Get Fit in Your 40s

Am I in Perimenopause? What is HRT? What Every Woman Over 40 Needs to Know

• Become Fit Forever • Season 1 • Episode 4

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Welcome back to Get Fit in Your 40s! In this episode we’re diving deep into perimenopause, how to know if you’re in it, and what you can do to manage it. If you’ve been wondering:

❓ Am I in perimenopause?
❓ Do I need treatment?
❓ What is Hormone Replacement Therapy (HRT), and is it right for me?
❓ Where can I go for support?

Joining us is Dr. Nicole Tully, a board-certified physician specializing in women’s health with nearly two decades of experience. She’ll break down everything you need to know about hormones, symptoms, and the best steps to take for your health. then this episode is for YOU!

What You’ll Learn:

✨ The early signs of perimenopause and how to recognize them
✨ Why weight gain, mood swings, and brain fog might not be “just aging”
✨ How to advocate for yourself when doctors don’t take your symptoms seriously
✨ What options exist for managing symptoms—including natural and medical treatments
✨ The truth about HRT—who it’s for and how it works

Resources & Links:

📞 Book a free consultation with Dr Tully https://tullymd.com/  

📥 Download your FREE guide: How to Optimize Hormones & Lose Body Fat in Perimenopause → Get It Here
📲 Follow me on Instagram for daily tips & inspiration → @become.fitforever

🎧 Subscribe & Review:
Loved this episode? Hit subscribe so you never miss an update! And if you found it helpful, please leave a review—your support helps other women find this podcast. 💕

Let’s Connect!
I’d love to hear your thoughts or questions! Send me a DM on Instagram or book a free call—let’s chat! Calendly Link

Disclaimer: This podcast is based on personal experiences and opinions. It is not a substitute for professional medical advice. Always consult a healthcare provider before making any changes to your wellness routine.



Doucky:

Welcome to another episode of Get Fit in Your 40s. I'm your host, Duki, and usually I'm here with my best friend and business partner, but today it's a little bit different. We have a very special guest. She's going to be diving into how do I know if I'm in pedimenopause? Do I need any treatment? What is hormonal replacement therapy, HRT? Do I need it? Where to go? All of those questions that we know that you're basically asking yourself. So now, let me properly introduce Dr. Nicole Tully. She's a board certified physician specializing in women's health with nearly two decades of experience. Dr. Tully earned her Bachelor of Arts and Biology and French Studies from Brown University, followed by a Doctor of Medicine M. D. from Rogers University. She completed her family medicine residency at the same institution and is diplomat of the American Board of Family Medicine. Additionally, She's certified menopause practitioner by the Menopause Society. Throughout her career, Dr. Tulley has been recognized for her dedication to patient care, receiving the Gold Humanism in Medicine Award in 2005. She was also recognized among the top docs in 2017 Her greatest passion lies in supporting women through transformational life stages, including pregnancy, the postpartum period, perimenopause, and the menopausal transition. Welcome Dr. Tulley.

Dr. Tully:

you so much.

Doucky:

What a pleasure to have you here as our first guest in the podcast. It

Dr. Tully:

is my absolute pleasure. This is one of my passion projects. Now that I've been in practice for so long, I've spent the last 20 years helping women through as you've read beautifully. Thank you. The transition of life. And as we age and we go through our getting our period as adolescents and Some of us considering families and all of what happens after postpartum period. But really finding ourselves in a time of our life that is not so celebrated, but very confusing with a thousand different symptoms that can be related to perimenopause. And we don't know. For some people it happens very young, and for some people it doesn't happen at all. But how to transition and find our way and find our answers on why we're feeling this way is really what I've spent the last Three plus years doing and learning.

Doucky:

Yeah, true. So it's just

Dr. Tully:

great to be here.

Doucky:

Thank you so much for coming. I always tell our followers and our clients that we are part of history now, because for years we were very confused and overwhelmed. So thank God we have doctors like you taking care of this transition in life because it's, as I say, very overwhelming. I know that you have your private practice. So how did this happen?

Dr. Tully:

Yes, I made this big transition for myself several years ago when I realized. As I was going through these changes, that something wasn't right. When I started medical school, it was when the World Health Organization came out and stopped a major study looking at hormone replacement, and said, everyone stop, because you're going to have cancer, you're going to die of heart disease, and everyone's going to get breast cancer, right? It was one of those where we couldn't help patients, and all we told them was, You can't take estrogen, stop everything you're doing and just grin and bear it and we'll try to help with some symptoms along the way. But what I realized is that there's so many concerns that women had, I couldn't fit it in. I couldn't fit it into my day. I was seeing a hundred patients a week, or more sometimes, and a lot of them just feeling terrible.

Doucky:

Some

Dr. Tully:

of them from menopause and some of them from not. But really teasing it out and really helping address all those symptoms, I realized I needed more time. And I needed to do more for these patients. So I left my traditional practice of medicine and I started something called a concierge medical practice, where I spend an hour with every one of my patients. They have my cell phone, they call me when they need me, and I do everything. I trained in family medicine, so I don't only do the gynecology, I do the HEPs and the pills and the bleeding, if there are concerns and issues that way. But I also take care of the hypertension, I take care of the dyslipidemia, I take care of the weight gain. care of the hair loss and the mood swings and the palpitations and the sleeplessness that comes with menopause and I Train to do all of that So now I can for all my patients because I have an hour of time and then if we do start a plan a medicine An idea of let's track this for two weeks. They call me. They text me. They send me all their results So it's just been amazing to be able to do this

Doucky:

with my patients.

Dr. Tully:

with cost of medicine and just being able to survive. I just had some friends text me that they practice in a state north of us they were in this wonderful practice and it was going just fine and all of a sudden the next day they declared bankruptcy and closed. And they were seeing the 150 patients a week per doctor and they were seeing all of a sudden because of healthcare costs and everything not being met. So it's become harder and harder for doctors to provide care for patients unless they see a ridiculous amount of them. And with COVID, a lot of primary care doctors retired or got sick. And so there's a big shortage. And so I realized again, instead of me having a four month wait list to see me, I'm just going to be available for my patients. I'm going to have a few of them. And I'm going to take really good care of them. And so this is why I'm, I am so lucky and I hope my patients feel

Doucky:

that too. You are what an accomplishment. that you can do what you love and helping them deeply than the system I bet that they are happier with you

Dr. Tully:

Almost every day. I think my patients have told me how happy they are and thankful that I was able to stay late and come at seven o'clock to see them after I had gone home and they were available after work. So it's been wonderful for my patients, especially with menopause symptoms, like the sleeplessness, the weight gain with not feeling well.

Doucky:

Totally. So I think that is a great way to start this conversation that is going to be A little bit, heavy, but interesting. So grab your coffee, your tea, your notebook, and let's take notes because what we're about to talk here is gold. many of our clients and followers have many questions. So I have a bunch of questions here let's just start by how do we know that we're in penny menopause? of us? In my personal experience, we have some symptoms. Some women have no symptoms. So how do we know that we are impediment of us?

Dr. Tully:

That's a great question. I think for every one person, it's completely different. Sometimes it can be a small shift in your period. So we know in medicine that there are traditional, norms that we expect some women to have. The majority of the time, it's that funny period. When you had perfect periods, they came every 20, 30 days, and now they're 27, and they're shorter, or longer, or lighter, a transition. And it's literally, it's how we call these periods through menopause, these, the menopause transition, they're different stages, and based on what symptoms people are having. So the earliest sign is usually a funny period when it wasn't happening before. Sometimes not. Sometimes it can be from something else, like diabetes, or weight, or thyroid. So

Doucky:

some of my friends were a little bit scared that they were getting pregnant

Dr. Tully:

Probably 40 percent of all Pregnancies in their 40s are unintended pregnancies because people think, Oh, it's probably menopause. But no, you can very much still get pregnant,

Doucky:

Be very careful bestie. Yes, it can happen. It

Dr. Tully:

can happen. So it's super important to talk to your doctor to make sure that you are being protected and no matter what kind of decisions you're making or what symptoms you're having. But usually again, symptoms are a funny period, Half lashes, night sweats. Some people tell me I've been having night sweats every time I've had my period since I was like 20. And some people do, but a change, right? Weight is a big one, and you've seen that too, right? So after menopause, a pound to a pound and a half on average, per year happens after menopause. You tell everyone what to do about that all the time, so I won't go there. But those are a lot of them. Sometimes people will have unusual symptoms, like Heart racing. Out of the blue. We'll have vertigo symptoms, where all of a sudden they start having recurrent episodes of these. They can't stand. They feel like they're going to fall over, or like extreme dizziness. And a lot of things coincide with higher risks, like heart, higher risks of heart disease, which happens in this menopause transition, right? Cholesterol goes up, blood pressure goes up. So all these medical things happen around the same time menopause is happening, that people don't even recognize.

Doucky:

Those

Dr. Tully:

are the typical symptoms. How to quantify it, people are coming all the time. Dr. Tully, can you please have my blood work? I think I'm menopausal. And it can give us some insight, but those levels change month to month. They change day to day. And, I've had people who haven't had the period at all and have perfect blood work, like that of a 16 year old at the age of 45, and then I've had people who haven't gotten their period in a year, and had no idea that they were menopausal because they had no symptoms. Okay. There are criteria if you're very young in your early 40s and miss a period for more than four months, there is a blood test that can be done.

Doucky:

and

Dr. Tully:

two readings a month apart, over a certain level will suspect that you're Early, very early in menopause, but usually not having a period for one year is usually that line in the sand of menopause.

Doucky:

That we are in menopause. Yes.

Dr. Tully:

So I always tell my patients when they start to get a little funny period, write it all down because we don't know when the last one's going to be. And that's how we usually go. But the blood work is a little bit less

Doucky:

Yeah. Let's talk about the blood work. Yeah. Because I think that is the main thing that I did and my clients and followers are like, where should I go? So I'm having these. crazy symptoms. For example, in my case, I have the varigo, which is very unusual. And then I thought, when I was having it, I was like, oh, I have a brain tumor. So that is like the, like what is happening to me. And then I went to the doctor and then they sent me to the ENT and then it passed. I realized that the more stressed I was. That was a trigger for my vertigo, but I put it like in the drawer, I forgot about it. And then when I started studying, I'm like, this was a symptom that I didn't know it was, due to pedimental pulse. The heart palpitations. Oh my God, I have to go to the cardiologist, like it's all these different symptoms and you just have to. start going to different specialists for this. So where do we do? We go to the PCP, we go to the, gynecologist, the endocrinologist. We feel like that. What is the next step?

Dr. Tully:

That's a very good question. There are some primary care doctors. I think it's important, depends on where you are and who you're seeing. Like I, I do all of it, right? So I'm the PCP, I'm the GYN, I do the endocrine. I am the all of it, but there are some PCPs, when you walk in and you say, I think I'm ha I'm in menopause, they're gonna freak out and run out the door because they want nothing to do with menopause. They didn't teach it. They didn't teach it in med school. They didn't teach it in residency. They didn't teach it for the last 20 years. So anyone who's just come out of medical school may have had a little inkling, but they're very young and have no, Way to really know or live it. So I think that it's really hard to find medic menopause providers at this point. You really do need to find someone who is a menopause provider. So the Menopause Society has a list on their website of certified providers, ideally doctors, because you're coming in with a lot of symptoms. You're coming out with a lot of very real symptoms. So there are therapists, there's pelvic floor people, there's chiropractors, and people can be certified in menopause, but you really want to find a doctor ideally who can help you through and guide you to get the right evaluations.

Doucky:

Yeah, exactly because that's what happens. We were talking about the blood work, right? So I go to the doctor and I know that for most of us that has been the experience and they tell you're too young or they tell you can take the birth control pill, or this is gonna pass, or this is just part of what it is, or they dismiss you. It's go to the psychologist because anxiety and symptoms of depression is another, symptom that I have heard and I have lived. So it's like the psychiatrist, therapy, all of that. So you ask for a blood work. Do we need that? In order to get treatment, do we ask for it or really it doesn't matter because I know that you just talk about it. If I miss a period for four months, definitely you have to go and check because menopause might be approaching. But then if I go to the blood work, should I ask for a blood work then or?

Dr. Tully:

I think with the missed period, when you had perfect periods, I think it's very important to seek medical care. One, blood work is very important because we're also ruling out other things.

Doucky:

So

Dr. Tully:

ruling out pregnancy, we're ruling out thyroid disease, we're ruling out something called elevated prolactin levels, which can be from a tiny tumor in your brain that can cause periods to stop. And so any patient who comes in and they tell me that they haven't had their period and these symptoms may or may not be happening, I always run that panel

Doucky:

regardless.

Dr. Tully:

And I will run the hormone levels for menopause to give us an idea but tell people it really has little impact on the advice I'm going to give them. It may give us insight, but that one reading doesn't count for anything. We need follow up information and follow up blood work. So I think blood work is important. And again, who does it?

Doucky:

A primary carer

Dr. Tully:

may or may not be comfortable with it. GYN should be comfortable with it. Endocrine will definitely be comfortable with it. But again, an endocrinologist, ideally, who's very comfortable with menopause as well. And usually their staff will be good enough when you call to ask questions and say, Does Dr. So and so endocrinologist see a lot of menopausal patients and treat them for menopause? And if so, then that would be a really great person to see. Okay. Yeah.

Doucky:

So what if I have, irregular periods or maybe regular periods. I'm having the symptoms and then you do the blood work. doctors that are not menopause informed told me the blood work is okay. What do I do?

Dr. Tully:

So the thing is, you're having very real symptoms.

Doucky:

And,

Dr. Tully:

if it coincides with the months that you have a normal period, you're totally fine. And the months that you skip your period, you're miserable, half flashy, haven't slept, moody, all of those symptoms, or more, or the, the palpitations, nights of, you still need treatment. It's, you can still get treatment even though you're still getting normal periods. The problem is with menopause, symptoms can start ten years before. And that's what we call this perimenopause. So women can be in menopause for 10 years. Sometimes more. There's about 15 percent of women that have menopause symptoms until they die. We have to address this, because it is people's livelihood. If they don't sleep, if their mood is not well, all of it has major impacts. Some of the things, right? Joint pain. We didn't talk about joint pain. So joint pain is a very real sign of menopause or symptom of menopause that people don't think about. It's their hip, their knees, their hands, like all of it. And

Doucky:

they tell there is arthritis. That is a diagnosis that I heard, I have heard from my clients.

Dr. Tully:

A lot of times it may be. And so imaging, physical therapy, regular exercise. But I can tell you I've treated so many women with estrogen who are having all these other menopause symptoms. And they're like My hands don't hurt. I wake up and I'm not in pain. My knees, I can run again, and it's pretty dramatic. It's very dramatic.

Doucky:

the Women's Health Initiative, research that was made in 2012, it's very controversial, right? news was it's gonna give you cancer when they did the research, a lot of negative things came out of that study, So can you tell us a little bit more why we shouldn't be Scared

Dr. Tully:

Absolutely. So I think 2002 so even longer because it was 20 years of this void of information There's a long time ago I didn't took good again 20 almost 20 years before we had more data and really relooked at that data and realized that Women The minute they had a menopause symptom, back in 1990, women were put on hormone replacement and they took it until they died. Because they were happy, they slept well, they didn't have hot flashes, their bones were nice and strong, and it was great. And so they enrolled all these women in the study and followed them for 40 years of use. The problem is sometimes they would start when they had first menopause symptoms. Some of them started in their 60s, when they already had heart disease, when they already had cancers that were not detected yet. And all of these people and all that information came into this study. And what did we find? That women, especially if they were older, were having higher rates of breast cancer and heart disease and strokes, or blood clots, from using these hormones. When we looked at the young women who were usually less than 50, especially if they only used estrogen, actually they had lower rates of breast cancer, they had lower rates of heart disease. The slight risk of blood clots still happen because estrogen happens at any point, even when you're 20 and you take estrogen, there's a small risk, but that risk is low. The benefits that come from it, only we can decide whether we want to or not, so that still probably stands regardless of age. But the idea is that it was more helpful than harmful. Now, a lot of the studies 20 years later, and even looking back at that data, we see that if you are young, and you're healthy, and you take it for a short period of time, right around the time of menopause, ideally less than 5 years, but less than 10 years and less than 60, those rates of heart disease, strokes, and breast cancer are very low. And again, if you're in pain, if you can't sleep, if your mood is terrible, if you can't have a normal shirt on without sweating through

Doucky:

it,

Dr. Tully:

Then, for people, just feeling well, it makes sense to try to be on estrogen. If that's the reason why, you're taking it, some people will use it indefinitely. Without concern, there are some longevity studies looking at women who are taking it more than those 10 years after 60. And those studies are looking very positive now. Again, really healthy women with low risks of strokes and heart attacks and cancers. All those women are So far, the data looks good, but it's not out yet. So there's hope that if the estrogen is helping us feel well, then that will be good. But the idea is it doesn't always have to be estrogen, and there's some women that can't take estrogen. And often with estrogen, there's a lot of other different medications that do, that are part of that hormone replacement therapy, that is definitely worth talking about as well.

Doucky:

Yeah. Okay, so that is the other question. What is the treatment? What is hormone replacement therapy that comes in peels, creams? Just tell us all about it.

Dr. Tully:

Sure, yes, those two and a couple of other things. Hormonal replacement therapy, it really depends, what your health status is as far as, two things. One is do you have a uterus or do you not have the uterus? And when we're talking about Hormone replacement, we also think of how old you are and whether or not you're having periods still. If you're having periods, it's thought that you may still get pregnant. And hormone replacement, those levels are not high enough to suppress you from ovulating. And if you're ovulating, then there's a chance you can get pregnant. For those people, we often talk about birth control. A low dose birth control you can take. There are studies looking at even taking it to 55 now. And still having it be safe, it helps all of your symptoms of menopause. And then at 55, or sometimes 52, really talking to your patients and patients talking to your doctor, you can figure out when you want to try coming off and seeing if you have symptoms. Some people, when they come off, there's a little transition period, but may not have symptoms, and you avoided all those crazy extreme hot flashes, night sweats that happen for years and years. You might get them for a month or two, but then all of a sudden, you feel fine, and life goes on. So that's for the young perimenopause that are still having regular periods. We can

Doucky:

take a

Dr. Tully:

birth control pill.

Doucky:

Birth control pill that is going to help you with perimenopause symptoms.

Dr. Tully:

Exactly. Now, those people can also benefit from an IUD with progesterone. That protects your uterus, but also if they're having the hot flashes and night sweats, we can then give estrogen separately. So if women are done with having their periods, it depends if they have a uterus or not. If they don't have their uterus for surgical reasons, then they can just use estrogen alone. And if they haven't had surgery, then they need progesterone, because if you use estrogen alone, without the progesterone, then there's a higher risk of endometrial cancer. you need, most women, if they haven't had surgery, We need both estrogen and progesterone, and that comes in different forms. The estrogen, comes in the form of pills, comes in the form of patches, it comes in the form of gels, that are applied topically. All right, the pills, you swallow. the gels are applied topically, the patches are applied topically. The gel's usually on the upper arm, the patch is usually lower abdomen or lower back, and then you switch them out. Sometimes the patches come in combination.

Doucky:

Okay.

Dr. Tully:

There are vaginal, estrogens. That's usually not enough to help all the systemic symptoms of the hot flashes in night sweats. That's usually for symptoms of vaginal dryness, pain with sex, decreased libido, climate, and orgasmia. So that's a different kind of estrogen that we use vaginally, but yes, there's also intravaginal gels, and intravaginal tablets. There's a lot of stuff in intravaginal

Doucky:

suppositories. And it's not normal to have low libido because I think we don't talk enough about that because people feel embarrassed maybe. So that is another symptom of perimenopause and menopause. And You shouldn't be leaving that way.

Dr. Tully:

No. In fact, with every menopause patient I talk to, I ask everyone about pain, dryness. Interest, desire, orgasms, and what sex life is like. Just because you're not having sex infrequently doesn't mean it's terrible and you have a terrible sex life. It really depends on what you and your partner or you or yourself really want to get out of. Sexual life. So I think it's really important to have someone you can talk to about that and having a physician that's open to it. I asked my cute little like 80 year olds and they're like, what? I haven't had sex in forever or. I've loved when I've had my eight year olds that have had wonderful sex lives. And it's just wonderful to know that it's all still possible, but it's really asking for help and being open to suggestions. And so I really talk about it with everyone. It's totally embarrassing for some people, but I'm like, if you feel, if you don't feel comfortable, we don't have to talk about it. But if there's a question, I really want to be here to answer for her. Exactly.

Doucky:

No, super interesting. And, you need, you needed to hear that. I know that.

Dr. Tully:

Yes. No. Lots of questions about, about, yeah.

Doucky:

So what about the pellet?

Dr. Tully:

Oh, okay. yeah, so the pellets, the menopause society and pretty much, every literature that comes out suggests that the pellets are not. advice. The problem is that there are high doses of hormones in them, you don't know how you're going to react, and they're in there indefinitely. They're literally, they put the pellets in and they stay there. So you have a foreign body in your body, underneath your skin, and till the end, it's with you. You can't reverse the symptoms. I've had patients come in with severe symptoms. Nausea, headaches, chest pain, irregular bleeding, mood swings, horrible weight shifts and changes. There's nothing.

Doucky:

so no recommended

Dr. Tully:

No. I feel that with dosing, you can get to just as good as the pellets. I'm a very Start low and go big as you need to and really titrate it and make it very personal for every person and see how much medicine you need and when you get there, you stop and you stay, but this is all flooding. You get it all at once and then little by little and little it goes away, but it can be pretty dramatic for a lot of people and don't advise it

Doucky:

Good to know. So what about, do we have any side effects with HRT? So now with pellets we know that it can go a little bit crazy. But, should we be scared of the side effects? Even though we know that it's going to improve our quality of life. What are those common side effects?

Dr. Tully:

There can definitely, with anything, even with Tylenol, there can be side effects, right? With anything there can be. With hormone replacement, there can be, like we said, blood clots. So that is a major risk, but it's a very low risk, especially if you're starting low. And then that is also one of the reasons to have topical, estrogen versus the pill. There are lots of studies that are looking at the safety and efficacy of these medications and they realized that the people who take the pills with oral estrogen have a higher risk of having a blood clot. So that risk is much lower, almost, very low when you're using the patches or the gels. So that is obviously the big one. Bloating, headaches, nausea, mood changes. Everyone reacts very differently. And that's why my recommendation is always, oh, you go low and then you slow. And certain hormones may not feel well to certain patients. And So in, in pharmaceuticals, there's probably six different types of estrogens. There's probably four different types of progesterone. So really working with everyone and feeling which one works and which one doesn't is very important.

Doucky:

So in, now I know that you are always checking the symptoms of your patient until you finally get the right dose. So what is the period of that? Because it's not like I go to your office and say, Dr. Tulli, I feel terrible. Let's just do something about it. You give me the dose and then I just go on my way after a month. What is the period that we should be working without physician like you who is menopause informed?

Dr. Tully:

So again, it depends on the provider and their availability. I've, in, in practices I've known of. The patient gets the script, and they say, I'll see you next year when you come back for your annual. And I think that's not great follow up at all. Maybe for me, it's too much where I check in with them. In two weeks, like, how are you doing? I text them. After a month, I have them come back and check in. We do a weight check. We see how it's working. But usually around the three month mark. If it's going to work, it's usually around that three to four month mark where you're starting to see changes.

Doucky:

Okay.

Dr. Tully:

Nuki, I can tell you, after four years of really like delving in and this being

Doucky:

my

Dr. Tully:

everyday, I finally decided I can't live like this anymore and I started my own hormone replacement. Was living with crippling back pain for about two years. Like coming out of bed I was like a 82 year old woman, it was, I couldn't get out of bed.

Doucky:

Wow.

Dr. Tully:

I put the patch on and took my, my progesterone pill and the next day

Doucky:

it was gone. It was gone. No way.

Dr. Tully:

My hand pain was gone. It was remarkable. I have back concerns.

Doucky:

you can see results literally within a week, let's say, because that was extreme like in a day.

Dr. Tully:

It was a day. It was a, so some people will respond very quickly. Others, it may take quite some time, but there's nothing that I did different that day.

Doucky:

So you just started hormonal replacement therapy just now. You are?

Dr. Tully:

I'm 49. 49.

Doucky:

You look amazing, bestie, by the way. Thank you. So you just now started your

Dr. Tully:

About three, four months ago. Yeah,

Doucky:

is one of the questions I have here. When do we start? Like you, I, you have, you, as soon as you have the symptoms, should I start?

Dr. Tully:

You can.

Doucky:

Okay. There is some other stuff that I should do before asking for the hormonal replacement therapy to ease the symptoms.

Dr. Tully:

There are several, several different medications that for the 20 years we were trying to bridge people from not losing their mind of, symptoms. It really depended on what people's symptoms were. Definitely, medications like SSRIs, like Lexapro and Effexor, were well studied, and even Pax, Prozac in a very low dose was also studied to reduce symptoms of hot flashes. It reduced it by 50%, in severity and frequency, so it worked really well. And especially for people who had the mood symptoms, I think it was a really good thing to consider. Especially if they were hesitant about starting estrogen. But that is one. There is, one medication on the market right now called Vioza, which also helps with hot flashes. It really depends on what the symptoms were, right? Depending.

Doucky:

In your case, you just had the back pain and then you

Dr. Tully:

Oh, I wasn't sleeping for years, and, my half lashes were crazy. At first, I was like, oh my gosh, it's the half lashes, this is so cool, it's really on fire on the inside, this is really interesting. And then, after the fifth one, I was like, okay, that's not fun anymore, The night sweats were, like, drenched in sweat, and I was tired of changing the sheets every night, and I just eventually started moving over. I was like, okay, this is It's too much now. So it came to that breaking point of this is too much and it's not, but

Doucky:

I'm

Dr. Tully:

one of those people that don't do a lot and don't take medicine and don't complain. So it took me like A

Doucky:

because it was only those two symptoms that you had, right? So you could have,

Dr. Tully:

there were a couple. Like I haven't had a half flush in four months. it's pretty dramatic.

Doucky:

So there is no way that you take the chance. You can just go check with a doctor like you. To just check your symptoms and just have a quality of life. There is no reason why you shouldn't. So what about the patients who are experiencing cancer?

Dr. Tully:

Good question. women who have cancer. it depends on their type of cancer, especially if we're talking breast cancer.

Doucky:

Yes.

Dr. Tully:

Then, estrogen therapy is usually not advised, or progesterone therapy is not advised if they had estrogen or progesterone receptor sensitive tumors. Vaginal estrogens, there's some really new studies that are looking at the safety and the fact that the vaginal estrogens. such little is absorbed systemically that they can use vaginal estrogen. Cause the problem with after, breast cancer, oftentimes they take medication that can decrease their estrogen levels so very much that vaginally they become very, it becomes very dry, very painful to have sex and just. recurrent urinary tract infections, recurrent infections that way. And so vaginal estrogen now has been cleared by many oncologists. That is a decision that has to really be a case by case and discuss with your oncologist and your gynecologist or your menopause provider to see the safety of it.

Doucky:

Yeah, because if you have a patient with cancer, but she is suffering with hot flashes, with heart palpitations, With anxiety, depression, so what do we do? Maybe we do first the other set of medications that you just mentioned before just to see if you improve and then the last resort would be try the vaginal estrogen.

Dr. Tully:

that again would only help for the vaginal symptoms.

Doucky:

Oh, the vaginal, so low libido. Painful intercourse. Exactly. Those symptoms.

Dr. Tully:

Exactly. But there's lots of options still. And so I think having that open dialogue and communication with your doctor is really important. And just a lot of women live with their symptoms and don't ask for help and are embarrassed to talk about these issues, especially after a treatment like cancer and think there's nothing you can do. And there's still so many ways to be made feel comfortable after something so terrible.

Doucky:

Okay. Will HRT affect my risk of osteoporosis heart disease or breast cancer?

Dr. Tully:

For osteoporosis, yes, it significantly decreases your risk of osteoporosis. Cancer, what I had mentioned before, as far as breast cancer, after 10 years and after 60 years of age, and if taken many years after the start of menopause, there is a slight increase in breast cancer risk. That risk is low, but it's positive, and so it's one of those things you would have to take into account and really talk about with your physician about your personal risk. So heart disease again, that same answer of that 60 is that cut off, where below that most women who don't have a baseline cardiovascular risk, will still have very safe, window to be using hormone replacement before I start any of my patients on hormone replacement. And again, because I do all of it, I do a very significant assessment on a patient, cardiovascular health, check their cholesterol, check for diabetes. I check, to also see as far as like a baseline EKG, any symptoms of cardiovascular disease. And sometimes if they do, especially if they're having the heart, razy hearts. I have him see a cardiologist for a full workup before I start the monhormonal replacement, just to be sure that this isn't already, there's something there, and I'm not going to mask it. But what we do see often with menopause is that cholesterol levels go up, and we know that increases your risk of atherosclerosis and heart disease. So by starting estrogen, that usually will lower your cholesterol. So it actually is a nice little thing to see,

Doucky:

flip

Dr. Tully:

down after it's been climbing for years with my

Doucky:

patients. Yeah, especially because 50 percent of women get osteoporosis later in life.

Dr. Tully:

so

Doucky:

so that is a good advice, just.

Dr. Tully:

50 percent of the bone loss happens in the first five years around menopause.

Doucky:

Okay.

Dr. Tully:

the time is now to do that strength training I tell everyone to do all the

Doucky:

time. Yeah.

Dr. Tully:

And certainly to consider estrogen. especially if they have a family history of osteoporosis or if they're not very

Doucky:

So how do you know that you have osteoporosis?

Dr. Tully:

Usually no pain. Osteoporosis is usually painless unless you have a fracture. Okay. But osteoporosis you get a dance. a DEXA scan, a bone densimetry scan, and it's a very painless exam. You just lie on the table, they do some measurements and it looks at the bone density. There's some more fancier tests that are starting to become available, but are very expensive and really only done for people who already have irregular, bone. For now, again, I think it's going to be much more available later on.

Doucky:

That is like in the routine. Check off

Dr. Tully:

It's not so routine. It's usually advised. At the age of 65, or 10 years after menopause, but usually 65 is the guidelines the U. S. Preventative Task Force suggests after 65. But there are people who are at risk. There are people who have, had a history of smoking. There are people who may have. Celiac or other malabsorptive disorders, problem like inflammatory bowel diseases and people who have digestive issues. There are also people who have history of eating disorders. And if there's a family history, that would also be a risk or medications. And even things like fibroid disease can sometimes be a risk factor for osteoporosis. So there's several risk factors. And again, one of those things to ask your provider, ask your doctor about, Am I

Doucky:

at risk?

Dr. Tully:

When should I get it? And a lot of them will just say 65. Early menopause is a risk factor. So I will usually get a baseline right after menopause and if it's fine I'll check them again in five years just to be

Doucky:

sure. So I've been reading about GLP 1s and ozempic and, that's a

Dr. Tully:

other topic. And that

Doucky:

that is another episode that we should, talk about I have read that there is bone loss because you're taking GLP 1s, ozempic, not taking care of the other part, which is that lifetime changes. Of course, we need to talk about that the things that you can do, right? I like you.

Dr. Tully:

100%. So with every pound essentially, every bit of weight that is lost in the GLP1s, especially with menopause and all the shifts that are happening in menopause, half the weight is fat and the other half is muscle. And if you don't have muscle to support those bones are going to become weak and you're going to be at risk of fracture.

Doucky:

Exactly. Because, there's sarcopenia, which is, muscle loss, due to aging. after the age of 35, we start losing muscle mass. We need to eat an adequate amount of protein. We need to do a strength training. And what I see now is that lot of people are going to ask for the GLP 1s or Zempig. It's very tempting, because you lose weight really fast, especially if you've been struggling. So of course it's tempting and I totally understand that. But not doing the right so if they're losing bone density, you cannot build bone density back, or can you? There is something that we can do.

Dr. Tully:

You can, and that strength training is one of those things. I have had patients that have done really amazing jobs when they've had osteopenia, and they've either

Doucky:

So it's never too late.

Dr. Tully:

It's never too It's never too late, in that we have great medication that when it goes past a certain point, we sometimes need to use because their fracture risk becomes so high. That, complications definitely happen if we don't take that into account. But working with someone like you that can keep them strong and and not become osteopenic are very important. And again, this time in this perimenopause phase and immediately after menopause. Throughout menopause. It is so important to continue that weight bearing exercise. It is so important to continue the protein Not only again for the weight loss, but again for bone health for sure

Doucky:

Yeah, because we have heard about all these benefits that HRT has but you have to do your part It's not that you're gonna start getting the patches and suddenly you're gonna lose the weight You are going to build muscle, right? So we need to do the part of the lifestyle regardless

Dr. Tully:

so sad fact is that hormone replacement is weight neutral. it's not, so people think oh my gosh, I'm in menopause, I'm gaining all this weight, I'm going to start hormone replacement, I'm going to lose it all. It doesn't happen. What's done is

Doucky:

done. Did you hear that? I need you to repeat that again because that is, so it is very easy just to blame other factors, right? Like before. It was, I'm pregnant. And then it's all this baby weight is here. And then we blame the kids because we're too busy. And then now we are blaming the hormones. So that's why I keep gaining weight. So I think we have to take responsibility and to work on our habits and lifestyle. HRT is another help. The same with those 1s, they're gonna help, but you have to do the rest of the things.

Dr. Tully:

Exactly right. And again, like with the GLP 1s. And, the others coming to market and in the market. I think the one thing is that maintenance phase that happens and learning how to live with it. And really, again, doing all that hard work and learning how to be healthy. And there is a thought of diet and can diet contribute to menopause symptoms as far as like hot flashes and night sweats. And we do know that sometimes diet can be involved. Exercise doesn't help with hot flashes, unfortunately, helps you sleep better, and certainly helps your heart. So there

Doucky:

are For me, it has decreased stress. And then I have noticed easing my symptoms with exercise just because, I'm less stressed.

Dr. Tully:

I always joke that any time people come in, I was like, I wish I could just write a prescription for a vacation on all my patients and everything would get better, because stress reduction, cortisol reduction. It is, it makes all the difference in the world from, again, your glucose levels and how you sleep and everything and weight for sure. We know that menopause and insomnias and basal motor symptoms, aha flashes and night sweats are directly related to weight gain. So we want women to sleep well. We want them to feel well. And by doing that, they will also avoid weight gain.

Doucky:

Exactly. So caloric deficit, very difficult in perimenopause and menopause due to insulin sensitivity because estrogen is declining. So important to understand and learn about your portions. You guys are not eating enough protein. You guys are not eating enough fiber

Dr. Tully:

I completely agree. And

Doucky:

HRT won't help you with that.

Dr. Tully:

No.

Doucky:

But it will help you to feel happier with more energy, right? Like sleeping better. So you can meal prep your protein and your fiber, right? And you can show up to the gym.

Dr. Tully:

Yes. And again, HRT can definitely help with symptoms, but all of that. Everything else I think is so important and not everyone needs HRT to feel well and to be well and to lose weight and to sleep better. It can help for some. So I don't want to be here and say everyone needs to be on estrogen because I really don't truly feel that. But it can help a lot of people for a short period of time, but it is one of those things to be open to. There's no reason to grit and bear it, but the exercise and all of that is. We'll make you feel better. I have not had one patient say, I feel terrible after starting to work out. Everyone comes back energized and happy and smiling and their mood's better and their sleep's better.

Doucky:

Yeah. So we start with the lifestyle changes. We look for a physician like you who is menopause informed and then we take decisions just based on that, right? Yeah. Good. So Does insurance typically cover HRT? Will I need to pay out of pocket?

Dr. Tully:

Ah, great question. Yes, insurance usually pays for hormone replacement medications, specifically estrogen and progesterone. We didn't talk about the bioidenticals, we didn't talk about compounding pharmacies, the menopause society, and myself. Don't recommend compounded pharmaceuticals for these reasons. We Are concerned about the safety Who's compounding them where they're coming from the actual dosing in them how People are absorbing them. So there are a lot of issues with the compounding versus The ones you can buy in the pharmacy, so I write prescriptions for ones you can buy in the pharmacy with those companies that have been through rigorous years of testing before they can sell you something. I do that. Sorry for all the compounding people. But, testosterone. We didn't talk about testosterone. Lately, testosterone, which is a huge help. We talked about that. Low libido and pain and all that great stuff. Testosterone can be very helpful in menopause and I write for it often. For the right patients if needed. I

Doucky:

I understand testosterone is only approved for

Dr. Tully:

men. So it's not covered for women. And that is a concern because it's not covered. The good news is we use such little amounts of it that it is reasonable in price. So the tubes that you would need for maybe three months is somewhere like 40. It's three months worth, it's still 40, why isn't it covered better? The HEA supplements are not covered, which are vaginal, supplements that we could use for improvement in sex drive and vaginal health as well. That also we didn't really talk about as well, but that is not covered typically with insurances either.

Doucky:

Wow. So we have to save money just to pay for this treatment? Oftentimes, yes. Wow. Yeah.

Dr. Tully:

So

Doucky:

unfair guys. Hopefully these conversations and, Doctors like you who are preparing professionally to get more informed about this transition is going to open also new doors for us and future generations so we don't have to pay out of pocket for these treatments that we deserve. I bet that if men were going through these symptoms, we would have had Already, options for us in vending machines. Oh,

Dr. Tully:

for sure. I

Doucky:

easy, right? Yes. congratulations on being a woman. Yeah. But we're going to get there. I'm very hopeful that we're going to get there. So I just wanted to take this opportunity thank Dr. Nicole Tuley again for giving us her time and I have a surprise for you if you live in New York or New Jersey. She is open to give you a free consultation. You just have to go to her website. www. tullymd. com and you can book a free consultation. I'm going to put it in the notes So you can talk to this amazing doctor who is opening the doors for us to feel better and happier in the future.

Dr. Tully:

Thank you, Dookie.

Doucky:

Do you have anything you want to share with our audience just to close this episode?

Dr. Tully:

I think everything we talked about, asking questions, listening to your bodies, I think it's so important to ask for help and know that help is available, finding the right person who's going to listen. Being great about exercising as best you can. We're all busy, but even if you can do a little bit, you're going to feel better. Getting enough sleep, eating well, which she'll help you with, don't you? Of course. Is the expert, I will defer. And, just being well and knowing when to get help is really important.

Doucky:

Thank you

Dr. Tully:

And talking to your friends about it. Cause everyone needs to get involved and know how everyone else is feeling.

Doucky:

Yes, I think we all have that WhatsApp group just talking about our symptoms and perimetopause. Now it's really funny, we just laugh about it But, it's important to understand that you don't want to do it alone. You have a team. that is supporting you. So we have doctors, menopause Tooley. You have BFF who is going to help you with the other components. So don't try to do everything alone. Don't try. You can read all you want. We have many books that we always recommend, but the main thing is just ask for help. You don't have to suffer in silence.

Dr. Tully:

And,

Doucky:

Yeah, let's just enjoy this transition.

Dr. Tully:

Absolutely. We have to. Because there's a lot more to come. We're going to be in this phase forever. Exactly. So we have to make the most of it and just learn to feel amazing.

Doucky:

Let's make pedimenopause and menopause the best era of our life. So thank you so much for listening. Please don't forget to subscribe. Check the notes because we always have some freebies for you to start your journey. Thank you and see you in the next episode.

People on this episode

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Kausar

Host
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Doucky

Co-host