In this episode, we discuss:
- Discovering the impact of hormone imbalance in their own personal journeys
- The overlooked roles of hormones in women’s health
- The Women’s Health Initiative study and separating fact from fiction
- Understanding hormone replacement therapy and personalizing treatment
- How to empower women through knowledge and resources
Show notes:
Hey everybody, Chris Kresser here. Welcome to another episode of Revolution Health Radio. Historically, female hormones have really only been a concern for the medical establishment, at least in women who are menstruating, and particularly for fertility and pregnancy, and maybe the postnatal period. Once a woman is through that phase of life, hormones are not part of the discussion in mainstream medicine.
That has changed a little bit over the past couple of decades. There was certainly interest in hormone replacement therapy back in the 90s. Then there was a very well publicized, but unfortunately not well designed, study on hormone replacement therapy that ended up misleading a lot of women into the belief that hormone replacement therapy was ineffective and even dangerous. That really changed the conversation in the public health world and mainstream medicine, and unfortunately has led to a lot of women not getting the support that they need as they transition into that life phase. So I’m really excited to welcome Maria and Kristin on the show today. They have both had issues themselves going into menopause, and in one case [was] in the health field already, [and] in [the other] case decided to join the health field as a result of the difficulties they faced navigating these challenges. They bring a lot of wisdom and experience working with women going through this phase.
They’ve recently written a book called The Great Menopause Myth, and that’s the subject of today’s show. We talk about the critical health impacts of sex hormones beyond fertility all the way through the life cycle, the importance of optimizing metabolic health for aging well, why hormone replacement therapy, or HRT, has been inappropriately maligned and misunderstood, and the importance of personalizing treatment, which, of course, won’t come as a surprise to you if you’ve been listening to this show. That’s a consistent principle in Functional Medicine, and it’s also true in this situation. This was a great conversation. I think women of all ages will be interested in it, but particularly if you’re approaching or in perimenopause or menopause, this is a must listen, and I hope you get a lot out of it. With[out] further ado, let’s dive in.
Personal Journeys: Discovering the Impact of Hormone Imbalance
Chris Kresser: Kristin, Maria, welcome to the show.
Kristin Johnson: Thanks for having us.
Maria Claps: Thanks for having us.
Chris Kresser: Let’s just dive right in. This is a very important topic. I don’t need to tell you both. You’re well aware, and you mention this in your book, [that] this is a growing area of concern for many women. You can see that in web searches, interest in products, supplements related to menopause, demographics, aging population, and the lack of attention that it’s received in the conventional medical world. And maybe even [in] the way that it’s been characterized historically as a disease state, and just kind of ignored. Very, very few solutions [are] offered to women who are struggling with this life transition.
So maybe we can start there. What led you to become interested in this area, and what have you seen as the shortcomings of existing approaches? And I’ll say both conventional approaches or any other approaches that led you to feel like there was a need for the book in the first place.
Maria Claps: Sure. Well, what often leads people to their areas of passion when it comes to health is definitely a need. We were both around the same age when we first started to feel that something was happening, and that was early 40s. 43, to be exact, for me. And I think, Kristen, you as well. There were palpable changes. They were physical, they were kind of mental, [and] emotional. And I had always been somewhat holistically oriented, so I knew that I needed to seek a little bit more progressive care. So I checked into Manhattan, saw a pretty well published physician, medical doctor, and I was kind of over-treated and under-explained. He actually did give me lots of supplements, and he gave me hormone replacement therapy, and it was bioidentical. And I was like, “Okay, I’ll do this.” But I didn’t stick with it because I had no idea what was going on. I was given no education whatsoever. And just in case you can’t sleep, which you have voiced a struggle with, here’s some Klonopin as well, all from a holistic doctor.
So at that point, I knew that I had to kind of go back to school just for my survival. I needed a level of education and knowledge to be able to advocate for myself, because I knew what was coming, [but] I didn’t know the extent of it. I just knew there were significant changes afoot for me, and this was at 43. So that was my story.
Kristin Johnson: Yeah, and I love it when people ask this, because I feel like Maria and I kind of represent the two bookends. I was living in Boston at the time, ground zero for conventional medicine and Big Pharma, let’s be honest. And I didn’t know it was hormone driven, to be perfectly honest. I was 43 years old, just like Maria. For me, I didn’t have anything to identify it [with] related to my cycle because I had an [intrauterine device] (IUD), so I was not a cycling female at that point. I didn’t have hot flashes. I kind of lacked all the traditional type symptoms that women identify with midlife, and I just thought I was sick, to be perfectly frank. I couldn’t function any longer. I started developing arthritic joints in my hands. I was in pain all the time [and] not sleeping. Definitely [experienced] the loss of libido, which is very common for a lot of women. But to be honest, women in their 40s, whether it’s careers or families, kids, et cetera, we have a lot on our shoulders. And you can even add in aging parents, right? And many of us are in that sandwich generation. We’re taking care of everybody. So who’s not to think that you don’t feel well because you’re just super stressed out?
So that was kind of where I was mentally. I was also a national and world level competitive rower, so I was throttling my body through training and whatnot. [That] probably had something to do with it. But I went to my physician, who was at Mass General, one of the world’s leading hospitals, and said, “Something’s wrong.” And she said, “Nothing’s wrong with you. You have no reason to be here.” And I started going through all the list of things. Is it Lyme disease? Could I have mold infection? Could this be hormones? Do I have adrenal fatigue? Everything I was hearing as possible issues. And unlike Maria, she refused to test me, refused to give me anything to help, and pretty much sent me on my way, making me feel like I was losing my mind, and that I was a worried, well woman and making this stuff up. So I got the opposite end of the spectrum and decided, “Okay, forget this. I want to do things differently.” And too, [I] decided to go back to school. I think both Maria and I can say that you start to work with people in your field who somewhat resemble you, whether that’s by coincidence or deliberate intent. We started to kind of put pieces together, like, “Gosh, gee, a lot of women our age are dealing with similar things and there must be something to this.” And that sort of leads everyone down the path of hormones once they start to dig into it. So that’s how we got here.
Chris Kresser: Great. [There’s a] lot to unpack there. We’ve talked, of course, at length on this show about how common that experience is of going to the doctor and knowing there’s something wrong [and] being told there’s nothing wrong, which is just unbelievable to me that happens, [both] as a clinician, and I’ve been on the other side as a patient. Why do you suppose that happens? What do you think the medical establishment is missing in their understanding of women in your situation? When she said there’s nothing wrong, what does she actually mean by that?
Kristin Johnson: Yeah, well, and she also said I was too young for it to be hormonal, once I finally raised that issue. And I think that really goes to the crux of the issue, [which] is [that] they’re not educated on this. I mean, honestly, I hate to make this analogy, but asking a medical doctor to dig into menopause with you is pretty much the same as asking a medical doctor what you should eat. They get zero training on nutrition. They get zero training on menopause. Last year there was a huge Mayo Clinic study released [that] said even OBGYNs do not feel equipped to deal with women past the age of fertility. They just don’t know what to do with us. And so I think there’s a little bit of lacking tools, and sort of lacking knowledge. Then I think on the flip side, there’s sadly a mindset of, “Can’t you just white knuckle it and get through it? This too will pass. Get over yourselves, ladies.” I think a lot of women do get treated like they’re acting as though they’re [over] worried. You’ve got these issues that you think are concerning, but they really aren’t that big of a deal. Get over it. They’ll pass.
So I think there’s two things, whether you want to call it gaslighting, some people call it patronizing, whatever. We’re not going to get into that part of the discussion. We hate when people infuse social politics and things into this discussion, because it doesn’t really matter what stripe of a woman you are, we all are going to go through this, and we’re all unfortunately going to hit a bulkhead when it comes to our medical provider in order to get some help.
Beyond Fertility: The Overlooked Roles of Hormones in Women’s Health
Chris Kresser: Absolutely. So let’s talk about that, because that is historic. I mean, in medical school, the focus on women in terms of hormones is for fertility and pregnancy and maybe the postnatal period. And then the textbooks really kind of stop after that. Most of the book is on that period, and then there might be a few pages towards the end on the physiologic roles of hormones in the later ages of the life cycle for women. There’s a little bit of discussion of it for men, mostly just testosterone. “How’s your testosterone?” But I would say that’s probably even more widely known than the roles of estrogen and progesterone and other hormones for women at that phase.
So why don’t we talk a little bit about that? And then that can also be a segue to talking about the diversity of symptoms that can happen when those hormones are out of balance. Kristen, you mentioned you didn’t have the typical presentation. And I think a lot of the women that I’ve treated also fit that description. If they’re not having hot flashes, dryness, and some of those symptoms, they figure it must not be hormones. Which, of course, is not the case at all.
Maria Claps: Yeah, absolutely. And what’s saddest to us, Chris, is the women that have no symptoms and they think that they’re perfectly fine. You mentioned the physiologic roles of hormones. When we both started researching this, [it was] probably about 10 years ago, before it was really popular like it is now. Most people can probably see that menopause is really having a moment, I think, as we were alluding to before we [started recording]. There’s a plethora of options available. Not all are really good. A handful of them are good. But they just affect everything, from the dryness of your eyes to your liver health. Women after menopause are more prone to fatty liver. And it’s mostly lifestyle, but it does have something to do with loss of those estrogen receptors in the liver. And, gosh, I mean, it goes like, we kind of know that it’s bones right now are important. And there’s a, maybe a bit of a focus on cardiovascular health. But there is like mood and skin and gosh, you literally have estrogen receptors on your optic nerve. I mean, there’s teeth, teeth get affected in menopause, mouth gets affected in menopause. Ability to rest well. It’s just so much. And, again, when women don’t have those symptoms, they think that they are okay, and your lifestyle absolutely does matter, and you may be more or less okay. But with hormone loss, again, women who skated through menopause, talk to us when you’re 63 or 65 right? Because that’s when we see what we’ve kind of termed, it’s completely unofficial, but we’ve kind of termed it as a health halo, or an estrogen halo. Or maybe it’s a little bit of that estrogen from the androgens, right? So from your adrenals maybe that’s giving you a little bit of benefit, a little bit of symptom suppression, but that is usually not enough for the great majority of women.
Kristin Johnson: We’ve got a chapter in the book called “Hormones Beyond Fertility,” because I think it’s an area that most women literally never know [about] their entire lives. We’re hoping that education of younger girls can start to change this, because we are the generation, and I would say probably the generation coming [just] after us, and definitely the generations before, [that] were taught to loathe their menstrual cycle. We were taught that the monthly bleed was just related to fertility, and that was that. That’s pretty much all we were told about this estrogen and progesterone [cycle] in our body. And the sad thing is [that] if a woman, let’s say, at 29 years old, loses her menstrual cycle, everyone raises the alarm and says, “Oh my goodness, we must treat her.” Why? They immediately put a patch on her and say, “We want to protect your bones,” or, “We want to protect your heart,” or, “We want to protect these things.” And nobody bothers to question that this beautiful rhythmic dance in hormone production out of the ovaries while we are premenopausal is relevant to our health as we age.
And whether you’ve got the symptoms or not, we are seeing increasing growths of insulin resistance. We’re seeing more carotid artery plaques. We’re seeing changes in blood pressure. Lipids are starting to increase. And women are like, “I didn’t do anything different. I’ve changed nothing. I’m still exercising the same way. I’m still eating the same way.” What’s changing? Unfortunately, as a society, we just keep saying it’s age. “This is just aging.” Just kind of move on and there’s a pill for that sort of thing. And this is where Maria and I want to change that narrative, because it’s not just aging. If it were just aging, women wouldn’t be the ones predominantly with Alzheimer’s [disease], osteoporosis, and overcoming men in their late 50s and 60s even with heart disease. We want everyone to start to pay attention to the fact that all that wonderful life, where we just thought it was about fertility and menstruation, actually those hormones were literally keeping your health intact. They were the homeostatic regulator of the female body. So if we lose them in midlife, why are we not addressing that loss and the loss of the stimulus that they provided as women age? That’s the biggest thing, because too many women, it’s like, they’ve got a statin, they’ve got an anti-anxiety [medication], they’ve got a sleeping [medication], maybe they’ve been told they have fatty liver [and] they’re drinking milk thistle tea until the cows come home, and not much is changing. And that’s because we can’t just continue to address the outcome of hormone loss. We have to address [the] hormone loss first.
Chris Kresser: Right. I mean, this is the root idea of Functional Medicine in a nutshell. And big surprise, it applies here as well. And in this case it’s even more notable, because most people aren’t even looking for the root cause. It is a prime example of the problem with a very fragmented healthcare system, where you have a different doctor for every different part of the body, and nobody’s really making the length that all of these various symptoms that seem like they’re disparate and not connected are actually probably stemming from the same root cause.
So with that in mind, let’s talk a little bit about some of the causes of hormone dysregulation in women at this life stage. I mean, they’re similar throughout the life cycle, but you mentioned there are probably some unique causes that are more prevalent for hormone disruption as women age. Women in their 40s, for example, who are working outside of the home, raising kids, maybe training hard, and burning the candle at both ends. That’s maybe different than causes of PMS or irregular menstruation in a teenager. So, in a perfect world, the hormones are great [and] stay balanced all the way through life. Our lifestyle is pristine. Our diet is pristine. We have no problems. But what are the main drivers, from your perspective, of imbalance? [Where are] things going wrong for women who are entering into that transition?
Maria Claps: Sure. We can actually start with the perimenopause stage. Everything that you mentioned, like burning a candle at both ends and not eating well, not taking a break to nourish yourself and rest, absolutely contributes. But, again, even in a perfect setting, perimenopause is challenging. It just is. The body is going through some pretty dramatic changes. A lot of women will talk about how they’re estrogen dominant at that point, and that is because their progesterone has fallen, and that is because they may get some last bursts of estradiol from the ovaries. Or if they’re not getting bursts, they just don’t have enough progesterone to buffer the actions of the estradiol. And they go about thinking that they have to flush their estrogen, which is the furthest thing from the truth. But that creates symptoms, right? Even for the healthiest among us, that can absolutely create symptoms. So it is a challenging phase of life by default. It’s just those shifting hormones. When there are lifestyle issues on top of that, it makes orders of magnitude worse.
Kristin Johnson: Yeah, there’s a study [that’s] been out for a long, long time, but it’s starting to get a little bit of traction. [And there’s] these new menopause experts that have self-titled themselves and pivoted their entire medical practices to suddenly being in the menopause space when they’re actually quite new to it. But it’s a neurological transition to start, right? We know so much about the endocrine cycle, and looking at the brain’s interaction with different endocrine glands and the ovaries are no different. So if we’ve got kind of this decoupling of the brain with the ovaries, we’re going to have the ovaries start to sort of fail in their production. We’ve got mitochondrial changes in the ovaries that they’re starting to sort of shut down. We get the senescence, and the brain is like, yo, hey, what’s going on? I need more of what you guys used to give me, and that’s what sort of brings about so many of the changes. But when you add in kind of throttling that hypothalamus pituitary action, because you’re overtraining and you’re under eating and you’re stressed out and you’re never sleeping and everything else, you can make it many folds worse.
Are there issues with endocrine disruptors? Absolutely. Too many women are still on birth control coming into this phase of life. That’s going to make for a pretty hard transition for them once they stop the birth control. Do we have the stress issue in kind of the lifestyle? Absolutely, that’s going to become a problem as well. But for the most part, whether your lifestyle is pristine or not, you’re not going to be able to escape the hypothalamus and pituitary ovarian disconnect that’s coming, and that is the principal driver of what is going on for midlife women. Like Maria said, you could have these other issues because of lifestyle when you’re younger, but honestly, right around the age of probably what, Maria, 47, 48? It’s really a brain, ovary disconnect that’s driving just about everything at that point.
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The Women’s Health Initiative Study: Separating Fact from Fiction
Chris Kresser: Well, with that in mind, let’s talk about the importance of hormones. Because there’s been a lot of misinformation and misunderstanding here, particularly with the early HRT studies. I think there was an initial period before that where in the hormone replacement world and, at that time, there was a group of clinicians who were really using that quite a bit. And then those studies came out, and all of a sudden it was like, stop doing that. Nobody should, we should not be giving women hormones. So let’s kind of break that down starting with just what you think, and the research suggests is normal for women, which is a very controversial topic. And depending on who you talk to, you’ll get very different answers ranging from women who are in menopause should have the same level of hormones as women who are still, as a 20, 22-year-old woman, or all the way back down to the other side of just kind of let it ride, and we shouldn’t be giving any hormones. So where do you two fall on that spectrum?
Kristin Johnson: Well, one of our favorite chapters in the book does look at hormones through the lens of history. And the reality is is we have two kind of intervening things. Is early 1900s women weren’t living past menopause as long as we are living past menopause now, right? So the problem wasn’t as palpable and obvious. There was sort of this aging and death. And Maria has a beautiful article in one of our mighty network groups that says, if menopause is natural, why should I replace my hormones? Well, because natural menopause used to be death. That’s the, what used to happen. But about the early 1900s we actually had every major medical society recognize the loss of hormones in menopause as a disease risk, and they looked at hormonal replacement therapy as preventative medicine. And it was well adopted as preventative medicine. So women are starting to live longer, people are starting to realize, wow, longevity and healthspan are two different issues here. These women aren’t living well longer. So let’s start to address the hormonal issue that’s at play that’s driving these disease states. And that went along happily for about 40, 50, years, until we had Big Pharma kind of come in and say, hey, we can commercialize hormones for you. And we started to get this hormone product. Maria and I sort of refused to refer to them as actual hormones. But they were hormone products. They were not on a molecular basis, what women had been given for years and years before. We know that if we’re going to give something that’s not recognizable by the body, there’s probably going to be some problems. And over time, we’ve got a lot of social, political things happening with women emancipation, we’ve got women going to work, not wanting to have children in order to satisfy their careers, birth control comes on the market. All of a sudden we’re realizing, hey, we can kind of change women’s cycles with this birth control. Suddenly, birth control becomes du jour for women in their 40s and 50s. That wasn’t really the original intent. And we sort of just lost the plot, to be perfectly frank, with this change in aging, wellness being the focus, suddenly medicalization becomes the focus, and then, hey, Big Pharma has got a solution for that.
So there were some issues that started to arise. Nobody was paying attention to the nuance of the different types of hormone products that were being given to women and sitting back and thinking, hmm, maybe it’s the product and it’s not the hormone that’s the issue. And ultimately, there was call for, hey, we need to get a better study to really look at these things. And the better study that came out of it was the Women’s Health Initiative, and it was one of the worst things that could have happened to women, to be perfectly frank. They use synthetic hormones, they used hormones that were derived from equine urine. There’s 10 different estrogens in those, they’re metabolites, they’re not actually really doing the same functions as women’s ovarian produced hormones. We use synthetic progestins, which we now know are endocrine disruptors, and alter the receptor, particularly in breast tissue, causing folded proteins leading to cancer risk. So we took these really crappy products, and then we decided to give them to women with the guise of, let’s look at we can prevent diseases of aging in these women, but we’re going to use women who’ve already got the diseases of aging, because they’re in their 60s, right? And so we chose a really bad cohort to look at and then we didn’t really get healthy women. We got women who already had disease process, who were diabetic and who were obese and who were smokers and who were all these things. And then we gave them these fake hormones that we didn’t want to recognize were maybe going to cause a problem. And voila, we started seeing cancer and clots and some other things. And so they stopped the study prematurely and said, women, throw out your hormones. Everyone get rid of them. And it was, governments got on board, medical schools dropped hormone discussions from their curriculum. So now we’ve got generations upon generations of doctors who truly believe hormones are bad. Not just that they’re not educated that would be bad enough, they literally think they’re bad, and we still see it. Maria and I will give women, my doctor won’t let me get on that because estrogen causes cancer. Oh my goodness, have you had a baby? Did you get out of pregnancy without cancer? Shocking, because you had really high levels during that time.
So, we ended up just getting too many interests, kind of cooking up in the kitchen, the wrong recipe, and not shockingly got bad outcomes, and then extrapolated that result to all hormones. And one of our mentors loves to say it’s sort of like giving little kids fruity Skittles and seeing them getting cavities and blood sugar issues and then blaming fresh fruit, right? And that’s sort of what ended up happening with hormones. And so it’s taken, it’s only been about 22 years since that WHI study was stopped. The authors have since walked back a lot of their conclusions. People now recognize most part that it was wrong, but the damage has been done. Sadly, the damage has really been done. And the only pioneers to sort of shift the conversation, go back to people who are saying, let’s look at personalized medicine, let’s look at individualized care. Compounding pharmacies started to be able to produce molecularly identical hormone compilations to give women. But there’s, you can’t patent compounded hormones. And so now there’s kind of this tug of war between FDA commercial products and unpatentable, ie, not profit driving products. And sadly, women are the ones who lose.
Chris Kresser: Yeah, and there’s another rabbit hole to go down there with the social, political aspect of this, which you have indicated that, totally fine not to go there. But it’s real and it really affects what’s available to people and the public perception of these treatments, because there’s no sales rep for the bioidentical hormones going around and talking to doctors as there is for the pharmaceutical treatments. And they’re not, doctors are not getting taken to Aruba by the bioidentical hormone companies for conferences, and all of this stuff really affects what the average person who goes in to see their doctor has access to or even what the doctor themselves has access to in terms of information and education. And the reality is, as you both pointed out, not only did doctors not receive education about this while they’re in school, they don’t receive continuing education about it. Whereas they do receive continuing education ad nauseam about pharmaceutical treatments. That opportunity is never missed, whether it’s through a pharmaceutical sales rep or a conference that they attend for CME credit, etc.
So there’s a whole establishment that exists that doesn’t include any of this information. And if you’re a woman who’s listening to this podcast and you’re wondering why you haven’t heard these things before, there’s a very good reason why. And the reason is not because these things that we’re talking about aren’t validated by research, because they are. The reason is what we’re talking about now. So it’s important to point that out, I think just because I think people can have a kind of skepticism of like, well, if this is true, why haven’t I heard about this? My doctor is a good person, which is almost always true. They’re trying to help me, again, almost always true. I’ve met very few malicious doctors who are not trying to help. But there are systemic forces at work that make it difficult for them to do their job the way that they would like to.
So, okay, we’ve established hormones have important physiologic roles all the way through the life cycle of women and men for that matter. Many women struggle with maintaining those adequate hormone levels for a variety of reasons. Number one, just the transition itself is challenging and difficult. I mean, you could even say that about the transition into pregnancy. I mean, I’ve worked with many women on fertility in pregnancy, and that can be a rough transition for many women. And postnatal period, like a lot of, we know that the incidence of autoimmune disease and the onset is statistically highest in that postnatal period after giving birth, because of the dramatic swing of the immune system that happens after that. I saw so many women who came to see me with autoimmune disease. When I did a full history, it was so common that that was the time when they first started experiencing symptoms. So these are just examples of how important hormone shifts can be in the life cycle of women. And then we know that hormone replacement therapy, there is actually an evidence based way to do it that leads to good clinical results, and that we don’t need to be concerned about those early HRT studies that got so much publicity because of the methodology that was used in those studies. So let’s talk a little bit now about the approaches that women are having the most success with, in general terms, obviously recognizing that each person is different, and that’s kind of one of the keys, is this biochemical individuality. There’s no cookie cutter approach to follow, but just in general terms.
Hormone Replacement Therapy (HRT): Understanding the Options and Personalizing Treatment
Maria Claps: Yeah. Also just kind of want to note that you said, the kind of the incidence of autoimmune disease in the postpartum phase. That postpartum phase is really like a temporary menopause-like state for women because of low hormones. And then, even more so, if they’re breastfeeding, their estrogen and progesterone tends to be really low. And interesting, since it is the shifts. But what Kristen and I have seen is it’s the shifts downward. I’m not saying it can’t also be the upward shifts, because sometimes the spikes of estradiol in the cycle can be problematic for women, give them things like sore breasts. But again, it’s what often triggers that migraine for you, Kristen, or when it happened, was what?
Kristin Johnson: Yeah, my estrogen dropping.
Maria Claps: Yeah. So I just wanted to point that out. But okay, so yeah, super individual. But what we have found, Chris, amongst conventional and some conventional doctors will prescribe HRT. I went into my gynecologist for a Pap smear, and I was transitioning from New York to Delaware, and she’s like, I’ll write your patch prescription. Yeah, she’ll just write the prescription. I was like, I’m good. Thanks, doc. because I had a doctor who was handling my hormones. So whether it’s conventional or more holistic, functional minded doctors, we find that they tend to be afraid of estrogen, like that still kind of gray cloud is over their head. So if they are going to write a hormone prescription at all, it’s usually going to keep women at a very low dose that we tell, we say sometimes that you can be on HRT and you can still have a menopausal level of, blood level of estradiol. So we find that-
Chris Kresser: I’ve seen that, just for the record.
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Kristin Johnson: Yeah, I mean, the medical society sort of control what the doctors think is safe, right? They’re really, the talking points are coming from, and particularly NAMS, the North American Menopause Society, or now they call themselves the menopause society. But the approach, because unfortunately of that continued fallout from the WHI has been the lowest dose for the shortest amount of time, and only during a certain window, and really only for women who have the palpable symptoms of hot flashes and advancing osteoporosis. So that’s this quote, unquote, medical society standard of care. But what’s really interesting is, if you go to Wolters Kluwer, you go to UpToDate.com the standard of care is not that. And I think most women don’t realize this is the standard of care is to essentially replicate the cycle, give women estradiol. So let’s be honest, a lot of people think estrogen is a hormone. Estrogen is not. It’s a family of hormones. We like one in particular, estradiol, because it has a very balanced presentation against the receptors that are throughout our body. And so they’ll give women estradiol. And then standard of care is to actually cycle progesterone with that. And what that means is to do what we did in our cycle, which was have ovarian production of progesterone during the second two weeks of a 28-week or 28-day cycle.
Unfortunately for women with a uterus, what that means is they would bleed because there’s a withdrawal of that progesterone. And so there’s kind of this footnote in this quote, unquote, up to date standard of care that says, but if women don’t want to bleed, or the physician is uncomfortable managing this, you can just give progesterone all the time. So I’d say that’s predominantly what we see, which is estradiol, usually at a low dose, because of what Maria identified as that fear, and then progesterone all the time. And that can be effective for symptom suppression. Absolutely. You probably won’t have a hot flash. It doesn’t take a lot of estradiol to suppress hot flashes. You probably, you might have a little bit more vaginal lubrication, maybe your bones don’t hurt as much. But unfortunately, those low levels of hormones are not going to continue to maintain LDL receptors through the liver in order to clear our lipids effectively.
There’s nothing more scorned than a 63-year-old woman who’s been on a patch for 10 years and finds out she has osteoporosis notwithstanding having been on quote, unquote, HRT. So there’s different degrees to which we can give hormones, and I think that’s one thing that a lot of women are misunderstanding, is that HRT isn’t a standardized, single formula or regimen, right? It’s not a bottle of Advil that we can pull off the shelf. And so understanding what your goals are. Is it to bring down your lipids and to maintain your arterial flexibility and not have them turn rigid and have increasing blood pressure. That might take a different level of estradiol than what your OBGYN is willing to prescribe to you.
So understanding everything about what these hormones do in the body, what your goals are for your aging and your health span, and then identifying what can accomplish those goals. And that, really is kind of the process. I mean, clinically, we’ve got providers who’ve got three decades of giving physiologic levels of hormones to women cycling progesterone, mimicking the ovarian cycle and these women are absolutely thriving. We have other women who are plenty happy to have 80 picograms per ml of estradiol in their blood from the highest dose patch and say, well, I can have sex with my husband because my vaginal tissues aren’t tearing any longer. I’m maybe not having as many UTIs, and I don’t have any hot flashes, and they’re perfectly happy. And that’s honestly that’s all that really matters, is that women identify what they’re looking for, what these hormones can do for them, and then get a formulation for that. But there’s a huge gamut, and we know birth control is still given out by very well meaning physicians as hormone replacement therapy. It is not. Pellets are a huge business, right? We’re going to give these super physiologic doses of women, have them kind of slowly wane over the course of three months, and then shoot another pellet in their rear end and call it HRT. And then we can go all the way to looking at these compounded formulations that really give women those premenopausal levels. So there’s so much along that spectrum of HRT. They all have things that they accomplish. It’s just whether or not, it’s what each individual woman wants to accomplish.
Chris Kresser: Yeah, and that’s a great point, and it goes back to functional medicine again, and one of the reasons why it’s difficult to study compared to conventional treatments. Usually in a randomized controlled trial for example, the goal is to limit the number of variables, and so you will have a standard dose of a medication that’s offered to the participants, and then a placebo that’s offered to the control arm, and those are the main variables that they’re changing. And so it’s difficult to study adequately prescribed hormone replacement therapy, or treatment of women in menopause from a holistic or functional standpoint, because the treatment might differ and sometimes in significant ways, from person to person. But that again, we are different in significant ways, as you just pointed out. Different goals, different health status, different background, different entry points, different medications they’re taking. Life circumstances, genetics, epigenetics, diet patterns, the whole nine yards. So this is why it’s so important to personalize.
When I treat women and men for that matter, but it can be dramatically different from what they get to the amount that they get to the amount of time that they’re on it, to the response. I mean, you can give the same treatment to two different women, and they can respond to it entirely differently, as you both know from your work with people. So maybe we can talk about that a little bit too. If someone is thinking about how to pursue this, first of all, where should they be looking? If their family doctor, if they’ve already had a conversation with their family doctor and they’ve gotten the standard response, where might they start looking for help?
Maria Claps: Well this is going to sound a little bit harsh, and I certainly don’t mean it to be, but Chris, Kristen and I feel pretty strongly that unless you have a certain level of knowledge about hormone replacement therapy, and you have identified your goals that you should not be asking for it. Because what happens is you’re going to go to someone and you’re going to get there one maybe two options.
Chris Kresser: I think it’s good advice, because you, yeah, you get into the factory treatment and you don’t have enough knowledge to know when you’re not getting the right treatment and that can be risky, for sure.
Empowering Women with Knowledge and Resources
Kristin Johnson: Yeah, there’s nothing more sad to us than women saying, I tried HRT and it didn’t work. And our response to that is always, then you didn’t have the right HRT. And I think it’s hard for women, because who’s the one physician that if we’ve had children, most of us have a very close relationship with? It’s our OBGYN. And OBGYNs, unfortunately, their real wheelhouse is helping women conceive, delivering babies and caring for the female body through that stage of life. It’s not unfortunately this. And so we always say sadly, you probably have to realize that your OBGYN should be there for breast exams and pap smears and those sort of diagnostic things and screening, but not your HRT.
So where do we look for HRT? Looking at anti-aging doctors, longevity doctors, things like that, they usually have a different focus, right? They’re not going to be trying to correct an ill, they’re going to be trying to optimize your health. And it’s one thing that Maria and I always say that HRT is magic, but it’s not a magic pill. It truly is an optimizer. Ladies need to be putting in the effort and intention with their nutrition, their movement, their stress management, their sleep and everything else. If you’re not bothering with those low hanging fruits, honestly skip the HRT too, because HRT needs a healthy vessel and it needs a non-stressful environment kind of coming in. So, looking at the doctors, the anti-aging, the longevity docs, they usually have the similar goal that women are looking for to really kind of up level their health. A lot of times, compounding pharmacies in local areas are a place to kind of go and say, hey, who’s giving out HRT? What are they giving and kind of who’s doing it well? Pharmacists will usually be more than happy to share that information. But again, like Maria said, you have to know what you’re asking for and you have to know what it’s capable of giving you. And that’s where I think a lot of women are just sort of wrong in their efforts. And for better or for worse, there is a groundswell around menopause right now. There’s a huge market boon for supplements to correct the gut microbiome and GLP-1 type actors and get rid of meno belly and all the kind of trendy things that are going on. But none of those supplements are going to remodel your bones. None of those supplements are going to clear out tau protein accumulation in the brain. Only hormones do that.
So, try and avoid the shiny objects that you’re being sold in every algorithm on social media and everywhere else. But then we’ve also had this rise of what we call the femtech platform, right? We’ve had, whether they kind of benefited from the onset of Covid and the boon of telemedicine, or they were going to do that anyway, I don’t know. But we’ve got these venture capital firms sort of propping up these femtech platforms that are doling out HRT of varying degrees to women with whom they have zero patient relationship. That too is very dangerous in our opinion. HRT, as you just said, not every woman has the same experience. Some women have different receptor sensitivity. Some women need to kind of slow on ramp with HRT. Others might be better if they just dive head first into it, because their symptoms are such that they’d rather have a little discomfort in the short run in order to get their big bang in the other side. So again, it’s better or worse? I don’t know. We’ll say better because we have more attention being given to the topic, but worse, because all we’ve done is sort of muddied the waters. We really haven’t educated women, we haven’t empowered them, and we haven’t kind of given them a roadmap. It’s not that we give them the solution. They need a roadmap, and they need to understand how to navigate where it is they want to get to. Identify your destination and then map it out. Women aren’t being given that opportunity right now, so that’s kind of the frustrating crux of where we’re at.
Chris Kresser: Great. Well, speaking of roadmap and education, we have your book, The Great Menopause Myth, The Truth on Mastering Midlife Hormonal Mayhem, Beating Uncomfortable Symptoms and Aging To Thrive. That is a long title that says it all. I like it. It’s descriptive. So this book is either out now or will be out shortly, depending on when this podcast is released. And where can people learn more about it and pick up a copy?
Maria Claps: So it’s Amazon or your local booksellers, pretty much anywhere books are sold. We just actually found out that our book is going to be published in Spanish and in French in 2025 so we’re really, really, really excited about that. But UK would be about, it’s going to be published in the UK. That comes out about a week or so after it does in the USA.
Kristin Johnson: Yeah, you can go to our website WiseandWell.me. We have a menu selection for the book there where we kind of explain what we’re going to be talking about, sort of what drove us to write the book, and what things women can expect to get out of it. We’ve been really lucky to have a lot of providers like yourself, pre-read it for us and sort of give feedback. And it’s been very well-received. I think one of the things Maria and I like to say is that we’re not shackled by the talking points of regulatory bodies. We’re not licensed practitioners. We do not have medical societies telling us what to say, insurance paradigms limiting what we can say, etc. That’s not to say that we’re kind of shooting from the hip. This is incredibly well researched. We’ve been doing this for years, and we work with some of the leading HRT experts who have 30-plus years of clinical experience looking at this. And women just wanted a place to kind of have it all in one spot. And so that’s what we hope the book provides for them.
Chris Kresser: Awesome. And you mentioned your website for people to follow you and stay in touch with you. Anywhere else? Instagram?
Maria Claps: Instagram is WiseandWell.me. Or just Wise and Well, if they put it in the search bar, they’ll find it.
Kristin Johnson: Yeah and we’ve got a Mighty Network that we try and do a little bit more long form discussions in. They can just search, I think, Wise and Well or Mastering Midlife in a Mighty Network search bar, and they’ll find it, and they can join that for free. Or in our Instagram bio, we’ve got links for that too.
Chris Kresser: Excellent. Well, thank you both so much. It’s such an important topic, and I know a lot of women are going to get a lot out of this, because there’s just not great information out there that’s available. I really appreciate the work both of you are doing, and thanks again for coming on the show.
Kristin Johnson: Thanks for having us.
Maria Claps: Thanks for having us.
