Season 7, Episode 6: Implementing Bioidentical Hormone Replacement Therapy During Menopause with Dr. Manna Semby

Evelyne: I am so glad you are here too. I’m really looking forward to this conversation today. We’ll be diving into all things peri and post menopause, talking about brain health, bone health, heart health, and some of the issues that we just don’t talk about enough when it comes to supporting women during this transition.

Dr. Manna Semby specializes in midlife transformation through hormone optimization, brain health, and systems biology. She’s the founder of Aruna Personalized Medicine and creator of the Aruna method, a multimodal model designed to help high achieving women reclaim energy, clarity and resilience during life’s most pivotal transition. A ReCODE 2.0 certified practitioner and recent TEDx speaker, Dr. Manna brings together science, wisdom and strategy to help her patients not just feel better, but step fully into the next chapter of their lives as clear, confident leaders.

I love this. Manna, before we dive in, what is lighting you up this week?

Dr. Manna Semby: What is lighting me up? There is that I’m working on my first book. Ooh. That’s exciting. Yes. For a long time, I kept resisting. I’m not going to do it. I’m not a writer. I’m not an author. And then a while ago, I was like, okay, I can do this. And then I finally stepped into it. And, I think the difficult thing was just getting started. And once you get started now I’m on a roll.

Evelyne: I love that I’m so excited for you. Very cool. So I’d love to hear more about you and your journey. Can you share more about how you got into naturopathic and functional medicine?

Dr. Manna Semby: Yes. So my first career was in finance. I worked at PricewaterhouseCoopers and then I worked at Goldman Sachs for a number of years, and my world was all about numbers and equities trading and balance sheet and risk and, all of those things. And after that, I did some research in the equities world, also consumer products and retail companies.

And, somewhere along the line, my life changed, unwittingly, without a decision on my part. My young children got diagnosed with autism, and I used to be the mom that would fight for the doctors, staff, if any vaccine or a booster shot was late because, that’s medicine. You know, I need to get everything on time for my children.

And then when they got diagnosed with autism, the pediatrician had no answers for me. And not only did she not have answers, she was just like, I can’t help you at all. But at the same visit, all she was concerned about was, are you going to get the next shot for your child or not?

And I was like, this is irrelevant right now. I need I have a bigger problem than just making sure that my kids are up-to-date on vaccines. So, that was a lesson to me that many times doctors don’t have the answers. And yet we gave our authority away to them, thinking that they have all the answers for us, and many times they don’t. So that was an eye-opening moment for me.

And then I got really into figuring out, well, what is it? What is health? What is wellness? What is our role in our own health and wellness? What can I do for my family, for my children? And that’s how I got started into naturopathic and functional medicine.

Evelyne: So you went in after school after you already had kids? This was like definitely a second or third or fourth career.

Dr. Manna Semby: Yes. Yes, I went back to naturopathic school in my 40s.

Evelyne: That’s amazing. That’s very, very inspiring.

Dr. Manna Semby: I find that it’s not so uncommon. I think most women have second or third acts. Most people, I would say. You probably did something else before your current career now, right? And so most of us reinvent ourselves, at least once or twice during our lifetimes. And I think the same thing happened with me. The difference was just that it was six long years in grad school, full-time. It took a while. And I had young kids that needed extra attention and there was a cross-country move and other things happening at the same time. But I don’t think I’m unique in that, though.

Evelyne: Still very admirable though. So then how did you focus on brain health and then on midlife women? How did that happen after you graduated?

Dr. Manna Semby: So for brain health, when I was in naturopathic school, we were all trying to figure out what is it that each one of us would specialize in or focus in. And for me, the natural thing would have been to become interested in pediatrics because I had my own experience of working with children with autism spectrum disorder.

I found when I graduated that that was the last thing I wanted to do, because that is such a sensitive spot for me. Children’s autism and the struggles of parents are so close to my heart that I just couldn’t do it in my professional life as well. I had to create kind of like a gap, a distance between what I do at work and what I do at home.

So I decided to focus on really neurological issues at the other end of life. And I trained in Doctor Bredesen’s ReCODE 2.0 program pretty shortly after I graduated and at my first job, which was at a big, integrative medical center in Irvine, I began to create a program on brain health preventing and reversing dementia.

And then at my second job, I got to work, at a local clinic in Encinitas, where I worked more closely with patients that had, that had dementia or were diagnosed with mild cognitive impairment. And then I had my own experience when I was diagnosed with breast cancer shortly thereafter. So what happened with me was, when I was in medical school in my 40s, I went through a pretty quick perimenopause.

And then before I graduated, I went through menopause as well. And it was on the earlier side. And I’m not surprised because there was a lot of stress in my life. I was doing too much. Self care was nonexistent, right? So shortly after I graduated, you know, there was this excitement I had this new, wonderful job, which I loved, but I was also extremely burnt out, without knowing that that’s what had happened to me. And now I know that when we begin to go through peri menopause, there is a slow and insidious decline in our energy and our global health. Unless we know what’s happening and we can do something about it.

So what happened was I ended up getting burnt out, having to quit my first job, took a few months out, started my second job, the building back of myself and bringing myself back to baseline had not yet been done, but I, plunged into the second job. And then shortly after, well, about like six, seven, eight months after I had been at the second job, I got diagnosed with breast cancer. And that is what kind of forced me to take a step back and kind of see, like, I need more time for myself. I need a break for myself. My body needs rest. My mind needs rest.

So I did the treatment and took several months out. And after I did the whole thing with the chemo, the surgery, the radiation. What happened was a week after I had finished radiation, I was sitting at home and I remember wanting to think about something. And that’s not something that normally we think about. We are constantly thinking without thinking about thinking.

This time what happened was, I’m sitting there unable to formulate a thought. I’m sitting there and my brain is completely empty. It’s like flat lined. Like you know how you see in the hot monitors and movies, like when the like when there’s a flat line, that means you’re dead, right? It felt like my brain was flat lining and I was very curious, but also very concerned as to what in the world is going on. And this happened the next day again.

Now, having worked with early onset dementia with patients, I kind of felt like there is not that much of a difference between chemo brain, brain fog after chemotherapy and radiation. Perimenopausal and menopausal. I was like, this is a real challenge. So that’s one thing that kind of made me double down into brain health for midlife women.

And the second thing that made me very passionate about midlife health for women is because I went through my own journey with being on hormones while getting diagnosed with breast cancer, and then the surgeon telling me that I was doing the wrong thing by staying on hormones while undergoing treatment. And she told me that I was choosing quality of life over longevity.

My cancer was triple negative, which means that there wasn’t really a hormonal component that makes us concerned. So if you do your research, for the most part, if you are hormone negative, then a hormone therapy shouldn’t be that much of a concern. So I was really upset with the surgeon that she hadn’t taken the time to educate herself on what she should advise patients that come to her, and she is giving me incorrect information when I’m trying to make a decision on what kind of surgery I should have.

So that made me feel like midlife women just don’t get the right information because the focus has really been on first do no harm. And what that translates into is also, do no benefit. And that’s unacceptable. That was unacceptable for myself. It is unacceptable. Unacceptable for all the other women who are faced with similar decisions. And those two things made me really passionate about combining both of these things into one umbrella, because this is where they belong anyway.

We now know that dementia is not a disease of old age. It’s a disease of midlife. It just gets diagnosed, later, late 60s, early 70s, that’s when it gets diagnosed. But it begins in midlife. And of course, this whole thing with breast cancer, as soon as we go through menopause, our risk of breast cancer increases.

So many women are faced with this decision, okay, if I have a history of breast cancer or if I’m concerned about breast cancer, what am I going to do? Hormones or not? So I made it kind of my life’s work to save the men’s brains. That’s my mission. And also to share information about what to do. If you have a history or a fear of breast cancer and educating women about all the nuances of hormone therapy.

Evelyne: Thank you so much for sharing you. You shared a lot in there. So I actually want to just dive right into the breast cancer piece since you brought it up, because I do have a lot of questions. And I think this is quite controversial. And I think that, as practitioners, even in our field of functional naturopathy, integrative medicine, maybe we don’t specialize in this and probably not enough people are specializing in it. And people do search for, you know, an integrative oncologist, but they probably have different information as well. So I’m curious, is there a time based either on research or your experience, everything that you have studied when hormones are not okay in breast cancer?

Dr. Manna Semby: Yes. There is a time when hormones are not okay. By no means am I stating that any woman who has breast cancer or has a history of breast cancer, that it’s okay for her to be on hormones. What I am saying is that, the decision for each woman is an individual decision to be made, with her practitioner or with her hormone literate practitioner and with her history of breast cancer or family history of breast cancer, or a concern of breast cancer. So it’s between the patient and the practitioner and the history. It’s an individual conversation in each instance.

Breast cancer comes in many different types. There’s a triple negative. There are different kinds of hormone positive. There is estrogen, progesterone positive, HER-2 negative or all positive. And then it is also something to consider, also is how positive, if you are hormone positive, how positive are you? The estrogen receptor positivity. Are you weakly positive? Are you strongly positive? That also plays into this decision.

And the other thing that goes into this is, have you already had treatment? Are you in remission? Have you been on some kind of therapy like an aromatase inhibitor or a selective estrogen receptor modulator, like tamoxifen. How did you do on that? How far are you, how far out are you from treatment? What is the risk of recurrence in your case? What are the real quality of life issues that you are currently faced with? All of these go into the calculus for is hormone therapy right for you? What kind of hormone therapy might be right for you? Is vaginal hormone therapy right for you? And in most cases, we end up seeing that that is okay to use estrogen or DHEA, vaginally.

But whether systemically you should take hormones? Again, this should be a nuanced conversation in each case, considering all the information and then bringing into the conversation the results of testing that will be done for pretty much each woman. What does the Breast Cancer Index say for you? What does the OncoTarget DX show for you? So we use all kinds of tools that are at our disposal to help a woman make the decision that is right for her.

What I am saying is that just because you have a history of breast cancer or you’re concerned about it, it’s not a blanket that you cannot, or that you must put the hormones away right. What I am saying is that make sure you speak to somebody who knows, who has experience guiding other women and can really work closely with you to get you the information you need so that you have the quality of life that you want, and your risk is not unnecessarily increased for any recurrence.

Evelyne: And, for the practitioners listening, what do you think are some of the best resources to learn more about this? Like who sets these guidelines? Is it the Menopause Society? Is it some oncology association?

Dr. Manna Semby: There is I would say that there isn’t really a merging of a position statement from the oncology societies, oncology associations and Menopause Society just yet. What the Menopause Society is comfortable saying is that vaginal hormone therapy is okay, even if you have a history of breast cancer.

I don’t know if at any point soon, we will get a statement from either the Menopause Society or any oncology association combining these two things. What I will say, though, is that in my profession, in the world of natural medicine, we have a board of oncology, and we have a board of endocrinology. So perhaps at some point there could be a merging there, and they might be a position statement.

But remember, I think this is an area where anybody has to tread very, very carefully. Because we live in a very litigious society. And every practitioner wants to make sure that their license is not jeopardized. But we also want to make sure that our patient is getting the help that they need. So if we want to safeguard our license at the cost of helping the patient, well, that’s not why we got into the profession in the first place, right? So that’s why I say do no harm should not become do no benefit.

I think the other thing that I take exception with is that sometimes the medical profession thinks that if we don’t share certain information with women, it might be better, because perhaps if we gave them all the information, they might not choose the right thing. And I think that’s incorrect. I think choosing information in its completeness with women and, telling the clinician, telling the patient, this is what I recommend, but the decision is yours, right. I think there is a there is a lot of room and space for that, and there is space for all of us to grow.

This is new stuff. I mean, a lot of doctors don’t even prescribe hormones, right? Not even regular standard hormones. So there is a huge spectrum of where a doctor can go and what they can talk about.

Evelyne: Yeah. Okay. I have several questions that are coming up for me. One on timing of hormones and the other on what you just said. So I remember watching a video of yours on your YouTube channel about the Women’s Health Initiative and that landmark study that was published in 2002 and the negative effects of that, and like a whole generation of women who weren’t treated and a whole generation of doctors who weren’t taught how to work with peri menopause and post menopause. And my question is, so were hormones actually being prescribed prior to that? And then we completely stopped? What’s the history there?

Dr. Manna Semby: The history is that most women, a majority of women, before the Women’s Health Initiative came out were actually on hormones. We were a hormone friendly, I don’t know, society, civilization, culture. But what happened was there was this precipitous decline after the WHI came out, right? Such that I think it dropped to like only 4% of women were on hormones after that. And even now we are still struggling to catch up.

So there was a huge decline after the news came out. And in the last 23 years, we are still struggling to catch back up. And now you must have seen in the last couple of years there is a lot of talk about peri menopause and menopause and hormones, and wherever you turn, it looks like people are talking about that.

But remember, we see that because this is our world, right? We live in a bubble. It’s an echo chamber. We are in this echo chamber. But the average woman on the street is not. A lot of women still don’t know what are the right questions to ask. They don’t even know that if they’re menopausal, and they’re suffering, what is a potential reason for that? Or that there is a way out, or that there is a safe way out, or that there is good, reliable information available?

Which is why I think, so many people are talking about menopause, and I feel that we have barely begun to scratch the surface of, what women need, you know, women that, are in our circle. Of course, we are hearing about it, but most of the women are not in our circle. Right. So it’s up to each of us to see how can we reach the women, that are perhaps not listening to this particular podcast, where can I go and give a talk? Who can I talk to? So a lot of women don’t have the information, and it’s up to us to kind of see how do we get it to them.

Evelyne: I love that you just brought that up because, I think before Covid, a lot more doctors were doing talks. And then I think it kind of like died down. But people are also maybe tired of attending online things, even though it’s such a great way to reach more people right, through online programs. But I’ve seen recently that you have done more in person talks. And so I’m curious, speaking, you know, as a practitioner on here, do you feel like that’s been really helpful for your practice in bringing in more patients?

Dr. Manna Semby: Yes. Any time I give a talk in person, it makes a big difference. It’s like because we are sitting in the same room for an hour or two, I’m sharing my story. But then the best thing about in person events is that women get to ask their questions, and women get to share their experiences, and that’s what women want. They want to hear other women sharing their experiences. So all of them, including me, can know that we are not alone. We are all having, this experience of perimenopause and menopause in common, and we are marveling that no one talked to us about it. No one told us about it. Our mothers and our, the older sisters, all the friends didn’t. And now we find like, oh my gosh, we are going through such a big thing and we need to talk to each other. And so, the events that I’ve had in person have been very gratifying for me.

And I’m doing another one, this coming Monday, and it’ll be great to have women there in person. And my point is really not to give a lecture. My point is to start the conversation right. Be a conversation starter. Be the catalyst for women to get together and begin to have these conversations.

And depending on how a few of these events go, I would love to make this a recurring thing where we can get together and talk about these things. And of course, it’s not like you can’t ask questions if you want to ask a question about what’s going on, by all means, and I’m happy to share. When women get together, we can do so much more than when we are just online.

Evelyne: Absolutely. And, for anybody listening who doesn’t know, Sahara Hub is a coworking space here in San Diego where Manna and I both are.

What are some other organizations that you’ve partnered with or for somebody listening who’s like, you know what, I want to do this in my community. I want to start doing more talks. Is it like partnering with businesses, chamber of Commerce?

Dr. Manna Semby: Yes. So I have partnered with Rotary Clubs. I’ve partnered with smaller women’s groups. I’ve partnered with chambers, and all of these are options, right? And we can go to gyms and offer a talk. We can go to Pilates studios, yoga studios, any of these places where women gather, any place that women and women love together. So any place, any gathering is an option is a place to talk about all of these things.

Evelyne: Absolutely, I love that. I hope if you’re listening, you feel inspired to do more of this in your own community. I want to go back to the hormones. So can you talk more about the current thinking and guidelines around when to start bio-identical hormones? And I know that it’s still an individual decision for the person. And based on your medical history and all of these things. But can you talk about some of the nuances around starting too early versus too late, and for how long?

Dr. Manna Semby: Yes, I think from my perspective, the best time to start is in perimenopause. And how do you know that you’re in perimenopause? That’s a good question. There is no cutoff date. There is no timeline. There is also no clear signal. Right? Your body slides into this perimenopausal state very, very slowly. You almost might not know. And then one day you wake up and say, what’s going on? I haven’t been feeling like myself, in my early 40s or mid 40s, I feel like I have less energy than before. My brain isn’t as sharp. I don’t feel as motivated as before. I’m not even interested in sex.

All these things begin to happen, and what women will often think is that they’ve got too much on their plate. The stress is too high. And all of that is correct, right? They’re juggling their careers. They’re juggling family, children, parents. All of that is happening at the time when you are also going through perimenopause. So it is so easy to not know that in addition to all the things that are happening in your life externally, there are things happening in your life that are kind of stealing your resilience. And when your resilience begins to go down, most of us don’t we don’t think that it’s anything internal, because you may still be cycling normally, you may still be having normal cycles. You may not be ovulating, your cycle may become, lighter, it may become a little bit irregular. So these things can happen and you won’t know.

And that’s why a lot of people like me are talking a lot about it is time to break the silence on perimenopause. Right? That was the whole point of my TEDx talk. It’s time to break the silence. Like if women don’t know, then they don’t know to ask for help. Then they don’t get the help. And then all these things like collateral damage happens.

Women will end up not going for promotions that they have worked so hard for. They will end up changing their careers into something less demanding because they think that work-life balance has become too much to manage.

But unwittingly, what’s happening is your resilience is being stolen by perimenopause, right? And all the other things that also happening. But if we understand what’s happening in your body and we replenish and we work together to replenish your hormones and bring them back to a level that you feel better, more like yourself again, and we manage that process your perimenopause in a way that you keep cycling as long as you would.

But the drawdown that’s happening in your estrogen and progesterone, and also to some extent in testosterone that we can manage that. We can manage that in a way so that ends up happening for a lot of women is that they get put on low dose birth control during perimenopause, and it’s a pet peeve of mine, like there are better ways we can help women in better ways.

So I think women should begin in perimenopause. Women should learn the signs of perimenopause. There are no reliable blood tests. Even the urine tests are, all they’ll show is that your hormones are all over the place. So it’s really by your symptoms. And if you know the symptoms, then you know what to look out for.

You know the symptoms and you know the severity of your symptoms. And you work with a practitioner that you feel comfortable with. And you start looking into this in your early to mid 40s, whenever you’re having these symptoms, instead of waiting until the last minute.

Evelyne: And it also, shows just the importance of practitioners listening, like we all need to be educated in this, right? So that we can address like the hormonal aspect rather than just like treating each individual symptom separately.

Dr. Manna Semby: Yeah. I also think, in my case, what happened with me, hormone replacement should really begin in perimenopause. I didn’t do that for myself. I didn’t even do it right early in menopause, because so much was happening in my life that my self care, taking care of myself, there was no time. I just didn’t have time for that. And knowing that, I should have done that, now, I know in hindsight what a heavy price I paid for not taking care of myself for those several years during my when I was in medical school, learning to do this for myself and others. I didn’t have time or the bandwidth, to do that.

And then I do feel that all of this, the hormone rundown and events in my life led to this extreme burnout. Right? And then, I did start hormones before I started breast cancer. And had I be less educated, I might have thought, oh, my gosh, I started hormones like a year ago, and now I have breast cancer. And I would have said that caused the breast cancer. But I knew that by this time I knew better, I knew better, and so I could manage things.

If there is one takeaway from this conversation, I would just say to if there are practitioners listening here, is that speak to your patients early about perimenopause, educate them about the symptoms early on, even in their 30s, to at least put it in the ear that this thing will happen, most likely in your 40s and you might not know. And here’s a list of symptoms that you should look out for. And if you have this, then come talk to me.

Evelyne: Yeah, I think some of us who aren’t there yet, it’s almost like we don’t want to hear it. Or I think, sometimes as practitioners, like we know so much, but then maybe we don’t always take the steps to like, prevent some of that. And I also feel like you, well, you can’t prevent it. Every single thing goes through it. Right. So it’s just something that we have to be prepared for.

I want to go back to my previous question. So you said starting, you know, when perimenopause hits is a good idea. Is there some stopping point? Is this a lifelong thing? And for somebody who did not start at perimenopause, is it true like that ten year window? Like if you miss out on that, it’s too late. What does the latest research show about that?

Dr. Manna Semby: Okay. So great questions. You know we used to say to do hormones at the lowest doors for the least amount of time to get you from having difficult symptoms that affect your quality of life and to as soon as you can get it off from them, then you do. And what that does is that perpetuates the fear around hormones is like, okay, you should do only the littlest dose and for as little as possible, but it turns out that that is actually incorrect.

What happens in menopause, and it’s really important to understand, is that there is a long term deficiency of hormones. Your body is just not the ovaries are not going to produce eggs. There’s not going to be any follicles. They’re not going to produce progesterone. So that when the ovaries go through this, winding down of their business, when they close shop, it’s like it is done. And now estrogen and progesterone, like certainly estradiol we don’t have in the body and suddenly we don’t have progesterone anymore. So the only way to get those levels back is by externally replacing them.

And it feels like a big deal that, oh my gosh, am I going to have to take these for the rest of my life? I would say yes. If you want to live healthy and if you want to make sure all your organs are functioning, as healthfully as possible, because we know that there’s hardly any organ and very, very few cells in our body that don’t have receptors for estrogen and progesterone and testosterone. So every organ, in the absence of these hormones performs less well than it does with the hormones onboard. So does that mean we take it when we go through perimenopause and menopause and stop at a certain time? No. There are women that are have been taking hormones for decades, feel well, feel great, and they will continue doing that until as long as they live as will I. And a lot of doctors visits talk about, that they are taking hormones and they plan to keep taking it for as long as they live because they help you live more healthfully.

The other question that you have is the, conventional wisdom was that if you start within ten years of menopause, that’s the best time to begin. There’s a reason for that, right? It came out of the WHI study. One time, what they said that the men were helped with hormones was participants between the ages of 50 to 59. And they showed when they took estrogen only that they benefited. There was a reduction in, breast, slight reduction in breast cancer and blood clots.

What we have to see is that great that the WHI came and said that. However, this whole thing about that the older women should not start, hormone therapy later is something that I don’t agree with. Because remember the WHI used synthetic hormones, the average age of women that, they had in the study was, I think, 63. The range of women in the study was from 50 to 79. A lot of these women had comorbidities, meaning they already had other diseases. Some of them were smokers. So if you combine all those things together, we are not going to get the best results that we can using the best kind of input. So I don’t think we are going to do another billion dollar study, recruiting the right kinds of women and then giving them bioidentical hormones to see how they benefit.

So now it’s really up to see, to kind of use the studies that have been done subsequently. And there’s a number of them that show that hormones do not increase any kind of risk for breast cancer. And in fact, in some cases, it shows that it helps. So I would say I do not agree. And a paper actually came out I think, last year sometime there was a paper that was printed, that that said that it is time to revisit that recommendation that hormones should begin in the ten years after menopause. So I think, more and more practitioners are getting comfortable doing that. And in my practice, I have some women that have been diagnosed with mild cognitive impairment. I started them on hormones in their 70s. And of course, we are doing the whole ReCODE 2.0 protocol with them. And I see what a difference they have made in the 7 to 8 months is what I think it takes for a woman, when she does the whole brain health protocol to begin to see, getting back to your older self, your brain is suddenly waking up, you have more awareness, and you can do the things that you were beginning to think you can’t do anymore.

So from my own practice, I can say that older women benefit, and there is no doubt about that. But again, it has to be an individual decision, right? I wouldn’t say put everybody on hormones indiscriminately. But I think the, the alarm bells need to stop ringing. And it needs to be a why can’t I do hormones are there instead of, like, instead of being the other way around, like the default should be yes hormones. Is that an exception? Is there a reason why I shouldn’t instead of is there a reason I should?

Evelyne: Yeah. Thank you for sharing all that. I want to talk a bit more about the relationship between hormones and brain health, menopause and brain health, because that’s your that’s your area, right? The relationship between hot flashes and brain health.

Dr. Manna Semby: Yes. So most women don’t understand that hot flashes are actually a neurological symptom. And the reason they’re a neurological symptom is that the temperature control center, our temperature control center is in the brain, is in the hypothalamus, which is one of these master organs in our body that controls a lot of things. The pituitary, it controls other hormones that control our other hormones, like estrogen and progesterone and luteinizing hormone and FSH and all of that.

So the temperature control center is in the hypothalamus. It’s in the brain. So one way to interpret a hot flash is really the hypothalamus sending signals to you that your estrogen is actually at a very, very low level, literally flashing you to say go replenish your estrogen.

And the thing that I will say is that I see that even a small amount of estrogen can give you relief from hot flashes. So when you have hot flashes, your levels of estrogen are actually very low. When I do blood tests on women that are having hot flashes, they are from nonexistent to two, three, four, five, ten. Meanwhile, in premenopausal women, it can range anywhere from 50 to 350, 400, 500. And of course, when you’re pregnant and all that, you know, the numbers can go way higher. And so when you are at nonexistent or 5 or 10, depending on the units that you’re looking at, whether it’s, nanograms per microliter or a per ML.

So it’s like, how are you going to make sure that the brain isn’t seriously hampered if your estrogen is running so low? In female brains, estrogen is the master regulator, right? And I would say for women who have not gone through perimenopause yet, like you mentioned, that there for women that have not yet and it feels like, oh my gosh, this terrible thing is coming down the pike. I actually want to promote the opposite message, which is that you’re getting educated. The women older than you are telling you how much they suffered because they didn’t have this information. But I think I would say that see it in a very powerful way. That you have the information, you know what to look out for.

And the moment you begin to see the symptoms, you know to address it head on and go forward. And I think that this needs to extend further to younger women in their 20s and 30s and even in teen age, when a lot of women have difficult periods, painful periods, PCOS or any of that, and we put them on synthetic hormones, there are better ways of dealing with that.

So I feel like all of women’s health needs to go through this big transformation, kind of like a metamorphosis to go from how we’ve just been shutting down the symptoms to treating the symptoms the right way by understanding what’s causing the symptoms.

So, yes. So coming back to hot flashes, being a neurological symptom is because it’s coming from the hypothalamus and the brain is telling you to get some estrogen.

Evelyne: Super interesting. Okay. When the time comes for me, I need to schedule a consult with you.

Dr. Manna Semby: Yes of course. And one more thing. If I can, say this thing about menopause and brain health is that, one of the things that I say is we know that heart disease is the number one killer still for women. And a lot of women don’t know that. Right? If heart disease is the number one killer for women, and there is data out there that women are sent home from urgent care and emergency rooms in the middle of a heart attack without them being given proper treatment.

One, it’s because women don’t know what are the symptoms of heart attacks for women. It’s not like the chest pain and gripping and all of that. It can present as a side ache. It can present as gut symptoms. It can present as nausea. So it’s important to know what symptoms to look out for.

And the other thing I say is that because women have a higher risk of heart disease, why and why does the risk go up at perimenopause and menopause is because our blood vessels, the lining of the blood vessels is something called the endothelium. And our endothelium works well when we have estrogen in the receptors. The endothelium has a lot of estrogen receptors. When we begin to run down on the estrogen, the health of our endothelium goes down. The health of our endothelium also goes down because estrogen is, having estrogen in the body promotes the production of nitric oxide.

If you don’t have that, then you know what happens in the absence of nitric oxide, right? You need nitric oxide for your blood vessels to dilate properly and in and around the heart, in the brain. So by multiple mechanisms, when you begin to run down on estrogen, you become prone to heart disease. And then the blood vessels in the brain are smaller, so women become prone to those small blood vessels in the brain getting occluded in different ways. So it’s really important to understand the mechanism of why hormones are important for women. Right. So this is what ties the whole thing together. Menopause, heart health, brain health. So it’s super important of course. And we are not touching on all the other things that impact, like what is your homocysteine and why is it high. What are your toxin levels and why are they high? What is the health of your gut and why is it suboptimal? All these things are talking to each other, impacting our experience of menopause, impacting how that will have a knock on effects on global health. So it’s up to us to understand all of this and to teach each other so that we can go and speak to our patients and our larger communities.

Evelyne: Yeah, and thank you for touching on that. I was actually going to ask about cardiovascular health next. And I do hear that from a lot of practitioners I work with. It’s like, hey, I’m seeing these patients in their 50s or like early 60s and they were always healthy. They eat a healthy diet, yet cholesterol levels are shooting up and just their cardiovascular health all of a sudden is not optimal anymore. And yes, there are things we can do supplemental. But I think one point that you keep underscoring is, that estrogen is important there.

Dr. Manna Semby: Yes. It’s important also because we have studies which show that when you take hormones, the right kind of hormones in the right dosage, that your cholesterol numbers can come down, your LDL can come down by up to 50% by 30 to 50%. The increase can come down. I’m not saying your total cholesterol will come down, but whatever increase you tend to see from, going from perimenopause into menopause, if you are on hormones, you have the chance to reduce that up to 50%. Statins do that by about 25%, maybe 30%. So to understand that estrogen has a bigger impact on your heart health than statins.

And yet, if you compare the number of prescriptions written for estrogen versus written for statins, there is no comparison.

Evelyne: Interesting. I want to talk about bone health. But before I do, I have something that keeps coming up for me. So evolutionarily, I mean estrogen first it goes all over the place and progesterone and testosterone, but then it just goes down. And yes, we are living longer, but isn’t this just kind of like something natural that happens and it’s maybe supposed to happen? And also another thing I’m thinking is, well, bioidentical hormones are not cheap. So how is, and I actually don’t know the prices of, non-bioidentical hormones. I have no idea. If you can tell me, how is it possible to even support everybody in this way? Or does it become something that like only if you have money you can support your estrogen levels? Maybe it’s more of a philosophical question.

Dr. Manna Semby: It’s a great question. So you asked a bunch of really good questions. The first thing is, the bioidentical hormone, the patch that you get at CVS that’s covered by our insurance is bioidentical. The progesterone that you can get at CVS or any other pharmacy. The oral micro progesterone is bioidentical not the hydroxy progesterone acetate. So make sure when your doctor writes a prescription, ask for the oral microprogesterone or promethium. Those are covered by insurance and they are bioidentical. If you’re going to work with a compounding pharmacy to get your bioidentical hormones, then work with the right compounding pharmacy that charges you reasonable prices. I work with a pharmacy who has great prices. I mean, I don’t think you can find prices better than them. And they’ve been in practice for, I don’t know, 35 years or so. So a month’s worth of estrogen could be, I don’t know, 30 bucks, something like that. So it doesn’t have to be too expensive. It doesn’t have to be.

And if it is covered, if your patches are covered by insurance and your order progesterone is covered by insurance. And if you’re doing a dosing that is that that covers you know, if you’re doing static dosing, that’s because you can use that. So that’s that. So yes, there is a cost. But it’s not out of reach. And it’s important to know which pharmacy to work with. And it’s important that your doctor knows which pharmacy to work with.

Coming back to isn’t menopause natural and why do we have to deal with it in this way? Like, it’s almost like saying, why are we medicalized menopause? Is that what we’re saying? Because I have heard that before. Right. And to me, it is like, you don’t have to. We don’t have to. I mean, there are women, and I have women in my circle, right? In their 50s and their 60s that are not on hormones. I see the difference. I see the difference. Right. You can do it naturally.

And I’m not saying that, there isn’t a role for eating right. You can eat foods that will promote a healthier balance of hormones in your body, estrogenic foods like broccoli and kale and Brussels sprouts and all of that. They’re good for you. Organic tofu is good for you. Organic soy products are good for you. These produce phytoestrogens in the body, and that’s helpful. There are supplements right? Litex can help you promote progesterone in your body. There they are things like macca root. There are things like black cohosh. So there are things out there from the natural world that can be done. And remember, the bioidentical hormones are also made from yams and things like that from natural stuff. So I think every woman gets to choose what she calls natural versus medicalized menopause or however you want to see it.

I will say that in my experience being with women, I mean, they’re not every woman will have symptoms. Not every woman had hot flashes either. They don’t. They are, I don’t know, maybe 15% of women that don’t have symptoms of menopause. And they just go right through it and they just slide right through it, glide through it, and it’s great. And we don’t really know yet why that is. I would love for there to be studies on women that don’t have symptoms and don’t seem to suffer at all. Their brain remains sharp. They don’t have genitourinary syndrome of menopause. They don’t have vagina atrophies. Sex is not painful. There’s not that many of them.

But I would love to have a cohort of those women and run some tests to see what is different inside your body, and perhaps their genetics or somehow their epigenetics. I would love to understand what is it in their bodies that helps them be like that? Versus others that do have symptoms. So that is out there.

But I will say that in my view, most women that are not on hormones and are menopausal, they have symptoms. I don’t think most of them are in optimal health. And I can tell them just by looking at them, open the window, close the window. Open the door. Close the door. Give me a blanket. I take it away or like, oh my gosh, my joints are hurting. Oh my gosh, I don’t have the energy. Oh my gosh, I just can’t do all these things anymore.

And I really have to seal my lips from like saying the same thing all the time because like, okay, I say it enough. Every woman has the right to choose for herself. So by all means, I am not trying to say that you must. Right. Every woman gets to choose for herself, but it’s like another way to look at this is, if for some reason you had a thyroid problem and your thyroid was removed, right? You would have to take thyroid hormone for the rest of your life, right? You’re not going to question, well, I’m medicalizing my thyroid. Yes you are because you need the thyroid for metabolism in your body. In the same way I feel that you need these hormones for optimal functioning, you can still continue to function. Yes, women have done that until now.

Evelyne: Yes, right. Great points. And actually you answered one of my questions among the 30 or so that we’re not going to get to of like if you could design a trial, related to perimenopause or menopause, what that would look like.

I want to touch on bone health. I know that there’s also like the musculoskeletal syndrome of menopause. Dr. Vonda Wright wrote a great paper about that. But I want to talk about bone health, actually, because I saw you share a statistic somewhere, when perimenopause first starts, we have the quickest rate of bone loss. What is that?

Dr. Manna Semby: So, what happens is, when you go three months without a period, and this is in this SWAN studies, the study of women’s health across the nation. And on their website, they have all these papers that they’ve made available for public consumption. You can check there. They say that when you begin to go three months without a period, which is still in your perimenopause, you begin to go through a period of fast bone loss, which can be up to 2% a year, which is very, very high.

So, even before you’re fully in menopause, you begin to have this bone loss because what’s happening is estrogen, in bone you have osteoclasts and osteoblasts, right. The osteoclasts are breaking down bone. And the osteoblasts are building up the bone. What estrogen does is it keeps the osteoclasts in check. When you lose your estrogen, the osteoclasts are going to become more active. So your bone breakdown becomes more pronounced. And running down of progesterone is taking away the health, the building back of osteoblasts because it’s osteoblastic.

So you take away the breaking down. You take away the bone building so you can understand how there is an immediate impact on your bone health once you begin to go about three months without a period, which is why I say it’s important that when you begin to go through perimenopause, to be working with somebody experienced, knowledgeable, to help you so that you don’t have these changes. This is a stepwise change in bone health, just like there is a stepwise change in heart health, right? So if we know, then we can take steps to prevent that.

Evelyne: Absolutely. And we recorded a podcast episode recently on osteoporosis. And I just worked at the National Association of Nutrition Professionals conference. And bone health was such a huge topic of conversation for people. I think because it’s happening to more women now, they’re going in for the Dexa scans and seeing that, oh my gosh, I thought I was healthy. I thought I was taking care of myself, but actually I have some osteopenia. And I also heard some amazing success stories about some of our products for that. So that was exciting.

I do want to talk about supplements a little bit more, because we’re on the Designs for Health podcast, so what are some of your favorite ways to support women through this time period? And do you think that for anyone, it’s possible to like just support with supplements? I think you tried that, right?

Dr. Manna Semby: Oh, you mean for menopause?

Evelyne: Yeah.

Dr. Manna Semby: There are women who get significant amounts of help from some supplements, some things that have maca or vitex or baccahort. Some women do get helped. There are others that don’t get helped at all. Like, for myself, I did take a supplement with maca root in the beginning, when I was just having these warm flushes, I would call them, it didn’t help me. I think it depends on, it varies from person to person. So certainly I will recommend to women, especially when they’re early on in the perimenopausal stage, I will go with the supplement route and the food route and the making sure you’re working out and all of those things.

And the other thing that makes a big difference to hormonal health for women now is that we do have so many endocrine disruptors in the world.

What is not an endocrine disruptor? So that is probably a big reason why the experience of menopause is becoming, in some ways more challenging. And so more women are speaking up and more practitioners as more women are feeling, stepping into their power. I feel more women are stepping into their autonomy and speaking up about their experiences, which until recently were considered like, women would feel shame talking about menopause openly or talking about periods openly. And I feel like our society is going through this big shift, this big change where women are like, what if we don’t speak up we’re not going to get the help, right?

And we are carrying the load in the world in so many other ways. So we need the help that our bodies need, if we have the help that we can do all these things that we want to do.

Evelyne: When somebody is on hormones, do you also recommend certain supplements to make sure that they are metabolizing those hormones efficiently and that it goes down the right pathway? What are your thoughts on that?

Dr. Manna Semby: So, what I do with that is every so often I will run that panel for women to kind of see how are they metabolizing. How are they metabolizing? And then when I see if something is concerning, if some enzymes are high that should not be high or if some metabolites are going down the wrong pathway, then I will, make recommendations. Okay. I need you to take this, but I don’t generally put somebody on these supplements right away, because I really do believe that supplements should be supplemental. And, most of our health should come from living right and eating right and learning to manage our stress instead of leaning on something externally to do something for us.

I feel like building our own resilience is so important. And then I feel if you are doing that, then targeted supplementation actually works better. Instead of sending somebody a long list of supplements. And what I also do with people is I will cycle them in and out of supplements, you know, I will tell them, okay, for the next 2 to 3 months, I want you to be taking these, 3 to 4 times a week. I don’t I don’t require them to be taking something every day. Unless it’s something like I would say Omega-3s, yes. Take it every day. Vitamin D, especially if your levels are low. Do take it every day. Right. But other things like, let’s say things like, detox agents. Right. Let’s say there’s glutathione and or charcoal, plus or other binders. I don’t routinely put people on those unless I am doing labs on them. And I show results that are pretty high, and then I will put them on those things. So generally when I’m working with women and it’s not just we do your hormone prescriptions one and then you’re done. Generally I’m working with them in programs over a period of time. I’m working with them for three months, six months, nine months. And that allows me to go into detail. And so the supplements play a very important role. But I don’t have anybody take one supplement for nine months together. Because I am cycling them in and out of those.

Evelyne: Yeah, that makes sense.

Dr. Manna Semby: And so it really depends. And I’m beginning to play with this analytics that are now coming out and kind of doing my own studies, like, okay, this patient I think I want to try, give her this analytic at this time and then not have any other changes like supplements or things change in her so that it’s kind of like an N of one study for this one person. And that helps me kind of come up with my own, my own thesis on, okay, so this supplement works in this situation for this kind of patient, and then I can test it in the next one. So targeted supplementation for short periods of time.

Evelyne: Great. Thank you for sharing that. I want to wrap up with our questions that we ask every guest. The first one is supplement related. What are your three current favorite supplements for yourself?

Dr. Manna Semby: Mag citrate, Vitamin D and melatonin.

Evelyne: Awesome. And what are your favorite health practices that keep you resilient and balanced?

Dr. Manna Semby: Oh my gosh have you heard a lot about this morning routine thing?

Evelyne: Well which one?

Dr. Manna Semby: Okay so a good morning routine is a thing right. People talk about their morning routine. For me I cannot have a morning routine unless I have an evening routine, right? The evening routine is so much more important. And what I am noticing in myself and in the people that I work with because, I’ve been recommending the same to them also is, it’s so hard for us to give up our screens in the evening and stop and okay, now we’re going to go to bed.

It’s really important to understand that if you don’t go to bed at a decent time, which is really 10 p.m., you are giving up prime time for your brain to do the cleanup in your brain that’s going to take away the build up of Tao and all the amyloid plaques. So it’s really important to do that.

So what I like to do is around 8:30 or 9, screens are put away, right. Wrap up the day, everything is done. And by about 9 or 9:30 I am in bed. And I have my journal, and I journal at night, and I take a little bit of melatonin and I take my other stuff, whatever I’m going to take, my progesterone or whatever else. And I journal at night and then I get into bed, and that feels really good because I feel like I offload stuff from my body, my mind, my ether. I put it into the book. Yeah. And then I get into bed and I do this practice of progressive muscle relaxation. So it’s like you go through your whole body. It’s like 8 or 9 minutes, but you’re tightening and relaxing all the muscles of your body like 2 or 3 times. And then I settle into a practice of deep breathing. I’m telling you, that makes such a difference to the quality of sleep. And then when I wake up in the morning, I’m in such a rested state, I’m still breathing low and slow, and I’m rested. But I don’t want to get up because it feels so good. But I must get up. But it just feels so good. So that’s my practice and I feel that gets the sleep, the stress, the melatonin and the vitamin D. All of that gets encapsulated in that.

Evelyne: Yeah, I love that. Thank you for sharing. What is something that you’ve changed your mind about through all of your years in this field?

Dr. Manna Semby: There was a time I used to think doctors have all the answers. Now I know they don’t. So you must find your own. And there was a time, very early on when I first got exposed to the word hormone, I used to think of these steroids, this illegal use of steroid hormones to do bulk yourself up. So I had this impression of hormones like, ooh, I don’t know about that. So I’ve changed my mind about those in a big way. Not the growth hormone but yes.

Evelyne: Yes. Great. Well, thank you so much, Mona. This was such a great conversation. And I would have loved to ask you, like 20 or 30 more questions, but we’re out of time. And I also appreciate that you really shared a lot for practitioners listening. But as practitioners, we’re also going through these things, right? So if you are a male practitioner listening to this, talk to your wife, talk to your daughters, talk to your patients about this. And as females, I think that it was really just enlightening for me. I feel like I need to keep hearing this over and over again to make sure that we are proactive, you know, about our health. So thank you so much. Really appreciate you.

Dr. Manna Semby: Thank you. It’s my pleasure.

Evelyne: And thank you for tuning into Conversations for Health today. Check out the show notes for resources from this episode. Please share this podcast with your colleagues. Follow, rate, or leave a review wherever you listen. And thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence based, cutting edge research and practical tips.