Ep.69 We Have Options! The Changing Landscape of Menopause and Hormone Therapy

After episode 64 of the podcast, I had many listeners reach out to me to express their frustration over the lack of healthcare providers in their area who were in the know in the latest in hormone therapy treatments and protocols.  When the company Winona contacted me to speak to one of their medical providers, I jumped at the chance to bring our listeners a possible option to fill a void in their quest to feel better and be their best.

As telemedicine becomes more and more commonplace, many doctors are seeing it as vehicle to reach more patients and to broaden the conversation and community, especially when it comes to women's health issues.

When Cat Brown, D.O., was doing her medical training, she was encouraged to pursue the family practice route as part of her Army commitment, but she found her true love was obstetrics and gynecology.  This do-it-all mom and current OBGYN hospitalist decided to join the medical team at Winona in 2021.  

Winona is a company revolutionizing the treatment of menopause to help women get the solutions they need.  They aim to empower, educate, and treat women throughout the entirety of their menopause journey.  

Winona offers doctor-prescribed, bioidentical hormone replacement therapy that is backed by science and shipped directly to your door.

Check out Winona here: https://winona.pxf.io/oq5OPE

In this episode Dr. Cat Brown and I discuss:
- Cat's path to becoming an OBGYN
- The obvious and not so obvious symptoms of menopause
- The data on hormone therapy and alzheimer's
- The role of cortisol and how to minimize its effect
- Is estrogen dominance really a thing?
- Oral vs. topical hormone therapy - deciding who gets what form
- How DHEA fits into the treatment regimen
- Blood and saliva hormone tests and why they may not be reliable
- The future of telemedicine
- Cat's words of advice for midlife women

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*Transcripts are done with AI and may not be perfectly accurate.

**This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their healthcare professionals for any such conditions.

Transcript

Asking for a Friend Podcast
We Have Options! The Changing Landscape of Menopause and Hormone Therapy
Michele Folan
Cat Brown, D.O.

SUMMARY KEYWORDS

patients, women, estrogen, body, winona, hrt, midlife, hormone, telemedicine, symptoms, work, state, testosterone, menopause, progesterone, dhea, doctor, physician, call, ovary

Speaker 1  0:00  
After episode 64 with Dr. Nicole Lovat, I had many women reach out to me to express their frustration over the lack of health care providers in their area who were in the know in the latest in hormone therapy treatments and protocols. It's my intent with the podcast to bring a variety of thought leaders and opinion to the table. And there are women's health companies popping up out there who are able to provide convenient and effective solutions through telemedicine and when the company Winona reached out to me to speak to one of their many doctors, I jumped at the chance to bring to our listeners a possible option to fill a much needed void in their quest to feel better and be their best.

Speaker 1  0:57  
Health, Wellness, career, relationships and everything in between. We're removing the taboo from what really matters in midlife. I'm your host Michele Folan and this is asking for a friend. Welcome to the show everyone. As telemedicine becomes more and more commonplace. Many doctors are seeing it as a vehicle to reach more patients and to broaden the conversation and community especially when it comes to women's health issues. Winona is a company revolutionising the treatment of menopause to help women get the solutions they need. They aim to empower, educate and treat women throughout the entirety of their menopause journey. Winona offers doctor prescribed bio identical hormone replacement therapy that is backed by science and shipped directly to your door. Our guest today is Dr. Kat Brown, and she joined the medical team at Winona in 2021. Welcome to the show, Dr. Cat Brown.

Unknown Speaker  2:09  
Thank you. Thank you so much for having me.

Speaker 1  2:12  
I am very happy to meet you. Is it okay if I call you cat?

Speaker 2  2:16  
Absolutely cats short for Kathleen. But it's really what I use every day. So please.

Speaker 1  2:23  
So you have a journey. And I would love for you to tell the audience about how you came up through the world where you're from where you went to school, and then how you landed at Winona.

Speaker 2  2:36  
I'm originally from Philadelphia. I grew up in the city and actually went to college at a small state school in Pennsylvania called Shippensburg University. I was the first person in my family to go to college. So there was no college fun. There was no money, anything like that. The funny thing is at orientation for college, I saw these people rappelling off the field house. And I thought, wow, that looks fun. I want to take that class. Turns out it was Army ROTC. So I joined that class just for fun, to do some camping and to do some rappelling and to maybe get the chance to jump out of a plane. And the next thing you know, within about a few months of taking that class, the instructors said, Would you like a scholarship? We're taking applications and so a couple other girlfriends and I were like, yeah, why not? Let's see if we can get a scholarship. So that became my journey into the army actually, I got a scholarship for college. They paid for the rest of my college career. And then when it came time to apply to medical school, I applied for a medical scholarship as well. I went to medical school at the Philadelphia College of Osteopathic Medicine here in Philadelphia, and then right upon graduation, that's when you go active duty. So when you finally get the degree that you're seeking, that's when the army kind of grasped you after they've paid for all your education. Of course, yeah, our school was very much into grooming primary care physicians and trying to groom family doctors to really make those available to rural areas in Pennsylvania. But every time I tried to like any other specialty, I kept gravitating back to OB GYN. Women's Health was something that I was very interested in. I was good at I had a vested interest in because I had so many friends and family that had bad experiences, negative experiences. It was one of those things that I was very interested in and I felt like I can make a difference in did my residency and OBGYN with the army at Tripler Army Medical Center, which is in Honolulu. Oh, which was quite a hardship living in Hawaii for three years. Rough. I know right? It was wonderful though. Because you know, when you're a resident, we call them residents because you're basically living at the hospital. You're working as much as you can to learn everything you can about that specialty. And for OB GYN. It's a four year residency. So when I wasn't working, we pretend to like we were tourists and we would go to the beach and do the touristy things, but it really helped to balance out that crazy work environment and all the crazy hours that I was working all the time. As a result of the army paying for my education for college and med school, I had an eight year commitment that began after my training was finished. So the residency was four years. And so after that four year period, then I had another eight years to pay back. So I was stationed in El Paso, Texas for some time. And then at Fort Bragg, North Carolina, which is about an hour southeast of Raleigh Durham area, and then also made it back to Texas in San Antonio. And then ultimately, when I got out of the army, I decided to relocate back home to be closer to family while my kids were young. So that's why I came back to the Philadelphia area. Most OBGYN 's work in the office, they do surgery, they also are on call on labor and delivery. We also cover emergencies, it's the only specialty where you get every aspect of medicine, you're not just in the office, and you're not just in the operating room, you get to do a little bit of everything. But I started a job back here in Pennsylvania, where I'm an OB hospitalist, meaning that I just work in the hospital right now. And I work 24 hour shifts covering labor and delivery and covering emergencies. But when I did that leap, and I made that change to just doing more of inpatient obstetrics. I really missed the connection I had with women in the office, that Chief Medical Officer of Wynonna Dr. Michael Green approached me because Wynonna was expanding and he needed a doctor in the Pennsylvania area to take care of patients for Wynonna. Personally, I was starting to go through my perimenopause journey. I was reading everything I could and doing as much as I could to learn about how to take care of myself best. So when he approached me about this opportunity to take care of women going through this transition, I was like, Absolutely, yes. Oh, yeah. I joined them in 2021. And so that's a second job for me, in addition to doing the hospital job, and it's been wonderful. I mean, patients are so grateful, you know, it's telemedicine platform, so the patients have access to us pretty much 24/7, they can send us messages, and we write back and forth. But it's been wonderful to be able to help patients that are struggling. And the hardest thing is hearing so many of the negative stories that women have going to their physician, whether it be their family doctor or their OB GYN and telling them how they're feeling and what they're going through. And the common thread that I keep hearing from patients is they're just told, Well, you just need to suck it up. It's just a part of life. Yeah. Or you're just gonna have to deal with it. There's just such a lack of focus on this particular part of women's health. And I joke sometimes that all the research in midlife is going toward men and erectile dysfunction, but it's actually kind of true. All this money was poured into those medications and helping men but really not a lot of focus has been put on women's health at this particular time of their midlife journey. It's really an important topic for me. And I think it's something that we need to really put more focus on for women and let women know they're not alone. They don't have to suffer in silence, and they do not have to just suck it up and take it.

Speaker 1  7:52  
Oh, I so agree, which is why you're on the show today. I mentioned in that intro, which I will record here soon, was the fact that after doing a show on HRT, it was episode 64. I got so many comments from women asking, Where do I go? I want to be able to offer options to women who may not have access to a doctor cat Brown. We have to create community, we have to create conversation in order for women to feel like they've got those resources. So the other question I have for you is, how do you do it all? You're a mom, you're doing the telemedicine your hospitalist. you're juggling a lot.

Speaker 2  8:43  
Yeah, it is. Although my hospitalist job is unique in that, you know, when I was working full scope, obstetrics and gynecology. I worked Monday through Friday in the office, I was on call rotating and my life was chaotic. And this job with the hospitalist job, even though I do the 24 hour shifts, I only do that about seven times a month. So the days that I'm off, and I'm home, there is no pager for me to answer. There are no other calls for me to take. And the nice thing about Wynona being telemedicine, I can do my Wynona charts and message patients even before my kids get up to go to school, I make coffee in the morning and I sit down and I do an hour or so of responding to messages. But I think with any woman who works and also has a family, this eternal juggling act, you know that we're always trying to balance and there really is no such thing as work life balance, really, there is no way to perfectly balance. It's just an ongoing process where we're constantly putting efforts in different places and trying to redirect and you know, it's a challenge to prioritize sometimes, but we do our best and we try to show up our best in every arena that we can agreed, but luckily like right now in order to do this podcast and have my kids not begging me for everything because traditionally anytime I get on the phone or any kind of zoom call, they're always needing me at that moment. So right now they're on electronics. That's how I'm balancing.

Speaker 1  10:05  
Hey, you do what you gotta do. Exactly. You also post quite a bit on Instagram for Wynonna, which I love. You're very engaging, by the way. Oh, thank you. You posted something recently, some of the things you would never do in midlife as a GYN. Can you talk about that a little bit?

Speaker 2  10:26  
Yes, I think one of the biggest things is listening to patients. One of the biggest problems that we have with interactions with patients and their physicians is that they don't feel heard. And when women come in, and they're complaining of symptoms that are bothersome, that are affecting their quality of life, you have to listen. One of the things I've heard patients say repeatedly over and over again, well, I'll tell in your head. And that's something I vowed I would never ever say to a woman, no matter how old she has, no matter what struggles she's going through, I don't care if she has a psychiatric illness that's been documented, and she's on medication. Symptoms are valid, and what we experience as patients and we're bringing to somebody's attention, how we're feeling and what we're going through, they should never be belittled and told it's all in their head, because it really is not. And we know now they're doing more and more research on trauma history and even psychiatric illness and how it can affect our bodies and how it can manifest as physical symptoms too. There's so many things that you need to address that you want to make sure that you listen to your patients,

Speaker 1  11:30  
and you're treating the whole patient, right? Absolutely. Mind

Speaker 2  11:33  
and body are interrelated and as an osteopath, my medical education was a little bit different than an allopathic for my degree, instead of having MD after my name I have do so that's a doctor of osteopathy. We do everything that all the MDS do in medical school. But what we do in addition is we learn osteopathic principles and also osteopathic manipulation. But the guy that founded osteopathic medicine, really believe that the structure and the function of the body are totally interrelated. And so osteopath is trained to really look at the total person and to the total patient. So if somebody comes in for back pain, we're not going to be that doctor who just throws you medicine to treat your back pain. We're going to think about what are you doing ergonomically that's causing this? Like, what activities are you doing that are putting that area of your body under stress? And we're gonna lay our hands on your body to check it out, not just throw painkillers? atcha I think that that goes along with this treating patients and perimenopause and midlife too. Is that looking at the total person than total body?

Speaker 1  12:33  
Well, I appreciate you defining the difference between what a do is and an MD because I believe there might be some confusion out there. Yes. Because people may be looking at a selection of doctors and not know, hey, why can go to a do? It's very similar. Thank you for that. Sure. We know that obvious signs of menopause. But what are the lesser known symptoms that women should be aware of

Speaker 2  13:03  
the lesser known symptoms, I think really brain frog confusion, depression, anxiety. Mood swings are another one too. I've had a lot of patients that at this point in their life start to talk about well, like, I think I need to get divorced, I can't get along with my partner anymore. Like tolerance is reduced. But there's also some very strange symptoms that can make you think like you really have something horribly wrong with you, like you can get tingling of the skin, you can get ringing of the ears. And I've had patients talk about feeling a burning or metallic sense in their mouth are a burning taste in their mouth, the skin changes, you know, feeling like your skin is crawling, feeling like you might have bugs crawling on your skin. It's like a strange sensation. But that is related to that loss of estrogen. But in addition to the classic ones we know about like the hot flashes and night sweats some of these other symptoms that patients experience, they may go in and talk about them. And they're so diffused, they might be all over their body. And if someone's really not trained to recognize those as symptoms of this, they might be thinking like God, like she's really crazy. There's something really going on. That's constellation of symptoms, it's so vast, but even in having the sleep disturbances are pretty common too. But a lot of women don't realize that that sometimes that's the first symptom that women will start to notice is that they wake up feeling exhausted in the morning, and they don't realize because they've been in bed all night, but they might never really be getting into that deeper sleep that's restorative, right? They might be tossing and turning or you might wake up and be semi conscious tossing the covers off because you're hot or putting them back on or back and forth. But you're kind of in that semi sleep state and you don't really know what's happening. You're not really cognizant of it overnight, but you just wake up and you just feel exhausted. loss of libido is another thing too. That's another thing that women experience a lot as well. But vaginal dryness, pain with intercourse. The other thing that can happen is if you're going through that apparent menopausal transition your periods if you're still having periods and just get crazy, get haywire, no rhyme or reason. Sometimes you skip a month, sometimes you'll skip a couple months. Sometimes you may have two or three periods in one month. Yeah. And that's basically down to the miscommunication between your ovaries and your uterus. At that point, the hormones aren't being reliably released like they were when you were younger, lots of things can happen. Fun, fun, fun. I know the things that we have to go through as women. I know. And

Speaker 1  15:29  
there is that occasional friend of mine that really thinks they got through it unscathed. But they may have some of those weird things that they don't associate to menopause. And I will say, from personal experience, the ear ringing is real. Yes. My husband and I went to a gun range. And I was blaming it on bad headphones, because I was wearing like, love your protector things. I was blaming it on that. That is actually menopause. Wow. Anyway, long story short, and I still have ringing in my ear. So there is some data out there now that shows a correlation between Alzheimer's and HRT. Can you talk about that data a little bit?

Speaker 2  16:19  
We think that HRT can be protective against Alzheimer's, specifically, the estrogens mean, really, it comes down to that estrogen is just in a woman's body, it's so beneficial in pretty much all the tissues throughout our body. And that really, it can help protect those neuronal connections in the brain and help keep the brain healthy. I mean, I think there's more research needed. I mean, it's not something that we would if someone doesn't have menopausal symptoms to warrant taking HRT, it's not at the point where we would be prescribing HRT just for Alzheimer's protection. But it's one of those side benefits, that we're noticing that women that do take HRT have a lower chance of developing Alzheimer's later in life. So that's something and there's been a recent article that came out talking about dementia of other kinds, though, talking about women taking HRT being at higher risk for dementia. But the study design, when you read through, it was not very good. It was saying that there was an increased risk, even if you were on a day of HRT, or a week of HRT, and Dr. Greene and I were actually just talking about this last night, we had a webinar for Wynona for prospective patients, and one of the patients had asked that can you discuss the Swedish study about dementia and HRT. But really, whenever you get information, especially with when it comes to research, you have to look at the quality of it, and looking at what was their hypothesis? And what were they trying to prove? What was their data collection? And for that particular study, I don't think it's sound enough that we can take that and extrapolate that to the whole population right now. But as far as the Alzheimer's, we do know that the stuff that's been published there, has showed us that if you take HRT that your development of Alzheimer's can be a reduced chance later in life. Okay, I think it's a positive.

Speaker 1  18:03  
Yeah, definitely. I think we're learning more and more the benefits of HRT, and then I'm learning more about the breadth of the effect of cortisol on midlife women, yes. How can we better manage our cortisol levels, and I guess if he could explain what cortisol really does to us,

Speaker 2  18:24  
cortisol is your stress hormone. Whenever we're going through any period of stress in our life, any kind of major event, we get into that fight or flight state, and that cortisol level is really what puts you there. Often, in midlife, not only are we going through all these changes physically in our body and going through the peri menopausal changes, which just having the estrogen decrease and having all of that puts your body in a stress response, the cortisol levels go up. And what your body is thinking is that you're in this fight or flight state, we better not waste any calories or any energy and we better just collect it because we're going to need it for later. So it all collects in our mid body, in the belly especially. And then we start to see this what we call the meadow belly or the menopause belly, we're retaining weight because our body is in this stress, state stress response. But even also, when we're in midlife, the other things happening in our life too, in our kids are getting older, sometimes going off to college, or we might have aging parents that might have health issues, women in general, I mean, I think more so than men, especially going through midlife, we have so much that we carry on our shoulders, and so much that we're dealing with and trying to orchestrate while also balancing our lives. It's almost like we have this constant state of just going, going, going, going going. And when we're in that state, that cortisol level is just through the roof. The hardest challenge that we have is trying to slow down in life trying to do those things that we can do for ourselves that will relax us and also get us out of that fight or flight response. Things like meditation just slowing down doing it workouts as far as like yoga or pilates or something, something you can do each day to quiet your mind, because I don't know if you experienced this, but for me personally, anytime I sit and even try to meditate, it's like, what do I need to add to the grocery list? When does the car need to go and do this? When do I need to do that? We have a hard time turning our brains off, to completely quiet your mind. And just be with yourself in the moment. It's so difficult when you're orchestrating so many different things in your life.

Speaker 1  20:31  
I love my afternoon walk. That, for me, is my stress relief. It's my quiet time. That's what I do. Also, this is really a great argument for getting better sleep. Yes. And really working on our sleep hygiene. Because so much of that helps with the cortisol, I believe.

Speaker 2  20:52  
Absolutely. Because when you're not sleeping, your body doesn't have a chance to reset at all. And you're constantly in a stress state. Yeah, like in survival mode, basically, you know, if you're chronically sleep deprived, we're still

Speaker 1  21:05  
programmed for cave days, when we were trying to just get by each day on a few calories. It's just the way it is, I guess. Yeah. Winona offers a lot of different products. And what I noticed from the website, you offer oral estrogen, and topical. And I'm curious how you decide what a patient should get, should they get oral or topical treatment of any of your products?

Speaker 2  21:35  
I think that the first and foremost thing is having the discussion with the patient. When we go over their medical history when they onboard with us, part of what we're asking them is that what do we think that they could fit into their lifestyle the best, because I could believe that maybe the transdermal or the topical estrogen is best for them. But if the patient doesn't feel like they're going to be able to reliably remember to take that it's not going to do them any good if they're going to miss doses. So often, it's a conversation we have with the patient, I tend to prefer the topical better, just because by taking a transdermal method of estrogen, you're bypassing that GI tract, when you take an oral pill, it has to be broken down by your stomach and processed by your small intestine before the hormone is actually even released into your bloodstream to get to the intended tissues. But for some patients that are already on medications already, or maybe they take vitamins every morning, and just adding another pill into the regimen would be the easiest for them, that may work better for them. I would say probably the majority of our patients are on the topical, but a small percentage prefer the oral pills and still want to do those. But that's really how we decide. I use the analogy for patients that sometimes with medication, and especially with HRT, trying to find the right formula and the right dosage, and the right forum is kind of like trying on clothes, especially jeans. If you take 10 women, we all like a different cut a different style, different fit. And sometimes you just never really know until you try it on. And I've had some patients that want to do the oral pills, but then they start them and they say, you know, something just doesn't feel right. Can I switch? Choosing a treatment option doesn't lock you into that forever, you know, we have some room to change things up and tweak as we need to. But it really is trial and error sometimes trying to figure out what's best for each patient.

Speaker 1  23:18  
Okay, we've become pretty estrogen focused. But there's also progesterone. And I would love your thoughts on why a patient would be a good progesterone candidate.

Speaker 2  23:31  
Well, the main focus for giving progesterone is actually to counterbalance the estrogen effects on the uterus. Like I mentioned earlier, estrogen has so many beneficial effects throughout the body. But the one place that can do some harm is in that uterine lining. Estrogen can cause proliferation of the lining. And if you think back to our menstrual cycle, the way that our hormones are released naturally, when when our reproductive prime estrogen is causing that lining of the uterus to fluff up and get ready for a fertilized egg to implant. And then when we don't get an egg fertilized, you know, after that period of time, then progesterone comes in in that latter part of the cycle and says, Okay, we didn't get the egg fertilized. Let's shed the lining. So that's the way that estrogen and progesterone compete with each other in the uterus. So if you give a woman unopposed estrogen, meaning estrogen alone, and she still has a uterus, then there's a risk of that endometrial lining overgrowing even if you're postmenopausal the progesterone helps to counterbalance that. That's the main reason for giving progesterone. When you compare progesterone alone to estrogen. There are some women that prefer to take progesterone alone for some of their menopausal symptoms, but they're going to have limited efficacy doing that. When you have vasomotor symptoms like the hot flashes, the night sweats the insomnia. Estrogen is by far it's always going to beat out progesterone when you look at them head to head as far as what actually treats those symptoms best. But for some women, if maybe they can't take estrogen for whatever reason, progesterone can help with insomnia It can have the effect of making you a little bit drowsy. Taking that at night can help with that, if that's one of your main focuses, I do have some patients that want to do progesterone alone. But really, it has limited benefit in helping the whole slew of menopausal symptoms compared to estrogen. But really the reason we give it is to counter effect that negative effect on the lining of the uterus.

Speaker 1  25:22  
If you don't have a uterus, then you don't really need it. So you don't need it. But you still can take it if you want to, if there's some benefits to taking it. Right. And then do you all offer oral and topical progesterone? Yes, we do. Okay, so that's offered in both ways. These are good things to share. Yeah. What is estrogen dominance?

Speaker 2  25:49  
Well, the interesting thing is this has become kind of a buzz term lately, and I'm not quite sure like who started it. It doesn't exist as a diagnosis in the medical community at all. If you look in any textbook of OB GYN, there is no term called estrogen dominance. But what this state is referring to is when a woman has an inequality of her hormones to the fact that her other hormones in her body is particularly male hormones that are in female bodies can be out of proportion to the estrogen. And so sometimes you can have a counterbalance it's not normal. One of the typical things that we see for this PCOS, if you've heard of that polycystic ovarian syndrome, is a syndrome for women in their reproductive prime where the hormone released by the ovary, it's not coordinated as much as it should be, it's not regulated, what we have is instead of each month, one follicle getting prepared to release its egg, they have a lot of follicles holding eggs ready in reserve, as a result, they can have what we call a hyper estrogenic state, meaning that they have a lot of excess estrogen in that ovary, that can cause some side effects and some problems. But they can also have an excess of testosterone as well. In our female body, we have both testosterone is responsible for your libido your sex drive, it also can give us more of a push in our metabolism or strength or muscle energy, that kind of thing. But when you have excess testosterone in that condition, you can also have mask analyzing side effects. So women can notice increased acne, hair grow, things like that. In that state, those follicles are basically creating too much estrogen and too much testosterone, and they're not in check. That's really what can happen in this estrogen dominant state. Most of the time, women that are given that diagnosis are told that they cling to that term estrogen dominance. But really, when it comes to menopause, it doesn't matter who you are and what you were doing when you were in your reproductive prime. When we hit our 40s and 45. And 50. There is no woman anywhere in the world that has too much estrogen. Yeah, because our ovaries are starting to basically age. I mean, we're born with all of the eggs we're ever going to have. And the eggs being present and are over here is what drives that hormone production. As the ovaries are aging, and they're not able to provide that anymore. The estrogen is declining. But I have so many patients that come to me saying, Well, I was estrogen dominant. I had PCOS. When I take my HRT, I don't need estrogen. But then at the same time, they're reporting to me that they're having hot flashes and night sweats. And they're talking about all the symptoms to me that are very indicative of low estrogen, vaginal dryness, loss of lubrication. It's counterintuitive. And I have to explain to the patients that yes, you may have had that problem when you were younger. But as we're aging, and as we're going through this transition, it's no longer an issue because the ovary is decreasing its production, your estrogen level is declining as well. You can't be estrogen dominant when you're Peri menopausal. It's just not something that's physiologically possible, if that makes sense.

Speaker 1  29:01  
I wanted to ask that because I've heard the term and I wasn't sure if it was something that could affect women over 50. And clearly it's not an issue. Then there's D H E A an honest to god, I just heard about D H EA recently. And I really don't think it's discussed much.

Speaker 2  29:22  
And then the problem is too, you go online, and if you Google DHEA, there's some information online. If you look up DHEA, that's very negative about DHEA because it's been very widely used by the bodybuilding community as a performance enhancing drug. But in very high doses. DHEA stands for de hydro epi and dosterone. It's a precursor hormone to our hormones, basically, and for us, we actually use it at Wynona to help boost testosterone levels for women to help libido to help with metabolism and to help with weight loss because testosterone also because it's been so abused by the bodybuilding community. I saw it a lot when I was in the military, a lot of soldiers were misusing it to try to be able to perform better to lift more to bulk up. But as a result, testosterone has become a controlled substance mustered in the way of narcotics and benzodiazepines and things like that. dangerous medications that have a highly addictive potential are controlled substances. And so testosterone is so you can't prescribe testosterone through the internet, like telemedicine, like our service at Wynona. So the way we get around that is by doing low doses of DHEA. And what happens is when you ingest the DHEA, it's processed by your body and it's broken down into estrogen and testosterone. So it's a gentle way of increasing your testosterone to get those benefits of improving the libido, improving your energy level, improving metabolism. It's something that can be taken by men and women. Because typically in a man's body, if you take DHEA, it's going to convert into more testosterone, and a woman's body, it does both. And men do have estrogen as well in their body. That's not just testosterone, we both carry both female and male hormones. But it's a nice gentle way to increase those levels. And for maybe a woman who's not ready yet to take estrogen. She could take DHEA, which is technically over the counter, and it's broken down into the estrogen and testosterone and she can get some benefit as she's going through perimenopause from taking that supplement. Oh,

Speaker 1  31:23  
that's super interesting. See, you taught me something else today. I love this. There you go. Winona offers their products through telemedicine as we were talking about, how does that process work? Do you need a blood test? Or how are you prescribing?

Speaker 2  31:41  
Technically, for hormone replacement therapy, you really don't need a blood test. years ago, a lot of doctors would check your estrogen levels, they would check your follicle stimulating hormone level and tell you whether or not you were menopausal and then offer you medication. But really, lab tests are really not that helpful. It's really a patient's symptomatology that is more helpful for us to know what they would benefit from as far as treatment. If a patient comes in and they're complaining of the hot flashes, night sweats, insomnia, vaginal dryness, right away, I know, in my mind, they have those symptoms, their estrogen is low, they would benefit from estrogen therapy. But if we just treated on labs alone, we wouldn't really be treating patients very well, because there are women that may have low estrogen levels. But maybe you've never experienced vasomotor symptoms, or maybe never suffered from hot flashes and looking at the labs and just treating based on those might give them medication that's unnecessary. In those situations, like every woman's experience of menopause is different. Not everyone necessarily needs HRT, and it's really about how their symptoms are affecting the quality of their life. If the symptoms are bothersome enough that it's affecting their ability to function throughout their day, do their normal daily activities work, then that warrants treatment, so you don't need a blood test before doing it. And unfortunately, there's a lot of companies out there right now, other than Wynonna that are offering hormone replacement therapy, but they're requiring salivary hormone testing, or they're requiring some other kind of special hormone testing. And most of the time, the hormone testing is not something that's covered by their insurance. They're paying a pretty hefty fee. But if you look at even our American College of OB GYN, and even the North American menopause society, they caution against doing any kind of that testing, because there's no data to back up that the testing is even valid like that even hormone levels in your saliva are even accurate. And the hormones can change our ovaries as they're starting to age, they might have one day where it's a good day, and the ovary might be like, Oh, here's some estrogen for you. And that's the day you're getting your labs that day, your estrogen levels normal. But then the rest of the month your estrogen is not being released. Yeah.

Unknown Speaker  33:50  
And they feel like hell.

Speaker 2  33:52  
But hormones are released in a post natal fashion. It's not like checking a blood count for anemia. And knowing what your iron level is and repeating it, it's not the same. Hormones respond a little differently, and especially female hormones, they can vary from day to day, from time to day. So if you get your blood drawn in the morning versus the evening, if you had a heavy meal the night before versus if you were fasting, so many things can affect those levels, that they're just not very accurate to base. Our treatment on basing the treatment on symptoms is better.

Speaker 1  34:24  
Got it. And then telemedicine is growing. But I do know that it's regulated state by state. Yes, Winona is in how many states now? Where can they get access to your services?

Speaker 2  34:38  
We're adding states all the time. I think right now we're in about 30. Some states out of the 50 in the Union, but I think our goal is to get in every state eventually. But yeah, it's something that's interesting from state to state, the difference in getting a medical license but also the difference in what the telemedicine laws are as well. Why no one it is what we call an asynchronous telemedicine plan. For meaning that it's not required that you have a live face to face video with a physician before getting treatment. But some states still require that all telemedicine be live like a video visit. In some of those states, we're not in those states just yet. Because we really want the patients to have the convenience of being able to contact us whenever and not to have the roadblock of having a difficulty scheduling an appointment, a patient typically gets on our platform, when they start the onboarding with us, they fill out a pretty comprehensive and adaptive medical history questionnaire. So that's our way for screening to know who's safe to take HRT who's not, and to be able to screen patients to see if they're good candidates or not. And then what happens is, once they complete that process, and they complete that whole medical history questionnaire, it is then forwarded to the physician for that state to review everything. Often I get charts in front of me that were sometimes the patients will list medications that they're on, but then they don't have a condition listed that they're being treated for. And so I have to clarify, we might go back and forth asking questions before we're ready to prescribe anything I'll say like, okay, so what are you taking this medication for? But it's nice, because I might be on call at the hospital, and I might be responding to a patient's message at one in the morning, when she gets up before work, she messages me back. The convenience factor for me is great for patients, because really, they can message us anytime of the day. They don't have to wait until they have an appointment scheduled, which is nice. But as a result, some of those states that require the in person live video chat. We're not live in those states just yet. But we're adding states all the time. The only way to really know if we're in your state is to check the website, like when you first get on why known as website, which is by wynona.com. It'll ask you some information about your age, and it'll ask you where you're located. And right away, it'll tell you whether or not we're in your state or not. What are your thoughts

Speaker 1  36:53  
about the future of telemedicine and how it fits into the medical landscape?

Speaker 2  36:58  
I think it's giving access to care for patients and really helping a lot with getting in to care and to getting the help we need. You know, I think that for too long, there were so many barriers for patients getting in to see a physician for any condition. But now telemedicine not only is here for women's health, like with us with Wynonna, but it's really helped tremendously with mental health issues, especially now, the post COVID era, we're seeing now what we're calling the shadow pandemic, it's everything that's coming after the fact that we were isolated for so long. Mental health and behavioral health issues are really at an all time high right now in this country. And so now there's telemedicine platforms for patients to be able to get therapy online. So I think it's great. I think it's a great option. Now, if you asked my parents, they're not cool with it, because they're not very tech savvy, and they're very confused, trying to do a zoom call or any kind of video chat with them. They don't understand that it might be more challenging for the older generation, I think, especially if they're not using technology as readily. But I really think that improving the access to care. It's been wonderful, because you know, there's patients that live in remote areas that maybe don't have the access to a specialist or to a physician, and now through telemedicine that can get that. I think it's a great opportunity.

Speaker 1  38:14  
I think it's great. Winona has great posts, too. I think it's Angela, she's head of PR. Yes, she does a lot of great things. And it's not just hormone related stuff. It's anything midlife recipes, exercise, I recommend anyone listening to get on Instagram, look at Winona, and look at all the things that they're doing because they really are trying to create that community around the conversation. I would love for you to share like any last words of wisdom or advice for our audience.

Speaker 2  38:51  
My biggest advice to women at midlife, but also at any point in their life. My most important advice to patients is to empower yourself. I think that learning is much about your body and about your anatomy and about how your body works, is the most powerful thing you can do. We are our best advocates, you may go see a physician and you have a 1015 20 minute visit. And they see you for that timeframe. But I'll tell you, I've been to medical school I know about the anatomy, but I don't know your body as well as you know your body. So I think that's the most important thing, collecting as much information as you can. The other thing too is putting yourself first. I'm really a culprit of this too. As a mom and as a physician, I tend to do a lot for other people. If we don't put ourselves first we can't be the best that we can be. We can optimize our health. I have a little thing actually posted in my bedroom that I look at every day that says feed your body like you love your body. Treat your body like you love your body and basically exercise and move your body like you love yourself. And it's one of those things that just as a daily reminder, like we need to read We put ourselves first, we need to make sure we get active every day. You know, whether it be walking, whether it be gardening, whether anything it can like moving your body is going to be protective and helping you against that aging process, and staying fit, staying flexible. And the other thing too, don't ever be afraid to get another opinion. empowering yourself and knowing what you're going through. If you feel like you're not being heard by any provider that's taking care of you, whether it be a physician or a nurse practitioner, a PA, if you don't feel heard, move on to the next person. There's no reason that you should ever leave a medical appointment feeling like they didn't help you and they didn't understand you and that you have nowhere else to go. You should never feel hopeless after leaving. And any good provider should never feel offended. If you ever ask for a second opinion. I want you to feel comfortable. If you're my patient, I want you to feel totally comfortable. We are in a partnership to take care of you. It's not just a dictatorial like, you go to the doctor, they tell you what to do, and you go home and you do it. As the patient you have to incorporate any changes or recommendations we have into your lifestyle to really improve your life. I think knowledge is empowerment, and really doing the best you can you know my other plug to is that be weary of what's out there in the media, get the information that you need from valid sources, but also focus on nutrition too. There's just not enough focus on putting food that fuels your body into your mouth. There's so many marketing ploys to try to get us to eat things that they think are healthy, but it's really just not a high now. And in midlife to women. We don't get enough protein, we need more protein. That's one of the biggest things.

Unknown Speaker  41:41  
Oh my gosh, so much more than we ever thought.

Speaker 2  41:44  
Yes, but yeah, I think that's the biggest point I'd like to get across to women. It's just put yourself first and I need to listen to my own advice a lot of days.

Speaker 1  41:55  
Oh, we all do we all do. Very wise words. Dr. Cat Brown, thank you so much for being on the show today.

Unknown Speaker  42:02  
Well, thank you so much for having me. I appreciate it.

Speaker 1  42:12  
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