Dr. Alexa Fiffick: EPISODE LINK
Menopause Society Statement: LINK
TRANSCRIPT:
COLLEEN: Welcome back to hot flashes and cool topics today. We have on dr. Alexa Fiffick welcome to the show
DR. FIFFICK: Thank you for having me.
COLLEEN: Well, we’re thrilled you’re here and we have so much to talk to you about. You recently attended the menopause society, 2024 annual meeting, which we unfortunately were not able to attend, but so much came out of it. We thought we’d start with a few takeaways that you thought really kind of highlighted the week’s events. So what do you think was the one of the most important things that you learned from last week?
DR. FIFFICK: I think one of the things that hits home for me a lot is the reiteration of the stance on menopausal hormone therapy and its benefits and things that we don’t have any proof that benefit from it. As you guys probably know very well, menopause and women’s health has been having a really interesting moment on social media and in a lot of other venues that it comes, it comes with good and bad, right? Like it’s really great that we’re talking about it. And, you know, it’s a bigger conversation. I think that’s why it was such a big meeting this year. But at the same time, there’s a lot of misinformation and disinformation. And so that kind of, that sort of topic, whether or not it was just frustration with the misinformation, disinformation, you know, prevalence, or if it was more of the questions of what can we do about it and what is the official menopause society stance on it. I think it was very interesting that a lot of the other clinicians there and a lot of the board members seem to have been feeling the same thing. And that came up as a topic. So honestly, my biggest takeaway probably from it was the reiteration of, you know, this is the evidence we have that we don’t have evidence for some of these other things and we can’t stand behind some of those commentaries.
COLLEEN: When you say stand behind those other commentaries, so you’re saying that their stance is consistent that HRT is safe under most circumstances to take. I just wanna make sure our listeners are clear on what.
-DR. AFFICK: Yeah, and to further clarify as well, claiming that we have enough evidence for it, you know, it to be kind of this fix it all pill for multiple different things and that it’s always right for everyone in every scenario, which is, it’s having a hot moment is not, it’s not valid. And I am obviously a menopause expert and a hormone expert, but I don’t use it for every single woman that walks through my door. And so understanding the pros and cons of when it’s the right thing, when it’s not the right thing, as opposed to a lot of what’s happening on social media is more of a claim that we can fix everything with hormones. It’s not true. And additionally, the other thing that is really hot on social media right now is vilifying birth control. And so one of my big takeaways from the meeting was really that a lot of the other experts in a lot of the data and the evidence we have so far really justifies using it in the right people at the right time. And everyone else feels a little bit frustrated that it’s again making a go around of being vilified on the internet.
BRIDGETT: So when you’re talking about birth control being vilified, can you give us an example of who it would be right for and maybe who it would be wrong for or maybe it would be time to move on to menopause hormone replacement.
DR. FIFFICK: Yeah, and so I love that question because it really is, it’s very specific to each individual woman that walks through the door. And anyone who really truly is a menopause expert knows that each individual case, each individual woman’s life and body and all of those things have to be taken account with her specific kind of plan that you’re making, whether it’s medications, hormonal, non -hormonal, supplements, et cetera. And for a lot of women, birth control really is a phenomenal answer to treating perimenopausal symptoms.
As you guys know, perimenopause can start as early as in someone’s 30s naturally without it being associated with any other negative things. And unfortunately, until you go past those 12 months of having no menstrual cycles, it is possible to ovulate and get pregnant. So in someone who doesn’t have another form of contraceptive or has really terrible periods, contraceptives are an amazing tool, particularly for people who are in perimenopause, who are having irregular cycles that are specifically more frequent, heavier, life disrupting, uncomfortable. Suppression of ovarian function is a really amazing way to keep that period or menstrual cycle under control while at the same time treating the symptoms of what is associated with perimenopause or menopause.
Because a common misunderstanding is that it’s only when estrogen bottoms out that women are symptomatic and realistically it’s what the scientists call the delta of estrogen, it’s the change in that level. And in perimenopause it’s going up and down really willy nilly and preventing that from happening or controlling the cycle, controlling the ovarian function is really what makes so many women feel a lot better. And it isn’t inherently bad for you. Unfortunately, there’s a lot going around on social media right now that doing some sort of ovarian suppression is unnatural and unsafe. Realistically, we have a lot of very, very safe tools if they’re used in the right person at the right time. But there are some cases in which perimenopause is treated better with menopausal hormone therapy. And so it’s not, it can’t really be a one size fit all. But it’s not, it’s not sexy to, you know, say, oh, hey, it’s different every time and like what’s right for her might not be right for her it’s a lot sexier and you know click bait if you just come out with one thing so we get it but it’s frustrating.
BRIDGETT: Yeah and you know what we’ve heard from some women that they’ve been on birth control and they aren’t even sure when they you know start at menopause I guess if it if it suppressed their cycle so much that they didn’t have a cycle. What is there something that can help women if they realize, you know, how would a woman realize they are in menopause if they don’t have symptoms or if they just quit having cycles?
DR. FIFFICK: Yeah, so that’s a really great question. Typically, if it’s someone who’s got very good control of their symptoms and kind of the other proportions of what was being, you know, aimed at being treated. You can safely keep most people on birth control as long as they’re, you know, not meeting that list of contra indications, like they smoke a pack a day or anything over 15 cigarettes really, which is less than a half pack in case anyone did not know that. But but the average kind of person who doesn’t have any contraindications towards contraceptives, you can safely keep that person on birth control until at least 52, depending on each different person, whether or not they’re noticing symptoms that maybe the pill is a little too much for them or that they aren’t quite feeling feeling as great as they were a couple years prior on the pill. Every now and then I noticed that will happen. You can keep people on that birth control pill until they’re like 55 or 56 years old depending on each kind of different situation. Not something people know a whole lot of and it’s not every girl that walks through your door but there are going to be some that stay on it for quite some time because As long as the symptoms are controlled and the risks,
you know, aren’t outweighing the benefits, then it makes sense to keep on it. Ways that I’ve noticed patients can sort of tell that the transition is a little bit closer is that particularly if they’re on a progestin only option for a pill specifically, because that’s the only way you can control ovarian function, is that they start noticing a little bit more of those estrogen deficient symptoms creeping in. And usually that means that we kind of carried them into that phase of we stopped the fluctuations and now we’re seeing them feel the estrogen deficiency.
There’s a lot of times that we’re not gonna know until we try and from where the data shows, if you’re not stopping your birth control for at least like two months before you do those levels, I can’t honestly prove whether or not you’re fully menopausal yet. So if there’s still a chance and we’re worried about it and you’ve got no other contraceptive, chances are we’re going to probably stay on it until we’re like real good and sure about it.
COLLEEN: Another thing that I heard that came out of the Menopause Society meeting was their reiteration on the stance of dementia and HRTs because like you said there’s a lot going around social media right now and hot topic is to say well HRT is preventative or proactive in avoiding or decreasing your chances of dementia. Can you talk about what they discussed and their stance?
DR. FIFFICK: Yeah so mainly the position kind of holds that we don’t have enough evidence to prove or disprove that fact. While we have, if you’ve taken a look at the 2002 Menopause Society guidelines back then, it was still called NAMS, North American Menopause Society. At the time that that statement was made, it was noted that menopausal hormone therapy started after the age of 60 or beyond 10 years of becoming menopausal is potentially associated with increased risk of dementia. I’m not sure that we have data to say whether or not that’s true yet. And that’s the problem is that we just don’t have that clear information yet. Now, if you’re paying attention to social media and media in general, you’ll know that Dr. Lisa Mosconi recently came out with some fantastic research and a fabulous book, which does a really good audible read in the car if you’re a driver like me. But it demonstrates a lot of the things that have come out of the work of people like J. Dean Hoffey and Rebecca Thurston looking into the Ms. Flash studies where we look at the MRI images of the brain, showing that the more hot flashes somebody has, the more white matter lesions that they have, aka for the non scientists on the podcast, basically little tiny mini stroke looking lesions. And typically that is what we see when we’re talking about somebody who has vascular dementia.
Is it the chicken or the egg? we don’t know. It is suspicious to a lot of us in the space that the more women have hot flashes, the more likely they are to have these lesions on the brain, and the more likely they are to end up with some sort of cognitive decline or dementia. But again, is it the flashes? Is it because they were already prone to these cardiovascular, vascular events? We don’t really know. And so while the data is investigating that. We can’t honestly say we know whether or not hormone therapy prevents it.
In fact, they’re now looking into whether or not treating the vasomotor symptoms, the hot flashes, night sweats, with anything such as our two newer medications that we talk about a lot with Bayer and Estella’s coming out with some cool new stuff, whether or not even just using one of those to treat the vasomotor symptoms is going to be protected for the brain. We just don’t know.
COLLEEN: One of the things that we hear from our listeners is that Veozah, which is the one you’re talking about with Estellas, is very expensive for them to get. Do you think with this second FDA approved non -hormonal treatment for Hot Flashes coming out soon that might balance the pricing and make it a little more affordable?
DR. FIFFICK: Oh, I sure do hope so. It’s difficult because I recently had a conversation with someone who is in the pharmaceutical space. And the gist of kind of the struggle that I don’t think a lot of us saw coming is that menopause and the vasomotor symptoms, the sleep issues, everything that is associated with menopause is still looked at as a bothersome thing and not a life -altering, life -threatening, disease -inducing thing. And while that is for some women true, for some it’s very untrue. We know that just going through menopause in general is putting you at an increased risk of metabolic syndrome, high cholesterol, high blood pressure, type 2 diabetes, the insulin resistance, a slew of other things. And just that fact alone, I think gets looked over when we’re talking about these medications for what appears to be a little bit more lifestyle, despite the fact that we know that poor sleep is associated with like a bajillion things, such as weight gain, metabolic syndrome, et cetera, et cetera. And so the disconnect that had happened, in my opinion, between, you know, kind of the FDA and the payers understanding, they was a fezolinetant and this other upcoming one for Bayer, Ezolinetant, they’re not to fix a bothersome problem. They are to improve quality of life and functionality for these patients. You guys know as well as I do that some women lose their jobs because of their hot flashes night sweats the cognitive decline that comes with not sleeping for days or weeks or months on end. And just being overall run down after those things. You know, I have women every single day come into my office, you know, that are CEOs of large companies or small business owners or, you know, moms of small children and they all come in crying, telling me I can’t function, I can’t do this, everything’s a mess, I feel like a failure. Yada, yada, yada, whatever phrasing that she uses. And to call that bothersome when it’s showing up is what did we say, $26 billion in the American fiscal loss in a year because we can’t keep women in the force and we can’t support them through menopause is just a complete disconnect to me. So my hope is that when Bayer goes up for their FDA approval, they not only are able to get the acknowledgement that, hey, yeah, maybe we should make more competitive like payments happen, but that we stop treating this as if it’s something that’s a small problem.
BRIDGETT: You brought up some really great points there about treating it as a lifestyle issue,not as a bothersome thing. And I feel like that is so important because every expert that we’ve ever talked to in any field, it all leads back to sleep and quality of life and it just everything,
you know, longevity experts, fitness experts, food, you know, somebody to do with diet and food, it all leads back to quality of sleep. And I just, I appreciate that you brought that up, because I don’t know, it’s such a bad issue. And is there, what, do you have any suggestions on what we can do to have this brought up to people?
DR. FIFFICK: Yeah, I mean, I’ll say again, Menopause and the symptoms that go along with menopause are not bothersome for some women, they’re crippling, they’re life -changing, and they are incapacitating. One of the things that I think was interesting from the menopause society meeting this year on actually Saturday, one of the sessions in the morning was talking specifically about sleep and sleep sleep in midlife, started talking a lot about women who are undergoing breast cancer treatment and kind of looked at the different ways that those medications affect sleep in the way that I’m going to pause in general, affect sleep. And the problem is, is that we currently don’t really have a lot of really good medications for the sleep portion of taking care of patients symptoms. Ironically, some of the data that is coming out about the NK1 and the NK1 and 3 inhibitor, the Fezolinetant and the still being studied Ezolinetant is that there is some data that those improve sleep. And they’re really looking into how the NK1 receptor binding in the brain can help with sleep because the frustrating portion of that session was,hey, we know this is a giant problem and it affects literally everything about everything, but we like don’t have a way to fix it yet. It was also, it’s also like very reassuring to know that some of the things, you know, that are newer to the market and or are not quite to the market yet are going after this problem Because if you already had that discussion about making menopause work kind of thing with menopause society and another group I’m affiliated with menopause mandate. If you’re not sleeping and you’re showing up in at work, you know, late because you fell asleep again and you couldn’t get up or if you were up all night and you’re just super Um, people don’t realize that that is a large portion of why women are either leaving the workforce, downgrading or not accepting, um, promotions. And again, it hits us in our packets. And if that’s the only way that people are willing to pay attention to it. You not taking care of your menopausal colleagues and employees is hitting you in the pocket, even though you just think it’s kind of lame that she complains about her sleep. That is that is so well said. I mean, I think sometimes that’s what it takes to get people’s attention.
Right. Yeah, it’s like they’re affected. Yes, yes, their fiscal loss will tend to like bring the ears perked up and say, wait a second, I’m losing money on this. And it’s not just their mother, their daughter, their sister, their whatever, they care about their pocket. And giant news flash, it’s been hitting us in the pocket. – Very true. And like Bridget said, because it’s just, it’s becoming a larger conversation, but it still really hasn’t reached into the workplace as much as it should.
COLLEEN: Was there anything that they changed their stance on or anything that surprised you during the convention?
DR.FIFFICK: Finding out that a lot of the people in the space, like from the academic perspective of menopause and like the, you know, boots on the ground, menopause experts taking care of patients. The fact that we’re all feeling that kind of pressure from social media and media, and that it’s showing up in everyone’s clinics is, it was surprising to me because, you know, when you’re out boots on the ground seeing patients every day, it does not feel like that there’s a big support system for the way you feel about a lot of things. And it becomes pretty frustrating one day after day after day, like people are bringing you, you know, recommendations for someone supplements that are not FDA regulated and or third party tested and may or may not have potentially, you know, harmful outcomes that we don’t know because that’s not something we study or regulate here in the United States. It is so exciting to know that other people feel the way you feel.
And that sounds kind of, you know, I don’t know, I don’t think that’s like maybe what patients want to hear that we’re frustrated but we’re frustrated for them because if it’s my job to help you figure out what’s true what’s not true and you’re being inundated with untrue things consistently then how hard is it going to be for patients to help figure out where they need to go for help in the first place let alone
the giant dearth of menopause experts that there are out there in general. How do you even find yourself to one if you’re getting wrong information? Right
BRIDGETT: I mean that there is so much and it is, it’s all over social media and Colleen and I have really found this since we started the podcast five years ago and we will try to research something and we’ll say okay what’s the source of that? Where did that come from? I saw something today, like just like right before we came on here about maybe hormone therapy, reducing insulin resistance. And I, I, you know, was curious what, if that was talked about at the menopause society meeting or what are your, what are your thoughts on that?
DR. FIFFICK: Yeah, so if it was spoken about, it was like directly, it was not in a meeting. Okay, it totally could have been. But there’s a lot of congruent things that happen at those meetings. Sure. The, that is data that we’ve had for a while, though, that there is some association with insulin resistance reversal with menopausal hormone therapy. When you take a look at a lot of the data over the over the last five years it’s been booming, but even prior to that, menopausal hormone therapy has been associated with improvements in a lot of the metabolic functions. So if you are unfamiliar, estrogen depletion that comes with menopause and even the fluctuations that are occurring in perimenopause are highly, highly associated with increasing insulin resistance, increasing of LDL, your bad cholesterol, increasing its inflammatory little brother, ApoB, as well as decreasing the functionality of HDL, your good cholesterol. So all of those things are things that we’ve known for a while. I think it really kind of showed up a little bit earlier this year. I believe it was in the spring when we started getting the studies that women who went on menopausal hormone therapy and a GLP -1 were significantly outperforming those who were only on GLP -1 from a weight loss in a A1C improvement. So I really have found that data to be super interesting, especially when another thing that’s being vilified is these GLP -1 and GLPI medications that are helpful for so many, knowing that, you know, it really does help with hormone being combined with hormone replacement therapy or hormone therapy.
COLLEEN: Can we dive a little bit into more what you’re talking about with cholesterol and the HDL and the LDL, because I don’t think a lot of women realize the relationship between menopause and your cholesterol and what role it plays in the latter, what’s, can you talk a little bit more about that?
DR. FIFFICK: Yeah. So, um, we have had data that, uh, menopause is in increased risk factor for heart disease for probably many years now. Um, however, the American Heart Association only came out with kind of that statement in 2020. Um, and so in 2020, uh, the American Heart Association came out with that that statement saying that, you know, not only is early menopause associated with an increased risk of heart disease, but regular, you know, normal ages of menopause are associated with that. And that really stems from estrogen’s role in the blood vessels. And so in the blood vessels, when they lose estrogen, the actual walls of your arteries become more stiff. So things like blood pressure going up because you’re kind of working against a really stiff hose, it can’t flex or bend the same way. It gets a lot of resistance, pushback, and blood pressure goes up. Additionally, on top of that, lack of estrogen is just a very pro inflammatory environment. And so things like ApoB, which is a subparticle of LDL, the bad cholesterol, that his job is essentially to act as like the one who calls the people over for the house party when mom and dad leave. He calls all of his inflammatory friends and says, “Hey, go make something sticky and gloopy that sticks on the side of the artery wall.” And in addition to that, the loss of estrogen also is associated with decreased functionality of HDL. HDL is our good cholesterol. His job is to act like a scavenger. He’s like the cop that shows up and is like,
“Oh, hey, there’s too many people. There’s a noise ordinance thing. Let’s get you guys out of here and take some of those away.” And just going through menopause and having those couple things happen where your arteries are stiffer, there’s more junk in them and the stuff that’s supposed to get junk out of them, stops working quite as well, is a really risky environment for heart disease. And it gets looked over a lot because men don’t have the same sort of onset offset of when things kick in for heart disease as women do. So people walk around thinking, oh yeah, men are just at a higher risk of heart disease through their whole life and that’s just how it is. Until you lose your estrogen and then all of a sudden, all of these things are happening and you’re at this increased risk. Not to mention, you know, you’re not sleeping, meaning you’re not eating super well, the weight gain happens, the central adiposity happens, all the things. Oh, and I did forget to mention one interesting thing. the loss of estrogen also is associated with increased risk of like visceral fat, meaning so like the fat that wraps around your organs, it wraps around your heart, it wraps around your liver, it wraps around your pancreas, you did not know your pancreas is what makes your insulin. So when that fat is sitting around your organs and it’s secreting inflammatory markers, it’s stressing all of those things out. So it’s stressing out your cardiovascular system, your liver, your pancreas, everything. And it’s contributing to that sort of metabolic syndrome that we’re seeing. So it’s really, really multifactorial. And so it’s really important to know that that’s a risk, particularly if you have an increased family risk, because if you have that increased family risk, and then all of those other things start setting off, you’re really in an environment in which it’s going to be much riskier.
COLLEEN: Is it important for women to get all of this checked? Their A1C, because I know sometimes insurance companies don’t cover A1C and cholesterol. And how can they find out about their own personal health information?
DR. FIFFICK: Yeah. So I do. I think it’s very important. And I recently read an article that I maybe even like a week or two ago was released, basically stating that we really need to be more frequently checking things like LP little A, ApoB, ApoA, ApoB, A ratio, the, you know, some of the more extensive metabolic markers in women because women’s heart disease presents so differently than men’s that not having that underlying information is not particularly helpful to women. And the way I talk about it with my patients is a sort of yeah we could wait and see what happens but I’d rather find out you know that the train is you know headed the wrong direction on the tracks and fix that as opposed to just waiting for the crash to happen so I think it’s important to advocate for yourself and to ask your physician hey can we do this if this isn’t covered by insurance do you have any cash pay ways to do this. And fortunately, these days, that is a much more common option than it used to be. A lot of people don’t realize that you can flat out ask some of the lab facilities and /or hospital facilities to run you a cash rate. I fortunately work in the concierge medicine space, so my services are based on cash. I will apply insurance to anything else outside myself, whether that’s labs, medications, imaging, etc. And so figuring out what labs and what facilities have really good affordable cash pay options, should it not be covered by your insurance, I think is important. If it were me, and I knew my insurance was not going to cover them, I would probably at minimum ask for them every like two to five years and figure out a cash way to make that happen.
Some of them like LP little A is theoretically you only need at once in a lifetime. I think we’re finding out more about that that’s going to change over time. And then same thing with things like CT coronary artery calcium score. There are a lot of people that qualify for it and get it covered by insurance. There are some that don’t but a lot of the hospital systems and imaging places around you will offer cash rates if you ask.
For example, one of them that was recently offering a really good cash rate just decided that they were gonna cover them in full for everyone that walks through the door here by me in Cleveland. So you just gotta ask, but that also is pretty much menopause in general, right? Or like women’s health in general. Like you have to ask because no one’s gonna just tell you. So, do what you think is right for you and advocate and if you get told no, ask somebody else or ask again.
BRIDGETT: One other thing that I had heard about and I wanted to know if they discussed it or your opinion on it is the extension of testosterone being prescribed during telehealth appointments and the fact that it may only happen until December of this year.
Did they talk about it? And what is your opinion on it?
DR. FIFFICK: Yeah, so it was spoken about a little bit. Testosterone in general is, again,hot topic.
BRIDGETT: Not approved for women.
DR. FIFFICK: Correct, we do not have an FDA approved product for use in women in the United States currently.
BRIDGETT: Is that the case worldwide?
DR. FIFFICK: No. Is it guideline recommended in certain scenarios for women using FDA approved products that were FDA approved for men but not women? Yes. And so there are a lot of women that need testosterone that benefit from testosterone. Now, is it as willy -nilly as the internet will let you think? Probably not. But the fact that there are quite a few people that are going to be limited who do need it and and truly if you are, you know, someone who’s gone through surgical menopause or some sort of other chemo induced or medication induced menopause and like you genuinely don’t have any ovarian function or any ovaries. There’s a decent chance that you probably could benefit and /or need testosterone. So if the only way that some of those patients are getting it is via telehealth, we have a big problem and a lot of us have been signing petitions in order to bypass that. So maybe you guys can link one of the petitions in your podcast.
COLLEEN Yes, we can.
DR. FIFFICK: Because it really, it’s something that I think is gonna be potentially very problematic. Now, if we’re talking about testosterone prescriptions that are happening in ways that are not recommended, then maybe that’s not like the worst thing in the world to get a little bit cracked down on. But if it’s gonna hurt people who need it, I got a big issue with it.
BRIDGETT: You just answered what I was gonna ask, like why the pushback? But so is it because of places that are prescribing it that probably shouldn’t be in ways that shouldn’t be prescribed?
DR. FIFFICK: Most likely it’s really it’s really difficult to regulate those places. I’m sure you guys have spoken to many many people that are like very anti pellets and unfortunately pellets and compounded unregulated hormones still is a very consistent issue in my neighborhood and the neighborhoods around a lot of my friends where they practice and if if listeners do not know. The reason that we really dislike testosterone pellets or pellets in general is because there’s no way to control what you’re getting and to make you stop getting max.
In particular, the thing that gets overlooked really frequently, and I actually was on a different podcast talking about this topic only for a while, was the is the fact that once a testosterone pellet is in your body and it gives you these super therapeutic meaning higher than you could possibly need as one doses. I can’t take that pellet back out it disintegrates to some degree inside of your that tissue, which is realistically like near your butt cheek. And we can’t go out and get it in one piece. So you’re getting these really crazy high doses of testosterone and we can’t remove it from your body. Okay, so problem with that short version. If you still have a uterus, you are making that excess testosterone turn into estrogen and run a really severe risk of having endometrial or uterine cancer.
Additionally, those super therapeutic levels of testosterone are highly associated with increased risk of metabolic syndrome conditions.
COLLEEN: Okay. We are not aware of that. See, we learned something in every podcast. Every podcast. Every interview. Everyone that, you know, the menopause experts that we speak with, no one is a proponent of pellets.
DR. FIFFICK: Some of them do, but they’re not even even proponents of it. But that’s a really clear image and information for women to fight us on this on our website and our posts. So I’m going to say this, not that you guys asked this question, but because it needs to be said and because I am probably going to die on this hill unless they come up with a lot better information over my Um, the other problem with supra therapeutic testosterone is an issue called tachyphylaxis. Tachyphylaxis is basically the fact that you can keep giving the body more and more and more testosterone, and it will stop being capable of having the same response to the same dose. So think about it the way you think about opioid addiction. you end up forming more of these receptors that are just waiting to get all this extra testosterone and then you eventually fill them, you make more. So at some point you just have a bunch of empty receptors and the effects of that super therapeutic problematic testosterone that might be causing you other issues in your uterus and or heart or somewhere else,
you no longer feel that great. And so that’s part of the reason that we really have an issue with pellets in general as well is that it’s basically like doping. You’re really overdoing the testosterone and your body recognizes that response to it and then you no longer have any capacity whatsoever from a like cellular level to make that amount work for you. And so it’s associated with a lot of aggression, a lot of like energy spikes or depression. It’s basically what shows up in the inbox when people are saying like, but I felt so amazing on this and I really need these. These are important for me because it’s before the crash. You’re still in that point where it’s working and your body hasn’t had that tachyphilaxis reaction quite yet and you haven’t come off of it, but it will happen and it’s really uncomfortable and we don’t really have a lot of ways to help you through that, unfortunately.
BRIDGETT: How long does that take? Is there an average of how long you have to be on the pellets before you have the crash?
DR. FIFFICK: I forgot that number right off the top of my head, naturally, as you asked the Um, I have seen it anywhere from about like 12 to 18 months. Usually people feel good for a little while and then somewhere around that second, you know, uh, half of their second year is when it really starts going downhill. Some people it’s a little longer than that. Um, but again, that’s the problem with pellets is some people,
um, you know, are metabolizing those in the course of like one to three months, some aren’t metabolizing them for six or nine months. And meanwhile, they keep getting pellets every three or four months because it’s cash and somebody’s making money on it.
BRIDGETT: Wow. So it’s, so you’re talking with this and I just want to clarify, cream formulas of testosterone, does that have the same effect of the pellets or is that that’s different? Okay. It’s different. It’s like I take because I’m off the cream.
DR. FIFFICK: Yeah, and so that’s why we’re like really particular too about the way that we dose testosterone in women and why it is,
it’s finicky, right? Because it’s one -tenth of the dose that we would give a man every single day. So give or take five -ish milligrams per day is what like a pea -sized amount. And so if you are like me and many of my other colleagues, I think actually Rachel Rubin was one of the people that put this out on the internet first was to use the little syringes and measure them with the ccs or the milliliters so that patients could see that. We do it that way. Some people will, because it’s cheaper and easier, have it compounded from a reputable compounding pharmacy that they know the people. My compounding pharmacies that I do work with when I work with them. I know the pharmacists, I know their process, I know all the things, I’m not just sending it to wherever. At a reputable compounding pharmacy, it does become a little bit easier to have it made in sort of what we call like push click little tube where it’s dose -needed, but it’s very, very much different when we’re dosing you for appropriate postmenopausal, premenopausal, female dosing versus these crazy super therapeutic numbers.
And when I’m talking crazy super therapeutic, I mean, we’re seeing them in the hundreds when we get these blood levels. And don’t forget, there’s still some of that that’s converting to estrogen, so.
BRIDGETT: Wow, it’s just scary. ‘Cause women don’t know that. They just go in and they’re like, my friend says the pellets makes her feel amazing. Can I have the pellets?
DR. FIFFICK: You know, they don’t know. Yeah, she’s got so much energy. She can lift at the gym. Her libido is amazing. It fixed her marriage at whatever people say. It just is so wrought with disinformation. I think a lot of the people that push pellets in general, I would like to think that they are going into it with a misguided, honest attempt at trying to help people, truly. I just don’t believe that there’s that many bad people in the world and maybe that’s me, but I think they’re trying to go in and help people. Unfortunately, there is not enough data to back up doing that as a choice. And unfortunately, if you don’t know what you’re talking about When you tell somebody else who is not medically educated at all, that little bit that they understood from your, you know, Latin mumbo -jumbo that you told them, it’s going to be even disseminated, you know, to a much lower level of understanding. And when it’s already not well understood,
I got a problem because you’re not being, you’re not actually being consented to what you’re doing in that
COLLEEN: Well, such good information. Thank you so much, Dr. Fiffick, for what you’re saying.
DR. FIFFICK: I mean, really, it’s– – It’s, yeah, I’m passionate.
COLLEEN: Yes, but it’s important. It’s so important. So many of the menopause experts that we talk to are passionate about this and they want the information to get to women. They’re so generous, like you are with your time and your energy, because they want as many women to hear the proper information. And like you said, not just look on social media and be like, wow, there’s a supplement that promises that the, you know, visceral fat will be gone in six weeks. Oh, so thank you so much for coming on. We really appreciate your time,
your information.
DR. FIFFICK: It’s always fun to talk about menopause.