Title: Predictive Utility of Coronary Artery Calcium Score Added to the PREVENT Atherosclerotic Cardiovascular Disease Equations

The Purpose of the Study

To determine WHEN a coronary artery calcium score enhances the ability to predict the risk of cardiovascular disease

Background

It is increasingly common for adults to be referred for a coronary artery calcium score (CACS), or to request one, as a measure of the likelihood of developing heart disease or having a heart attack.

The test itself is a computerized tomography (CT) scan that measures the amount of calcified deposits in heart arteries. The more calcium present, the greater the likelihood of reduced blood flow to the heart due to plaque (atherosclerosis ) and the greater risk of future heart disease.

CAC scoring will not tell if an artery is blocked. It is intended to tell you if you are at risk, in the absence of symptoms or known heart disease. Unlike most other tests, a low score is what you are aiming for.

Coronary Artery Calcium Scores(CACS)

0: No calcium found. This indicates a very low risk of a heart attack over the next decade.

1–100: Mild plaque. This suggests a low-to-moderate risk, where lifestyle changes may be advised.

101–400: Moderate plaque. This indicates an elevated risk of heart disease, and an intervention such as a statin may be appropriate.

Above 400: Extensive plaque. This reflects a high risk for a future cardiac event, often requiring aggressive risk reduction. In other words, if you are not already seeing a cardiologist, it’s time to make an appointment.

In general, the American Medical Association states that adults with risk factors such as smoking, high cholesterol, or a family history of heart disease would benefit from a Coronary Artery Calcium Score. But there is no need for folks with known heart disease to take the test, since it doesn’t tell you anything you don’t already know.

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August Questions

I’ve been on .1 twice weekly patch but switched to .1 Femring due to patch shortage. I’ve had a hysterectomy and do not have a cervix or uterus so the ring sat down at vaginal opening - kind of at vulvar/vaginal plane. I switched to Divigel which I don’t like (it takes too long to dry).

Isn’t the equivalent Divigel dosage 1 mg x2 for a .1 patch?

If I were to switch back to Femring is it effective if it sits so low?

Can I still use vaginal estrogen cream on my vulva with Femring?

How long should I allow post menopause bleeding before working up, after starting HT, adjusting doses, or if the patient misses doses?

As far as alternatives to micronized progesterone, can you give exact doses to use? Instead of 100 mg.

I have breast cancer patients in their early 50s, likely peri- or early menopause, whose only symptom is cognitive problems, not sleep or VMS or mood… would Veozah be helpful? Other options?

55 on HT since age 30 due to surgical menopause TAH BSO. On Premarin until I had switched her to patch a few years ago .

Q1- She has VMs on a low dose that is tolerable; came in wondering if she should I increase the dose.

Q2- She may have had a heart attack last week. She also has osteoporosis auto immune problems and multiple sclerosis!

Can you speak about the link between breast cancer risk and progesterone?

Can you speak to whether birth control pills should be avoided during perimenopause if the patient has elevated Lp(a)? This would be an inquiry for patients with normal cholesterol levels, a 0 calcium score, and normal blood pressure who happen to have an elevated Lp(a).

52 yo who started MHT March 2025. She was still having periods every 4-6 weeks and didn’t want to take OCPs even though her symptoms were consistent with perimenopause (breast tenderness, mood swings). Most recent dosing E 0.05mg weekly patch/ MP 200 qhs. On 7/9/26 hysteroscopy D & C path showed grade 1 endometrial ca.

Q1: Do we have any data on the risk of continuing MHT prior to surgery?

Q2: Post-op, can she take estrogen? Does she need to take progesterone?

What do you consider the most significant research from the past 5-7 years regarding menopause and MHT?

Fast forward 10 years, do you think the standard of care for women in menopause will have changed?

What is your understanding and current practice of the updates guidelines surrounding VTE history, thrombophilias and MHT?

I’m 65 and have been on MHT for four months. I’ve always been active and have lifted weights. In spite of this, the most recent bone density scan showed“low bone mass” (osteopenia) range at the spine, hip, and femoral neck. More importantly, compared to my scan from May 2022, bone density has dropped in both the spine (about 12%) and the hip (about 10%).

I’ve recently engaged a trainer to make sure I’m lifting heavier and more efficiently and I’ve upped my calcium. My doctor is also recommending a bisphosphonate. I’d like your opinion.

In 5 years the BMD of my spine decreased 17.7 percent. While the radiology report noted “Significant REDUCTION in bone mineral density,” my primary care only documented “Mild bone loss” and acted like I was being dramatic when I scheduled an appointment to discuss it with her. How do we find doctors who will take bone loss seriously and actually monitor us in meaningful way??

What do you think of adding MHT when someone already is on bisphosphonate?

Do you have a preference for one neurokinin inhibitor over the other?

Are there any studies from the 70s, 80s, 90s, before the WHI, that studied women being on HRT through to end of life.

I am seeing a 42 year old female diagnosed with primary ovarian failure at age 17. She doesn’t recall how she was given that diagnosis, but has been on OCP her whole life. She does bleed or spot, but very rarely. Presents to me with the common PM symptoms: weight gain, brain fog, poor sleep, occasional flashes. She has a good sleep routine, but wakes at 2 am every night.

Not currently sexually active; orgasms have always been difficult to obtain with self and others; has needed to use lubricant most of her life; but not having any pelvic pain, recurrent UTIs, or other pelvic issues. She is not currently sexually active. I have not done my pelvic exam yet to evaluate for vulvar changes. She has been taking drospirenone 3 mg-ethinyl estradiol 0.03 mg tablet for the past 3 years. I am checking her testosterone, SHBG, insulin, CMP, HGA1C, thyroid function tests, and LH/FSH (just to see...).

Q1 Should I layer estradiol on top of her OCP?

Q2 Use progesterone for sleep even if the evidence is weak for this?

Q3 Should she stay on the OCP until she is 55?

Q4 Would you obtain a DEXA scan at age 45 or wait until 60?

Q5 How best to minimize current symptoms and optimize for long-term health.

Postmenopause bleeding, U/S, and sonohystogram normal.Biopsy had fragments of normal endometrium, endometrial polyp, and 2 small 2cm submucosal polyps. Can you assume polyps or fibroids caused bleeding, not a thickened lining issue? Of note, she had been on E/T pellets prior to bleeding. Symptomatic, so wants to go back on estrogen. She wants to continue her compound progesterone 200mg daily. And if bleeds, should she get hysterosocopy to check that polyp was actually removed since just picked up on bx, not U/S?

My recent PAP results were: “NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY. CELLULAR CHANGES ASSOCIATED WITH INFLAMMATION ARE PRESENT. Endocervical and/or squamous metaplastic cells (endocervical component) are present.”

What does this mean? What causes cellular inflammation?

I have a 50 year old patient with a stable small prolactinoma on cabergoline. She came to me extremely symptomatic with menopausal symptoms. Thoughts on estrogen supplementation in this scenario?

I have a 53 year old with a Mirena in place. She has psoriatic arthritis and osteoporosis in 2023. She’s been getting Reclast infusions and her endocrinologist increased to a 0.75 Estrogen patch Her main symptoms are continued fatigue, ‘cognitive fatigue’, UTI symptoms with neg cultures, night sweats, dry throat and dry eyes. She realizes that many of the symptoms of her psoriatic arthritis overlap with menopausal symptoms. Vaginal E has been added. I did an estradiol level, and it came back at 19 pg/mL.

Should I increase her E patch to 0.1mg, switch to Femring 0.1mg, or switch to oral E?

Can a perimenopausal woman take Duavee? I only see that it is approved for postmenopausal patients.

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Don’t Be Duped

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In this Inside Information Substack LIVE, I chat with Dr. Marilyn Cornelius, an associate professor at Northwestern University in preventative and behavioral medicine, and one of the authors of the position statement from the American Heart Association.

(scroll down for video and transcript)

Like millions of folks all over the world, I am a huge coffee drinker, so I was relieved a few weeks ago when I got an alert from the American Heart Association that most adults can safely consume the equivalent of three to five cups of black coffee per day.

The video and transcript of our conversation are below, but here is a summary of the American Heart Association statement on coffee consumption.

• A regular brewed, non-specialty, caffeinated coffee typically contains 9.4-20.6 mg of caffeine per fluid ounce.

• Consuming up to 400 mg of caffeine per day, or roughly three to five 8-ounce cups of black caffeinated coffee per day, is not just safe…it may be beneficial for most adults.

  • Consuming caffeinated coffee was linked to a lower risk of Type 2 diabetes, heart disease, stroke, heart failure, and some irregular heart rhythms such as atrial fibrillation

  • The benefits only apply to black coffee that does not contain sugar, cream, sweeteners, flavors, or added fillers

Specific Health Impacts of Caffeine

Blood Pressure

In people with optimal blood pressure, drinking 1–3 cups a day was associated with an increased risk of developing high blood pressure, while drinking more than 3 cups per day was associated with a lower risk. High doses of caffeine (such as those from energy drinks or energy shots) can significantly increase blood pressure, especially in people who already have high blood pressure.

Type 2 diabetes

Caffeinated coffee may reduce insulin sensitivity in the short term. In addition, drinking black, caffeinated coffee (no additives, flavors, or sweeteners) regularly was linked to a lower risk of developing Type 2 diabetes. However, this benefit may be due to compounds in coffee other than caffeine.

Cholesterol

Data from randomized clinical trials indicate cafestol, a component in both caffeinated and decaffeinated coffee, was associated with higher levels of low-density lipoprotein (“bad” cholesterol). Cafestol is present in unfiltered coffee (such as espresso, French press, Turkish coffee, or boiled coffee) but not present in coffee brewed with paper filters or instant coffee.

Heart Rhythm

Drinking 1-3 cups of caffeinated coffee per day was not associated with an increased risk of atrial fibrillation or abnormal heart rhythm. However, caffeinated coffee at that same level may be associated with more early beats from the lower chamber of the heart, called premature ventricular contractions (or PVCs).

Very high doses of caffeine (such as those in caffeinated energy drinks or energy shots) have been linked to abnormal heart rhythm in people usually considered to have low cardiovascular disease risk, such as healthy adults younger than age 30.

Heart Disease and Stroke

Drinking 2-4 cups of caffeinated coffee per day was linked to a lower risk of heart disease, heart failure, and stroke. However, drinking more than 4 cups of caffeinated coffee a day may increase the risk of heart failure.

My take:

These findings are based on observational studies, which means there may have been some bias.

Folks who drink coffee may be healthier overall than those who do not.

So while it’s reasonable to conclude that it is SAFE to drink 3-5 cups of coffee a day, it’s too soon to say that it is RECOMMENDED to drink 3-5 cups of coffee a day.

There would need to be a randomized placebo-controlled trial to make that statement.

So, with that, brew yourself a cup of FILTERED BLACK coffee, sit back, and listen to our conversation, or, if you prefer, read the transcript below.

Lauren Streicher MD: I’m Dr. Lauren Streicher. This is Inside Information Live, and today I’m talking with Dr. Marilyn Cornelius, an associate professor at Northwestern University in preventative and behavioral medicine, and we’re going to talk about coffee. How caffeine can benefit your health, and when it can hurt your health. So, welcome, Dr. Cornelius.

Marilyn Cornelis: Hi, thanks for having me on.

Lauren Streicher MD: You know, I’ve always been a huge, huge coffee drinker, and I was so happy last week when I was sipping my second cup for the day, and I’m scrolling through the medical news, and then I get this alert from the American Heart Association that -who knew -caffeine can benefit your health, but then sometimes it can hurt your health. So that’s what we’re going to talk about. You’ve been studying coffee for a long time.

Marilyn Cornelis: I’ve been doing caffeine research since 2001. My, claim to fame was in, like, 2006, when I had a JAMA report looking at, genetics and interactions with coffee consumption and heart disease, and so that’s really what sparked my research career.

Lauren Streicher MD: So let’s start with that, because we all know that person who could drink 3 cups of coffee after dinner and sleep like a baby, and then that person who, if they have coffee at any time, at 2 in the afternoon, they’re up all night. So, is this because people handle coffee differently because of genetics, or is there some other reason?

Marilyn Cornelis: Yeah, there’s a number of reasons. The cool thing is that caffeine, because it’s so widely consumed, we actually know a lot about it. It’s probably one of the most well-researched drugs in the world, yes. Caffeine’s a drug. And the half-life can range from 2 to 5 hours on average. People do vary in their ability to metabolize caffeine, and it’s largely due to a particular enzyme t that’s responsible for over 95% of caffeine metabolism. And there’s a lot of variation in the activity of that enzyme between people.

Genetics is one component, and that’s where I spend most of my research time. I’ve been identifying variants in that gene, but also other genes that alter caffeine metabolism, and at the same time, it also alters people’s consumption behaviors. And the cool thing is we find this on a population level, where we find that variants that are linked to higher caffeine metabolism, individuals who have those particular variants also naturally consume more caffeine. It’s kind of cool because we’re naturally titrating our caffeine levels to align with our genetic differences in metabolism of caffeine. It’s pretty insane. It’s very habitual when it comes to the coffee. They know how much they consume a day, typically how much they have in the morning with their breakfast, or in the afternoon when they cut off, because they’re so… they’re so well aware of the effects of caffeine.

Lauren Streicher MD: We’re going to be talking primarily about the impact of caffeine on cardiovascular health.

Marilyn Cornelis: Well, that actually, brings me back to my, 2006 paper on my thesis, where we found that individuals with, variants related to caffeine metabolism, there is no, adverse effects on the heart. There’s even potential for it being beneficial, which is what we see in the literature now.

Lauren Streicher MD: So, as we talk about this caffeine research, just to be clear -when you are talking about caffeine, you are talking about drinking black coffee. That double mocha with whipped cream and 3 packets of sugar is not part of this research, correct?

Marilyn Cornelis: Right, so this AHA system paper,

Lauren Streicher MD: AHA is American Heart Association,

Marilyn Cornelis: It summarized all the literature that we have on coffee and its impact on cardiovascular disease. And a lot of that research has been based on large cohort studies, 50, 60 years ago. So a lot of them were drinking their typical coffee with maybe a little bit of sugar and milk. So it’s quite different from what we see now, but… so that’s something to think about when… when we… when we interpret this, the, the findings, or the overall statement of… from AHA. It really does talk about black coffee, because black coffee is unlike the sugared stuff, or even other caffeine sources, like sodas.

Coffee is chock-full of polyphenols and other things, which might be contributing to the beneficial effects.It has been linked to a beneficial impact on glucose levels, which might contribute to the reduction in type 2 diabetes that we consistently see with coffee consumption. So it’s not just caffeine; it could be other things in coffee.

Lauren Streicher MD:If someone puts a little milk or a little sweetener in coffee, does it negate the benefits, or you just get less benefit, or we don’t really know?

Marilyn Cornelis: Just a little bit, it shouldn’t make any difference. We’re just concerned about people that are adding coffee to their milk and sugar. Right. So, that’s not really what we want, but adding a little bit of sugar and a little bit of milk, it shouldn’t… impact those things.

Lauren Streicher MD: That’s good news for me, because I like a little bit of that, vanilla milk, but I don’t put a lot in. Alright, let’s talk about blood pressure first. And as we talk about the impact of caffeine on blood pressure, I think there are really two groups. People who are known to have high blood pressure versus people who have a normal blood pressure. What’s going to happen when these two different groups drink coffee?

Marilyn Cornelis: Caffeine has acute effects and also has chronic effects.So, we know that in the lab, if you consume coffee or some sort of caffeine, within about 30 minutes, your blood pressure will go up. That’s shown. And so, we’re actually more interested in knowing how consuming coffee over the long term impacts blood pressure. And this is where we see it for the opposite, where we see more of it being beneficial.

There could be other things, like we mentioned; it might be besides caffeine.

Lauren Streicher MD: Again, I just, I want to be real clear, because I want to differentiate between the person who has normal blood pressure, and you say, okay, so you get this transient increase, but in the long term, it’s actually going to benefit them. Would you say the same thing for someone who has known high blood pressure that’s controlled on medication?

Marilyn Cornelis: I would say that it should be safe, especially if they’ve had a longer history of drinking coffee anyway. You know, like, years ago, physicians would often tell people to cut back on their coffee. That’s changed quite a bit, and that advice from your physicians is not well-grounded anymore. It’s because a lot of that earlier research was not well done. It didn’t control for smoking, which was always a major confounder.

Lauren Streicher MD: Well, you know, that’s so funny that you should mention that, because I was going to bring that up, that in the early research, when they’re looking at people who were drinking coffee, it’s, you know, you know the old ads, they’re sitting there with their cup of coffee and their cigarettes, and they never bothered to separate the two.

We saw that a lot in pregnancy, actually. The advice to not drink coffee in pregnancy was because in the early studies, they were also smoking cigarettes.

Alright, diabetes. What happens to diabetics when they drink black, coffee? No sweetener.

Marilyn Cornelis: Diabetes? Well, we do know, if we look at just the risk of diabetes, one of the most reproducible findings is that coffee reduces the risk of type 2 diabetes.And it’s both decaf and regular. There’s no… there’s no data suggesting that they should be cutting back. Again, with the polyphenols, that should actually help with their… with their blood glucose control.

Lauren Streicher MD: so potentially beneficial. Yeah. Cholesterol, any impact?

Marilyn Cornelis: You need to filter your coffee! If you have a history of high cholesterol, and you’re a big coffee drinker, I’m not going to tell you to cut back on your coffee, but double-check to see that it’s being filtered, because coffee contains what we call diterpenes. Diterpenes are lipid fractions of the coffee and may have been shown in the lab consistently to increase your cholesterol.

My dad used to be, a major, big coffee consumer, and his health is great, but when he found out if you don’t filter your coffee, your cholesterol will go up. He immediately made sure that he was filtering everything.

Lauren Streicher MD: Okay, when you say filter your coffee, you’re talking about just putting one of those mesh or paper filters in? At a Starbucks, do they filter their coffee?

Marilyn Cornelis: That’s a good question, because you’re getting your typical French press, that’s not filtered. World coffee, anything Turkish, not… not, not filtered. And I believe some espressos might not… might also be not filtered.

Lauren Streicher MD: Important thing to know! when… So many people are struggling with their cholesterol.

Marilyn Cornelis: Yeah, and French press is actually gaining a little more popularity.

Lauren Streicher MD: Okay, heart rhythm, that’s the one everyone’s always told, you know? You’re going to get an arrhythmia if you drink too much coffee. True or false?

Marilyn Cornelis: False. There’s this recent clinical trial showing that that whole palpitation thing, it doesn’t happen. There could be people that are just susceptible to palpitations; maybe they might be wary of their caffeine intake, and that was really what drew physicians into telling people to cut back, because of those palpitations.

Lauren Streicher MD: Yeah, I’m going to bet you don’t know the answer to this one, because it’s so rarely studied, but I’m, of course, in the perimenopause and menopause world, and a lot of women who are perimenopausal will have a lot of palpitations, increased in heart rate. So, the question is, is caffeine going to make that worse in the perimenopausal women? Has it ever been studied?

Marilyn Cornelis: People have, but it’s limited research.: clearly there’s probably need for more research on that, but I have come across that, because I think I… given that your audience is interested in that, I think I had a lookup at that, and it’s like, there’s, you know, some data, but…

Lauren Streicher MD: But not great data, just… Right.

Marilyn Cornelis: Right, and over time, people’s response to caffeine also changes. Like, my mother used to drink a lot of coffee. Now she’s just down to have a cup of tea in the morning; that’s all she needs.So that, you know, some of your viewers might feel the same way, that their response to caffeine changes.

Lauren Streicher MD: Is there any data that’s come in on the people who are using a GLP-1? Because, of course, that’s such a huge portion of the population right now, and the most common users of GLP-1s are women between the ages of 50 and 55. So, what’s going to happen to coffee consumption? Has any data come in on that yet?

Marilyn Cornelis: No, no, no one’s ever looked at that..

Lauren Streicher MD: It would be interesting to look at. You know, okay, so let’s talk about decaf for a minute, because we’ve been talking about caffeine, but decaf coffee also impacts heart health. You would think it doesn’t, but that’s not true, correct?

Marilyn Cornelis: Right, it, I know for diabetes, it also reduces risk. It’s probably the polyphenols, so these other things…you know, coffee’s a mystery. When you… when you buy your package of coffee, you don’t see the ingredient list, because it’s natural, you don’t have to have an ingredient list, because we don’t know what other chemicals are in there. But again, it’s probably polyphenols that would be having any benefit with decaf. And decaf has always been kind of difficult to study in observational studies, because The question is, these people who are drinking decaf, why are they drinking decaf? Is it because their physician told them to cut back? They think it’s healthier? They’re different people. These decaf consumers are different people.

Lauren Streicher MD: Well, one of the other reasons, also, I think people drink decaf is this idea that if you drink a lot of coffee in the morning, that you’re going to have this fatigue in the afternoon, and by drinking decaf, that’s not going to happen. Is there any truth to that?

Marilyn Cornelis: I would say that they might be consuming decaf in the afternoon so that they could sleep at night.

Lauren Streicher MD: But it’s not going to cause that mid-afternoon slump if someone has… because that’s what I’ve been told, without any data to back it up, that people that drink a lot of caffeine, their body’s so used to having caffeine on board that when it gets metabolized by 2 or 3 in the afternoon, they’re going to have this slump unless they have more caffeine.

Marilyn Cornelis: That means that the withdrawal symptoms, which are… which happens, that happens quite early, I guess. For some people it does, but for most people, if they don’t acquire that unless they go a whole day without coffee consumption. But, like you said, these people who are used to consuming a lot of coffee, and suddenly they just take, you know, maybe half a day off. They could start feeling withdrawal symptoms, perhaps.But yeah, but they’re… everyone’s… the reasons behind consuming decaf, it’s quite variable, so they’re quite a unique group, and when we do our research, we always need to be careful with that particular group. Do we use them as control? Probably not, they’re different. Often, some of these studies have shown that the people that are on decaf, they’re less healthy than other people.

Lauren Streicher MD: So, let’s go back to the recommendation, because the American Heart Association is now saying that it’s beneficial to have 3 to 5 8-ounce cups of black coffee a day.

Marilyn Cornelis: It’s safe to be consuming that. It’s not a recommendation. I think that’s important for your viewers to know that we’re not telling you to be drinking up to 5 cups per day. If you’re already consuming that, and you’re healthy, there’s no reason to cut back.

Lauren Streicher MD: Okay, but There’s data that shows that it’s beneficial, so why wouldn’t we tell people? You started this off by saying caffeine’s a drug, and drugs are things that are either going to help you, harm you, or have no impact on you. And you’ve just made the case that caffeine has benefits, so why aren’t we all using this drug?

Marilyn Cornelis: Because I think this is the first step towards, you know, getting… because we’re… we’re moving away from, you need to cut back on coffee. We’re at a stage where it’s like, okay, we’re at a point where it’s like, we don’t need to cut back. People are happy with that for now. If we need to start telling people to start consuming coffee, I… that might be a little bit… I think there’s public health implications of that, because again, even the demographics of the coffee consumer is changing. Younger people are consuming coffee. I know my nieces and nephews, they were going to coffee shops in high school. I never went to a coffee shop in high school.… the basis of these recommendations are based on adults, so we really don’t know the impact that it might have on, say, adolescents or even children. That’s why energy drinks was always a bit of an issue with the statement as well, because we needed to mention something. But the research on energy drinks is so bad, it’s very inferior.

Lauren Streicher MD: I’m going to get to that in a second, but before we get to the energy drinks, because I have an audience of skeptics, and I’m the lead skeptic here, I just want to talk about who’s funded all this research and make sure it’s not from the coffee industry, because you’d think they would be all over it. So, where did the funding for all this research come from?

Marilyn Cornelis: Most of it doesn’t come from coffee, because I remember when I was thinking about doing a coffee trial, I reached out to the coffee industry, and they weren’t doing trials on it. They actually have placed more of their funding on growing coffee.It’s not the health research.

Lauren Streicher MD: Okay. Alright, so before we get to the energy drinks, because I think this is important, when we talk to… about a cup of coffee, usually 8 ounces, but for some people, like me, it’s more like 12 or 14 ounces, but I think the difference and the range is because there’s different amounts of caffeine in different kinds of coffee, depending on how strong it is, and I think we have to keep that in mind. Yeah. So, the American Heart Association said up to 400 milligrams of coffee a day is what they were saying is okay, and depending on how strong your coffee is, is going to then impact on how much you can have, am I correct in that?

Marilyn Cornelis: Right, yeah, and so it… and it brings up a good point, because it’s very difficult to track your caffeine when it can be so variable, unless you’re making coffee on your own at home all the time, and you’re used to the amount that you’re adding to make it.going to different coffee shops throughout the day, it’s really hard to kind of keep track of your caffeine intake, because what’s the most popular mug size at a coffee shop. It’s not 8 ounces, that’s for sure.

Lauren Streicher MD: That’s, like, 12 ounces or something.

Marilyn Cornelis: Right, exactly. So people don’t realize that 8 ounces is… that’s the cup.

Lauren Streicher MD: No, it’s nothing, because when I make my coffee in the morning, and if I… I usually press 10 ounces, and it’s only half of my cup. I have one of those great big mugs. And I feel like, oh, that’s not very much, but it actually is. It’s like wine, you know, we tell people how many glasses of wine, and then there’s glasses of wine, and there’s glasses of wine. Right. Alright, let’s go back to those energy drinks, because those are not the same thing. Those can be harmful, so talk about that a little.

Marilyn Cornelis: Well, I’m not sure about harmful, but… because it, again, I think it’s more confounded, but energy drinks, the classic one is Red Bull, so we’ll start with Red Bull, and its standard, size was, I think, 8.7 ounces, and it contained 80 milligrams of caffeine. Which is less than a cup of coffee. People don’t realize that. When they think about energy drinks, they think, oh, that contains 200 milligrams. Well, those are those big, fancy cans. And they’re targeting a different group of people, and it’s typically the younger people. And the issues around those are that, obviously, it’s a colder beverage; it’s not typically sipped as we do with coffee, it’s a hot beverage. You can’t down 4 cups of coffee in 15 minutes. Energy drinks, you can down multiple servings. And those people that are consuming those kind of energy drinks, or that number of energy drinks. They’re usually what we call risk takers. They’re not… they’re not your average person, and I think that’s where it’s kind of missed in… in the literature. And we haven’t done a lot of research on energy drinks. Energy drinks also, well, just besides caffeine, they contain other compounds, like taurine and other things that haven’t been well researched, and so we don’t know the interaction among those ingredients and how it might impact health, but a lot of what we see, or even these, these broad statements about them being harmful, are based on case-only studies. And we know that case-only studies are naturally biased towards adverse effects. No one is going to write a case-only study on a successful energy drink episode. No one wants to do that. It’s adverse effects.

Lauren Streicher MD: That’s when something bad happens that you get the reports.

Marilyn Cornelis: Right. And again, what we see are often the acute effects. We don’t know the long-term impact of regular energy drink consumption over time. And again, it’s targeting a different audience. Sometimes they’re younger kids, because they’re… those… those cans are… are quite colorful and attractive, and they contain a lot of sugar.

Lauren Streicher MD: The thing also is that they generally are marketed to younger people, and in this American Heart Association statement, did they make any differentiation between, say, the under-40 crowd and the over 40 or the 60 or 70 crowd? Because we’re looking at baseline heart health as very different. And if they’re just saying, no, it doesn’t really matter, it’s not going to have a negative impact on the heart if you have your 3 to 5 cups a day. That would be really good news for people who are older and are thinking. There might be different issues, correct?

Marilyn Cornelis: Yeah, it’s, that statement is really targeting the adults.… there hasn’t been a whole lot of research on adolescents, because years ago, they weren’t the primary drinkers. It was really the adults. It wasn’t because coffee is an adult drink. But now, because it’s…Showing up in our… in the food supply in such different sources that there’s… there’s more interest in it.

Lauren Streicher MD: Now, other things, of course, have caffeine, like tea and chocolate and all of that, and I’m assuming that you can’t extrapolate, because you’re also, as you mentioned, looking at the other ingredients in coffee, the terpenes, etc. So…Can you take a caffeinated tea, for example, without any additives, and make the same kind of statement, or you cannot?

Marilyn Cornelis: There have been beneficial associations with tea as well, but it has a very different, a different chemical, profile. It has, most people would be probably familiar with catechins, which are, are, other poly, other kind of… it’s an antioxidants as well. People mostly associate that with, say, green tea, and we know that you can get green tea capsules and things like that, and they’re trying to market that as a healthful. But, it’s a very different beverage from coffee, and it has, you know, about half the amount of caffeine, but there have been benefits. A lot of the… a lot of the research on tea has been done predominantly in Asian populations, because that’s their primary, primary beverage.

Lauren Streicher MD: I want to circle back to the 2018 study, because one of the things that struck me is there were half a million women in that study. They were drinking up to 8 cups a day, and there were overall lower death rates, lower mortality rates. So: Do we know that that’s from coffee, or was that potentially because of what we call healthy user bias, meaning that people who drink a lot of coffee tend to be healthier to start with, and therefore have lower mortality rates? Do we… do we know that? Can you comment on that?

Marilyn Cornelis: That was one study, but there have actually been a lot of studies that looked at copy mortality, and they do… and they are… are pretty consistent, showing that it, that it… it prolongs, prolongs life.So, I think that the… the way we do these studies, we account for all those… all those questions that researchers have always wanted to, you know, is it biased by this? Is it, I think the way we do these studies, we take into account that. So I think what we’re seeing with mortality, it’s… I think it’s real, and there’s a lot of even potential mechanisms that…Perhaps drinking… you’ve been drinking coffee all your life, you haven’t been… you haven’t been consuming soda, so it might be that… that… that, that substitution effect as well. You haven’t been exposing yourself to sodas every day.

Lauren Streicher MD: I’m just saying, yet we’re not at the point that we say, this is something that’s good for you and you should drink, which is a very different message than it’s okay if you drink it, you know? Right.

Marilyn Cornelis: Yeah, like, for me, I would say that there’s more benefits than adverse effects, but I’ve always been…

Lauren Streicher MD: You’re not a clinician, you’re a PhD, a professor, and at the end of the day, you’re not the one that’s there talking to patients. So, while this came out as a statement from the American Heart Association, do you have the general sense that most cardiologists are familiar with this data and are giving their patients the message that it is okay to drink coffee, or are most cardiologists still cautioning their patients that they should not drink too much coffee?

Marilyn Cornelis: Cardiologists are probably cautioning because they want to be on the safe side, right? But sometimes I think that it’s… it’s the patient that asks the doctor, am I drinking too much coffee? Should I be cutting back?

Lauren Streicher MD: Well, I think that’s an important point, and I will put in the notes, the actual statement from the American Heart Association, so that people want to share that with their internists, with their cardiologist, in case they are getting a little pushback on coffee, because at the end of the day, it is individualized, everyone has different circumstances, different hearts, so it’s not like you and I are sitting here and saying everyone should be doing this, because everyone’s individual Medical history is different, but it certainly is an interesting conversation to have with the person who does know your medical history.And they may or may not be familiar with these new recommendations. So, this has been really illuminating. Thank you so much for taking time out of your day.

Marilyn Cornelis: Great, it’s been a pleasure. Hopefully, again, or just the next time it’ll be, you need to consume 5 cups per day. Lauren Streicher MD: Now it’s not. Like medicine. Like medicine. Drink it down, whether you like it or not.

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The news that hormone therapy prescriptions are on an upward trajectory is no surprise.

In this just-released data from a database of 307 million patient records compiled by EPIC, an electronic medical record company, estrogen prescriptions escalated in 2023, have continued an upward trend, and overall have doubled in the last decade. The growth is likely much greater since this survey only included hospital and clinic records that use an EPIC electronic medical record and does not include compounded hormone prescriptions and major tele-health companies, which account for a significant portion of prescriptions. While this is significant growth, it is nowhere near the pre-WHI numbers when 20% of post menopause women were taking estrogen.

This is not the first time the estrogen pendulum has swung.

Read more

In this Inside Information Substack LIVE, I chat with Dr. Lucy McBride about her new book, Beyond the Prescription: A Doctor's Guide to Taking Charge of Your Health.

Take a listen, or, if you prefer, read the transcript of our conversation below.

“For the few people who are not already following Dr.McBride on her Substack, Are You Okay?, Dr. McBride is a Harvard- and Hopkins-trained internist, primary care physician, who I just learned holds a master’s degree in pharmacology. She practices in Washington, D.C., and has over 25 years of experience.

Lauren, thank you so much for having me. It’s fun to be here.

I’m really excited about this book, which is rare for me. I mean, there’s so much junk out there. But there are two reasons I think everyone needs to own Beyond the Prescription. One is the information. It’s accurate. It’s not crazy. It’s evidence-based. You’re not making false promises. But the main thing is, Beyond the Prescription isn’t just another guide for patients. This is, as you put it, a roadmap to help people become the CEO of their own health. So let me start with this. Why did this book need to be written? I went to Amazon, I searched “how to be a good patient,” and over 200 books popped up.

How is Beyond the Prescription different?

The difference between this book and all the other books like How to Be a Good Patient is that this is not prescriptive, hence the title. It’s not a do-as-I-say book. It’s here’s how to think broadly about your health and here’s how to get and ask for the help you need.

We are living in this era right now of Information overload, right? Like we have got headlines coming at us. We’re like drinking water out of a fire hydrant with information coming at us online. We’ve got ChatGPT, we’ve got Claude, we’ve got Open Evidence . Patients have more and more information and less and less ability to contextualize it and make sense of it. And to then action information and apply it to their own lives. So I wanted to help the person out there who’s probably listening. This is most people who’s been dismissed or talked over by their doctor through no fault of their doctor. They just don’t have time.

And who has left a doctor’s appointment with a prescription but no plan. And then, of course, goes on the internet to figure out what’s wrong with them. And they end up not knowing who to trust. This book is basically a five-step guide to being an empowered patient, to being your best self-advocate in this dizzying landscape.

I don’t know if you saw it, but there was a study that just came out a couple of weeks ago that looked at when patients are given a prescription and an explanation by a doctor. And in this particular study, they’ve all had GERD and they were also shown a little video and then they followed up with them a month later and one third of them had no idea how to take their prescription.

This is exactly the point. Health is not just about getting more answers. It’s about having space to ask questions of the people responsible for your care. Well, having that space and that time is important and not wasting the time, because you have this five-step roadmap. Practical advice, specific advice.

So, obviously, people need to read beyond the prescription, but as a teaser, I’d like to run through these steps so people get a sense of your approach.

So step one, top of the list.

Step 1: Redefine health on your own terms.

That’s right. It turns out it’s really important to understand why you’re alive, what your values are. What are you going for? Are you someone, for example, who wants to optimize every body part, every lab test at all costs, even if it makes you anxious and you take unnecessary supplements sometimes and you take prescription medications that could not be employed if you were to change some parts of your life habits? Or are you someone who’s like, oh, natural. Like, I would rather not take medicine at all costs. Like, know who you are, know your goals. And so it makes the relationship between you and your doctor and, frankly, making a decision on whether to get a vaccine or not or whether to take Lipitor or not much easier if you know what your health goals are and what your vulnerabilities are.

How do you approach the person who says, I don’t want to take medicine at all costs, yet they have no problem loading up on all manner of supplements and don’t think of that as medicine?

You need to ask yourself: Is my goal to follow someone else’s definition of health, right? This guru’s advice is definite. So you have to ask yourself, whose playbook are you following? Is it yours? Or are you subscribing to someone else’s definition of health, which for a lot of people is about sort of a body mass index, a number of steps, a certain set of grams of protein? And look, I recognize that exercise and protein are good for you. But what I’m trying to ask patients to do in this step one is to, like, take a minute and understand your own health and what it means to you. What’s your relationship with your own body? What’s your relationship with your doctor? What are your goals? Who are you? In any other profession, as a consultant, me as a doctor, you wouldn’t operationalize a plan around a client without knowing what their goals are. But medicine, if you don’t understand someone’s goals, will default to Lipitor for high cholesterol, Prozac if you’re depressed, GLP-1 if you have stubborn weight. I love Lipitor, Prozac, and GLP-1s. They are wonderful medications. But unless you define your health goals and why you’re alive and what you want, like what are you shooting for?

How do you want to feel in five years or 10 years? What do you want to be doing in five years or 10 years? Medicine will default to factory settings and have you on a prescription for every body part and every symptom. And by the time you’re 80, you’re on a boatload of meds and none of the specialists are talking to each other. So you have to be in the center of that conversation first with yourself and then with the people who are caring for you. Yeah, that makes total sense. All right.

Step two: Map your full health ecosystem.

So this is the bulk of the book, is mapping your health ecosystem. We have conceptualized health in the US as a set of lab tests, a normal mammogram, as external metrics. When health is actually much broader, health is about your mental health. How does your stress and your work-life balance or imbalance affect your sleep, and how does your sleep affect your caffeine intake, and how does your stress affect your alcohol intake, and how does that affect your menopause symptoms? We need to think of a much broader sketch of your whole health. We need to think about not just what you eat. Not just how much you drink, but what’s your relationship with food like?

Are you a restrictor because you’re too busy or because you’re dieting to meet someone else’s definition of sort of health? Are you a binge eater to self-medicate uncomfortable feelings or the shame of having to go see your gynecologist and talk about your STDs? What does your whole health map look like?

It’s not just about a set of labs once a year in your doctor’s office.

Your health is not just about winning your appointment with your doctor. It’s about the 364 days a year you’re living your actual life. That’s where health is.

This so resonates with me because an hour ago, I read an article, a study that came out in a journal, which you may not get because it’s a menopause journal called Climacteric, that looked at the impact of loneliness on health. And we have a lot of data with older people and loneliness and the impact, not just on mental health, but on actual heart disease and dementia.. And this particular study looked at younger people, you know, 45, not just older people. They calculated with their algorithm that the impact of loneliness had the same impact as obesity and cigarette smoking. So talk about an ecosystem.

Well, that’s it. I mean, the most important data for your health isn’t always found in lab tests. If you’re grieving, if you’re experiencing loneliness, or if you’re depressed, that doesn’t show up on a CT scan or a lab. That’s a conversation that needs to be elicited with your physician and ideally with yourself.

And the mapping of the health ecosystem- again, the bulk of the book is about asking; it’s prompting people to flesh this out in a visual way. So you can see not just the different components of your health, informatics, inputs, infrastructure, and insight, but also to identify the connections between your loneliness and your cardiovascular health.

The fact that you were bullied on the school bus for your weight and the sort of narratives in your head about worthiness, and then how you eat today.

And those early experiences have later on. I think that there’s really not enough appreciation of the fact that it does have an impact.

And your doctor won't have time to ask you all these questions. Like no doctor, I mean, few doctors have that time. So what I’m asking patients is to put it up, you know, as at the top of the list of what’s important.

So it’s basically saying, like, do the homework, the pre-work so that you can walk around with a more honest and authentic rendering of what your health actually looks like. So then bring that rendering to your next appointment, whether it’s in the ER or your GYN, so that you can say to a doctor, for example, you know, I have a history of sort of minimizing symptoms because I wasn’t taken seriously and I’m a binge eater. And so that’s maybe why my cholesterol and blood sugars are high. I wonder if I need a GLP-1 or if I just need, you know, some self-compassion, right?

Or both. Or both, right?

Step 3: Reckon with your patient personality.

I love this one because so much of being a good doctor is understanding that there is a lot of different patient personalities and people not only digest information in different ways, but I mean, face it, some people want a lot of information and share in decision making, and we both have those patients who just want to be told what to do. So is that what you’re talking about?

Yeah. So I basically sketch out four archetypes of patient personalities. This is the version of yourself who shows up in the doctor’s appointment when you’re in a vulnerable state. I have a patient personality, too, and that’s neither good nor bad. This is just awareness. So I talk about, are you the optimizer where you’ve conceptualized health as, you know, optimizing every body part and, you know, taking every piece of advice from influencers online and conceptualizing health as, like, willpower equals outcomes, right? Like brute force guarantees health. Are you the person who’s the people pleaser, who just wants to please their doctor and win the appointment, and you kind of live by the notion that if I just don’t make my doctor upset and I kind of get out of there unscathed, then that’s healthy? Or are you the outsourcer who doesn’t want to understand the mechanism? You just want the prescription, the pill, and you just want to get out of there. You’ll just do whatever the doctor wants.

Or are you the internet warrior who comes to the appointment with reams of data and spreadsheets and thinks about health as just more and more and more data accumulated and has sometimes a lot of anxiety? We’re all sort of a Venn diagram of different patient personality types.

The point here isn’t to shame, blame, or pigeonhole yourself, but rather to leverage your strengths and understand your vulnerabilities. So the people pleaser could come into the doctor and say, for example, “ Hey, doc, I tend to minimize my symptoms because I don’t want to bother you. So when I’m telling you that I’m experiencing fatigue,

I want to make sure that we talk about it in a little more detailed way because I’m probably not going to tell you the whole story, right? And I will say you probably know yourself, know yourself, know yourself. And so I don’t know if you’re like me, Lauren, but like, I love it.

It makes my job so much easier when a patient signals that they are interested in a partnership and are owning their role. I also need to own my role. We have patient personalities. Sorry, we have doctor personalities, of course. Right. We definitely do. And that’s a whole separate book to be written.

But I think to signal to your doctor that you’re aware of how you process information, how you receive information, whether or not you’re someone who likes authority or is afraid of it or bucks authority- like that’s good information to tell your doctor. It really is.

It makes all the difference in the world. And speaking of the book that we need to write together to be directed at doctors, this brings me to step four, which is:

Step 4: Learn to ask better questions.

The book that you and I need to write together is, quite frankly, how to get doctors to ask better questions.I mean, this is a huge point. You and I both give a lot of lectures to physicians, and one of the things I do is very often give them a new script so they can ask their patients the right questions and get more meaningful answers.

But what you’re talking about is not from the doctor; you’re talking about how patients can ask better questions.

So, for example, the fourth step is to ask better questions to get the help you need, not the help someone else needs. Take, for example, how to get the help you need. Take, for example, the question I get all the time: should I be on hormone therapy? It’s a good question, a great question, but a better question isn’t a should I, because that implies permission-giving; it implies like you’re asking your mom, “ Can I have the car keys, right? A better question is, doc, what are the risks and benefits of hormone therapy for me, and only me,

And what are the risks and benefits of not being on hormone therapy for me, and only me? What that does is flip the conversation from a permission-giving, mom-child kind of maternalism or paternalism to a dialogue about risk and benefit. It acknowledges that you, as a patient, are asking a sophisticated question, with the inherent understanding that every decision has trade-offs and that there’s no right answer. There’s no yes or no. There are very few yeses or nos. It’s about risk on both sides of each decision. And what are you willing to live with? And what are your particular health issues to begin with?

You know, I’m actually in the middle of writing a Substack post about the very common question that I get when it comes to hormone therapy is, do you take hormone therapy? What do you take? And I’m talking about why that’s not the right question to ask.

The right question to ask when you’re talking to an expert who has a lot of knowledge is, if you were me, given my set of symptoms and medical history, what are the pros and cons of me taking hormone therapy? What I do is irrelevant to me because I have a different medical history.

So we’re on the same page with that. And you have a different risk tolerance. You may be someone who doesn’t have any symptoms, and you’re not willing to tolerate the potential downsides of HT, which we know are less than the general public understands. Yeah, I think the goal of this section of the book and the goal in general- it’s not just about the book- is to help people realize that the way they frame their questions really matters. And the person you’re asking the question to really matters, too. So you don’t want to ask a nutritionist necessarily about how to handle your heart disease. You want to make sure you’re asking the right person the right question they can answer. And then you want to make sure you’re asking the question you mean to ask, because no one has time. So you need to come in there like a sophisticated, educated. You don’t have to understand all the medical information. You just need to understand what it is, what you are getting at?

Yeah. Well, you know, my mantra has always been: you give women good information, and they’ll make good choices and ask the right questions. So that’s really. Right. Huge, huge.

Okay, the last thing is, and maybe the hardest, I don’t know. ..

Step 5: Accept what you cannot control.

Forget about medicine. How about in life?

Yeah, I mean, acceptance is a bitch, if I can say that out loud. It is the hardest part of being human, accepting the things we can’t control, like mortality and chronic disease. We can’t control every element of outcomes. We can’t exercise and step-track our way out of certain conditions that aren’t under our control.

What I see in my practice all the time is people fighting unwinnable battles. So my patient, who’s in his 50s, for example, comes in every year with a spreadsheet of data and metrics, and he feels healthy and has excellent habits. He also has coronary artery disease that is genetic. It’s not his fault.

It wasn’t a failure of his healthy diet and exercise routine. The only problem he had was thinking that habits were sufficient for health. So he and I have had to work on accepting the fact that he can’t change his genetic predisposition to coronary disease and his willingness to therefore take cholesterol medication, not as a sign of failure, but as a sign of strength, understanding that two things can coexist. You can have excellent habits and still have a disease.

I mean, this comes into play all the time, of course, when we’re talking about life and death decisions, right? Patients have to accept the, you know, Sad reality of their cancer diagnosis and then decide, given that there’s no cure on the menu, how to proceed, right? Acceptance and the process of working on acceptance are really what make us human. And it’s hard, especially in the world we live in right now, where we are talking about longevity and anti-aging, which, by the way, is an oxymoron. And like, you know, living longer.

To be clear, my job is to help people live longer, but it’s also to help people live better, to think about quality, and to consider the invisible aspects of health that you can’t measure.

It doesn’t do you any good to live to 100 if you’re lying in a nursing facility with frailty and bilateral hip fracture.

Or, you didn’t take the time to think about what you wanted at that age and then inform your family members to then make decisions earlier. Right? We have more agency over our health than we think. We don’t have agency over everything.

But the question is, where do you have agency and where do you not? And then let’s put your energy, time, and money into the areas where you have control, which is a lot. I mean, we have a lot of control. It’s just people need to be educated about those levers.

I have about a million more questions, but we are running out of time. So there’s one thing I really want to talk to you about because I did not know until I was reviewing your biography about your additional training in pharmacology, which is huge, because that’s one of the big deficits in medical education.

How has your additional training in pharmacology not only made you a better doctor, but how does it show up in Beyond the Prescription?

We need pharmacological tools. We need drugs, right? We need them. What is interesting is to watch the supplement industry grab people’s attention and create this sort of false dichotomy in the public square between natural and pharmaceutical. Remember, cyanide is natural, right?

I always say arsenic, and maybe I’ll stick to cyanide now.

The point is that there’s a bit of an arbitrary distinction between pharmacology and nature, right? And patients are increasingly suspicious of pharmacological interventions, including prescription medications. Don’t get me wrong. Lifestyle, diet, exercise, sleep, managing your stress, those have immense benefits on health, cardiovascular, brain, et cetera.

But there’s still a role for pharmacological intervention. The question isn’t, do you need pharmacology? It’s to what extent do you need it paired with lifestyle? And that’s the art of medicine.

Yeah. But what you bring to the table is that you have an understanding of the nuances of a lot of these pharmacologic agents. . But for most physicians, yes, we know the drugs that we use. We try to learn about them. But the level that someone who’s had pharmacologic training is very, very different. So that is just yet another thing that’s very special about you.

Thank you. It’s a great bonus. And it’s fun to think of a mechanism of action of these drugs, like the GLP-1s. I mean, they’re the most sophisticated pharmacological tool that’s come on the market in my lifetime. And the mechanism of action is really, really cool. And it’s fun to think about it and nerd out on those things.

I wish we could keep talking, but we’re out of time. So, okay. Everyone’s got to buy this book. And thank you. Thank you. Busy week, pub week, lots going on. So thank you for taking the time. And thanks to everyone who joined in.

I’m Dr. Lauren Streicher, and this is Inside Information: LIVE.

More information on Beyond the Prescription

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Years ago, someone mentioned that during the 1700s, masturbation was considered to be a potentially fatal affliction. I assumed that the risk of death was because of the danger of masturbating while perhaps riding a horse and then falling off. But no, it turns out that prior to the 1800s, there were medical experts who declared the act of masturbation was in and of itself considered to be not only evil but also medically dangerous

At that time, the term for masturbation was onania, derived from Onan, a biblical figure who, according to the book of Genesis, married his dead brother’s widow Tamar, but always withdrew during sex and “spilled his seed on the ground” to avoid producing a child who would inherit his brother’s property. Evidently God was not happy about this turn of events and struck him dead.

Onanism subsequently became synonymous with withdrawal as a means of contraception… and masturbating. Obviously, coitus interruptus and masturbation are not even remotely the same thing, other than both “spill seed,” but were nonetheless linked in 1712 with the publication of a pamphlet titled:

“Onania, “The Heinous Sin of Self Pollution and all its Frightful consequences in both Sexes considered with spiritual and physical advice to those who have already injured themselves by this abominable practice“.

No need to read the pamphlet; the title gives you a pretty good idea of what was inside. The author was “anonymous” (can you blame him?) but later revealed as a surgeon/huckster by the name of John Marten who conveniently sold the “cure” for the disease he invented.

Read more

Around a year before her death, I was chatting with the late, great Dr. Ruth Westheimer. Not about sex. Not about orgasms. We were talking about her next big (and what turned out to be her last) project… a book on loneliness and its impact not just on our happiness but also on our health.

As a holocaust survivor who lost her entire family, spent considerable time in an orphanage, was divorced twice, and then widowed after marrying the love of her life, Dr. Ruth knew a thing or two about loneliness. As an icon who ultimately became one of America’s most beloved therapists, she also knew a thing or two about the life-changing impact of building connections.

The Joy of Connections: 100 Ways to Beat Loneliness and Live a Happier and More Meaningful Life was published a few months after Dr. Ruth’s death at age 96, but if I were to have a conversation with her today, I suspect she would not be the least bit surprised at the results of a new study that quantified the health impact of loneliness.

Estimates suggest that loneliness contributes to over 800,000 deaths annually, a statistic that is right up there with smoking and obesity

Being alone and being lonely are not the same thing.

• Social isolation (being alone) is objective and defined as having few social interactions. A lot of people like to be alone and may even prefer it.

• Loneliness is an emotional state that occurs when someone feels distressed or sad about a lack of social connections. That can happen in a room full of people or by yourself. You can be surrounded by people at work or in a living situation, yet feel very lonely.

It has been studied and known for some time that loneliness in older men and women contributes to problems in both mental and physical health. In 2023, Surgeon General Dr. Vivek Murthy issued a U.S. Surgeon General Advisory stating that loneliness and social isolation “represented an urgent public health concern”

Until now, most studies regarding the impact of loneliness on health have been skewed towards older populations. A new study of over 21,000 people, recently published in Maturitas, the journal of the International Menopause Society, is the first to examine the health impact of loneliness in men and women aged 40-65.

It’s no surprise that loneliness is associated with depressive symptoms and depression. What is less obvious and really concerning in this younger population is that loneliness is associated with chronic inflammation and a shorter lifespan.

Social isolation and loneliness are associated with

• 26% greater risk for all-cause mortality

• 30% increased likelihood of cardiovascular events

• 50% higher risk of dementia

The message is clear. Loneliness is no longer viewed as just an emotional or mental health problem or a general quality-of-life issue, but as a modifiable health risk factor that is highly associated with medical problems.

So, what’s the solution in a world where people live alone, work from their kitchen table, order groceries online, and go days without being in the same room with another human, much less someone they connect with?

Dr. Ruth came up with 100 strategies to connect with others. Real strategies. Doable strategies.

For example, imagine you’re at a party where you don’t know anyone. Joining a group of people already deep in conversation can feel daunting—almost impossible. My approach is to take the easy way out and pretend I need to go to the bathroom, and then just hide out there for a while.

Dr. Ruth’s suggestion? Walk up to a group, whip out your phone, and say some version of, “The host asked me to get some pictures- gather and pose, please.” And suddenly you are chatting with them and are now part of the conversation.

There are 99 others.

Thanks, Dr. Ruth.

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Title: Vaginal Estrogen Prescription is Associated with Reduced Risk of Serious Adverse Outcomes in Women of All Age Groups with Recurrent Urinary Tract Infection: An Epic Cosmos Database Analysis. Urology. 2026.

The Purpose of the Study

To determine if postmenopausal women who use a local vaginal estrogen are less likely to develop sepsis, be hospitalized, or die after recurrent urinary tract infections.

Background

Urinary tract infections (UTIs) are the second most common infection in the United States. 40% of women who get a UTI end up with a repeat infection. Recurrent urinary tract infections are defined as more than 2 infections within 6 months or more than 3 infections within 1 year. In the general population, 1 in 4 women with a urinary infection ends up with recurrent infections, but post-menopause, that number climbs to 55%.

More than half of women who are post menopause who get a bladder infection end up with recurrent bladder infections.

The reason is straightforward. It’s not just the vulva and vagina that change when your estrogen tank is on empty. The urinary tract is rich in estrogen receptors, so the tissue along it also becomes dry, thin, and much more prone to infection. In addition, postmenopause, healthy vaginal lactobacilli get wiped out, allowing the bad bacteria to take up residence in the urethra and making the urinary tract even more prone to infection. These changes in the vulva, vagina, and bladder are all part of genitourinary syndrome of menopause (GSM).

If a UTI is untreated, bacteria have the potential to invade the kidneys and quickly turn into pyelonephritis, which is a lot more serious. If bacteria enter the bloodstream, sepsis sets in. Urosepsis occurs in 1.6% of women who develop a post menopause urinary tract infection. This may sound like a rare event, but since there are 75 million postmenopausal women, it is a significant number.

A Potentially Catastrophic Complication

Sepsis can result in complications such as kidney failure, blood clots, heart problems, loss of limb, and even death in up to 30% of cases. Urosepsis accounts for roughly 25% to 30% of all sepsis cases.

• Urinary tract infections are more than unpleasant- they are potentially life-threatening.

• Urinary tract infections are preventable with the use of a local vaginal estrogen, DHEA, or ospemifene.

• Only one of four women with recurrent UTI receives a prescription for a local vaginal estrogen.

The Study

304 million patient records were reviewed

1,891,956 women with recurrent UTI were included and divided into 2 groups

• Group 1: Post menopause women who received a vaginal estrogen prescription within 2 months of their second UTI

• Group 2: Post menopause women who never received a vaginal estrogen prescription

Both Group 1 and Group 2 were followed for 8 years to determine who developed sepsis, was admitted to the hospital, or died.

The Results

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Dr. Goldstein was, and is, always ahead of his time. Today, it would no doubt be a bestseller.

Perimenopause, the lead-up time prior to menopause, usually begins when women are in their mid-40s, but can occur earlier. It is estimated that approximately two million women begin perimenopause each year in the United States and remain in perimenopause for roughly 4 to 8 years.

While women who enter perimenopause before 40 are the exception, it is increasingly common for women as young as 30 to think they are crashing into an early perimenopause when they experience symptoms like missed periods, hot flashes or moodiness (because 30-year-olds never get moody).

This “epidemic” of young women thinking they are perimenopausal took off after a 2025 study reported that over 50% of women between the ages of 30 and 35 experience moderate to severe menopause symptoms. Overnight, perimenopause was trending, and scores of women in their 30s were convinced, driven by social media, that hormonal fluctuations were the cause of everything from anxiety to insomnia. I wasn’t surprised when I got this text from a friend:

“My 34-year-old niece is perimenopausal. Who should she see?”

The study that fueled this confusion was based on a large sample of US women from age 30-35 who sought help for what they perceived to be “perimenopause” because of symptoms they were experiencing. Over 25% of those women were told, based on their reports of irregular periods, absence of periods, pain with intercourse, and hot flashes, that they were in perimenopause. But most cases were not medically confirmed to be perimenopause, and it’s not unusual for women of reproductive age to have painful sex, irregular periods, and other perimenopause-like symptoms that have nothing to do with ovarian aging.

According to a study published yesterday in the journal Menopause, the confusion continues. In this survey of 7,640 women over age 35, one in three women was unsure of their reproductive stage. 42% of women aged 40 to 44 (the group most likely to be in perimenopause) were unclear about what their hormonal status was and were unable to identify which phase they were in.

Why the Uncertainty?

A combination of factors is responsible for women not knowing if they are pre-, peri-, or postmenopausal.

• There is no single blood test to definitively determine perimenopause status

• Hormones and hormone markers fluctuate during perimenopause

• Perimenopausal symptoms are highly variable and come and go

• Many perimenopause symptoms also occur in other conditions such as PMS, thyroid problems, mental health conditions, or from medications.

• Almost half of women do not menstruate and cannot rely on cycle changes.

• Many women in this age group do not have regular medical care, and even if they do, chances are their clinician does not have expertise in perimenopause.

• The messaging on social media is inconsistent and often wrong,

  All paid subscribers are invited to my monthly Ask Me Anything Webinars! The next one is 8/25

  Why it Matters

All of the hormone therapy in the world will not alleviate painful sex or treat mental health issues like depression or anxiety if the ovaries are fully functioning and cycling.

In addition, it would be helpful to know whether pregnancy is still a possibility, whether a positive test would be welcome news—or a full-on catastrophic “cancel everything and breathe into a paper bag” situation.

Most important, though, is that perimenopause, menopause, and premature menopause (premature ovarian insufficiency) have different issues and require different treatments to both manage symptoms and prevent long-term issues like bone loss.

How to Know

The details are in my post, but here’s the headline: 90% of the time, an expert will know which phase you are in just by getting details about your menstrual cycle, symptoms, and age.

If you do not menstruate because of a hysterectomy, IUD, or endometrial ablation, or there is concern for premature ovarian insufficiency, there are blood tests that are useful, such as FSH, estradiol, and anti-mullerian hormone. But ideally, these tests (which often need to be repeated) should be ordered and interpreted by an expert.

And in case you are wondering, home menopause tests are not only worthless but often misleading.

Having perimenopause symptoms is not the same as being in perimenopause.

I am pushing Dr. Goldstein to publish an updated version of “Could it be Perimenopause?”, but in the meantime, take a listen to our conversation about how to know if you are in perimenopause, and the best way to manage it,

Dr. Goldstein on Instagram: dr.goldsteinshareswisdom/

References

Xu Y, Fergus D, Hewings-Martin Y, Hedges M, Prentice C, Cunningham A, Zhaunova L, Shufelt C, Faubion S. Exploring prevalence and drivers of perimenopause uncertainty among US Women: a mixed-methods study. Menopause. 2026 Jul 14. doi: 10.1097/GME.0000000000002837. Epub ahead of print. PMID: 42445976.

University of Virginia Health System. Young women suffering menopause symptoms in silence, study reveals. Eurekalert. February 25, 2025. Accessed February 27, 2025. https://www.eurekalert.org/news-releases/1074704

Cunningham AC, Hewings-Martin Y, Wickham AP, et al. Perimenopause symptoms, severity, and healthcare seeking in women in the US. npj Womens Health 3, 12 (2025). https://doi.org/10.1038/s44294-025-00061-3

See you next month. All paid subscribers are welcome to attend.

Please remember to put questions in the subscriber CHAT!

July Questions

• Can you clarify the recommended estradiol dose for a postmenopausal woman. I wasn’t sure if that was specifically for women in perimenopause when the greatest bone loss occurs, or if this dose is for post menopausal women too?

• Can you give some references to give to my gynecologist?

  Levin VA, Jiang X, Kagan R. Estrogen therapy for osteoporosis in the modern era. Osteoporos Int. 2018 May;29(5):1049-1055. doi: 10.1007/s00198-018-4414-z. Epub 2018 Mar 8. PMID: 29520604.

  https://www.tandfonline.com/doi/full/10.1080/13697137.2021.1957818

• Who are your go-to experts for information on bone health/osteoporosis?

• Last month, you mentioned micronized progesterone helping with sleep. Is it effective for sleep if taken vaginally or only if taken orally?

• I am interested in your thoughts about vaginal progesterone for endometrial protection. Just had a patient present who was prescribed vaginal progesterone for endometrial protection by a telehealth company. 100 milligrams vaginally daily. Using the oral capsule.

• Progesterone shortages and alternatives

• What if someone has a peanut allergy and can’t take micronized progesterone?

• Any options to get around the expense of vaginal DHEA? (Intrarosa)

• What about the efficacy of Julva, the over-the-counter DHEA?

• What about oral DHEA?

• 45-year-old woman with chemotherapy-induced menopause from treatment of CNS lymphoma at age 44; severe VMS, current normal bone density; no prior hormonal therapy.Medical history: obesity sleep apnea, elevated lipids, insulin resistance.Current plan: Statin, Mirena insertion, TD E2, GLP1 therapy. This patient experienced early menopause at age 44 due to chemotherapy.

  • Would you treat this as POI/early menopause and target higher physiologic replacement (e.g., estradiol 75–100 mcg)?

  • What kind of dose would you use? Oral vs transdermal?

• Does taking a GLP-1 impact the dose or type of estrogen?

• Does the history of CNS lymphoma and autologous stem cell transplant influence your comfort with full-dose estrogen replacement, assuming her hematology/oncology team has no objections?

• Would you routinely seek explicit oncology clearance before initiating MHT in this setting, assuming no known contraindication and ongoing remission?

• What are your thoughts on continuing use of compounded vaginal hormone therapy- estrogen, progesterone, testosterone, DHEA at a dose high enough that the gynecologist says it is systemic? I’m a 66-year-old woman who has been on HT for many years.I have a recent diagnosis of atypical ductal hyperplasia, which was removed via an excision biopsy with no residual signs of ADH. Gynecologist says ok to continue use, and breast surgeon says not ok.

  (Note- I continue this answer later in the webinar (at 27min) after the person supplied her dosage)

• I am 59 years old (had a total hysterectomy but still have ovaries) and have been on .1 twice weekly patch since June 2023. Due to the shortage, I tried the .1 Femring but am not a good candidate due to prolapse, so I will be switching to a gel when I see my OBGYN at the end of this month. You answered my questions last month about the gel options – thanks! 4 weeks ago I was having increased joint pain so re-inserted my Femring (which is good for another 60 days)and have been using that along with my patch so have doubled my dosage. My joint pain has disappeared!

  • My questions are concerning any risks of .2 dosage and how to get my doctor to increase my dosage. I want to do all my research so when I see him at the end of the month I’m well informed to present my case for higher dosage when I switch to gel. I have been doubling my dose for a month now and have not had any adverse effects that I can feel.

• 55-year-old BRCA had risk reduction surgery with total hysterectomy (still has breasts). My understanding is estrogen is okay. She has lipid-lowering meds. Starting her on TD estrogen. But- would Duavee be a better choice? She has an upcoming kidney surgery, so I am hesitant about oral. Thanks!

• Question about the ratio between the Estrogen Patch and Oral Progesterone in order to protect the uterus from Endometrial Cancer. I ended up with endometrial cancer on the standard protocol.

• Is there adequate absorption of micronized progesterone on a GLP-1 drug?

• Going back to Progesterone for a woman who has had a hysterectomy... other than sleep, are there any other beneficial reasons to be on progesterone if you do not have a uterus?

• For vaginal estrogen cream (estradiol) is there a dose that has been researched that would reach a serum level similar to transdermal or oral estrogen?

• Have you ever removed ovaries or done Lupron + add back E2 in perimenopause for severe mood disorders in luteal phase? 42 yo peri patient with long history of complex mood disorders and PTSD, also ADHD and self diagnosed neurodivergence. Tried and failed compounded low dose progesterone 75 mg, 100 and 200 mg progesterone, norethindrone and OCPs /POPs over the years. She sees a psychiatrist and those meds are in a “good place” for her. Estradiol 0.0375 patch has been great for her and she is still having regular 20-28 day cycles. On her own, she stopped the norethindrone altogether and feels much better. She still experiences 2-3 days a month where she does not function for her family. We discussed future regular ultrasound imaging if periods become irregular or skipped. She is desperate for options to stop cycling!

• Who is the best specialist for ovarian suppression?

• I am 59 and despite being in excellent health, I was diagnosed with Stage 0 DCIS last year. I had a bilateral mastectomy in January. No radiation or endocrine therapy necessary, but I can no longer take MHT. I lift weights regularly but I have had 2 knee surgeries, so I am limited in terms of what I can do leg-wise. I have high cholesterol but no arterial plaque / zero calcium score. My most recent DEXA scan revealed slight osteopenia. I’m very concerned about bone density, cardiovascular health, brain health, and skin health

• Are there any new options out there for women who can no longer take estrogen?

  • Osteopenia?

  • Hot flashes?

  • Dementia?

  • Heart Health?

  • Skin?

• What about peptides?

• I have a 40-year-old who has been on continuous Junel 1/20 for 15 years. Having night sweats, low libido, brain fog, weight gain, and hair loss. I know we can get hormone-mediated vulvodynia, but can the prolonged suppression cause systemic symptoms? I recommended stopping the OCP and using condoms or getting an IUD, and then maybe adding an E patch down the road if symptoms don’t improve. Can birth control pills cause bone loss? Many teens have low bone mass.

• Is there any benefit to taking progesterone when you’re on Duavee ?

• My doctor told me that progesterone is a cancer catalyst. Is that true?

• A pt told me she had a “genetic test” that told her she should never do estrogen due to “poor methylation” at an outside “age management” office.

• If I am feeling anxious, does it make sense to get cortisol levels checked?

• I tried some oxytocin at the med spa. It made me feel great! What do you think about that?

• I always wonder about the milk question. There are a lot of cultures that don’t really do dairy (and have high rates of lactose intolerance), and to my knowledge, they don’t have widespread osteoporosis, or do they?https://drstreicher.substack.com/p/can-women-at-the-highest-risk-of

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FACT: 30% of postmenopausal women complain of dry mouth

FACT: In 2025, women ages 50-64 were the highest users of GLP-1 drugs

FACT: Over the last year, there has been an 8% increase in sales of gum and mints, attributed to epidemic rates of dry mouth and bad breath

While the manufacturers of sugarless gum and mints are doing the hora at this boon in sales, postmenopausal women and dentists are not taking part in the celebration. And that 30% statistic? Those studies were published pre- GLP-1 use. I have no idea what that number is now, but I suspect it’s a lot higher. While not usually mentioned, given the number of postmenopausal women using GLPs, it's another contributing factor to why dry mouth in GLP1 users is so common.

So, let me break down WHY it happens, WHY it’s a problem, and WHAT to do if your mouth is just as dry, or drier than your vagina

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You know what a hack is…something that solves a problem, simplifies a task, or reduces frustration. Who doesn’t love a good hack?

Toothpaste hacks alone account for millions of views on TikTok. Gunk on the bottom of your iron? Stains on the soles of your white sneakers? Toothpaste will clean it off. A video titled “How to whiten your armpits with toothpaste” has 26 million views. Evidently, there are 26 million people out there who want whiter armpits. This is 8% of the US population, more than the number who read a daily newspaper.

While I have no toothpaste tips for you, I do have a long list of tips, tricks, and solutions for frustrating gyne problems and alternative uses for products that are intended to be used on your vulva or in your vagina. Here are three of my favorites.

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Silicone Lube

Anyone who follows me knows I am a big fan of silicone lubes. They are the most slippery, last the longest, and are the most vagina-friendly. But silicone lubes also come in handy for many household uses. Ring stuck on your finger? Silicone lube will ease it off. Need an emergency shaving cream? Coat your legs..or whatever… with a little lube. Jewelry chains hopelessly tangled? Lay it flat, put a few drops on the knot, then use a couple of straight pins to untangle it.

But, if you really want to get the biggest bang for your buck, here’s my hack.

Last year, I was at a menopause conference and forgot to pack my usual hair product. It was humid, and I was having an unusually bad, frizzy hair day. Being resourceful, I headed down to the sponsor booths. Replens Silky Smooth was handing out little travel samples, so I grabbed one for my hair. Worked like a charm.

Yup- those silicone hair products to make your hair smooth and shiny are basically the same thing as your silicone vaginal lubricant. The only difference is that the hair products add perfume.

So, next time you travel, don’t forget to pack your silicone lube. A little down there, a little up there, and you will be good to go. Your vagina will thank you, and your hair will thank you.

But, caution! Don’t use your hair product down below- the perfume and other potential additives are not vulva friendly.

Easily Remove a Vaginal Ring

Novel technologies for delivering hormone therapy have included innovative vaginal rings such as Estring™, Femring™, NuvaRing™, and Annovera™.*

Estring™ is a disposable ring that is placed in the back of the vagina and slowly releases a small amount of estrogen to treat vaginal dryness and bladder symptoms due to genitourinary syndrome of menopause. After 3 months, you pull it out, throw it away, and replace with a new ring.

Femring™ delivers systemic levels of estrogen via a vaginal ring and is an alternative to other systemic transdermal options such as patches, sprays or creams.

Annovera™ and Nuvaring™ are hormonal rings that release estrogen and a progestin as a convenient alternative to birth control pills. NuvaRing™ (and generics) is good for a month. Annovera™ is effective for a year, but if you choose to have a period, you still need to remove it for a few days each month.

Women love the set-it-and-forget-it convenience of these products… until it’s time to take them out. Some women just can’t reach it, or their nails are so long that any attempt at removal …well, it can get bloody.

I had one patient who came in every 3 months for me to replace her Estring™ because she couldn’t get it out herself. Her insurance wouldn’t cover the visit, so I told her to just bake something for the staff. For 5 years, my office staff enjoyed chocolate chip banana bread, courtesy of my patient with short fingers. When she died, I think my staff mourned more than her family did. She baked great chocolate chip banana bread.

But then, I discovered a great hack for women who were frequent flyers to their gynecologist for ring retrieval, had abandoned using rings because it was too stressful, or were routinely scratching the walls of their vagina in desperate attempts to get their ring out.

It’s really simple: Before you put the ring in your vagina, tie a long loop of unminted, ribbon dental floss to the ring. Once the ring is in place, shove the floss inside your vagina, just as you would a tampon string. When it’s time for removal, reach inside, grab the loop of floss, and pull the ring down to the vaginal opening so it is within easy reach.

Dental floss bonus hack: Dental floss, is also the best way to cut cheese cake.

So keep 3 rolls of unminted dental floss around- one for your vagina, one for cheesecake, and one for your teeth.

Hands-Free Vulvar View Hack

This is huge. If you have ever had a bump or a sore spot and needs to do a little inspection, it’s about impossible to get a decent view of your vulva without an assistant to hold the mirror, the flashlight, and separate your labia. And, though attempted by many, a crotch selfie is equally challenging. If you need to apply medication to a specific area of your vestibule or vulva, good luck.

So if you are tired of doing gymnastics to get a look at your vulva or apply medication, this is for you.

All you need is a 6-8-inch travel makeup mirror with magnification and a folding stand. If you spring for one like this, it has a nice built-in light.

You just place the stand under the front of the toilet seat so the mirror faces the toilet. Have a seat ..and adjust the tilt of the mirror. Voila- a hands-free, clear vulvar view complete with magnification and light. You can easily inspect and apply medication. This is also a great hack for women who self-catheterize to urinate.

Much easier to picture than describe, so check out the video and admire the nice tile I installed in the bathroom.

You’re welcome.

*I have no financial relationship with any of these products.

Quick Links to Posts on Specific Topics

Health & Wellness

Menopause

Women’s Health Research

Sexual Health

Hormone Therapy

Health Politics

History

Don’t Be Duped

• What’s the right dose?

• Is it too late to start? Too early?

• What are the actual risks?

Meanwhile, you’re left dealing with hot flashes, brain fog, sleep issues, or changes in libido — wondering whether hormone therapy could help, but getting a lot of conflicting information, which leaves you wondering who to trust and what to do.

So, I created this class.

Hormone Therapy 101: The What, the Why & the How covers what hormone therapy is, how it works, your estrogen and delivery options, and what the science really says about safety.

You’ll walk away ready to have an informed conversation with your doctor and advocate for yourself.

Hormone Therapy 101: The What, the Why & the How is now available as a standalone class— no subscription required, which includes a live Q and A with me.*

· For $75, you get lifetime access to:

• 12 on-demand video lessons

• Two bonus Q&A sessions

• A complete class guide with checklists and an action plan

Sign Me Up!

One more thing, and this part’s time-sensitive…

Enroll between now and Thursday, June 25, to attend a live Q and A session on Friday, June 26 at 12:00 PM ET.

This is your chance to turn on your camera, say hello, and ask me anything directly – about hormone therapy, the class, or whatever’s on your mind- even if you do not subscribe to my Substack.

The session will be completely informal and run about an hour. If you can’t attend live, send your question ahead of time, and I’ll answer it during the session. You’ll also receive the recording.

And, if you sign up by June 25, you’ll also get my second class, Orgasm: The Science-Backed Guide to Getting Your Orgasm Back, at no extra charge.

As always, I hope this is helpful!

Warmly,

Lauren Streicher MD

P.S. The Office Hours invitation is only available for enrollments through June 25. After that, the class remains available – but the live session won’t be repeated.

More information and sign up

*Information is for educational purposes only and not individual medical advice.

** Anyone is welcome to attend, but this class is geared toward and intended for NON-HEALTH care professionals.

If you own a uterus and take systemic hormone therapy, you are probably aware that in addition to estrogen, you also need to take progesterone or a progesterone alternative.

But, evidently, progesterone is about to be as rare as an honest politician. And no, this is not part of some nefarious plot to keep women from taking hormone therapy. It appears t…

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There were a number of questions about alternatives to oral micronized progesterone because of the current shortage. Since this is a hot topic, I skipped those questions and will publish a post on it tomorrow.

Also, I didn’t get to all the questions (so many this month!), so if you submitted one that wasn’t included, I will include it next month.

June questions

My health care clinician quits giving pap smears after 65;

If I’m on Duavee or HT should I continue to get pap smears?

Does someone over age 65 need a pelvic exam?

Do clinicians ever evaluate or prescribe low-dose topical testosterone for women with a remote history of ER+ DCIS, and a bilateral mastectomy, or is that an automatic exclusion?

What about taking estrogen with ER+ DCIS?

Which formulation is best?

55-year-old woman, menopause age 48, on MHT age 48-52, stopped by clinician since she was “on it for a long time”. Patient has: Hot flashes, night sweats, fatigue, insomnia, anxiety, osteopenia. NO contraindications to resuming MHT - EXCEPT Coronary calcium score 40.2 in 08/23; on Rosuvastatin 20mg. Patient is asymptomatic from a cardiac standpoint; no other personal CV risk factors, BUT strong Family History of CAD.

In view of coronary calcifications, can MHT be safely resumed?

In October, my total testosterone was 33, free testosterone 2, and sex hormone binding globulin (SHBG) 98. This month testosterone was <3, free testosterone <.2, and SHBG 193. I’m concerned, but when I asked my clinician, she responded with no more than ‘hormone fluctuations are normal in perimenopause.’ I’m 45yo and taking estradiol oral tablet 1mg (2xday) and micronized progesterone oral tablet 200 mg (1xday).

Is a testosterone fluctuation like that typical in perimenopause?

Does testosterone gradually decline starting in your 30s?

Why would her sex hormone binding globulin increase so much?

Many patients in early peri not interested in birth control pills despite detailed education about benefits of suppression +/- add-back at this stage). Some requesting oral progesterone only because of what they have seen on social media.

Thoughts on nightly progesterone alone in perimenopause? Is it reasonable to consider because low risk, even if benefits purely placebo?

In what circumstances does it make sense to give MHT in perimenopause?

I got a DEXA can in May and it shows I have osteopenia. I am currently on Combipatch 0.05-0.14 mg. My current estradiol level is 16 pg/mL. My PCP mentioned that level is may be too low to help with bone health. I am currently weight lifting and doing jump training. I eat plenty of protein, eat dairy products take Vitamin D3 and K2 supplements. My menopause symptoms have generally gone away, except I do have disrupted sleep. I also have Hashimoto’s hypothyroidism that is controlled by medication,

What should the estradiol range be for supporting bone health?

Could it be I am not a good absorber on a transdermal patch and need to go up in dosage

What about testosterone for bone health?

I would like to get bone turnover markers (CTX, P1NP) to monitor my bone turnover and to see how interventions are working, but so far no luck getting doctors to order these tests.

Do you order bone turnover markers for women with low bone mass?

What circumstances would you order bone turnover markers?

On EST patch 0.0375 + cyclic micronized progesterone (100mg 14 days ON/OFF) The annual measure of uterine lining was at 4mm. Then switched to EST patch 0.05 + continuous micronized progesterone (100mg nightly). After one year, annual measure of uterine lining at 2.9mm. Everything else is normal (no abnormal bleeding, symptoms well managed with this new protocol).

Is the reduction in uterine lining from 4mm to 2.9mm of any concern?

Is there a lower limit or min cutoff for a healthy uterine lining in postmenopausal women HRT? Is there such a thing as a uterine lining being ‘too thin?’

I have dense breasts; I had an Atypical lobular hyperplasia biopsy 8 years ago- no cancer. I was told I was at very high risk for HT; I’ve tried Duavee which is pretty good and feel much better on HT. I’m 65.

Any thoughts on my real risk model here?

I’m 56 and breast arterial calcifications first appeared on my mammogram at age 39. I see it noted on radiology reports, but no doctor has ever discussed cardio risk with me. In recent years I have been reading about association between BAC and cardiovascular risk, especially found in younger women.

Do you inform patients/ have discussion when breast arterial calcifications are found on mammograms in regard to cardiovascular risk?

My understanding is that there are limited data guiding the use of bisphosphonates in premenopausal women.

In practice, are bisphosphonates typically prescribed for osteopenia in premenopausal patients

How would you manage low bone mass in a pre-menopausal woman ?

When would you prescribe a bisphosphonate in a pre-menopausal woman

In a patient using a Mirena plus a 0.1 mg estrogen patch, is there any disadvantage to not adding oral progesterone?

I have heard suggestions that some perimenopausal weight gain may relate to treating l low estrogen without addressing declining progesterone levels. Is that true?

80 year-old woman with hx of hypercholesterolemia (on statin) and atherosclerosis of the aorta (seen on CT imaging), otherwise healthy with a normal bone density. She has been on Premarin 0.625mg ever since her hysterectomy at age 45 per her previous PCP. I referred her to gynecology who is also a menopause specialist who suggests switching to transdermal estrogen and then gradually wean off because of increased cardiovascular and cerebrovascular risk due to the patient’s age. The patient has an appointment with me tomorrow.

What are your thoughts on continuing her current prescription vs switching her to a patch?

Could you talk about post-menopausal bleeding? I’ve 60 and have been on MHT for 13 years. Last year I had breakthrough vasomotor symptoms and my GP increased Estrogel from 2 pumps to 3, which immediately stopped the hot flashes. I was already on 200 mg of Prometrium, and 3mg of local estrone. About a month after increasing the Estrogel, I started bleeding, for about a week, just like a period. Had a transvaginal ultrasound showing an increased endometrium to 9mm. I was referred to a gynecologist and had a hysteroscopy. The results from the sample were normal, and she said that bleeding was most likely due to imbalanced hormone levels. My GP increased Prometrium to 300 mg, but I’m still bleeding every month or so. She is reluctant to go to 400 mg of Prometrium. I’m not happy about the bleeding but also don’t want to reduce the Estrogel and have the hot flashes return.

I’m a 50 year old woman on MHT. I have been experiencing chronic hip and back pain, including chronic gluteal tendinopathy.

How much may hormone levels, either too low or too high contribute to this kind of pain?

If yes could at home urine hormone testing kits help determine if hormone levels could be a factor in my hip pain ?

I am 59 years old and recently switched over to Femring from the patch due to the patch shortage but Femring does not stay in place and I am not a good candidate for it. Now I am thinking of switching to either Estragel and Divigel-

Can you go over the differences between Estragel and Divigel? Wondering about the pros and cons?

Texture and drying time?

Does it matter if applied morning or night?

Can it help with sleep if done at night? I have read some women talking about it making them tired.

What is the best time and site to rub in as I already use Testosterone cream and rub that into my inner thighs.

Can I put estrogen gel in the same area or should it be different?

50-year-old perimenopausal woman with stable multiple sclerosis, status post gastic bypass, with obesity, hypertension, dyslipidemia, sleep apnea, iron deficiency , and depression. She has hot flashes, sleep disruption, cognitive symptoms, low libido, and heavy menstrual bleeding.

I am planning on putting in a Mirena IUD. Progesterone alternatives if Mirena is declined/not suitable? I think oral P is problematic given dual absorption concerns. Maybe Slynd — even though still concerns with oral absorption, at least more potent vs OMP.

Is it OK to give her MHT?

Thoughts on endometrial biopsy timing? (Normal biopsy ~2 years ago, but ongoing heavy bleeding)

Would you use vaginal progesterone and avoid an IUD in this patient?

On estradiol (0.75% patch) and vaginal cream daily to vulva, and progesterone x 6 months. Still with some GSM, low energy and libido.Initial total testosterone level 4. Testosterone started, gel to skin (thigh, behind knees) 1/10^th male dose daily.Total testosterone level 40 after 3 months of application to skin. GSM still lingers. Energy and libido improved a little.Testosterone cream started for vulvar area. Applied chickpea size amount daily. Vulvar issues completely resolved (YAY!!!). Libido and energy much better.Total Testosterone level 111 (yikes).I then went to a lecture by a meno/peri specialist (OB-GYN). She shared that she only orders testosterone cream to be applied to the vulva, she does not order testosterone gel to be applied to the skin. She said with vulvar application you will see increase in blood levels. I thought this was interesting as I haven’t heard of this approach before and it is in contrast to estradiol application (vulvar application does not increase serum levels).

What is the target testosterone level?

Where should you apply testosterone? Is there an advantage to applying it to the vulva as opposed to the thigh?

What are your thoughts on why serum levels would increase for testosterone but not for estradiol applied to the level?

Any thoughts on maintaining a total testosterone level of 111?

During an appointment with my hematologist, he called me a red blood cell superproducer and ran a bunch of genetic tests, all negative, to see if there was a bad reason for it. My hematocrit and hemoglobin have been slightly higher than the normal range since beginning female-dose testosterone gel after oophorectomy. The T has been extremely beneficial for me and those numbers are in the good range - but my doctors don’t seem to agree on whether the higher hematocrit/RBC/hemoglobin is worrisome - and the thread below seems to indicate I’m not alone.

At what threshold should they become a concern?

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Title: Cardiovascular Health Characterization Using Life’s Essential 8 Score in Perimenopausal Women: An Analysis of the National Health and Nutritional Examination Survey (NO Paywall!)

The Purpose of the Study

To compare cardiovascular health across premenopausal, perimenopausal, and postmenopausal stages to determine the timing of onset of cardiac risk factors, including which are the most likely to increase prior to menopause.

Background

Your cardiovascular system is at its best when there is plenty of estrogen on board. It is well established that the risk of atherosclerotic heart disease accelerates during the menopause transition due to hormonally mediated metabolic, and vascular changes.

In addition to the direct impact of estrogen, women who have persistent moderate to severe hot flashes have up to a 77% higher risk of future heart attacks and strokes. Women at the highest risk are those who experience an early (40-45) or premature menopause. (under age 40).

So while genetics, lifestyle, and diet have an enormous impact, estrogen-driven cardiometabolic changes at least partially explain why cardiovascular disease remains the leading cause of death in women.

All of this explains why menopause is designated as an important time frame to implement prevention strategies to minimize the likelihood of future strokes and heart disease. But menopause may be too late to implement risk-reducing behavior.

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It is beyond unfair that when someone with menstrual migraines is finally heading into menopause and no longer has to worry about monthly headaches, the perimenopausal hormone roller coaster kicks in, and those migraines ramp up instead of letting up. And when the hot flashes start, she is often told that because of her migraines, she is not a candidate for hormone therapy.

The connection between migraines and hormones is well established but not fully understood. While migraines can start at any age, for a lot of women, the misery starts when menstruation starts. Menstrual migraines are triggered by the drop in hormone levels that occurs with a monthly period. Migraines generally decrease during pregnancy, when estrogen levels are sky-high. It appears that the issue is not that estrogen is high or low, but changes in estrogen levels. The theory is that since estrogen is a vasodilator, and migraines can be triggered by a change in blood vessel diameter, a change in estrogen changes blood flow to the brain. The migraine follows.

There are 5 issues when it comes to migraines and menopause.

• What happens during PERIMENOPAUSE when hormone levels are fluctuating

• If it is safe to take a low-dose birth control pill during perimenopause

• What happens POST-MENOPAUSE when estrogen is absent

• The IMPACT of menopausal hormone therapy on migraines

• If it is safe to take menopausal hormone therapy with a history of migraine

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A few years ago, the New York Times interviewed me about the purpose of pubic hair. They were writing an article about the pubic hairstyles of celebrities such as Lady Gaga and Cameron Diaz. Evidently, Lady Gaga’s pubic hair was a matter of public interest. Suddenly, I was getting calls from major media outlets who wanted to interview me about the purpo…

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In case you missed it, check out my segment on menopause on PBS with Dr. Sharon Malone.

May Questions

1. When vaginosis panel comes back negative 3 times, but severe symptoms persist for more than 3 weeks, is this “vulvodynia?” I am 76 year old and otherwise in very good health.

2. If it is vulvodynia, what treatments are possible?

3. Is there a vaginal estrogen that doesn’t cause burning? Both the compounded and the regular estrogen cream caused burning. Should I just stop altogether?

4. What is the role of MHT when you have LOOP (Luteal-Out-of-Phase) cycles and estrogen levels that are already very high?

5. When the estrogen levels are low during perimenopause, I can see how MHT may help buffer the drop, but could it exaggerate some symptoms of high estrogen when you get supraphysiologic levels?

6. Can estrogen still be “working” in the bones/brain/heart even if hot flashes aren’t controlled?

7. Most gynecologists are not trained to diagnose genitourinary syndrome of menopause. (GSM) Which specialty is trained for this? Urologist?

8. You have quoted a few times that 50% of post menopausal women will respond to testosterone treatment. Where does that statistic come from?

9. Are OCPs an issue for patients with low libido because of the effects on sex hormone-binding globulin (SHBG)?

10. I am having trouble understanding how conjugated equine estrogen alone decreased the risk of breast cancer in the WHI, yet the increased risk of breast cancer in overweight women is thought to be due to increased circulating estrogen levels.

11. How does DHEA/Intrarosa compare to vaginal estradiol cream? Is a combination approach better?

12. Does DHEA address all GSM symptoms?

13. Can you mix products (e.g., DHEA and vaginal estradiol, etc)?

14. I heard you on the news this morning talking about a new study that CV risk increases during perimenopause, but I missed the beginning.

15. Can you comment on when cyclic progestogens are indicated over continuous combined progestogen therapy? Which do you have more bleeding with? How do you manage it?

16. How do you know you have enough uterine protection with the cyclical regimen, and why would someone prefer a cyclic regimen?

17. When does it make sense to use MHT in perimenopause over OCPs?

18. I keep getting asked if MHT can help with tendon and ligament issues. I know MHT can help with generalized joint pain, but what about a poorly healing hamstring tendon injury?

    Chidi-Ogbolu N, Baar K. Effect of Estrogen on Musculoskeletal Performance and Injury Risk. Front Physiol. 2019 Jan 15;9:1834. doi: 10.3389/fphys.2018.01834. PMID: 30697162; PMCID: PMC6341375.

19. What are some options for women in perimenopause who are not tolerating estrogen but having mood symptoms suggestive of erratic cycles that would likely benefit from OCPs. Is Slynd a good option?

20. Don’t progestogens also contribute to mood symptoms?

21. 65 y/o was doing well on HT, but then was told to stop. Flashes came back, so restarted E2 gel /progesterone and vaginal estrogen. Had some episodes of bleeding. Evaluation reassuring. Switched doctors who recommended stopping vaginal estrogen; Currently taking 1.0 mg E2 gel/P4 . And so far, no break-through bleeding. but still having some heat surges and insomnia.

22. Why would vaginal estrogen cause bleeding?

23. What to do about continued heat surges?

24. I had a pt stop Duavee due to neck pain. I looked and it is a common side effect! How can that be and have you seen or heard of this with other people?

25. If someone continues to flash on Duavee, can you add more estrogen? Either a patch or additional oral?

26. Early DEXA scan makes sense. 65 is way past the perimenopausal bone loss. But at 55, still in perimenopause, and on 0.1 estrogen patch (with Mirena IUD) for 5 years already would there still be the concern that there would even be Perimenopausal bone loss?

27. Dr. Streicher may you share your menopause approach and routine? That is, your complete routine which I assume is multifaceted: pharmacology (systemic and local) supplements, nutrition and exercise and sleep. How has your approach evolved over the years? ·

28. Read your Substack on vulvar care today. Do you have concerns about toxins in certain brands (ie, lulu lemon), especially is you choose to not wear underwear. Are toxins a real concern we should be aware of in terms of fabrics. You spoke about organic vs non organic underwear, so curious how concerned we should be - I have started wearing underwear as fear of getting cancer from “breathing in” these types of toxins.

29. I am 57, DCIS- and BRCA-negative but CHEK2-positive. Had mastectomy and hysterectomy with one ovary removal (age 41)I am testosterone-curious (libido & energy). Currently taking oral E & Micronized Progesterone (200 for sleep) along with local Estring & vag cream. What is the best delivery system for testosterone?

30. Can you talk about the management of endometriosis in perimenopause? I have a patient with severe pain, who is refusing birth control pills, IUD, and surgery.

31. I initiated standard MHT for a patient 8 years from last period. Meno symptoms improved but 3 mos into therapy developed ganglion cysts, joint pain, skin rash so she stopped MHT and still has residual symptoms. Rheum and derm evaluation is negative for autoimmune disease. 3 mos after stopping MHT -dry skin, new osteoarthritis in fingers. Can you comment on MHT causing or promoting symptoms of an underlying condition?

32. How do we handle the new ACP guidelines for breast cancer screening starting at age 50, mammogram every 2 years, and discouraging additional imaging for women with dense breasts?

33. What’s the oldest you’re been using Mirena for endometrial protection w estrogen use? I realize insurance isn’t going to cover after age 55…

34. 57 year-old with no complaints during menopause except for mood changes. Wants to start the estrogen patch but how long before she would see an improvement if it was going to help with mood?

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