How Changes in Sex Hormones in Menopause Impacts Your Energy with Betty Murray, PHD

Episode 94:

How Changes in Sex Hormones in Menopause Impacts Your Energy with Betty Murray, PHD and Evan H. Hirsch, MD

Evan H. Hirsch, MD  00:04

Hey everybody, welcome back to the energy MD podcast where we help you resolve your chronic fatigue long COVID and M casts by finding and fixing all your real root causes, which as you know, as we've talked about before, heavy metals, chemicals, mold, infections and trauma. So really excited because today we're going to be talking about some of the deficiencies that go along with some of those toxicities that we talked about. We're going to be talking about menopause, we're going to be talking about your hormones. And we're going to be talking about energy with my friend, Dr. Betty Murray. So let's learn a little bit about her. Betty Marie is a nutrition expert, PhD researcher, certified Functional Medicine Practitioner and speaker, Betty helps women over 40 harness their hormones to lose weight, optimize sleep, restore energy and thrive. During her research for her PhD Betty made several key discoveries that lead to hormone and metabolic imbalances that plague women over 40. restoring balance to these key metabolic and hormone pathways is the basis of her hormone reset program. This program has helped her and hundreds of women lose weight easily, improve hormone balance, reduce hot flashes, restore sleep, and turn up their energy without living on a diet of deprivation. I love that. She is also the host of the menopause mastery podcast, and the founder and CEO of living well, Dallas Functional Medicine Center, and the coming into our own project. She is a featured writer for brains magazine and has been featured in garanzia or Grazier magazine. She's a frequently featured nutrition expert on Fox News broadcasting CW, three, three, NBC and CBS. Wow, that's impressive. Betty, thanks so much for joining me today.

Betty Murray, PHD  01:47

Thank you, Evan, for having me. Thank you. Thank you.

Evan H. Hirsch, MD  01:51

So we're going to be talking today about how changes in sex hormones and menopause perimenopause, how they impact energy. And so you know, one of the biggest things that I see, and one of the biggest complaints that people have is about weight gain. So why does weight gain happen around menopause? Before and after? Yeah,

Betty Murray, PHD  02:13

so it's a multifaceted situation. So the average woman gains 10 to 15% of their body weight throughout the menopause transition. So if you're 150 pounds with a woman, that's a good 15 to 18 to 2023 pounds, that just automatically occurs, you know, over that time. And in some of the things that we think about is first as we go into that transition, when we enter into our usual 40s, mid 40s, we're in a state actually, where in most cases, we are estrogen dominant. Right. So what's happening is the two hormones that are really fluctuating throughout our cycle, estrogen is still fluctuating at a relatively normal amount, but progesterone is actually declining. And that's why we see fertility issues as we enter into our 40s. Chris progesterone's job is to really sort of prepare the uterus lining and kind of prepare it for implantation. When estrogen is high like that, it does a couple of things. Number one, if we already have some level of insulin resistance, which about 88%, of westernized countries, particularly America, has some level of insulin resistance, estrogen and insulin sort of play together, right, they have this symbiotic relationship. The other thing that we also see is, we also see other areas where other hormones will be affected. So for instance, the loss of progesterone starts to affect sleep quality, which then means we're not sleeping very well. So we have this hormonal effect of often cortisol going higher, and then impaired sleep, which makes us more insulin resistant. So we see that that starts it, and then it's, it's almost like Goldilocks, so for a woman, it's you who wants to have enough, not too much. So when you're like myself, and I'm 54, I went through menopause at 48. When you're on the other side of it, when you lose the activity of estrogen completely, you lose some of the capacity at the mitochondria and other areas that we can talk about, that actually affect your body's powerhouses inside yourself and mitochondria of working. And so it's this multifaceted approach. It's an increase in insulin resistance and stress chemistry and other things that go along with it that we usually see as we enter into the transition, which is on average eight years for women. And then as you lose it, everything sort of, you know, goes to zero, we lose some of that metabolic capacity all the way to the mitochondria that affects our ability to just burn fat and burn glucose efficiently. And so we become a slower moving machine, every single cell. And so that's part of the reason why we see such an extraordinary increase in weight for women and also a difficulty of losing weight, often doing things that worked before, you know when you were 25 or 30.

Evan H. Hirsch, MD  04:54

And so for those who aren't familiar, mitochondria produces about 70 to 90% of our energy so What you're talking about is that this is also negatively affecting their energy output. Exactly,

Betty Murray, PHD  05:05

exactly. So at the mitochondria, we have the powerhouse. So I like to explain it this way, we have a powerhouse. And once we've gotten, let's say blood sugar, glucose inside the cell, we have a transporter. And that transporter is kind of like a very, very mild grade Hill, right? So almost flat not, it's called glute four. It's not an aggressive transporter, but glute four is affected by estrogen. So when we lose estrogen, it's kind of like that that slight incline that we had that basically lets glucose rolled downhill to the powerhouse, now has flattened. And so at the end of the day, just being able to get glucose from from outside the powerhouse into the powerhouse is significantly impaired. Most of that research was actually done on individuals looking at cognitive decline and mitochondrial function in women in post menopause. And this is where a lot of the research really showed. But if that's happening in the brain, it's happening everywhere, everywhere.

Evan H. Hirsch, MD  06:03

And so when we're looking at Perry, and menopause and post menopause, it's really affecting, I mean, you've named a lot of different hormones insulin and and, and thyroid and adrenals. And some of these, can you talk a little bit about that interaction with like thyroid and adrenals?

Betty Murray, PHD  06:22

Sure, sure. So I like to think of our hormones as a symphony. So in the in the symphony, we have the director of the show, that's the hypothalamus. It's in the brain, it's sort of taking in information from everywhere, ticket sales, the environment, how do they want it to look and feel. So the hypothalamus is getting information from everything. And then it communicates to the pituitary, which is the conductor of the orchestra. And the most primary thing that orchestra runs on is the power and the speed and the cadence of the percussion. So the percussion, it to me is your adrenal glands. The first and most primary important hormone in our body, honestly, is whether we are safe or not. Right. So if our body perceives that we're starving, we're freezing, we're not safe, it is going to adjust the entire symphony to play along with it. So if your percussion, which is your adrenal glands, producing stress chemistry, are playing scat, jazz, and the rest of the entire you know, the entire orchestra thinks you're playing a waltz, they're going to change what they're doing to adjust to it. So in many cases, I think this is this is my opinion, this is my hypothesis is that we see worse symptoms of menopause and perimenopause in the United States, because our stress chemistry is significantly more impacted than any other country in the world, even other westernized countries. And so, so when we look at the orchestra, the adrenals are going to drive a lot of it, and then you have the thyroid, that's now going to just we'll call that the brass section. And then you've got then you've got your, your metabolic hormones like insulin that are going to adjust to try and respond to that stressor. And then at the very end of that game is your sex hormones, which are the wind section, and they are a luxury item. Your body makes those nice and balanced. When everything's good on the Serengeti and you've got food and it's not freezing, you're not starving to death. But when you've had that environment for a very long time, the sex hormones are going to down regulate, because it makes sense from an evolutionary standpoint, that our body wants to make sure that we are in the best possible situation for fertility. And then when you get into perimenopause and menopause, you've got this natural transition that's happening. But most women myself included, spent my 20s 30s and 40s with my hair on fire, right, stressed out, stressed out and that did not leave a lot of reserve for this transition.

Evan H. Hirsch, MD  08:58

And if if the adrenals are functioning correctly, they should take over production of the sex hormones right and things should be pretty smooth. Is that what you see?

Betty Murray, PHD  09:09

Well, yes, so when the ovaries peter out, so the ovaries think of them as like an egg carton. And once all the eggs are empty, the impetus to to make estrogen and then to turn around and make progesterone is now not there. And so the adrenals are responsible for picking up the pace so they can make a little bit of estrogen they can make a little bit of progesterone along with the cortisol and adrenaline and even some testosterone. The other place that we actually make estrogen is in our fat cells. So our fat cells actually have the enzyme called aromatase that can take testosterone and make estrogen. That's the same enzyme that's in the ovaries that helps testosterone and men and women also make estrogen and it's also in the adrenals. And so if we have good adrenal function, and let's say we've taken care of ourselves and everything's good, our true conditions should be a little bit better, right should be a little bit better. But here's here's the Frank reality of this, Evan, we are not designed to live long after menopause, our life expectancy in 1900 was 57 years old. So that means I've got three years to go. So if I went through menopause seven, eight years ago, it didn't really matter. But the truth is, is with modern technology, and sanitation, and all that other stuff, we're living 35 to 40 years longer, without hormones, so we are on the planet and equal amount of time without hormones. You know, so our longevity hasn't caught up, you know, or our, I guess our hormones, and our body's kind of biological clock hasn't caught up to our longevity. And so that's a big part of it, too. We just weren't really designed to live into our 80s and 90s, you know, living as an animal on this planet.

Evan H. Hirsch, MD  10:54

So, you know, everything we read, talks about how we're getting sicker. And yet, what you just told us about this comparison with the 1900s? Why do you think that I mean, this case, women are living longer than they did in 1900, even though we have so many more exposures? Is it the medicines or what do you think, you

Betty Murray, PHD  11:18

know, prior to prior to like, really, honestly, the late 1800s is where you see the dramatic shift. Most deaths were caused by infection, right? You'd have massive swaths of like cholera going through Europe, and it would kill off, you know, 10s of 1000s of people. So truly, honestly, the biggest leap forward we got in lifespan was sanitation. It's clean water, you know, sewer systems, and all those things that that really cleaned everything up and cleaning up all the rodents and things like that, that carried disease. And then the second one behind that being warfare, right. And we got a lot better at technical warfare, which is what Western medicine was really born out of. So so a lot of what we're looking at is yes, we're, pardon me, we're living longer. But the truth is, truly, we had actually a boomerang that happened. So we're living longer, we hit the 2000s, we're actually starting to reverse that process a little bit. So we actually losing ground in the last decade, where we weren't before. So there was an incredible explosion of longer lifespan. And it's because we can keep people alive longer, but they're not healthier, longer. Western medicine is very good at triaging acute problems, right, going in and doing a stent, giving you drugs to keep your blood sugar controlled somewhat when you're diabetic, but we're not good at preventing them. And the reality is our lifespan is much longer, but the average person is spending anywhere from 12 to 15 years in some sort of long term decline health wise. And I think that's the take home message is what we want is a long health span and a very short death span, right? We want to basically live as healthy as long as possible and shorten that window. But that's not what we're seeing in the West. We are sick for a very long time, but we don't die.

Evan H. Hirsch, MD  13:03

Yeah, thank you for that explanation. Yeah. I want to touch on something that you talked about. You said that perimenopause happens about eight years before menopause, is that correct? On average, on average. And so women should really start and then the average age of menopause is around 5050 to 52. So women should really be starting to think about this things around 45. And, and and they need to be diligent about this, which would you say,

Betty Murray, PHD  13:35

you know, so So if the average is eight, that means some of us are outliers, and we might be 1516 years and some of us might sail into the last two years, and then you know, kind of sail through it. So I would say the first and foremost, as most women need to start paying attention in your mid 40s. Right? If you're not symptomatic, these things are probably going to start showing up. Now, if you're like me, like I went back for my PhD, not because I wanted to have a whole nother set of student loans. It's because I really wanted to understand my own. I do have it, which is awesome. But I do I do, I did want to understand what was happening with me and I wanted to be able to help women that I saw that I felt like even in functional medicine, we understood a part of it, but not all of it. And my my symptoms started in my late 30s I mean, I started showing signs of perimenopause at 39 and I was done by 4849 years old. You know, some people it can start much earlier, you know, so I would say if people are starting to show those symptoms, it's women I should say are starting to show those symptoms, it's probably important to look at them.

Evan H. Hirsch, MD  14:36

So then what can women do? So if they somebody is listening to this and they're in their early 40s And they're thinking okay, how can I be proactive? What kind of things can they do now? You

Betty Murray, PHD  14:48

know, I would say first and foremost, you know is Get Tested I'm I'm definitely a person I don't like guessing at things I think it's kind of like when you guess you get into your car. And let's say you're planning on going to the spa, but you You don't bother to look up the directions on Google Maps or whatever, or Waze, or whatever you're using, you just get in the car and kind of drive right. So without data, you don't really know what's happening. What I have found, after two decades in practice is often what's happening is that sort of stress chemistry is has been going on for long enough that, that it's starting to adjust all of those sort of controllers. So think of the Levers inside the machine are now getting adjusted to this long term situation. But you won't know that unless you test your adrenal function, your thyroid function and your sex hormones, I think it's valuable to know that even if you're not really symptomatic to get a baseline, because the reality is what my level of normal is going to be different than another woman's level of normal we have, we all have unique variability within sort of an optimal reference range. So I think it's valuable to test that. And then I think it's also valuable to start evaluating how you want to go through this transition. You know, we've been told because the Women's Health Initiative that you know, hormone replacement was unsafe, and that was a poorly done study, and we can tear that apart if you'd like to. And it was absolutely inaccurate. And actually, after an 18 year follow up every single like, thing they sort of proposed has been has been debunked, right. But it terrified women, millions of women got off of the hormone replacement in a matter of days. And it completely changed the medical system, particularly in the US and Western world. And so all these women are paying the price. So the reality is you got to figure out where you are on that continuum and how you want to address it. Because, you know, the truth is, is when you lose these hormones, as a female, everybody, you can get a pass on a lot of things, but you can't get a pass on menopause, they will be gone. And your adrenals will pick up what they can, but they're nowhere close to what you made. And at that point, we age match men for cardiovascular risk, and one out of two women die from cardiovascular disease. And stroke is actually higher and more deadly in women than it is in men. We have a higher risk of osteoporosis, that is also the leading cause of accidental death for anybody over the age of 55 from a fracture. And then we also have the increased risk of dementia and Alzheimer's. And Dr. Moscone is group out of Cornell just published a meta analysis of 6 million women. And they showed a 34% decrease risk in dementia, if you replaced estrogen early, right in the transition not 10 years later. So so the reality is you got to figure out and work with a practitioner, I think that can help you navigate where you are, where you're going, and how you feel about these things and get educated so you know how to proactively make, like, make steps to address it. i By the time I actually got to true menopause, I had done enough and learned enough that I sailed through and I didn't have the I had horrible 40s. Like, my 30s, early 40s. Horrible, but by the time I actually hit that I didn't have hot flashes, I never had night sweats. I didn't have a lot of those symptoms, because I got in there and started addressing the hormones before I went into full blown menopause. But I think it's important for a woman to feel connected to that, and have a deep understanding of her own body.

Evan H. Hirsch, MD  18:20

So you're so then what do you recommend? And so if somebody, you do the testing, and we're talking about somebody who's pre menopausal and menopausal yet, they're probably about 40 ish, and you do the testing, and it comes back with low adrenals, low thyroid, low sex hormones. Where do you start?

Betty Murray, PHD  18:39

Yeah, so So then the next thing is to figure out who you're going to work with, right? Some of these things we can actually address nutritionally, and lifestyle, you know, like, I would look at somebody with that, let's say result, come back. And I would start with let's get the stress chemistry, the adrenal, let's dial in the exercise, the eating the sleep, let's make sure that that is in a position where it's actually nourishing you and helping you. And then look at how much of that impacted because again, your thyroid may be low function, because your cortisol and your hair's on fire and your day, stressful every day, and your sex hormones are responding. So even if even if you're somebody that maybe doesn't have somebody in your back pocket like Dr. Hirsch or me that can help you navigate this, you can look at it and go, Okay, I am obviously under a lot of stress. Maybe I can learn to say no, maybe I can protect my sleep and, you know, do the things that help the lifestyle, then if there's still problems, then I would say it's time to look for some assistance with with somebody who does functional medicine. That can help because it might be time to use thyroid support if you've tried nutritionally and it's not working medically. Or it might be time to introduce progesterone because you're already on the decline because you're in your 40s. Maybe estrogen is still fine, but your progesterone is on the decline, because it doesn't necessarily have to be wait for everything to end The and then do something you can sort of intervene as you sort of walk through this pathway. But I think it all has to start with managing the stress chemistry. Like I can tell I tried Evan for the longest time, because I'm somebody that was like, I'll sleep when I'm dead. I've got things to do. And I tried, there's no, there are supplements that help. But there is not a magic bullet that will make up for lack of sleep, lack of taking care of yourself and burning the candle at both ends. There just isn't. I tried it. And I can tell you right now you have to you have to put effort into those things. Yeah,

Evan H. Hirsch, MD  20:32

I hope everybody who's listening and watching pays attention to that, because that's incredibly important. And it's really, it's you're running uphill, you know, when when you're when you're in that situation. So thanks for saying that. So let's pivot a little bit then to the menopause, a woman who's having all of these symptoms, presents with the low adrenals, the low thyroid, the low sex hormones, how would you address that person?

Betty Murray, PHD  20:58

Yeah. So so in that case, they're kind of at, you know, ovarian, or kind of ovarian burnout, right. So nothing's happening at the ovaries anymore. And I still think that we have to sort of step back and look at the same diet and lifestyle thing. So we still have to address the adrenal function. Because putting hormones so for instance, putting thyroid medication on top of somebody who's got an adrenal problem, you can probably answer this too, because I'm sure you see this is you'll have thyroid labs that looked great with no symptom resolution. Right. And they're like, but that puppet, I'm like, Yeah, because we haven't fixed the adrenal problem that's causing the bigger problem, right that the thyroid is probably adjusting to. So I still think we have to do those things. And then this is where I really look at it and say that the this is where we have to start addressing the hormone replacement. And I'm a fan obviously a bioidentical hormone replacement, individualized to the person, right, there's a high variability in the dose that somebody might need, one person may be great on a very low dose, because they never really produced a lot, and another person might need quite a bit more, but it has to be a physiological dose. One of the things that very much frustrated me after the Women's Health Initiative, they said, Okay, nobody can do hormones, they're gonna kill you, which was absolutely inaccurate, completely inaccurate. You know, it went from four and 1000 risk to have breast cancer in in your lifetime as a female to five and 1000. That is not statistically significant. And they blew that up, believe me, I'm, I'm, I'm a researcher, and I do statistics, and I know how to make something look extreme in statistics. You can you can lie with math all the time. And, and so it scared women. So of course, you know, eight years later, they proved that that risk was no longer present. There was none, none. And so the next answer was, okay. The new cookbook is, oh, you can do hormones, but the least amount possible for the shortest amount of time to take care of vasomotor symptoms, which is, you know, hot flashes and night sweats. The truth is, is if you're going to do hormone replacement, which I think is valuable, you want a physiological dose, or otherwise, you're not going to help the brain, the heart, the bones. So you've got to work with somebody that's going to help you get to that physiological dose. And in most cases, your sleep gets better, your brain gets better, you know, the memory stuff, all those things start to get better. And and we've got improvement that we know is going to help those body systems work. And then my argument is you stay on him, you stay on him. Right? Because we lose that important that important support as soon as we stop them.

Evan H. Hirsch, MD  23:33

And do you like to cycle them? Do you say a certain number of days on some days off?

Betty Murray, PHD  23:38

Now, estrogen, estrogen we generally keep in, right, and then sometimes sometimes we will go up and down and dose because if you were to look over the course of a month that it does fluctuate, we don't cause as great of a fluctuation, at least clinically in our clinic. We don't necessarily try and mimic that very high luteal phase sort of it peak. But but we may adjust it a little bit. And we leave a lot of that to the woman, honestly, you know, you're in your body, you kind of know your symptoms. So we help them sort of understand how to kind of go up and down and sort of figure out their sweet spot. And in many cases, if somebody doesn't have sleep problems, we might, we might rotate progesterone in and out. So progesterone is really only high in that second half of your cycle right before your period that lasts 14 days before your period starts. And so we would mimic that natural rhythm. If somebody has a lot of sleep issues like I'm one of those people, if you take progesterone away, I'm not going to sleep very well. And so I keep a static dose of progesterone. Because progesterone that hormone holds the receptor open for GABA, which keeps us asleep. And, and the truth is, is that hormone has been studied by itself alone in oral micronized form in menopausal women for sleep alone and showing significant improvements with very low risk profile. So progesterone in somebody who can't sleep, we just sort of keep In their right, and the variability, they might be somewhere between, on average about 100 to 200 milligrams a night.

Evan H. Hirsch, MD  25:07

Okay, so you're you're finding that you have to get up to those doses in order to really see the benefits. Yeah,

Betty Murray, PHD  25:13

occasionally, you'll have somebody that does well at 50 milligrams, but even even in the literature in the studies, that the starting dose was 100 milligrams, and there's a couple studies that took it quite a bit higher, like 400 milligrams, which I think is in most women's very sedative, you know, sedative, like, you know, so most people go there.

Evan H. Hirsch, MD  25:32

And prometrium is a conventional medication. That is bioidentical and almond oil, right, what do you think of projet prometrium versus compounded progesterone.

Betty Murray, PHD  25:44

It has to be if you're doing oral, it has to be micronized. If it is not micronized, it is not going to work. It doesn't it's not. It's fat soluble. So the micronization makes it absorbable. Right. So if you just take powdered progesterone and put it in there, it's not going to do anything. The studies that were done on sleep that evaluated topical and oral micronized, were actually done on prometrium. I don't necessarily love that prometrium has the ingredients that it has. But sometimes, you know, we'll have patients that come to our clinic, and they're like, I really want to be able to get it at a regular store. And you know, I want to do that or what my insurance might pay for. It's like, okay, I'm not gonna I'm not gonna fight. You know, at the end of the day, I think the compounded especially if I'm a 503 B, pharmacy, one of the bigger pharmacies that has really good quality controls, is just a really good idea.

Evan H. Hirsch, MD  26:34

And do you do any sort of ramp up starting with a lower dose and ramping up to their ideal dose? And how do you know when you've hit their ideal dose?

Betty Murray, PHD  26:41

Yeah, you know, I would say most of the time, we start at somewhat of a lower dose, often either 50 or 100 milligrams, and we're usually looking for improvement, let's so nine times out of 10. With progesterone, it's the sleep starts to improve, right? Or in progesterone is also very strongly calming, right? So anxiety gets a little bit better. That's also another sign. So we're looking for those. And when we hit that sweet spot, then we kind of stay there. And we often test so we do urinary hormone metabolism to sort of see are you in that range where we want it to be? But we're also looking for symptom improvement at the same time?

Evan H. Hirsch, MD  27:20

And do you prefer I know that there's some debate around oral versus? Versus cream? When it comes to progesterone? Since it doesn't go through the liver? What are your thoughts on it? What do you prefer? Um,

Betty Murray, PHD  27:33

most of the time, oral just because it has such a better impact on sleep. If somebody doesn't have any sleep issues than progesterone cream, or you know, a topical is easily done.

Evan H. Hirsch, MD  27:46

And then in terms of estrogen, are you a trial just or biased? Or what kind of combination? Do you like to see?

Betty Murray, PHD  27:55

Yeah, you know, I, we've used a little bit of everything, you know, I think especially I'll be the first to say I'm a guinea pig. I've used, you know, every every delivery mechanism and hormones, I'm like, let's do it. And then look at my lab side. So I'm the guinea pig for everybody if you want to know what it looks like. And so I would say first and foremost, some people respond to things differently. Generally, I'm a biased person I don't want so there's three estrogens estradiol, which is what your ovaries make, which is protective Estrie, all which is very weak, and has a lot of localized activity. And then we have estrone, which is more pro inflammatory. And your body when you're in menopause makes a stone, right? The fat cells, that's what it makes. And so we generally have more estrogen in the tissues relative to estradiol. So I don't give I don't, I don't give anything I don't, I don't recommend doing a stone. But a bias, which is estradiol and s3 all is similar to what our ovaries would actually make, you can have slightly varying concentrations. But every once awhile, we'll have somebody that really does better on a straight extra dial, right? Compounded or patch or something like that. So I would say the majority are on a combination of bias, but sometimes we have extra dial alone.

Evan H. Hirsch, MD  29:10

And do you have a certain percentage that you like 80%, estriol versus 20% estradiol or something like that?

Betty Murray, PHD  29:18

Yeah, I mean, that's, I'd say we usually start with 8020. And then some people might go to, you know, a 7030 concentration, you know, and I've even we've have we do all forms in our clinics. So we do all forms of delivery. We don't, we don't do injectable, I'm not an injectable, because it's way too much of an up down. But we do creams, patches, pellets, we do a little bit of everything, because not everybody responds to every mechanism. You know, even the pellet companies. I've had every major brand in my own butt. So, you know, I've had I've tested each brand to go, which one do I think works better for me? So, yeah, I've done it for everybody. I've done all the testing of one, the end of one I just see what the response was like. And

Evan H. Hirsch, MD  30:03

so And can you just talk a little bit about pellets, so so people know what they are. So

Betty Murray, PHD  30:08

pellets are a very popular delivery mechanism, it's grown in popularity over the last decade in the US. And essentially what it is, is it's it's a small, it's a small pellet, that is about the size of a hen tip, it's not very big. And it gets injected up on the kind of flank of the body. So kind of at the top of the butt cheeks, and it's basically gets injected right underneath the surface of the fat and the muscle right where they meet. And it's real small, makes a very small, you know, incision, and then you let it encapsulate so for over the course of a couple of days, it closes up and encapsulates and then it slowly dissolves over a period of time. So for most women, that takes about three to four months for that dissolve to happen. And then men we can dose higher for testosterone, so they have a longer span, it's usually five to six months. And then you come back. So the idea is that the testosterone and or estrogen that you're that you're doing, has this kind of slow delivery mechanism. And then there's three major manufacturers in the United States that make these pellets. They all actually just little inside story, they all work together, they were in the same company, got in a fight and then broke up, went through a bunch of legal battles. Now they have all their own companies, but it's pretty funny because it all happened in Dallas. So I know all the background skinny on it, but you know, I would say the biggest thing with the pellets is to individualize the testosterone therapy for women. I believe a lot of times, it's there's kind of an overwhelming thing, like if a little bit of testosterone is good, a lot is better. And we have to be careful with women because we get a lot of other unnecessary and unwanted side effects if testosterone gets too high, like hair loss, chin hair, facial hair, that kind of stuff. And that's true of any hormone replacement if we it needs to be balanced.

Evan H. Hirsch, MD  31:57

And you I think you said that estradiol is protective. Is that correct?

Betty Murray, PHD  32:01

Yes, as style is the most protective. Now estriol just to give a little bit of clarity estriol is often used in vaginal suppositories or creams, because it can affect the some of the other nasty side effects of menopause that no one talks about is Valjoux vaginal dryness, vaginal atrophy which is basically the tissues shrivel up and paying for sex. And sometimes that pain is bad enough that just walking doing physical activity can be painful. So Estrie off somebody's like, I don't want to do hormones. I just want to protect that you can do estriol as a suppository. And what it does is protect the tissues locally, it doesn't work systemically. And that's commonly prescribed even in women going through breast cancer treatment, because it does act locally and protects that area. But that's one of the things that they never talk about that happens and women are like, Oh my God, what just happened down there? You know, it's it's not a pleasant experience.

Evan H. Hirsch, MD  32:56

Yeah, so I'm glad you mentioned that because it does matter where you put the cream and in this case, and it sounds like even with receptor positive breast cancer, it's safe to to put the cream in the perineum. Yes. Okay, excellent. And so, and in terms of the application, is it in the groin, in the vagina on the vulva? What do you generally recommend? Yeah, so

Betty Murray, PHD  33:25

if we're trying to preserve vaginal tissue, which is the area inside that you can't really see, then you would use a suppository. Now if you've also got volver pain, which is the area outside that you can actually see, you can even use some of the cream there as well, because UTIs yeast infections, bacterial vaginosis, and all those things increase, because when we lose those hormones, the pH of the that area changes and we get overgrowth of things that we don't want. So we often get a bunch of nasty symptoms that we don't want. So sometimes we can use it in those areas.

Evan H. Hirsch, MD  33:57

Coming back to the estriol and the estradiol, estradiol is also the more active component, right? Yes, yes. So then, so then I had always heard that the or learned that the purpose of the bias was that the estriol was kind of protecting against the any sort of negative effects from the extra dial, but if extra dials protective and the most active component, why don't we just use that? Right,

Betty Murray, PHD  34:22

right. I mean, there are there are definitely products out there that are extra dial suppositories extra dial alone. Part of the reason why the biased as is I think the most prescribed is without going through hormone metabolism. We have our ovaries produce estradiol, and as our liver metabolizes it, so think of it as we're packaging it to get rid of it. One of the pathways the 16 Alpha Hydroxy pathway makes estriol and so when you give a biassed you're sort of mimicking what would have happened at that moment. So it's mimicking the distribution that would have been seen if the ovaries and everything was working normal Lean is kind of the idea, okay? As the women that don't do they prefer estradiol they feel better on just straight estradiol.

Evan H. Hirsch, MD  35:10

And do you start at a certain dose of that and ramp up? Or how do you like to dose it?

Betty Murray, PHD  35:15

You know, it's a, it's different depending on how you're dosing or what you're using, you know, so a patch is going to be different than a cream is going to be different than an oil. I would say most of it is standardized, you see kind of a low end where most people almost always start. So like I'll give an example of a patch is a point 035 micrograms, like, which is the very low end and a work all the way up to one milligram. And so most of the time, we start there, and especially if somebody's like, let's say, they're several years outside of menopause, it, it's kind of good to start at a low level and sort of wake up those receptors, you know, and see where somebody hits, like I said, the thing is, is we, we don't do this for anybody, we don't check people and go, Oh, you're 30, let's look at everything we can look at and get a baseline of you probably at the top of your game, to to know when you get to 50, where you deviate from your norm. And we just we don't have that. And there's a lot of variability in the the normal ranges for a woman in their hormones.

Evan H. Hirsch, MD  36:20

One of the things that I learned is that you kind of ramp up your estrogen until you get sore breasts or you get, you know, symptoms of too much estrogen. And then you back down a little bit. And that's your ideal dose, how do you like to find somebody's ideal dose,

Betty Murray, PHD  36:34

I'm definitely sore breasts would be the sign that we've probably gone one step too far, you know, I like to look at hormone metabolism. And so hormone metabolism shows how much of the free hormone is circulating, so the stuff that's truly active that you can use, and then also how you metabolize it. So how your body sort of wraps it up to get rid of it. The gold standard is a 24 hour urine test that actually looks at the total output. And then there's also tests like the Dutch test that does kind of a spot of what's going on. To me, I want to know where that therapeutic range is. Because for some people, we may not ever get sore breasts and be above where our therapeutic ranges, or women might get a little bit of tender breasts because we need to adjust the difference between estrogen and progesterone. And they're still not at therapeutic range. So I'm definitely if I can, I'd like to test and test in urine, because that's the most accurate measure to understand, are we are we in the ballpark range of where we get the benefit from it from the body systems?

Evan H. Hirsch, MD  37:37

And does everybody who's on estrogen need progesterone to balance it out?

Betty Murray, PHD  37:42

So the the old western adage was, if you don't have a uterus, you don't need progesterone, because it was only reason we would use it is to protect the uterus, uterine lining. And for sure, if you've got a uterus, you have to have progesterone, because estrogens job, its natural job is to increase the blood supply to the uterine lining. If you don't have progesterone there to sort of balance what's happening, you're gonna get breakthrough bleeding, right? It's not anything terrible happening. It's just you did it because you didn't balance the hormones. But I also believe testosterone needs to be placed. For women, we make five to 10 times the amount of testosterone at any given time, then we do estrogen. We have a ton of testosterone in our body, but relative to men, it's miniscule. But we need testosterone to now the FDA has not approved that for women. But that doesn't mean it's not used millions and millions and millions of times a year in the United States off label that we need testosterone, but progesterone, especially for sleep and anxiety, Trent neurotransmitter function, these hormones have their own job, they're not just there to counterbalance each other. And I think we need to restore those hormones to functional levels to see the full effect and the full body improvement that you want to see.

Evan H. Hirsch, MD  38:58

And estrogens come from testosterone in the metabolic pathway, right. Am I remembering that correctly? Yeah. Yes,

Betty Murray, PHD  39:04

yeah, we make we make testosterone and androstane diet and get made into a stone and estradiol.

Evan H. Hirsch, MD  39:13

And what do you find is a typical dose for testosterone where libido comes back, and you get all the other benefits from testosterone? Yeah,

Betty Murray, PHD  39:23

so So the study so like I said, I'm a researcher, so I'm always like, let me tell you what the research says. And then we can die because I obviously don't prescribe. But the research shows in women, both five and 10 milligrams of testosterone daily, will improve particularly libido and sexual dysphoric disorder, which is a lovely new term that we're using so they can, you know, label us with something new. So basically, if your libido is low testosterone at five milligrams for most women will improve symptoms, and you might go as high as 10 and anywhere in between, but you'll see an improvement

Evan H. Hirsch, MD  40:00

And then they'll also be increase in muscle mass ability to make decisions more quickly. I mean, these are some of the benefits of testosterone, correct?

Betty Murray, PHD  40:09

Holy, yeah. Yeah, you feel more motivated, right? Both men and women will say, I just feel more me like I have the drive that I used to have, you know, I have the recovery that I used to have. So that happens in both men and women. So

Evan H. Hirsch, MD  40:23

you mentioned that you don't prescribe. But you work a lot with these hormones. And so how does that work?

Betty Murray, PHD  40:29

Yeah, so, so I'm a PhD, I'm a researcher. So I don't I'm not an MD or a do. So I don't prescribe and I don't label, right. So I don't, I can't attach a new label to somebody. Although I've owned a clinic for over 20 years. And I have, I have clinicians in psychiatry, internal medicine, hormone replacement. At one point we had rheumatology. And so so I have medical providers in my office. And we really work as a team, like my skill set is really understanding the biochemistry of the body. And obviously, when I went back and got my PhD, I'm an I'm the world's expert on hormone metabolism and what's happening with the gut in the liver, or just study something no one else had studied. So and that's, that's what really my passion was, is understanding the impact of these hormones and how we metabolism in the body. And so I really help people kind of understand what they're looking at and understand the science and then my team really prescribe and manage them.

Evan H. Hirsch, MD  41:23

So we've talked about, you know, what to look for in terms of the symptoms, we've talked about the treatment, and how beneficial it can be. It sounds like everybody really deserves an assessment to determine whether or not bioidentical hormones would be supportive for them. And it sounds like for most women, you would say probably yes. Would you say 100% of women? Would you say 90% of women would benefit from bioidentical hormones? What do you think? You

Betty Murray, PHD  41:51

know, there's, um, you know, so I would say, probably one of the most important things any woman should do is read this book or listen to the audible, and it's called estrogen matters. And it's by a Dr. Avram blooming, and Carol harvests PhD. And it is a laundry list and and a very well put together book about every single study that's ever been done, up until the Women's Health Initiative and then a little bit afterwards about the safety and efficacy of using hormone replacement. Right, because we've been we've been sold a bill of lies about it. So I think the vast majority of women are candidates for hormone replacement. Now there are situations where we might have blood clotting disorders, history of like deep vein thrombosis, maybe pretty strong, like brockagh, history, and ovarian and breast cancer history. However, you if you really look into the literature and the research on that, that doesn't necessarily exclude you from hormone replacement. What's interesting is they've done studies looking at hormone replacement in women with breast cancer with the risk for metastatic cancer. And actually it was only when they added tamoxifen at the same time as as estradiol are actually conjugated estrogen, so Premarin, only when they added Tamoxifen was a risk higher, when they took it out, there was no risk of metastatic activity. So I think even if somebody's had breast cancer, they could be a candidate. And it needs to probably be individualized. If a woman has gone a long time past menopause, let's say they're 1215 years past menopause. It's not that they can't do estrogen. But there is there is some research out there that shows that, that they could have a slight increased risk of cardiovascular activity. And the reason why is estrogen protects our blood vessels, our arteries, when we lose estrogen, that protection goes down arterial plaquing, so we get more cholesterol buildup and all that other stuff. And especially where the aorta kind of crosses the heart, we can get we can get build up in that area. And that women that have what they call aortic stenosis, which is a super small percentage of us may have a little bit of that break loose, if you give estrogen without paying attention to it, and maybe doing some statin therapy or some other cardiovascular support therapy. So in a woman who let's say, let's say they're 70 and they want to go on hormones, our team would probably do an additional cardiovascular workup and send them to a cardiologist have all that checked out and just monitor closely. You know, the reality is, in most people, it's protective and it's protective. Regardless, we this study study done by Moscone looked at the use of Premarin which is a Horse mare urine. Sorry, people. It's 13 estrogens made out of Equine pee right, along with a synthetic progestin not a real progesterone, which is very bad for everybody. It causes clotting, right? It causes increased thickening of the blood, if you want to think of it that way. That group showed an increased risk for dementia when you add it later in life. Right? So So the earlier you intervene, the better off it is, but it doesn't mean that you can't do it later in life. We just might have to do some additional additional kind of footwork to check out mm Hmm.

Evan H. Hirsch, MD  45:01

And so for people who are interested in exploring this further with you, where can they learn more about? Okay,

Betty Murray, PHD  45:07

so you can find me at Betty murray.com. And the last it's it's spelled b e t t y Murra y. And then I also have my clinic livingwell Dallas that you can get to from there. I have a great hormone quiz. If you're curious, like, am I going through this transition, I have a great hormone quiz. It's gonna help you navigate which hormones are out of balance. So there's a lot of good stuff there that you could do, as well. And

Evan H. Hirsch, MD  45:30

we will put all those links below. Any last things you want to share with our audience. This has been really amazing, Betty, I really appreciate you sharing all this knowledge with us.

Betty Murray, PHD  45:40

Thank you. Thank you. I guess the other thing is, if this is an area that you feel like you need more information, menopause mastery, that podcast we basically pull this stuff apart all day, every day. You know, I put out a new episode every week and talk about it. And and so follow me there. If that's something you're interested in. I dropped an episode every week. So yeah, excellent.

Evan H. Hirsch, MD  46:01

Well, thanks so much for coming on today, Vidya. So appreciate you sharing all this knowledge with us.

Betty Murray, PHD  46:08

Thank you for having me, Evan. It's been great.

Evan H. Hirsch, MD  46:12

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