around outcomes, and those are at multiples of the doses that would be used that we're talking about here. I'm really...curious to see how that bears out over time because it's going to be difficult to deny at least safety. Maybe the need for testosterone would still be debated, but the safety data for testosterone for women should be made pretty clear. Or if it's not already, I haven't looked at that literature yet, but we should be seeing more and more.

Tara Scott, Hormone Guru (17:14)

Yeah, and according to this global consensus in 2019, there was not a concern about heart disease and cardiovascular and breast cancer. They didn't put dosage recommendations on there, right? So they didn't say super physiological doses will or won't.

Jaclyn (17:26)

Mm-hmm.

Tara Scott, Hormone Guru (17:31)

So that will be interesting. There have been some studies on pellets, which is generally superphysiology, that there wasn't an increase in breast cancer specifically. I haven't pulled the literature for cardiovascular or anything, but actually at the conference that you and I both had, I think she did speak about that. And there wasn't, there didn't seem to be an increased risk of cardiovascular risk with women using pellets. So, I mean, as anything in our space, you really have to treat the patient in front of you. We say N of one, meaning like,

Jaclyn (17:32)

Yeah.

Hmm.

Tara Scott, Hormone Guru (18:01)

What is your personal history risk? And that's why I think it's important to know how everyone metabolizes hormones, all hormones, cortisol, estrogen, testosterone. And I feel like everyone at some point, if they're able, should do the dried urine tests to look at their pathways, because those are genetically influenced. They're augmented and induced by other external factors. And it's a critical piece after being in the industry for 30 years of what we missed, what I missed when I started doing hormone therapy.

Jaclyn (18:29)

Mm.

That's great. Thank you for that. And I do I think you're absolutely right. So I want to shift to the breast cancer piece, which is really the intent of what we're talking about today. But I appreciate you sharing your thoughts on this kind of more current release. And we will link to that in the show notes if you're a provider and you want to read it. And I think really the underlying sentiment of misinformation on the web is very real. I see it all the time. I see nutritionists who come online or health coaches who come online and say every woman should be on hormone therapy and and of course those broad sweeping statements are never true or very rarely true but I love the way you position it that 100 % of women should be told about this option as a transition through perimenopause into menopause and have their individual risk factors assessed so they can really understand you know, whether that's a positive thing for them or whether that would be a risky approach for them and whether they even want it. But I love the way you say 100 % of women really deserve to know. I couldn't agree more.

Tara Scott, Hormone Guru (19:30)

Yeah, they deserve it. You're absolutely right about the misinformation. I mean, I've seen people post that there's no increased risk of breast cancer. you know, going by the guidelines of the Menopause Society, we have to quote, and I quote all my patients, three out of 1000 is what the risk is thought to be if you choose to use PremPro, which I don't prescribe, but one out of 1000 for bioidentical.

Jaclyn (19:37)

Mm-hmm.

Tara Scott, Hormone Guru (19:55)

So not a percent, but one out of 1,000. So you still have to say there's that, how do we know in the patient that we're seeing that there isn't already a cancer brewing there?

Jaclyn (20:04)

Right. Well, and studies only go out five years, right? So we, as far as what is, you know, when can we really say that with authority, guidelines say in the first five years of use.

Tara Scott, Hormone Guru (20:08)

Okay.

Yes, and if we look at the statistics of one in eight, having a breast cancer risk and about 13%, somewhere around 13 to 20 % being genetic, well, now people are getting their genetic predisposition. If they know they have a family issue, there's more and more genetic testing, which is great. women are acting on that. But yes, I don't think you can never say there's no risk of anything.

Jaclyn (20:41)

Right, yeah, of course. One thing about the WHI, the study that you talked about, the beginning that really set the negative tone around hormone replacement therapy for females is that they put relative risk in that paper, not absolute risk. So they showed it as like percent increase from a woman not on therapy to a woman on therapy, but it was almost like a disproportionate, except the wrong tone for the results because like you said, on therapy, was like one in 1,000 women, is, although the relative risk went up, the absolute risk was still very, very low.

Tara Scott, Hormone Guru (21:14)

Yeah, and that's, know, when you see the data published on estrogen only, and I know this is a debate on breast cancer and I…I will eat crow if I have to, but I feel like estrogen only is a risk for breast cancer. The statistics of people who took a placebo in the estrogen only arm of the WHI that got breast cancer was 0.35%. And the women that got breast cancer on Premarin was 0.27%. That's the difference. That's the decrease. It's not even a half a percent. And that's what they're broadcasting. That was the percentage. Now I'm not a statistician.

I don't know how you do relative risk, P value, was it statistically significant, but everyone I talked to was like, there's no risk of breast cancer with estrogen only.

I do feel it's a risk and is very concerning to me because that was 5,000 people in placebo and 5,000 people that got the drug that were 65. But we have the nurses health study that was 122,000 people, younger women, that the longer they were on estrogen only, was like 10 to 19 years was 15 to 20 % and longer than that was up to 30 or 40%. And don't quote me on the percentages, but it was large percentages of increased risk of breast cancer. And then we have the E3 EPIC. Another observational trial, but 80,000 women, 40 to 64. And in the women that took estrogen only, and most of that estrogen was transdermal estradiol because it was a French study and they weren't using oral estrogen. They weren't using Premarin, they still showed an increased risk of breast cancer in estrogen only, and that will last eight years. So it concerns me what we know about the uterus is we would never give estrogen only to somebody with a uterus. And if you go to my textbook that I had in residency on reproductive endocrine and gynecology, our author, Dr. Spirov says the breasts and the endometrium are similar cells. Like you can even see studies, one study by Stanzyk that people with endometrial cancer had an increased percentage incidents of breast cancer. So I am not with the standard of care, which is to only give estrogen to people with no uterus. And that concerns me. I mean, if there was another recent study that was published that said there was no increased risk, I don't remember the details of it was a retrospective chart study, I believe.

Jaclyn (23:41)

Mm-hmm.

Tara Scott, Hormone Guru (23:42)

but Romanoski, think was a lecture, was the lead author and they did a retrospective chart site. Now, I don't know. And the other theory that I can't collaborate is that in Premarin, because there's a lot of things in Premarin, there is some progesterone. There's like 500 things in there. So is there some progesterone in conjugate equine estrogens that's giving some protection versus estradiol only? I don't know, but that's

Jaclyn (24:11)

Hmm.

Tara Scott, Hormone Guru (24:12)

I feel that as a risk factor for breast cancer based on those three larger observational trials and based on my textbook.

Jaclyn (24:20)

Now when you say you're not with the standard of care for estrogen only for a woman without the uterus, what you mean is that you would still consider giving progesterone to a woman without a uterus for breast cancer. Thank you. I just wanted to make sure we said that out loud so that like that's exactly what you'd meant was that.

Tara Scott, Hormone Guru (24:30)

always can't progesterone. Yes. When I describe estrogen, I always prescribe progesterone. I have a few patients that cannot tolerate certain forms of progesterone, so we may pulse it and find a form that is acceptable for them. But

Well, you, as soon as you get a breast biopsy done, you have an estrogen and progesterone receptor. And that's what we send to pathology as well as her to new. So everyone gets the receptors. So there is progesterone receptor in the breast. There is a progesterone receptor in every cell of your body. So when you say you're replacing one hormone without the other, you know, it just be like you took your money and you put all of it in the stock market and you didn't have any real estate and you didn't have any savings account. mean, the stock market is so volatile, you could lose your whole, you know, there are different types of investments, right? So why would you not diversify, right? And so it's one hormone versus three or potentially four or five that our body produces. So it's controversial because the standard of care and what is traditionally acceptable.

Jaclyn (25:22)

Mm-hmm.

That's great. I love that analogy.

Tara Scott, Hormone Guru (25:34)

is to give estrogen only after because I think that came from the WHI where the progestin group increased the risk of breast cancer and then they started blaming it on the progestin which was provera or midroxyprogesterone acetate and there's several studies that do confirm that that actually increases the risk of breast cancer. So they don't understand the difference pharmacologically, physiology of a progestin and a progesterone. That's the problem. So don't give a progestin to someone without a uterus.

Jaclyn (26:04)

Now there are a couple of small French studies that look at progesterone and impact on breast that aren't really widely talked about, but do seem to show that it is a safer alternative to a synthetic progestin when it comes to breast health.

Tara Scott, Hormone Guru (26:04)

I see.

Yes.

Yeah, there's actually a lot of studies, but I don't know that any of them are randomized placebo control trial, right? And some are head to head. Yeah, that's the problem. And, you know, think about that for a second.

Jaclyn (26:21)

Mm-hmm. Yeah, they're observational. The ones I've seen are observational. Yeah, so we just need better data.

Tara Scott, Hormone Guru (26:29)

Is it can you really do a randomized controlled trial in women with what you know about estrogen detoxification? Can you really randomize that everyone is the same? If you really wanted to accomplish that, you're not talking about height, weight, age, oophorectomy, no oophorectomy, and metabolites. You'd have to really say that all of those are equal before you actually said that was a control versus randomized.

Jaclyn (26:48)

Right.

That's a great point. There's a lot that you'd have to normalize to really look at that one variable a lot more clearly. Yeah. So let's take a step back, and I want to talk about this from the perspective of a patient who might be listening. So let's clarify eligibility for HRT for a patient that has a personal history of breast cancer and a family history of breast cancer. Let's start there.

Tara Scott, Hormone Guru (27:20)

So when you're talking about a family history of breast cancer, we usually try to define it as first-degree versus second-degree. So first degree would be mother-sister. So even grandmother is not first-degree relative. So the degree of relative and actually how many relatives matter. It's not an absolute contraindication, right? So for us in the functional space, we want a new root cause. So what was the cause? Was it premenopausal, postmenopausal? Was she taking hormones? Was she not taking hormones? Was it triple negative? Were the receptors positive? Of stuff for a first-degree relative, but it's not a reason that you can't take hormones, although people are told that, right? Because if you think about what are the risks and benefits of hormone therapy, you know, yes, there's a risk of breast cancer. And what's the leading cause of death for women? Heart disease, number two stroke, number three lung cancer, number four breast cancer. If you add up the deaths from two, three and four, you don't equal the amount of deaths from heart disease. And although we can't say it prevents heart disease, we have a lot of observational studies that show that it's protective

Jaclyn (28:07)

Mm-hmm.

Tara Scott, Hormone Guru (28:20)

and it's favorable for heart disease. So as a woman with a mother with breast cancer, you still have a higher risk of dying of a heart attack, period, right? And the death rate from osteoporosis-related fracture is higher than the death. Cancer. So what about if you personally have a history of breast cancer? I can't really generalize that recommendation, but I can tell you that we normally don't want to give estrogen to those. And if you look at the NAMS position statement of 2022, they say for severe vasomotor symptoms, it's not amenable to other treatment under the agreement of the oncologist, then maybe you can prescribe breast cancer. So it doesn't even say in the position statement that it's an absolute contraindication to use hormone therapy in breast cancer. But everyone, if you look at the verbiage of it.

What we say is we want you to be five years out from your treatment, right? And then a lot of it depends on a lot of things like what kind of cancer, what stage, what grade, what were your receptors. I have patients who have had breast cancer in their late 30s. And then by their late 40s, they have osteoporosis related fractures and heart disease and they've begged for estrogen and I've prescribed it without any problems so far, right? So age at diagnosis depends. So it's an individual question. I will tell you that most people won't give estrogen to a breast cancer survivor. Now, a position statement by NAMS also says that you can use vaginal estrogen without any concern. However,

If you look at the data using Prem and vaginally, there have been some systemic estradiol levels that increase after the use of that. So we always recommend a lower dose estradiol or a different form of estradiol versus Estriol or DHEA. DHEA is FDA approved for vaginal use. that the recommendation is that it is safe to use. was a recent study done, gosh, I don't know if was Danish or Swedish, Danish or Swedish breast cancer survivors that were, were given both vaginal hormone therapy and systemic hormone therapy. And they did not see any increase in recurrence when those patients were given hormone therapy. But what they did see is people who are on an aromatase inhibitor, which blocks the conversion of testosterone estrogen, did have a slight increased risk when they're on vaginal preparations, which is interesting. Yes, it was really interesting. and I think that...

Jaclyn (30:49)

that's so interesting. You'd think it would not have any kind of impact or it would have an improvement in rates, but that's so fascinating.

Tara Scott, Hormone Guru (30:58)

Well, and that's what doesn't make any... Well, see, because if you're seeing testosterone, the aromatase inhibitor is blocking any endogenous production in a postmenopausal woman because it's mostly coming from adrenal sources, and then you're giving estrogen. But what would be the difference if you weren't blocking that? You'd get that... It seems counterintuitive, you know?

Jaclyn (31:08)

of astrogens.

Right.

It seems counterintuitive, definitely. Did they see a difference in vaginal estradiol versus vaginal DHEA?

Tara Scott, Hormone Guru (31:26)

I don't know that the study in breast cancer has been looked at. I think there was an observational study that they looked at breast cancer survivors in vaginal DHEA and no increased recurrence. But the study that I was referring to was serum estradiol levels where vaginal permanent did increase, which if you think about it, you're getting a vaginal that's getting into the serum. So there is a concern that it could get to the breast. Whereas DHEA doesn't raise the serum levels of estradiol.

Jaclyn (31:29)

Okay.

Okay.

There was actually another longer term study that showed it did for after six months. You could measure changes in estradiol. I can get you that study just for your interest. But because we thought the same thing, our team was digging into it before. But the whole idea was vaginal hormones.

Tara Scott, Hormone Guru (31:57)

for DHEA.

Yeah, that'd interesting. Everything that

Jaclyn (32:09)

for those of you listening, is that it really, you insert, especially in the upper third of the vagina, there is a first pass effect within the uterus. So you get actually a lot more of that hormone in the uterus and in that kind of perineal region. And so especially if a woman's main symptoms are.

genitourinary, where everything is kind of localized in that area, it's a really nice option because it doesn't raise systemic levels substantially as a transdermal application or an oral application might. So the thought is it could be a safer alternative, particularly for someone who you don't want to increase systemic estrogen. unless it's done at high doses, it wouldn't address hot flashes. Now, it can be done at high doses as a systemic.

route of administration also, but that's not done quite as often.

Tara Scott, Hormone Guru (32:55)

Yeah, I don't really see how. I mean, I trained with a pharmacist, you know, and so he's just saying labial administration isn't really systemic. I know it's touted as that.

Jaclyn (33:05)

Mm-hmm.

Tara Scott, Hormone Guru (33:07)

But it's interesting. And the thing about genitourinary symptoms of menopause is don't go, hot flashes eventually go away, right? But genitourinary symptoms of menopause progress. And so there was one article that was like, the headline was, vaginal dryness causes death, you know? And it was like an assessment of like...

Jaclyn (33:17)

Mm-hmm.

No, it just causes discomfort.

Tara Scott, Hormone Guru (33:27)

Well, they were extrapolating that vaginal dryness leads to UTIs, leads to Euro sepsis, which can be deadly. And I'm like, that's a little bit of a stretch, but I get the point, you know.

Jaclyn (33:37)

Yeah, it's a sign. It's like an early sign of something that could leave you with other risk factors there. That's interesting. So I want to talk a little bit about, and thank you for clarifying all that information on breast cancer. One of the things I think about often is that there is...

a lot more consumer awareness of hormones just generally, which is such a wonderful thing. And it's leading women to go into their OB-GYN or their functional medicine provider sooner during perimenopause with the thought of like, think I want to get on hormones and can we do it as soon as possible because I'm starting. I'm at that late perimenopause. I'm not menopausal yet, which is 12 months without a bleed, without a period. But I'm perimenopausal. I'm disturbed enough that I want to start this therapy.

Do you think that we're going to see trends shift in women who start younger on hormone therapy? When we talk about that breast cancer risk increasing after five years, if we're starting hormone replacement therapy sooner, is that going to be a bigger problem for women?

Tara Scott, Hormone Guru (34:38)

So I absolutely am seeing younger and younger patients in my office. And if you look at my social media demographics, I have more followers that are like 25 to 30, than that are older. So it's interesting. And they're very in touch with their body and being proactive and being healthy, right? I think that what is mostly happening in perimenopause is the use of progesterone.

I don't see, I mean, I'm hoping, maybe I'm being naive to think that people are prescribing estradiol to people who don't need it. You don't need to wait till 12 months post-period, but you do need to wait till estrogen levels are low. You don't prescribe it if the patient... And we were always taught if the patient's having a period, a monthly period, they're making enough estrogen and they don't need it. Now, for the most part, I would agree with that.

with the exception of some hypoflamic, like super skinny people that over exercise that maybe, you don't have low estrogens in their forties. And so it's a good point. Like what if they are getting estrogen and testosterone and progesterone and like anything, you know, there's still that controversy about testing. What is traditionally accepted is just prescribe.

And so there's going to be some prescribing without checking of levels, especially in the patient that has had her uterus removed, no ovaries, an IUD, no bleed, an endometrial ablation, no bleed. And if you're not testing hormones and you're starting them, like if you've had your uterus removed and you still have ovaries and all of a sudden you start with hot flashes and you're 43, 45, whatever, they're going to give you estrogen only, which is the last thing you need.

Jaclyn (36:01)

Mm-hmm.

Tara Scott, Hormone Guru (36:15)

What you need is progesterone. You could be making still large quantities of estrogen and there's no testing done. It could be an issue. I mean, you're right. But I feel like at least if they're seeking out people that are testing and even the traditional doctors that are menopause doctors may seem like they might be checking some blood levels. So I'm hoping that it shifts the right way.

Jaclyn (36:39)

Yeah, I hope so too. And certainly, women should, like you said, start when they need it. Progesterone might be the first start, but it does make me think about longer exposure to hormone replacement therapy when we're kind of trending to start a little bit earlier. yeah, a dose will definitely be key, and proper monitoring as well.

Tara Scott, Hormone Guru (36:55)

So dose is gonna be key for that, right?

Jaclyn (37:01)

So what about non-hormonal options for menopausal symptoms? Are there things that you're using in your practice maybe for patients who have a high risk and where hormone replacement therapy is not a great option for them?

Tara Scott, Hormone Guru (37:13)

So one of the important things to remember is hormone therapy doesn't include only estrogen. There's progesterone, there's testosterone, there's DHEA. You know, there's a lot of hormones, there's insulin. So we're working with our patients to optimize all of their hormones. So a lot of times when they have a lot of insulin, they have hot flashes. So all breast cancer means is let's be very careful about estrogen before...

If you let's try to avoid estrogen unless we can avoid it and the patient is miserable and then let's do risk benefits. Let's try to get them to the five years. But progesterone is questionable. You know, I've given progesterone many, many times to breast cancer survivors and that has helped a lot of symptoms. I've given DHEA to breast cancer survivors many times. That has helped symptoms, bone health, know, sleep, everything. There are some herbal supplements that have been studied and depending on who

There's been recently a couple of complimentary studies on like the literature. I just saw one that said that primrose oil.

you know, vitamin D, lavender. So it depends on what the symptoms is. Is it hot flush? Is it anxiety? Is it sleep? So the supplement choice or herbal therapy may be a different based on what your symptom is. That's why sometimes people ask me, what's the best supplement for menopause? Well, what's your issue? Is it sleep, you know, or is it anxiety? It's going to be a different recommendation. There is an FDA approved and I'm not going to be able to pronounce the generic name. So I'm just going to say the trade name, which is Vioza.

Jaclyn (38:21)

Mm-hmm.

Right.

Mm-hmm.

Tara Scott, Hormone Guru (38:47)

for hot clashes. works through the neurokinin receptors in the brain so it's not hormonal.

and it has been approved for hot flashes. The cost is pretty high, but I prescribe that for a young breast cancer patient who is in her 30s and they're giving her Lupron to shut her ovaries down. Hasn't had any kids yet, so she's miserable with hot flashes. So, but it's pretty costly and probably not covered by insurance. Off label. Actually, I don't know if it's FDA approved or not, but Paxil was often given for

Jaclyn (39:04)

Hmm.

Tara Scott, Hormone Guru (39:22)

hot flashes or effects or I actually if you're on yes the effects or was mostly you're not supposed to give Paxil if they're on a rope Jason hip or if they're on tamoxifen because it interferes with the metabolism but these SSRIs SNRIs which are usually used for antidepressants have also been encouraged to use for hot flashes again I can see how it would help mood possibly hot flashes not gonna help a lot of the

Jaclyn (39:26)

I didn't know that. Interesting.

Mm-hmm.

Tara Scott, Hormone Guru (39:52)

other symptoms like low libido, up menopause too.

Jaclyn (39:55)

Mm-hmm. In fact, maybe make it worse with SSRIs don't have a great track record when it comes to libido.

Tara Scott, Hormone Guru (40:02)

Right, so there are couple FDA approved for low libido that are non-hormonal, flabasteron, which is ADDI. So there's a few things that are available for patients who don't feel they can take hormone therapy.

Jaclyn (40:09)

Mm-hmm.

That's great. The other thing that I would just throw out there for listeners is exercise, which actually has been studied and shown to reduce hot flashes, which is exciting, those lifestyle pieces. And then the other thing I see clinically is just avoiding alcohol. Like alcohol seems to be a big trigger for women, particularly in that perimenopausal stage where hot flashes are starting. So just a couple of things I'd add.

Tara Scott, Hormone Guru (40:40)

Yeah.

alcohol and sugar. I just did a of a review of literature because I'm doing this workshop at the yoga studio. So I was like, what about yoga and menopause? So actually yoga in one study didn't reduce hot flashes and some it did. It definitely seemed to help sleep and the how do they term it? Neurosympathetic anxiety, definitely improved those. It didn't help the symptoms in premenopause or perimenopause, but

Jaclyn (41:03)

Mm.

Tara Scott, Hormone Guru (41:10)

and menopause it did. So absolutely exercise is an option. Dietary changes, cutting out the sugar like you said, the alcohol, especially red wine seems to precipitate hot flashes. Sugar.

Jaclyn (41:23)

and probably stress management's worth mentioning too. I think it's hard. A lot of providers are surprised to learn that postmenopausal E when the ovaries stop producing hormone, pretty much all of our hormones come from adrenal produced DHEA that then gets converted. So DHEA is made by a different part of the adrenal glands and cortisol, but they're actually both stimulated by ACTH. And it's the same process from the brain to tell the adrenals to produce that. So they're made.

Tara Scott, Hormone Guru (41:36)

You know.

Jaclyn (41:52)

I wouldn't say an equal amount. It can vary from person to person, but they're made the same way. So if there's HPA axis dysfunction physiologically, it makes sense that if you had abnormal cortisol or even kind of a history of that, so you didn't have good communication along the HPA axis, that menopause might be tougher. And interestingly, there's anthropological data that if you look at traditional tribal cultures that still exist, they do have cessation of menses, but

Across the board, they don't report other symptoms of the menopausal transition, which is fascinating.

Tara Scott, Hormone Guru (42:26)

Well, yes, because hormone therapy wouldn't be available necessarily in indigenous nations, right? And so when you talk about cortisol, there is that feedback of high and low cortisol, but there's no feedback for DHEA. So I'm seeing so many patients through the pandemic, through stress with really low DHEA. And if you don't check it, the patients don't necessarily know there's not a signal back to the brain to like produce more. So they can have very low DHEA and that directly affects how they will experience menopause.

Jaclyn (42:32)

Right.

Mm-hmm.

Yeah, that's another reason why I love the Dutch test because it looks at the adrenal output, DHEA, cortisol, and you can really see what's happening in totality. And certainly that's something that I like to look at in perimenopause to help women make sure that they're making as much improvement as possible before they hit that menopausal transition.

Tara Scott, Hormone Guru (43:12)

And for all of my breast colistal survivors that I see, they're able, we run the Dutch test because there are also studies that correlate like flat cortisol curves with not as good of a prognosis for breast cancer or so.

Jaclyn (43:26)

Well, my last question that I want to wrap with is for patients who are listening who are looking for a provider to support them, especially if they've had breast cancer, but really across the board.

I was shocked to learn that only 4 % of women age 55 to 65 are on hormone therapy right now. And when you say like 100 % of women should have it as an option, I don't think that 100 % of women are hearing from their providers the full story. And actually, I still talk to providers who have not updated their philosophy since, you know, WHI was released 20 years ago. How can patients find a provider who they can trust to really get

the risks and benefits and not find someone who's like really a Yahoo who is overprescribing, but not find someone who is over emphasizing risk. How do we find the right people?

Tara Scott, Hormone Guru (44:19)

That's.

Such a great question and there are many levels to answering that first of all what you took touched on is prescriber, right? So the first thing is I do see that patients are coming to a health coach or a chiropractor or non prescriber, right and and they may be evaluating your hormones to check your hormones and helping you with everything but they're never gonna suggest it and they're never gonna be able to sit down and tell you these are the risks these are the benefits I think you should have it because they're always gonna go the non prescription route because they they aren't trained or able to prescribe

So you're not going to get a totally accurate risk benefits ratio unless you go to a provider. I'm a traditionally trained OBGYN. We get zero training on menopause. So it is. I just thought, I haven't lectured the residents lately because after COVID happened and everything, was so shut down in hospital. But I used to do four lectures a year and that's all they got.

Jaclyn (45:03)

insane.

Yeah.

Tara Scott, Hormone Guru (45:17)

So I haven't done that lately, so they're probably getting nothing, but.

Don't assume that your OBGYN is trained. So do you go to a certified menopause practitioner? You would go to menopause.org. They have a directory at their site. Keep in mind that to get that designation does require an examination, but that's kind of it. You you have to like study their book, take the test and you have to keep it up. And I have to go to give so many hours because I got certified in 2006. And so I have to keep it up and do so much so much of their education to get credits. They will at least be able to properly tell you about the literature and the studies and the risks and benefits just as we outlined per the position statement of the menopause society. They are probably not going to check your levels. They're probably not going to titrate your levels, but you won't have to, they won't hesitate in prescribing it if it's an option.

If you go to a functional medicine provider, not all functional medicine providers are trained in hormones. So I don't know very much about Lyme disease and mold and that kind of stuff. So I'm but I'm certified, you know, I have a Board certification. So just because you're going to somebody who has either an IFM certification or an A4M board certification or an integrative medicine board certification does not mean that they are trained in hormones. So for the most part with social media websites, you can vet your provider before.

A4M does have a directory and there are little icons to who actually you could be a member and not have enough education. So you want to look for those that are fellowship trained, board certified from A4M. Dutch has a directory of providers who are trained to use the Dutch test.

Other labs have directories, functional labs that have their people who use their tests as far as hormone tests go. So you have to dig a little deeper. so just going to a functional medicine. So for example, I'm 30 minutes south of Cleveland Clinic and you know, not all and they're like functional medicine center, but not everybody is trained for hormones. I just connected with somebody who is, which is nice, but not everybody is. And so it's very difficult to find someone. So I would suggest asking your provider, do you feel that you have training in menopause? know, how do you feel about have you had extra training in hormones and menopause? Do you feel comfortable prescribing? If you don't prescribe because I don't think the practitioner should tell the patient you can't take hormones, right? Our job is to tell them what the risks and benefits are. So if you're not trained, do you know somebody who is or can you refer me to somebody who is? Because when a patient comes to me, I'm not doing their pap and their pelvic and

Jaclyn (47:36)

Mm.

Tara Scott, Hormone Guru (48:04)

their surgery. I'm not stealing a patient from my colleagues, right? I'm just going to manage their hormones and send them back to them for their annuals. So I think they're, you know, they don't feel threatened by me. So there's a concern that patients have to stick with their family practice doctor or their GYN. You don't have to leave your GYN. You can just go and get your assessment and then, you know, go back for all your gynecological care. But ask your provider.

Jaclyn (48:23)

Hmm.

Tara Scott, Hormone Guru (48:30)

You can't really go to your provider and say, can you check these hormones? Right. Because that'd be like me walking into Pizza Hut and saying, I want Greek food. We don't have Greek food here. No, I want Greek food. This is what I want. I want Svanakopita. want, know, like Pizza Hut. Right. They're not, they don't make anything, you know. So going to a provider, even having a list of these are the things that I want you to order. Maybe that provider would order that because they're really open and they want to help you, but they're not going to really know how to interpret the different levels and what's appropriate when to get your testing done. If you're perimenopausal,

Jaclyn (48:41)

Hmm.

Tara Scott, Hormone Guru (49:00)

pause, you know, if you're still having cycles. I mean, you might pay for the blood testing or maybe it's covered, but then people come to me with their testing. I'm like, these are not normal.

Jaclyn (49:10)

Mm-hmm.

Tara Scott, Hormone Guru (49:10)

I was told they're all normal. Well, they're not normal, right? So I mean, looking for, you know, if you just want a traditional provider that's not going to necessarily check you, then you could go to a menopause provider, menopause trained clinician. have a directory or like I said, a forum, IFM, but making sure you kind of look at their websites. Do they talk about hormone therapy? What do they say? mean, with YouTube and TikTok and everything, you can go and see what you think about your provider. And do they seem like they

talk about hormones a lot or do they talk about Lyme disease a lot, you know, so.

Jaclyn (49:44)

And looking for someone who has a balanced view, I think is really critical because you want someone that you can trust, someone who's not going to be selling a paradigm, whether that's for or against. That's, think, so critical. Like, I love that you bring up all these ways to look into it. And if you are a healthcare practitioner, the NAMS Metapod Certification is not limited to medical doctors. So if you're an atropathic physician, you could still go through that education, and it's not expensive to take the test. So if you're a provider listening, and this is an area where you want to hone your expertise. One, I think that every provider could benefit from NAMS education because understanding the literature and understanding the standard guidelines are really critical to be able to practice safely with patients. And if you are deviating from that because of a practice style. That's okay, but you should at least know what the standard is so you can be making a conscientious choice around that. I I think their education would be wonderful. And as a provider who, you my whole career was cycling females, I do fertility, cycling females and males. Since working with Dutch, we work with so many menopausal women that my last two years have been at boot camp. And now I'm like so passionate. Of course, I'm starting to start my perimenopausal journey, but my passion for helping women in this space has deepened and grown so much. And I also understand like how deep and how complicated the literature can get as you're trying to sort through this decision making that don't go into it loosely, learn it, dive in. It's very interesting.

Tara Scott, Hormone Guru (51:15)

But thankfully there seem to be a lot of more options for menopause care. Now there's these pop-up telemedicine companies that are, you know, but the perimenopause are where they're still neglected, right? That they're saying, we can't help you because you're not 12 months or we can't help you. Your labs are normal. So that's where I feel called to serve is the thirties and the forties, you know, with hormone disorders.

Jaclyn (51:22)

totally.

Mm-hmm.

Well, we'll have to have you back to talk about that because there's a lot we could unpack around perimenopause. But today, thank you so much. This has been an awesome conversation. I've learned a lot. I'm sure our listeners have loved it as well. how can we help you? How can people find more about you if they're interested in connecting with you further?

Tara Scott, Hormone Guru (51:42)

Right.

So I have a YouTube channel, Tara Scott MD. It might be Hormone Guru now, which I trademarked. And so it's Hormone Guru MD on Instagram, Hormone Guru on TikTok. Lots of free information up there that patients can take a look at.

Jaclyn (52:12)

Wonderful. Thank you so much.

Tara Scott, Hormone Guru (52:14)

Thank you.