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Speaker 1: Hi, Perry, Hi, eamily, Are you excited to talk about

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Speaker 1: hormone replacement therapy? I just want to tell the listeners

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Speaker 1: that Perry was extremely reluctant to discuss hormone replacement therapy.

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Speaker 1: Isn't that right that you preferred maybe hair loss, things

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Speaker 1: about hair loss, and no other man topics.

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Speaker 2: It's not for the reason you thought when you pitched

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Speaker 2: hormone replacement therapy. I think I said something like, oh, brother,

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Speaker 2: and you assumed, incorrectly, incorrectly, incorrectly, that I was being

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Speaker 2: a man, and I was like, oh, lady stuff, and

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Speaker 2: that's not true. I said, oh, brother, because it's really

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Speaker 2: really complicated, and I know it's going to take a

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Speaker 2: ton of research to get it right.

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Speaker 1: I'm very excited, But also I wanted to mention, do

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Speaker 1: you know about manopause?

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Speaker 2: I have heard the term of manopause, and I think

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Speaker 2: it's I think it's really good that we're finally recognizing

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Speaker 2: men changes in men's life that are clearly just as

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Speaker 2: severe and disruptive as anything that could possibly happen to

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Speaker 2: a woman. And I say that as a man and

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Speaker 2: as a father of a man.

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Speaker 3: I think you may be in manopause you'll have to actually.

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Speaker 2: Tell me what manopause is, and then I'll.

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Speaker 1: Tell it's when you gradually decay between the ages of

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Speaker 1: forty and fifty.

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Speaker 3: Are you gradually decaying?

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Speaker 2: I mean more or less?

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Speaker 1: I believe it begins with the rotator, cuff at rotator,

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Speaker 1: and then it's all downhill from there. I'm Emily Aster,

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Speaker 1: I'm an economist and a data expert.

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Speaker 2: And I'm Perry Wilson, I'm a medical doctor.

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Speaker 1: It's Thursday, April twenty third, twenty twenty six, and this

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Speaker 1: is wellness actually.

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Speaker 2: Because you're getting a staggering amount of health and wellness

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Speaker 2: information nowadays from every source imaginable, and some of it

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Speaker 2: is awesome.

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Speaker 1: And some of it is well actually both. Fortunately, we're

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Speaker 1: both people who know how to read studies, how to

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Speaker 1: parse data, and can tell you what's worth thinking about

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Speaker 1: and what you can safely ignore.

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Speaker 2: But before we dig in, a note that this podcast

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Speaker 2: is for educational purposes and should not be construed as

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Speaker 2: medical advice. We don't know your unique situation, so talk

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Speaker 2: to your doctor for personal health decisions.

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Speaker 1: This week we're asking what's the deal with hormone replacement therapy?

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Speaker 3: And this is a two Parter.

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Speaker 1: Next week we'll talk about testosterone, Perry and I will

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Speaker 1: give the official smasher pass, and then we'll get to

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Speaker 1: your question of the week. But first, let's do the

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Speaker 1: health news roundup after the break, and now for the

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Speaker 1: health news of the week, Perry, there is a new

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Speaker 1: kind of diabetes, as if we didn't have enough with

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Speaker 1: the first two kinds.

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Speaker 3: It is called type five diabetes.

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Speaker 1: This has been recognized for many years, but it is

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Speaker 1: now official diagnosis. So tell me what is type five diabetes?

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Speaker 1: And what happened to three and four?

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Speaker 2: Yeah? This is this is fascinating. The International Diabetes Federation

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Speaker 2: has officially recognized type five diabetes. After some period of time,

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Speaker 2: I think people listening will know about type one diabetes,

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Speaker 2: which is a childhood onset form usually an autoimmune disorder.

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Speaker 2: Type two diabetes, which is the syndrome of insulin resistance

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Speaker 2: that's associated with overweight and obesity. That's so prevalent in

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Speaker 2: the United States. Type three diabetes does exist. There's like

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Speaker 2: various subsets, but one is caused by damage to the pancreas,

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Speaker 2: like like trauma to the pancreas or severe pancreatitis. For example.

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Speaker 2: Type four is a very rare form of diabetes recognized

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Speaker 2: as insulin resistance in lean older adults, so it's sort

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Speaker 2: of an aging related form of diabetes. And then we

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Speaker 2: have type five, which is really interesting and very different.

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Speaker 2: It's caused by severe malnutrition and actually protein malnutrition. We

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Speaker 2: just did the protein episode. So this is quite common,

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Speaker 2: but not in the developed world. So there are probably

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Speaker 2: ten to twenty million people in sub Saharan Africa who

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Speaker 2: are suffering from type five diabetes. Scientists are still trying

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Speaker 2: to understand the exact causes and treatments of this because

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Speaker 2: it does seem like it is not purely due to

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Speaker 2: issues with insulin sensitivity, and it is driven by protein malnutrition,

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Speaker 2: so these are people who are getting enough carbohydrate, enough fat,

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Speaker 2: but not those essential proteins. It can affect the pancreas.

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Speaker 3: That is extremely interesting. Okay, but this is rare.

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Speaker 1: This is much rareer than either type one, certainly than

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Speaker 1: type two, but even then type one.

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Speaker 2: It is certainly rare in the United States. But you know,

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Speaker 2: twenty five million people around the world probably suffer from this,

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Speaker 2: and so it's good that we're drying some attention to it,

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Speaker 2: hopefully get some research in that area, speaking of research

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Speaker 2: that might start to happen now, NPR and multiple news

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Speaker 2: outlets have reported that some psychedelics, including psilocybin and iyebo gain,

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Speaker 2: may be reclassified by the Trump administration and make them

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Speaker 2: eligible to get an expedited FDA review for mental health conditions.

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Speaker 2: Emill you and I have talked about I think it's

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Speaker 2: on our show, our upcoming show list actually talking about psychedelics.

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Speaker 2: So what do you think about this news that it's

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Speaker 2: going to be easier to study them.

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Speaker 1: I mean, broadly, I would say I'm supportive of this.

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Speaker 1: You know, there was a period of time in the

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Speaker 1: nineteen sixties when psychedelics were something people thought, we're going

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Speaker 1: to be so great, and then they started using them

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Speaker 1: more recreationally and it became, you know, something that we

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Speaker 1: weren't thinking about as medical treatments.

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Speaker 3: But actually seems like in the.

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Speaker 1: Last you know, decade or so, there's been a lot

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Speaker 1: more evidence that used appropriately, psychedelics can actually be quite

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Speaker 1: effective at treating some pretty refractory conditions like pete severe PTSD.

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Speaker 3: There was actually a really interesting episode of.

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Speaker 1: The Daily which I realized is not research, with the

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Speaker 1: reporter sort of talking about his experience doing a sort

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Speaker 1: of particular psychedelic in Mexico as a treatment for kind

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Speaker 1: of long standing trauma issues.

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Speaker 3: So I mean this feels to me like I always

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Speaker 3: like more research.

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Speaker 1: It does feel like an area that's probably under research

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Speaker 1: for reasons that are you know, understandable, but maybe we

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Speaker 1: should try to get past. I will say, of course,

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Speaker 1: for many people, they're going to read some of these articles.

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Speaker 1: Trump made an announcement about this, and Joe Rogan said he

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Speaker 1: texted Trump about I Begain, which is one of these psychedelics,

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Speaker 1: and the President responded, sounds great.

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Speaker 3: Do you want FDA approval.

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Speaker 1: Let's do it, which of course is not like it's

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Speaker 1: going to cause some people to be like come on,

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Speaker 1: but I actually think we should be researching these.

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Speaker 3: Maybe we don't text FDA approval.

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Speaker 2: Yeah. The categorization of dangerous substances you've heard, like category one,

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Speaker 2: category two, does have implications for research. It does make

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Speaker 2: it much harder to run a placebo controlled trial, like

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Speaker 2: in a university like mine, if you're testing something that's

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Speaker 2: category one or category two. So moving these into category

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Speaker 2: three does just kind of open that door. But you're right,

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Speaker 2: it should follow the pathway like let's find out if

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Speaker 2: these things work. If they work, that's great, and we

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Speaker 2: should learn how to give them safely.

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Speaker 3: We'll see, all right.

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Speaker 1: Speaking of political questions, there is a new nominee for

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Speaker 1: CDC director. This has proven to be an extremely difficult

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Speaker 1: job to fill. People keep getting in and then getting fired.

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Speaker 1: This new person the quote I saw on CNN was

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Speaker 1: we just need someone who is not crazy.

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Speaker 3: So what do you think about the nominee?

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Speaker 2: So this is Erica Schwartz, who is very much a

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Speaker 2: straight down the middle nominee for for the director of

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Speaker 2: the CDC. She is a physician. She's a lawyer who

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Speaker 2: has a master's degree in public health. This CDC position,

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Speaker 2: as you mentioned, has been it's like a defense against

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Speaker 2: the dark arts in the Harry Potter universe. Like it's

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Speaker 2: just a tough one to keep every year different every

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Speaker 2: year someone or more more often than that. This is

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Speaker 2: I think very much a reaction to some real pressure

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Speaker 2: the administration has been getting sort of pushback against the

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Speaker 2: so called Maha agenda. President Trump I don't think is

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Speaker 2: as on board with the full RFK Junior philosophy than

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Speaker 2: that group of people or the people who support those policies.

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Speaker 2: Would like, and there's been you know, particular pushback against

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Speaker 2: the anti vaccine rhetoric in the face of the rising

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Speaker 2: number of measles cases and whatnot. So here we have

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Speaker 2: a CDC director who's like could have been appointed by Biden,

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Speaker 2: could have been appointed by Bush, like you know, an appropriate,

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Speaker 2: down the middle CDC director. What is really going to

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Speaker 2: be interesting if she gets confirmed is like, how does

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Speaker 2: she work with RFK Junior because clearly they have some

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Speaker 2: different policy beliefs.

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Speaker 1: Absolutely, I mean, this feels like someone who can definitely

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Speaker 1: get confirmed on like some of the people they've nominated.

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Speaker 1: But the question of, you know, can can she work

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Speaker 1: inside this administration?

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Speaker 3: I guess we will find out.

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Speaker 2: We'll find out. And that's it for the health news

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Speaker 2: of the week. After the break, what's the deal with

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Speaker 2: hormone replacement therapy?

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Speaker 3: Welcome back.

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Speaker 1: So we're going to talk about hormone replacement therapy, and

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Speaker 1: I want to start by saying up front, you know,

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Speaker 1: this is not a full discussion of all of the

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Speaker 1: potential benefits and whether you personally should be on R

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Speaker 1: replacement therapy. I think what we find in Perry, you

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Speaker 1: can correct me if this isn't what you find interesting here.

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Speaker 3: But I think what we've found interesting here.

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Speaker 1: Is kind of how the discussion of this science has evolved.

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Speaker 1: And so we'll talk a little bit about how we

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Speaker 1: got to where we are now, where we were before,

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Speaker 1: some of the data, and then some of the benefits

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Speaker 1: that are potentially true here. But this is really something

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Speaker 1: where whether one should be on this or not is

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Speaker 1: very dependent on talking to your doctor about where you are.

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Speaker 2: Yeah, this is complicated, folks. You know. This isn't red

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Speaker 2: light therapy where it's like, well, it's going to cost

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Speaker 2: you some money, but it's probably not going to kill you.

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Speaker 2: There are benefits, there are risks. We'll touch on some

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Speaker 2: of these. There are subgroups of people that would benefit more.

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Speaker 2: There are subgroups of people that have higher risks. This

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Speaker 2: is like a real deal talk with your doctor, but

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Speaker 2: it's also a completely fascinating area. I do want to

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Speaker 2: give one other disclaimer. There's like sort of an elephant

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Speaker 2: in the room here, which is that I'm a and

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Speaker 2: no true talking about hormone replacement therapy for women. This

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Speaker 2: could be like the worst case of recorded man'splaining in history.

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Speaker 2: So Emily, I think we need like a safe word

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Speaker 2: or something. If I start saying something like boorish or dumb,

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Speaker 2: you know, if I if I'm like, oh, menopause, you know,

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Speaker 2: is that that ba really beautiful transition or something like

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Speaker 2: you just say say rude, bega and I'll back off.

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Speaker 1: Safe word tampon, that's safe and you shut your mouth.

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Speaker 2: That this actually can work.

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Speaker 1: We can use this in all episodes. But yes, I

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Speaker 1: take I think that is a reasonable point. And I

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Speaker 1: will also say disclaimer on my side. You know, although

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Speaker 1: I am a woman of perimenopausal age who is presumably

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Speaker 1: somewhere in perimenopause, the actual experience of a lot of

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Speaker 1: the symptoms that people are using hormone replacement therapy to

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Speaker 1: treat is very different.

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Speaker 3: And so I can say something.

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Speaker 1: About what it is like to be a forty six

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Speaker 1: year old woman, but certainly cannot speak to the experience

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Speaker 1: of all forty six year old women. So with that

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Speaker 1: lengthy tampon disclaimer and so on, let's go. And I

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Speaker 1: think the place to start here is with the biology

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Speaker 1: of what hormone are we replacing and why so? Can you,

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Speaker 1: very briefly, from your doctor's standpoint, tell me what hormone

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Speaker 1: are replacing.

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Speaker 3: And why.

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Speaker 2: So? Can I say, for again, very briefly, that hormones stop.

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Speaker 2: I'm like, I'm just gonna like spin my chair around

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Speaker 2: and sit in the corner. Okay, we're talking about steroid hormones,

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Speaker 2: which include estrogen progesterone, and we'll touch on testosterone at

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Speaker 2: the end as well. And I do want to say

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Speaker 2: something about the biology of what makes steroid hormones, and

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Speaker 2: there are a few others as well, really special in

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Speaker 2: the body. We have these cells in our body which

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Speaker 2: are like little factory. They have a job to do,

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Speaker 2: and most of the way that they sense the outside

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Speaker 2: world or the world outside the cells, is through these

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Speaker 2: receptors on their surface, and the drugs we take and

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Speaker 2: a lot of the chemicals in our body buying these

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Speaker 2: receptors on the surface of the cells, but they don't

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Speaker 2: get into the cells. They just sort of bind their receptor.

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Speaker 2: They say hey, we're out here, and it causes the

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Speaker 2: cell to do something else, like produce more insulin, you know,

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Speaker 2: if it's a factory, produce more widgets or something. The

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Speaker 2: steroid hormones receptors are not on the outside of the cell.

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Speaker 2: They're in the nucleus of the cell, which is where

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Speaker 2: the DNA lives. Steroid hormones have the ability to go

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Speaker 2: right through the cellular membrane because they're lipid soluble and

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Speaker 2: into the nucleus where they bind their receptors, and their

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Speaker 2: effect is to change what DNA gets transcribed inside that cell. So,

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Speaker 2: to continue the factory analogy, it's like, you know, most

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Speaker 2: drugs and substances kind of like send a telegram to

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Speaker 2: the factory and are like make more widgets, and steroid

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Speaker 2: hormones go into the factory and can redesign the entire thing,

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Speaker 2: which is why you can take a hormone like testosterone

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Speaker 2: and all of a sudden, a cell that didn't grow

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Speaker 2: hair now grows hair. That also explains why the effects

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Speaker 2: of stereoid hormones are so broad, like they can do

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Speaker 2: so many things, and we don't even fully understand why

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Speaker 2: they do all the things they do, so they really

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Speaker 2: are a special group of things. And that's my very

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Speaker 2: basic biology of what we're talking about here. When we

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Speaker 2: speak about hormone replacement therapy in terms of women in general,

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Speaker 2: we're I mean, it is what it sounds like. We're

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Speaker 2: talking about giving doses of the hormones that go down

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Speaker 2: in perimenopause and postmenopause, which is estrogen and progesterone HRT

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Speaker 2: is supposed to replace those levels, not to make them higher,

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Speaker 2: but to get them back to sort of where they

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Speaker 2: were at baseline. In contrast, for women who are premenopausal,

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Speaker 2: who might have used oral contraceptive pills or something, where

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Speaker 2: the doses of those hormones are much much higher because

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Speaker 2: they're designed to actually suppress the endogenous hormone levels. That

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Speaker 2: wasn't very brief.

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Speaker 3: It was not brief, but it was I thought it

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Speaker 3: was interesting.

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Speaker 1: I think that's great, and I think the kind of

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Speaker 1: big picture here you want to imagine is that during

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Speaker 1: perimenopause and menopause, your estrogen, in particular, although both estrogen

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Speaker 1: progesterone change, estrogen goes down a lot. Estrogen is part

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Speaker 1: of what supports a lot of ways that we feel good,

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Speaker 1: and so hormone replacement therapy is potentially a way to

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Speaker 1: improve some of the symptomatic experiences perimenopause. We'll talk about this,

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Speaker 1: but things like hot flashes or sleep disruptions, which are

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Speaker 1: kind of characteristic of many people during perimenopause, estrogen is

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Speaker 1: a potential treatment. Vaginal dryness is another example of where

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Speaker 1: just as your estrogen fallows, this goes, this symptom gets

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Speaker 1: more significant, and so we're kind.

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Speaker 3: Of all of these reasons.

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Speaker 1: There is a biology behind the idea that replacing some

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Speaker 1: of that SAM would improve some of your symptoms, absolutely

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Speaker 1: make you have more more of the hormone profile of

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Speaker 1: a thirty five year old than of a fifty one

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Speaker 1: year old.

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Speaker 2: Exactly, And that made so much biological sense that for

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Speaker 2: years and years and years this was a very common practice.

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Speaker 2: It was like we had access to these hormones. They

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Speaker 2: were first discovered in the nineteen twenties, I think, and

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Speaker 2: it is true that estrogen to this day is still

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Speaker 2: a lot of the estrogen that people received comes from

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Speaker 2: horse urine. Premarin is pregnant mary urine. There are seven

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Speaker 2: hundred and fifty thousand horses around the world that are

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Speaker 2: giving their urine to make some of these estrogens. Isn't

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Speaker 2: that fascinating? So nice of that all of a sudden,

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Speaker 2: this study happened that essentially overnight tanked the use of

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Speaker 2: hormone replacement therapy in the United States. That's the Women's

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Speaker 2: Health Initiative study. And Emily, can you tell us the

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Speaker 2: story of the Women's Health initiative, because I think it's

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Speaker 2: hard to understand any of this without talking about that.

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Speaker 1: Yeah, So I actually before before I tell you the

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Speaker 1: story of this, I want to spend like I remember

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Speaker 1: how you nerded out on physics. I'm going to nerd

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Speaker 1: out on statistical external validity, just very briefly, and then

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Speaker 1: I will talk about this. So when we talk about

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Speaker 1: scientific studies, we often talk about randomized control trials as

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Speaker 1: kind of the gold standard for generating causal effects. And

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Speaker 1: that's because when you have a randomized trial, you take

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Speaker 1: some people, you divide them up randomly, so you know

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Speaker 1: they're kind of the same at the beginning. You do

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Speaker 1: something to want and not the other, and then you

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Speaker 1: can be confident that for those people, if you see

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Speaker 1: different outcomes, the different outcomes are a result of the treatment.

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Speaker 1: That's like the idea, but that is going to tell

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Speaker 1: you a causal effect for the people that you study.

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Speaker 1: And if that effect is the same across all people

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Speaker 1: in the entire population, then you have learned about the

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Speaker 1: whole population. But if you have a population where the

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Speaker 1: effect might be different than like the rest of the world,

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Speaker 1: then you haven't actually learned about everybody.

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Speaker 3: So like to be simple.

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Speaker 1: Let's imagine that you have a study of a drug

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Speaker 1: and you only include men, and then you want to

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Speaker 1: be like, Okay, this was effective for men, now I'm

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Speaker 1: going to give it to everyone. Well, it's very possible

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Speaker 1: the effect for women could be different.

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Speaker 2: I mean, we did this for fifty years. By the way,

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Speaker 2: this was all of medicine.

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Speaker 3: This is the case.

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Speaker 1: It's worked, and it turns out, actually that doesn't port

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Speaker 1: very well. There are a lot of things where women

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Speaker 1: react differently than men. So this is an idea called

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Speaker 1: external validity. And we worry when we want randomize trials

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Speaker 1: about this external validity. And this is a topic that

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Speaker 1: I work on, so I feel very passionate about it.

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Speaker 1: But I say that at the top, and then I'm

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Speaker 1: going to tell you about the Women's Health Initiative because

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Speaker 1: I think in some ways that's some of the issues

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Speaker 1: that came up with that trial. So the Women's Health

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Speaker 1: Initiative is a study launched by the NIH in the

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Speaker 1: early nineteen nineties. It included about thirty thousand, twenty seven

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Speaker 1: thousand postmenopausal women. These women had an average age of

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Speaker 1: sixty three, and they they randomized them to sort of

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Speaker 1: two different treatments of sort of hormone replacement therapy and

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Speaker 1: also a placebo. And when the follow up was published

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Speaker 1: in two thousand and two, they actually the people doing

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Speaker 1: this study halted the study in two thousand and two,

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Speaker 1: or halted one arm of the study because of a

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Speaker 1: concern that there was an increase in both breast cancer

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Speaker 1: and cardiovascular events which exceeded what they saw as the

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Speaker 1: benefits of this. And it was a relatively small increase numerically,

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Speaker 1: but percentage wise it was quite sizable. So the relative

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Speaker 1: increase about twenty five percent in invasive breast cancer and

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Speaker 1: about thirty percent in cardiovascular events, was actually also an

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Speaker 1: increase in strokes. And with that change, we pretty much

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Speaker 1: saw a absolute tanking of any hormone replacement therapy prescriptions.

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Speaker 1: So this was sort of the end at least for

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Speaker 1: some period of kind of widespread hormone replacement. And I

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Speaker 1: would say that's the nadier and then sort of over

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Speaker 1: time this has returned. But fundamentally the thing to understand

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Speaker 1: is a randomized trial of this which showed some elevated risks.

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Speaker 2: I want to double click on the relative risk versus

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Speaker 2: the absolute risk, because that's another important concept. That people

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Speaker 2: need to sort of be aware of when they think

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Speaker 2: about these studies. So let's take invasive breast cancer. When

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Speaker 2: that arm of the Women's Health Initiative was stopped, there

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Speaker 2: was a twenty six percent relative increase in invasive breast cancer,

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Speaker 2: and so people interpret that as like, my risk of

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Speaker 2: breast cancer would go up by twenty six percent. But

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Speaker 2: if you look at the absolute numbers, there were thirty

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Speaker 2: cases of breast cancer per ten thousand women per year

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Speaker 2: in the placebo group, so thirty per ten thousand per

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Speaker 2: year in placebo, thirty eight per ten thousand per year

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Speaker 2: in the hormone replacement therapy group. So we're talking eight

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Speaker 2: extra cases per ten thousand women, right, And that doesn't

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Speaker 2: sound as bad as a twenty five percent increase. Here

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Speaker 2: twenty five percent, and they're like, oh my gosh, that

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Speaker 2: means I'm going to have a twenty five percent chance

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Speaker 2: of getting cancer or worse or something like that. Really,

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Speaker 2: the absolute risk is very small, not zero, but very small.

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Speaker 2: And sometimes the way we help explain that to people

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Speaker 2: is with a concept called number needed to harm, which

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Speaker 2: is like, how many people would you need to treat

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Speaker 2: for there to be one extra case of cancer, And

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Speaker 2: in this case, if you do a little math, it

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Speaker 2: would be one thousand, two hundred and fifty women. If

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Speaker 2: you treat one thousand, two hundred and fifty women with

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Speaker 2: hormone replacement therapy, you would get one extra case of

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Speaker 2: invasive breast cancer per year, not nothing. But again, Emily,

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Speaker 2: and you're about to talk to us about this, that's

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Speaker 2: assuming that the women in the study are the same

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Speaker 2: as the women that you're prescribing the hormone replacement therapy too.

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Speaker 2: And is that the case?

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Speaker 1: So first of all, let me just say I hate

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Speaker 1: those number needed to treat things. I understand doctors like

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Speaker 1: those as a way to describe risk size, and they

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Speaker 1: I don't think they make any sense to It don't

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Speaker 1: work for you.

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Speaker 2: People, a right, it doesn't work for me. Listeners tell

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Speaker 2: us if you like number needed to treat.

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Speaker 1: Yeah, I don't like it, but I guess I'm not

404
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Speaker 1: the only listener, but I'm the first listener and I

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Speaker 1: don't like it. I will say that I think that

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Speaker 1: there is this sort of difference between percent and percentage points,

407
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Speaker 1: which is very important. People here twenty five percent increase

408
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Speaker 1: and they immediately think, you know, that raises my risk

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Speaker 1: from zero to twenty five percent as opposed to it

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Speaker 1: is a twenty five percent increase from an already low

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Speaker 1: number relative to a very low number. So I think

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Speaker 1: that's that's like we can talk more at some point

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Speaker 1: about how to talk about small numbers to people. Okay,

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Speaker 1: So getting back to the to the women Tell initiative,

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Speaker 1: you know, in this when this sort of first stuff

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Speaker 1: came out in two thousand and two, I think the

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Speaker 1: prescription rates for HRT drop by like eighty percent. I mean,

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Speaker 1: it was a real tanking. And because it sort of

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Speaker 1: fell to people like so it sounded like the you know,

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Speaker 1: hormonal placement therapy gives you breast cancer. That was kind

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Speaker 1: of like the headline was like, you take this, You're

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Speaker 1: gonna get breast cancer. But then sort of almost immediately

423
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Speaker 1: things got like quite more complicated. So there was a

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Speaker 1: second arm of the trial that treated in a slightly

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Speaker 1: different way, and that arm was halted in two thousand

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Speaker 1: and four because of a concern about an increased risk

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Speaker 1: of stroke. But actually in that group, the risk of

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Speaker 1: invasive breast cancer had gone down.

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Speaker 3: So now already.

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Speaker 1: There's like a little bit more of a complicated story,

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Speaker 1: which may relate to the overall small numbers could relate to,

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Speaker 1: you know, some actual differences in impacts, but it was

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Speaker 1: sort of made the story immediately more complicated. And then

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Speaker 1: you know, over the past, probably over the ten years

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Speaker 1: or fifteen years following this initial publication, one of the

436
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Speaker 1: things that became pretty clear was that the age group

437
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Speaker 1: in the study seemed to matter a lot. So the

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Speaker 1: primary group, the average age of people enrolled in the

439
00:24:17,880 --> 00:24:22,000
Speaker 1: study was like sixty three, but when they cut the study,

440
00:24:22,040 --> 00:24:27,000
Speaker 1: they what it's called stratified, divided the study into people

441
00:24:27,080 --> 00:24:30,720
Speaker 1: who were sort of closer to menopause, so people who

442
00:24:30,720 --> 00:24:33,160
Speaker 1: were fifty to fifty nine, so the kind of younger

443
00:24:33,280 --> 00:24:35,560
Speaker 1: group within ten years of menopause.

444
00:24:36,200 --> 00:24:37,920
Speaker 3: They actually looked like.

445
00:24:38,320 --> 00:24:42,520
Speaker 1: The treatment decreased their risk of cardiovascular disease and all

446
00:24:42,560 --> 00:24:43,560
Speaker 1: cause mortality.

447
00:24:43,600 --> 00:24:45,720
Speaker 3: So actually in that group they seem to have.

448
00:24:45,680 --> 00:24:50,359
Speaker 1: An overall mortality benefit and a reduction in cardiovascular disease

449
00:24:50,400 --> 00:24:54,320
Speaker 1: which sort of was offset by these older individuals. So

450
00:24:55,040 --> 00:24:57,840
Speaker 1: in some sense, what's really important about that is you

451
00:24:57,960 --> 00:25:00,320
Speaker 1: kind of, again getting back to this external validity point,

452
00:25:01,160 --> 00:25:04,040
Speaker 1: we put in a bunch of people, we drew some

453
00:25:04,080 --> 00:25:07,280
Speaker 1: conclusions based on a much older cohort, and then we

454
00:25:07,320 --> 00:25:10,879
Speaker 1: applied that conclusion to everybody, even though A it looked

455
00:25:10,880 --> 00:25:14,800
Speaker 1: like the younger cohort, if anything, had some benefits, and

456
00:25:14,920 --> 00:25:17,800
Speaker 1: B actually treatment with HRT is somewhat more common in

457
00:25:17,840 --> 00:25:19,760
Speaker 1: these younger cohorts, you know, and that is where this

458
00:25:19,800 --> 00:25:23,240
Speaker 1: symptomatic stuff shows up most significantly. And so you're sort

459
00:25:23,280 --> 00:25:25,040
Speaker 1: of learning from a group that's like not even the

460
00:25:25,040 --> 00:25:28,920
Speaker 1: group you're really interested in treating. And I think that

461
00:25:29,000 --> 00:25:33,720
Speaker 1: realization over time has kind of we've started to return

462
00:25:33,840 --> 00:25:36,240
Speaker 1: to the use of HRT, but it has taken a

463
00:25:36,320 --> 00:25:37,960
Speaker 1: very taken a very long time.

464
00:25:38,080 --> 00:25:41,199
Speaker 2: Yeah, the Women's Health Initiative study was not designed to

465
00:25:41,280 --> 00:25:44,760
Speaker 2: test whether HRT reduces the symptoms of menopause, because, as

466
00:25:44,760 --> 00:25:46,800
Speaker 2: you point out, seventy percent of the women in the

467
00:25:46,840 --> 00:25:49,960
Speaker 2: study were more than ten years past menopause, like they

468
00:25:49,960 --> 00:25:53,440
Speaker 2: weren't symptomatic anymore. It was designed to test whether hormone

469
00:25:53,480 --> 00:25:57,919
Speaker 2: replacement therapy is cardioprotected it protects the heart, because you know,

470
00:25:57,960 --> 00:26:01,040
Speaker 2: there's long been an observation that women tend not to

471
00:26:01,119 --> 00:26:04,520
Speaker 2: have heart attacks and stuff until after metopause, and it

472
00:26:04,560 --> 00:26:07,080
Speaker 2: was thought the asternom to be protective. That obviously didn't

473
00:26:07,080 --> 00:26:09,360
Speaker 2: pan out in that older group of women. It may

474
00:26:09,400 --> 00:26:12,560
Speaker 2: among younger women. There's like, the study wasn't designed to

475
00:26:12,680 --> 00:26:14,960
Speaker 2: test the thing that we're using it for now.

476
00:26:15,960 --> 00:26:18,119
Speaker 1: Yeah, I think, I mean in some ways many people

477
00:26:18,160 --> 00:26:21,000
Speaker 1: would say, well, well, like what why not? And you know,

478
00:26:21,040 --> 00:26:25,680
Speaker 1: one answer is like you know, the patriarchy or something.

479
00:26:26,400 --> 00:26:28,920
Speaker 1: But you know it really it is a really important

480
00:26:28,920 --> 00:26:32,000
Speaker 1: point because for many people, the reason to treat this

481
00:26:32,200 --> 00:26:35,400
Speaker 1: is because of symptomatic you know, because of improvements and

482
00:26:35,480 --> 00:26:36,200
Speaker 1: in symptoms.

483
00:26:36,400 --> 00:26:37,840
Speaker 3: This study just wasn't about that.

484
00:26:37,920 --> 00:26:40,919
Speaker 1: It's not that it was it evaluated symptom profile and

485
00:26:41,040 --> 00:26:42,560
Speaker 1: show that it didn't work or anything. It just like

486
00:26:42,600 --> 00:26:44,760
Speaker 1: that wasn't one of the outcomes, and it wouldn't have

487
00:26:44,760 --> 00:26:47,480
Speaker 1: made sense with this age go work because again the

488
00:26:47,520 --> 00:26:51,600
Speaker 1: sort of symptomatic pieces of menopause are earlier, and so

489
00:26:52,119 --> 00:26:55,359
Speaker 1: it really is an example of a place where I

490
00:26:55,359 --> 00:26:58,320
Speaker 1: think a lot of people's lives were made substantially worse

491
00:26:59,040 --> 00:27:02,800
Speaker 1: by this research, which in principle was very well meaning

492
00:27:03,480 --> 00:27:06,520
Speaker 1: and from which perhaps we did learn something, but it

493
00:27:06,800 --> 00:27:09,240
Speaker 1: caused a lot of people to not have symptom relief

494
00:27:09,240 --> 00:27:15,280
Speaker 1: who could have. So we then find ourselves in the

495
00:27:15,480 --> 00:27:18,920
Speaker 1: current moment where I think like overall we are starting

496
00:27:18,920 --> 00:27:23,320
Speaker 1: to see HRT. It's like it's having a moment, it's

497
00:27:23,320 --> 00:27:24,240
Speaker 1: like having a comeback.

498
00:27:24,640 --> 00:27:26,000
Speaker 3: Absolutely, people are into it.

499
00:27:26,640 --> 00:27:29,680
Speaker 2: Yeah, I think that the word has gotten out and

500
00:27:29,800 --> 00:27:32,480
Speaker 2: it's making people very curious. But part of this is

501
00:27:32,480 --> 00:27:35,399
Speaker 2: word of mouth, because unlike a lot of drugs we

502
00:27:35,440 --> 00:27:39,359
Speaker 2: take and give ourselves, like, hormone replacement therapy really works

503
00:27:39,600 --> 00:27:43,919
Speaker 2: for symptoms of menopause. And so if you are a

504
00:27:43,960 --> 00:27:46,480
Speaker 2: woman or no, a woman who has those symptoms and

505
00:27:46,480 --> 00:27:48,960
Speaker 2: then they start taking HRT, they'll tell you how much

506
00:27:48,960 --> 00:27:51,440
Speaker 2: better it is, and that's that's real. And so this

507
00:27:51,640 --> 00:27:52,800
Speaker 2: percolates really quickly.

508
00:27:53,280 --> 00:27:55,600
Speaker 1: But can I like sort of set back one STEC,

509
00:27:55,680 --> 00:27:58,640
Speaker 1: which is, you know, looking at the Women's Health Initiative results,

510
00:27:59,040 --> 00:28:00,840
Speaker 1: sort of what would you think we should have taken

511
00:28:00,880 --> 00:28:01,520
Speaker 1: away from.

512
00:28:01,320 --> 00:28:03,640
Speaker 2: That from the initial results?

513
00:28:03,800 --> 00:28:06,119
Speaker 1: Yeah, in two thousand and two, what would you have

514
00:28:06,160 --> 00:28:08,360
Speaker 1: had them do sort of do or say differently?

515
00:28:09,920 --> 00:28:13,480
Speaker 2: To be honest, because the purpose of the study was

516
00:28:13,520 --> 00:28:16,639
Speaker 2: to determine whether hormone replacement therapy reduce the risk of

517
00:28:16,640 --> 00:28:21,160
Speaker 2: cardiovascular disease, and it didn't in the overall population, I

518
00:28:21,200 --> 00:28:23,160
Speaker 2: think I would have said, Okay, you should not give

519
00:28:23,160 --> 00:28:26,040
Speaker 2: hormone replacement therapy to reduce the risk of cardiovascular disease

520
00:28:26,320 --> 00:28:29,520
Speaker 2: in post menopausal women, in post menopause women. And I

521
00:28:29,560 --> 00:28:33,280
Speaker 2: would probably still say that today to be honest, although

522
00:28:33,359 --> 00:28:37,160
Speaker 2: you know, you could maybe convince me. But the problem

523
00:28:37,200 --> 00:28:41,200
Speaker 2: is when we extrapolate from one outcome to all outcomes. Yeah,

524
00:28:41,320 --> 00:28:43,080
Speaker 2: and we'll get to some of those other outcomes. But

525
00:28:43,160 --> 00:28:46,040
Speaker 2: I did want to give I think, you know, women

526
00:28:46,080 --> 00:28:48,800
Speaker 2: who are reading about this, it can be very confusing

527
00:28:49,320 --> 00:28:52,360
Speaker 2: what is out there? Right, I said estrogen and progesterone

528
00:28:52,800 --> 00:28:56,720
Speaker 2: in terms of the biology, but there are so many

529
00:28:56,720 --> 00:29:00,880
Speaker 2: different types and preparations. I think think it's worth just

530
00:29:01,280 --> 00:29:04,840
Speaker 2: giving people a framework to sort of think through how

531
00:29:04,880 --> 00:29:08,640
Speaker 2: to take these hormones. And so the framework that I

532
00:29:08,680 --> 00:29:13,920
Speaker 2: have found useful is to remember that really the hormone

533
00:29:13,960 --> 00:29:16,520
Speaker 2: that you want to get for homone replacement therapy is estrogen.

534
00:29:17,000 --> 00:29:19,560
Speaker 3: Yes, that's the best one. The Estrogen's a great hormone.

535
00:29:19,600 --> 00:29:23,360
Speaker 2: So it's a great hormone. We love, we love estrogen it.

536
00:29:23,920 --> 00:29:27,480
Speaker 2: Estrogen is responsible for what makes women women, the secondary

537
00:29:27,520 --> 00:29:31,040
Speaker 2: sexual characteristics and a lot of other things. Progesterone is

538
00:29:31,080 --> 00:29:33,800
Speaker 2: there to stop you from getting uterine cancer. I mean

539
00:29:33,840 --> 00:29:39,080
Speaker 2: that's really what it is. So estrogen flogs the lining

540
00:29:39,080 --> 00:29:42,280
Speaker 2: of the uterus to grow and develop, that's one of

541
00:29:42,280 --> 00:29:46,440
Speaker 2: its jobs during the menstrual cycle. If you don't allow

542
00:29:46,520 --> 00:29:49,640
Speaker 2: the lining of the uterus to settle down and mature,

543
00:29:49,760 --> 00:29:51,959
Speaker 2: which is what progesterone does, and it keeps getting hit

544
00:29:51,960 --> 00:29:54,560
Speaker 2: by estrogen, the risk of uterine cancer really does increase.

545
00:29:54,640 --> 00:29:59,640
Speaker 2: And so you want the estrogen, you need the progesterone

546
00:30:00,160 --> 00:30:03,160
Speaker 2: if you have a uterus. And that other arm of

547
00:30:03,200 --> 00:30:05,240
Speaker 2: the Women's Health Initiative study that you alluded to was

548
00:30:05,240 --> 00:30:07,560
Speaker 2: an estrogen only arm, and you could only get in

549
00:30:07,600 --> 00:30:10,280
Speaker 2: that arm if your uterus had already been removed for

550
00:30:10,320 --> 00:30:14,560
Speaker 2: some reason. And I mentioned that because a lot of

551
00:30:14,600 --> 00:30:18,920
Speaker 2: the outcomes for estrogen only hormone replacement therapy are actually

552
00:30:18,960 --> 00:30:22,760
Speaker 2: a little bit better than estrogen and plus progesterone therapy,

553
00:30:22,800 --> 00:30:24,800
Speaker 2: it's just like not everyone is eligible for that. So

554
00:30:24,840 --> 00:30:29,360
Speaker 2: particularly breast cancer, for example, the risk in the overall

555
00:30:29,360 --> 00:30:32,400
Speaker 2: Women's Health Initiative was elevated, but among those women who

556
00:30:32,440 --> 00:30:34,880
Speaker 2: were on estrogen only because they didn't have a uterus,

557
00:30:35,240 --> 00:30:37,960
Speaker 2: the risk was slightly reduced. So really interesting there and

558
00:30:38,000 --> 00:30:40,840
Speaker 2: something to keep in mind. So ask about the uterus.

559
00:30:40,880 --> 00:30:43,560
Speaker 2: The other thing is whether you're taking these as pills

560
00:30:43,920 --> 00:30:47,800
Speaker 2: or not as pills. The pill forms have to get

561
00:30:47,840 --> 00:30:50,800
Speaker 2: digested and pass through the liver before they get to

562
00:30:50,840 --> 00:30:54,080
Speaker 2: your blood, and depending on the type of estrogen, the

563
00:30:54,120 --> 00:30:57,320
Speaker 2: liver can break down like straight up estrogen, like seventeen

564
00:30:57,360 --> 00:31:00,880
Speaker 2: beta estra dial which is the norm the that women

565
00:31:00,920 --> 00:31:02,600
Speaker 2: make in their own bodies. You can take that in

566
00:31:02,640 --> 00:31:04,720
Speaker 2: pill form, and if you do, your liver will break

567
00:31:04,760 --> 00:31:06,600
Speaker 2: down ninety five percent of it before it gets to

568
00:31:06,640 --> 00:31:08,800
Speaker 2: the rest of your blood. So you're actually taking pretty

569
00:31:08,840 --> 00:31:12,160
Speaker 2: high doses to get like relatively normal blood levels. In

570
00:31:12,280 --> 00:31:15,040
Speaker 2: contrast to a patch which goes right through the skin.

571
00:31:16,000 --> 00:31:19,240
Speaker 2: You know, there's transvaginal or like vaginal preparations as well,

572
00:31:19,320 --> 00:31:21,680
Speaker 2: which can get right into the bloodstream and the doses

573
00:31:21,720 --> 00:31:24,920
Speaker 2: are much lower. That's worth mentioning because some of the

574
00:31:25,000 --> 00:31:29,600
Speaker 2: risk of clot seems to be driven by these oral preparations,

575
00:31:29,640 --> 00:31:32,600
Speaker 2: and I don't think people are entirely sure why there's

576
00:31:32,640 --> 00:31:34,760
Speaker 2: a higher risk there. But if you've got the liver

577
00:31:34,880 --> 00:31:37,640
Speaker 2: breaking down ninety five percent of stuff, you know that's

578
00:31:37,640 --> 00:31:39,880
Speaker 2: going to be variable woman to woman because everyone's liver

579
00:31:39,920 --> 00:31:41,719
Speaker 2: is a little bit different. And I bet dosing is

580
00:31:41,800 --> 00:31:44,440
Speaker 2: just trickier to get right in those situations, so I

581
00:31:44,520 --> 00:31:46,040
Speaker 2: just wanted to that's the framework.

582
00:31:46,400 --> 00:31:51,000
Speaker 1: I think partly, that somewhat complicated framework illustrates sort of

583
00:31:51,040 --> 00:31:55,320
Speaker 1: why this is a challenging thing to talk about in

584
00:31:55,360 --> 00:32:01,440
Speaker 1: a podcast. And you know, because everybody's not for us,

585
00:32:01,640 --> 00:32:04,840
Speaker 1: but for other people, you know, because everybody's needs here

586
00:32:04,880 --> 00:32:07,880
Speaker 1: are going to be somewhat different. So there's an oral preparation.

587
00:32:08,040 --> 00:32:11,040
Speaker 1: There's a patch, which I know is what a lot.

588
00:32:11,000 --> 00:32:14,720
Speaker 2: Of people like, and there's a shortage of right now, and.

589
00:32:14,680 --> 00:32:15,480
Speaker 3: There's a shortage.

590
00:32:16,240 --> 00:32:19,480
Speaker 1: There are you know, vaginal creams which really are are

591
00:32:19,600 --> 00:32:23,600
Speaker 1: kind of intended to treat or are effective mostly at

592
00:32:23,600 --> 00:32:28,000
Speaker 1: treating the specific issue of vaginal dryness, so people you know,

593
00:32:28,080 --> 00:32:32,200
Speaker 1: experience that symptom. A vaginal estrogen based cream can be

594
00:32:32,320 --> 00:32:36,360
Speaker 1: very effective. Can also be usable even for people potentially

595
00:32:36,440 --> 00:32:40,680
Speaker 1: who would not be wanting to take estrogen only therapies

596
00:32:41,120 --> 00:32:43,880
Speaker 1: in other ways because of other risks. So it's sort

597
00:32:43,880 --> 00:32:46,800
Speaker 1: of like all about you know, what are the particular

598
00:32:46,800 --> 00:32:49,000
Speaker 1: symptoms that I am experiencing, what are the other risk

599
00:32:49,080 --> 00:32:51,600
Speaker 1: factors that I'm holding on too, and then what's the

600
00:32:51,680 --> 00:32:56,480
Speaker 1: right way to address those symptoms and getting back to

601
00:32:56,560 --> 00:32:58,200
Speaker 1: the idea that a lot of what we're trying to

602
00:32:58,200 --> 00:33:01,040
Speaker 1: do with this hormone replacement therapy, in contrast to what

603
00:33:01,080 --> 00:33:03,200
Speaker 1: the Women's Health Initiative was evaluating, a lot of what

604
00:33:03,200 --> 00:33:06,040
Speaker 1: we're trying to do is, you know, dial down symptoms

605
00:33:06,120 --> 00:33:10,760
Speaker 1: of perimenopause and menopause, which are very disruptive to people's lives.

606
00:33:11,240 --> 00:33:12,520
Speaker 2: So let's talk about the symptoms.

607
00:33:12,680 --> 00:33:13,800
Speaker 3: Let's talk about the symptoms.

608
00:33:14,760 --> 00:33:19,600
Speaker 2: Does hormone replacement therapy Yes, work for hot flashes, It really.

609
00:33:19,360 --> 00:33:21,400
Speaker 3: Really really does. So hot flashes, you.

610
00:33:21,320 --> 00:33:27,400
Speaker 1: Know, vasomotor symptoms are very very common experience of perimenopause.

611
00:33:27,480 --> 00:33:30,400
Speaker 1: This is like the like joke on television shows where

612
00:33:30,400 --> 00:33:33,800
Speaker 1: someone's sticking their head and the refrigerator that's that's a

613
00:33:33,800 --> 00:33:34,360
Speaker 1: hot flash.

614
00:33:34,400 --> 00:33:35,320
Speaker 3: People get a lot.

615
00:33:35,160 --> 00:33:40,120
Speaker 1: Of these at night, and it's very disruptive at night

616
00:33:40,280 --> 00:33:43,640
Speaker 1: because you know, you sweat, you wake up, your bed

617
00:33:43,880 --> 00:33:47,920
Speaker 1: is completely soaked, and then you know you can't.

618
00:33:47,600 --> 00:33:50,000
Speaker 3: Just go back to sleep because you're like literally.

619
00:33:49,640 --> 00:33:54,680
Speaker 1: Drenched, and it is very unpleasant having had this happen.

620
00:33:54,760 --> 00:33:58,640
Speaker 1: It's very unpleasant, and hormone replacement therapy reduces the risk

621
00:33:58,680 --> 00:34:00,760
Speaker 1: of hot flashes and these studies by some like seventy

622
00:34:00,840 --> 00:34:04,600
Speaker 1: to eighty percent, So can be really really effective at

623
00:34:04,640 --> 00:34:10,600
Speaker 1: what is probably the most disruptive experience in perimenopause that

624
00:34:10,600 --> 00:34:10,960
Speaker 1: people have.

625
00:34:11,800 --> 00:34:14,200
Speaker 2: And perimenopause can go on for quite some.

626
00:34:14,200 --> 00:34:17,360
Speaker 1: Time, it goes I mean yes, it can go on

627
00:34:17,480 --> 00:34:21,120
Speaker 1: for many years, so people maybe it's worth saying. So

628
00:34:21,360 --> 00:34:25,799
Speaker 1: menopause actually defined as twelve months. You sort of are

629
00:34:25,840 --> 00:34:29,880
Speaker 1: in menopause when you are twelve months past your last period.

630
00:34:30,000 --> 00:34:33,840
Speaker 1: So it's a thing that sort of defined retroactively. So

631
00:34:33,880 --> 00:34:35,759
Speaker 1: there's like a moment at which your last period was

632
00:34:35,800 --> 00:34:39,160
Speaker 1: twelve months ago and now you are in menopause. Perimenopause

633
00:34:39,200 --> 00:34:41,239
Speaker 1: is the sort of period leading up to that when

634
00:34:41,640 --> 00:34:45,000
Speaker 1: periods get less frequent or more frequent, like they kind

635
00:34:45,000 --> 00:34:48,839
Speaker 1: of mess around. Your cycle isn't so regular, and that

636
00:34:48,960 --> 00:34:51,759
Speaker 1: is where many of these symptoms start showing up.

637
00:34:51,840 --> 00:34:55,000
Speaker 2: And I want to be clear that perimenopause has nothing

638
00:34:55,040 --> 00:34:57,200
Speaker 2: to do with Perry Wilson. There's no relation.

639
00:34:57,760 --> 00:34:59,960
Speaker 3: It's no, it's not even spelled the same.

640
00:35:00,239 --> 00:35:03,799
Speaker 2: You know, I was not named after after you.

641
00:35:03,920 --> 00:35:08,400
Speaker 1: I don't know if menopausad Perry.

642
00:35:10,280 --> 00:35:15,040
Speaker 2: I think though hot Flashes clearly works. You talked about

643
00:35:15,160 --> 00:35:19,880
Speaker 2: the general urinary symptoms, where the topical preparations are probably

644
00:35:19,920 --> 00:35:23,760
Speaker 2: superior to oral preparations. Another reason to kind of discuss

645
00:35:23,800 --> 00:35:26,440
Speaker 2: with your doctor about how exactly you are going to

646
00:35:26,480 --> 00:35:29,960
Speaker 2: go about this. But it's the vaguer symptoms I think

647
00:35:30,040 --> 00:35:32,640
Speaker 2: that are where a lot of women who I talk

648
00:35:32,680 --> 00:35:35,200
Speaker 2: to are really have their questions like, yes, that's great,

649
00:35:35,200 --> 00:35:37,040
Speaker 2: I don't want to have hot flashes, but also what

650
00:35:37,120 --> 00:35:41,040
Speaker 2: about my brain? What about sleep? What about you know, memory?

651
00:35:41,480 --> 00:35:45,319
Speaker 2: And you'll hear people online saying that, like they start

652
00:35:45,360 --> 00:35:50,000
Speaker 2: a hormone replacement therapy and the scales fell from their eyes,

653
00:35:50,080 --> 00:35:52,120
Speaker 2: and you know, it was like they were granted a

654
00:35:52,120 --> 00:35:55,040
Speaker 2: whole new lease on life, which, to be honest, and

655
00:35:55,120 --> 00:35:59,800
Speaker 2: maybe this is another safeword thing I'm always skeptical of naturally,

656
00:35:59,840 --> 00:36:02,080
Speaker 2: just because I never think there's like any one thing

657
00:36:02,160 --> 00:36:04,799
Speaker 2: that can be that transformative except the power of love.

658
00:36:06,200 --> 00:36:06,680
Speaker 2: Oh my god.

659
00:36:08,160 --> 00:36:11,000
Speaker 1: So I let me say sort of two things about that.

660
00:36:11,160 --> 00:36:14,360
Speaker 1: So one is, you know, if you think about the

661
00:36:14,360 --> 00:36:17,640
Speaker 1: the sort of experience of the menstrual cycle, there is

662
00:36:17,680 --> 00:36:19,840
Speaker 1: a period of the of the menstruds is like before

663
00:36:19,880 --> 00:36:21,840
Speaker 1: the men's recycle, when your estrogen is higher in the

664
00:36:21,920 --> 00:36:25,200
Speaker 1: kind of pre ovulatory phase and then the estrogen falls,

665
00:36:25,200 --> 00:36:29,360
Speaker 1: and a lot of people do experience fairly substantial mood

666
00:36:29,400 --> 00:36:33,839
Speaker 1: shifts with those cycles. So the idea that estrogen could affect.

667
00:36:33,560 --> 00:36:35,600
Speaker 2: That's why whenever a woman's in a bad mood, my

668
00:36:35,680 --> 00:36:38,359
Speaker 2: first question is like, where are you?

669
00:36:38,680 --> 00:36:40,680
Speaker 1: That's my question where that's where you want to start

670
00:36:40,760 --> 00:36:43,399
Speaker 1: totally totally is this, yeah, and that's where I that's

671
00:36:43,440 --> 00:36:46,880
Speaker 1: always That actually is a great marriage tip that many.

672
00:36:46,719 --> 00:36:49,080
Speaker 3: People could we should.

673
00:36:49,080 --> 00:36:50,240
Speaker 2: We could help so many people.

674
00:36:50,280 --> 00:36:51,360
Speaker 3: We could help so many people.

675
00:36:51,760 --> 00:36:55,400
Speaker 1: So I think it's not crazy to imagine that estrogen

676
00:36:55,480 --> 00:37:00,600
Speaker 1: could affect your mood. I think a lot of that experience,

677
00:37:00,680 --> 00:37:03,920
Speaker 1: the brain fog, the fatigue, whatever, is in fact sleep.

678
00:37:04,320 --> 00:37:07,120
Speaker 1: So if you think about there's a sort of evidence

679
00:37:07,360 --> 00:37:11,200
Speaker 1: that that hormone replacement therapy improves people's sleep, that maybe

680
00:37:11,200 --> 00:37:13,480
Speaker 1: because of a reduction of basil motor symptoms, there may

681
00:37:13,480 --> 00:37:17,000
Speaker 1: be other you know, they're like, no, you're not waking

682
00:37:17,040 --> 00:37:18,479
Speaker 1: up in the middle of the night to change the bed.

683
00:37:18,840 --> 00:37:22,160
Speaker 1: But it may also have sort of other other things

684
00:37:22,200 --> 00:37:25,400
Speaker 1: that impact sleep. If you have slept better, you feel better.

685
00:37:25,680 --> 00:37:27,960
Speaker 1: And so if the whole whole thing here was just

686
00:37:28,000 --> 00:37:30,719
Speaker 1: improving sleep, I actually could explain a fair amount of

687
00:37:31,239 --> 00:37:33,200
Speaker 1: just a general set of like, boy, do I feel

688
00:37:33,239 --> 00:37:35,640
Speaker 1: a lot better? Yeah, the same way the first time

689
00:37:35,640 --> 00:37:37,359
Speaker 1: your baby sleeps to the night you're like, oh my god,

690
00:37:37,360 --> 00:37:40,480
Speaker 1: I'm going to conquer the world because I haven't, you know,

691
00:37:40,560 --> 00:37:41,919
Speaker 1: because I've I've slept.

692
00:37:42,080 --> 00:37:45,239
Speaker 2: Right, absolutely, And this is randomized trial level data. There's

693
00:37:45,239 --> 00:37:48,160
Speaker 2: been a number of trials, but one called the Keeps trial.

694
00:37:48,840 --> 00:37:52,520
Speaker 2: This was in sort of just recently. Menopausal woman showed

695
00:37:52,560 --> 00:37:56,440
Speaker 2: a pretty significant improvement in global sleep quality scores in

696
00:37:56,480 --> 00:37:59,400
Speaker 2: the group that got hormone replacement therapy compared to place ebo.

697
00:37:59,640 --> 00:38:03,319
Speaker 2: As you mentioned, Emily, when they stratified that population by

698
00:38:03,320 --> 00:38:07,600
Speaker 2: women who were having severe vasomotor symptoms, severe hot flashes, like,

699
00:38:07,680 --> 00:38:09,960
Speaker 2: that's where a lot of the benefit accrued. So it

700
00:38:10,040 --> 00:38:14,680
Speaker 2: might just be that you'll see people online talking about

701
00:38:14,880 --> 00:38:19,279
Speaker 2: progesterone actually in particular binding the GABBA receptor in the brain.

702
00:38:19,360 --> 00:38:23,000
Speaker 2: That's the same receptor that alcohol and benzodiazepines bind to,

703
00:38:23,880 --> 00:38:28,520
Speaker 2: one of my personal favorite receptors. But not much data

704
00:38:28,560 --> 00:38:32,760
Speaker 2: beside the mechanistic like petri dish stuff that would suggest

705
00:38:32,760 --> 00:38:36,239
Speaker 2: that progesterone is a calming factor. But I think if

706
00:38:36,280 --> 00:38:38,880
Speaker 2: you're certainly if you're waking up with hot flashes like

707
00:38:39,440 --> 00:38:40,839
Speaker 2: this can be really good.

708
00:38:41,440 --> 00:38:43,400
Speaker 1: The other thing we should say is that there's some

709
00:38:43,440 --> 00:38:46,719
Speaker 1: evidence of an improvement in fractures, so people are risking

710
00:38:46,719 --> 00:38:50,120
Speaker 1: oft osteoporosis. That's another that's another place where we see

711
00:38:50,800 --> 00:38:53,880
Speaker 1: some hormonal placement therapy benefits.

712
00:38:54,400 --> 00:38:57,600
Speaker 2: Yeah, no, I mean it's it's so important. I looked

713
00:38:57,640 --> 00:39:00,960
Speaker 2: also a little bit more into brain stuff. The problem

714
00:39:01,000 --> 00:39:03,319
Speaker 2: with brain fog is it's a bit of a Potter

715
00:39:03,360 --> 00:39:05,760
Speaker 2: Stewart thing, you know, Potter Stewart, the Supreme Court justice.

716
00:39:06,040 --> 00:39:08,520
Speaker 1: So like pornography, you know, and if you you know

717
00:39:08,560 --> 00:39:10,080
Speaker 1: when you see it, you know when you see it

718
00:39:10,120 --> 00:39:11,520
Speaker 1: right now, when you see it? Is that in my

719
00:39:11,520 --> 00:39:13,839
Speaker 1: class literally all the time, I'm constantly telling them it's

720
00:39:13,840 --> 00:39:16,000
Speaker 1: like what the Supreme Court's out of pornography, And people were.

721
00:39:16,000 --> 00:39:20,840
Speaker 2: Just like as they like load up Browns, like report

722
00:39:20,880 --> 00:39:22,240
Speaker 2: your professor page.

723
00:39:22,360 --> 00:39:24,360
Speaker 1: I don't let them have devices in classes, just to

724
00:39:24,400 --> 00:39:25,600
Speaker 1: avoid that kind of behavior.

725
00:39:25,680 --> 00:39:29,279
Speaker 2: Mart So, I think brain fog is you know, we're

726
00:39:29,280 --> 00:39:31,239
Speaker 2: all like, oh, yeah, I know what that is. And

727
00:39:31,280 --> 00:39:34,360
Speaker 2: then but no one's study there's no randomized trials of

728
00:39:34,400 --> 00:39:37,120
Speaker 2: like brain fog because that's what do you mean, Like,

729
00:39:37,160 --> 00:39:39,319
Speaker 2: how do you quantify that? And so what you do

730
00:39:39,440 --> 00:39:44,600
Speaker 2: get is you get randomized trials of neurocognitive testing, which

731
00:39:45,000 --> 00:39:48,200
Speaker 2: is across a variety of domains, you know, executive function,

732
00:39:48,719 --> 00:39:51,520
Speaker 2: verbal memory, physical memory, like all these different tests that

733
00:39:51,560 --> 00:39:55,000
Speaker 2: you can put people through, and the data is really

734
00:39:55,000 --> 00:39:58,960
Speaker 2: not super compelling that there are dramatic brain improvement effects,

735
00:39:58,960 --> 00:40:02,640
Speaker 2: with the only exception being verbal memory. There did seem

736
00:40:02,640 --> 00:40:06,080
Speaker 2: to be an uptick in verbal memory. And again just

737
00:40:06,480 --> 00:40:09,440
Speaker 2: you know, get out your your your your shock buzzer

738
00:40:09,560 --> 00:40:13,160
Speaker 2: or whatever we're using for me here. But I did

739
00:40:13,239 --> 00:40:15,040
Speaker 2: feel like there, I was like, oh, that's kind of

740
00:40:15,080 --> 00:40:17,000
Speaker 2: like a mom brane thing, like you can't find the

741
00:40:17,040 --> 00:40:18,480
Speaker 2: word for X y Z right.

742
00:40:18,880 --> 00:40:20,240
Speaker 3: That's called fatigue.

743
00:40:21,360 --> 00:40:22,960
Speaker 1: I mean, I just I feel like so hard to

744
00:40:23,000 --> 00:40:24,840
Speaker 1: separate all this stuff from being tired.

745
00:40:24,920 --> 00:40:28,320
Speaker 3: But all right, so let's let's just leave.

746
00:40:28,160 --> 00:40:32,160
Speaker 1: The hormone replacement therapy at You know, this is especially

747
00:40:32,200 --> 00:40:36,560
Speaker 1: if you are someone who is experiencing symptoms of perimenopause.

748
00:40:36,600 --> 00:40:39,240
Speaker 1: This is something you for sure would like to discuss

749
00:40:40,280 --> 00:40:43,600
Speaker 1: with your doctor, absolutely right.

750
00:40:43,880 --> 00:40:46,040
Speaker 3: What about testosterone?

751
00:40:46,080 --> 00:40:50,360
Speaker 1: So that feels like we're diving in a little more

752
00:40:50,360 --> 00:40:54,120
Speaker 1: more talk about testosterone for men separately, but testosterone for

753
00:40:54,239 --> 00:40:57,759
Speaker 1: women feels like is it? I always think of this

754
00:40:57,800 --> 00:40:59,480
Speaker 1: as like, this is how I could cheat in my

755
00:41:00,000 --> 00:41:00,880
Speaker 1: sports performance.

756
00:41:01,000 --> 00:41:04,400
Speaker 2: Oh, but you will not be allowed to because testosterone

757
00:41:04,400 --> 00:41:09,919
Speaker 2: hormone replacement therapy is banned by almost every international sports

758
00:41:09,960 --> 00:41:13,040
Speaker 2: authority and by the wellness actually metric of is it

759
00:41:13,080 --> 00:41:13,960
Speaker 2: banned doesn't work?

760
00:41:15,600 --> 00:41:16,200
Speaker 3: It does work?

761
00:41:16,520 --> 00:41:20,600
Speaker 1: Yes, So why are people using this in menopause? And

762
00:41:21,040 --> 00:41:22,600
Speaker 1: are there reasons they should do it?

763
00:41:23,640 --> 00:41:27,359
Speaker 2: Yeah? So women do have testosterone just like men have

764
00:41:27,600 --> 00:41:30,239
Speaker 2: some estrogen. It's just men have about ten times the

765
00:41:30,280 --> 00:41:33,400
Speaker 2: testosterone and women have about ten times the estrogen and

766
00:41:33,719 --> 00:41:40,040
Speaker 2: Viva la de France. Women's testosterone levels peak around age

767
00:41:40,120 --> 00:41:43,799
Speaker 2: twenty and sort of decline slowly thereafter. They do not

768
00:41:44,000 --> 00:41:48,200
Speaker 2: suffer the same menopausal cliff as estrogen and progesterone, so

769
00:41:48,200 --> 00:41:50,040
Speaker 2: they do sort of more the male thing, which we'll

770
00:41:50,040 --> 00:41:52,280
Speaker 2: talk about next week, which is kind of like a slow,

771
00:41:52,320 --> 00:41:58,040
Speaker 2: steady decline over time. The interest in testosterone is really

772
00:41:58,120 --> 00:42:01,359
Speaker 2: more recent than for women at least is much more

773
00:42:01,400 --> 00:42:05,880
Speaker 2: recent than the broader HRT, in part because this is

774
00:42:05,920 --> 00:42:09,480
Speaker 2: a hormone that people associate with, you know, muscle growth,

775
00:42:09,560 --> 00:42:14,000
Speaker 2: and maintenance vigor to some extent, and to be honest,

776
00:42:14,160 --> 00:42:18,280
Speaker 2: a lot of the research has been driven by sexual dysfunction.

777
00:42:19,200 --> 00:42:23,680
Speaker 2: So testosterone in women's sort of first foray into organized

778
00:42:23,680 --> 00:42:29,080
Speaker 2: research was to treat what's called hyperactive sexual desire disorder.

779
00:42:29,760 --> 00:42:32,640
Speaker 2: You know, there's no there's no viagra for women yet,

780
00:42:32,680 --> 00:42:36,840
Speaker 2: and so testosterone was sort of used for this purpose.

781
00:42:37,760 --> 00:42:38,440
Speaker 2: Does it work?

782
00:42:39,120 --> 00:42:42,239
Speaker 3: Yeah, pretty it does. It does work for.

783
00:42:44,440 --> 00:42:48,720
Speaker 2: Sexual stuff. It works. The largest meta analysis comes from

784
00:42:49,040 --> 00:42:53,759
Speaker 2: the Lancet combining data for multiple studies about eighty five

785
00:42:53,840 --> 00:42:58,560
Speaker 2: hundred women total randomized trial data. And there's a bunch

786
00:42:58,600 --> 00:43:02,839
Speaker 2: of different ways to to measure sexual satisfaction, but the

787
00:43:03,080 --> 00:43:07,359
Speaker 2: women for getting disastroone replacement therapy had approximately one additional

788
00:43:07,840 --> 00:43:12,080
Speaker 2: satisfying sexual event per month. So a satisfying sexual event

789
00:43:12,480 --> 00:43:15,680
Speaker 2: could be with a partner, it could be alone. It

790
00:43:15,719 --> 00:43:18,359
Speaker 2: doesn't necessarily mean there is an orgasm. It just has

791
00:43:18,400 --> 00:43:22,560
Speaker 2: to be satisfying. Beyond that, though, yeah, I don't have

792
00:43:22,640 --> 00:43:24,920
Speaker 2: much for a testosterone I don't think.

793
00:43:24,719 --> 00:43:25,960
Speaker 3: It feels so like.

794
00:43:26,800 --> 00:43:29,440
Speaker 1: We know that tesosterone is a part of why people

795
00:43:29,880 --> 00:43:32,520
Speaker 1: no offense. Men like sex more than women on average,

796
00:43:33,560 --> 00:43:35,839
Speaker 1: or at least on average, desire that's true. That's true

797
00:43:35,840 --> 00:43:38,480
Speaker 1: in the data men men would like. The optimal amount

798
00:43:38,480 --> 00:43:40,360
Speaker 1: of sex that men want is more. I want to

799
00:43:40,360 --> 00:43:44,399
Speaker 1: be offended that you're not. You don't be offended, and

800
00:43:44,440 --> 00:43:46,360
Speaker 1: so I don't think it's that surprising that if you

801
00:43:46,400 --> 00:43:49,120
Speaker 1: gave people you're more of this this hormone, they might

802
00:43:49,680 --> 00:43:53,800
Speaker 1: be more excited about sex. But the sort of other benefit,

803
00:43:53,800 --> 00:43:55,600
Speaker 1: which is like a real benefit, I mean again, if

804
00:43:55,680 --> 00:43:58,600
Speaker 1: you like, if you have a mismatch sexual desire with

805
00:43:58,680 --> 00:44:01,800
Speaker 1: your partner, or you miss how much used to like sex,

806
00:44:01,840 --> 00:44:05,480
Speaker 1: this is this sort of interesting thing too to think about.

807
00:44:06,440 --> 00:44:09,160
Speaker 1: The other benefits don't really seem to be there. And

808
00:44:09,200 --> 00:44:13,200
Speaker 1: of course there are some symptomatic side effects of testosterone,

809
00:44:13,239 --> 00:44:15,879
Speaker 1: the same kinds of things you see if you use

810
00:44:15,920 --> 00:44:19,200
Speaker 1: it to improve your sports performance, like hair growth and

811
00:44:19,280 --> 00:44:23,240
Speaker 1: acne and other and other things. So certainly not something

812
00:44:23,239 --> 00:44:26,920
Speaker 1: you should be purchasing, you know, along with your peptide

813
00:44:26,960 --> 00:44:29,120
Speaker 1: stack from foreign countries.

814
00:44:28,800 --> 00:44:29,840
Speaker 3: On the internet or whatever.

815
00:44:30,600 --> 00:44:38,200
Speaker 2: Yeah, and testosterone is probably not as beneficial for heart health.

816
00:44:39,000 --> 00:44:41,759
Speaker 2: If estrogen is beneficial for heart health, testosterone is not.

817
00:44:41,920 --> 00:44:45,200
Speaker 2: It is sort of the yang to the yin of estrogen.

818
00:44:45,239 --> 00:44:46,919
Speaker 2: I'm not sure which one is the sort of more

819
00:44:47,000 --> 00:44:51,040
Speaker 2: like violent one, but testosterone supplementation can increase cholesterol levels

820
00:44:51,080 --> 00:44:54,879
Speaker 2: potentially promote athrosclerosis. So it's like, I don't think we're

821
00:44:54,880 --> 00:44:58,239
Speaker 2: all there yet, but you're going to see more and

822
00:44:58,239 --> 00:45:01,400
Speaker 2: more of it, and especially as we just have to

823
00:45:01,440 --> 00:45:05,080
Speaker 2: mention there's an entire industry that is out there that

824
00:45:05,200 --> 00:45:10,440
Speaker 2: is selling hormone replacement therapy to women and men, you know,

825
00:45:10,560 --> 00:45:15,640
Speaker 2: using telemedicine, the sort of direct to consumer prescription model.

826
00:45:15,680 --> 00:45:19,120
Speaker 2: And I'm not weighing in on, you know, the like

827
00:45:19,160 --> 00:45:21,879
Speaker 2: ethics or legality of that. I'm just saying it is there.

828
00:45:22,480 --> 00:45:26,399
Speaker 2: So people have access to these treatments in a way

829
00:45:26,440 --> 00:45:29,319
Speaker 2: that they've never really had before. And so you're going

830
00:45:29,400 --> 00:45:31,600
Speaker 2: to see more and more and more of this, and

831
00:45:32,040 --> 00:45:34,200
Speaker 2: it makes it all that much more important to like

832
00:45:34,360 --> 00:45:38,080
Speaker 2: be really cognizant and talk with someone really knowledgeable before

833
00:45:38,120 --> 00:45:40,879
Speaker 2: you start, so you know what you want to get

834
00:45:40,880 --> 00:45:42,600
Speaker 2: and that you can make sure wherever you're getting it

835
00:45:42,600 --> 00:45:44,520
Speaker 2: from is legitimate.

836
00:45:45,680 --> 00:45:48,200
Speaker 1: So Perry, of course, people can buy these hormones online.

837
00:45:48,200 --> 00:45:49,800
Speaker 1: But the other thing I see a tremendous amount of

838
00:45:49,880 --> 00:45:51,879
Speaker 1: is these tests, Like you know, get this blood test.

839
00:45:51,920 --> 00:45:53,719
Speaker 1: It's going to tell you where you are and your

840
00:45:53,719 --> 00:45:56,239
Speaker 1: different thing and which kinds of things you need. Is

841
00:45:56,280 --> 00:45:59,040
Speaker 1: that I, of course I've had all of these tests

842
00:45:59,040 --> 00:46:03,520
Speaker 1: because crazy person. But is there a sort of actionable

843
00:46:03,560 --> 00:46:07,600
Speaker 1: piece of that? Is that just selling people nonsense? Should

844
00:46:07,600 --> 00:46:10,400
Speaker 1: I care about my T three free number is not

845
00:46:10,520 --> 00:46:13,960
Speaker 1: as good as I whoop says it should be saving?

846
00:46:15,280 --> 00:46:19,520
Speaker 2: Honestly, No, when it comes to estrogen progesterone levels, yes,

847
00:46:19,640 --> 00:46:22,480
Speaker 2: you can certainly buy tests online to measure your levels,

848
00:46:22,480 --> 00:46:25,359
Speaker 2: but no, they don't really change the treatment paradigm, which

849
00:46:25,400 --> 00:46:28,359
Speaker 2: is how we decide whether a test is valuable or not. So,

850
00:46:28,760 --> 00:46:32,640
Speaker 2: particularly in perimenopause, the levels can be all over the place.

851
00:46:33,200 --> 00:46:35,319
Speaker 2: Estrogen can go up and then crash and kind of

852
00:46:35,320 --> 00:46:38,800
Speaker 2: go up again. That's part of the difficulties of perimenopause.

853
00:46:38,840 --> 00:46:42,800
Speaker 2: And so the indications for treatment with hormone replacement therapy

854
00:46:43,360 --> 00:46:45,920
Speaker 2: is are you at an age where it's reasonable that

855
00:46:46,040 --> 00:46:48,760
Speaker 2: you're in perimenopause or menopause, and do you have symptoms

856
00:46:48,760 --> 00:46:52,719
Speaker 2: of perimenopause or menopause? And that's it, so, you know,

857
00:46:53,200 --> 00:46:56,640
Speaker 2: getting you to spend a subscription fee to continually measure

858
00:46:56,640 --> 00:46:58,920
Speaker 2: these hormones over and over air event or even once,

859
00:46:59,040 --> 00:46:59,960
Speaker 2: I think is a bit of a cap.

860
00:47:01,080 --> 00:47:06,560
Speaker 1: Okay, fair enough, Thank you, smash your past Perry.

861
00:47:06,600 --> 00:47:10,120
Speaker 3: Hormone replacement therapy smash.

862
00:47:10,200 --> 00:47:14,440
Speaker 2: I'm going to go with a lot of the society

863
00:47:14,440 --> 00:47:18,160
Speaker 2: guidelines which say, you know, Perry, menopause, first ten years

864
00:47:18,160 --> 00:47:21,680
Speaker 2: of menopause, you know, potentially five to seven years of

865
00:47:21,880 --> 00:47:25,000
Speaker 2: therapy is a clear smash. Probably need some more data

866
00:47:25,080 --> 00:47:29,120
Speaker 2: on how long you can extend this into menopause, Emily

867
00:47:29,200 --> 00:47:29,799
Speaker 2: Smash Paths.

868
00:47:30,200 --> 00:47:32,200
Speaker 1: I'm going to go with a smash based on my

869
00:47:32,280 --> 00:47:36,879
Speaker 1: friends who say that it's great, and when I feel

870
00:47:36,960 --> 00:47:39,799
Speaker 1: like I need it, I'm gonna be trying it. Let

871
00:47:39,880 --> 00:47:42,720
Speaker 1: us know, all right, that's it for hormone replacement therapy.

872
00:47:42,960 --> 00:47:45,520
Speaker 1: Your mail bag Question of the Week after the Break.

873
00:47:50,800 --> 00:47:54,279
Speaker 4: Hi, Emily and Perry. This is Mary from Toronto and

874
00:47:54,360 --> 00:47:58,080
Speaker 4: I have a question about lime disease. I've heard that

875
00:47:58,239 --> 00:48:02,600
Speaker 4: dogs can get vaccinated for it, but I can't. Does

876
00:48:02,680 --> 00:48:04,800
Speaker 4: Lucy the beagle know something I don't?

877
00:48:05,480 --> 00:48:07,800
Speaker 3: Thanks so much, okay, Perry.

878
00:48:08,120 --> 00:48:12,040
Speaker 1: I love this question because it is asked in my

879
00:48:12,040 --> 00:48:14,440
Speaker 1: household all the time, like if there, if, and when

880
00:48:14,440 --> 00:48:16,600
Speaker 1: there is a lime disease vaccine for humans, my husband

881
00:48:16,600 --> 00:48:18,759
Speaker 1: will literally be the first person to get it, Like,

882
00:48:18,840 --> 00:48:21,680
Speaker 1: if there's a line, he is standing. He's like, he's

883
00:48:21,719 --> 00:48:23,799
Speaker 1: like the people wanted to buy the first iPhone. That's

884
00:48:23,880 --> 00:48:25,279
Speaker 1: my husband is going to be like that for a

885
00:48:25,320 --> 00:48:28,520
Speaker 1: lime disease a vaccine. No, he hasn't had it, but

886
00:48:28,560 --> 00:48:31,520
Speaker 1: he's like a he's like a tick lunatic. He's like

887
00:48:31,560 --> 00:48:33,959
Speaker 1: afraid every night when he gets to Tix season. Every

888
00:48:34,040 --> 00:48:36,080
Speaker 1: night when we get into bed, he's like, Okay, can

889
00:48:36,120 --> 00:48:36,919
Speaker 1: you check me for ticks?

890
00:48:36,960 --> 00:48:37,600
Speaker 3: Every single night?

891
00:48:37,640 --> 00:48:37,839
Speaker 4: Oh?

892
00:48:38,600 --> 00:48:41,200
Speaker 2: I find that kind of romantic. Actually, it's a little

893
00:48:41,800 --> 00:48:44,040
Speaker 2: it's like a rooming prime thing. Do you eat the

894
00:48:44,080 --> 00:48:46,560
Speaker 2: ticks if you find them?

895
00:48:47,760 --> 00:48:49,680
Speaker 1: Uh, there's one summer I found like five ticks on

896
00:48:49,719 --> 00:48:52,960
Speaker 1: my kid. Anyway, we never got we never got lime disease. Okay,

897
00:48:53,080 --> 00:48:56,200
Speaker 1: so uh so there is a lime disease for dogs

898
00:48:56,239 --> 00:48:59,200
Speaker 1: but not for humans. And there used to be a

899
00:48:59,200 --> 00:49:00,960
Speaker 1: lime disease vaccine for humans.

900
00:49:01,120 --> 00:49:06,040
Speaker 2: Yeah, yeah, yeah, it existed nineteen late nineties. It came

901
00:49:06,360 --> 00:49:09,400
Speaker 2: out and basically the only reason we don't have anymore

902
00:49:09,440 --> 00:49:13,080
Speaker 2: is it was a commercial failure. There are a few

903
00:49:13,120 --> 00:49:16,400
Speaker 2: reasons for that. One is the vaccine schedule wasn't great.

904
00:49:16,520 --> 00:49:19,080
Speaker 2: I think it was zero, like so you got one

905
00:49:19,120 --> 00:49:21,160
Speaker 2: and then you had a booster a month later, and

906
00:49:21,200 --> 00:49:24,239
Speaker 2: then another one twelve months later. So it's like a

907
00:49:24,280 --> 00:49:27,360
Speaker 2: series of three vaccines, which is a little bit annoying.

908
00:49:28,080 --> 00:49:32,200
Speaker 2: Because lime disease is not transmitted human to human, it

909
00:49:32,280 --> 00:49:37,360
Speaker 2: sort of shifts the public health landscape of the vaccine.

910
00:49:37,400 --> 00:49:39,279
Speaker 2: So the line vaccine was never going to be part

911
00:49:39,320 --> 00:49:42,400
Speaker 2: of like the childhood vaccination schedule, which is really designed

912
00:49:42,520 --> 00:49:46,040
Speaker 2: to protect all of society, right like lime disease really

913
00:49:46,360 --> 00:49:49,280
Speaker 2: only the vaccine is really only going to protect the person.

914
00:49:49,920 --> 00:49:52,520
Speaker 2: The other thing about lime disease is it's a bacteria,

915
00:49:52,640 --> 00:49:56,160
Speaker 2: not a virus. We have antibiotics that can treat it,

916
00:49:56,239 --> 00:50:00,399
Speaker 2: so it's not you know, the sort of risk isn't there.

917
00:50:00,440 --> 00:50:02,720
Speaker 2: But I mean, we had its AFT approved, you could

918
00:50:02,760 --> 00:50:05,160
Speaker 2: have gotten it and then just stop making it because

919
00:50:05,160 --> 00:50:06,200
Speaker 2: they weren't making enough money.

920
00:50:06,800 --> 00:50:12,720
Speaker 1: But exciting news is that there is actually a new

921
00:50:13,040 --> 00:50:16,239
Speaker 1: lime vaccine that is in phase three trials and they've

922
00:50:16,320 --> 00:50:19,200
Speaker 1: just announced that. Basically, I think the phase three trials

923
00:50:19,239 --> 00:50:22,279
Speaker 1: went well. This is like a very recent announcement, and

924
00:50:22,320 --> 00:50:25,040
Speaker 1: so I do expect there to be a line vaccine

925
00:50:25,600 --> 00:50:27,719
Speaker 1: coming down the line. And although you're right, I think

926
00:50:27,719 --> 00:50:30,799
Speaker 1: the commercial success was somewhat limit. I actually think people

927
00:50:30,840 --> 00:50:33,080
Speaker 1: have gotten more concerned about the sort of long.

928
00:50:33,000 --> 00:50:34,440
Speaker 3: Term impacts of lime disease.

929
00:50:34,480 --> 00:50:37,160
Speaker 1: And it is true that although if you notice the

930
00:50:37,200 --> 00:50:40,680
Speaker 1: tick and you get treatment, basically you can avoid getting

931
00:50:40,800 --> 00:50:43,719
Speaker 1: long term lime disease, many people don't. And so this

932
00:50:43,880 --> 00:50:46,239
Speaker 1: is you know, it can be a very significant it

933
00:50:46,280 --> 00:50:50,359
Speaker 1: could be incredibly debilitating if people don't have My brother

934
00:50:50,440 --> 00:50:51,600
Speaker 1: hadline disease.

935
00:50:51,520 --> 00:50:54,320
Speaker 2: Once, my daughter HADLME disease.

936
00:50:54,920 --> 00:50:56,840
Speaker 3: Because you live near lime, Connecticut, that's what.

937
00:50:58,760 --> 00:51:01,120
Speaker 2: My backyard is mostly ticks.

938
00:51:01,360 --> 00:51:03,000
Speaker 3: Yeah, that's where they live.

939
00:51:04,120 --> 00:51:05,960
Speaker 1: And so yeah, I mean it's like, you know, it's

940
00:51:06,000 --> 00:51:09,759
Speaker 1: a there's a telltale rash. If your child has a tick,

941
00:51:09,800 --> 00:51:13,279
Speaker 1: watch for the rash. But I am excited about the

942
00:51:13,360 --> 00:51:14,520
Speaker 1: line vaccine.

943
00:51:14,680 --> 00:51:17,440
Speaker 2: Yeah, tick checks. You have twenty four hours after the

944
00:51:17,440 --> 00:51:19,680
Speaker 2: tick has bit to get it off with before it

945
00:51:19,719 --> 00:51:22,479
Speaker 2: can transmit the bacteria. So tic checks on a daily

946
00:51:22,480 --> 00:51:23,840
Speaker 2: basis if your kids are outside.

947
00:51:24,160 --> 00:51:27,279
Speaker 1: Yeah, my brother did not get My brother he got

948
00:51:27,280 --> 00:51:29,759
Speaker 1: treated and he did not have lun He did not

949
00:51:29,800 --> 00:51:31,160
Speaker 1: have any significant long term yeah.

950
00:51:31,200 --> 00:51:33,520
Speaker 2: Line, Yeah, you can save the tick if you want

951
00:51:33,520 --> 00:51:35,920
Speaker 2: to show your doctor. They'll have fun with it. But

952
00:51:36,360 --> 00:51:38,000
Speaker 2: a lot of the time if the tick has been on,

953
00:51:38,040 --> 00:51:42,560
Speaker 2: and certainly if there's that target lesion, you'll get empiric antibiotic.

954
00:51:42,040 --> 00:51:44,040
Speaker 3: Treatment Taxi cyclin for the win.

955
00:51:47,239 --> 00:51:49,839
Speaker 2: All Right, that's it for us today. Stick with us

956
00:51:49,880 --> 00:51:53,000
Speaker 2: next week when we'll ask what's the deal with testosterone

957
00:51:53,320 --> 00:51:53,680
Speaker 2: for men?

958
00:51:54,200 --> 00:51:57,640
Speaker 3: Yay, finally we're studying men. Phew.

959
00:52:00,280 --> 00:52:03,600
Speaker 1: Wellness Actually is produced in association with iHeartMedia.

960
00:52:04,200 --> 00:52:06,120
Speaker 3: Our senior producer is Tamar Avishei.

961
00:52:06,560 --> 00:52:10,200
Speaker 1: Our executive producer at iHeart is Jennifer Bassett. Our theme

962
00:52:10,239 --> 00:52:12,880
Speaker 1: music is by Eric Deutsch, and our content is for

963
00:52:13,000 --> 00:52:14,240
Speaker 1: educational purposes only.

964
00:52:14,920 --> 00:52:17,200
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965
00:52:17,560 --> 00:52:20,319
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966
00:52:20,400 --> 00:52:23,120
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967
00:52:23,160 --> 00:52:26,200
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968
00:52:26,239 --> 00:52:29,399
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969
00:52:29,840 --> 00:52:32,360
Speaker 2: Head over to Wellness Actually dot fm and leave us

970
00:52:32,360 --> 00:52:34,960
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971
00:52:35,000 --> 00:52:35,680
Speaker 2: a future show.

972
00:52:36,440 --> 00:52:38,279
Speaker 3: We'll let the influencers have the last word.

973
00:52:38,560 --> 00:52:40,959
Speaker 5: Ladies, I want you to know these symptoms of perimenopause

974
00:52:41,000 --> 00:52:47,680
Speaker 5: and menopause. These are thirty four common symptoms acne allergies, anxiety, floating, constipation,

975
00:52:48,040 --> 00:52:54,719
Speaker 5: body odor, breast soreness, brtal nails, cholesterol changes, depression, difficulty concentrating,

976
00:52:55,000 --> 00:53:00,040
Speaker 5: dizzy spells, fatigue, gum problems, hair loss, headaches.

977
00:52:59,640 --> 00:53:06,440
Speaker 6: And migraines from palpitations, hot flashes, irregular periods, irritability or rage,

978
00:53:06,960 --> 00:53:12,640
Speaker 6: itchy skin, joint and muscle pain, libido changes, loss of breastfulness,

979
00:53:12,760 --> 00:53:13,719
Speaker 6: memory lapses

980
00:53:13,960 --> 00:53:19,239
Speaker 5: Mood swings, nausea and night sweats, osteopenia and osteoporosis, pain

981
00:53:19,320 --> 00:53:26,000
Speaker 5: during sex, panic disorder, sleep issues, baring countenance, vaginal dryness,