Optimizing Women’s Hormone Balance with Shawn Tassone, M.D.

Content By: Ari Whitten & Dr. Shawn Tassone

In this episode, I am speaking with Shawn Tassone, MD – who is board certified in obstetrics and gynecology and holds a Ph.D. in mind-body medicine. He is has helped more than 40,000 women balancing their hormones and improve their health using integrative medicine. We will talk about the SHINE method, and how to use it to balance your hormones

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Ari: Hey there, welcome back to the Energy Blueprint podcast. With me today is Dr. Shawn Tassone who is an MD and PhD, he’s known as America’s holistic gynecologist. He’s the first physician in the US to be double board certified in obstetrics and gynecology and by the American Board of Integrative Medicine. He holds a medical degree in addition to a PhD in mind-body medicine. He’s a practicing OBGYN in Austin Texas, hormone specialist, author, speaker, highly-rated patient advocate, and creator of the world’s first Integrated Hormonal Mapping System. In his 20 years of practice, he’s seen over 40,000 women, and he’s determined to remove the myths surrounding women’s health.

As an integrative health practitioner, he believes that you should have an active role in your care. His work includes studies and publications on hormonal imbalances, spirituality and medical care, whole foods to heal the human body, and integrated medicine. He’s featured in many publications including New York Times, NBC News online, Stanford Med X, and his new book The Hormone Balance Bible published by HarperCollins which was published just a couple months ago. Right, Shawn?

Dr. Tassone: Yes, July.

Ari: Okay. Awesome. Welcome to the show. Welcome back for round number two.

Dr. Tassone: Hey, thanks. Nice to talk to you again.

Ari: Yes. Let’s talk about just overarching your approach to women’s health as a holistic OBGYN, and how does it differ from let’s say standard mainstream thinking, or maybe also contrast it to maybe alternative approaches, or wherever you want to take them.

Dr. Tassone: It’s an interesting place that I’ve wound up in 20 years of practice. I think the integrative approach that I take, that I espouse if you will, so like today I did five surgeries and I used the robot, so I’ll do robotic surgeries. I use the allopathic model, and the things that are there because sometimes you have to have surgery, but I also will recommend that women have yarrow flower in their medicine cabinet to help if they have heavy periods, or I’ll use CBD oil or other things.

As you’re aware you’re constantly learning new things and what works and what doesn’t work, but I think for me, it’s just been this evolution of my own personal being that has allowed me to just be more open to different therapies. That has translated into patients too. You know what I mean? A lot of patients now are coming with labs drawn from somewhere else, and stool tests and all these things. I’m trying to learn as I go, and so it’s been a great thing. I think patient empowerment is huge for me. I prefer the model where the patient is more active and the doctor is more passive, but in some instances, it’s more beneficial for me to be more active like when people need surgical intervention.

I just have one foot in each of the camps.

Ari: Well, actually I need to ask you, did you say that you’ve already done five surgeries so far today?

Dr. Tassone: Yes.

Ari: Damn, you’re a busy man. It’s only noon my time. [chuckles]

Dr. Tassone: It’s two o’clock here.

Ari: All I’ve done is [crosstalk]–

Dr. Tassone: We flip flop rooms, and I start real early.

Ari: Nice. Well, in contrast, all I’ve done so far today is surf for two and a half hours. We’ve had a bit different mornings.

Dr. Tassone: I don’t know if you’re rubbing it in or what that is, but [inaudible 00:04:02] [crosstalk]–

Ari: Well, you’re helping people and making a good living. While I’m just being a beach bum. [chuckles]

Dr. Tassone: Well, if you move out to Austin, as we were chatting, maybe we can just hang out. There’s no beaches here though.

Ari: Yes. Well, you do have some good lakes.

Dr. Tassone: We do.

Ari: Yes. Now I’m remembering as you’re mentioning surgeries that didn’t you pioneer some unique surgery? I’m forgetting the term for it. I want to say laparoscopy or I’m probably getting it wrong but what was it?

Dr. Tassone: Yes, there’s a medical device that was out on the market starting in 2002 called Essure which it was a permanent sterilization device. A metallic coil that we would put into the fallopian tubes through the vagina and uterus. The problem is the way that they worked was they would cause inflammation and the body would granulate that coil inside the tube, and it was supposed to be permanent. The problem is there was no way to remove it. A lot of women were having hysterectomies to have these things removed in their 20s because they were having reactions.

I just came up with a way where we could remove the tubes with the coils still inside the tube and not have to remove the uterus, and probably had done around 1,000 of those.

Ari: Wow. That’s awesome. Well done.

Dr. Tassone: Thanks.

Ari: Saving many women’s uteruses, uteri. What’s the plural of uterus?

Dr. Tassone: You can do both. You can do either.

The most common causes of hormone imbalance in women

Ari: Okay, nice. Your new book is The Hormone Balance Bible. Let’s talk about why there’s even a need for that. What is going on that is causing women’s hormones to be out of balance, and what specifically, what hormones are getting out of balance?

Dr. Tassone: I mean what I was seeing in my practice the last 15 years, it’s probably been going on much longer than that, is that a lot of women will start to say things like, “I’m tired all the time. I’m gaining weight. I have headaches. I’m having heavy irregular periods. I don’t feel like doing the things I used to like to do,” and they’ll get their labs checked, and they’re told 95% of the time, “Oh, your labs are normal. You’re just getting older.” We don’t tell men that, but we tell women that all the time, and it’s true. A lot of them did have normal labs, but their labs were normal at the bottom of normal. I likened it to you’re in the house, but you’re laying on the floor in the basement.

Well, it might feel better to be on the main floor, and so I was treating these subclinical things, thyroid, testosterone. Testosterone is completely ignored in the medical community by most physicians in women. I found what I was doing was I was hearing all these stories, and what I did was I started noticing some trends, and I’m a very narrative person, I like stories, I like to tell stories. I think some of our disease processes tell a story. What I was noticing like women that had low testosterone, they were all telling me the same stories. At the time, I was reading a lot of Caroline Myss and I was reading Sally Hogshead’s book on How to Fascinate, and they talked a lot about archetypes.

What I found was that this archetypal language when I would talk to a patient with low testosterone and I would relate it to this archetype of the nun, the N-U-N, it was resonating.

Women were like, “Oh my God, that’s the first time somebody’s told me a story that actually, that’s me, that’s my life.” It was funny because it wasn’t me, and I have women all the time thank me so much. It’s like, “Look, I just got lucky enough to be able to listen to all these stories over the last 20 years, and I just have the ability to put them into a book.”

Then, the other part of the book is my six-step process called the SHINE protocol that each of the 12 imbalances has a spiritual practice, hormones, infoceuticals, which is more like energetic medicine, so acupuncture, essential oils. I’m sure you’re friends with Harry Massey, but some of his type of energetic medicine, nutrition, exercise, and proper supplementation, and that’s what the book came out to be.

Ari: Nice. What are some of the most common hormone imbalances that you find most? Is it possible to say that most women are suffering from a particular one or two or three hormonal imbalances or is it just totally diverse, every woman is different?

Dr. Tassone: Here’s the rub, there’s a lot of my colleagues on Instagram and Twitter that will say hormone imbalances don’t exist, it’s quackery. Look, we know hormone imbalances exist. We have diagnosis codes for them that I can bill for. I don’t know why they’re taking that approach, but I think what they mean is there are certain times in a woman’s life when hormone imbalance is normal. Puberty, menopause, pregnancy, sometimes part of the menstrual cycle it’s imbalanced, and that’s normal. When I like to get involved is when the hormone imbalance is interfering with the way that you want to live your life.

That’s one of the questions I always ask, is this interfering with how you want to live your life, and if it is, then that’s not normal to me. I think we should fix that. The top three things that I would say in my practice that I see, and I have a quiz online I’ve probably had 30,000 women take, and it goes along with that, number one, testosterone deficiency across the board, all age groups, number one. Number two, estrogen dominance or too much estrogen in relationship to progesterone. Then, three, hypothyroidism or what I would call subclinical hypothyroidism, that woman who is at the low end of normal, but she’s having all the symptoms of low thyroid, like hair thinning, weight gain, fatigue, brain fog, and things like that.

Ari: I have to say, I find it baffling that anyone would try to deny that hormone imbalances are a thing.

Dr. Tassone: They’re just getting stuck on that semantics. It’s the same six or seven doctors, and weirdly enough, they’re all women. I think it’s horribly misogynistic to tell a patient that their symptoms, whatever it is, aren’t real. I’m not you. It’s funny because I can’t imagine telling a woman that her periods aren’t that bad or that they’re normal because I don’t have them. I just believe what they tell me, and I’ve always been that way. I think they’re just getting caught in the semantics. They’re very anti-alternative therapies and so this just falls into that. You know how it is in the foot that I have in the alternative world, there are folks out there, unfortunately, that do some weird stuff.

I don’t think it’s harming people, it’s just not understood, like applied kinesiology that we’ve talked about before and things like that. I may not agree with some of the stuff, but I don’t chastise those people because there are people that do find help, they get better. I can’t explain it, but if it works, worst-case scenario, it may lighten your wallet a little bit, but these docs go on a crusade. A friend of mine, I’m sure you know Dr. Will Cole, he wrote a book about intuitive fasting and these folks just decimated him. They rallied their followers to go leave bad reviews on Amazon. Poor guy had like 21 star reviews before the book even came out. It doesn’t make sense to me, but there is a lot of that going on.

Ari: There’s two extremes. There’s the one extreme of people who are actually doing really wacky stuff that’s just total pseudoscience, and then the other extreme of the evidence-based internet trolls. Oftentimes, it’s the doctors who want to say that everything except what they do in the status quo mainstream is by definition [unintelligible 00:12:27] because if it had any evidence to support it, it would be conventional medicine.

Dr. Tassone: Oh, you’re really good. You’re really good about publishing studies and stuff when you make comments, but I mean, even when you do that about COVID and whatnot, you’re going to get people that don’t agree with you. It’s just fine. I think it’s great to disagree, but to just rip people to shreds makes no sense to me. Usually, it’s glomming onto one study and you know how that is. You can find any study to promote your ideas. I think we’ve just gotten so divisive on everything and medicine is a social construct that just follows along with societal evolution I think and so we’re struggling in medicine too.

How testosterone deficiency affect women

Ari: Well said. There’s these three hormonal imbalances, you said testosterone deficiency is really common, which is interesting by itself. I want to circle back to that because I find among a lot of our mutual friends who are in your niche, I think you’re one of very few that seems to be talking about that. A lot of others will focus much more on estrogen dominance and progesterone, and almost never even seem to mention testosterone, which is interesting. Then, you said estrogen dominance and subclinical or clinical hypothyroidism. Let’s talk about the testosterone deficiency aspect. What do you think is contributing to that? I know you mentioned earlier, there’s this nun archetype.

Maybe you can explain that as well and talk about what kinds of dynamics are at play there.

Dr. Tassone: A lot of the symptoms will overlap and could be a lot of different things, but they do cluster together. For the nun archetype, we’re looking at things like decreased libido. Decreased libido is what I call the plague of the 21st century. A lot of women have it. They don’t talk about it. It’s not just testosterone obviously. It’s relationships and stress and body image and things like that. Chronic fatigue, especially around 4:00 or 5:00 in the afternoon. A lot of women will talk about they need to take a nap in the afternoons and they don’t know why. Bone loss, sleep issues, depression, anxiety. I’ve often said, if testosterone deficiency was a t-shirt, it would just say, “Meh.” You just don’t care.

You don’t care about the stuff you used to like to care about like you’re going surfing and maybe your wife likes to surf and she’s just like, “Yes, I don’t really want to go.” You just don’t feel that oomph, that zest, and that translates into decreased libido, which a lot of women will come in for decreased libido because it’s a very common problem. Men, unfortunately, every guy practically now in America is on testosterone because there’s a testosterone clinic on every corner.

We’ve got these guys all juiced up and yet we’re not helping the women, so it makes that discord even bigger. You’ve got the guy in super sex drive and then you’ve got the woman that is probably normal, she just doesn’t feel like having sex all the time. It makes it come more to the forefront. As far as other people not really talking about it, testosterone has a bad rap. I think that the bodybuilders screwed things up for it. Then, it’s a controlled substance, on par with Percocet and hydrocodone and all that stuff, so it’s hard to prescribe. I think a lot of these folks, like the coaches and whatnot, they don’t prescribe anyway. They stay more with the supplements. There aren’t a lot of supplements that boost testosterone.

There’s a ton on the market that say they do, but do they really?

Ari: What do you do in that situation? What are some of the key therapies that you use for someone with testosterone deficiency?

Dr. Tassone: Well, as you talked about, you asked what’s some of the main causes? Number one would probably be obesity, which in this country is a problem because the more fat that a woman carries in her body, usually the higher her estrogen levels are and then that drives down her free testosterone levels, which is the active form. Birth control pills are a huge cause of low testosterone. How many women in this country take birth control? I’m not bashing birth control pills, I do prescribe them for birth control, but the problem is we have a lot of women that take birth controls because they’re having irregular periods or they’re perimenopausal.

That just takes an already low testosterone level and drives it down even lower. We’ve got a lot of neuroendocrine disruptors in the world. Different types of chemicals, these Essure coils like I was talking about, have polyethylene terephthalate and aluminum and nickel and all these things that can cause issues with the way the brain communicates with the ovaries. I think that there’s a lot of reason for it. I’m sorry that I answered your previous question and now I forgot your recent question.

Ari: What kind of strategies you’d use to address that testosterone deficiency?

Dr. Tassone: It depends. That six-step process I talked about. Nuns, this is how my SHINE protocol works, nun, when is being a nun a bad thing? Because it can be a good thing. Nuns are great, they’re intelligent, they’re dedicated, they like to research and do things, but when being a nun can be a problem for a layperson is when they’re cloistered. That’s what I talked about with the meh. You don’t want to go out. You don’t want to do anything. You want to stay in the house all the time. A spiritual practice that I usually recommend is I don’t care how or what, just get outside. Go for a walk. Get out in the sun. Maybe call a friend and go for a walk.

Hormones, obviously, a big one. A lot of times I will prescribe testosterone. You can do it topically, sublingual. There’s a lot of women on hormone pellets, which I’m not a fan of but that’s another method. Infoceutically-wise, there’s a lot of essential oils that I talk about. Our friend Mariza Snyder has got a great book that I refer to a lot for that, acupuncture can work. Nutrition. I have a great friend, I’m sure she’s your great friend too, Gabrielle Lyon, she’s a big proponent of weightlifting and nutrition. I talk to her a lot and I find, and you obviously are into this too, but increasing protein, women really underestimate the amount of protein they should be eating.

Then, good fats and staying away from processed foods, which we all harp on already. Exercise. Obviously, I think women need to do more weights. I’m sorry, but they’re blowing leaves outside. If that gets too loud, I’ll stop.

Ari: It’s fine. Don’t worry about it.

Dr. Tassone: We need more weightlifting. If women get daunted by that, you can hire, try a personal trainer. There’s so many places online you can get workouts now. Then, supplements. There are a few supplements, but they’re dangerous. Yohimbine is one, it can raise blood pressure. Then horny goat weed, or Tribulus, which they’re in a lot of studies to show they work but some people will get that feeling like it’s working. You can try that too.

Ari: I tried Yohimbine once maybe six or seven years ago, and I’m very sensitive to stimulants and I’ve never been on crack before, but it’s something like I imagine being on crack feels like.

Dr. Tassone: It’s quite stimulating and it works, but it makes your blood pressure go through the roof for a lot of folks.

Ari: Yes, I had high energy but extreme levels of anxiety. It was awful. I was like, “Okay, no more meth for me.” Then, the use of testosterone itself, in what scenario would you actually prescribe testosterone? Would it be a cream or something like that? What scenario might you just say let’s try the natural methods or, no, you have such an extreme testosterone deficiency that we need to get you on some kind of exogenous testosterone?

Dr. Tassone: I will usually layout possible options like I just did, and then I will give them a combo like, “You could do this, this, this.” The great thing about the six steps that I have, you can do all of them, you can do one of them. The only one you need me for is the hormonal part, but I would find most women that get to me are feeling so miserable that what I do is I usually will prescribe testosterone to give them that immediate within a couple of weeks like they feel better finally, and then going forward, I’ll try to integrate the nutrition, the exercise because you can tell somebody to go do weights, lift weights, eat right, but if they feel crappy already, who’s going to go do that?

I like to get them feeling better, and then a lot of women will say to me, “Yes, I use a topical cream or a sublingual. How long do I have to do it for?” Well, as your body changes, as your exercise routine changes, or your diet changes, your hormones are going to shift, but I always think this is really interesting to me. Women have this ability to think that if they’re using hormones or something like that that they’re cheating or that they should suffer. Men, we don’t do that. We’re just like, “We want to feel better.” Women sometimes, and I see this a lot, they’ll say this, “Well, how long do I have to take this?” I say, “Well, are you feeling good?” “Yes, I feel great.”

“Well, why don’t you just want to feel great for a while?” I always check hormones afterwards blood-wise to follow up because I want to make sure for a female that we’re keeping them in that normal range. I just like them to be up on the higher end of the normal range rather than down in the basement. Yes, I use creams mostly and sublinguals.

Ari: Got it. This is a bit of a technical question, but is there an issue with sublinguals as far as liver toxicity?

Dr. Tassone: I think it’s hard to know for sure, but there was a study that was done that shows that if you give a sublingual dose, about 20% of it gets swallowed. Yes, some of that is going to process through the liver. The other thing is we used to have on the market years ago, it still may be around and you probably know a lot about this just because men used to, not you, but men in general, used to use methyltestosterone. Methyltest is horrifying. It will literally crush the liver, and there was a product on the market years ago called Estratest, which was Premarin with methyltestosterone. Two of probably the worst medications known to man, and we gave them to women all the time.

I’m giving a bioidentical testosterone structurally but yes, still some of that dose is going to get processed through the liver, but in most cases, like in a woman that doesn’t have issues with her liver from being overweight or from alcohol or something like that, which is pretty rare, a dosage of testosterone sublingual isn’t going to probably make a big difference.

Ari: Got it. Is that something they would take every day, they pop a sublingual tablet every morning?

Dr. Tassone: Yes, either you do it in the morning or you put the cream on in the morning. The nice thing too about the sublinguals or the creams is I can put pretty much anything. I can put estradiol, I can put progesterone, testosterone, DHEA all in one cream. For a lot of women [crosstalk]–

Ari: You get it done at a compounding pharmacy where they mix according to your specification?

Dr. Tassone: Yes. The interesting thing about testosterone is there are about 10 FDA-approved testosterone replacements for men on the market. There are zero for women. It has to be compounded, and while the testosterone that’s used is FDA-approved, the compounding pharmacies themselves are not FDA-approved. The product is FDA-approved, but if you go to a reputable compounding pharmacy, I think they’re perfectly safe. It’s quite a dichotomy. The medications that we have for men versus women for this are basically night and day.

How Estrogen Dominance can affect women

For someone in night sweats, headaches, cramping, fibroids, endometriosis, thyroid issues if your estrogen’s too high, that brain fog, so it can feel just as bad as even menopause sometimes. Then there’s estrogens in the food supply. It’s a lot better I think now than it was in the past with hormones in beef and milk, and most people, I don’t recommend you drink milk anyways, but I think most of our beef has gotten cleaned up, but for those folks that can’t afford grass-fed or organic, they may still be getting a lot of Xenoestrogens in their food.

Ari: Got it. Is it more an issue of too much estrogen or is it a deficit of progesterone and is there a distinction as far as causes of those two things?

Dr. Tassone: That’s a good question. There’s both. Some women have a normal estrogen level. It’s in a decent level and they have hardly any progesterone. Technically still a little estrogen dominance, but it’s more of a lack of progesterone. Then, you can also have the double whammy where you have a super high level of estrogen and a low, low level of progesterone. The two archetypes I have, the estrogen dominant solo is called the queen because that’s obviously a woman in overdrive. That’s the consummate female hormone. Low progesterone, I call that the archetype of the unbalanced heroine because progesterone, for me, is super high when you’re pregnant.

It’s supposed to be, and that’s the consummate hero’s journey for a female, I believe, and so I called it the unbalanced heroine. Then if you have both, if you combine a queen with an unbalanced heroine, that archetype’s called the mother. A lot of moms are just suffering, they’re not sleeping. Progesterone deficiency, lack of sleep, a lot of anxiety during the day, gallbladder issues, headaches, and a lot of moms suffer from that.

Ari: I actually just referred you someone via email that has been suffering from chronic migraines and [inaudible 00:28:24] [crosstalk].

Dr. Tassone: The first thing I thought of was progesterone deficiency when you sent me that.

Ari: Yes, and our mutual friend Gabrielle Lyon, who you just brought up, also said the same and she recommended that I refer her to you.

Dr. Tassone: Because she knows how good I am [unintelligible 00:28:40].

Ari: [chuckles] That’s right.

Dr. Tassone: She’ll beat me up for saying that, but it’s fine.

Ari: [laughs] In the scenario of low progesterone, would you always pretty much use exogenous progesterone? Would you try nutrition lifestyle interventions first? What does that look like?

Dr. Tassone: When I talk to people, like we had that food pyramid, I have the hormone replacement pyramid where the bottom row that I think is the most important is nutrition. Nothing is going to get fixed if you have bad nutrition, obviously. I can give you a pill, but it’s not fixing the problem. On top of that would probably be exercise. I think that’s probably second, but hormones probably right above that, and the reason that I would give, in this individual, let’s say it was progesterone deficiency, I would probably start with progesterone right off the bat because I suffer from migraines. If I can get rid of people’s headaches, that would be the first thing I’d want to do.

Now, that also gives her a better quality of life pretty quickly because I will tell you, people that I talk to, myself included, when I feel bad like that, if I have a migraine, I don’t make good decisions. I eat poorly and I don’t want to work out because my head’s killing me. You can’t really do the things you need to do. To just get her feeling better can make a huge difference. Then yes, going forward, I’m sure she probably eats super good and works out anyways, but maybe she’s a mom, a young mom, and she’s not sleeping super great and that kicks off migraines, you also got to figure out what the triggers are because there’s food and there’s lack of sleep and stress and all kinds of things.

Ari: Actually, between the time I referred her to you and now, maybe this was just five or seven days ago, I found an interesting study that just popped up in my feed from someone I follow that was on female [unintelligible 00:30:53] who were put in through a resistance exercise training protocol and they showed an average of 60% reduction in the frequency of migraines just from lifting weights for I think it was eight weeks. I was like, “Wow, that’s quite a magnitude of an effect from just simple weightlifting.”

Dr. Tassone: Somebody that’s super motivated, that’s awesome. I will tell you, unfortunately, a lot of the women that I see, I think this is just populational in general, to tell somebody they have to lift weights for eight weeks to get migraine relief probably is going to go down like a lead balloon. If I can get them feeling better and tell them that, and then what I do is I’ll maybe wean them off the progesterone after a couple of months and see if their lifestyle changes have taken effect.

Ari: Got it. Just to delve into this specific case a little bit more. I know that maybe four years ago or something like that, she had seen someone who diagnosed her with progesterone deficiency and then put her on progesterone and she said it made her feel worse. I’m just curious, what would be your response to someone saying that and how would you troubleshoot that?

Dr. Tassone: It depends first what type of progesterone they put her on, if it was a progesterone or a progestin. Sometimes even if it’s bio-identical, they might cut it with peanut oil or something and some folks have problems with peanuts. That’s one thing. Some women that I talk to will indeed what happens with progesterone is it turns into allopregnanolone, upregulates GABA receptors in the brain. What happens is it helps you sleep because you stimulate those GABA receptors and you’re tired. A lot of women will just feel blah or flu-ish during the day even when they take 100 milligrams of progesterone. I just had a lady that that happened to, so what I was doing with her is slowly bringing her up.

Instead of starting with 100, I started with 25, and then we worked our way up. She tried progesterone like three times, we did it that way, I think it just gave her body more of an acclimation to the dosing. I got her up to 100 and she didn’t have any problems.

Ari: Nice. Very cool. Right after we finish recording this, I’ll forward her this podcast so she can hear that.

Dr. Tassone: We just talked to her today too, so-

Ari: Oh, great.

Dr. Tassone: -I’m on the case.

Hormone replacement therapy

Ari: [laughs] Good, I’m glad to hear that. What was I going to ask you next? Oh, menopause. I’ve had a couple of people on the podcast previously. It’s been, geez, probably two or three years since I did those episodes, but I had Christiane Northrup, who I’m sure you’re familiar with, and I had a more conventional-minded person named Dr. [unintelligible 00:34:01].

Dr. Tassone: I know [unintelligible 00:34:03], yes.

Ari: They had somewhat different takes on menopause. A big focus of those interviews was on a hormone replacement therapy for women as they go through menopause or after menopause. I know, not remembering all the details offhand, and please correct me if I’m misremembering something, but there were some big studies that were done. I think they were published around the year 2000 and they were with thousands of women on post-menopause hormonal replacement therapy, and there was some controversy around those studies. There’s been some divergence of thinking among experts in your field around the best approach to dealing with hormonal replacement therapy.

I’m just curious, what’s your take on that landscape? Who would you recommend hormone replacement for in the case of post-menopausal women? Do you have a preference as far as bio-identical or do you think that doesn’t matter?

Dr. Tassone: Whenever I do your podcasts, you’re the only person that makes me nervous because I never know what you’re going to ask and I know that you ask really deep questions and you know the literature, but luckily I know the answer. About 15 years ago, give or take, the Women’s Health Initiative, I think is what you’re talking about, came out. It was like 40,000 or 50,000 women, and it caused this major ruckus in women’s health because all they harped on from this study was that breast cancer is caused by estrogen and all of these women went off their hormones and felt horrible. It’s still lingering today. Here’s what it found.

There was a study that was done. There was an estrogen-only arm and there was an estrogen and progesterone arm. They used Premarin and they used Prempro, which was Premarin with medroxyprogesterone, which it’s not a progesterone, it’s a progestin, which is a little different. The estrogen and progestin arm had an increased risk of breast cancer and increased risk of deep venous thrombosis in the leg of about one in a thousand, so not super high. The estrogen-only arm, interestingly enough, did not have an increase in cancer, that arm was never in threat at all. It was the combination, but it was also combining two synthetic hormones, they weren’t bio-identical so I don’t know if it correlates at all.

Second, they forgot to mention or it never made it into the news that there was a 50% reduction in colon cancer rates with both arms, so it wasn’t necessarily bad. The information that they told us was already known, it was in the package insert. We already knew it, but nobody reads the package insert. The big point, though, was this study was done, I think the average age of the women involved was 63 or something like that, so these weren’t even women that were in their younger menopausal years, they had been around for a while.

When you have [crosstalk]–

Ari: There’s something to that. I remember there was some discussion. I forget whether it was Christiane Northrup or [unintelligible 00:37:23] that mentioned this, but there was something about whether the women went on to the hormone replacement therapy within a year or five years of going through menopause or if they went on after 10 years later. If there was a big gap in many years, then they were more likely to have adverse effects or cancer, or something like that.

Dr. Tassone: Yes. Basically, we found these women were 63 and above. Well, naturally women 63 and above have a higher rate of breast cancer anyways just based on age. What you’re referencing is a study that came out that showed women who start estrogen in particular, if they are more than 10 years out from menopause, so let’s say you go into menopause at 50, if you called in, you’re 61 years old and you’ve never, ever been on hormones. This doesn’t apply to a woman that maybe was taking them from 52 to 54 and then stopped them for five years. This has never, ever been on estrogen.

There was a study that showed women that have calcified plaques in their arteries, in their coronary vessels, when you give them estrogen brand new for the first time, you can soften those plaques and they can potentially break off and cause a heart attack. There was a slight risk of heart attack. That doesn’t apply to testosterone or progesterone. It was merely from the estrogen component. What I do is I just tell those patients, if they’re interested in looking at hormones, it’s like $75, $95, now you can go get one of those cardiac CTs that gives you a calcium score. Sure, if you have a lot of calcium, and I always talk to them about that anyways, the risk of that.

There’s a new study that’s currently at seven years that’s following women that just started hormone replacement therapy and they’re following them outward and there is absolutely no increased risk of breast cancer or heart disease in that population so far.

Ari: That’s great. Is that using bioidentical hormones or not?

Dr. Tassone: They are using, I believe, estradiol and bio-identical progesterone, yes.

Ari: Okay. To take all of that information and turn it very practical, let’s say you’re dealing with, I don’t know, a girlfriend or a wife of yours or something like that, and she’s going through menopause. She’s, let’s say, 50, 55 years old. She comes to you and she says, “What should I do? What do you recommend I do? I’m suffering these symptoms. I just went through menopause. Do you suggest that I go on hormone replacement therapy or not? Should I use bioidentical hormones or not?”

Dr. Tassone: I think one of the reasons that I have ended up where I am right now is, when I was a resident, my mom died of ovarian cancer, and part of that five-year journey, she was in her 50s or early-50s, they wouldn’t let her use estrogen because they were afraid that she would somehow stimulate these ovarian cancer cells. She had a miserable existence for the four or five years she was alive because she suffered and I don’t think it necessarily would’ve changed the outcome, but she might have had five more productive years. My current belief system is give people the information, you can take estrogen, you can take maca, you could try Vitex for progesterone. You can try all these different things.

There’s a lot of good books out there, like [unintelligible 00:41:07], and talk about the estrogen windows and things like that. Christiane Northrup obviously wrote Women’s Bodies, Women’s Wisdom. You have to make that decision for yourself. My thing is I wouldn’t give you something if it was at a severely increased risk, obviously, I don’t want to do that. I want to continue practicing medicine and it wouldn’t be good for the patient. Maybe I’m a little biased on the other side, but I have seen lives change from just giving small doses of hormones, and usually, most of my patients are low normal still. They’re still in the range for a female, but they’re on the low end.

We’re not hyperstimulating tissues, we’re just giving you your life back. For me, I think the risk of osteoporosis and coronary artery disease from not having the hormones is much higher than you having an issue from the hormones and I just think that’s super important. I have that discussion with patients and let them decide.

Ari: Got it. Do you take a more cautious attitude than some of your peers, meaning, do you maybe go with lower doses to start with than is common for some of your colleagues?

Dr. Tassone: I’m always surprised at the doses that the patients come in on what they’re on and I tend to go low and work up rather than go high on everybody. This is a lot of what the pellet companies talk about when they train these providers for a weekend on how to manage hormones. They like it to be on the high end. They literally will say, “You should get a woman’s total testosterone up to a hundred.” Well, normal for a woman is up to 54. You’re doubling the normal range. To me, that’s not good, but that’s what they promote. I had a long answer but I’m usually a little more on the cautious. I’m a minimalist. I believe in the smallest dose possible to get the best result.

Ari: Yes. A personal note, after my baby daughter was born, she just turned two by the way, but after she was born, she was maybe a few months old and I reached out to you because my wife’s thyroid levels were a bit low post postpartum and was having some hair loss issues. I had you look at her blood test results and you prescribed a thyroid medication for her. She ended up taking I think a third of the already small dose that you had recommended. She was taking a third of it and that fixed the hair loss issues and I think she had some not so much energy issues, but she had some maybe mood struggles or sleep struggles. I forget what else. I think hair loss was the main symptom.

Dr. Tassone: Hair loss is rampant. I can’t tell you how many women have a complaint of hair loss. It’s like 80% of my patients. It’s really common. The three hormones are thyroid, testosterone, and progesterone.

Ari: Yes. You identified that issue very quickly, you made that prescription. She took it for maybe three or four months and with very small dose and then weaned off and she’s been fine ever since.

Dr. Tassone: That’s probably most women that I see, you start low, you’re on it for a little while, and you wean. Your wife’s situation was a little bit different because hers was I think probably a little bit of a more transient phase because she is postpartum whereas somebody that’s in full-blown menopause, that’s probably not going to change. That just goes to show you, just because perimenopausal women 35 to 55, they’re the hardest ones to work with hormonally because they’re not just at zero, they’re going to have ups and downs, which are normal.

What I try to do is, I try to mellow the highs and bring up the lows so you’re not swinging like this because that’s where I think a lot of women have the issues is it’s just that turbulence, and to just have it maybe a little bit more cyclothymic isn’t as bad.

Ari: Got it. Just to wrap up, let’s say someone’s listening to this and they are wondering, “Well, do I have hormonal issues? How do I know? Can I tell just based on symptoms? Should I go get a test? If so, what test should I get?” What would you advise to those people who are maybe thinking that they have one of these imbalances that you’ve mentioned, and they want to take the next step to see if they can get diagnosed or how to fix it?

Dr. Tassone: Shameless promotion, but it’s a fun thing. Everybody has a quiz. There’s 9 million quizzes, I know, but my quiz is like 36 questions and have a mathematical algorithm on the back end because I’m a geek. If you answer those questions, it will give you a starting point. It will give you one of these 12 imbalances and it’s not to substitute for medical care, but it’s at midnight, you’re not sleeping, you want to know what the heck’s going on. The quiz is available. Obviously, testing is the best way to know. My favorite methods of testing are either blood, which you can use through your insurance, or the Dutch screen, which is a urine test that checks for a lot of great things. There’s so many things you can do.

The information on the internet is amazing, but it’s hard trying to bring all that together. That’s why I did the quiz because I think it’s a lot of women and it’s funny, it’s fun. It’s like, “Oh, I’m a workaholic,” or, “I’m an underdog,” or whatever. It comes with a story too, and most women can relate to that. They’re like, “Yes, yes, yes, that’s me.” It’s funny because like I said, it’s not me. I’ve just listened to all these stories from 20 years and just put it all together.

Ari: Excellent. Are there any final words that you want to leave people with as we finish off and then also make sure you tell people where they can go do that quiz?

Dr. Tassone: The main thing is if I could get one a message across, normal isn’t normal if you don’t feel normal. What I mean by that is so many women know something’s off, they go to the doctor, they get their labs done, and they’re just like, “Oh, things look fine,” and they’re brushed off. They don’t know what to do because the doctor’s telling them it’s normal, but they don’t feel normal. Know that normal is a range. It’s a massive range for testosterone. It’s a 30 fold range. It’s 0.2 to 6.4. There’s a huge range there. If you came in at 0.2, that might not feel too good, but maybe you’d feel better if it was 3.0, which is a huge increase. Don’t just take that laying down if you don’t feel good. Find a second opinion.

Find somebody that will help you. We’re out here, we’re practicing. I take insurance. I don’t know why, but I do. Then, finding me, I’m on Instagram, shawntassonemd. My quiz is at, tassonemd.com/quiz, and my book, The Hormone Balance Bible, is pretty much everything I just talked to you about for the last hour. There’s a QR code on page 14. You can just scan the code and it’ll take you right to the quiz.

Ari: Awesome. Dr. Tassone, thank you so much. Really a pleasure. Thank you for sharing your wisdom with my audience. I really appreciate your time.

Dr. Tassone: Thank you.

Show Notes

The most common causes of hormone imbalance in women (05:33)
How testosterone deficiency affect women (13:17)
How Estrogen Dominance can affect women (25:12)
Hormone replacement therapy (33:40)

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