Ann Hathaway transcript

Written by Christopher Kelly

Feb. 3, 2017

Ann.Hathaway.on.2017-01-18.at.12.05

[0:00:00]

Christopher:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and today I'm joined by Dr. Ann Hathaway. Hi, Ann.

Ann:    Hello. Good to be here.

Christopher:    Thank you for coming on today. Yeah, thank you so much. I'm really excited to have you.

Ann:    Thank you.

Christopher:    Ann is a medical doctor who has been treating both men and women with bioidentical hormones and other natural remedies since 1995. She is a member of the Institute of Functional Medicine and is the director of the Orthomolecular Health Medicine Board. Ann, I'm so happy to have you. Can you tell me a bit about your background and the medical practice that you're on?

Ann:    Well, I'm a traditionally trained MD, graduated many years ago from University of California-San Francisco and did a traditional family practice residency training program here in California, Monterey County Hospital, and I practiced conventional medicine for many years working in indigent care, basically taking care of poor people for Marin County.

    And at some point along the way, I got disenchanted with the limitations of conventional medicine and began looking for something that was broader, something that was bigger, something that really took in the in depth kinds of triggers and problems that people suffer from.

Christopher:    Tell me about that. I'm really interested to know what sort of problems that you saw that weren't addressed very well by the conventional system.

Ann:    Fatigue, pain, depression, complaints of low energy, and all kinds of trivial things, considered trivial in basic medicine like rashes and just chronic aches and pains.

Christopher:    Right, anything that's been going on for a while perhaps.

Ann:    Yeah, yeah. Long term things that people suffer from that they end up being told, "Well, this is just something that you suffer from and there's really just something that you have to put up with." Gastrointestinal problems, bloating, gas, headaches, on and on and on, where there's no attempt in conventional medicine really for those things to look for the underlying causes, identify them and make changes especially when those changes include looking at the person's diet carefully.

    I find changing someone's diet, simple things like taking them off gluten and dairy, will make a profound difference in people's quality of life. A good probiotic, simple things like that. But you have to look carefully and take this person as an individual and it takes a lot more time to do this kind of interview, identify the issues and bore into them. So, a typical appointment in a functional medicine practice, the first appointment, is almost always minimum an hour and a half. Follow-up appointments are often an hour.

    Often hormonal imbalances are missed. Thyroid, what's considered subclinical thyroid disorders are often missed. Estrogen deficiencies in post menopausal women are something that has a profound effect on women's sense of well-being, their intellectual capacity, their mood, their energy, et cetera, their sleep, so many factors. So, hormonal issues are often overlooked. And correcting a thyroid problem or an estrogen deficiency or progesterone deficiency can have a profound effect on someone's sleep, sense of well-being, energy and mood.

Christopher:    Right. I know absolutely what you're talking about. We've talked about these issues many times before on the podcast. I'm starting to realize there's no connection between the type of credentials that you have and your ability to solve the types of problems that you've just described. In the beginning many years ago I thought that medical doctors were the only types of doctors that were worth your time and then when those people failed me so badly with the types of problems you just described there it was actually a chiropractor doing functional medicine that fixed me.

Ann:    Sure, absolutely.

Christopher:    And then I sort of swung full circle. And now I realize it really doesn't mean anything. Like you could have a conventional medical doctor that's doing really good functional medicine or you could have an acupuncturist doing something that's not very helpful which really the credentials almost don't mean anything at all. And so it makes me really interested how did you find functional medicine? Did you transition straight into IFM? Were they immediately your people or did you find something before them?

[0:05:02]

Ann:    No. I went on a long search in the early to mid '90s trying to look for better answers. I actually went to conferences and participated in many different organizations. The American Academy for Environmental Medicine was an important organization for me back then. I hadn't heard of IFM yet. I think it was still small at that point. But when did finally go to IFM, the first lecture I ever heard by Jeff Bland, he talked about liver detoxification all day. And I did not understand more than half of what he was saying but I knew that it was very important and that I needed to dig in here and figure out what the heck he was talking about because I knew it would be helpful to myself. I mean, I went searching for answers because of friends and family and my own health issues that just were not solved by conventional medicine pills or tests. They just didn't give any successful answers.

Christopher:    Right, of course.

Ann:    Yeah. Acupuncture helped me at one point and chiropractic helped me at one point. My brother who was seeing conventional doctors ended up getting diagnosed with celiac disease by his chiropractor after three conventional doctors missed it. So, I agree with you that it doesn't really matter what the degree is. It's just someone who's willing to take the time and the energy and the interest to dig in and really look for the real solutions.

Christopher:    Absolutely. And to fill people in listening to this, we, so I say we, Tommy  and me, were at the Buck Institute for Research on Aging recently for Dr. Dale Bredesen's training on reversing Alzheimer's and Ann was one of the doctors who was presenting on stage. I have to say the first thing I noticed was your striking stage presence. You look absolutely fantastic.

    And it's something else I've always wondered about with doctors. You've got so much knowledge and you're clearly not lacking discipline. Anybody that can get through a medical residency is not lacking in discipline or motivation, right? And so if you combine those two things, surely every doctor would look fantastic and you absolutely meet that bill. But I'm not sure that every doctor does.

Ann:    Well, thank you very much. That's not what I see when I look in the mirror but I appreciate your feedback on that.

Christopher:    So, Ann was presenting on the role of estradiol in cognition and Alzheimer's disease. I think this is a really important topic and it's why I wanted to get you on to the podcast and talk about this specifically. But before we get into that, I really wanted to ask you about whether you have any general principles that you adhere to when addressing hormonal imbalances? Because I know that there can be some problems with, say, traditional endocrinology where they may not even be doing a test and just prescribing a drug that will leave a block or replace a hormone. So, I'm just wondering, do you have any thoughts on that or any specific principle that you adhere to before starting?

Ann:    The main principle is pay attention to the patient, what their symptoms are, what they're telling you they're experiencing, and their physical exam. Because you can't just look at the numbers and say, "Well, hey, you're in the normal range for your age and your gender and so, therefore, you're fine." We look at the numbers. Certainly, biomarkers are very important. In functional medicine, we tend to look at massive amounts of data in terms of biomarkers much more than is typically looked at in conventional medicine. But you don't hold those numbers up as gospel. You need to address and take into account what the patient is telling you. So, that's my basic guiding principle.

Christopher:    Excellent. And then tell me about your understanding of root causes. So, I'm a computer guy and I love understanding mechanisms and what might be causing a problem. Do you think the functional medicine model sufficiently elucidates those mechanisms and uncovers the causes?

Ann:    Well, that's a really huge question. Functional medicine provides a framework for looking at things but I don't think it necessarily incorporates every single aspect of every single problem.

Christopher:    Let me be more specific. So, you make this claim that estradiol improves cognition. Let's just say that's true. My initial question is: Is a woman deficient in estradiol for a reason and maybe that is the reason that needs to be addressed and not just medicating with estradiol?

[0:10:05]

Ann:    Yeah. That point is often made and many women come to menopause with the understanding, they've sort of made the decision on their own mind, "Well, I'm not going to take hormones. That's not natural. I'm going to just do this the natural way." But then they get to menopause, and this is not everyone, this is only some, they get to menopause and they tank. They can't think the way they used to. For example, a CEO or a woman who functions at a very high level doing a lot of delegating, prioritizing, holding a lot of things in the area once juggling and managing, and all of a sudden her brain is fuzzy and she can't do that.

    And when we measure her estradiol level, it's almost always very low, well below 20. A typical women, as she's cycling, a pre-menopausal woman, in the reproductive part of her life, her estradiol level will average somewhere in the 200s. It varies through the cycle. But when your estradiol level drops precipitously to the low 20s, all of a sudden you can have a profound difference in your brain function, in your mood, in your energy. All of those things can change dramatically.

    And when that happens, if that happens to an individual woman, she needs to correct it so that she can just live her life. So, the idea that menopause is a natural process, it's a natural part of life, sure, you can make that argument. But you have to realize that humans evolved over millions of years to live 35 to 40 years. That was the average lifespan for the majority of our evolution.

    Now, women are living to 90. So, they're living approximately half their life without estrogen and without ovarian function. Their testosterone drops precipitously, they have no progesterone, and they have a very low estrogen in many cases. Now, there are some women who, at the time of menopause, do maintain an estradiol level in the range of 40 without any supplementation. Why do some women do that? We don't know. It's hard to pinpoint what the factors are.

    But for those women, they're fine. They don't need estradiol replacement. But for those women whose estradiol level drops to well below 20, and I see estradiol levels all the time of two or four or six, it results in a profound change. Why is there such a change? Well, our brain is full of estradiol receptors. And in particular, parts of the brain that have to do with memory and executive function are very rich in estradiol receptors. So, estradiol receptors maintain the density of neurons in multiple areas of the brain. And the density of the synaptic connections and the density of the support system, the microglia, that is all maintained by estradiol.

    All of the neurotransmitter systems are favorably impacted by estradiol. Acetylcholine, which is the neurotransmitter most associated with memory, serotonin, norepinephrine, dopamine, all of those systems are enhanced by estradiol. So, there is a tremendous amount of basic science that demonstrates and supports the effect that estradiol has on the human female brain. And there's also documentation, excellent documentation in a Stanford study that shows that when you take an approximately 60-year old woman who's been on estradiol for an average of ten years, when you take her off, areas of the brain rapidly deteriorate over a two-year period.

    And those areas of the brain that deteriorate are the areas that are specifically associated with deterioration in Alzheimer's disease. So, there is strong evidence in that study that estradiol could and would prevent Alzheimer's disease in many, many women.

[0:15:12]

Christopher:    Right. And do you think that women are particularly susceptible to the disease?

Ann:    There is an increased risk for women to have Alzheimer's disease. Of course, more women are alive at age 85 than men proportionately. However, the odds ratio for women to develop Alzheimer's disease is 1.56. In other words, for every one man who gets Alzheimer's disease, one and a half women get Alzheimer's disease.

Christopher:    That's quite a big difference.

Ann:    68% of those living with Alzheimer's disease right now are women. Yeah. Over age 71, 16 of every 100 women have Alzheimer's disease and 11 of every 100 men have Alzheimer's disease.

Christopher:    Okay. And so, talk to me about hormone replacement then. Is it just as simple as replacing the missing estradiol?

Ann:    No. You do have to always balance estradiol and progesterone. Some women also need testosterone. Some women need DHEA. And some women need pregnenolone. So, it's good to look at all, to measure all these hormones and to specifically evaluate how they're doing once you're replaced. It's important when you give estrogen that you always also give progesterone unless the woman does not have a uterus. Because estradiol will grow the uterine lining and progesterone will reverse that growth.

    If you don't reverse the growth of the uterine lining, you can develop excessive growth of that uterine lining and over time that can turn into endometrial hyperplasia which can turn into uterine cancer. So, you always want to balance your progesterone with your estrogen. Progesterone is a benefit to many women also because it improves sleep. Because of progesterone's effect in the brain, it stimulates the GABA receptors, which are the most calming and sedating of the brain receptors. Progesterone can help most women to have deeper, longer and more restful sleep.

Christopher:    And talk to me about the testing that you do. So, you mentioned some reference ranges there. Is it just blood that you're testing?

Ann:    I do blood, yes.

Christopher:    Okay.

Ann:    There's debate about what kind of testing is the most effective but in the medical literature the reports are all blood, reports of blood levels. And so I do use blood levels and I find them quite useful. Estrogen, progesterone, testosterone, DHEA. The only urine testing I use, and we may want to go into this later, is when I'm assessing for breast cancer risk. I do what's called the estrogen metabolites on a urine sample.

    Because when estradiol is broken down, both estradiol and estrone, by the way, because etradiol and estrone do interconvert, the post menopausal woman does tend to continue to make some estrone via an adrenal source after her ovaries are no longer functioning. And so you do always want to measure both estradiol and estrone. We never give estrone because it's a less favorable estrogen and generally we're trying to push that estrone down as far as we can and get the estradiol up.

    But the urine testing that I use, to get back to that question, is the metabolites of estradiol. So, estradiol is broken down via multiple pathways, 2-hydroxy, 16-hydroxy and 4-hdroxy. The 2-hydroxy pathway is very favorable pathway because 2-hydroxy converts into 2-methoxy and 2-methoxy is an anti proliferative agent. It's an anti cancer molecule.

Christopher:    So, that's the direction we want to go.

Ann:    So, that's the direction we want to go and we want to have less conversion into the 16-hdyroxy and the 4-hydroxy.

[0:20:00]

    The 4-hydroxy is the least favorable because the 4-hydroxy can convert to a molecule known as 3,4-quinone and 3,4-quinone can diffuse into the nucleus of the cell, bind to the DNA and form something called depurinating adducts which breaks the pieces of the DNA, purine sequences of the DNA, out of the molecule. And, of course, when you break DNA, that's never a good thing. That's by definition a mutation. And when you collect many mutations, of course, you increase the risk of cancer. In this case, we're thinking specifically about the effect in the breast and the increased risk of breast cancer.

    So, we're always trying to improve and increase the 2-hydroxy pathway to 2-methoxy and to decrease the other pathways. Some of the things that you can do to increase the 2-hydroxy pathway are eating a high cruciferous diet, taking a supplement called diindolylmethane or indole-3-carbinol, two closely related substances, and they are one of the active ingredients that's found in the cruciferous vegetables. Making sure that you have sufficient iodine also promotes that pathway to the 2-hydroxy. And high lignan flaxseed, the lignans in flaxseed also promote the enzyme that will convert estradiol into 2-hydroxyestradiol.

    Then the second step, converting the 2-hydroxy into the protective molecule 2-methoxy, that is accomplished by, that is promoted by the COMT enzyme, catechol-O-methyltransferase with methylating agents. So, you want to increase your methyl B-12, your methyl folate, trimethylglycine can be helpful, and to some degree B6 and B2 are also helpful in promoting that step. So, when we measure those and if we're not seeing the picture we like then we work hard to increase the activity by all those supplementation and dietary changes that I just mentioned.

Christopher:    And do you see genetic mutations that might be affecting these conversions?

Ann:    Yes. So, people do have, the enzyme that converts the estradiol into the 2-hydroxy, for example. That's cytochrome P450 1A1. People can have mutations in that that will downregulate it and so then you have to work harder. The next enzyme, catechol-O-methyltransferase, yes, that you can have mutations there that will slow the activity. But these are what we call single nucleotide polymorphisms that are found frequently in us humans and they do have an impact but their impact is not huge. And so the enzyme still has activity. It's just less activity so it is easily influenced by dietary and supplements.

    The enzyme that converts estradiol and estrone into the 4-hydroxy, that's a cytochrome 450 enzyme called 1B1 and that can be upregulated when there are mutations. And those are the kinds of mutations that are, of course, unfavorable because we want to decrease the activity of the 1B1 enzyme. That's harder to do. But it is important to know that xenoestrogens and other toxins will increase the activity of 1B1. Phthalates, organochlorines, many different toxins will increase the activity of that enzyme so you want to be careful about your food sources, eat organic, avoid GMO and stay away from things like car fumes, et cetera.

    When you avoid those things as much as possible, you can avoid some of the toxins that affect this. And then the other thing is pharmaceuticals are often processed by that cytochrome P450 1B1 enzyme. So, taking people off their pharmaceutical will often also decrease the activity of that cytochrome P450 1B1 enzyme.

[0:25:06]

    So, those are some of the things that you can do. Once you've made the 4-hydroxy from the cytochrome P450 1B1 -- And, of course, this is a lot easier to follow if you're looking at a diagram of it.

Christopher:    Yeah. I was going to say I should post the diagram in the show notes for this episode so that people can look at the diagram as you're -- That's what I'm doing right now. I'm looking at all of the pathways as Ann is speaking here. It's quite easy.

Ann:    Yeah. Once you're looking at the pathway, you can follow this. But otherwise, if you've never heard these terms before, it's just a bunch of letters and numbers and probably isn't very easy to follow. But I just was going to say once you've made the 4-hydroxy, that can still be converted to 4-methoxy, which is a safe molecule, by the COMT enzyme. And remember what we said does that, the methylation enzymes.

Christopher:    Right.

Ann:    Also, once you've made the 3,4-quinone, that's the really bad guy that can break your DNA, that can still be neutralized by glutathione. And if you're not familiar with glutathione, that's something to learn about because glutathione is a premier detoxifier and antioxidant made by every cell in our body. So, enhancing your glutathione is a way to do that. I typically enhance glutathione by using R-lipoic acid. That's my favorite antioxidant because it's fat soluble and water soluble and it will literally free up glutathione by taking the oxidant or the free radical or the toxicant off its hands and allowing the glutathione to be re-circulated.

Christopher:    That is interesting. Are you measuring glutathione status in any way?

Ann:    Yes, I am.

Christopher:    Can you explain?

Ann:    Well, there is a comprehensive nutritional evaluation that I do frequently. There's a couple different ones. There's something called the NutrEval that's available through Genova and there's also ION panel available through Genova and both of those will measure your blood glutathione level.

Christopher:    Okay. And then what do you do to -- So, you mentioned alpha lipoic acid there. Is there anything else that you do to improve glutathione status?

Ann:    Well, anything that you do that improves the antioxidant levels in the body. So, just something as simple as getting someone to eat a high vegetable diet with lots of different colors involved in the diet. That's like a fundamental principle of functional medicine really, eat a lot of vegetables and eat a big variety of vegetables. But after that, any antioxidant, anything that falls into the category of a polyphenol, a flavonoid is an enhancement here.

    But vitamin E, vitamin C, those kinds of classic antioxidants, making sure that you have sufficient quantities of those in your diet, or taking them as a supplement also enhance glutathione. But removing sources of toxicity from the body, of course, will enhance your glutathione level also. So, you have to think of it from both directions, helping enhance the glutathione level by the antioxidants and the diet and taking away the toxic load, pharmaceuticals, toxicity in your air, your water, your food, et cetera.

Christopher:    Tell me about some other things. Do you worry about personal care products and maybe makeup for women? Is that a problem that you see?

Ann:    Absolutely. I tell all women that they should check all their, any kind of cosmetic product, moisturizing cream, et cetera, on the Environmental Working Group's site. Anyone who's not familiar with the Environmental Working Group, it's a fantastic organization that rates products both in terms of their effect on the environment and on their safety for human use. And they will provide a number from zero to ten, I think, is the worst, for your product. I think we should all be very, very careful because anything that you're putting on your skin really you should think of it as the same as eating it. Would you be willing to eat this product? If not, it's probably not safe to put on your skin.

Christopher:    That's a really good advice. Okay. To take a step back from the testing then, if the evidence is clear for the benefit of estradiol, why do you think that the therapy is not more utilized?

Ann:    Excellent question. We have a very large study, the Women's Health Initiative Study, the results were published in 2002.

[0:30:05]

    And in that study, 16,000 women were given estrogen and a progestin. The estrogen that was given was an oral horse estrogen called Premarin. It was combined with a synthetic progesterone called pedroxyprogesterone, trade name Provera, and that was given as a combination pill to 16,000 women. And the important thing to realize is that the exact details of a molecule are extremely important in its impact.

    If you take a molecule like morphine and a molecule like naltrexone, just as an example, those molecules are almost identical, very slight changes, but morphine decreases pain and naltrexone blocks the morphine. It has the exact opposite effect. And the differences between estradiol and premarin, which come from pregnant mare's urine, are profound. They're very, very different. And so when you do a study on premarin and then you say that that applies to all estrogens including human bioidentical estradiol you really create important false impression and a very important mistake is made in equating those two things.

    Same with bioidentical progesterone. And what they used in this study, medroxyprogesterone. Medroxyprogesterone is a very different molecule in its biochemical formula and its effect on the human female body and brain. So, when they use premarin and provera in this large study, they got very bad results. Women had an increase in breast cancer, heart attacks, strokes and blood clots. They did have a decrease in colon cancer and fractures.

    But the unfortunate thing is that that study's results are being used to say that post-menopausal estrogen and progesterone replacement is unfavorable for women. The reason why that study is so powerful is that it was so huge. There were probably 40 different medical centers, medical schools and medical institutions involved in that study, billions of dollars had been spent on that study and on studying the results subsequently. And, unfortunately, it has been transferred to estradiol and progesterone in general are a negative.

    So, they showed in that study using those things in women over 65, premarin and provera, that there was a decrease in cognition and increased risk of Alzheimer's disease. And in studies that use estradiol topically, estradiol should only be used on the skin topically because oral estradiol is unfavorable. Any kind of oral estradiol increases inflammation in the body in various ways and increases blood clotting. But when you put estradiol in the skin you get an extremely different result.

    Cognitively, you get protection. Cardiovascularly, you get protection.  And you still get the protection in the bone strength. You get an improvement in mood. There are many studies and Whitney Wharton does a very good review paper, which you could post the reference to this.

Christopher:    Yes, of course. If Ann mentions a thing, a noun or a study, whatever it is, it will be linked in the show notes. I'll make sure it's all there.

Ann:    Right. But in Whitney Wharton's review, she showed that there were a very large number -- Let me see what the exact number was here. With estradiol, 15 of 20 studies show cognitive benefit. None show harm of any kind. In studies with benefit, when they used estradiol, topical estradiol only, then 15 of 16 studies showed cognitive benefit.

[0:35:03]

    In comparison to that, if you use estrone, conjugated equine estrogen, which is what premarin is primarily, estrone, and the other name for premarin is conjugated equine estrogen. I know the vocabulary here can be quite challenging when you're not used to it. But the premarin studies, let's say, the conjugated equine estrogen studies, three show harm and all the studies that showed harm were the WHI related studies. With just premarin, seven of 14 studies show benefit. Why are the WHI studies so much worse even than all the just baseline conjugated equine estrogen premarin studies?

    Well, we think that's because all the women in the WHI studies who were in the cognitive study were over 65. So, when you take a woman who's been off estrogen for 15 years and then you put her on oral estrogen, which increases C-reactive protein and fibrinogen, those two things increase inflammation in the arteries and increase blood clotting. You're going to have the potential for cerebrovascular negative impact.

    So, in comparison to that, transdermal estradiol does not increase C-reactive protein, does not increase fibrinogen, and is of benefit and of ongoing benefit in women who have been on it continuously for ten years, and it's quite possible, evidence is fairly strong, that if you started a woman even in her 60s on transdermal estradiol that you will get benefit. There's even two studies that show women who have Alzheimer's disease benefiting from transdermal estradiol having increased cognitive testing results and reports by their caretakers that they improved significantly.

    So, the Women's Health Initiative study has set us back quite a ways. It did provide some important information about premarin and provera given orally in combination. But it's made it very difficult for people to even study estradiol now because the starting assumption is that estrogen replacement is harmful to post menopausal women. So, even to get a study approved through the ethics and human safety committees, there are big issues now with it. So, it's creating a lot of difficulty.

    There's only one study that looks at topical estradiol in the form of an estradiol patch and bioidentical progesterone in post menopausal women and in that study there was no increase in breast cancer and no increase in dementia. That study was 730 women. But the WHI study was 16,000 women. So, there seems to be some kind of--

Christopher:    Power struggle.

Ann:    It's very difficult for a study with 700 women to override a study with 16,000 women. It's just the way statistical analysis works and the way that the United States Preventative Health Services and other entities that provide guidance to all physicians, they take the huge data sets as being very important and they take smaller data sets, even from my point of view being outside of real logic, but that's what's prioritized, the large data sets.

Christopher:    How do you think this could have happened? Because I know that you can make very small changes to a molecule and have completely different impacts on biology. And even when you got the unexpected results, even when the results of the WHI came back and they were negative, surely someone must have said, "Hey, you're studying the wrong molecule. Maybe we should have used a bioidentical." Why did that happen?

Ann:    So, the reason why they made the choice to use what they used in the WHI study is because that's what physicians were prescribing in the United States and most European countries from the mid '60s until 2000s. That's what was being used. That was the replacement.

[0:40:05]

    And one thing that did happen after that study came out is the pharmaceutical companies, they got it and guess what they did? They started producing bioidentical estradiol in the form of gels and creams and sprays and patches. So, we have many, many products now available that kind of give the lie to the conclusions that are being made.

    But if you pick up a package of estradiol patches completely bioidentical, transdermal patch and you open up the product literature for that and you read the warnings in the top box of that, it will be very terrifying. I've had patients call me when they open up their packages and they read those warnings. It's like, "Wait, they're saying a lot of scary things here about this estrogen patch that you prescribed for me, that it's going to give me breast cancer and it's going to cause blood clots and strokes. What's up with this?"

    That's because of the WHI study's impact and the power of those big numbers and those billions of dollars that had been spent on that study and the litiginous climate that we live in. They feel that they have to give that warning and the US Preventative Health Services feel that they have to give that warning because it's in the way medicine is practiced now defensively. You have to give the worst case scenario. The possibility exists in the general consciousness that estradiol might be just as bad as premarin and bioidentical progesterone might be just as bad as medroxy provera.

    Until we do a study with 16,000 women that shows that these things are different and better, we have to assume that they might be just as bad and proceed from that point of view. It's a defensive worst case scenario way of looking at it. Unfortunately, the negative result of that is that women do not have available to them the information and the understanding and the awareness that comes from 40 years of basic science research and tremendous amount of smaller studies in clinical research that document the benefits of bioidentical topical estradiol and bioidentical progesterone.

    In terms of prevention of cardiovascular disease and prevention of dementia, it's quite profound yet it's hidden. It's off the radar. And this is why I speak about this because I really think it's of major importance to -- I think women should be able to hear this, get the information and make their own decision. But that's not happening now. This information is not in the general consciousness. People are not aware of it. When I give my patients access to this information, they're astounded.

Christopher:    As I was as I sat in the audience listening to you present at the Buck Institute.

Ann:    Yeah. I don't know what to say. I mean, it's a passion of mine. My mother died of Alzheimer's disease and I had her on hormones until she was 78 and then she didn't want to put that cream on anymore. And I didn't really know how important it was at that time and three, four years later, she had significant cognitive loss. So, it's an area that is of personal significance to me and when I talk to a woman whose mother had Alzheimer's disease or who carries the APOE4 gene, that higher risk gene, or has a history of major depression, all those things increase risk of Alzheimer's disease. And, I think, that women deserve to have access to this information. And right now, they don't.

Christopher:    Right. I know you can't practice medicine over the internet but is it possible for you to educate a woman right now, say, she discovers that she's not taking or she's taking something other than transdermal estradiol? What can that woman do? Can she grab some of the references from the show notes and go to her doctor? What would you think would be the best thing to do?

Ann:    I think most gynecologists, if you request, say they have you on oral estradiol, some gynecologists, for reasons that I can't understand, are still using oral estradiol or even occasionally premarin.

[0:45:01]

    And so I think if you just ask to be switched to a commercially available product such as there is a product called EstroGel or there's many versions of that patch, the estradiol patch, those are both topical, bioidentical estrogens. And there's Vivelle, there's Minivelle, there's Climara, there's many different patches. I think most women would be able -- If your gynecologist refuses that, then I would look for another gynecologist.

    Because it's a completely accepted and available therapy. The problem you run into though is if you're somewhere in the range of 62 to 65 to 68. They typically will want to take you off. And that's another area where I strongly disagree. If you want to argue that point, you can look at the study by Natalie Rasgon. Take that study to your gynecologist and say you really think this is an important study and you want to continue on estradiol, and progesterone if you have a uterus, on into your 60s and 70s because you see that this study shows that there is very rapid deterioration of the brain when women are taken off estradiol. That's Natalie Rasgon at Stanford. That reference is in the slide show. You can post that, Chris.

Christopher:    Okay. Yes, of course, I will.

Ann:    Yeah, yeah.

Christopher:    And where can people find you online? Is your practice open at the moment?

Ann:    I have a website. It's just annhathawaymd.com. And we are taking patients, yes, however, I believe my assistant told me we're scheduling new patients for April. So, we are busy.

Christopher:    Yeah, I'm sure.

Ann:    There is somewhat of a wait, I'm sorry to say. I wish there were three of me so that there wasn't a wait. But this is the reality now.

Christopher:    Okay. And do people have to come and see you in person before you can prescribe?

Ann:    Yes.

Christopher:    Okay. And remind us where you are?

Ann:    I'm in California, just north of San Francisco, in San Rafael.

Christopher:    Okay, yes, of course. Excellent. Well, this has been really, really helpful. I think you're doing an amazing job in educating both doctors and the lay public like me. And so I'm extremely grateful for you. Of course, this is definitely going to be an episode you're going to have to come to the show notes to get all of the details. I will link to that. I will send out an email with the link to the show notes as well as you'll find it inside of the app that you're using. So, if you're using Overcast, if you look on the details for this episode, you'll see that the show note is linked in there also. Ann, this has been fantastic. Thank you so much for your help. I really, really appreciate you.

Ann:    Thank you, Chris. I really enjoyed talking to you and as you can tell I'm very, very happy to get this message out because it's a really neglected area. So, thank you so much.

Christopher:    Yeah, absolutely. Thank you.

Ann:    All right. Take care. Bye.

Christopher:    Thank you. Bye.

[0:48:13]    End of Audio

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