The EngagED Midwife
The EngagED Midwife
Sweaty Sheets and Foggy Brains: A No-BS Guide to Menopause
Are you feeling exhausted, irritable, foggy-brained, or experiencing night sweats that leave you drenched? These symptoms aren't just "part of getting older" – they're signs of hormonal changes that can be effectively treated. In this eye-opening conversation, Dr. Val Schulte joins midwives Missi and Cara to demystify perimenopause and menopause with straightforward, evidence-based information that healthcare providers often miss.
"I can't describe how excited I am about today," says Missi at the start, acknowledging that many midwives received minimal education about menopause, especially after the Women's Health Initiative study created widespread fear around hormone therapy. Dr. Schulte, who transitioned from traditional OBGYN practice to focusing on hormone therapy and lifestyle medicine, shares how her own perimenopausal symptoms sparked her passion for helping women navigate this transition.
The conversation dives deep into practical aspects of hormone testing and treatment options. Dr. Schulte explains how bioidentical progesterone can improve sleep and mood, why testosterone (often overlooked in women) dramatically affects energy and libido, and how proper estrogen therapy protects heart, brain, and bone health. She details the advantages of different delivery methods – from daily creams to pellet therapy that slowly releases hormones over months – and dispels myths about hormone risks.
What makes this episode especially valuable is the real-talk about symptoms many women experience but rarely discuss: brain fog that interferes with work, anxiety that appears out of nowhere, joint pain, changes in body odor, even ridges in fingernails. Dr. Schulte connects these seemingly unrelated issues to hormonal fluctuations and offers solutions beyond the standard "here's an antidepressant" approach many providers default to.
Whether you're approaching perimenopause, in the thick of menopause, or supporting someone who is, this conversation provides clarity and hope. As Missy realizes toward the end, "I do not have to feel this way for another five years." Listen now to discover how you can reclaim your energy, mood, focus, and quality of life through evidence-based hormone therapy and lifestyle approaches.
#EngagEDMidwife #MidwiferyMatters #HormoneTherapy #MenopauseCare #PerimenopauseSupport #WomensHealth #MidlifeHealth #HotFlashesAndHope #ToolsInOurToolbox
@menopause_society @acog_org @drjennsimmons @drrachelrubin @dlberkson @auria.care
Welcome to the Engaged Midwife Podcast. This is Missy and this is Kara. Oh my gosh, Kara. I can't even describe how excited I am about today.
Speaker 2:We're phoning a friend again.
Speaker 1:We're really good at phoning friends. We're always looking for people who are smarter than us. But I also said this is an episode that we have been teasing in our podcast for six months at least, right Right, and it's because it's something that, as midwives, we are not good at.
Speaker 2:Well, we haven't had a lot of education about it, um, but I think things are getting better until we get to a certain age.
Speaker 1:We haven't had a lot of education about it, but I think things are getting better Until we get to a certain age.
Speaker 2:We haven't had a lot of experience with it, right. Right, we're going to talk about menopause and perimenopause and I think back as I was prepping for this episode it's really about when you and I graduated from our midwifery programs about why we don't feel comfortable with the topic is because everything everybody kind of threw all the papers in the air and said we don't know what to do anymore. The WHI totally trashed everything, and so I feel like we're finally coming back around to. I keep telling all my friends, gen X, we're not going to take this lying down Like we're going to do something about this. So I'm excited about this topic and, as you said just before we got on here, this is a little bit of a personal consultation as we go through the topic.
Speaker 1:Yeah, and I also said like a lot of us who go into midwifery go into it when we're young in our careers and so we also don't have any personal experience. I, when I became a midwife, also didn't have kids, so I'm like I can't talk to you about what it was like when I was pregnant because I don't know. So now here I am, like approaching perimenopause and I'm like, well, I guess now I'm going to know all the things because I'm going to have personally experienced it. But all right, so I'm going to introduce our guest. Dr Val Schulte is a friend of mine. We were in practice together and she is brilliant when it comes to all things perimenopause and menopause and I'm so excited to host her today, so welcome.
Speaker 3:Hi we're excited to have you. It's so funny because you guys were talking about you know how you really weren't taught and you know I would say the same thing. You know, I went through a OBGYN residency and also I don't feel like I was really taught how to deal with women's hormones. I mean, I was taught how to, okay, prescribe birth control pills, keep people from getting pregnant. Now, when I was a resident because this was pre-WHI study coming out, okay I remember we'd have menopausal women come in so let's say they were, you know, 55, not had a period for the last couple of years, and we would be like, oh my gosh, you're not on hormones. Why aren't you on hormones? Do you want? Do you care about your heart? Do you care about your brain? You know this stuff like and oh, we have to get you on them. Like I mean literally, like we would look at the person, like they were had two heads or something. There was something wrong with them not considering. So it was so interesting when the WHI study then came out, like right, when you know, I was first starting practice and all of a sudden everything changed, you know, and so I guess a little bit about me.
Speaker 3:I am a DEO. I went to medical school at Ohio University. I graduated in 1997 from medical school, did my residency in Dayton, graduated from residency in 2001. Well, right around 2002 or so as WHI study came out. So and anyway, so I practiced in Dayton for a couple of years and moved up to Wilson in Sydney, ohio, in 2005. Moved up to Wilson in Sydney, ohio, in 2005. I, after 20 years of doing OB and GYN and just the typical practice like that. Obviously I did a lot of hormone stuff. I'll get into that a little bit more. But I really was losing my love for conventional medicine and decided I had to look for other alternatives and found out about an area of medicine called lifestyle medicine, which is really approaching how your life, you know, how your health is overall through lifestyle, for through your nutrition, exercise, sleep, stress management, social connections. And then I got certified in lifestyle medicine and opened my practice that I'm currently in in Tip City, ohio, april 1st 2022. So three years ago. We've been opened.
Speaker 3:I'd say people would say more of a concierge practice. We do not take insurance here. I do say that the nice thing is is people know exactly what they're paying for, because if you go to have whatever. You don't know what your insurance is going to pay. And how many times have I had people come to me and say, oh my gosh, those labs cost me, you know, twelve hundred dollars or something. And I'm like, well, in our office that would cost you 100, you know, or 85 or whatever, and so we have a membership part of our practice. But we do do, between myself and my nurse practitioner, a ton of things with hormones. We have a huge hormone practice also, and so, yeah, so that's really what I'm super passionate about is hormone therapy and just the benefits and all the things that we were told about hormones being so negative are just. Luckily, we're finding out more and more that it's. A lot of that was false information and not good information, and so, yeah, that's a little bit about me.
Speaker 1:Amazing Carol, where do you want to dive in?
Speaker 2:Well, I think um, you know I'm curious, I I teach students maybe even just the definitions and kind of normal timeframes of ages of patients that are seeking care around this. But you know of ages of patients that are seeking care around this. But you know, I tell my students all the time that menopause is a clinical diagnosis. Like you don't need labs to tell if someone's menopausal, but there's all those years before and after and everything that really encompass that whole perimenopausal period. So maybe if you could give us a little bit of how you approach it or how you explain it to patients, I think that would be helpful.
Speaker 3:Yeah. So menopause technically is yeah, you haven't had a period for a year Very interesting thing though, and I don't know if this is since COVID or what. So, first of all, sometimes people don't have a period that long. That doesn't always mean menopause, so other things can be going on. Average age of menopause is technically 51.
Speaker 3:But I would say on the most, I mean the last couple years, I swear the majority of patients I'm seeing are more like 53, 54, 55 going into menopause. I mean I just went into menopause last year and I'll be 55 this year. So I was 54 when I was going through menopause. So you know, I think then perimenopause is all the hormone craziness before that. I mean some women I treat for perimenopausal symptoms and they're, you know, 30s or 40s. I would say definitely. By the time a woman hits 40, she definitely starts noticing changes more. Perimenopause is typically more of a decline in progesterone and or testosterone levels. Usually estrogen levels are the last thing to decline and that will happen with menopause. But the one thing I started to say was it's sort of weird. I've noticed a lot of women who I would say, because I do get blood work, I get blood work to just know where someone's levels are at, for even if they haven't had a period for 10 years. Because I can give an example I saw a patient about probably about a year ago 64 had a period for over 10 years was considering wanting to start hormone therapy. I said, let's get all the labs. Well, when I get her labs back, her testosterone was sort of higher, like than it should be for menopause. For 10 years it was above 100, not above 200 that we get concerned about, but it was above 100. And I was like, well, that's unusual. So I just verified with her that her husband wasn't doing any type of hormone cream or anything like that that could be rubbing off on her, which he wasn't. Um, long story short, I got an ultrasound. Then, cause this does, I said like this doesn't make sense. Um, sometimes I'll repeat labs too if I don't believe them. Um, because I'm like, did they label someone else's name on this person's labs? So you know, um, but I got an ultrasound. She had a big like nine centimeter mass on her ovary. That was benign, non cancerous, but at the same time it was what was causing her testosterone to be so high and she had no idea. So I say that I don't like to, just, you know, not get labs first. I usually will.
Speaker 3:But I've had women who you know in one sense look like full blown menopause or FSH. You know which is a hormone your brain releases. You know, I was always taught you know, if that's over 30, that's technically menopause. That was another way if you wanted to get some labs on a patient and I've had so many patients through. Fsh could be 80, 100, their estrogen level's really low. But then you know, six, nine months, whatever goes by, they have a period or something. You repeat labs and then all of a sudden their FSH is like 40, and their estrogen's 40. And you're like what just happened? So I think that there's a lot of hormonal fluctuation when women are going through the actual last few years of change. So I don't get real obsessed about like, are they perimenopausal versus menopausal? When I'm deciding to treat them. I'm just like more obsessed what are their symptoms and what should I be treating them with at that time? Not like what's the exact definition of that person, it's more like okay, what's their complaints and what are they lacking?
Speaker 2:So I think you raise a really good point too of you know there's lots of reasons. People don't have periods God bless the Mirena IUD. And people don't have periods God bless the Mirena IUD. But you know, having that lack of menses for 12 months really can complicate the picture when you really just want to treat the person in front of you.
Speaker 2:Right right, yeah, yeah. So with that perimenopause, maybe can we start there and talk about some of the common symptoms and then what, um, what your approach might be in really figuring out what would be the best treatment or options for people.
Speaker 3:Yeah. So I'd say um, first of all, the one thing I'll say first when you guys said you didn't have much training, um, you know, same thing, like I said for me, and um, I would say right, when I was getting around 40, I started noticing for myself things changing.
Speaker 3:And I'm like what is up with this, you know, and that's where I really started paying more attention and really was like, okay, I want to look at this more because, like this also applies to me now and so most of the things I learned was really on my own, not because I was taught in residency or taught in medical school or anything like that. I think actually we're really bad about that. Even in medical school medical school, you learn OBGYN stuff, but you don't really go into like treatment, for you know hormone, you know hormones as far as, as far as menopause is concerned, and the crazy thing is is our hormones are so important. So what do I see in perimenopause? Most common complaints, I would say, is sometimes just like I know something's wrong and I don't know exactly what, but I just know I'm changing something's wrong with me. Like fatigue super common. Low or no libido or sex drive super common Sometimes. Brain fog, sometimes more irritability, anxiety, depression, issues. You know they're like usually I'm really low key Now I'm getting super irritable all the time or super anxious. This is not like me. They just know something's wrong. Maybe they've had a little bit of weight gain. They're just like I haven't changed anything. I don't understand this.
Speaker 3:And so they go to their primary care or even a lot of their OBGYN doctors or nurse practitioners or midwives or whoever. And a lot of times it's like oh well, you're just at that age, you know, that's what you know. Um and uh, you know they may check maybe just a basic TSH or something, especially if they complained about weight gain and fatigue. But in general they don't. Even even if the patient asks like, can I get my hormone levels checked, they're like well, there's really no reason to check your hormones. This is just normal. What are we going to do? We're not going to change anything different. And then if they complain of, let's say, cycle irregularity or whatever, then it's just like well, let's just put you on a birth control pill. Or if they complain of too many, let's say, anxiety, depression, irritability, whatever issues, then it will be like well, let's just put you on, you know, ssri or Zoloft, or you know Prozac or Alexa Pro or something like that. Never is really, you know. Unfortunately never has really thought like, oh, could this be her hormones, you know. And so that's why a lot of times I have patients come to me. They've already been, they didn't come to me because they didn't already go to the person who typically they go to. They typically have, and sometimes they've gone to.
Speaker 3:I remember I had one lady, probably six months ago she had been to seven different doctors over, you know, seven years or something, and her number one complaint was her libido. She had some lower energy too, but she was like it was so unusual for her Like she's like this is, this is something typically. We had a really good sex life, and now I I don't ever think about it, and so it was really disturbing to her. She was told things like well, maybe you should start watching porn, maybe you should like just give it to them, even if you don't feel it whatever, and again through those. So when I saw her I was like you know well, has anyone checked your hormones? And no, no one's checked her hormones. Oh, maybe they had, but they said they were normal Because, again, as we get older, our hormone levels will decline and and so I said, well, let's check, because it had been a while and her testosterone level's low, and so I started on testosterone.
Speaker 3:I just I remember when I called her after labs, after she had been doing some therapy with me for a month, she was like, oh my gosh. And then she was just like so mad though too, because she felt so much better. But she was feel like so like I have wasted the last seven years of my life on all these providers and no one has helped me. I come in to see you one time and you fix this problem. And I said, yep, I said, but the problem, you know, the problem is, is we can't change time. You know we can't go back and undo it, so we just have to. You just have to be happy now that you know that there is something that can help you. And but yeah, I mean, it's just ridiculous. I, I see people like that every day.
Speaker 1:I, you know yeah, when you were talking, I just wanted to be like where are the check boxes? Yes, I have crippling anxiety that I used to not have. Yes, I'm super irritable and everybody hates me like a couple of weeks out of a month because I just I'm like I just wish I could pinpoint every single time, right. And here's the added challenge, right, the added challenge for somebody like me who doesn't have a uterus, right, I can't even correlate anything to bleeding, right, which is such I feel like, as midwives, we're always like well, are you bleeding? Are you not bleeding? Like, do you have PMS symptoms? Do you know when you're in your luteal phase? Like all of those things, right. And then you, you hit somebody who's I'm I will be 49 next month who I'm like I can't correlate anything with bleeding. I just know I feel like trash, right. And then it's like well, I know what my FSH is and my. But every time you listed a side like a symptom, I was like that's it, right, correct.
Speaker 2:Yeah, and anxiety, anxiety, because you know that something's wrong, right, but you put your finger on it. Is it exactly what you said earlier?
Speaker 1:And it's like the idea of somebody like checking my thyroid. I know my thyroid function is fine. Here's some SSRI. I'm like, yeah, I don't want that SSRI though because it tanks my libido. I don't want that medication because it tanks my libido and it made me gain weight. The worst thing ever is to be perimenopausal and get fat and have no sex drive, like that is feels so bad.
Speaker 3:Right, well, and so many women are already dealing with that problem anyway, and then you add a medication like that and all you're doing is adding to the problem. You know, so you're not fixing anything. So I would say, you know what's what is. I guess if you want to say, well, what labs would I be checking then so obviously, you know, if I'm concerned about thyroid, I do like to look at more than the TSH. I do like to look at the free T3, free T4 also, because you know those numbers I like to see in certain ranges too, just to make sure. So if they only had a TSH, I like to look at that a little more. I will look at things like B12 and D. You know B vitamins have a lot to do with our energy, d just overall health. But I've had some people just improve their D levels and have had a lot more energy Plus. We live in Ohio and you know we don't get enough sunshine and all that, um, uh and so. But then as far as hormones like if they're, if they're still having their periods um, so, like for someone like you, missy, like I would probably do okay, we need to get an FSH too, because you're not having period because you got a hysterectomy and you're at that age where you could be. But even if you were like in your early forties, I might still check the FSH too. But otherwise I always check the estradiol progesterone testosterone. I typically do it through blood.
Speaker 3:You can do saliva testing. I was on a really good webinar about a year ago, a little bit over a year ago. One of the ladies her name is Dr Lindsay Berkson. She actually she's probably in her mid 70s. She had breast cancer herself, like 30 years ago. She's a huge advocate for bioidentical hormones, including estrogen, even in women who've had um history of breast cancer and um. You know, what I really learned from them is to just they also thought you can just do blood work on patients. You don't have to necessarily get cause saliva testing. The only bad thing is is a lot of times it just takes more time and it isn't always covered by insurance. So sometimes I will do it, but I won't. I won't. You know, routinely I do a lot more blood work than I do with saliva testing, um, and it's just easier for the patients to get um blood testing too.
Speaker 3:Um, so if there's having regular, so the estrogen, progesterone, estradiol progesterone, total testosterone. If they're having regular cycles like you know they're yep, their periods are very regular I'll usually have them do that around day 19, 20, 21 of their cycle, just because I really want to see where their progesterone is, because a lot of times their progesterone level tank out at that second half of the cycle. But if they're not, then I just don't. Or if their cycles are all over the place, I'll just do the labs whenever.
Speaker 3:Um, uh, if they're on a birth control pill, like I had a patient yesterday, she's on a birth control pill, um, but really my concerns she was only 38. My concerns was a little bit more about her testosterone. Testosterone can be lower, Obviously, if you're taking a birth control pill. What does a birth control pill do? Sh testosterone? Testosterone can be lower, obviously if you're taking a birth control pill. Was a birth control pill do? Shuts down your ovaries, gives you artificial estrogen and progesterone but does not give you any testosterone level testosterone back. So I did check just her testosterone just to sort of see where that was. She was in the office and I was just like let's just check this today. If this doesn't make sense, then I'll probably have you be off your birth control pill at least, I usually want at least five days and to recheck their labs and stuff. So that's pretty routine for, like if I'm thinking someone you know, more perimenopausal I guess.
Speaker 2:I've heard recently people get all tick tock, you know people sharing their experiences and there's all these other symptoms and you mentioned a couple of them that the sleep disturbances, the mental fogginess, but also like intense itching or changes in body odor. Those are some pretty common experiences as well, but we don't hear them talked about as much joint pains I mean.
Speaker 3:No, I do think a lot of that gets a little bit worse once people are going. The estrogen decline, you know um, but yeah, joint pains um just obviously change in skin. Um, you know, they feel um again, just again. A lot of it's just not themselves. They just feel like so much not themselves, they could have actually ridges in their fingernails. I just had a lady say that the other day, like my fingernails are all ridged.
Speaker 3:Well, that can be a lack from a lack of estrogen. Your keratin level goes down. So some of those are more common when you're actually going through menopause than if you're just perimenopausal. But, like I said, even though I'm not concerned a lot about having to replace estrogen in the perimenopausal woman, sometimes I have to bring the estrogen level down though, because I see sometimes women, you know their estrogen is like 700 and something Well, you don't need your estrogen to be 700 and something that's like a little high. So and then their periods are super heavy and stuff like that. And yes, I can help raise their progesterone level, but also, I think, sometimes using like a DIM supplement or something that can help lower their estrogen, some, when they have those type of symptoms can help too.
Speaker 2:So yeah, yeah, so let's talk about some of those different therapies or treatments and how you might tweak them or what the options are for people lower than if.
Speaker 3:And if they're having a sleep problem, I love having them use progesterone at bedtime because progesterone at bedtime is great for sleep. It's also progesterone is a very calming hormone. So if they are feeling a little more irritable, restless, whatever, um, progesterone, so let's what's. And there's a difference between progesterone and, like progestin, that's in a birth control pill or provera that sometimes we would use for a heavy cycle or something like that. I always say it's like a key in a lock. So like if you have the correct key for the correct lock, it's going to be able to get it. Hormones are supposed to go and do their work and then leave. And when you have the for the, the lock, then either it's going to not be able to get in there and do any work or it's going to get in there and get stuck and stay too long. Um, and then that's where that can be not kind to our body. So, um, like I said, progesterone if they're having a sleeping problem, I love using that early at bedtime. If they're just having, typically just like a PMS, like that last week or two before their cycle, they're really super moody and their cycles are real regular. Sometimes I will just use cream for a progesterone cream that they can use for maybe even two weeks before their period, sometimes longer, but, um, and then testosterone is another thing. Definitely, I use a lot in perimenopausal women. So before menopause, um, and the only thing with testosterone the really only ways to use is in cream form or pellet form. I do have just about three or four ladies who use some testosterone injections. Um, but there's not anything out there that, um, you could just go to CVS or whatever and pick up for testosterone for women. Plus, with testosterone and really estrogen too, it is best to have those transdermal. Why? Because if you take them orally, they trigger the clotting cascade and then when it triggers a clotting cascade, that increases your risk for blood clotting issues. So like getting a DVT in your leg, a blood clot in your leg, or a clot in your lung or something like that, a PE, and so and as we get older, since we're more prone to things like that anyway, we want to try to avoid a complication. So if you do transdermal, whether it's a cream you apply to the skin, you do an injection or a pellet. So pellets are like, if you can take imagine taking a Tic Tac they're like a little grain of rice. They're implanted in the upper outer buttock so they're going to the subcutaneous tissue of the buttock area, your body. I say it's like licking a lollipop, so they just dissolve over. For women typically three to four months and all those ways. Then it gets directly into your bloodstream. So you bypass the liver, bypass the digestive tract, all that kind of stuff.
Speaker 3:The one other thing I just remembered I want to say about progesterone. So with the progesterone you can get because you can get progesterone in 100 or 200 milligrams at a regular pharmacy like CVS, walgreens, whatever the difference between that and something compounded. Two things One, if you compound a progesterone you can get, like any dose, 25 milligrams, you know, 250 milligrams. You can get a lot of different doses. There's probably a max, I think typically you don't want to go over 300 milligrams in one capsule. So if you'd want to have someone go up higher dose, you'd want to have them take more than one. But the other difference is the particle size of the progesterone within the capsule. Cvs, walgreens, whatever, with a regular prescription is going to be probably about a 40 to 50 microgram particle size, whereas your compound it's going to be more of a 10 to 20. Sometimes that's about absorbability and bioavailability. Same thing.
Speaker 3:I talk about patients with supplements all the time, like if you're going to do a supplement, you want to get one that you know is going to, probably you're going to be able to absorb and your body's be able to do something with, because otherwise you're just wasting your money. And so that's for some people. They don't do well with the progesterone, they can just get it CVS or Walgreens, so they do need it compounded. Or if they're a woman, especially if she's over like 60, 65, sometimes they will convert some of that progesterone over to L-pregnenolone and L-pregnenolone will make them feel like hungover the next day, because usually progesterone you take at bedtime, so they'll just feel like man.
Speaker 3:I was so tired or dizzy, just not right. Actually, the first time I took progesterone and it was a compounded one I think I did one or 200 milligrams, I guess, for the first time. And I remember waking up the next day and I was going to come to my gym at my office and I was like felt like, oh my gosh, can I drive you know? And probably about an hour later it it went away. But not only happened to be the first time, but so that's good info yeah.
Speaker 2:Yeah.
Speaker 1:Also and Kara and I have talked a lot in our podcast I feel so strongly about a compounding pharmacy because they can just do some amazing things, you know, and in midwifery circles we talk a lot about like do we use it for? Like compounded nipple cream right when people are having breastfeeding issues but but for bioidenticals and for hormones, I'm like, find a good compounding pharmacy and I know, like when we were in Sydney, there's a, really there's a good compounding pharmacy that I knew I could always call. But talk a little bit more, please, about testosterone and about pellets, and I love that analogy of like it releasing slowly. How long does it take for people to feel better and how? What do you see in terms of progression? Like, you know, once they're all the way through menopause, is it something that they continue to do or like what does that look like?
Speaker 3:So, so pellets into specifically testosterone. I guess probably one of the biggest researchers and testosterone replacement in women is Dr Rebecca Glazer. She was a breast cancer surgeon herself in Dayton, for she stepped away from doing surgery and stuff like that probably at the end of my residency. At that time malpractice rates were going through the roof and stuff and she was primarily just taking care of breast cancer patients and so she decided to stop practicing. But she was always a huge advocate of hormones, specifically testosterone.
Speaker 3:Why Testosterone? They always say maleness protects femaleness. Okay, so um, but we think of testosterone. What we've been thought of is testosterone for men and estrogen and progesterone are for women. That's the way it is. I have some men who take progesterone to help them sleep at bedtime. Um, so now it's rare. I've never had to give a guy estrogen so far, but I do sometimes have to lower it a little bit. Some estrogen, but you know the hormones we, we all have them, you know. So we just have to. Men just have way more testosterone than women have. But yeah, testosterone is so important for us feeling strong, having a libido or not having energy.
Speaker 3:I would say with pellets. The nice thing is is when patients are trying to decide what route do they want to go with me? It depends, if they're, if I can tell from them or they've tell me like I'm super sensitive to hormones or whatever. I would definitely want to encourage them to start with a cream first, primarily because they can just stop that then. So if they feel like they're having I don't know some type of side effect from it or whatever, they can stop it, whereas if I put pellets in, we just can't go in and remove them. So with pellets, though, the great thing is is like back to that patient I just talked about with a libido issue for seven years, or whatever we did, I put her pellets in. A month later I have patients get their levels checked, because that's typically where the level peaks out from the medicine, and I called her back and she felt amazing right away.
Speaker 3:So I would say 80% of my patients feel better in that first month, and so when you've been, people typically don't come in when they've only been dealing with symptoms for a couple of months. Most of the time, women are taking care of others, and so they put themselves on the back burner, and so by the time they actually come in and actually decide to do something about it. It's been going on for quite a while. So by the time they actually come in and actually decide to do something about it, it's been going on for quite a while. So they they wanted to feel better a while ago, but they kept on putting it off because they were taking care of everyone else. And so it is nice that typically I can get people feeling better pretty quick and then it's convenience, like when I learned more about pellets.
Speaker 3:You know, I really, when I got to that point, I was doing a ton of bioidentical hormone creams for my patients for years, but sometimes still not getting patients better, and I still have a lot of patients who do creams and are doing well with them. But I decided to look into pellets a little bit more, primarily because I thought, well gosh, if I'm, if I'm needing this, am I going to want to put a cream on myself every day? And I just thought, oh no, because I can't even remember to do you know, some basic tasks, sometimes daily, taking my multivitamin or whatever. I'm not, I'm just not going to do it. And then I'm going to be like it's not working. Well, why isn't it working? Cause I to do it every day, and so for women typically it's most women it's only four times a year at the most. So it's a convenient thing too.
Speaker 3:I just had a husband and wife start to see me. They, they live here in the area close to my center and they've been going down to Florida for the past two years to get their hormone pellets. So, and they've been. He usually gets them about every four months, four or five months. She gets them about every three months and they're literally going to Florida to do that. Now they're, you know, found out about me, so they're gonna come closer. But you know, again, it's reasonable. It's sort of it seems crazy, but okay if you only have to go there a couple times a year. It's reasonable. It's sort of it seems crazy, but okay If you only have to go there a couple of times a year, it's reasonable to consider doing that.
Speaker 1:So are you at any point in this new practice that you're running doing traditional hormones? Is there still a value in that for some people?
Speaker 3:So I do have some patients who do um estradiol patches, estrogen patches sometimes, um, I don't think I have anyone who does oral estrogen, whether it's esterase, estradiol, cromerin, um, I don't I have. I have women. I we have some women, younger women, in our practice who do do birth control pills um just for preventing pregnancy, primarily Um, but I don't think I have anyone who's using and even if they're of a bleeding problem, usually I'll I'll address it with progesterone, um, maybe 400 milligrams of progesterone to stop heavy bleeding, but um, I'll still try that over progestin or Provera Um, I don't have any when I'm replacing their progesterone, low progesterone levels with Provera or progestin Um, and then there's no testosterone out there for. So yeah, I would say I have a few estrogen patches but no oral estrogen, no oral progestins, and then there's not a conventional testosterone replacement for women.
Speaker 1:Vaginal progesterone or vaginal estrogen?
Speaker 3:sorry yeah so we do like. So I love Vagifem just because it's like clean and easy and stuff like that, you know Vagifem. For anyone who might not know what it's like, or Uvifem, I would say it looks like a pen, has a little pill at the end. You know, just stick that up inside, click, it releases a tablet. So it's just less messy than the estrogen creams. But we do have patients who do esterase vaginal cream sometimes. So I don't always compound it with just an esterile vaginal cream if I'm trying with for dryness but also at the same time to like.
Speaker 3:Know that even women who've had history of breast cancer can be treated with esterase vaginal cream or esterol vaginal cream, because even conventional medicine says that's okay. Now, and think about when. I mean, what do we think about women? I tell my friends who have their moms are older, whatever. If your mom starts talking crazy out of her head, she has a urinary tract infection and she's probably getting septic till proven otherwise, you know. So we can totally prevent this. Like, why are we not, you know, preventing? We can totally prevent this like, why are we not, you know, um, preventing? Well, we're not preventing it because we're just too scared of estrogen in general and, um, at least be kind to, because that's another thing, especially if they're going into menopause estrogen incline, recurrent urinary tract infections, recurrent bacterial infections I've never had these problems before, you know. Obviously sex can become having discomfort with that. So not only is her desire gone down, but now it's also hurts, you know, and if we wait until it's way too bad, sometimes it's hard then to treat Like.
Speaker 3:I don't know if you guys have heard of she's on Instagram, I think a lot Dr Rape. I think it's Rachel Rubin. She is a urologist. Actually I don't know where she practices, but she's really into women's health and she's really about you know, and where your clitoris is okay and all about how you know the clitoris is basically the woman's penis and how you know she shows diagrams of how it looks like a penis, just like a, and that's where we're going to get our stimulation.
Speaker 3:But what happens with menopause too is that hood over the penis, just like covers, and then they can get such bad phermosis and stuff like that around there that you know you can't. So then well, now she can't even get her pleasure really out of intercourse anymore because it's just, you know you can't. So then well, now she can't even get her pleasure really out of intercourse anymore because it's just, you know, it's in there and it's just all dried up and like can't be seen. And it's like trying to take a guy's penis and like completely covering it up and thinking he's going to get some type of arousal. But you just rub them through his pants and he's, you know, 50 or 60 some years old and going to get. No, maybe with 16, he might get excited about that, but not, you know, not when he gets older.
Speaker 1:So you know it's crazy because, um, not that many years ago I called my urogyne and I was like I need estrogen cream. And he was like why would you need estrogen cream? I said because I don't have a UTI, but I have dysuria. Right. And I said I think I have urethral atrophy. I know what I do for a living, like I need you to listen, right. And interestingly enough he drug me into the office and put me through like a terrible speculum exam that I didn't need all to say, oh, you're right, you have urethral atrophy and just use some Premarin and it will fix your urethra. And it did almost instantly. Within a few days it felt so much better. But I think it's that kind of stuff too that we don't always recognize. We're always like, oh, do you have a UTI? It hurts when you pee. It's not always a UTI, like that atrophy thing, right, is something that will like eat away at you, right?
Speaker 3:Right, well, and those estrogen levels really can be whack-a-doodle like those last few years before menopause. I mean it might be fine, like I know, when last summer, when I was like, okay, yeah, I'm finally in menopause, I was having the night sweats. My estrogen was down to like eight. My FSH was like 98 or something. I put I had my nurse practitioner just give me a little dose of estrogen. My estrogen went up to like 160 or something. I'm like, well, my ovaries must have still been alive a little bit, because there's no way my estrogen would have went up that high with just that tiny bit of a dose. But so that's just showing like those levels can really wax and wane a lot. And so even if the woman is in perimenopause, you know, and what are you going to do? Hurt her if you give her some estrogen vaginal cream? I mean first of all that if that's if you're trying to treat her hot flashes or things like that, that is not going to help, it's not going to give enough in the bloodstream. So, like you, you I don't know how you'd hurt anyone with giving them a vaginal estrogen cream.
Speaker 3:And I I can think about when I was doing OB I remember I had a patient this was probably like seven or eight years ago Our locums doctor had delivered the patient. Um, she came in to see me one week postpartum and she had a bad tear, like bad, like she couldn't even barely sit in the office, you know she's, and she's miserable, crying. You know, of course, postpartum hormonal, whatever and um, I look at it and I'm like holy shoot. I thought this might be the one time I have to take someone back to the OR potentially to repair this and I was like let's just start some estrogen vaginal cream on this. Okay, I want you to do this at least once, twice a day, whatever. You know, she came back in a week and was almost like not completely healed but totally fine sitting on her bottom, fine, like I mean, that stuff is like you know, it's like miracle work you know, like for anything down there.
Speaker 3:You know, sometimes if people went, for whatever reason, don't want to use some estrogen vaginal cream or you know like, unfortunately Medicare doesn't pay for it, then I sometimes will have them use some coconut oil to extra virgin coconut oil. I'm like you can probably have some in your kitchen. Just put a little container in your bathroom and because it's antibacterial it can help. They can even use it for lubrication for intercourse, um and um. You know, I used to use it around my eyes for the dryness that I would get in the winter and stuff too. So, um, but estrogen is still going to be better than that. But if, if they really want help with the dryness, um, some coconut oil, I think, is great too.
Speaker 2:So I love that you mentioned that. Um, you did mention hot flashes, which, um, I think we haven't talked a lot about. Um, when people say how are you here? I'm like, I'm 50, I'm hot and miserable all the time, so tell me best, best options for hot flashes.
Speaker 3:Yeah. So I mean you can do different. Like you know, uh, you know, evening primrose oil. I mean there's other you know, um, soy. You know soy is really good for hot flashes because soy is okay, like people used to say soy is bad, it's going to increase your risk of breast cancer, but there's. So it's a different, it hits a different receptor, so you don't have to worry like, oh my gosh. Plus, what we're finding out is well, through the WHI study, they've seen the women who are on Premarin only, versus women on no hormones, 20 to 30% less risk of breast cancer in those women. You know, and I always say all the time to women I say listen, I was like if it was just from the hormones, the estrogen, why don't we have all our breast cancer in our 20s and 30s when we have tons of estrogen?
Speaker 3:you know, it doesn't make sense that we the majority of breast cancer becomes more common as we get older, when our hormones levels actually decline. But, um, you know, I like. I like using estrogen. Why? Because it's so good. If you have no, estrogen is so good for your heart, brain and bones.
Speaker 3:It's so good for your heart, brain and bones. So another reason I started my whole practice or stopped left doing deliveries and stuff because I was never sleepy and always exhausted Learned how lack of good sleep also increases my risk for Alzheimer's, dementia and cancers and you know. But estrogen is also super important for that. So I go if you're flashing a lot and stuff like that and you have no estrogen, then we should be using some estrogen. So typically my approach would be if I'm doing pellets, I'm going to. You can do that in estrogen form to or cream or a patch.
Speaker 3:I do again like to encourage to stay away from oral just because of the potential negative of the liver effects and stuff like that. But like when it was crazy, because I would just be constantly like just say, we're even do this podcast, I can be sitting here all of a sudden like literally my whole body would just be like dripping wet. I was like heck, you know, like I mean, and it wasn't like I'd get red faced or like start actually sweating down, but I could just feel perspiration in every spot.
Speaker 3:Like and and then it would go away. You know, but it's hard. You're carrying on a conversation with someone and you just are like, do they notice that I can feel wetness everywhere? You know, it distracts you. Then you're like trying to concentrate and then all of a sudden your brain goes somewhere else and so, you know, I've once I did, you know gave myself some estrogen because when I got to that level I was like, forget this, you know. And plus, I'm not afraid of estrogen, you know. And so, man, I haven't had any since, I mean, within probably two weeks of me having my first dose of estrogen, you know it's. I've never had any sense and it's been the.
Speaker 3:It will be a year in July, so yeah, I think times the estrogen given to me, but yeah, I've had none.
Speaker 2:So my girlfriends and I will talk about how now we're wearing period underwear, just so we don't leave sweat everywhere. But, oh my goodness, we're not having periods, but you know, the period underwear are helpful, so you're not so sweaty everywhere.
Speaker 1:Right, right. Yeah, I said I've been so lucky that I've had no hot flashes like daytime hours, but in the last, like six weeks, it's like maybe once a week I wake up drenched and I have to like take all my clothes off and put all new dry things on and go back to bed At like two or 3am right. Yes, that's a big thumbs down, right.
Speaker 3:Yeah, yeah, yeah. I tell women all the time will ask me once they start hormones, you know well does this mean I have to continue them? When do I stop them? Blah, blah, blah. If they're, I would say that yeah. So hormones are your friend, first of all. I mean, if you look at even the healthiest people, when you start seeing okay, let's take examples Like average woman, when she goes through menopause will increase her cholesterol by 10 to 20%. She will probably gain some weight, so her A1C starts going up. Then she will, you know, become pre-diabetic, diabetic. They start putting on more fat. It's just. It's just this vicious cycle of insanity.
Speaker 3:And so not only can it help you feel better, it can help prevent you from having long-term negative effects from aging. And so we're not trying to. I always say all the time only God knows when I'm going to leave this earth, Okay, I'm not outsmarting him, Okay. But at the same time, I do feel like I'm responsible for taking care of this body while I'm here, and so part of that, and me feeling well and me being able to feel well so I can do for others and help others out, is taking care of myself. And if I'm not doing the things that I'm telling other people about, then how can I really like lead them well? So I think you can do hormones, like I tell people like let's say, you start them and you do them for five years, then you're like I'm feeling great. Maybe they lost 20 pounds, they're exercising now they're doing other things too. Because I always say you can do hormones. But if you, um so, because sometimes people are just like I, I'm no motivation, like I know I'm supposed to be exercising, I know I'm supposed to be eating better, I know I'm supposed to be doing these things, but I just can't. Literally it's impossible. Okay, so they do the hormones, they start feeling better. So I always say you don't want to just rely on the hormones making you feel better. You want to start doing the things that are going to help you feel better too making sure you're sleeping, not just eating processed food all day. You know, um, you know do prioritizing those type of things getting some exercises, stuff like that. So let's say they do that, they lost some weight, they're feeling great. Spend five years.
Speaker 3:I would say you could stop your hormones if you want. I mean, you could try it. You're gonna know whether you're going to really truly need them, probably within six to 12 months at the most. And but know that they're not only helping you with those right now, how you feel, but they are doing things to help protect your heart, brain and bones, because there's estrogen, progesterone, testosterone receptors all throughout our body, you know, from our brain to our you know intestines, to our bones, to our muscles, to you know. You know everything, so you're going to feel. To your heart. You know why do women's heart disease risk increase at menopause to a man's? Pretty much? Well, because of estrogen decline, you know, and so you know I would say it's going to do better for your long term too. So you don't have to stop, unless I mean if, but if you want to, I mean that's you're an individual. You can make choices for you, but I tell them you don't have to.
Speaker 3:The other thing I'd like to explain about I was just thinking about one thing that I hear a lot about, because you know we talk about, you know, estrogen, progesterone receptors and breast cancer, and so that's where we go. Oh my gosh, it causes the breast cancer. This was on when I was with Dr Lindsay Berkson on that web podcast or the webinar. I was with her. She explained it this way and I thought this was brilliant, because I'd never really heard it explained this way If we biopsied all our breasts like the three of us and anyone who's watching this all of our breasts, of our breasts, we would expect to find estrogen and progesterone receptors in our breast tissue, because that's normal, Like there's other receptors for, you know, all of our hormones, all these other places too. We should find that that means we have good tissue.
Speaker 3:Now, when they, you know, do those receptor tests when you have cancer, then they go oh, it's the, but the lady's 85. She hasn't had, you know, she hasn't had hormones in like 30 years. How are you saying so it's not again. It's like a misinterpreted way that they're saying that Like I love too. They were talking about prostate cancer. They're like okay, are we going to tell men who've had prostate cancer oh, you can't have testosterone anymore. No, no one's gonna say that. Okay, because a man would never put up with that. Also, a man would never allow his you know, his prostate or his testicles to be slammed in some machine and radiated to figure out if he actually has cancer down there. You know, um, so I don't know, for, and I I'm not all about like just women, women, women, but yeah, we let ourselves get put up with a lot of crap that men would never be okay with.
Speaker 1:That's Kara and I's theme song right there. Like we put ourselves in so many positions with our health, professionally, personally, that no man would ever tolerate. It's crazy. Dr Schulte, before I let you off the hook, I want to share with you this beautiful menopause remedy that you sent to me a million years ago and I want to still ask you so. This sheet of paper that I'm referring to is called Natural Remedies for Menopause, and she wrote it out for me years ago and I love it. But could you highlight some things on here for our listeners who are really interested in looking at some of these more natural remedies, the things that you think are the heavy hitters, what here on this list? And I will, kara, and I will try to find a way to post some of these things off of this list for our listeners, but what do you feel strongly about that's on this list?
Speaker 3:Yeah, I think you know people are going to get benefits of things. Definitely, evening primrose oil and black cohash, I think, are some of the main things If they are having a lot of depression, anxiety issues. St John's wort is really good too. Um, you know, b vitamins in general can be great. So, like the B6 with the serotonin production, can help a lot. Um, and then as far as soy, I think you know soy's um, actually, dr Christy Funk, she was a breast cancer surgeon out of California that I follow a lot she's into.
Speaker 3:Um, she has a book called Breast the Owner's Manual. Follow a lot she's into. Um, she has a book called breast the owner's manual and um, she talks about recommending for women who want to lower the risk for breast cancer, having like three or four servings of soya a day and ideally, you know, the less process is better. So if you can get edamame or you know versus, you know obviously tofu is a little bit more processed than that and stuff, but she, yeah, that's what she recommends. If you, she has a whole section in her book. You've not had breast cancer before, how to lower your risk. You've had breast cancer. Now, what do you do in your post breast cancer. What do you do? So I think those are the main things that I usually have patients look at. You know some of the other things, um, the Valerian, the motherwort I don't know if I've had many people really use those on a few occasions, but not anything that I'd say, oh yeah, I've seen huge results with that, um. But the black hoash, the evening, primrose oil, st John's wort for depression um for sure. And then GI.
Speaker 3:You know, if we're talking about depression, anxiety stuff and things like that, there's another really good book. It's called this Is your Brain on Food. It's written by a psychiatrist. Her last name is weird, it's like umbo or something I forget. You can find it on Amazon, but it's called this Is your Brain on Food, and she's a psychiatrist. She believes in medications for it. You know, depression, anxiety, bipolar, ptsd, whatever. But she has a chapter on each one of those diagnoses and then she explains through the chapter how our foods affect OCD, bipolar anxiety, depression, whatever. And at the end she has like a little like summary these are the foods you should embrace more of and these are the foods you should really avoid. Um, and I love that book, it's so good. I actually have a patient who's been recently diagnosed with OCD who's borrowing it from me Um yeah, so this is helpful.
Speaker 2:I think we should probably talk about some resources or where people can get additional information. The North American menopause society, which is now the menopause society, but you can still search it under NAMS has really good guidance, and you've hit on a lot of the different topics Dr Schulte about. You know vaginal estrogen and that it's safe for use in most people and all of the different options and starting low. And you know using for no more than 10 years or you know starting to think about how long are people staying on it and starting hormones earlier is better than waiting, yeah you're going gonna get the most benefit.
Speaker 3:They do say now I start women post 10 years but ideally especially the long term benefits, not just the short term. Right, it's gonna get benefits short term whenever you start them, but if you're really wanting to help decrease, help with your brain health, help with your heart health, things like that, ideally five to 10 years within, ideally five within five years of menopause, but 10 for sure. But I always tell I start people 75 plus and you know I mean they've been 10 plus years but I just tell them you know I can't tell you're going to have as many long-term benefits. You know it's going to help you with whatever you're dealing with right now. But the long-term benefits, you know we just don't have as much information about that dealing with right now, but the long-term benefits, you know we just don't have as much information about that.
Speaker 2:So that's great. What are some? Do you have any other resources?
Speaker 3:For testosterone information. Dr Rebecca Glazer has a great website. It's called hormonebalanceorg. I tell my patients to go there all the time because it has. She has a lot of information, a lot of research articles and stuff like that about testosterone replacement. I think that's the best place to get information about testosterone. That.
Speaker 3:Rachel Rubin, I think I don't know if she she probably has a website or something, I just know I see her a lot on Instagram. That's where I first heard about her, but actually she was. I forgot she was at a conference I was at. It was more for about male hormones, but there was a half day on female hormones and she was there. Um, and then Dr Lindsay Berkson is a really good resource too. Um, I like a lot of her stuff. Um, and I think it may be. If you just Google Dr Lindsay, uh, l I N D S E Y BerksonB E R K S O N. Um, that may be the name of her website, I forget.
Speaker 3:Carol Peterson, then, is a really good resource for progesterone, about progesterone Specifically. She's a compounding pharmacist whose passion is progesterone and the benefits of progesterone. Before our talk I actually pulled out so. So she literally in the conference. I was with her. I have like a 10 page like all the things progesterone can help with, like it was just like. But she'll use doses of progesterone up to like 2800 milligrams a day. Now, obviously not at one time, but um, and that's know why do women a lot of times feel well with pregnancy where they have some high progesterone um state. Um, so she yeah, that's her information is really good about progesterone. Um, I was trying to think if there was anything else that I referred to a lot. Um, I think those are the main things.
Speaker 3:Oh, and then the other thing about breast cancer. I love Dr Jen. Yeah, dr Jen Simmons, s-i-m-m-o-n-s. So she was a breast cancer surgeon out of California and she has a lot of really good information about different imaging for breast cancer. There's actually it's called QT imaging. It's super fascinating. It just uses sound waves. It is FDA cleared for breast cancer imaging. Unfortunately, in the United States she's in Pennsylvania, there's a couple of places in California but it uses sound wave technology. So it has gone up against mammogram, ultrasound and MRI and has had seen superior results to all three areas. And then also, the other thing I learned from her is there's actually this it's called ARIA tier test, a-u-r-i-a I think if you do ariacare I think it's a website, but it's basically a tier test that there's certain like HPV we know is makes us certain types of HPV makes us higher risk for breast or cervical perhaps cervical cancer. This ARIA tier tests can detect a couple of protein biomarkers that if they're higher, that means we have a little bit higher risk for breast cancer.
Speaker 3:It's not a genetic test, but it can. And so let's say you haven't had, you know, any screening. In a while you get that tear test comes back oh, it's higher risk. You go have your screening. It says it's clear. Well then, what do you want to do? Well, okay, well, no alcohol, like you know. Prioritize sleep, um, you know. Uh, get rid of processed foods. There's things that we can do to help lower our risk. We don't have to just like sit back and go. Okay, I guess I'm going to get breast cancer, you know, um, but I love that and I think that test is like pretty cheap. It's like 150 bucks or 160 bucks, but super fascinating too.
Speaker 2:So Well, thanks, you've given us so many different things to go do, oh my gosh.
Speaker 1:Take a look at I also think, kara and I just need to take a field trip to come see you, like we'll both just be new patients. Because, you know, my biggest take home message right now is like I do not have to feel this way for another five years.
Speaker 3:Right, right yeah longer.
Speaker 3:Right, right, and that's the thing is like women, just again. But what do we do? We're prioritizing everyone else, and you know, in just putting us on the back burner. So that's why, like I said, when I started looking into pellets, I was like, okay, well, there's other people out there like myself who want convenience, who want faster results, and so I wanted to be able to offer that to them.
Speaker 3:And I went and spent a couple of days with a guy who had been doing them. He's an OBGYN down in Tennessee who'd been doing them for over 10 years in this practice and I just kept on asking patient after patient, like, why do you do this? Why do you continue to do this? I just kept on hearing the women over and over say this is saved my life, this is saved my marriage, I'll never stop this. Like I feel so much better. And that's where I was like I gotta, I gotta do this for my own patients.
Speaker 3:And so, innocently, I started talking to patients about it and, um, now I don't know, we do probably over 200 pellet insertions a month in my practice right now at this point, and we started, you know, our first month, probably doing like 15 or 20, you know, um, so it's a big thing that we do, but we deal with people with all types of you know we'll do creams and things like that too. Um, the other thing lindsey bergson really taught me is, like you know, have a lot of tools in your toolbox, you know, because some people only treat things one way. And if you only treat things one way, you're not going to be able to necessarily help. And you want to be able to help, you want to meet people at where they're at and have them do something they're actually going to do and not be afraid of, and everything like that. And so you have to have different ways to be able to treat people, because we're so different, everyone's so different.
Speaker 2:Yeah Well, thanks, dr Schulte, you've been so informative.
Speaker 1:I mean, I can't even tell you that it was worth all of the weight to get you on the podcast to just talk about the things, and we're so appreciative and I know we're going to get so many questions via our website that I'm just going to be like, oh, I don't have all these answers, but we are going to make a list of all the resources that you gave us and we're going to post those so that our listeners can have them. But thank you so so much for joining us today. Well, thanks for joining us for the Engaged Midwife Podcast. We can't wait to talk to you again. Take care.