Menopause Matters: A Hormonal Health & Aging Chat, With Dr. Felice Gersh

On Wednesday, January 15th, 2025, FMCA hosted an engaging webinar featuring Dr. Felice Gersh, a globally recognized expert in women’s health, and FMCA founder Dr. Sandra Scheinbaum. Together, they explored the complexities of menopause, hormonal health, and how health coaches can support clients during this transformative life stage.

This must-watch session covered:

• The Physiological Changes of Menopause and how they impact overall health.
• Insights on Hormone Replacement Therapy and other evidence-based treatments.
• Lifestyle Strategies to empower clients in managing their hormonal health.
• The Role of Health Coaches in guiding clients with empathy and expertise.

The discussion also included a LIVE Q&A with Dr. Gersh, where attendees posed their most pressing questions about menopause and aging.

Whether you’re a health coach looking to expand your knowledge or simply interested in learning more about women’s health, this replay offers practical insights and actionable strategies

We don’t have to wait until that arbitrary definition of menopause to start giving hormones and starting all of our lifestyle measures aggressively, because we can really see on a menstrual mapping how the hormone levels are really changing and not for the good.

Dr. Felice Gersh

About the Speakers

• Dr. Sandra Scheinbaum is a pioneer in functional medicine and health coaching, with nearly five decades of experience in healthcare and education.
• Dr. Felice Gersh is a dual board-certified OB-GYN and integrative medicine physician, bestselling author, and internationally acclaimed women’s health expert.

Don’t miss this opportunity to deepen your understanding of menopause and the powerful role of health coaches in promoting healthy aging.

Watch the Replay

Menopause Matters: A Hormonal Health & Aging Chat, With Dr. Felice Gersh

More Resources On Menopause & Hormonal Health

Lifelong learners are a pillar of the FMCA community! If you’d like to explore this and similar topics further, here some additional resources you may want to browse.

• The Truth About Hormone Replacement Therapy, With Dr. Felice Gersh [Podcast Episode]
• Hormones as Communicators with Dr. Deanna Minich [Webinar Replay]
• The Romance Prescription: Exploring Love, Fertility and Preconception Health, with Dr. Kalea Wattles [Webinar Replay]
• Food is Medicine: Why What You Eat Really Matters [Article]
• Mastering Circadian Rhythms, With Dr. Deanna Minich [Podcast Episode]
• The Gut Microbiome: Uncovering Secrets to Enhanced Health and Wellness [Webinar Replay]

Transcript

Dr. Sandi: So, I could not be more excited to be with not only my esteemed colleague but a very special friend. We have gotten to know each other at many events over the years, and we just have a very special relationship. So, I want to welcome Dr. Felice Gersh. She has an amazing background. She is a world renowned lecturer, writer, speaker, and she is dual board certified in integrative medicine and as an OB/GYN. And I’m going to turn it over to Dr. Felice Gersh, again, to tell you more about her background. And then we will get started with our talk today.

Dr. Felice: Well, I’m thrilled to be here, invited to be on your wonderful podcast. And so I am a practicing OB/GYN. I take care of women at all stages of life. I have a practice called the Integrative Medical Group of Irvine in Orange County, California. And in addition to seeing patients all day long, I’m actually in a converted exam room as we speak. I also love to lecture. I tour speaking at conferences nationally, internationally. I’ve written three bestselling books, two on polycystic ovary syndrome and one on menopause. I write articles that get published in peer reviewed medical journals. And I love being on your podcast so that I can help to educate both medical professionals and the lay public wherever they are to really optimize their health.

Dr. Sandi: So, let’s start out by talking about just in general terms about menopause. And remember I’m old. I’m turning 75. And so I remember my mother now many years ago, and I would hear her talk on the phone with her sisters, with her friends about, “Oh, somebody’s going through the change.” And that’s what they talked about. We’re going through the change. And from what I thought, and I know what she thought as well, was you just stop having your period. You can’t have babies anymore. And maybe you get some hot flashes. And that was it. I had no notion of hormones.

And so can you start by just talking about what are the key hormonal changes that are happening during this stage? And even before, perimenopause, I didn’t know anything about perimenopause when I was going through it. Not even a word that I remember being discussed, and I was in healthcare. I was a psychologist.

Dr. Felice: Well, you think that’s bad. I was trained as an OB/GYN, and I didn’t get trained in any of that either. In fact, I was trained like all…and unfortunately still ongoing OB/GYNs in the reproductive aspects of female hormones, and that menopause was really looked at as the loss of fertility, which of course it is.

But the way nature puts it together, puts us females together, is that it’s intricately connected, having both fertility, reproductive capability, and having our hormones, those amazing hormones that females all must have in order to be optimally healthy. Estradiol, the estrogen made by the ovaries and progesterone. Now, testosterone is also in there, but we’ll touch on that maybe later because you don’t need any eggs to make testosterone, and the ovaries do make testosterone for the entire life of the woman as long as she has her ovaries in.

So, now we understand or we should really grasp the concept that these hormones are the hormones of life. They’re not just about making periods and about making babies, which is huge. And in fact, that’s what I always say, the prime directive of life in every organism and every species, everything that’s living is the creation of new life. And to that end, you need to have a healthy body. You need to have a really robust cardiovascular system, musculoskeletal system, genitourinary, neurological, you name it. Everything in the body has to be working in the same time zone and working optimally to have optimal fertility and reproductive success.

So, those hormones that are involved in reproduction and menstrual cycles are about everything. That’s the takeaway. It’s about optimizing total body health. There are hormone receptors for estradiol, for progesterone in every single organ. And so nature has to have us have the change of life and have this process of ovarian aging.

And that’s really what menopause is. We have to just accept that the word menopause is a made-up word. It’s a made-up criteria of diagnostic. You have no period, no bleeding for 12 months. Why is it 12 months? Because we love that number, 12, because there are 12 months. But it could be 15 months. It could be 11 months. It could be seven. It’s whatever, because that is not what menopause is about.

The change of life actually was a much better term that your mom used, that our moms used, because it’s really about ovarian aging and the loss of hormonal production in an optimal way. So, you go through this perimenopause where the hormones are very unpredictable. I guess nature just wants to make an extra exclamation point that menopause is a huge change in a woman’s body. And it’s not just about loss of fertility. It’s about loss of optimization of every organ system. And it’s a process that goes on over many years. And then, of course, it becomes the rest of your life, which for many women is literally half their lives is spent as a post-menopausal woman.

So, you lose the ability of the ovary to produce properly and then at all, estradiol, the estrogen of life itself. That’s the main dominant estrogen of the reproductive age woman, and progesterone, also known as P with a number four, the amazing hormone that is optimal in young reproductive women who are healthy. And when we lose it, it’s often not recognized as also another vital hormone. Progesterone is, sort of, like the underdog. And estrogen needs more emphasis in terms of what it does. And progesterone is often forgotten altogether. And that has its own vital role in the female cycle of life and health.

So, there’s so much to talk about. But I guess everyone should take away instantly that menopause is a word that doesn’t really at all encompass what is happening. It’s a huge dramatic shift in the production of these hormones, which affects literally every organ system.

Dr. Sandi: That was such a wonderful explanation. Can you talk about the connection between menopause and overall metabolic health?

Dr. Felice: Absolutely. So, I love the word metabolism, but most people throw it around and don’t really think about what it means. So, it’s the production, utilization, storage, distribution of energy—the essential spark of life. And it’s really critical to have an optimal state of metabolism. And that involves the intake of energy, also known as eating food, with output like the expenditure of energy. And that’s a really critical thing, which many people are not doing very well these days because they may intake too much food and then they don’t burn, you know, and create the energy utilization, and then they end up storing it as fat. And so, that’s a huge problem.

And it’s really critical that you intake the amount of energy to create proper amounts of storage of fat. So, you have the right amount of storage fat. That’s really important. And then you also have the right amount of energy that you take in that you can utilize on a day-to-day basis. And this is a critical management system that estradiol is really the key player in. In order to be healthy, you have to have proper regulation of appetite. You have to have proper regulation of what burns energy, which are your mitochondria.

So, a lot of people don’t realize how critically important estradiol is for mitochondrial function. So, mitochondria are involved in so many critical functions, creation of energy and the cell cycle, controlling when cells die, like what they call senescent cells or zombie cells. And we want to get rid of those cells because that’s why people talk about senolytics. Well, estradiol is a senolytic. It controls that cell cycle so that when cells get old and yucky and they need to die, they will die. The body will trigger programmed cell suicide. Estradiol is critical for that to happen.

And when you need to have cells rejuvenate, like say you’re not eating enough and your cells need to rehab, that’s called autophagy. And estradiol is critical for triggering proper autophagy. And mitophagy, having mitochondrial rejuvenation, the enzymes to create energy in mitochondria and for maintaining mitochondrial health by working through the enzyme system, manganese superoxide dismutase that maintains the optimal health of mitochondria by transforming the toxic metabolic byproduct of energy creation called superoxide into hydrogen peroxide, which can then… because superoxide can’t get out of the mitochondria but hydrogen peroxide can. And then it gets transformed in the cell to harmless water.

But if you don’t have enough estradiol, your mitochondria will become damaged and you’ll have fewer of them and less functional. So, you won’t be able to burn fat. So, after menopause and, in the process, women have appetite dysregulation. They often always feel hungry. They’re not sure when they should eat, when they shouldn’t eat. And they’re so very dysregulated.

The master clock that sits atop the optic nerve that controls all of our time functions, like our clock genes and having all the organs work in the same time zone, is regulated as well by estradiol. So, when women go through this process into menopause, their metabolism is dramatically changed. They become circadian rhythm dysfunction like they’re living jet lag, like they’re always in jet lag, which increases metabolic dysfunction such as diabetes and depression, which is often inflammation in the brain. They become more inflamed.

And so you end up having bad metabolism and you accumulate fat, but you can’t burn fat. You have fatigue. And so every system involving metabolism is harmed by loss of estradiol. And this is huge. That’s why I’m so excited that you brought up metabolism, because without having a healthy metabolism, appetite regulation, and proper energy creation and burning of our fuels, our glucose… And in terms of glucose, the glucose transport system is regulated by estradiol called the GLUT, the GLUT4s. And glucose is the prime energy source for the brain.

So, that’s why a lot of times when people have dementia, that they have Alzheimer’s, they say put them on a keto diet. Now, why would they say that? Because the glucose transport system is so damaged, it doesn’t work. And the brain can’t get the glucose into the cells to use as an energy source. Well, in the peripheral cells of the body, the glucose isn’t transported properly either. So, the response is to make more insulin. So, you have all that insulin, and insulin also independently promotes the production and storage of fat. So, you can see this is a triple whammy. You can’t burn fat, you end up storing fat, you have too much insulin. And when you don’t have enough estradiol, it affects the gut microbiome.

This has been good published data that every woman as she goes through menopause without having adequate hormones will get leaky gut. And then that leads to more systemic inflammation when you have the toxins in the gut leaking between the cells, creating that endotoxemia of a certain degree, a chronic level of toxins coming into the body, also known as lipopolysaccharides. And that triggers a systemic body-wide inflammation, which then creates even more havoc because chronic low-level, unrelenting inflammation underlies so many of the chronic diseases associated with aging. So, it’s complex, yes, but the fundamentals are estradiol controls metabolism, which is essential for life and optimal health for every single organ system.

Dr. Sandi: So well said. And what you have talked about here is the basics of a functional medicine approach. It’s systems biology. We can’t just look at female hormones in isolation. And if you are wanting to or if you are a functional medicine health coach, these are the things that you will be learning about so that you can educate your clients.

And so we do start with diet and lifestyle first. That’s a big part of functional medicine. So, what would you say would be key in terms of some of the highlights in terms of nutrition and exercise for managing this menopausal transition and post-menopause and stress as well? So, those lifestyle factors, how critical are they?

Dr. Felice: They are absolutely critical. And I prescribe a lot of hormones. Now, of course, health coaches don’t prescribe hormones. And everyone needs the health coach in their life. I can tell you that because hormones, I always say, foundational, essential but not sufficient, because even the best hormone prescriber isn’t going to give you hormones that are even vaguely close. I mean, they’re similar but not like having a new set of 21-year-old ovaries. That’s impossible. So, by foundationally understanding the profound metabolic changes, we can use lifestyle. I call it the backdoor rescue to really help the body to get through all these years, maybe 50 years or more of life spent in the menopause.

So, one thing, okay, you recognize that there’s jet lag, essentially, circadian rhythm dysfunction. So, what can we do? We can work to optimize sleep hygiene and sleep environments, okay? So, sleep is essential, and I’m not going to give a lecture here on sleep. I know you all know how important sleep is. And women who are in menopause and transitioning have universally altered sleep habits in terms of they feel often more energized because their sleep is disturbed, and they often will have cortisol high at night when it should be low, you know, because they’re actually in a flip circadian, kind of, a state.

So, you can do everything you can to use mind-body practices, meditation, guided imagery, progressive relaxation, tapping, all the skills that you can use to increase vagal tone. You know, you can do laughter yoga, so many things. You want to try to get that cortisol down and then bring on the melatonin, watching the sunset, you know, taking a hot bath or shower before bed, you know, listening to soft relaxing music, all the things that lifestyle has to offer to help promote proper sleep environments, like make the room really dark or use a sleep mask. So, everything that you do as a health coach to promote optimal sleep is critical.

Then when you know that you have appetite dysregulation and that you’re not sure when you should eat, not eat because your cues are all messed up, then you can help people to have, sort of, a more regimented diet and to increase your own natural GLP-1. You know these drugs that are out there, I don’t have to tell you, you know, and they’re so super popular. Well, guess what? You can increase your own natural GLP-1 that helps to control appetite, not just estrogen. Estrogen does help with GLP-1. But what about fiber? What about exercise and sleep reduction and all the things to remove toxic food that’s going to damage and then give you more leaky gut? So, you can optimize through exercise, through fiber intake. You can actually do tremendous amounts to increase GLP-1 and regulate appetite. You can do time-restricted eating.

Well, you try to eat most of your food in the morning because I told you there’s insulin resistance, there’s inflammation, improper glucose transport. Well, naturally, insulin works better in the first half of the day. So, you can work to encourage more food intake in the first half of the day and less at night. And because there’s alterations as well in the neurological system, you can tell people don’t eat too close to bedtime because they’re going to get more reflux that dramatically increases in menopause. So, timed eating, time-restricted eating, and then, of course, trying not to snack all day because every time people snack, they’re going to raise their insulin and their glucose. And that’s not going to be good for maintaining an optimal weight. So, you can do all the things with diet.

And we have these amazing foods that nature gave us. I call them nature’s gift to women. Phytoestrogen foods. So, they are amazing, and they are the source of so many of the polyphenols that are so popular used as supplements, which, by the way, are also very good. So, there are supplements like berberine that can be very helpful, quercetin that can be anti-inflammatory, curcumin products. So, there are many natural supplements derived from plants that can really help reduce inflammation. They can really help in many ways with glucose regulation, appetite regulation, and gut microbiome control because everyone needs to have some sort of a gut liver reset. We call it a reset in my practice. Some people call it a detox. But you’ve got to work because fatty liver, now called hepatic metabolic steatosis, is like super prevalent in postmenopausal women. So, you have so much that you can do to improve the gut microbiome, which is phenomenal.

And I didn’t mention, but I think you all know, that stress is very prevalent because the autonomic nervous system, which is so critical for regulating everything that we don’t think about, is dysregulated in perimenopause and menopause. And the vagal tone goes down. And you have too much sympathetic overload. So, once again, not just for sleep, but for all the different times of the day when women are feeling stressed, you can use your mind-body practices. And wonderful natural calmative herbs like bacopa, like holy basil, tulsi, like ashwagandha, Chinese skullcap. So, learning about the different herbs that can be super great for helping to lower sympathetic output, increase vagal tone. So, these are also phenomenal.

And when you talk about the phytoestrogens, basically, every plant group and even legumes, so you have the still beans that come, like that’s what resveratrol is. And that’s a phytoestrogen, like from red grapes. And then quercetin, which I mentioned, is also…and that’s from apples and onions and garlic. And then you have the isoflavones from beans and legumes. Of course, soy is famous for that. So, there’s so many. And then you have the lignans. Those are phytoestrogens that come from seeds. The famous one is flaxseeds. And so all of these are amazing.

And by the way, there are certain things that you can do by adding lots of antioxidants and phytoestrogens that, in perimenopausal women, may actually extend the lifespan, the function of the ovaries for even a few months, which actually is statistically significant in the overall health of the woman. And even a few extra months of having normal ovarian function can delay the onset of bone loss and other degenerative diseases by years. So, the payback is huge by emphasizing having these wonderful lifestyle habits that can actually help to prolong ovarian function in perimenopausal women.

Dr. Sandi: Wow, that is fascinating. So, we have a lot of questions coming in to the Q&A. Before we turn to that, I just want to have one final area to discuss. And that is your perspective on hormone replacement therapy. And we know that it got a bad rap and women were pulled off it. And I was amongst the generation that was scared away. Don’t dare, don’t take it. And we know that now the thinking has changed. So, where are we at right now? What is the state of the art on bio-identical hormone replacement therapy? And how does that fit into the mix of the diet and lifestyle recommendations you’ve just gave?

Dr. Felice: Well, I don’t want to go into a deep dive of the evils and the evil legacy that came from the Women’s Health Initiative. But I urge you all, if you haven’t, to Google that and just put in something like, you know, the problems with the Women’s Health Initiative. So, it’s a very simple thing. Back 23 years ago, this study ended that used non-human hormones. So, it would be like doing a study that… You’ll get this. You do a study with strawberry flavored jelly beans and it increases diabetes and cavities and obesity, okay? So, the conclusion is never eat organic strawberries. It’s like, “Excuse me, you know?”

So, you can only draw conclusions for what you actually study. And even if you call it strawberry flavored jelly beans, they’re not strawberries. And if you call something a hormone, well, okay, but it’s really an endocrine disruptor, you know? If you lick your plastic containers, that’s not your estrogen dose but those are xenoestrogens. It’s such crazy thinking. I don’t even know how this could happen in a world that has, you know, educated PhDs and MDs and they actually just talked about like non-human hormones like they were human hormones. And they still do that. They talk about progestins like madroxyprogesterone acetate like it’s real progesterone. It’s the equivalent of strawberry flavored jelly beans are the same as organic strawberries.

So, the bottom line is once you understand what hormones from the ovary, estradiol and progesterone do in the body, which is regulate pretty much everything. In fact, I’ve made a habit of this over the years. Whenever I learned something new, I would look up the relationship to these hormones. And of course, there was always a relationship, because these are the hormones of life.

And women go through menopause. The normal so-called span is 45 to 55. So, how could it be that these hormones of life itself… I don’t call them sex hormones anymore. I call them life hormones. How could it be that they turn evil at 45 for some women or even earlier, if they have early onset of menopause, or they’re still okay if you are 55 or 56 and you are just going into menopause as some women do.

So, of course, that’s nonsense. These hormones are always wonderful. The only reason we have to go through menopause is that nature doesn’t want us all to die in pregnancy, okay? If we could be highly fertile throughout our entire lives and be equally fertile at age 55 as 25, everyone would die at 55, you know, because I can tell you, having done thousands of deliveries, when I had a patient in her mid-40s, I knew I had a very high-risk pregnant patient on my hands. And they have many, many more complications and high rates of complications. So, you do not want to have really elderly women getting pregnant. So, nature had to shut it down. So, you can’t get pregnant and die. It’s really nature trying to save us.

But the reality is that the hormones are completely blended with fertility. So, it’s a package deal. We lose the hormones. So, when you understand what these hormones do, that they’re natural to the body, that every cell is a different age in the body, except for a few that are still there from the day we were born. Most of the cells in our bodies are all different ages. They’re genetically programmed to do whatever they’re genetically programmed to do. They don’t think, “Oh, well, Dr. Gersh, you’re such and such in age, so I’m going to act old.” No, they’re born from our stem cells, and they are programmed to do what they’re supposed to do.

But they can’t do it… This is where you’re so critical. They can’t do their jobs as cells if they don’t have what they need. They need the right micronutrients and macronutrients. They can’t be poisoned by environmental toxicants all the time. That’s not going to help them to do their job. But they need the hormones. The hormones are the directions. They’re like the instruction book so that the cells know what to do with all those wonderful ingredients that you work to get into those bodies of your clients.

So, you’ve got to have the directions for what to do. It would be like you had this gigantic puzzle, like a construction toy, you know, and you had all these little pieces all over the place but no instructions. You didn’t even know what it was supposed to be. You didn’t even know what it was supposed to turn into. So, how is it going to happen?

So, hormones are essential. They’re really essential to give the cells the information they need to do their jobs with all the different micro and macronutrients and such that need to be there as well. So, once you foundationally accept that hormones are great, the Women’s Health Initiative study was a piece of garbage, okay? Let’s just get it out there. It was totally appropriate to make conclusions from it for what they studied, which would be, “Please don’t use Prempro.” Okay, so beyond that, forget it. There were a few offshoot studies that had some validity but not very useful in most ways. And it’s been misused and created fear by healthcare providers and the public alike for no good reason. So, it would be like everyone’s afraid of strawberries because they heard bad things about strawberry-flavored jelly beans. So, we got to get over that.

So, hormones are wonderful, but we don’t have a lot of clinical data on how to optimally use them except for, you know, reducing night sweats and hot flashes, which for that, it takes a whiff. So, that’s the smallest dose. If that’s your goal, if your goal is just to reduce night sweats and hot flashes, which is not irrelevant, it’s really bad for you to have those, then all you need is a tiny, tiny amount of estrogen and a little bit of progesterone. But if your goal and not everybody’s goal is this but some is, to be an optimized, healthy ager, then, like everything, dose matters. Like, you know how many vegetable servings you have matters, how much exercise you have matters, how much sleep you have matters. Well, the dose of hormones matter. It’s like, come on, of course it matters.

So, what I advocate for is simple thinking. We want to have an optimal amount of hormones in an optimal, you know, sort of structure. So, how do I know what that is? Well, I look to nature. Okay, so when is a woman healthiest? Well, like in her 20s. So, I want to recreate as best I can—which is not going to be the same, that would be a new set of ovaries—but I want to get reasonably similar to what a woman would have in her body when she was optimally healthy. So, I want to get physiologic doses and have a physiologic rhythm to some degree in a way that’s manageable and useful so that we have every cell in the body getting the right instructions at the right time to do its job optimally.

So, it’s really simple. We’re just going for trying to get levels. And we know that from looking at and studying the menstrual cycle. We know what levels are appropriate in a normal menstrual cycle. So, we want to get in the ballpark, okay? We’re not going crazy here trying to be exact because that’s not doable. It’s not feasible. Nobody’s going to be compliant. We don’t even have any data on how to do that, but we do have data on how to match progesterone and estradiol for optimal function of vascular health because there are studies looking at what’s called flow-mediated dilation, how the vascular system is reacting to the hormones. So, that gives us a good idea of if you’re making proper nitric oxide, this critical gas that estradiol controls in the arteries to maintain vascular health. So, we do have that science, and we have small studies.

So, to me, it’s an easy kind of thing in principle. Now, in each patient, it could be more challenging, but in principle, the goal is to give hormones that are in synchrony with what nature did when women were their healthiest. That’s how I believe food should be. I feel the biggest failed experiment that we have ever done trying to outsmart nature was ultra-processed food. And I feel one of the biggest mistakes we’ve made is trying to recreate health—which we’re not going to do—by using hormones that would never exist in a human just like ultra-processed food should never be eaten. And why are we using chemical pretend hormones? They’re not human hormones. That’s a big mistake. And also using doses that make no sense. It would be like advocating for all your clients to never eat more than one serving of vegetables a week. How is that logical? How is it logical to say you should use the smallest dose? The smallest dose? What? I want to use the optimal dose for everything, okay?

So, that’s my real simple way of thinking. And then each one of my patients that I give hormones to, I have to work with her because there’s data showing that no matter what you give through the skin… The skin is supposed to be a barrier, but we give our hormones often through the skin. Well, guess what? Every woman absorbs differently. So, you know, you can’t do it cookie cutter. I’m sorry. There’s no shortcut. You got to look at each person, and you got to see how they respond and their tolerance and their goals to create an optimal hormonal environment to match the optimal lifestyle. That’s what we’re hoping to do.

Dr. Sandi: So beautifully said. So much information there. So, a question came in about screening. What screening tests do you recommend to determine whether HRT is an appropriate treatment, and what aspects of a health history might you look for and will be important to consider?

Dr. Felice: Well, to me, there are very few absolute exclusions to going on hormones. If you have just been diagnosed and have active breast cancer or uterine cancer, those would be traditionally—and I’m not going to go against that—contraindications to starting people or continuing people on hormones. But in terms of who would benefit, I think just about everyone would benefit. But here’s, sort of, an interesting thing which you brought up, okay, which is what about age? So, is age an issue? There’s this somewhat arbitrary kind of thing that says if you’re more than 10 years out from menopause or 60 plus, you’re too old. You missed the boat. You can’t go on hormones.

Well, why would that be? Well, there’s no exact answer. So, I’ve done a deep dive into trying to understand what would happen. And of course, there’s never an arbitrary point. Everyone is individual. But as we get further and further from having hormones in our receptors, the receptors get the equivalent of, like, rusty. But we know they don’t die. We know that they still can be brought back because we know that you can give a 90-year-old woman vaginal estrogen, and her vagina gets improved, dramatically improved. We know that you can put topical estrogen on the skin, and in just two weeks, the wrinkles are visibly reduced.

So, we know these receptors aren’t really dead. They’re just, kind of, like, you know, creaky. We got to get them back. So, I think that it’s not an absolute contraindication at any age, but I think we need to be more cautious. So, in women who are older but not just older, metabolically unhealthy, so say they have diabetes, they’re obese, they have hypertension, so those women can have a process called uncoupling. This is sort of complex: uncoupling of this enzyme, endothelial nitric oxide synthase, that makes this critical gas, called nitric oxide, in arteries that maintains arterial health and prevents random platelet aggregation, like you don’t get random blood clots, okay?

So, inflammation, oxidative stress, and free radicals will cause this uncoupling. And then there’s this hypothetical that, if you add estradiol—which estradiol drives that enzyme—that you may drive the enzyme. And instead of making the healthy nitric oxide, it goes down the wrong pathway and makes the poisonous superoxide. And from that, you can get toxic nitrogen products that are really bad.

So, I like to use certain supplements to try to improve mitochondrial health, reduce inflammation, along with all the lifestyle, to try to recouple nitric oxide synthase. And this is actually a plan that I’m going to put in place. I already have some people, and I’m going to write an article that’s going to get published—so I’ll let you know when that happens—to actually create a hypothetical, because we don’t have all the published data but we have a lot of science, on how women who are older, plus women who are metabolically unhealthy, should go through a process that’s critically important to involve coaches, lifestyle coaches, and health coaches because we have to do everything to improve the gut microbiome. We have to reduce systemic inflammation, oxidative stress, and get proper nutrient repletion because so many people are malnourished or obese, right?

So, there’s a whole process. So, I will get lots of lab tests. I love data so I get all the inflammation markers. I get like Lp-PLA2, so that’s an enzyme that will show inflammation that may be occurring in the arteries. Of course, hs-CRP (high sensitivity C-reactive protein), homocysteine. I like to get ADMA. That’s a surrogate marker for nitric oxide levels. I want to check a complete thyroid panel. I like to look for…if there’s autoimmunity, by getting an antinuclear antibody. I check nutrients. I check omega-3 levels, and B12, and the iron levels, you know, ferritin and iron. I can get CoQ10. I check all of these levels. I often get zinc and copper levels. So, I love checking nutrient levels. And then I’ll get a more advanced lipid profile. I want to look at how much the liver is producing. That you can get by measuring apolipoprotein B. And reverse cholesterol is apolipoprotein A1. So, I want to get those fractions. And now, I also check Lp-a, which is an independent risk marker for cardiovascular disease, which by the way, is regulated in part, not just by your genetics which is a big part, but also by estradiol. So, in menopause, Lp-a goes up, and estradiol can help it go down.

So, I get a lot of lab testing. I order ultrasounds of the carotid arteries, of the heart, looking for energy deficiency in the heart that you can see as a stiffer heart called diastolic dysfunction. So, I can actually see how energetic the heart is. That’s almost exclusively a female finding, by the way. And many cardiologists overlook it. They say, “Oh, lots of women have that.” Well, yeah, because they’re all energy-deficient in their hearts. So, that’s a really, really big deal. And sometimes I’ll get coronary calcium scores. So, I get lots of data. I get a lot of ultrasounds of the liver. That’s the best way to find the early stage deposits of fat in the liver. And if you have fatty liver, you also have fatty pancreas, fatty bone marrow, fatty heart because it’s not just affecting the liver.

So, we have to know all these things, because as I know you know, you cannot measure… I mean, you can’t… Sorry, you cannot monitor if you never measure. How are you going to follow something if you don’t even know where you started? So, I love creating a big pool of data. None of this is invasive. None of it is dangerous. No, it’s just a lot of really, really good data.

For women who are perimenopausal, and we’re not sure yet, they have maybe marginal symptoms, it’s unclear, I will often get a menstrual mapping where I can see the estradiol, progesterone, and LH levels throughout an entire menstrual cycle. And often women who have cycles that get shorter, like maybe they’ve gone to 22 days, they used to be 28 days, will see a very short luteal phase. And often the ridiculous little blip of there’s supposed to be a big spike of LH that comes after the big spike of estradiol. And they’re like little blips, you know, and those women will often benefit from hormonal supplementation. So, we don’t have to wait until that arbitrary definition of menopause to start giving hormones and starting all of our lifestyle measures aggressively, because we can really see on a menstrual mapping how the hormone levels are really changing and not for the good. So, there’s, you know, loads and loads of all this data that is so really critical for making good plans and for following as the years go by.

Dr. Sandi: Such a great answer. Along those lines of testing, if someone says and particularly in Mexico, the OB/GYNs have said that measuring hormones in blood doesn’t really help determining how much a woman would need. Does that sound right to you?

Dr. Felice: No, because that’s actually the gold standard, okay? So, all the research has always been in looking at the serum, the blood levels. Now, there was some concern, well, if you’re giving hormones through the skin, does that get absorbed in a way that you can actually see the levels? And we really have some pretty good data that the answer is yes. It may end up somewhat in lymphatics too, but, you know, the reality is that it does get into the blood. That’s the whole point, okay? Because then you really can get proper distribution through the body. So, absolutely, blood is the gold standard.

Now, urine is looking at metabolites, and there’s valid data on doing that. Now, I don’t see why anyone would just generally want to follow levels just by getting urine metabolites. It doesn’t seem like that would be very useful in general because we have much more data on blood. But for doing menstrual mapping, we are using metabolites and it is valid. The saliva, I know I hate to say this, and by the way, I’m totally open-minded. If data comes out showing otherwise, I’ll change. I’m totally flexible. I’ve changed plenty already. I’m still in a flux of a lot of things. But saliva is not yet validated for any hormone other than cortisol, which I do sometimes.

I didn’t mention this. I will sometimes… I don’t do it on everybody, but I’ll get the four-point saliva cortisol test to show people. Sometimes people want to see it, they don’t want to just hear it. They want to see, “Look, my cortisol is really wacky, you know, and I really do have circadian rhythm dysfunction, and I really do need to work on my autonomic nervous system and get more vagal tone and work on stress and so on.” Because when you have stress, part of the stress response is adrenergic, adrenal, and you get, whoop, too much cortisol, right? That’s part of the stress response. And some people really benefit by seeing what’s going on with their cortisol, and that is totally valid using saliva. So, that’s the only salivary test that I use. And I’m open to seeing future research on using saliva, but right now there’s just not enough valid data to make it a mainstreamed use of it. That’s my opinion, but it’s based on data.

Dr. Sandi: Some questions have come in, several about how long can you stay on it for life? Is it post-menopausal? Someone said, “I’ve been told to stay on for just a short term.” But I think we’ve talked a little bit about that, but what would you say? What do we know at this point?

Dr. Felice: Well, we know that your cells need to have that information, that hormones deliver at every age, no matter whether you’re 90, 100, you know, or 40. So, it would be like, to me, tantamount to saying, when are you too old to exercise? When are you too old to have fun? When are you too old to eat green beans or broccoli or something? The answer is never, okay, because hormones are for life.

So, if they’re part of life, they sustain life, they give life, and they should be for life. And there’s no reason to stop it. You would never say you’re too old for your thyroid hormone. So, I’m just trying to put hormones from the ovary back into the same bag as all the other hormones that we have, that the endocrinologist would never say you have adrenal failure. Like you have from autoimmune disease, you have Addison’s disease. And now we’re going to stop your cortisol because you’re 75. Well, no, that person would just die. But they would never do that. They wouldn’t say you’re a certain age, so we’re no longer going to give you thyroid.

I mean, why can’t we just put the hormones of the ovary back into the bag with all the other hormones of the body? If you’re a diabetic type 1, you would never say, “You’re too old now. We’re going to stop giving you insulin.” I mean, it’s just another hormone. It’s a critically important set of hormones, estradiol and progesterone. And they’re for life. We should just consider them like every other hormone, understand what they do, how important they are. And we would never take any other hormones away at some arbitrary, ridiculous point. And we shouldn’t do that with our beautiful life hormones that are ovarian derived.

Dr. Sandi: I love that. Absolutely. Totally in favor of that. So, some questions have come in about, kind of, the stubborn symptoms of weight gain. Another question about mood swings or depression associated with this menopausal transition. So, can you address that? And another question about are there natural things you can do? So, let’s say someone does not want to go on HRT, but what are some of the perhaps more natural things we can do?

Dr. Felice: Sure. So, it’s really important to realize the risk. That’s very critical for mood disorders. So, when women who have had no prior history of depression, anxiety, mental health challenges of any sort, when they transition into menopause, their risk of having a significant clinical depression or anxiety doubles. And if they had a prior history of something like postpartum depression, bad PMS, something like that, anxiety disorder, their risk goes up 400%. At least 25% of women out from scratch, new onset, are put on antidepressants in their 40s. So, this is a huge issue.

So, what can you do? Well, of course, I’m a pro-hormone person, but it’s never… It’s always to me necessary but not sufficient. And some people can’t or do not want to go on hormones. And that’s their prerogative. So, what can improve mood, okay? Exercise. They did studies comparing SSRI antidepressants, that’s like in the family of Prozac, Lexapro and so on. And they found that exercise did better than those antidepressant drugs did.

And what else? All the mind-body things like massage is amazingly beneficial for improving mental health, like craniosacral massage, foot massages and so on can be amazing. They actually help to increase vagal tone. Anything you can do to increase vagal tone will reduce anxiety. Of course, optimizing sleep is really critical. And sunlight. I always call sunlight the happy hormone, the happy drug, okay, because sunlight, actually there are receptors in the retina for sunlight. But those receptors, they go straight to the serotonin neurons and they generate serotonin, the feel-good neurotransmitter, which is what is increased, at least that’s the theory, by SSRI, serotonin reuptake inhibitor drugs. That’s exactly what Prozac and Lexapro are supposed to be doing, increase serotonin. Sunlight increases serotonin.

And what about sleep? You mentioned, well, everyone has problems with sleep. Well, the serotonin neurons don’t work optimally without estrogen but they’re not dead. They’re still going to work. So, in addition to eating all those wonderful phytonutrient-containing foods with the phytoestrogens, you can also do sunlight therapy. That’s why you’ve heard of seasonal affective disorder, when people are in a dark environment and they feel depressed. Well, women are always in seasonal affective disorder because they don’t have the proper amounts of serotonin production. But sunlight will increase serotonin, make them feel happier and calmer. But all melatonin is derived from serotonin. So, you’ll make more melatonin and your patients, your clients, will sleep so much better. They’re going to have a better quality sleep. It’s going to be wonderful. That’s why people who go to the beach and they’re out in the sun and they’re earthing, you know, they’re grounding on the earth and they’re getting rid of extra free radical electrons and so on, they will sleep. They’ll say, “I slept like a baby last night.”

So, taking walks, getting out in the sunlight. And if it’s too dark because it’s in the middle of winter, you can get a light box. And what you do is you get exposed to 10,000 luxe every morning, bright light, 10,000 luxe. And then do it again when you hit around noontime for another half hour. And then if you’re one of those people or you have patients, clients that are waking up at 2, 3 in the morning and it’s like, “I can’t fall back to sleep,” if you do… You have to experiment a little bit, like 10, 15 minutes of the 10,000 luxe, about 2 to 3 hours before they go to bed, it will do what they call a phase shift so that the brain won’t think what it’s doing, which is they’ll think it’s 6:00 in the morning when it’s really 2:00, okay? So, it’ll shift the brain’s perception of time by using the light receptors in the brain so that you’ll push back that awakening time back to 6 or maybe even 7 a.m. from 2 or 3 a.m. So, light is our friend, okay? So, light can help with sleep and it can help with mood. And of course, all the other mind-body practices can help with both as well.

And then I use a lot of ashwagandha for sleep, chamomile. I love herbal teas but not right at bedtime. You know, like an hour before so that they can not have to get up and go to the bathroom in the middle of the night. So, calming teas are wonderful to help with sleep and with mood as well. So, all of these things are fantastic. And then, you know, having fun things. You know, I always say… You know, this is a cliche, but laughter is the best medicine. But laughter dramatically triggers vagal nerve stimulation. So, I just say laugh whether you feel like it or not. You know, they’ve done studies with people smiling into mirrors. You’re smiling and they feel happier. There’s these reflexes in our bodies. So, smiling and laughing will help you to sleep better and feel better emotionally.

Dr. Sandi: So, so important. So, we’re drawing to a close. I just want to get at a few more questions. And we’ve had several come in about breast cancer. I know you said at the beginning, if you have active breast cancer, what about if you have a past history of breast cancer or you’ve had your ovaries removed? We’ve had a lot of questions about that in terms of BHRT. And then the other question that has come in is what form do you take it? Is it a pellet, a cream or what’s your recommendation on that?

Dr. Felice: Well, the conventional approach is that if you’ve ever had breast cancer or uterine cancer, although less so with uterine cancer now, that you should not go on hormones ever. The reality is that there are many women that can go on hormones, but it should be very individualized. Everyone should have full informed consent about everything.

So, estradiol doesn’t cause breast cancer. In fact, there’s now multiple studies that have shown and are published showing that estradiol… And if you use progesterone, that’s great. But if you use progestin, that’s not so great. So, we don’t want these fake imitation progesterones. But if you use the bioidentical, and most of the data is on estradiol, it lowers the incidence of breast cancer. And that’s like another whole discussion, but we understand the mechanisms.

Okay, so it’s not like it’s a mystery. It’s not a mystery, okay, but estradiol… In fact, like I even mentioned, one of the reasons is estradiol controls the cell cycle, so it causes cells to kill themselves when they’re old and yucky, the old senescent zombie cells. So, that’s just one of the mechanisms whereby estradiol is cancer protective, okay? So, it doesn’t cause cancer.

So, what about if you have cancer, though? Well, things are really upside down. Genes are reprogrammed. They’re behaving differently. So, you can’t compare active breast cancer to not having breast cancer in terms of a lot of things. But a lot of women who are diagnosed with breast cancer and then they have treatment, they don’t have breast cancer anymore. I wouldn’t talk about that you should give hormones to women who have metastatic breast cancer because they still have breast cancer.

But what about a woman who had ductal carcinoma in situ, which isn’t even actually cancer, okay? What about those women or a woman who had a very tiny little cancer and they had a lumpectomy? There’s no negative nodes. There’s no positive lymph nodes. There’s no evidence of spread. So, those women would be extremely low risk of any sort in terms of their breast cancer history, but it has to be highly individualized for a woman to go on hormones.

And so it certainly is not the standard of care. The standard of care is not to use hormones in a woman who has had breast cancer. So, everyone has a right. It’s not illegal, okay? No one’s breaking a law. But you have to have informed consent. You have to look at all the pros and cons to make a decision of that level for people who’ve had breast cancer.

Now, in terms of how I would deliver hormones, once again, since I’m a simple thinker, I want to give it in a way that’s most equivalent to what a woman would have naturally in life when she was at her healthiest. And that’s not pellets. I mean, for those of you who love pellets, I’m sorry. I hate pellets, okay? Because pellets are not physiologic. You can never get a good level that makes any sense consistently. When you put a pellet in, initially it’s way too high. Then it might be okay for a while. And then it’s too low. So, you go in like this. That’s not physiologic, okay? I do not like that.

And testosterone pellets… Almost every woman is just overdosed for a very long time, okay? So, for testosterone and talk about like if you don’t have ovaries, where does testosterone in the female body come from? Twenty-five percent comes from the ovaries. The other 75%, close to it, comes either directly or indirectly from precursors to testosterone like DHEA-S, DHEA, that’s converted in predominantly fat tissue into testosterone. So, 75% of testosterone in the female body, directly or indirectly, comes from the adrenal gland, which is not part of the menopausal process.

And in fact, due to stress, because I told you there’s a sympathetic overload from the autonomic nervous system and there’s more stress, that causes more cortisol. Well, the same trigger that creates more cortisol production, ACTH (adrenal corticotropin hormone) that comes from the pituitary under the control of the brain, produces more DHEA-S. So, you get more androgen production from the adrenal gland when you stimulate more cortisol production.

So, that’s why women who are stressed, they often will get a pimple. Like, how does that happen? What’s the mechanism? They’re making more androgens. So, throwing testosterone at every menopausal woman makes zero sense, so don’t do it. And if you have clients, tell them, maybe think this through better, because menopause does not lower your testosterone production. With aging, it does tend to go down generally mostly because of the adrenal gland. The part of the adrenal that makes androgens is called the zona reticularis. And it tends to, oh well, shrivel with age. But that’s separate, okay?

So, you have to treat every woman independently as a unique person as far as her androgens go and what’s going on. If you go to a nursing home, you see a lot of little old ladies and they all have whiskers and they all have really thin hair. You can see all their scalp. Is that because they’re all on testosterone? Of course not. That’s because they don’t have any estrogen. And when you don’t have estrogen, you make very low amounts from your liver of sex hormone binding globulin. Ninety-nine percent of testosterone is bound up in the blood. That means only 1% is free and available to actually act on tissues. If you lower sex hormone binding globulin, you will allow more testosterone to be unbound or free. So, essentially you’re increasing your testosterone level by having it unbound. So, that’s why little old ladies have all these whiskers.

So, you got to be careful. This testosterone craze got to be stopped in its boots right now. They got to stop it. Like, just giving all these testosterone pellets and high dose testosterone because women are going through menopause makes no sense. And women going through menopause with their stress, their adrenal output often will go up and their sex hormone binding globulin goes down. So, they have more unbound. And when you have inflammation, which goes along with menopause, you activate the enzyme that’s in the skin that converts testosterone to its more potent form, dihydrotestosterone. So, you actually have this more potent type of androgen in the skin. That’s why women around perimenopause will often suddenly get acne and facial hair and hair thinning, androgenic alopecia. The last thing they need is to throw more testosterone at them.

But lastly, in terms of how you give it, so I don’t want to give pellets. I don’t want to give oral estrogen. So, for estrogen, I want to give it through the skin. And I equally use gels, patches, and compounded cream. They’re all different. You got to look at each individual woman and decide which one works for her. You got to measure levels. This idea that you don’t have to measure levels makes no sense, and I measure them in blood. And you have to find what works for each woman, what’s acceptable to her and so on.

So, in terms of levels, I’m looking for levels that are around 100. That’s picograms per mil. And I’m actually now looking at changing the dose from when you do and don’t have progesterone on board, because I found some studies. I don’t want to get into it now for another time, that it might be better, like in nature in a normal menstrual cycle, to have a higher amount of estrogen in the bloodstream when you have the progesterone on board.

In terms of the progesterone, the typical is to give it as an oral pill. I’m also rethinking that, more to come in the future. I’m going to write some articles on that. That when you take it orally, it goes through the liver on the first pass, just like oral estrogen. And you get these huge amounts of metabolites. And the dominant one is allopregnenolone, which is good. It’s good. But too much of a good thing is not a good thing. And too much of allopregnenolone can be too sedating. That’s why some women feel groggy and they’re doped, like drugged. And that’s not a good thing. So, I’m re-evaluating how to give progesterone as well. So, more to come from there.

So, in terms of what I don’t recommend, I definitely don’t recommend oral estrogen and I don’t recommend pellets for anything. And I recommend trying to get levels that are reasonable, not teensy, okay, because I’m trying to actually have a good outcome. And the lowest dose is not the optimal dose, like anything else that we do. So, I know it’s complex. And I’m going to have more courses and things to try to help people who are actually into prescribing but even those who aren’t, to, sort of, understand it better. So, I’m still in flux myself on a few of these things, but I definitely know what I don’t like, okay?

Dr. Sandi: Well, I want to be very mindful of time. This has been outstanding. I know we have a record number of questions. We did not get to all of them, and we will send out a recording. And I cannot thank you enough, Dr. Felice Gersh. You are just such an incredible inspiration. You are a thought leader in this field. And so we are blessed to have you as part of our community.

If you like what you heard, you will be getting more of this. And I also invite you to, if you are not part of our community, to consider becoming a health coach. We are enrolling for our March class. And health coaches can educate people because, as we’ve heard today, there’s so much confusion. There are so many misperceptions about this topic, as well as so many other areas of health.

So, thank you for everyone who came to join us today. And I’m sorry we didn’t get to all of your questions, but we will continue to do more of this type of programming. And I know we will have you back as well, Dr. Felice. So, thank you so much.

Dr. Felice: My pleasure.

Dr. Sandi: Bye, everybody.