Philip Pape: 0:01

If you're a woman approaching and going through menopause, who's been afraid to consider hormone replacement therapy because you've heard it causes weight gain and you've been watching your body composition shift, more belly fat, less muscle, a metabolism that feels broken, wondering if hormones are part of the problem or part of the solution, this episode's for you. Today I invited on a board-certified OPGYN, nationally recognized menopause specialist with 30 years of clinical experience to separate fat from fiction on HRT and body composition. When you understand what the research shows about estrogen, progesterone, testosterone, their effects on fat distribution, metabolism, and muscle preservation, then you can make an informed decision about your health and physique. Welcome to Wits and Weights, the show that helps you build a strong, healthy physique using evidence, engineering, and efficiency. I'm your host, Philip Pape, and today we're going to tackle one of the most common fears that women have about hormone replacement therapy, and that is weight gain. Dr. Maria Sophocles is a board-certified OBGYN and certified menopause practitioner. I'm thrilled to have her on the show. She's been a visiting professor and NIH researcher. She spent three decades helping women navigate perimenopause and menopause. She's a TED speaker, author of the upcoming book, The Bedroom Gap: Rewrite the Rules and Roles of Sex in Midlife. Today you're going to learn what the latest research says about HRT and things like body weight, estrogen in your metabolism, fat distribution. We might get into testosterone therapy and muscle preservation and just how to think about hormones as part of an evidence-based approach to body composition and health after 40. Maria, thank you so much for joining me here on the Wits and Weights podcast.

Dr. Maria Sophocles: 1:56

Philip, I am so glad to be here. This is so much more fun than what I've been doing all morning.

Philip Pape: 2:01

Oh, glad. I love it. I love it. Let's bring the energy. And our listeners are going to love this too because they know I like to frame these discussions with like the basics and stepping back a bit. And what I would love to explore a little bit is we think of perimenopause into the menopause transition and postmenopause starting as early as mid-30s, you know, all the way through when that time occurs. And there's a lot of misconceptions about weight gain and body fat distribution. Now, I've talked on this show about some of the under our understanding of expenditure and metabolic rate, how most people on average have the quote unquote same metabolism from their 20s to their 60s. And yet women are experiencing all of these issues with weight gain and body fat into as early as their 40s and 50s. And so let's reconcile what's actually happening, even when there's no HRT involved with the average population, knowing many of them are not resistance training and a lot of our audience are, but let's just talk about the average to start.

Dr. Maria Sophocles: 3:01

Yeah, of course. I think that the first thing to know is let's let's do a super basic definition of what menopause is. It's our ovaries age more quickly than other organs in our body. That's how we're built as humans. And there's a lot of cool biotech companies looking into actually slowing or stopping ovarian aging, which is just mind-blowing if you think about it, because it means potentially women would be fertile for their whole lives. Uh also means you could have periods your whole lives, but it also means that you wouldn't have this aging out. You wouldn't have this loss of what we call ovarian sex steroids, which we know are worth a lot of gold. They're a lot more than just being able to be pregnant. Keeping estrogen, progesterone, and testosterone in your body affects bone health, brain health, heart health. We call it preservation of function. And all of those functions take a big hit when menopause occurs. So if menopauses, if that definition is sort of the cessation of function of the ovary, what that really means in terms of hormone production is you get a drop in estrogen, progesterone, and testosterone, those three big ones. I'm sure your listeners are smart and they all know that because they've been listening to your 400 episodes and you've got a whole following of bright, informed people. But for anyone who isn't sure, that's what menopause is. It's from when that happens, the average age in the United States, about 51 and a half. But women are living longer. So now you are gonna live as a woman if you're healthy and you do things right, a third of your life without the benefit of those ovarian hormones. And yep, you can get around that somewhat with uh strength training and you know, all kinds of exercise and and being perfect diet and all kinds of stuff. But the bottom line is those effects are going to begin. The effects on bone, on heart, on brain, on muscle. And we know that estrogen has effects on all of those things, plus joints, plus the synovial fluid that keeps our joints, you know, lubricated, plus our skin, plus our hair. I I could go on and on.

Philip Pape: 5:12

Pretty much every muscle mass plus muscle, right?

Dr. Maria Sophocles: 5:15

Uh and and and the unsexy stuff too, like eyes and teeth, dental health, gums, ears, it's pretty hard to find something that isn't impacted. Our heart, our heart rhythm. Um, so it's um it probably our gut microbiome, our vaginal microbiome, our bladder. Like I could go on and on. And I don't, I'm not being Debbie Downer. I'm just saying, you know, if you're a woman out there and you haven't had a urinary tract infection since you were a teenager and now you're getting two, three a year, don't kid yourself. It's because there's not as much estrogen making blood vessels around the bladder to keep things clean and healthy, and and making the vagina keep bacteria that keeps the bad bacteria out. So it's all very related. So that's kind of what menopause is. And people ask me pretty much every day, because I run a menopause practice that's virtual. So patients from different states call in, we have consults. They say, What why am I gaining weight and why is it all in my belly? Those are probably the two most common questions I get. Because everyone knows why they're getting hot flashes. There's not a woman in America that doesn't know that a hush is related to menopause, but they didn't expect the weight gain. And this really makes people frustrated when they are already health conscious and they're already doing all the things well. Yes. They're like, they they literally put their hand up and go, Don't tell me to stop going to Burger King because I don't. Don't tell me to stop eating cheesecake at the Cheesecake Factory, because I don't, you know, and I'm like, I'm sorry.

Philip Pape: 6:45

This is where you see the comments on Instagram under like some 25-year-old, you know, male uh personal trainer, right? And you see the comments like, Don't talk to me about this. I'm doing all these things already.

Dr. Maria Sophocles: 6:56

Yeah, but for midlife women, it is super frustrating because they they often truly are eating and drinking correctly and they've done their reading and they're listening to all the right podcasts, like wits and weights. So people always say, Why? Why? What did I do wrong? Why? Well, first of all, it's not like just you. 85% of all midlife women get have unexplained and undesired weight gain in menopause. 85%. So if you're gaining a little men know tummy, you're actually in the norm. Not that we want it. And society does not is not very forgiving. You know, no Hollywood directors like, I'd really like to cast someone with a belly hanging out over the bikini. I mean, we live in a society that doesn't accept that that's the norm and we don't want it. I don't want it either myself. So I feel you, is what I'm saying. But 85% will have undesired and unexplained weight gain in the abdomen. So if you want to understand the science behind why, because I do think, Philip, you and your followers seem to really want to know the science. This is a one I've I'm on zillions of podcasts, and some people actually don't want to know. Yours is pretty brainy, I find your followers kind of know. Yeah. So let me explain why. When those ovaries go to sleep in menopause, both the estrogen and the testosterone are decreasing, and but it's oversimplification to think they both just shut off and go to zero. They don't. The ovary stays alive and keeps making hormones, but a tiny little amount. And for most women, the estrogen drops more than the testosterone does. So if you look at my hands and they're both dropping, the testosterone drops less, so that metabolism sees something it hadn't seen before, which is a relative up of prevalence of testosterone relative to estrogen. And you haven't seen that as a woman your whole life. That's part of being a woman. That's why we don't have super high testosterone in your mom's uterus when you're a fetus growing, all these little things happened uh when you had two X chromosomes that quieted the testosterone. Whereas if you were an XY fetus becoming a male, you had a whole lot more testosterone made. So since you were as a female fetus, you've had this testosterone pretty suppressed. There, we've all made it. We make it for sure. But the estrogen kind of zoomed ahead and was sort of the dominant hormone. Now you're in menopause, they both drop, but the estrogen drops way more. So suddenly your body sees testosterone. Well, what does it do metabolically with that? Metabolically, with that picture, where fat is deposited is what changes. It doesn't make you fat, it changes where the fat goes. So it is preferentially deposited on the abdomen. How do we know this is the case? This isn't a Maria Sophocles idea. This is people way smarter than me who figured this out. They looked at male fat deposition. And if you look at a male who gains weight, they don't get heavy thighs and a big bottom. They don't get it on their hips, they get it on their belly.

Philip Pape: 10:13

That's right.

Dr. Maria Sophocles: 10:13

You know, look at those like German guys at Oktoberfest, right? Their little butts and their legs are skinny, but their bellies are huge.

Philip Pape: 10:20

And we kind of accept it, right? Like, okay, you expect men to have big bellies, even in their 20s and 30s. Yeah, yeah.

Dr. Maria Sophocles: 10:25

Yeah, I'm a male. This is where it's gonna go. And you and I know it doesn't have to be that way, and we know you can be more fit than that. But if you just leave it to wherever your metabolism wants to put fat, and you give it enough fat or calories, it's gonna put it on your belly preferentially as a male. And as a menopausal female, there is this shift. It doesn't mean you can't gain weight in your butt and your legs, but there's a shift towards a preference or uh to deposit in the belly. And man, does this piss women off to be living the same life you've lived for the last 10 years as a woman and suddenly you're getting a belly? And I think there's shame behind it, Philip. I think women see the belly and they think, man, everyone's gonna think I sit up all night and eat Cheetos, binging Netflix, and I'm not. I'm going to Pilates, I'm doing yoga. You know, there's a lot of psychology behind this belly fat that is devastating to women. I mean, you know, it's easy to be like, oh, come on, you're only 10 pounds overweight. But it really bothers them because they're trying to do the right thing. Their own metabolism is betraying them based on what's happening in the ovaries.

Philip Pape: 11:32

Does that make sense? It makes total sense because I hear it from women who are in that age and they're asking for like training advice where they've already gotten pretty lean and now they're like, my triceps and my abdomen, and they still, you know, want to work on the butt, right? That's always there. But it's like the uh the abdomen, you know, the belly area and the triceps and some odd areas that I hear over and over again. I don't again, I don't know where the try the arms come into it, if that's related as well. But definitely.

Dr. Maria Sophocles: 11:57

I think it's that we see it. Like the reason people women care about the triceps, because they all ask me the same thing. Like, how do I do this? It's because when we wear a sleeveless top, right, we know that if any fat deposits there, it's seen. You can see it. And so it's limiting, it's wardrobe limiting. I know that sounds so vain, but it it is wardrobe limiting, you've got something jiggling there. Whether you have a nice bicep or not, if you've got something jiggle there, that's it, it's like, oh, rats, you know. So midlife weight changes. So let's also do a real basic statement that menopause itself doesn't cause the weight gain, it causes a redistribution and a change in body composition. So weight changes are driven by I'm gonna give you like four or five points that we could list or we could, you know, declining estrogen, loss of muscle mass, because we need that muscle mass, because muscle mass requires more calories than fat does to maintain. So if we lose muscle mass, it's simple math, and keep the same calories, we're gonna gain weight. So you either have to really cut those calories down, which no one tells you, or you need to build muscle mass. Ideally, you actually do both, you know, and and this is why the GLP ones work so well. But GLP ones work well if you combine them with building muscle mass. You know, I didn't want to, I don't work for the GLP one company.

Philip Pape: 13:18

So don't worry, we talk about it a lot.

Dr. Maria Sophocles: 13:20

Okay, good, good, good. So I've been I've been prescribing them for 10 years, so I'm I'm in it's old hat in my office. So declining estrogen, loss of muscle mass, reduced resting metabolic rate. Our metabolic rate does drop down. Another reason why menopausal women need about 250 calories less a day, which by the way, Philip, no one tells you that. You know, there is no such thing as, you know, we have sex ed for teens. Well, in my opinion, we need a sex ed for menopause, but we also need a health and fitness ed for menopausal women. And there isn't that. So they're thank goodness they're learning it from people like you and me.

Philip Pape: 13:57

Can we hit on that one real quick? Because that's the one that I think has a lot of confusion, right? There's like all the new research from Herman Ponser about the constrain versus the additive model of expenditure. And there's, you know, we look at population studies that show pretty stable RMR, but then when it counted for body composition, we see the differences. And so I'm wondering if number two and three are just kind of linked, or is this specific to the hormones, you know, as an independent variable?

Dr. Maria Sophocles: 14:24

I think it's specific to hormones as an independent variable because if we take away any hormone factor, then what I said, it flies in the face of what you said. They're opposite, and they're not opposite. They're right, if resting metabolic rate stays the same, none of this should happen. But is that reminds some change?

Philip Pape: 14:40

Yeah, what I'm saying is the RMR dropping by 250 calories, is it part of the loss of muscle mass causing that?

Dr. Maria Sophocles: 14:48

Yes, yes.

Philip Pape: 14:49

They're all right as well as like, I mean, I always wonder how how often we're teasing out things like uh chronic stress in that population and stuff like that, because that also exacerbates.

Dr. Maria Sophocles: 14:59

I mean, you know, I'm making these big, giant generalizations. You understand that, right? There's individual variation and a lecture I gave this week on wellness. Uh, so cool. If any of your listeners uh belong to the Noom app, they can find the live stream of Noom's first Art of Wellness Summit that was done in Princeton, New Jersey day before yesterday. Incredible lectures on that. And one of the things we talked about, um, this is a little tangent, but then I'll come back, was that loneliness and not being socialized decreases your oxytocin even oxytocin decreases with age, but if you're lonely and isolated, it decreases even more. And the the kind of mic drop thing I brought to the lecture was that oxytocin actually relates to our ability to build and maintain muscle. So when you get old people living alone, their muscle wasting is even faster than old people who live in groups or go to church or a bowling league or whatever their book group, they're socialized, their oxytocin goes up, and we see they're better at building and maintaining muscle. Isn't that wild?

Philip Pape: 16:07

Yeah.

Dr. Maria Sophocles: 16:08

You know, so don't be alone. Go join a book group or something. Get your oxytocin.

Philip Pape: 16:13

I think it's also correlated with it's like the with happiness, like you know, social uh connection is the number one rated correlation with happiness and well-being, and you know, meaning in life.

Dr. Maria Sophocles: 16:23

Totally, totally. And my lecture was on sex and longevity and health and why being sexually active releases dopamine, releases oxytocin, you know, and actually is part of a pillar of health because when you're releasing those, you feel more pumped to exercise, to tackle your life, to go out and socialize. So kind of cool how it's all related, right?

Philip Pape: 16:44

It is all related. It's funny. I know we're not going to get into, well, we could talk about sex because I know it's an area of expertise, but like that also is a big frustration with women. You know, I work with a lot of clients one-on-one and we get into these more private conversations, but it's like, now you don't have your libido, now you don't have the desire, now you feel like you're not desired, and then that all exacerbates not having sex. Exactly.

Dr. Maria Sophocles: 17:03

Mike, tell them what Google TED Talk Maria Sophocles, and they'll see the TED Talk. We'll throw it in there.

Philip Pape: 17:08

We'll put that in there.

Dr. Maria Sophocles: 17:09

We'll throw it in there. So let's go back. Midlife weight changes. I kind of wrote this down so I wouldn't forget them. Driven by declining estrogen, loss of muscle, reduced RMR, resting metabolic rate. And there's also an increased insulin resistance. So so many factors. And again, I think that's also why, you know, people gain and they feel like they're not doing anything different. The same uh few snacks of licorice, which, you know, okay, we're all allowed to cheat and have something, uh, and and they're gaining weight and they feel like I'm not sinning any more than I used to. But if you have increased insulin resistance, you this is a different metabolic picture, you know.

Philip Pape: 17:48

Do we know if like things like leptin resistance are also part of the equation, which causes worsening in appetite from like usually it's from chronic dieting, but yes, but I think I gotta check that.

Dr. Maria Sophocles: 17:58

I don't want to misspeak. Oh man, you caught me. I gotta check that. And I got asked that a few months ago and I had to look it up. And my my poor little menopause brain, it leaked out. But that's a great question. And now I'm not gonna forget because I've been asked twice. But don't forget about lifestyle factors too. Midlife for men and women is often a time of sleep deprivation. People are peaking in their careers, you know. I need this report, I need this. Their parents are aging, their kids are older. They they tend there tends to be sleep deprivation and sleep sleep disruption because we know that hormonal changes cause sleep disruption. Lack of estrogen really affects sleep in multiple ways. So women are sleeping less, they're not going to bed at the same time every night, and their sleep is very disrupted, a lot of light sleep. So that massively affects. There's a study out that showed that women with sleep disruption consume 350 calories a day more than women who have, you know, perfect steady sleep. So that is such a bummer because the sleep disruption is so common. So you're getting all this stuff stacked against you. So I just want women out there to know this isn't just you. You're not just lazy or overeating cheetahs, or you know, this is really a lot of cards stacked against you. And it doesn't mean we can't help them. It just means it's not something you're necessarily doing wrong. During the menopausal transition, women gain on average, I think, five to ten pounds. But you know, the average height of a American woman's five, four. So I'm five, two. I can tell you five to ten pounds on me, it's a big deal. For sure. And sadly, some women saying it's 30, you know. Um, and that's also because of COVID.

Philip Pape: 19:44

Remember, we're coming off COVID where they might have gained, and then that I was wondering how far does that weight gain outpace male weight gain during the same age range? I'm curious about that. I'm guessing men gain weight just in general. Everybody gains weight as they get older because they're not doing certain things.

Dr. Maria Sophocles: 20:02

They gain waist circumference for sure, because remember, it's all getting deposited in the waist, but I know that women catch up in the waist circumference. They they start getting the waist circumference ads, but I don't know the absolute, like how many pounds men, because I don't treat men.

Philip Pape: 20:18

Oh, yeah, I was just curious the relative in terms of relative body weight, because I definitely know what you mean with the great question. Yeah. Okay, so that so this is good because you you listed some major factors. Fortunately, we we do discuss a lot of that here, and so it's very relevant, but it's also bidirectional, right? Because number one, you listed was the estrogen, and we started this conversation with framing around hormones, and we don't want to say like hormones are the root of every problem, right? Like any of these things, it's nuanced and multifactorial, and yeah, one supports the other. Yeah.

Dr. Maria Sophocles: 20:48

No, it's exactly stress, sleep, you know, a lot of things, uh, self-esteem, you know, a lot of these things, sexually active. I mean, all those things. We know that women who are sexually active actually have fewer menopausal symptoms. That doesn't mean they gain less weight, just means fewer and more mild menopausal symptoms. But estrogen therapy, can we switch to that for a sec?

Philip Pape: 21:07

Yes, because we're gonna talk about HRT and like there's fears of weight gain on HRT, which I actually didn't realize that was a big fear personally, because I'm in a different population where like people have heard good things about HRT. But yeah, we want to address this.

Dr. Maria Sophocles: 21:22

Well, anything that could be weight gain is a fear for women. They really hate it. Any med, if I put someone on medication that has nothing to do with weight or whatever, people's first question is like, Am I gonna gain weight?

Philip Pape: 21:32

Does it cause weight gain? Yes.

Dr. Maria Sophocles: 21:33

Don't you want to know if it like causes cancer or something? No, they just want to know if it causes weight gain. So, no estrogen therapy does not cause weight gain. Okay, that's happy. So, anyone out there who's staying off estrogen because they worried it causes weight gain, that's not. Does it mean we all don't know someone? Sure, there's always someone who says, Well, my aunt gained 30 pounds. We don't know. Was she gonna gain those 30 pounds? Was she did she quit smoking? Which can, you know, I'm glad she quit smoking. It's healthier, but some people who quit smoking start snacking. And so it's you know, who knows if it's the if it's the estrogen therapy. No, estrogen therapy itself, it also doesn't cause weight loss. So I don't want to mix that up, but it does reduce visceral fat. It does reduce, I mean it does improve insulin sensitivity, and it does preserve lean muscle mass. So those are all good things, and it may slightly increase resting energy expenditure. So I I don't want to sound like an estrogen salesman, but that's I but I also don't want people to think, okay, I'll go on estrogen therapy and I better lose all this weight. No, that's that's not why you go on. You go on estrogen therapy either to control menopause symptoms or to preserve function of brain, heart, bone, or both.

Philip Pape: 22:49

Yeah, but that's not sexy, Maria. I know, but no, no, that's I'm speaking for my listener, right? They're like, Yeah, yeah, okay, that's fine, but you know, I really need need a good reason to go. And and those are good reasons. I'm just joking.

Dr. Maria Sophocles: 23:00

Yeah, no, I know. Sexy is take this and you'll melt away all the fat, your legs will get longer and all your wrinkles are go away. And that that's a mistake, you know. I mean, even now women put estrogen on their face, and there's, you know, they're as long as you're not overdoing it, it's probably not dangerous. But we don't really have great data to say that if you put estrogen on your skin, the wrinkles are gonna go away. We know that the best thing that you can put on your face to is sunblock to prevent wrinkles, or retinoids, which uh have been shown to create new collagen. And there are some small studies that do look promising for estrogen on the face. So, you know, you're welcome to buy it and do it. I'm never gonna tell you not to, but you know, even things like that, we we don't have 10-year studies or anything. So, buyer beware. There's a lot of stuff out there, you know, it's it's probably it's probably harmless, but we, you know, and same thing with systemic estrogen therapy. We have tons of data on that, on cancer reduction risk. We know that's very strong. Dementia prevention, a little weaker, uh, cardiovascular benefit, pretty strong. Bone health, super strong, super strong. The best thing you can do to be a strong 75 to 95-year-old woman is regular exercise and using estrogen in your 50s and 60s systemically to slow the decline of the loss of bone.

Philip Pape: 24:25

So let's talk about then that who should be using it. If if you had a thousand women walk in your office, you know, taking out any conflict of interest for services, or like obviously, and they were in their 40s and 50s, like, are we saying 100% of women would benefit at some point because you're gonna lose it no matter what? You live till you're 80 or 90?

Dr. Maria Sophocles: 24:43

Close to 100%. Uh, the only women who absolutely should not are women who currently have a cancer that is dependent on estrogen, a breast cancer or an ovarian cancer. That said, that's stating the obvious, but I better state it. Otherwise, it's pretty hard to find a woman. Uh, we used to say no women with heart attacks or strokes because estrogen can make clots, but that was the old formulations that were oral. Now we don't use oral, we use transdermal gel, patch, spray. Because it goes through the skin, it doesn't go through the liver, and you don't have the clotting issues, you don't get the cholesterol bump, and they're so, so much safer. So now it's very rare that I have to look a woman who wants it in the eye and say, I'm sorry, you just can't do it. And it's usually someone who already has a cancer. We know the genetics of that cancer. And of course, those are the women that come in with a million hot flashes saying, please, please put me on it. But we do have non-hormonal things for those women, FDA-approved non-hormonal things. We have we have herbal supplements that actually work quite well. So we have non-prescription and prescription things. We have devices like this little bracelet, the ember wave. This was invented at MIT by two scientists. It goes on your wrist. The little bracelet part goes on the inside. It actually senses hot flashes in the brain and it cools the wrist in this funky uh on-off kind of pattern, and it stops the hot flashes. So plenty of things that are not estrogen if you need help.

Philip Pape: 26:14

Okay, I know I know some women that would like to know about that lot, that uh that jewelry there.

Dr. Maria Sophocles: 26:19

EMBR wave, embr wave.

Philip Pape: 26:23

Ember, like like on a fire. That's cool. Okay, yeah.

Dr. Maria Sophocles: 26:25

It also heats. Like if you're someone who's always cold, it's a different button you push and it'll warm you. So it's pretty cool. Ember Labs is the company. And uh I think I love it, it's interesting. Yeah, I love tech too. I mean, look at all the cool data we can get now, right?

Philip Pape: 26:40

It's right, that's right.

Dr. Maria Sophocles: 26:41

I think it's gonna help us be able to be better patients because we can advocate for what we have. And I hope that the medical education system will catch up. So when you walk in with an aura ring or whoop, your doctor will have it downloaded and your doctor will be able to say, Hey, right now, no, they're behind.

Philip Pape: 26:59

Right now, my two doctors a mile apart can't even get the same information.

Dr. Maria Sophocles: 27:02

So you know that we're embarrassed by where it is now. That's why people like you and I have to kind of own it ourselves. I think.

Philip Pape: 27:10

Yeah, I think it's great.

Dr. Maria Sophocles: 27:12

That's okay, it's just where we are. Um, but on the central fat accumulation kind of one last thing. Yeah, no, for sure. Women who are on estrogen therapy tend to have less central abdominal fat accumulation compared with those not on HRT. So that is a kind of sexy thing to say.

Philip Pape: 27:33

That's good.

Dr. Maria Sophocles: 27:34

That's as sexy as I might be able to get today. I don't know.

Philip Pape: 27:36

No, I mean we've established that most women probably could benefit other than via a specific population that that just can't. We've established that it helps with a lot of these things you talked about before, including maybe a resting metabolic rate, definitely your the symptoms, and gives you resistance, and gives them resistance, resistance, gives you physiological replacement, all of that. Uh and then like and the root, the root matters.

Dr. Maria Sophocles: 27:59

The transdermal A is safer, B, it's good for everyone, and C, you get less fluid retention, which is what a lot of people perceived as weight gain from the olden days when it was oral, and you get less impact on cholesterol and triglycerides in a negative way. And so if you prefer if weight gain's an issue for you or metabolic concerns, you want to make sure you're transdermal.

Philip Pape: 28:23

Transdermal. And then that segues into the other two hormones you mentioned. And I know there are others, there maybe thyroid and DHAA, but let's just focus progesterone and testosterone. Yeah.

Dr. Maria Sophocles: 28:33

Yeah. So progesterone is weight neutral. There's no effect on weight from progesterone. I have had patients tell me, I swear to you, I gained weight on progesterone. I I believe them because I believe my patients. But if you look at a thousand women and you look at the science, it's it does, it's not supposed to put any weight on you. I think if you treat enough people, you're gonna have someone for whom that's not true. But in general, weight neutral and progesterone, I call it proslee because it can have positive effects on sleep. If you take it orally, it releases something called GABA in the brain, which is almost like a whiteboard for your brain. So when you've got too much, your brain's gonna explode. It helps you sleep. And so what we said before counts. If you sleep better, you eat better, you exercise better, your outlook for the day is better. So I would say progesterone, if you have a uterus, you need progesterone. Remember, if you've had a hysterectomy, you do not need progesterone. You could take it if you wanted, but you don't need it. When we give it as hormone replacement therapy, we give estrogen for symptoms and preservation of function, and progesterone to protect the uterus from estrogen growing tissue. And you know, estrogen has great effects everywhere except the breast if you have cancer. Uh, if you don't have cancer, it doesn't have negative effects on the breast and on the uterus where it'll cause tissue to grow. And after menopause, you don't want any tissue growing there. That's why we give the progesterone. As far as weight, there are different types of progesterone. Okay. There's a micronized progesterone, and that is the most natural progesterone we have. The brand of that, I don't know if we're allowed to say brands, is called Prometrium, P-R-O-M-E-T-R-I-U-M. That is probably the best one in terms of no issues for weight. It's very natural. The more synthetic stuff, when you get into synthetic progesterones like MPA, madroxy, progesterone, acetate, those are more likely to cause an increased appetite. So now it may not be weight neutral, more likely to cause fluid retention, more likely even to cause mood changes. So let's just say the flavor. The flavor of progesterone you are given matters. Um, so do ask for micronized progesterone.

Philip Pape: 30:50

Micronized.

Dr. Maria Sophocles: 30:51

Yeah, it doesn't have to be made by a fancy compounding pharmacy. You can pick it up at CVS or Walgreens, but the type of progesterone matters much more than whether it's used or not.

Philip Pape: 31:01

Is that a cream as well?

Dr. Maria Sophocles: 31:03

Uh no, there are progesterone suppositories and creams, but those creams on the market are not FDA approved or anything. I'm not saying they don't work. I'm saying if you want to go with something with a lot of nice data behind it that's safe, you want a prescription for the prometrium or the generic of prometrium called micronized progesterone. Okay. Um testosterone. I want to do test progesterone because it's kind of short and sweet.

Philip Pape: 31:29

Right. I like it.

Dr. Maria Sophocles: 31:31

Yeah. So testosterone is kind of all the rage. I've been using it in women for 20 years. So I'm like, oh, everyone's just figuring this out. But it is made in women, as I said, even in little babies and young girls make testosterone. When the ovaries stop making it, we do have a deficiency in it. This can affect our libido. This can affect our ability to build lean muscle mass. So low dose testosterone in women. And I have to use the word may because it's not because there aren't studies or data, because again, we live in a country where we have to discern between something that's FDA approved or not. And we do not have an FDA-approved testosterone for women. We do for men. So I'll say may. It may increase lean muscle mass and improve insulin sensitivity, and it may enhance energy and motivation. So that's my textbook. If you were my med student, how I would teach you. What do I see with my patients? I see that in the right ranges, it definitely improves energy, outlook, lean muscle mass. It's been phenomenal and libido. The kicker is the levels, right? The levels in a postmenopausal woman are pretty low. They're close to zero. The levels in a pre-menopausal woman, 30 to 40. If I just give you enough, Philip, if you're my female patient and I give you enough to get you back to your pre-menopausal level, most of my patients don't feel much of anything. I have to really get a little higher than that. And that's where we're walking a little tightrope of we have data from trans women. You know, that's where the data comes from. Because when trans women choose to take testosterone to get a beard and stuff, they're taking huge doses.

Philip Pape: 33:20

To masculinize, yeah.

Dr. Maria Sophocles: 33:21

Yeah, to masculinize. So, and they're pretty safe. So, so I feel comfortable sneaking up a little above that normal range, uh, into like the 90 to 100, 120 range. And at that range, women come in and they're like, first of all, I want sex again, which is fun. I initiate, which is fun. I go to the gym and work and work and work and get nothing. But now that I'm taking the testosterone, I actually see some definition and that feels good and it makes me feel happy. One woman told me, My world is like, uh, what did she say? It's like a rainbow now or something. It was some corny phrase, but I knew what she meant. She had energy and a good outlook. And so I, you know, I use it. It does not cause weight gain, you know, when we dose it correctly. I never have anyone come in and say the testosterone caused weight gain. Um, so I think, you know, those those are your three. Um, but I want to hear what you want your listeners to hear more about.

Philip Pape: 34:21

I mean, two questions on testosterone. One, you mentioned earlier the ratio of testosterone to estrogen increases uh naturally. And so are you doing them in conjunction or is it just you get the labs and the testosterone is just really low. Yeah.

Dr. Maria Sophocles: 34:34

Well, let's talk about the labs, okay? I use labs for testosterone because I treat people all according to their symptoms. How do you feel? But also with testosterone, I follow the labs because I don't have an FDA-approved thing where I know this has been tested on 10,000 women and we don't need to check the labs. It's always between X and Y. So, and women metabolize it differently. They have a protein in their blood called sex hormone binding globulin. So, if anybody out there is getting testosterone therapy, your clinician should be checking your total testosterone and your sex hormone binding globulin, because if it's super well, I don't want to overkill it, but that that's important. So I treat according to subjective needs, but also within the parameters of safe levels for testosterone. For estrogen and progesterone, we actually don't treat levels, we treat symptoms, right? So if Mrs. Smith is on an estradiol patch and her hot flashes are totally gone away and she feels great, I don't need to increase her estrogen dose. If she comes in and says, Wow, you put me on this patch and my breasts feel huge and swollen and tender and I'm miserable and I'm spotting now, well, I probably aimed a little too high and we need to go down. It's kind of that simple. So a lot of clinicians who get money from labs are now charging a lot to do a lot of labs. And I would urge people to be very cautious about anyone who's ordering a hundred estrogen labs on you. Same with breaking the estrogen down into estrone and estradiol and estriol. Estradiol is the dominant estrogen. It's what we replace, it's bioidentical, even though you can get it at CVS and Walgreens, and you don't need it from a fancy compounded pharmacy. You don't need it in pellets. You can use the patch or the gel safely. It's been well vetted. The doses are very consistent and it's covered by your insurance. Um, and it's all you need. The others just morph into estradiol anyway. So people have made entire careers off of this many labs, stacks and stacks of labs, convincing people they're estrogen dominant or they need some weird form of estrogen. It's really you're spending money, you don't need to spend.

Philip Pape: 36:50

Yeah, it's kind of a wild west with functional medicine out there today.

Dr. Maria Sophocles: 36:54

And some of it's great. I'm not, but some people have taken it to such an extreme that patients come in with 50 pages of lab work and they say, I am so confused. I don't know what I'm on, I don't know what I need. And we usually can really simplify it down. So they're getting the true health benefits without eight different things.

Philip Pape: 37:15

Okay. And then the testosterone is also transdermal. I know you caution against like the pellets. I've never heard good things about those, but I'm not sure.

Dr. Maria Sophocles: 37:22

Oops, I caution against them, but but because they can be super, super high doses, but in the right hands, people tracking them, that's okay. You know, I just caution against um when people are having you know crazy high stuff and then their voice changes or the clitoris enlarges. Some of those things don't reverse.

Philip Pape: 37:42

And you can't do anything about it because the pellet is there, right?

Dr. Maria Sophocles: 37:45

Yeah, and it's stuck for the next few months. So I just I think at least I would say maybe baby step and start with the lower dose and come in and have a good clinician where you can face to face say, Hey, I know you're trying to be safe with me, but I don't feel any benefit. Okay, all right, we'll go up. But if you start wham, high and you've got acne and chin hair, and you're moody and you're raging and you have road rage, because I've had people come in with that and they say, get the pellet out of me. Somebody put that in, and I want to kill my husband, and I'm screaming at everyone, and I have acne. And I'm like, I I can't do anything for you, you know. Um, go to go to Bali for three months and do meditation. Like, so you gotta, you just gotta be careful of who's treating you and what's their ethos and stuff. I I think safety is a great place to start, you know. But I also have testosterone be so helpful for women.

Philip Pape: 38:38

I think this is great the way you're simplifying it today. And I know speaking of safety, maybe we should just put to bed in case anybody isn't already the any cancer risks, you know, from like the women's health initiative, you know, and also the synthetic versus the natural, if there's any differences there, yeah.

Dr. Maria Sophocles: 38:54

Yeah, yeah. So cancerous, that's so smart. And it it we could say it a hundred times. We could do a hundred episodes of it because in case anybody misses it, it's one of the single biggest sadnesses in women's health for the last 25 years. 23 years ago, a study came out and they evaluated the data incorrectly and they announced at the FDA hormones, estrogen causes cancer. It increases the risk of cancer. The whole world went crazy. Everyone stopped using it. When the data was redone and properly statistically analyzed, the fearful stuff did not make statistical significance. It didn't, it's like if I'm in the NCAA championships and it's tied and there's one second left, and I throw a three-pointer and it hits the rim and then falls out. I don't get a point for that. I lose. You only get it if it goes in the hoop. And this the data did not meet, did not go through the hoop, but they announced that it did because they kind of thought it was trending that way. And that oops has cost, we believe, 150,000 lives, premature deaths of women. Isn't that stunning? Wow. Stunning. Yeah, we've a Yale study now showed how many women have died prematurely because of that incorrect news because they got their estrogen prescription and then got scared and threw it out. The data since then, and there's a ton, has shown quite the opposite. Women on HRT, which is estrogen if you have no uterus, or estrogen and progesterone if you have a uterus, have a reduced rate of cancer. When they use that HRT between 50 and 60, probably even early 60s, it's a in the 30%, 30-something percent reduction in breast cancer, about a 40% reduction in colon cancer. I mean, there isn't enough fiber on the planet to lower your colon cancer risk that much. Massive reduction in osteoporosis development, which women my age, you know, 25, just kidding, I'm much older than that, don't think about osteoporosis yet. But believe me, when you're 70 and 75 and 80 and all your friends are falling and going to assisted living, you wish someone had told you this. So the best thing you can do to be a healthy 75, 85, 90-year-old is to slow the bone loss now. The most rapid loss of bone is in the first five years after menopause. That's your magic window. And so to get estrogen then and put the breaks on the bone loss then pays you dividends. It's like putting money in a savings account when you're young. It grows so much by the time you're old. So I think the WHI, by telling people it was dangerous, it caused a lot of harm. Now we recommend uh HRT for all women, with the tiny exceptions I mentioned, immediately when they become menopausal. In some women, we start in perimenopause just to relieve the symptoms they're having. But for bone health, we want everybody on it, you know, for 10 years. And some of us, like myself, I will stay on it forever because I have really strong family history of heart disease. So I don't want those plaques in my arteries to get a chance, you know, to grow. Cardiovascular disease is the number one killer of women. So if you have extra risk for that, just like if you have extra risk for osteoporosis, let's say you're on chronic steroid use or your mom and aunts all had osteoporosis, you may want to stay on estrogen for the long duration. Because guess what? Once you come off it, the bone health starts to deteriorate. So the key thing is to individualize it, is to go to a good menopause, educated, and trained clinician. And you can find them on menopause.org and put your zip code in and find someone and say, Hi, here, here's my life. Here are my risk factors. I smoke or I'm omit osteoporosis or breast cancer, whatever it is, and let them tell you, oh, I would, I think, you know, but they're if you're 50 to 60, they're gonna mostly suggest you be on it because the benefits so far outweigh the risks.

Philip Pape: 43:02

Yeah. And so that I guess the last question then related to that, when to go on it, what about women who are early perimenopause and the really only recourse they go to right now is maybe their GP or OBGYN? And I hear stories almost every day, Maria, about like I went to my OBGYN and she said, you know, some silly thing. No, there's no way you need to consider hormones ever. You know, it's like these blanket sandings you still get. Yeah.

Dr. Maria Sophocles: 43:26

So the other bad news, and in in my book, I talk about how we have to revamp sex ed for kids to be more inclusive and updated, but we also have to revamp medical education. Those doctors were not trained in menopause at all. I mean, you realize I got no menopause training in medical school. I did. And so if I got no menopause training and one of the country's top menopause experts, you know, all the rest of the doctors got nothing. And what did they read in 2008, 2010? The WHI. So If your doctor says boo poo-hoo on menopause HRT, you just thank them and you go find another doctor. Now, what you can do for yourself if you're in perimenopause and you're having symptoms, a boring old birth control pill is a wonderful gap closer. We used to sell, oh, you can't be on the pill after 35. That myth is old and disproven. We use the pill now from age like 40 to 50, just like uh I'm a Philadelphia girl, like the Phillies would use their eighth inning closer to bring in for the eighth and the ninth inning. You know, you need a change of picture. And same thing. The pill will smooth the fluctuations of perimenopause. Perimenopause is almost harder than menopause because the hormones are there, but they're going like this. And it makes crazy mood stuff. Periods go crazy. Women get really frustrated, and their doctors are like, You're not in menopause because you're still having a period. Maybe uh you need wine at night. You know, they get dismissed, really badly dismissed. But a simple little low-dose birth control pill can do a lot. Don't think of it as a birth control. Think of it as a, here's what I call it, a perimenopausal smoother, right? And if you're doing that from 47 to 50 or something, and then periods stop altogether, okay, you're probably in menopause now. You can get your blood drawn, look and see if your FSH is elevated. Yep, you're in menopause. Or no periods for a year, yep, you're in menopause. Now change from the birth control pill to the little patch and you're good to go.

Philip Pape: 45:33

All right, great. This has been a really good, you know, tour of the the big relevant. No, I I don't think so at all. No, this is perfect because I feel like you've simplified some things. We've definitely had some functional folks, and I've talked to a lot of people who are hormone experts, and sometimes it does get overly confusing or complicated. So it's really nice, you know, you you narrowed down how these relate to the symptoms we wanted to talk about, as well as uh sources and and testing and kind of how to take them. And I think this will be great for the listeners.

Dr. Maria Sophocles: 46:02

So I'm so glad. I I actually put I honed it down to four take-home points for your listeners. Want to hear them?

Philip Pape: 46:08

Yeah, let's hear them. There we go.

Dr. Maria Sophocles: 46:10

Number one, HRT does not cause fat gain itself, it changes where the fats uh well, HRT, if you get on it, you're not causing gain with weight gain. Number two, estrogen therapy often improves body composition. Number three, weight gain during menopause is driven by a hormonal decline, not driven by the HRT itself. So some people confuse that. They think the HRT is causing the weight gain. It's actually the decline in hormones that's causing it. And number four, transdermal through the skin, estrogen, and micronized progesterone is the most weight neutral approach to HRT.

Philip Pape: 46:54

Perfect. All right.

Dr. Maria Sophocles: 46:56

Yeah, four Thomas. You can you can punch them out or you know, whatever you want.

Philip Pape: 47:01

But yeah, no, those are great. Um, yeah, listeners, I hope you really enjoyed this one with Dr. Maria Sophocles. We're gonna include, you know, her TED Talk, the menopause.org website, her website. But where do you want people to reach out to you?

Dr. Maria Sophocles: 47:14

Um, I think Instagram's easiest. Maria SophoclesMD.com. Um uh or website, same website, Maria SophoclesMD.com is the website at Maria SophoclesMD is the Instagram. I got it backwards. Um so it's all the same. And um yeah, and to check out the book, I think the book deals with all this so nicely, and then it delves into uh sex and sleep and health and oh, all so much in there people will will love. And that's um, that's actually it's already on Amazon if and other places, uh, The Bedroom Gap by Maria Sophocles. I I think they'll get a kick out of it. And Philip, thank you so much for giving me this time.

Philip Pape: 47:55

Thanks so much for coming on. We're gonna include all that for the listeners, and uh, I learned a lot, so I know they did as well. I really appreciate your time on Wits and Weights.