Navigating Menopause with Dr. Briana Sinatra

Dr. Briana Sinatra: There are certain things no one wants to talk about, and menopause is one of them. Yet it happens to every woman at some point in her life. Today, we're going to take a deeper dive on how you can manage the symptoms of menopause naturally, why it is more important than ever to engage in self-care during this phase of your life, and what you should expect. We'll give you all the tools you need to manage this phase of life holistically — engaging your mind, your body, and your spirit. Hi, I'm Dr. Briana Sinatra.

Dr. Drew Sinatra: And I'm Dr. Drew Sinatra, and this is Be HEALTHistic.

Narrator: Welcome to Be HEALTHistic, the podcast that's more than just health and wellness information — it's here to help you explore your options across traditional and natural medicine, so that you can make informed decisions for you and your family. This podcast illuminates the whole story about holistic health, by providing access to the expertise of Doctors Steve and Drew Sinatra, who together have decades of integrative health experience. Be HEALTHistic is powered by our friends at Healthy Directions. Now, let's join our hosts.

Dr. Drew Sinatra: Hi folks, if you like what you hear today and you want to listen to future conversations on all things integrative and holistic health, subscribe to our podcast at BeHealthisticPodcast.com. Also, check out and subscribe to the Healthy Directions YouTube channel, which features video versions of our episodes, plus extra videos you won't want to miss. And finally, we have more with me, Dr. Drew Sinatra, my dad, Dr. Steve Sinatra, and other health experts at HealthyDirections.com.

Dr. Drew Sinatra: Well, I'm so happy to have Dr. Briana Sinatra back on the show again, thanks for coming.

Dr. Briana Sinatra: Thanks so much for having me.

Dr. Drew Sinatra: We did a previous episode where we talked about the unmentionables of menopause, which included insomnia, hot flashes and night sweats. And menopause, like we talked about earlier, is an individual process — but all women will experience it, and we wanted to provide as much information as possible in understanding and managing the most prevalent symptoms in the most natural ways possible. So today we're going to do a little bit of a deeper dive into menopause, and share some clinical “pearls” and tips that we use with our own patients. Welcome back.

Dr. Briana Sinatra: Thank you.

Dr. Drew Sinatra: What are some of the main symptoms or issues that your patients share with you about menopause?

Dr. Briana Sinatra: Yeah, I think there is definitely some symptoms that are the most common, but it also depends where on a woman's menopausal transition journey she is when she comes in seeking help. So if we want to recap, there are different phases of menopause. So stage one being perimenopause, and this is usually the first stage that happens, when a woman's estrogen production starts to fluctuate. It can elevate, it can decrease, it can be going up and down — and this can last anywhere from one to seven years for a woman. And it can be in their 40s, and it's when some of those first symptoms start to show up. So she can be experiencing intermittent hot flashes, sleep disturbances, mood swings…I see as a big one. Anxiety or panic attacks might come on for a woman, where she never experienced that before. And then also symptoms of low libido and vaginal dryness can be really common and can be what bring people in.

Dr. Drew Sinatra: And I find that most women do come in during this perimenopausal phase, because those symptoms are starting to come on.

Dr. Briana Sinatra: Yep, absolutely. And then that second stage is menopause. And so menopause, we're not diagnosed “menopause” until we've actually gone 12 consecutive months without a menstrual period. And so, sometimes when women come in in that pre or perimenopausal stage, they're just skipping their periods. They don't know when it's coming, their menstrual flow might be heavier one month, lighter another month. Their bleeding could last for a lot longer, and so, there's quite a variety in what we see. But you're not typically diagnosed as menopause until it's 12 full, consecutive months without a menstrual period. And that's when your ovaries stop producing eggs, and your ovaries stop producing that estrogen that it has been for so many years prior. And so, additional symptoms of low estrogen will usually be more pronounced at that time.

Dr. Briana Sinatra: And then the third stage is the postmenopausal phase. And so that is after you've gone through more of those fluctuations, after it's been 12 months without a menstrual period — and usually by that time, estrogen production levels off. For patients…and some women are symptomatic during that time, and some aren't, it really varies from individual to individual. But it's also the time when we lose those protective benefits that estrogen has given to us for all those years prior. And so, it's a time to re-evaluate and be conscientious about our bone health, cardiovascular health, and make sure we're doing the other things in our diet and lifestyle, nutrients to support us there, as well, too. Not just looking at the hormone balance piece.

Dr. Drew Sinatra: So, it's almost like a checkpoint in a woman's life, where they come in and you're not only assessing their hormone status, but also looking at their cardiovascular health, and also their bone health, and perhaps their colon health, as well.

Dr. Briana Sinatra: Absolutely. I think it's such a wonderful opportunity — even though it might be a really distressing symptom that brings the women through the door, it's a great time to get a baseline on how she's doing on all her different systems, so we can really address her holistically. So we can support not only her distressing hormonal symptoms, but also be proactive in supporting her health now and going forward.

Dr. Drew Sinatra: Well, you mentioned some of the menopausal and perimenopausal symptoms previously. What I see for women coming in, it's this — it's usually, they feel like their brain isn't working anymore, they forget things easily, they're not as focused as they were before. Insomnia seems to be a very common symptom that develops at this time. So women come in and they say they can't fall asleep, or they wake up multiple times during the middle of the night, and there's really a pretty big sleep disturbance that's happening. Some women also gain weight during this time, and that seems to be a really big issue — and a lot of women report that vaginal dryness and low libido, or they just don't want to have sex anymore. And there's other changes that happen, as well, but I find that those are really kind of the main ones that we see. Would you agree?

Dr. Briana Sinatra: Yep, those are the big ones, for sure. And it's like, what was working for them before, maybe with their diet or their exercise, isn't enough. Especially when we're looking at that weight gain around the belly, or maybe they could have interrupted sleep before and still function the next morning. And it's like, no, it's not...they're not able to do it to the same degree, it's really impacting their quality of life.

Dr. Drew Sinatra: Another thing I just remembered, too, is really changes in mood. So women will come in and they find that they're more anxious, or they're more depressed, or they're more snappy at their partner or their kids, or they're more impatient, or there's a big change happening with their mood.

Dr. Briana Sinatra: Yeah, it's like a heightened PMS…

Dr. Drew Sinatra: Yes.

Dr. Briana Sinatra: ...that lasts way longer than you want it to!

Dr. Drew Sinatra: Now, you mentioned some of those other things, as I said, as a checkpoint — where women come in and we want to do more of a detailed check-up, in terms of how they're doing. What other things are you kind of looking at, and what other things are you addressing when looking at a hormone imbalance?

Dr. Briana Sinatra: Absolutely. So I really believe that our hormones don't function in isolation. There's so many other things that are going on around that time, and we need to check in on all of those systems and support all of those systems because the function of those systems can really make a big difference, I feel like, if someone kind of coasts through menopause or really feels it has impacted their life in a negative way. So I think it's an excellent time to look at blood sugar levels, thyroid levels, their liver and kidney health, their adrenal health is huge. All the stress that you've experienced up to that time, how has that impacted your adrenals? Because that's going to affect your sleep, that's going to affect your mood — so that is really a big one that I like to focus on. Looking ahead and getting a good baseline.

Dr. Briana Sinatra: This is also a time in a woman's life when she is doing other screenings, such as a mammogram for breast cancer, a DEXA for her bone health, a colonoscopy for her colon health. So it's a great time to look even more in-depth at all her other organs and systems. So, getting a greater baseline for her cardiovascular health — not only cholesterol levels, but inflammation markers, as well, and just see where she's at. Because it's so important to have that baseline, and it's really important to support any imbalances — looking at her iron level, making sure she's not anemic, especially if she's been having more frequent or more heavy menstrual periods. It's really important to make sure she supported — looking at her vitamin D level, considering her B vitamin levels. There's a lot there that goes into play when we're looking at hormones, mood, neurotransmitter production, and so, there's a big piece there that needs to be supported and looked at holistically.

Dr. Drew Sinatra: Well, speaking about hormones, because we are talking about perimenopause and menopause today — how do you test for hormones in your practice? And I'll share how I test for hormones in my practice.

Dr. Briana Sinatra: I think this is a really good question, and you know, we’ve both been practicing for over 10 years now. And I’ve seen this change, even through what we were taught in school, what we're hearing at conferences, what doctors who have been practicing for long before us are doing. I feel like there's so many different opinions there, and that can be from testing and the form of testing, to not testing it all. There's some people that say, okay, we're going through menopause, your ovarian production of certain hormones is declining, so we're just going to do a symptom checklist and see what your symptoms are and go based on that.

Dr. Briana Sinatra: And sometimes I think that can be realistic. We assume it's going down, and so we go based on symptoms. I always think it's important to test, and when you're looking at testing there can be different ways to test. You can test through blood, which can be helpful, although that is just a spot in time. Some of our hormones are a little more pulsatile, it might not show our free hormone levels. But it could be a good baseline, and it could be a good, affordable option for someone. There's also salivary testing, which is an option, which looks more at the hormone that has gotten into the cells that's acting at the tissue level, because you're measuring the amount of hormone in the saliva. But there are times, especially if you're on certain hormones, where those levels can be falsely elevated, for example.

Dr. Briana Sinatra: And then there's also urine tests, and so that's actually something that I've been incorporating a lot more into my practice lately. I find it really helpful, I use a test called the DUTCH test, and so that looks at urine hormone metabolites. So why I like that test is because it looks at progesterone level, it looks at estrogen levels — but in addition to just looking at your estrogen level, it looks at your estrogen urine metabolites. So it shows if you have more of a tendency to form a gentler, more protective estrogen — or more of an estrogen that can promote DNA damage, that could be more of a risk factor if you have a family history of something like breast cancer. So for me, with having a family history of breast cancer, I feel like that's important — and I want to know if your body naturally has that tendency sooner rather than later, so that we can do protective and preventative measures to support someone.

Dr. Briana Sinatra: They can show your tendency towards methylation, and what your glutathione levels might be, what some of your B vitamins might be — so I find that it gives a lot of additional helpful information. It also gives a view on what your adrenal health is like. It will look at your DHEA, it'll look at your cortisol, your free cortisol — and it does it over a day. So all of these hormones are collected over at least a 24 hour period, to really get a full picture on your hormonal health.

Dr. Drew Sinatra: And the DUTCH test is a urine test.

Dr. Briana Sinatra: It is a urine test.

Dr. Drew Sinatra: Okay. Well while we're on the subject of hormone testing, not all woman out there will have availability of testing, whether it is the blood, or the urine, or saliva, for that matter. So I think, and you said this earlier, it is really important that we do a checklist. We run through lots of different symptoms that someone is experiencing, and I always like to have a baseline possible for doing some hormone testing, which I'll talk about in a moment. But in these years of the menopausal and perimenopausal years, I believe it's okay to, sometimes, because if testing is not available, to still support a woman through this phase and to treat her without having testing. I want our listeners to know that, because sometimes you may not have availability to testing.

Dr. Drew Sinatra: In my practice, I work with another medical doctor and I work with another naturopathic doctor who have decades of hormone-prescribing. And so over the years, they've fallen into more of the blood testing, and that's what we do at our clinic. So we do a blood test for women looking at the estradiol, progesterone, DHEA, pregnenolone, sex hormone binding globulin. And of course we'll run all the other hormones, as well, like thyroid. And I find that that's a good baseline, and a lot of people do have insurance that may cover it, if you go to LabCorp or Quest or wherever you get your blood drawn, so that's a good thing. And I do like to have a baseline…but like I said, if testing isn't available, I'll still go ahead and support women.

Dr. Briana Sinatra: Yeah, absolutely…I think it's always good to have a conversation with your practitioner, right? Here are the different testing…here when we're treating, here are our different options — we can test, we can not test, here are the different testing methods available, here are the pros and maybe the shortcomings of different testing options. And I think it depends on so many things — it depends where someone is in their menopausal transition, it depends on the severity of their symptoms, it depends on if they are on hormones or not, and the best way to monitor that for them. So I think it's all about having a conversation with your care practitioner. I think it also might depend on their comfort level and what they've done for years, and that experience has a weight to it that is important. If they've really seen a benefit by treating a certain way, or testing a certain way, then that's great. And if that does not give you the full picture, knowing that there are other ways to look can be helpful.

Dr. Drew Sinatra: And since we've talked about testing and different symptoms that women may experience, let's kind of dive into treatment here — and we'll talk about natural versus conventional treatments. Where do you like to begin? Where do you like to start off with people?

Dr. Briana Sinatra: Well, we just finished talking about testing, but we also talked about testing not only hormones, but all the other aspects of someone's health. So their adrenals, their thyroid, maybe looking at their iron, their vitamin D. So I think it's always important to look holistically and to support all of those aspects, if anything is out of balance — blood sugar, inflammation, I think that's really important. And I feel like the first place to start is always with diet and lifestyle.

Dr. Drew Sinatra: Absolutely.

Dr. Briana Sinatra: I think making sure that when people are eating, the majority of their food is food that's really going to provide beneficial nutrition and nutrients, and that it's going to help balance their blood sugar and support all their different systems. Because when our hormonal system is going through a huge change, we want to keep all of our other systems as balanced as possible, so that everything isn't in flux all at once.

Dr. Drew Sinatra: Yeah, I couldn't agree more, because you can have a woman come in and it's easy just to put her on hormones, for example, right? Or some herbs that kind of support her through a lot of these menopausal and perimenopausal symptoms. But really, when you address the other systems together — so if that's thyroid, if that's adrenal, whatever it is — those are all going to help prop up the system better, and someone's going to feel so much better with all those treatments.

Dr. Briana Sinatra: Absolutely, they're going to feel so much better now, and also going forward. Like I said, it's this amazing opportunity to take a deep dive and do a baseline, not only for your health now, but for really supporting you going forward, too.

Dr. Drew Sinatra: And then, so what else do you recommend in terms of natural treatments? What else do you like to start off with? So we talked about diet, right? What about lifestyle things?

Dr. Briana Sinatra: Absolutely. So like we've mentioned before in other podcasts, our estrogen and progesterone is protective for our stress response, or the cortisol that’s secreted within our system. The estrogen and progesterone kind of mitigate that cortisol response — so as our estrogen and progesterone are going down and maybe our stress level is still higher, we're not sleeping as much, and our stress level is elevated in the middle of the night and waking us up, we have less of a buffer. So we're so much more acutely sensitive to that stress response, and when our cortisol is elevated, that can affect our insulin levels, too. And so, maybe we're eating the same amount as we used to before, but our body is holding onto that glucose and storing it, and we are getting more weight on our body, we're getting more stubborn abdominal weight. And so, it is always so important to address our adrenals and our stress level in ways that help to reduce it.

Dr. Briana Sinatra: So things that I think are so important to talk about are, like, self-care. That common saying of, “Saying no to someone else is really saying yes to yourself.” I think there's so many times when that can come up, whether it's at work or responsibilities within the family, or other commitments. I think now more than ever, it's a time when a woman really not, you always have the right, but it's like, no, this is important. You need to prioritize yourself, so that you can continue not only having a positive outlook for your health going forward, but if you are still supporting family members and wanting to be there, you can only support them as much as you can be a strength and support for yourself. So really choosing the things that you need to do to give you more of a sense of calm — going for a walk, taking a bubble bath, doing a yoga class, reading a book, knitting — whatever that might be that's kind of a self-care. Getting a massage…all of that is so important.

Dr. Drew Sinatra: Yeah, I couldn't agree more about the self-care. Earlier you mentioned adrenals — how else do you like to support the adrenal glands? Is there any botanical medicine or herbs that you like?

Dr. Briana Sinatra: Yeah, so it kind of depends how a woman is manifesting with her stress and her energy level. There's different herbs, and the herbs are really like food, right, that help to nourish our adrenal glands. And so, if a woman is in more of a high-strung, anxiety, maybe panicky state, you can still support her adrenals, but you can use more calming herbs like ashwagandha, magnolia, vitamin B5, magnesium. Things that will also help with her sleep, and also just help calm that stress reaction, while still nourishing and building up her adrenals.

Dr. Briana Sinatra: And if someone is in more of that exhausted adrenal phase, where they just have the brain fog, and they just can't get up in the morning, or they're getting tired in the afternoon…of course, we're also looking at thyroid, but anytime we're supporting thyroid, we also want to support the adrenals. And so maybe some more uplifting herbs would be helpful — maybe more of a ginseng, or a rhodiola. Maca is a great adrenal-supportive herbs that also helps to balance the adrenals, so it can be very helpful during that perimenopausal phase when the hormones are in flux. And it can also be really helpful in the menopausal years, because it not only supports estrogen, but it supports testosterone levels and progesterone levels, and it can really improve a lot of the symptoms of menopause.

Dr. Drew Sinatra: Yeah, I agree that maca is one of these herbs that is so good for not only the adrenal glands, but also supporting hormone production.

Dr. Briana Sinatra: Yeah.

Dr. Drew Sinatra: Mm-hmm.

Dr. Briana Sinatra: Oh, another thing I was going to say, and I just kind of remembered this, is when we're talking about food — food to nourish, food to balance blood sugar — but also foods that I've seen help support the hormonal system, are phytoestrogens.

Dr. Drew Sinatra: Mm-hmm.

Dr. Briana Sinatra: So phytoestrogens are foods that have a component that can either in high estrogen states, they can bind to our estrogen receptors and displace maybe our stronger-acting estrogen, so it can have an overall estrogen-lowering effect. Or, in low-estrogen states, like in menopause, it can bind gently to our estrogen receptors and have more of an estrogen-like effect. So they can actually be helpful in high- and low-estrogen states, and this is what makes it really nice during the perimenopausal stage, when our hormones are in flux and are maybe going up and down. So something as simple as flax seeds, you're having the good fiber, it's helping to balance your blood sugar, it's great for your colon health — but it's also providing good, essential fatty acids and it can be really helpful as a phytoestrogen for supporting our hormonal system.

Dr. Drew Sinatra: So, do you recommend that women just take a tablespoon or two of flax seeds, freshly grind it up, and drink it with some alternate milk — like an almond milk or an oat milk, or something like that?

Dr. Briana Sinatra: Yeah, absolutely. They can have it in a smoothie, they can blend it with water, probably some almond milk or something like that can be a little more palatable. They can grind it fresh and put it over steamed veggies, they can add it to a salad. There's a lot of different options. So actually, Dr. Christiane Northrup wrote a really good book, Women's Bodies, Women's Wisdom, and in that she talked about seed and oil cycling. So this I often present to the patient, and if she's excited about it, then it's something that we talk in a little bit more detail about. But some women are totally keen to do this, because it is a great way to introduce beneficial seeds to the diet, and it's something that they can easily start incorporating.

Dr. Briana Sinatra: And when we're talking about phytoestrogens, we can also talk about something like soy. And there's so many different opinions on soy…soy's not something that we have a lot in our household. And there's mixed reviews, people are worried about the breast cancer risk. And so, I think this is always a conversation to have with your healthcare provider, based on your specific symptoms and your goals.

Dr. Briana Sinatra: But having soy, I think, in moderation, if it is in a whole food form — like edamame, or a fermented form, like tempe or miso — as long as it's not genetically-modified, if it's organic, can be a helpful addition for some women. Even having a clean soy isoflavone form, for some women, especially if they're a vegetarian, it can be beneficial. So I think it's always worth that conversation. When soy becomes more of a concern for me, I feel like it's when women are having multiple servings of soy from many different forms throughout the day, and it's more of the highly-processed, meat-alternative types that they're relying on.

Dr. Drew Sinatra: Right.

Dr. Briana Sinatra: So those were some of the food forms, where we can really support someone and their hormones. There's herbal options that we talked about, and that we talked a little bit more in our previous podcast. And then there's the question of hormones. So what's your take here on hormones, what do you do?

Dr. Drew Sinatra: Yeah, you know, I always learned this from my dad and other docs, as well — but this is really a quality of life thing, where women come in and they are feeling very uncomfortable. They don't feel good in their bodies, these hot flashes are keeping them up at night where they can't sleep. They feel like their mood is on a roller coaster ride. They're gaining weight, and they might feel even achy in their joints and muscles…they just don't feel well. And when that happens, and I see a lot of women, actually, for hormone replacement therapy — I'd say 20% of my practice, at least, is from women coming in wanting to be on hormones.

Dr. Drew Sinatra: And symptomatically they're showing signs of perimenopause, I'll verify that via labs, like I mentioned earlier, I'll run some blood work on them to look at all their hormones. And if all things are kind of in alignment, where we've had a discussion about hormone replacement therapy, the pros of it, the cons of it, they're showing signs and symptoms, and their labs are showing that they're deficient in certain hormones — like estrogen, or progesterone, or DHEA, or testosterone — then I'll put them on bioidentical hormones. And to answer your question, they are very effective, I do believe overall that they are safe. There's certainly some conditions that I would not put someone on bioidentical hormone placement therapy. For example, a patient has a past family history or they've got a personal history of breast cancer — I'm not going to prescribe estradiol to that person. But I always run through a checklist in my head of, "Okay, what are these? These are the risk factors, and this is where I should be sort of concerned about."

Dr. Drew Sinatra: And I will tell the audience this, I really believe that hormones can be a game-changer for women, they really can be. I've seen women come in that are just distraught in their life, they just can't function anymore. They feel like their brain is not working, and once we put them on hormones — within, I'd say even four or five days, sometimes a week, two weeks, they feel like a new person. And I love that when they come back in saying, "Thank you, I now have my life back.” And I'm not just doing hormones, of course, I'm doing all this stuff that you and I talked about previously, with healthy diet, and making sure they're reducing stress in their life, and maybe we're including some phytoestrogens, or some herbs to kind of support the hormones and such. But adding on that layer of the hormones, I find, is very effective and at this point in my career, I definitely recommend it a lot.

Dr. Briana Sinatra: Yeah, I think that's great, and I think that's so important. I've definitely had those patients who come in and their anxiety is just so high. It's kind of at the point of, do we consider an antidepressant, or do we give hormones a try and see if that could help. Not only with the other symptoms that are going on, but with this new onset anxiety, or some other emotional things that are going on. How best can we support you?

Dr. Drew Sinatra: I had a patient come in two weeks ago with depression. And I'd seen her about four or five months earlier, and she came in and wanting a prescription for Zoloft, because she'd been on Zoloft before and she felt better on it, in terms of her mood. Now I looked at her age, I went through a symptom checklist and I said, "You know what, instead of me prescribing Zoloft to you, how about we do some hormone replacement therapy?" So I put her on an estrogen patch, which is more of my preferred way to deliver estrogen, and I also put her on some progesterone at night, in a pill form. And she wrote me back over the portal, I think it was around four or five days later, and she said, "Oh my God, thank you for prescribing those instead of Zoloft, because now I feel like a new person and I don't need to go on an antidepressant."

Dr. Drew Sinatra: So sometimes it's so important to even look at this person holistically, and yes, they may be coming in with depression or anxiety, but in my opinion, that's not a neurotransmitter deficiency. They're not serotonin-deficient, they're likely hormone-deficient — and giving them hormones is really what the body needed.

Dr. Briana Sinatra: Yes, I love that, I think it's so important. And you talked about the patch and oral progesterone, and I think that's another thing that can be overwhelming for our listeners. There's so many different forms of hormone, not just conventional versus bioidentical, but there's so many different forms out there — from patches, to creams, to oral, to troches that dissolve in our mouth, to injections, pellets, even…there's so much out there. So, that's a whole other thing.

Dr. Drew Sinatra: Well, this comes down to the personalized medicine piece, where I've had so many women come in where I've given them Vivelle-Dot, which is the common estrogen patch that I give them. Some it works really well for, and then others, they go for the generic estradiol patch, and that one seems to work better. Even though it's the exact same medicine, essentially, that's being delivered into their bloodstream, the patch itself, the adhesion on there, is different. And so it's little nuances like that that really can change things up. I find, too, that women that have trouble sleeping at night, I like using the progesterone pill because it has more of a sedating quality, and it can actually work on GABA receptors that way.

Dr. Drew Sinatra: And then with testosterone, a lot of women think, "Oh gosh, I don't need testosterone.” But I find that giving women a small amount of testosterone can be pretty helpful, in terms of helping with their fatigue, or their brain dysfunction, or something just doesn't feel right in their body, I like to add on testosterone — particularly if their testosterone level is lower. And again, I've had women come in where pellets was the only way versus a cream. And so, pellets versus cream — it's a matter of trial and error sometimes with hormones, to figure out what is really needed for this person and what's going to work best.

Dr. Briana Sinatra: Yeah, it sounds like having that conversation with your doctor, what the easiest form for you is going to be, maybe what the best form for you based on your individual metabolism is going to be. There's so many different factors, and it's so great to know that there's so many different options out there — so that if you try one and it doesn't seem to work for you, there's another option you can try. Don't lose hope, just have a conversation with your care practitioner, and kind of go through and find the right combination for you.

Dr. Drew Sinatra: And we didn't even mention dose, right? Looking at Vivelle-Dot or the estrogen patch, there's four different doses that you can start off with. I tend to start off with either like the 0.025 milligram dose, or the 0.0375 dose. And I find that starting off with the lower doses tends to be more the approach that I take, so that we can titrate up, if needed. But oftentimes the lowest dose really isn’t enough, but we jump up to the 0.0375, and then maybe we jump up to the 0.05, and that's the money dose for that woman, and she feels really good on it. So it's a matter of delivery methods being different, the dose being different…so many things can kind of play here, and it's sometimes a matter of trial and error.

Dr. Briana Sinatra: Absolutely, and I think that's true with most medications, right? Even blood pressure medication — we were always taught when you're using a pharmaceutical, there's the standard starting dose, but everyone is unique and individual. And so I think you are really playing it the safest when you start low, and go slow and kind of titrate up, and find that ideal spot for someone. Because someone might need a higher dose, but if you start at a higher dose for everyone, that might be way more. So you could really miss a good, therapeutic, lower level if you don't, based on your clinical experience, based on their levels, based on the severity of your symptoms. There's a lot that goes into deciding the right level for you, and it's very individualized.

Dr. Drew Sinatra: Couldn't agree more.

Dr. Briana Sinatra: So we talked about a few different forms of hormones, and you mentioned pellets. For our listeners that might not be as familiar with what pellets are, what is that?

Dr. Drew Sinatra: Right. The pellets, these are a form of hormone delivery, and these pellets are actually inserted underneath the skin. They're about the size of a rice granule, and they may contain estrogen or testosterone, and…we don't personally do them, I don't personally insert these, but I do know other doctors that do. And for some patients they find that they're convenient, because you don't need to change them out every week or every month, but they can actually go for many, many, many months — up to six months, actually. And there's the convenience factor, where you don't have to apply a cream, or a patch, or take an oral pill every single day, or once a week, or twice a week. But you can just have these pellets inserted and not worry about it.

Dr. Briana Sinatra: Okay. And then there's also the troches that we mentioned, which can be formulated at different doses into a lozenge, which are not swallowed. So unlike an oral pill, which you would swallow, which will get metabolized by your liver and then leave a certain amount of that hormone available to act in your circulation, the troche is going to be absorbed through your buccal or cheek mucosa, or under your tongue, and absorbed directly into your bloodstream that way, without going through that first pass metabolism from your liver.

Dr. Briana Sinatra: So there's lots of different things…from compounding pharmacists, from pharmaceutical companies, there's a lot out there. So I think it's a great time even just to have a sit-down with your healthcare provider and say, "Okay, what are the options that are available to me? What are the pros and cons of each?" And then discussing your specific situation and what's right for you. And what's right for you might change throughout that menopausal transition for you.

Dr. Drew Sinatra: That's a great point.

Dr. Briana Sinatra: So maybe when your hormones are fluctuating initially, progesterone by itself could be helpful. And then as your estrogen level declines and gets lower, then adding on an estrogen in the menopausal years with the progesterone could be helpful. So it really depends where you're at.

Dr. Drew Sinatra: And I wanted to bring up, too, because I mentioned it in beginning of the podcast that oftentimes lab testing is not available. Now, what happens when someone comes in, and they are so symptomatic where they can't even be in their body and feel comfortable. I've had so many women come in where they feel like they're losing their mind, they're so anxious, they haven't slept in weeks, they have gained weight, their body is changing so quickly, hot flashes are just making them so miserable. And they'll say, "Doc, please just put me on something immediately."

Dr. Drew Sinatra: I, of course, like to run labs — but in the meantime, if they're really symptomatic and they're fitting all the signs and symptoms, I will prescribe some bioidentical hormones immediately, off the bat, just so that they can get some relief over the next four to five day period while the labs are processing and are ready. And then, of course, once the labs come back I may adjust the dose depending on what I find via the labs. But generally speaking, if women are really symptomatic and they need help ASAP, I'll put them on hormones immediately.

Dr. Briana Sinatra: Yeah, absolutely. I think some other things that might be overlooked, but we don't want to overlook because it's essentially important, is hydration, right? If we are having night sweats and hot flashes, making sure that we're well-hydrated is important. Also, exercise is so important. There's actually good research to show that exercise…because hot flashes are kind of this thermogenic, self-regulatory issue going on with the decrease in estrogen and progesterone, exercise can actually help improve the hot flashes, as well, symptomatically for someone. Plus, exercise has many other fabulous benefits, from stress reduction to cardiovascular health, all of that. So exercise is always an important thing to consider.

Dr. Drew Sinatra: Yeah. I think of exercise as being medicine.

Dr. Briana Sinatra: Right.

Dr. Drew Sinatra: In situations like this, it's absolutely essential that during these perimenopausal and menopausal years that women exercise.

Dr. Briana Sinatra: Yep, increasing circulation, helping with fatigue, clarity of mind. There's so many different aspects that exercise can really make a big, positive impact on.

Dr. Briana Sinatra: Additionally, checking in with yourself and your system, and being mindful of things like alcohol, caffeine, smoking, of course, is not a great thing — but being mindful of all those other things that we do, that we might be consuming, that can also have a negative impact on our sleep, on our stress response, our adrenals, on our liver — and really giving our body some TLC by being mindful of those things.

Dr. Drew Sinatra: Well, as we wrap up today's show, we wanted to leave you with some key takeaways. Uncomfortable symptoms due to changes in hormone levels may be what take you in to see your doctor, but also, use this time as an opportunity to address all aspects of your health, to increase your quality of life in your menopausal years.

Dr. Briana Sinatra: There are many ways to evaluate your hormone levels, and many ways to treat menopausal symptoms. This can range from diet and lifestyle modifications, to something as simple as remembering to dress in layers. It can also include natural supplements, and even hormone replacement therapy.

Dr. Drew Sinatra: The key is to find a practitioner who will listen to your goals and concerns, and who'll work with you to treat you the way that you want to be treated.

Dr. Briana Sinatra: Before we wrap up this episode of Be HEALTHistic it's time to share our Wellness Wisdom for today. You've probably heard a lot about soy for menopause, and different opinions of whether it's good or whether it's bad. Personally, if you tolerate it digestively, we don't think that soy is evil. It's a phytoestrogen and can be really helpful for managing menopausal symptoms. If you do choose to eat soy, we prefer that people choose organic, non-GMO options — and our preference is to have them eat more of the whole soy form, such as edamame, roasted soy nuts — or the fermented forms, such as tempe or miso. We like our patients to minimize their consumption of more of the highly-processed, refined soy, like the kind you would find in imitation meat products.

Dr. Drew Sinatra: That's our show for today, folks. If you have a question or an idea for a show topic, please send us an email or share a post with us on Facebook. And remember, if you like what you heard today and you want to be an active member of the Be HEALTHistic community, subscribe to our podcast at BeHEALTHisticPodcast.com, or on Apple podcasts, or wherever you download your favorites. You can also find more great content and information from us and the Healthy Directions team at HealthyDirections.com.

Dr. Drew Sinatra: Thanks for listening, I'm Dr. Drew Sinatra.

Dr. Briana Sinatra: I'm Dr. Briana Sinatra.

Dr. Drew Sinatra: And this is Be HEALTHistic.

Narrator: Thanks for listening to Be HEALTHistic with Doctors Drew and Steve Sinatra, powered by our friends at Healthy Directions. See you next time.