Discover Menopause’s Impact On Your Heart

Sharon Stills, ND

The website is DRStills.com, and for the last 12 years I have had mainly a telemedicine practice, but I am in the process of opening up a new 5,000-square-foot clinic in Scottsdale, to be of more service and bring all my diagnostics and therapeutics. Stay tuned for that coming soon.

Joel Kahn, MD, FACC

You are not cutting back and slowing down.

Sharon Stills, ND

Coming down the other way,

Joel Kahn, MD, FACC

Yes, you are. A brick-and-mortar practice is wonderful, and Scottsdale is a vibrant community. Where is it going to be in Scottsdale? What kind of relative area?

Sharon Stills, ND

Right off the one-on-one in 90th St. It is pretty centrally located.

Joel Kahn, MD, FACC

Great. Because a lot of people either live there or winter there; summer there, but not too many. Summer in Scottsdale. We can get out of there, and they do want to look for you. I have had the opportunity to work with Dr. Stills. She has her DrTalks Summit that I was able to participate in. She is a force. She has got a lot of knowledge. This topic, like reversing heart disease, spends a lot of time talking about nutrition. We have talked about various tests. We have talked about supplements. We are going to talk about perimenopausal evaluation, which is probably mainly focused on the female members of this summit audience, of which there are a lot. We will talk about bioidentical hormone therapy and post-menopausal hormone therapy. That sounds like a good plan to you, Sharon.

Sharon Stills, ND

Sure. We could speak for the men, too, and talk a little bit about testosterone.

Joel Kahn, MD, FACC

Yes. We should. Well, what I am always intrigued by is that until about 1992, hormone replacement therapy was recommended by multiple, medical organizations as a strategy to help reduce heart disease, development, and death. If we were doing this, and again, it seems like so long ago, 40 years ago, 35 years ago, we would be talking about the overall consensus. It was a good idea to take a perimenopausal woman and put her on hormones. But everything changed in the early 1990s with the Women’s Health Initiative and the Hirsch study. Tell us a little bit about that. Your spin on it took about 20 years to have dug out of it. But your spin on that whole period.

Sharon Stills, ND

Yes, I think, and that was before I was practicing medicine. I started practicing in 2002. I graduated in 2001, but I had to go back and look at that because it did change things. So many women had their hormones just stripped from them. I think that the study was improperly evaluated. Since then, it has been gone back, debunked, and shown that it was not accurately reported. The thing that sticks out to me is that they were using synthetic hormones. When I am talking about hormones, I am talking about bioidentical hormones. To me, it is comparing not even apples and oranges. It is comparing apples and monkeys because there is such a difference in what bioidentical hormones do in your body. Let me stop and define what that is for those who do not know. Bioidentical is biologically identical. These are hormones that are being compounded, and we are only using reputable, respectable pharmacies. I work with a pharmacy here in town, and I am always there to make sure. You hear a lot of people trying to be dissuaded from using bioidentical hormones because they say they are not regulated. But that is not true. When you are working with good pharmacies, they are regulated. These hormones are identical to the hormones that your body produces. 

When you are taking synthetic hormones, they do not fit in the receptor sites. They say a synthetic hormone is shaped like a diamond, and your regular hormones are shaped like circles. When a diamond comes to try and fit into a circular receptor site, there is a problem. We end up getting a lot of side effects. You want to only be using bioidentical hormones. Then there are a lot of nuances in using them. You want to be using them. I will get into it, and I will talk about some of the things you should be looking for and asking your doctor about. When we talk about bioidentical hormones, right away, when we think of perimenopause and menopause, we think of estrogen, progesterone, and testosterone. That is true. Those are the biggies. Estrogen specifically has a lot of benefits for cardiovascular disease. But I am going to kind of take you through each hormone because hormones are a symphony, and you would not want to go to the symphony and just see the woodwind section. You want to make sure the brass section is there and the percussion session is there. Sections are there in the wind section because they all work together. 

Just to give you an idea, when you are taking synthetic estrogens, those are given orally. When you take synthetic estrogen, it is typically just estradiol, which is E2. Estrogen is just a word. It is like an umbrella. then we have E1. E2, and E3. Those are the big break-down components of estrogen, estrone, estradiol, and estriol. Then, from there, we have a lot of estrogen metabolites, some beneficial and helpful, some not as beneficial and more inflammatory. We have to look at the whole cascade. When you are taking synthetic estrogens, you are taking them by mouth. As far as cardiovascular disease goes, we know that oral estrogens can raise your inflammatory markers and your C-reactive protein. Can raise your triglycerides, can raise your blood pressure, can raise your sex hormone-binding globulin, and elevate your liver enzymes. There are a lot of nasty negative side effects. Those are not the things we see when we are given bioidentical hormones. 

If you are watching this and you have never thought of hormones and cardiovascular disease and you are like, Wait, I just thought hormones were to get rid of my hot flashes or to make me not so cranky, One of the reasons I am such a passionate believer in proper bioidentical hormone replacement is not just for symptom reduction. Of course, I love helping women get rid of their symptoms, having a good night’s sleep, having nice skin and nice hair, and all of these things. But it is about the preventative aspects and cardiovascular disease; heart health falls into there in a very large way, as does bone health, as does breast health, as does immune health, as does your genital urinary tract. 

The hormones affect all of the systems in our body, but we know that proper estrogen replacement is important in helping to increase healthy cholesterol and decrease LDL. I remember back in medical school, they were like HDL healthy and LDL lousy. You want to decrease those, and of course, you want to break down the components, which I know Dr. Kahn has gone into because he is an expert in that. But they helped reduce triglycerides. They helped to reduce the coagulation of platelets and stickiness, which is a problem I see way more frequently than I would like to see these days. We are getting all of these benefits in addition to getting rid of the hot flashes and so on.

Joel Kahn, MD, FACC

Okay. That was a brilliant, and exciting introduction to the topic. It sounds like one; a key component is a proper pharmacy, a pharmacy that is of high quality; that is called a compounding pharmacy that will provide these natural, not synthetic, hormones to a sub z doctor that has experience like you. Has been trained, and maybe is certified by one of the organizations. It is not just for every gynecologist. It is not just every female endocrinologist, is it?

Sharon Stills, ND

No, unfortunately, it is not. I am probably in the minority at this point, and I am doing what I can to change that. But you do have to be careful, and I am sure a lot of you listening have gone through this where you go to your OB-GYN or you go to your primary care and they tell you you do not need hormones or hormones that are dangerous or you have already passed menopause and it is too late to start hormones. It is a huge topic where women are misled, not given the proper information, and even gaslit about what is important to them. I always say there are some things you can just ask a doctor off the bat to kind of go, Do they understand hormones? Are they unable to understand hormones? Because a lot of people like to say they are hormone doctors. But I can tell you that as long as I have been doing this and from the patients I see coming in, I see horror stories of how women are or are not prescribed hormones. I just want to go back a second to the breakdowns, because E2, which is estradiol, is an important key factor when we are looking at the cardiovascular benefits, decreasing inflammation, reducing the risk of heart attacks and strokes, lowering the blood pressure, and all of these important things changing the ratios. 

A lot of doctors out there just give E2; they might give it in a patch or give it orally, and what I am a proponent of is Biestrogen, which has two in it. You get the benefits, but it also contains E3, which is estriol. Estriol is not appreciated or acknowledged in mainstream medicine. You want to find someone who is working with estriol and estradiol. My experience and I can talk about how we monitor it and how we test it in a second. But my experience is that you need about 80%, sometimes 70%, sometimes 60% of estriol as opposed to estradiol, because estradiol is like 80 times stronger than estriol, and they have different actions on the estrogen receptor sites; estradiol hits more of the alpha and estriol hits more of the beta, which brings things down. You do not need to take just estradiol or large amounts of it. You can accomplish what we need to accomplish for cardiovascular benefits by doing this combination therapy.

Joel Kahn, MD, FACC

Okay, so that was powerful. People are listening, and I want to ask a question. At what age should a woman start to consider searching for an expert to work with and going through testing and the rest? What is too old? How far past menopause do you say? The train is out of the station, and we cannot have a program for you. What are the beginning and ending ages?

Sharon Stills, ND

When searching, you want to think about just historically what your experience has been with hormone-related issues. If you are someone who struggles with premenstrual syndrome, where you do not feel good before your period, if you have a history of high blood pressure, if you have a history of cardiovascular disease in your family, if you have fibroids, if you have endometriosis, if you have been infertile or had a hard time with infertility and had to go through IVF, I think I said fibroids. PCOS. If you have any of these hormone-related issues, when you are younger, you want to find someone to help you then. That is just showing that when you do get to perimenopause or menopause, you are going to have a much rougher time.  They have shown that women who suffer from more symptoms, such as hot flashes, tend to have worsening cardiovascular disease. There is a correlation between symptomology and what you experience as far as disease progression or just the disease showing up in the first place.

If you are, I think in this society, we have kind of seen it all the time with patients where we have just kind of come to accept that imbalances, struggles, cramping, breast tenderness, or mood swings are normal. I do not have PMS. It is normal that I get migraines or that I have water retention, and it is normal that my blood pressure goes up. It might be common, but it is not normal. Our cycles should be rhythmic; they should be smooth. We should not have all of these symptoms. When we have symptoms, it is our body’s way of saying, Knock, knock, something’s out of balance, and I want you to pay attention to me. If you are having acne or migraines, there are so many things, like weight gain, that will not go away. There are so many things that are correlated with a hormonal imbalance. If this is the case, I work with children sometimes—early teens, late teens, and young adults—because they are having problems, and usually they are brought to me by a very educated mother or they are patients. The mother is a patient of mine. They say, Can you help my daughter? It makes me so happy that I get to intervene and help them at a young age because I know it is setting them up for more of a hormonal, harmonious journey throughout their lives. 

If you do not have any of those symptoms and you do not have any of those diagnoses and you are just cycling regularly and not having any problems, you have been able to get pregnant. If you choose to get pregnant, then, around the age of 35 or 40, you just kind of want to find someone who is educated, who is open-minded, and who understands bioidentical hormones so that you can just come in and get your baselines, get some testing done, and just see where you are. It is getting that thumbprint and then having it followed every year; if you do not have any problems, there is nothing broken. I do not want to fix it. But just so that you are starting to be followed, so that levels can be checked, so we can start to see because estrogen will often drop in that perimenopausal period and waiting till your menopausal post-menopausal, you are losing a lot of protective value there. You want to be paying attention so someone can support you at the right times, and then, as far as it is concerned, is it ever too late? 

In my opinion and my experience, it is never too late. It is more optimal if you get on the train when the train’s leaving the station and everything is kind of flowing properly from the get-go. But I have had women because, let us face it, a lot of the education, the summits, and the podcasts were not always available. I know you have been practicing longer than me, but when I started practicing, there was no computer; there were just books. You went to a live lecture, and you tried to learn. We did not have the amount of information we had coming at us. Of course, the information coming at us is good and helpful. Then, of course, we can have over information and improper information that can get us confused. We have to be discerning about who and what we listen to. But I have had women who heard me on my summit or heard me on the podcast, and they are like, I am 70, and is it too late? I am like, No, it is never too late. Just from my clinical experience, since women benefit no matter when they start the hormones, it is always better to start earlier.

Joel Kahn, MD, FACC

Okay, well, that is a very thorough response. But I think we are going to do it; we are going to take a little break. People have probably been furiously writing down notes about E2 and E3 and some of the benefits. I want to come back after the break. Let us just talk a little bit more focused on cardiovascular benefits, and bioidentical hormone replacement therapy, because we want everybody listening to keep the youngest, most viable, most protected heart and not suffer from this awful statistic that is the number one killer of men and women across the Western world. Stick with us, Dr. Stills. Do not go anywhere. Okay? All right, everybody. Welcome back. We are talking to our premium audience. Thank you so much for being part of this. We still had the amazing Dr. Stills with us, giving us pearl after pearl. We could spend hours, and we can only have the Hors-d’œuvre tonight. We cannot do the seven-course meal. But let us just focus on cardiovascular benefits for the aging woman, peri, and postmenopausal. What are some of the benefits that being properly done and properly balanced by identical hormones might offer that woman?

Sharon Stills, ND

One of the things is that it is going to help reduce blood clots. What we hear is that estrogen is going to cause blood clots. You cannot take it. It is going to help your blood flow. It is going to help your arteries be stronger, be cleaner, and be cleaned out. It is going to decrease your cholesterol. It is going to decrease your blood pressure. These are benefits. It does not mean you are going to take some estrogen and voila; this is in the context of doing other things. But what my experience has shown is that it is like a big player. When we do these things, it is a lot easier to then tweak the other things, such as the diet and the nutrients. But without the hormones we are missing, there is just this big void. 

Of course, we are talking about estrogen; we are talking about E2 and a combination of E3. But I also want to shout out to progesterone and testosterone. Progesterone helps with fluid balance and also helps to lower the blood pressure. I call it, in nature, a chill pill that is like nature’s Valium or Xanax and non-addictive. But all the good side effects and all the good benefits side effects are good benefits, and we want to think about thyroid hormone because when your TSH is high, I mean when your cholesterol is high. Before we had a TSH, cholesterol being high was a sign that the thyroid was under-functioning. There is an intimate relationship between your thyroid and cholesterol that needs to be paid attention to. 

When you are working with your thyroid. What I am trying to say in this quick little Hors-d’œuvre is that you want someone who is going to be looking at all of your hormones—your thyroid hormone, your DHEA. DHEA helps increase the sensitivity of insulin. As your estrogen level drops, you can develop more insulin resistance. We need to always pay attention. You do not want to go to someone who just says, Here is some estrogen, and you do not have a uterus, so you do not even need progesterone. We always need all of the hormones, and we need them. We did not talk about it in the preview, but we are talking about it now with you premium people. You need to be monitored properly. You need to be doing 24-hour urine testing that shows all the estrogens. It shows the metabolites of estrogens. It shows how your estrogen is breaking down because that is a key factor. 

Hormones, I love them. I think they are very safe. But that is with the caveat that they are being monitored properly, that you are not being overdosed, and that you are not taking them orally. You want to apply your estrogen transmucosal. That is, to the external labia, which is mucosal tissue. A lot of doctors will tell you to apply your hormones to your belly and your wrists. But what happens then is that we get dermal fatigue, we get receptor site downregulation, and we have to either start using more and more of the hormones we have to overdose or the hormone just stops working and the liver gets overloaded and the bile stops flowing. We want to apply transmucosal because we can use lower doses and get better absorption, and we do not get fatigued from the route of administration.

Joel Kahn, MD, FACC

Wow, that was great. Another topic related to that is that so many women are concerned about their sleep. Menopause is a big disruptor, and the sleep-heart-health cycle is a very tight one. What can you tell women that they and we are talking to men, too, that they might anticipate getting the proper evaluation and the proper biogenic hormone program going in terms of their sleep?

Sharon Stills, ND

I just want to shout out for men because I love men too. I treat men in my practice like, You need to have your testosterone. That is the biggie evaluated. You can evaluate your testosterone and blood work. You can do total testosterone with free testosterone with SHBG, which is sex hormone-binding globulin, paired with a DHT, which is dihydrotestosterone, and an estradiol. That kind of gives you a big picture of what your testosterone levels are, how you are metabolizing them, and why they may or may not be low. As far as sleep goes, yes, we cannot heal if we are not sleeping. We need to prioritize sleep. Some of the big things that I see in practice are low progesterone levels. If women do not have enough progesterone when they do not sleep, that is one of the hormones that you can take orally, because when you take progesterone orally, it crosses the blood-brain barrier and has an effect on the GABA receptors. GABA is the inhibitory neurotransmitter. Getting the right amount of progesterone is usually 80–85%. Knock it out of the park, and you get a good night’s sleep. But there are some women, and that is not enough. Also, progesterone is the one hormone that I gave orally. But I also give trans mucosal because the oral gives you those inhibitory benefits in the brain for not only sleep but also anxiety. But when you take a trans mucosal, then it is more systemic and supports the cardiovascular system as well as the brain, the breast, the bones, and so forth. I like to do that one both ways. 

The other thing I see interfering with sleep is high cortisol levels, you have to be looking at what your circadian rhythm is and having a circadian rhythm practice to get in tune with sunrise and sunset. I will break into song, although I want to. You must be looking and making sure that your cortisol is not too high at night, which is what I often see with patients who are having a hard time sleeping. Of course, back to the almighty queen estrogen. If your estrogen levels have plummeted, you are going to have these motor symptoms; you are going to have hot flashes. That is a big thing that wakes women up in the middle of the night. As well as you are going to have incontinence if you do not have enough estrogen in your genital urinary system. That can wake you up at night. Again, need to dial in the estrogen so you are not having hot flashes. That is another thing, too. I have seen patients who come in from another physician’s office. They have been on bioidentical hormones, and maybe they have been on them for like nine months, and they are still having hot flashes. That is just not okay. If you are working with a doctor who does not get your hot flashes under control and at least start significantly reducing them within 4 to 6 weeks, they probably do not understand hormone replacement. You might want to look for someone else to put on your team.

Joel Kahn, MD, FACC

Wow. Well, how much does lifestyle play a role along with what you are doing with the hormones now?

Sharon Stills, ND

Huge. In my practice, everyone wants hormones and hormones. They provide all this protection, and they make you feel good. They give you back your libido; they give you back your shape. They make you look younger. They help with weight loss. They do a lot of fun stuff, but I am very strict if you are not doing the other stuff, and that includes supporting, you are eliminating organs, supporting your gut and your lymphatic flow and your bile flow and your liver while you are on the hormones, we take them away. If you are not doing your testing, we will take them away. You have got to be doing lifestyle. You have got to be moving your body; you have got to be feeding your body. You have got to be hydrating your body. You have got to be prioritizing sleep. We are talking about the heart and cardiovascular systems. You have to be chasing joy. You have to be; the heart is this huge electrical field. It has its brain. It has what is like 60 times greater electrical activity than the brain. It has an electromagnetic field. I am passionate about women and men, finding joy, finding their hearts, and finding what makes them sing. I talk about, as you read in my bio, finding your sacred second act. This is an opportunity to pause and connect with who you are as a human being, what brings you joy, and how you want to share joy and contribute to the world.

Joel Kahn, MD, FACC

Well, that is a wonderful note. Why do we not shut this down? Again, DrStills.com. That is D-R-S-T-I-L-L-S.com. If you are in Scottsdale, you can see her and her new brick-and-mortar coming soon. Of course, you do some telemedicine.

Sharon Stills, ND

Yes, I do.

Joel Kahn, MD, FACC

Okay. I know you run great programs. People just have to check out your website and get more information. The key is to find an expert. We are talking to a real expert who has helped so many people who are challenged by a convention that says hormones are bad or hormones are not for you; hormones are for the younger ones or the older ones. You have blown apart a whole lot of misconceptions and helped a lot of people. Thank you very much.

Sharon Stills, ND

Thank you. Thanks for having me.

Joel Kahn, MD, FACC

All right.