Today's conversation was one that's been overdue for more than two decades. We've lived through 25 years of fear, confusion, and missed opportunities in women's health, all because of a study that was misinterpreted and a black box warning that froze progress.

But as we heard today, the science is clearer than ever. The FDA has finally corrected the record, and women can step forward with confidence. If you're listening and this resonated with you, if you've been struggling, feeling dismissed, or told to just deal with it, please know there are answers, there are options, and there are clinicians who truly understand this space.

You deserve care that honors your quality of life, protects your long-term health, and doesn't minimize your experience. A huge thank you to Dr. Miskell and Dr.

Peterson for bringing clarity, truth, and compassion to such an important topic. And thank you for listening. We're rewriting the narrative around Metapods one conversation at a time, and we're just getting started.

Please don't forget to like, follow, and share for more. Your health is shaped by more than symptoms. Through real stories and expert insights, we explore how your genetics, environment, and daily choices affect your wellbeing.

We uncover root causes and share practical tools to help you find the healing you need. Welcome to the Forum Health Integrative Medicine Podcast. Welcome back to the integrative medicine podcast.

I'm your host Amanda with Dr. Peterson. And today we are joined by Dr. Melissa Miskell. We are so excited for our conversation today and we're going to dive right into it in a second.

But Dr. Miskell, thanks so much. I want to start and let the audience know who you are. Can you tell us a little bit about yourself? Sure. And thank you very much for having me today.

I appreciate it. I am a board certified obstetrician gynecologist and I've been in private practice for 25 years. I started doing hormone replacement about three or four years into my practice due to actually patients with breast cancer who had been pulled off of all of their hormones and were absolutely miserable.

And they're like, there has to be something else. So that began my journey into hormone replacement a couple of years after the Women's Health Initiative trial.

So we've been doing hormone replacement for over two decades and have lots of experience, lots of patients. And so I'm excited to talk to you all about it today.

I am too. Thank you so much for that introduction. And so today we're going to be talking a big component of what we're talking about today is the FDA pulling the black box warning off of HRT medications specifically for menopausal.

This study took place over about 25 years ago. So this was right around the time you really started using hormones for those listeners out there. Can you tell us what the original women's health initiative study was and what that resulted in?

Well, that's kind of a loaded question, actually. The Women's Health Initiative trial was started to show that hormone replacement therapy, estrogen alone and estrogen and progesterone, were beneficial for women.

And so there were thousands of women that were signed up for this trial. And two years into it, they stopped it, not even telling the primary investigators yet that they had stopped it and why.

They actually put them in a room at nine o'clock in the morning and gave them their reason why they were doing it and gave them three hours to say, No, we disagree.

And so they did that and they were like, too late. It's already in JAMA. It's already been published and it's going out. you didn't get a say in why you didn't want us to publish it, which is never, ever done.

And though it showed per the JAMA article that estrogen and estrogen progesterone combined were going to increase the risk of breast cancer in women, that it was cardiovascularly detrimental and also that cognitively they would decline.

which we know is all not accurate. All false. Yeah. So that happened 20, 25 years ago where they started a study, stopped it and didn't give a lot of time for people to really weigh in and labeled this, which in our industry you've been practicing for the last two decades, Dr.

Peterson, you've been using hormones for about that long as well. All through this, there has been a black box warning, but all of what they said, the increase in breast cancer, the cardiovascular risk, all those things, we actually see benefits in patients with that.

You're correct. 25 years, women were misled. That is absolutely right. Being told that HRT is dangerous, a single study that was misinterpreted and amplified created all of this fear, confusion and harm on a mass scale.

That is absolutely right. Yeah, it's a big deal. I was in residency when this happened. I remember because, you know, when you're in residency, you've got journal club, you have to go every week and they always have.

And, uh, oh my heavens, it was, it was just such a, it didn't make any sense. And yet it was right there in JAMA and we just all said, I guess that's what we have to do then.

I guess we'll stop giving women these medications. It's interesting. And correct any of this, Dr. Miskell, Wyeth was one of the big sponsors of this study with the NIH, right?

And Wyeth, I don't think they exist anymore because- I don't think they do either. I think they were. They actually were trying to show, and good for them for trying to show this, that hormones are protective of certain things and it makes physiologic sense.

If we understand physiology, we know that you have to have signaling molecules to save for bone to grow or muscle to heal or what have you. So they were gonna get the NIH to publish a study to prove that their drug was uniquely beneficial and somehow because they didn't know what they were studying or how to interpret the data, They sank their own ship.

Well, and the participants that they had. So the average age of the women in the Women's Health Initiative trial were 63 years old. So well past menopause.

I think 50% were smokers. A large number had diabetes. So all these pre-existing things. A large number had heart disease already. So, I mean, it was just a terribly designed trial.

And was the black box warning specific to menopause with HRT? Was there any specifics in the black box warning or was it just in general, women should avoid HRT?

So it's like, it's not on birth control pills, but it's on any type of estrogen that you would take for a replacement. I also think that it's worth mentioning that the Women's Health Initiative studied synthetic oral estrogen and synthetic progesterone, not bioidentical hormones.

Does that make a difference from a clinician's perspective? I think that you can still look at the trial and see where they went wrong and look at the data the way it should be looked at to see that there is no risk.

And of course, with us in functional medicine, we all are going to use bioidentical. So as far as the trial goes, it's kind of an apples and oranges. You can't really discern one from the other because they weren't used at all.

Right. Okay. Yeah. And I think that this is important. And I think that looking at it from that perspective, what they effectively showed, if they showed anything, is that for women who are an average age of 63 and they smoke half the time, see, that's the problem is you're trying to generalize something to you.

You shouldn't take a synthetic hormone. That's what they showed, right? And that's, I don't know. I don't think it takes a rocket scientist to figure out that if you take a synthetic hormone, it probably won't work exactly the same as the bioidentical hormone.

The, in fact, whole purpose of most of the synthetic hormones is bind to the receptor site and do some of what the hormone would do, but not all of what the hormone would do.

That's the whole point of birth control. If birth control was just progesterone, it would increase fertility. But it's not because it's binding to the site and causing a slightly different reaction.

So I think that that's a significant thing. And what we did is we extrapolated synthetic hormone use in women that are on an average 63 and have all of these other pre-existing issues and then said hormones must be dangerous, which is pretty absurd.

How did this impact your practices? I mean, you guys, this research and this black box warning that came out was in the height of you both growing a hormone practice.

How, and the media amplification of this really created a lot of fear that many clinicians felt that they couldn't combat. Doctors were trained to fear hormones and a lot of medical education froze in time around this topic.

How did that impact your practices and how you treated women with hormones? Well, I had just started private practice when the trial came out. And I mean, we all did the same thing.

We pulled everybody off of their hormones. And it was terrible. It was awful. And these women are then coming to your office and they're a CEO and they're drenched in sweat.

They can't have a board meeting without being completely miserable. Their hot flashes are all over the place. Their brain fog, they can't remember anything.

And so their lives were miserable, and they were pretty insistent that they had to have something. You're smiling, Dr. P. Somebody is going to die. And so that's how it all started and really, as far as I was concerned, I didn't…

I mean, when I was in residency, it was permanent provera. That's what we gave everybody. You know, you got 6.25 and that was the dose. If you were really symptomatic, then you might go up a little bit, but that was really rare.

And so, I mean, we were taught nothing about hormone replacement because that's all there was. So in having to learn about that and find other like-minded physicians that you could talk to and bounce ideas off of and that kind of thing, that was kind of difficult, especially for me.

I live in a very small town and I was definitely the voodoo doctor, so still might have that tag on me to this day. it's a proud tag it's a proud so you had to really seek out now that the FDA is having to Right.

So you had to pull women off of this. They're coming in, they're absolutely miserable. We know that the medical organization isn't supporting HRT and you really had to go start thinking outside the box and looking for reputable trainings and things like that so that you could service these patients and really get to the root and understanding of Can I use these?

And am I doing it efficaciously, safely? All those things. And I mean, you definitely were going against the FDA. So it was something that you had to really believe in and understand the science behind.

I think that's where it came down to. I actually am a little bit less experienced than Dr. Miskel on this. I'm not a gynecologist and I wasn't taking care of primarily hormone patients early on in my career.

And we both practiced in Texas at the same time during this and she was five years ahead of me. And, and I was in a little tiny town with only 2000 people and we were a long ways from anywhere.

We had to drive two hours to get to an actual city, right? To get to Amarillo. and five hours to Dallas. Well, along the way, as we drove to Amarillo, there's a little town named Clarendon and there's a pharmacologist there.

And she was probably, I want to say in her maybe early sixties, late fifties. And she came to our office and she said, well, Dr. Peterson, you ought to know about compounding and hormones.

And because there's a lot of women that are suffering ever since this trial. And, you know, she talked about the women's health initiative and I I think at that point, everybody was very familiar with this and we're taking people off of their hormones.

And, you know, you, you try to do it in a fairly, I don't know, kind and supportive way, but you're saying, Hey, this is bad for you. You really shouldn't take this.

You take them off or now they feel terrible. And so it was actually a compounding pharmacist who educated me and was patient enough with, Hey, right. I'm not suffering with these things.

I'm not a 60 year old woman. I was just this young, arrogant, you know, 30 year old doctor. So I think that's a big part of it is that the people making these judgments weren't really the people suffering from the judgments.

The people interpreting the data were interpreting it based exclusively on risk and not on benefit. That's one of the craziest things is if you look at the trial, they had 10,000 women and the increase of the incidence of heart disease, even amongst these women that were smoking in 63, et cetera, 10 out of 10,000 people had heart events that would not have otherwise had them.

11 out of the 10,000 women had strokes that wouldn't have otherwise had them. And 10 out of the 100,000 or 10,000, I'm sorry, had breast cancer events that they wouldn't have had.

So we're talking about a total of 30 people out of 10,000. Now, I'm not saying that that's trivial, that these 30 people suffered. What was interesting is they also found that 10 fewer people had colon cancer and 10 fewer people had hip fractures, right?

So the net difference was 10 people out of 10,000. And then we're just going to totally say to all these other people, sorry, you're going to have to suffer.

And the benefits of your mood and your sleep and your hot flashes and your brain fog and bone density. All of those things, those were not end points in the study so we can't even comment on what it did for your mood or what it did for your relationship with your employees or employer or spouse or whatever.

Well, one of the other super interesting things about the study is that they said that there was no life benefit. Yeah, exactly. Sorry. And if you look at the data, they did not include women who were symptomatic in the study because they didn't want to give them placebo and then they fall off the trial.

So women who were symptomatic were not included. And so they asked women who were not symptomatic if they felt any relief from the symptoms they didn't have.

I would make two comments on that one. It shows how hard it is to design a good trial, right? I don't think people are intentionally designing trials in a bad way, right?

Because you don't want to start. But it also showed how the way that we look at medicine with this double-blinded placebo controlled trial that is very, very rigidly defined.

It's not actually how humans work. And that's where the excitement of big data and how we're going to actually find the truth by taking sort of all this disparate information and then crunching it, we're going to get much, much better information.

And we're not going to be misled by some poorly done statistical analysis on such a finite group of people that it didn't, we didn't get any information anyway.

Yeah. This sounds like such a big piece of the puzzle. It's something that we do at Forum Health every day, and many, many of our clinicians have been practicing this for decades.

Why did it take 25 years to undo a mistake that we've known about for 20 plus years? Do you want to make that amaze first, or do you want me to? Oh, is that what I'm doing?

That's a great question. And so it is incredibly difficult to change a physician's mind. I meet with you guys all the time. Yeah, exactly. So if you have a black box warning label on something, then the FDA says, don't use it.

And so if my colleagues, I mean, we're a very litigious society. So if my colleagues are going to put somebody on something for their symptoms, it's not going to be something that has a black box warning label.

They'll try an SSRI first or something like that before they're actually going to use something that replaces what's missing. in that woman's body. So I mean, fear is a big part of it.

Even women, they're difficult sometimes to convince that this is the best way when you start talking about bone density, heart disease, lower colon cancer, all of that, then they kind of sometimes will make a little bit more of an, take more of an interest.

But if it's just to get rid of their symptoms, then also there's a lot of women who have that same feeling. But mostly it's fear, I would say. So there's a scientist named Max Planck, a German physicist.

He was actually Albert Einstein's professor. And he is famous for saying science advances one funeral at a time. And that's why, because we are so resistant to believing something new.

The group of people that discovered the thing, right? If I discovered that hormones are bad, you are surely not going to prove to me that they're not bad, right?

And I would have to turn around and say, we made a mistake. We misinterpreted this data. There was something we overlooked. Now, it's like an apology.

The sooner you make an apology, the easier it is. The longer you dig your heels in, the harder you push against it, the harder it's going to be. And I just think that's what happened here is we misinterpreted this data on the very first day and then became more and more entrenched.

And once you told the vast majority of physicians, hey, sorry, this is the reality now, we just want to be good little boys and girls. and not get in trouble and not make anybody mad at us.

And we'd sure rather not make the CEO of the hospital or the FDA mad at us, you know, making an individual patient mad at us. We're like, well, there's only so many doctors, they'll find, you know, they'll come back around, which is a terrible attitude.

But I honestly think that that's how physicians oftentimes have behaved. And it's the physicians that were not willing to accept that, like Dr. Miskell, who said, I can't let my patients continue to suffer like this.

I better look into this. I can remember being in medical school and being surprised at how little endocrinology and physiology we learned and how much pathology and pharmacology we learned.

Well, how do you understand pathology and pharmacology if you don't understand physiology, right? And endocrinology, right? And so the whole thing of these hormones, they're bad for you.

I'm like, well, why are a bunch of 40 year olds not getting more breast cancer? Why are we at most risk when we're 25? This doesn't make any sense, right?

But you could not, at least when I was in medical school, I could not find a text or a professor that could help sort this out, right? And so I do think that it was just one-off physicians like Dr.

Miskell who said, I can't let my patients suffer like this. Let me see if I can figure it out. And it's not because they were being exceptionally risky and doing bad things for their patients.

It's because they were diving deeper into the actual physiology, endocrinology and saying, how does this work? What would estrogen normally do? It being a normal thing that happens when we're 52 or 53, that doesn't mean that it is good for you.

It's also normal for you to have a heart attack and get gray hair. That doesn't mean it's good for you. It just means that that's the natural sort of slide to the grave between 35 and 70. But if you could say, wait a minute, how does this work?

How can we make it so that the trajectory to the grave sort of slows down a little bit? I'm not saying we'll even get there later. We probably will. But even if we died still at 78, could we change things by paying attention to how the hormones are sending and the signals and what our body is then doing in response?

So I think the reason why it was so hard, why we were so intransigent in admitting our mistake is just simply the way that science works. And then the people that did sort of insist on doing it better were individual doctors taking care of individual patients who said, wait a minute, the risk for you, I don't think is bigger than the benefit.

The benefit outweighs the risk. Let's move forward. Yeah, I think that those are some really big points. I'm so grateful for organizations like Forum Health now because we have this collection of providers and a collection of data that helps make movement in this field and progress in this field so much more attainable.

I think that What parts of the reasons it took so long and why it's happening now is in the past, women's health was not prioritized either. And we're starting to see women's health become more prioritized.

Men and women have different biologies and we've been looked at the same for a long time in certain scenarios. I think that when you throw a label like a black box warning on something that you start the prescribers start having this fear there's the liability concerns and so it's not being utilized as effective and it takes providers like you both to have the curiosity to go out and ask questions because it's being taught in a way today, or it was up until recently, that hormones shouldn't be utilized.

And it takes curiosity to ask the right questions of why. I'd love to hear your opinion on this, Melissa. I think it's largely because we have lived with a disease-based perspective of medicine rather than based perspective of medicine.

And if fear of a disease is why I do or do not do something, I might get cancer. I might have a heart attack. That changes how I live compared to if an optimistic intention of gaining some health is my goal, then I would do something differently, right?

Like I might take Lipitor because I'm afraid of a heart attack. but that's not gonna motivate me to eat more protein and healthy vegetables, because I'm not after health.

I'm just after avoiding the disease. I think hormones are sort of that way. What are your thoughts on that, Melissa? Well, I think absolutely that that's correct.

One of the things that there have been multiple studies that have come out over the last 10, 15 years that have shown the benefits of hormone therapy, but those are not printed in JAMA or they're not interviewed by the New York Times.

And so because it's exactly like Andrew said, those are healthy. They're not sexy. It's the way that you should do it to age in a good manner. And so the big headlines of, oh, let's scare you to death, let's tell you how terrible things are going to be, that unsell papers.

If you then have more studies that say, wait, this is actually decreasing heart disease, it's increasing bone density, all of the things that are very beneficial, that's rather boring.

Yeah, it's certainly boring to say my mood is better, right? Or my sleep improved. Because I could scare you a lot with a heart attack and you're like, what about my sleep improved?

And you're like, well, wait a minute, those aren't congruent. So we ignore all these benefits. What does the removal of the black box warning truly mean for women?

It sounds like there's just so much powerful changes that are happening right now, what does it mean for that black box warning to be gone? I think that it means that now women have the ability to go to their physician and say, I want to be on hormone replacement therapy because it's going to, I mean, the majority of women die from heart disease, right?

It's the number one killer of women, heart disease. Women survive breast cancer in a 90% survival rate now. So those women with breast cancer are going to die of heart disease.

And so I think it's women's ability now to be able to say, I want to make a concerted effort for my health. I want to not get osteoporosis. I want to not get colon cancer.

I want to not get diabetes. I want to not get Alzheimer's. All of those things that estrogen is protective of. I'm going to make a, I don't think it's outrageous, but at least a controversial suggestion.

I suspect that for the next 10 years, what it's going to mean is that women are going to have access to hormones and they probably are going to be getting it from doctors that have never done it before and don't know what they're doing.

I, that was a, I, now that there's access to it, it's so easy to go and ask for it. But I also know how much time and energy our providers in our network spend on educating themselves with hormone.

Yeah, absolutely. The whole time, because they were willing to say, wait a minute, this doesn't make sense. Let's see if we can understand it. And they understood it before the FDA was willing to say, we made a mistake.

And they haven't really even admitted that. All they've said was the study was on 63 year olds. They've never, they still haven't come out and said the study was on synthetic hormones, right?

They've only half accounted for the mistake. And so now what's going to happen is a whole bunch of women are going to go to their family doctor or their gynecologist and they're going to start getting synthetic hormones and they're going to feel better.

But what will that do for them? We still don't know. Because the studies that show the true benefits of this are done on bioidentical hormones. And they're relatively small studies.

Why? Because there's not a pharma company that owns bioidentical hormones. They're available without a pharma company being involved. So who's going to spend the $10 million or however many million dollars it costs nowadays to do that?

no one, and therefore the studies that show these things are at largest 70 or 80 women large, as opposed to the 10th out when they were in the Wyeth study.

Yeah. Right. And so now what we have is because they've taken this black box morning off, because they understood, wow, we made one mistake. They are not admitting to all their mistakes.

Now they're going to go and take a synthetic hormone and probably that's not as good. And that's sort of what the WHO showed, but they will be better off than with no hormone.

And they're going to be getting it from someone that doesn't do this. And they'll just say, hey, 6.25, let's go back to 6.25. That's in the right direction, but it was not very far in that direction.

Yeah. And they, I mean, I'll just go back to the old thinking in a lot of these physicians where you don't get progesterone unless you have a uterus. Right.

Because progesterone, what about those women that still make progesterone at age 23? What's it doing for them? Everything! It's doing all sorts of things for them.

It doesn't just cause you to be fertile. Progestin is the hormone that prevents your cells from breaking down too quickly. Estrogen and testosterone are anabolic.

They cause the growth of tissue. Well, that's fantastic as long as you have a place to put the new tissue, right? So understand the physiology of it is what doctors need to do, but now they're not going to.

Why? Because we love protocols. And before the protocol said, don't use that. And now the protocol says, you can use it if you want. Are we any better off?

Only the smallest amount for the shortest period of time. Exactly. Which also is not the way that you should prescribe bioidentical hormones. Right. And so now the average physician is going to go back to giving it for the symptoms that they weren't looking at to begin with for the shortest possible period of time.

And so instead of women going through menopause and being uncomfortable, they're going to be slightly less uncomfortable three to five years, and they're still going to end up with osteoporosis.

So it'll just be three to five years later. Why don't we treat them? Why don't we keep treating them? They continue to be people and women until they die.

You know, 90 years, there's still people that need hormones. I would like the listeners to know what questions they should be asking when they're exploring hormone replacement therapy, when they're meeting with their provider.

When they should get their blood drawn, because that's one of the number one things that doesn't happen. So if you're You know your menopausal, if you're 55, then the majority of physicians are just going to prescribe your hormones.

They will not draw your labs. So that's the number one thing that they need to start out with is, I would like my hormone labs drawn. I think they also want to ask, and this is because I think that they're going to get better care this way, are the hormones you're going to give me bioidentical?

And the reality is, if the physician doesn't know, the answer's still sometimes yes. You can get progesterone that's bioidentical and estradiol that's bioidentical from the, you know, CVS or Walgreens or whatever.

You don't have to get it compounded for it to be bioidentical, but you want to know if it is, because if it's not, if you're taking some sort of a, you know, PremPro, it's not.

It's important to know. because it's like asking my grocer, am I getting cheddar cheese or is this that Velveeta stuff that's not really cheese but looks like it?

There's a difference. I think that's very helpful. I think that the Misconceptions that removing this black box warning will also be a really big impact for what's happening now.

Misconceptions, the study said about cardiovascular disease and cognitive decline. We all know that HRT is not dangerous for healthy women and that it can help with cardiovascular protection, bone density improvements, cognitive and Alzheimer's reduction.

in those symptoms, it can help with mood, sleep, energy, sexual health. And now providers have this permission to treat without fear. However, it's important to advocate for yourself.

And when you are asking a provider to help support you in hormone replacement therapy, to ask the right questions, now that this black box warning is pulled, there's this permission to treat.

There's also different levels of experience that come with that. So I'd love your opinion on this, Dr. Miskell, because I know that you do all hormones and in a way that's robust and beyond estrogen and progesterone.

What do you think about that when you go to your physician and you say, can you test my hormones? Which ones would you include? Which hormone would you test?

Well, definitely estrogen, progesterone, testosterone, and then depending on the woman's age, you would need an FSH to see exactly where she is in menopause or perimenopause.

The way that we do our treatment for our women is very much their symptoms along with their labs. And the symptoms are even more important actually. The labs are just something that you can base your dosing on and, you know, safety reasons.

You don't want to be getting too high or then you'll know if you're too low. But their symptoms are really what is the most important thing. So they should have a physician that listens to them.

Like, what is your main symptom? Because every woman is different. My hot flashes being my big problem, but it may be low sex drive over here. It may be foggy thinking here.

You said you suggested that they need to have their testosterone checked. 100%. Now I'm going to throw out there. I 100% agree with you. I'm going to throw out there that you go to your regular family doctor.

You go to your gynecologist after this black box warning just came off. They're not gonna test that. They don't think you need it. That's not a female hormone.

Why would they check it, right? And so you can't just say, oh good, I can just go to my regular doctor now, because they're not gonna look at the whole picture, right?

They're only gonna look at your estrogen and progesterone if they look at anything. And so, and I would suggest that there are women that you're also gonna check their cortisol and their DHEA, right?

Because those are gonna play a role in their energy levels. So I guess the reason that I think it's valuable for people to hear that is because they're gonna say, oh, it's more than just that now I can take estrogen and progesterone.

Because I'll bet you your experience for 20 years has been that every single one of these hormones that you give patients has a fairly, can have a fairly profound effect.

Some women have better, you know, they take progesterone and they're like, oh my heavens, I'm sleeping again. Other women, they take estrogen and they're like, oh thank goodness, because now I don't want to bite everybody's head off.

And then they take testosterone and they say, oh wow, I feel like I want to do something, right? Like there's, they all matter. Yeah. Right. And it's the ratio together.

Exactly. So you got to do the labs. I think this discussion is really kind of standing out to me as why functional and integrative medicine practitioners are far ahead, like they're far ahead on this curve.

So from your guys' perspective, why are functional and integrative medicine practitioners so far ahead? Because these are For us, it's second nature that we're going to run the testosterone.

We're going to do monthly or quarterly labs to make sure your hormones are in the right place. We're going to listen to the symptoms of the patient, not just judge everything off labs, because we know that within normal range is unique to every person as well.

Why are we far ahead in integrative and functional medicine? Why are we so well prepared for this new wave of women having access to hormonal replacement therapy without fear?

Well, I think it begins with what Andrew had said earlier, having a curiosity about something that doesn't make sense. And so you have to be able to trust your own knowledge and judgment and feelings to go beyond what someone else is telling you is right.

the subset of physicians and practitioners who can do that and feel that, then it's just a natural thing that they're going to find functional medicine because it's logical.

Yeah. I also think that there's a greater connection to making it personalized to the patient. I think that In this little town that I practiced in Texas, there was 2000 people.

I couldn't avoid them. Grocery store, bank, football game, there they were, right? You have to confront your failures. I probably would not have become an integrative functional medicine physician had I practiced in a big city to begin with, because I just wasn't naturally, um, a caring enough person to say, I really am interested, but I couldn't avoid these people and I had to be interested because they kept coming up to me and saying, I'm still not better, right?

And so I got pushed into this, not with a lot of kicking and screaming, but I did find that listening to the patient's individual situation was so much more powerful than listening to the guidelines and saying, well, the guidelines say this.

Right. And so I think functional integrative practitioners make that their number one thing when Dr. Miskell said the symptoms matter more than the labs.

I'll bet you that most physicians are going to disagree with that and they shouldn't. And it wasn't that was not true. 80 years ago, and that's because we had not already thrown ourselves at the feet of the lab gods and said labs know everything.

Objective matters more than subjective, right? And I guess there's just a small group of people, functional providers that are like, wait a minute, that actually doesn't make sense.

Objective data is not superior to subjective data. They're equally valuable to us. And what the patient is telling me has to be the most important thing I'm hearing.

because the other one came in and told me that I didn't just get a set of labs on my desk, then I'm going to search out the patient, right? And so I think that when you go see an integrative doctor that is working for you and not your insurance company, you're going to get a personalized answer and they're going to look for what is optimal for you.

That's another thing is the bell curve, right? Normal just means you fall under the bell curve. You have something between a D and an A. If you have an F, you're outside the bell curve, and if you test it out of the class, you're outside of the bell curve.

But if you're under the bell curve, well, 96% of the population's under the bell curve. That's not that big of an accomplishment, right? So you're like, oh, you're normal.

OK, but I want to be optimal. Well, go find a functional medicine doctor, and they'll make you optimal. Dr. Miskell will make you optimal anywhere in Texas.

Well, what? What does optimal look like versus survival mode for midlife women? Optimal means that you continue to do the things that you've always loved to do.

You're not sitting on the couch or afraid to go outside or can't wear the clothes you used to wear. I mean, that's survival mode. Optimal is that you're living your life to the fullest extent that you want to live it.

Yeah, you're still active. You're still engaged. You, you know, you're probably at a point in life where now you have a few more choices because kids are growing up and finances are a little bit generally a little easier.

And then you're just like, I'll just sit on the couch because I can't do anything. Well, the thing is, I used to coach and I had a unique patient demographic at one point that were 65 plus and it was the time of their life that they wanted optimal health because they had the freedom they worked their whole life.

And now it's retirement age. And they're like, I feel like garbage. And it's the time in their life that they want to be active. They want to be out there.

They've worked this long to get to this point. And to feel like garbage is a terrible place to be. There's something that I think relates to that. You don't have to wait until you feel like it, right?

So don't wait until you go through a menopause. Your hormones are slowly going down, starting somewhere around age 40, probably, maybe as early as 35. 35. I'm going to advocate for 35. You're getting there, right?

And the first one you're probably going to need is progesterone and then the next one you're probably going to need is testosterone. Got it. And the last one you're going to need is estrogen.

Why is that the case? Well, because you're a woman and your body is saying, we have to do everything we can biologically possible to continue to make eggs because my biological purpose is to reproduce, right?

And so you're making estrogen until the very last moment. And then when that one finally goes down, then you're like, oh my heavens, it's over, right?

Then you go see the doctor. Don't wait that long. Go see one of our providers at Hormones by Design at age 38. And then you can be optimal the whole time.

And it's so much easier to be proactive than it is to be reactive in this state. I think a big piece of what has functional integrative focused clinics so far ahead is that we do take more of that proactive approach.

the as many times as we can, we look at the data differently. We look at the whole person, not just the different little bits and pieces, and we personalize it to them.

And we're not limited by guidelines. We want real world outcomes. And that's where labs are important, but the symptom reporting from the patient and their actual real life experience is just as important.

And so we have this emphasis on healthy aging versus just disease management. And we're looking at the longer longevity conversation for our patients.

And I think that's a really big differentiator in high quality HRT care. Yeah, I'll say this too. I have the benefit of being able to work with some of the advanced providers, advanced practice providers that work for Hormones by Design that Dr.

Miskell has built this fantastic model for patients all over Texas. And these nurse practitioners and PAs are not just doing labs and giving you something.

I look at their notes and I talk to them. We meet every month. And the focus on your optimal health, mood-wise, sleep-wise, energy-wise, all of these things, that's what they're doing.

And it's just, it really is whole person care. And I think that's the other thing to consider is that you're not just saying, oh, I'll go get my hormones.

Yeah, you're doing that, but you're getting this attention to all of those things that are going to help you be optimal. And I know that those providers are doing that because I get to spend an hour with them every day.

Yes, they're fabulous. So the future of menopause care is blasted wide open. Where do we go from here? What does modern menopause care done right look like?

Well, I think We have already been doing it. So I don't think in our offices that it looks too much differently than what we do, but it is a collaboration between the provider and the patient.

And that's just the most important thing. So I think that every woman deserves that and they should look for that and insist on it. Absolutely. I agree.

I don't think it looks much different than what's being done now by functional integrator providers. They haven't been holding anything back. I think that There are things that we will see that matter.

I mean, your DEXA scan is still going to tell you how thick your bones are. And if you're taking your hormones and your DEXA scan, if they're looking as good as it ought to, well, then hopefully your provider is going to tell you to start lifting weights and taking an actually absorbable calcium supplement, along with some strontium and boron, right?

There's things that we can do, not just this here, this is one pill, even if that one pill happens to be estrogen, right? So it's still a. I do think that there's gonna be more, there's gonna be more research now.

There's gonna be more proactive conversations around this because this has been lifted. And I also think that because of it, to your point earlier, Dr.

Peterson, is there has to be better provider education out there. I feel like it's gonna be rough for a little while, but it has to produce some better standard provider education Also, I know we're already doing all of that, but for the masses, it still goes back to the way that medicine is provided right now.

We're providing medicine to the masses because of the. um, payer system that we have. And so it really is a cookie cutter based system. And I don't think in a cookie cutter based symptom system, you're going to get the care that you need.

And I think that that's going to change. It's going to change over the course of about the next 10 years, but we're seeing a shift away from that, but that has to be driven by the patient.

You're not going to be able to get people that look at every single one of these details and, and does a complete job. Um, Patients either have to be very well educated or they have to be partnering with the right person.

Patients are going to need to empower themselves with information and the right information, and they're going to have to choose a partner in their care.

And I think that's going to be the most important thing for patients and women who are looking to have HRT therapy as a course of treatment and support, that educating yourself and making sure that you have the right partner for that.

More scientifically accurate protocols still only work well if you have personalized care with sufficient time to get all the answers. And knowledgeable practitioners.

Yeah. What do you both hope women take away from this moment in history? Because this is a big moment for women. Huge. It took 25 years to get here. Well, I think you kind of touched on it earlier, Amanda, when you said that women have just been pushed under the rug as far as our health care and what medicine does for us specifically.

I saw one quote. The other day that this woman said, I'm not just a little man. And so, I mean, that's so true because medicine is directed specifically at men.

And so I hope that that's one thing that comes out of this is that we continue to have more female testing that's done. The trials are actually meant for us.

Alzheimer's is one of the major ones because women get Alzheimer's twice as much as men. So that's just another area to be very proactive in. And HRT can really help with that.

Yes. I'm going to pray, and this applies to men as well as women, but it's a woman's moment at this point in this case. Don't trust authority inherently.

Just because they're in authority doesn't mean they should be trusted. And I'm not saying to distrust everyone, but Curiosity, questions. Trust your gut more than you trust your rock.

Listen to yourself. Um, and I, I think women are better at that than men is trusting. It's our voice. It's not that we don't listen to ourselves sometimes.

It's that we don't feel like we have a voice. And I feel like this moment in history is starting to show that we have a voice. We can speak up. We can start advocating for ourselves.

I also think that there's going to be a lot more happy women out there and what men are not going to like that. I mean, I got on hormones this year and I am so much happier, so much more pleasant to deal with.

Like you guys, this is a moment in history where we women are just going to dominate because we're going to be happy and healthy and our brain fog is going to be gone and we're going to have strong muscles and bones and this is it.

With respect to the science, don't forget the study from 25 years ago was done on women. That's all that was in the study. And so that's because we say, hey, we're going to do a study on women.

It still has to be good science. It does. And so it can't just be saying, let's do more studies on women. We need to do that because they are different.

We need to do them well. In spite of the fact that that's politically incorrect to say now, they are different than men. We have to take care of them in a unique way.

in a way that is appropriate for them, but we have to get good science. We can't just say the study was done on women, so we're going to trust it. No, the WHI study was done on women and it was bad.

So we have to do better for everyone by doing good science. And we have to recognize that we should trust our guts, our intuition as women more than some bureaucratic authority.

Absolutely. This was such a powerful discussion. Our industry, medicine, it's shifting and in such a powerful way. Are there any final takeaways for our listeners that either of you have?

Well, I would just encourage women to do exactly what we've talked about. Take control of your health yourself. It's okay to do that. Find a practitioner that you trust that you can talk to, not that they talk at you, but that you can talk to, that you feel like you're being heard.

I would say that. We live in the information age. And so you don't have to rely on someone else telling you what the information is. It's available to you.

You can go and read it. And that's why this changed, right? Peter Attia's research, and then people finding out about it, right? It'd be one thing if somebody did some research that said, hey, I think we got this wrong.

But when enough people find out, then that's powerful. Go find out. Yeah, I think that we're in a position now where we don't have to be as subservient to the authority of the physician.

And we can now say, you know what, I could go read about this. And frankly, so could anybody. That's why a lot of health podcasts that are out there aren't being, they're not, it's not a physician that's running this podcast, right?

It's an engineer. It's a software person. It's a nurse. And you don't have to go to medical school to read. And so as patients, empower yourself with the information.

And I will tell you that, I mean, that's what happened to me. A woman named Holly Johnson came to me. This is, this is a different person than the pharmacist.

came to me and said, will you look at this? I think this would help me, right? And I read the article she gave me and said, maybe that would help you.

I'd probably help a lot of people. So talk to your doctor, get them to change their mind. Some of them will listen. Absolutely. And if they don't, find us at formhealth.com.

Well, this was such a powerful conversation. Millions of women have endured unnecessary suffering for 25 years. Women were told to fear one of the most powerful tools for their health and longevity.

And today we started rewriting that story and we started rewriting it loudly. And I'm so proud that Our organization is at the forefront of this, and we've been screaming for this for so long, and it's finally here.

And I know it's not just us, but it's all of the integrated functional medicine providers out there who are just ringing their bells right now. So it's just such a great time in history for us.

Thank you so, so much, you two, for having this discussion with me today. Dr. Miskell, let the audience know where they can find you and your practice.

We are based in Texas, and it's hormonesbydesign.com is our website. And you can go there and see where all of our offices are. And we do have providers that are in other states that do our method.

And so that's all listed on our website, hormonesbydesign.com. Awesome. Dr. Peterson, how about you? How can people find your practice? Well, go see Dr.

Miskell for your hormone care, where they can find my practice quite easily. Just go to forumhealth.com. We do hormones as well, but Dr. Miskell's approach, what she's building for Forum Health and with Forum Health is fantastic.

Absolutely. Thank you. forumhealth.com and myself and our partners here in Utah take care of hormones all the time. Absolutely. Thank you so much. Tune in again next week.

You're welcome. Tune in next week for our next episode. Don't forget to like, follow, and share, and we will see you next time. Thank you for joining us on the Forum Health Integrative Medicine podcast.

Each episode, we help you understand your health from every angle and inspire your lifelong wellness journey. Follow the show, share it with someone who needs hope, leave a review, and take the next step toward feeling your best at forumhealth.com.

Melissa Miskell, MD

How Bad Science Shaped Women’s Health for 25 Years