360: Hot Flashes, Semaglutides for Perimenopause, and All Things Estrogen - Dr. Jessica Shepherd

Swell AI Transcript: Jessica stereo.wav

ELLA:Hey, you're on air with Ella and today I am joined by the one, the only Dr. Jessica Shepard. Dr. Jessica Shepard, how are you?

Dr. Shepherd: I am doing so well. I'm so glad that we have figured out how to be on this together. I can't wait to see what the next few minutes are going to bring.

ELLA: Listen, the reason you're a hot commodity is because you are out in the world. You're one of the few people in my universe right now who is really out in the world educating people about perimenopause and menopause and changing the narrative so successfully that it's my honor and my privilege to have you on the air. So thank you. Thank you. Thank you for joining us. Would you tell us who you are and what you do in your own words?

Dr. Shepherd: I'm Dr. Jessica Shepard, a board certified gynecologist, but also a menopause expert. You know, I think five years ago is really when I wanted to focus on women's health in the midlife stage. So that's perimenopause and menopause, but also looking at it from a perspective of how to enter this transition, but what's going to carry us through and create this longevity effect where we have amazing well span. And so That's a full, like, kit and caboodle of what I do, but there's so many aspects of it. So I hope that today we can even just get a highlight of what that really means.

ELLA: Yeah, let me get down into brass tacks straight away and share some of the things that we have talked about before and some of the things that we would love to dive in deeper with you today, Dr. Shepard. We have had Dr. Vonda Wright. We have had Dr. Stacey Sims. I know these are friends of yours. We have had Dr. Gita Nair. We have had Dr. Kara Fitzgerald. We have had so many intelligent women on this platform, who have helped us understand things from the musculoskeletal degradation, if you will, or how much more prone to injury we are when our estrogens declining. We have talked about menobelly, we have talked about menopause, hormone therapy, and debunking the very bad data that set, let's say, two generations of women completely back in time in terms of hormonal therapy and as it applies to menopause. So we have debunked a lot of myths and we have talked about a great myriad of topics, but I wanted to talk with you today, Dr. Shepherd, about a little bit more of a deep dive into estrogen, to why it matters so very much. I wanna talk to you very specifically about hot flashes

Dr. Shepherd: Yeah, I think, you know, when we think of women, we always kind of just look at, if you think a reproductive timeframe of a woman's life, but we kind of just like blow off that after that afterlife of perimenopause and menopause. And so that's why estrogen matters is because we know that there's a biological or physiological decline of it. But with that, that's where we really need to have more of the conversations of with that decline, what then happens to the rest of us, whether it's from our organ systems, whether it's from a disease process, inflammation, our sexuality, or even our emotional state. And so really, that is the whole woman. So that's why estrogen matters, because its decline impacts the whole woman, not just her ovaries, but her brain, her heart, her bones, her muscle, even her mood. So I think starting there is giving people an understanding of just how complex it is that we have estrogen receptors all over the body. And so when we have a decrease in that, that's why you're going to see that impact, which for so many years, women were dismissed and saying, Oh, you're just going through that. Just bear with it or just do whatever. And no, we need to change that narrative and allow women to understand why they matter.

ELLA: Dr. Shepherd, that's exactly what I wanted to ask you about. I learned from you that we have estrogen receptors all over our body and why that matters. And that was the first time I connected the dots because we think about these hormones, at least some of us do, in terms of sexuality, reproduction, our sex drive, maybe how we store fat in the body. But Dr. Shepherd, can you please make the connection for all of us as to why it matters that we have estrogen receptors all over our body and what that means when our estrogen is on the decline?

Dr. Shepherd: And also not even just the receptors, but the types of estrogen. So we really have three main categories of estrogen, whether it's estrone, which is like your E1, and then your estradiol, which is kind of our main estrogen, which is E2, and then your estriol, which is E3, usually seen in pregnancy. So the reason why this is important is because not only what type of estrogen is it, but how does it respond to the receptors based on where it is in the body? You can have an alpha receptor, a beta receptor. So it's just like any communication that you have, who's talking and who's listening. And so knowing kind of like the pharmacodynamics of estrogen is what we do and what I love to do. But then taking that information, explaining it to women so that they can truly see the importance of it, how it matters, how it can be affecting the symptom or condition that they're going through, and then bringing it all together. Because not only is it about the estrogen and the response and the message that's being sent, But it also determines how you're going to change some of your lifestyle habits. Because again, if that communication is not going through, then we also have to do other things in the aspect of what do we do outside of the exam room and how we live our lives. That also is very critical. And I spend a lot of my time with my patients in that lifestyle portion of it.

ELLA: Yeah, because we're whole people. But one of the things I get confused about, in all honesty, is there are so many women who are suffering with a capital S or a small s somewhere on the spectrum, okay, with declining estrogen, because let's throw out an average age, the average age for where your estrogen starts, the decline is what, what would you say?

Dr. Shepherd: I would say 35 is like the, you know, it declines, but maybe not noticeable. So then there's that difference of it's declining, but maybe you're not having as many noticeable moments. I really start to see the noticeable moments in the early to mid 40s and then the mid to late 40s is really when it starts to take this turn where now you can't maybe evade it, maybe you cannot ignore it, or maybe it's really impacting your quality of life. I think before it's kind of like touch and go, touch and go, although I have seen people who are outside of the normal distribution of that who come in and they have horrible symptoms. So that's why it was so important that we were missing all these women is because we were like, no, you couldn't be menopausal or no, there's no way that you're having any issues. Meanwhile, they were. And so that's really where we're trying to change the conversation is this is happening in your early forties.

ELLA: Exactly. And there I think that there's so much progress that has been made over the past pick a number four years, six years, eight years, so much progress. It's wonderful to see. But there is a group of people that I think may may still be feeling un seen. And that is this group of women where the decline is happening, Dr. Shepard, but they're still fully menstruating. They have their cycle pretty consistently. And they're not anywhere near menopause in the strictest sense, but they're suffering the consequences of having declining estrogen. And it's too early to take estrogen supplementation through or augmentation through menopause hormone therapy. What do they do? And let me just contribute to the problem a little bit further. I'll use myself as an example. I am having so much more musculoskeletal challenge than I did even two years ago. And I just celebrated my 35th birthday 15 years ago. And so I'm at the point… I love that.

Dr. Shepherd: We're going to do retroactive birthdays here.

ELLA: everything is still plugging along. I've got regular cycles and everything the world did not need to know this, but here we are. And yet, I'm suffering a lot of the consequences, but it's too soon for me to go whole hog into menopause hormonal therapy, according to my blood work and all other data points. Can you talk to us? Can you talk to the in between women who are like something's changing? What do I do about it right now?

Dr. Shepherd: Which is kind of the probably biggest group of these women that we're speaking of who may be falling into these categories or speaking to their health care provider, their physician who are like, well, you're kind of really not having an issue because I don't see it on labs or you're having a period every month. But what we really have to realize is internally or how a person experiences what is going on in their body may not always manifest in their age versus what we would think we would see on their labs because they're subjective. So for example, use arbitrary numbers. If your estrogen was at a 50 and mine was at a 50, does that mean that we're going to respond the same way? Absolutely not. A lot of that goes based on genetics. It goes on, say, body habitus. It goes on your health, any other comorbidities. So all of these things together, of course, no one's going to show up in the same way. So the real question is, if someone presents with some of these issues, is we really need to be more on the receiving side of, let me hear what you're saying so I can actually address it. And going back to what you'd said before, you know, whether you're 35, you're 40, 45, is we are in the last six years realizing that we truly do not have to wait till women are menopausal, which just from a clinical perspective means you have gone 12 months consecutively without a period. That's all it means. But prior to that, we used to not treat women with any type of menopause hormone therapy or hormone replacement therapy. And now we're really realizing is why are we waiting till the gas tank is empty before we're going to fill it? As it's starting to decline, that yellow light is coming on and it's like you probably in the next 40 miles need to do something about this. And if we're really waiting till women are depleted, then we're doing them a disservice and we have done that for so long and I think time is up on that.

ELLA: What should women be saying when they go to their practitioner?

Dr. Shepherd: Yeah, they should say, Hey, I really need a listening moment right now. It's kind of like collecting the room. I need my stage right now. This is what I'm going through. And I understand that hormonally, my labs may not reflect it. And yes, I do have a cycle or even if it's abnormal, I miss a few here and I have some there. And yes, I realize I'm still menstruating. I really would like to have a conversation about what to do to offset the symptoms that I'm feeling and see where the conversation goes. Now in that response, I think because we're so early on in the stages of really understanding the true importance of estrogen, how to replete it, how to replace it, how to categorize what women should get it and how much they should get. there are a lot of people who either don't feel comfortable with that, maybe don't even realize that we are in that space in the hormonal and the menopause and perimenopause world, or those who are just don't want to do it or uncomfortable, even though they may know about it, because it is some requires a new learning curve is that you have to then say, you know, at this juncture, if I'm not getting the response that I need, then it is okay to find another provider physician who's going to give me that feedback in which then I can carry on with thriving and striving in my midlife.

ELLA: Absolutely. I'm a big, big fan of reminding us that we have the power to walk away and that there are so many more ways now to find a practitioner who will actually get in it with you than there were, I mean, even five years ago, Dr. Shepard. Okay, I would love to ask you some really specific questions. The first question I want to ask you is very specifically about hot flashes and night sweats. Now, I have not experienced a hot flash before, but I see that women are experiencing extreme discomfort in these moments. And what I understand from you is that we can treat them through hormonal therapy, potentially, but also there are non-hormonal meds or other things that we can be taking to help us address those. Can you talk to us about what our options are if somebody is in that phase of life right now?

Dr. Shepherd: Yeah, and for all the women who are listening and have hot flashes and night sweats, one, know that you are not alone. Know that one, this is the most common or one of the most common symptoms that you'll have in this midlife phase. But the other thing is, I just want to give a quick little like narrative or story of how this actually happens. And then you'll really understand why estrogen is so important. So in our brain, we have this kind of command center that all it does is regulate temperature, it's like our thermometer, it has estrogen receptors in that neuron. Now when we have a decline in estrogen, it's like I'm not really functioning at full capacity because the estrogen is not there and the receptor can't receive it. So in that it's kind of like the seesaw becomes unbalanced and your body is not able to communicate. Remember we said hormones are messengers and it can't communicate and therefore your body is not able to regulate temperature, which is why we have hot flashes and night sweats. So that's just kind of to give people an understanding of just how complex this whole thing is.

ELLA: Clarification question. Can you have one without the other? Is it possible that you get night sweats, that's your thing, and you don't get hot flashes and vice versa?

Dr. Shepherd: Yeah, that's a great question, actually. So I would say most people get both, but I absolutely have seen patients who only get night sweats. I had one this week. She was like, yeah, no, it only bothers me at night. I don't have hot flashes during the day and vice versa. So yes, most people I think will have both. They do experience both. Okay. Thank you. And then hearing that kind of complex in the estrogen receptor and how it works with the rest of the body is now, okay, well, now that we know it's focused on estrogen, we know that estrogen most likely is going to be the best way to relieve our hot flashes and night sweats, which is why most people will give some form of estrogen to kind of get those receptors fed again. Now, for patients who either do not want hormone therapy, for those who may not be able to have it for a medical condition, there are options that they can take outside of hormones. Now, obviously, I'm always going to be an advocate for hormones, but for those who don't want it, I never shame them. And so for anyone who's listening is like, that's not my cup of tea, or I can't take it, do not feel ashamed. This is not the shame game of who breastfeeds, who doesn't, who had a cesarean, who doesn't, who takes hormones, who doesn't. We're not playing that way. And so I think for those who don't want hormones for whatever reason, is that there are medications, which one just came out recently, that actually impacts that same receptor that we were talking about on the brain, It allows for the seesaw to be balanced and for the temperature command control to really take its ownership back without having to utilize estrogen. The other thing is we do have studies that really look at the impact of lifestyle. So when I say lifestyle, I mean things such as complimentary alternative forms of medicine, such as acupuncture. breathwork, yoga. All of these are modalities that can actually fine tune when you think of the brain, but also through traditional Chinese medicine that can impact hot flashes and night sweats. The best thing that you want is a list of options. You don't want a list that's like, I only have one thing on here. And if I check it off, or I don't want to make the check, and it doesn't work, then what am I left with?

ELLA: Okay, so I'm, I'm a big fan of alternative practices, or that's how they're viewed anyway, in allopathic medicine a lot of the times, but you're saying acupuncture, breath work, even yoga and meditation can actually have a direct relationship with the reduction of hot flashes?

Dr. Shepherd: Yeah, because it's a physiological response, right? You can have a physiologic response from some of the things that I mentioned as alternative, which is why we are able to see with people who have maybe depression, anxiety, that these can actually be used as forms of medicinal, I guess you can say, ways for people to have alleviation when we think of hot flashes, sleep problems or sleep integrity, and also mood disorders as well. So something that I very much promote in my practice so that you don't feel like when you walk out, you're only given one option of something to do.

ELLA: Yeah, and I've heard you reference also that there are non hormonal medications that address what Dr. Shepard, do they do they address your ability to regulate your own temperature? Is that what they're doing?

Dr. Shepherd: Yeah, that was the one that I described that works on that specific neuron, the candy neuron in the brain, and it really helps really balance back out to the command center of temperature.

ELLA: Okay. Okay. Got you. All right. So you have more options than perhaps you think you do. And let's just be reminded that, say, a generation or two ago, they didn't know they had any options.

Dr. Shepherd: We went from like zero to, you know, maybe 10, 10 options. I think that's really good. And the timeframe that we went from no option, whatever, you know, I really feel, and I have this conversation with a lot of my patients, I really feel bad for like women, like say in the twenties or thirties when they were one, maybe no AC or they were wearing those huge dresses with 50 million layers. And then they're going through perimenopause and menopause. The other thing that I didn't mention as well, another option are wearables. So there's a wearable that actually. really impact hot flashes and night sweats. It's Ember Labs EMBR, and it's kind of like the one that I'm wearing here. This is a whoop, but I'm wearing, you can wear this wearable, and it actually uses, through technology, the ability for hot flashes to be controlled or minimized or prevented. Either one of those. Okay, you're changing lives. Thank you. Thank you very much. Let's do that. That's what we're doing on this. You are changing lives. This is the goal.

ELLA: And is there anything else, like does a cold compress help? Does anything just super practical help?

Dr. Shepherd: I think that, you know, when we think when we see women who are like carrying fans or the cold cloth, I will never ever say, no, that's not the way that you should do it. I think that, you know, in everyone's experience, what they've been exposed to, what they've been told and shared by with friends and family, we should never look at it as something that shouldn't be done. But we should always be looking to maybe advance the practice of how to alleviate some of these symptoms because we really do have some, some good options out there.

ELLA: Okay. Thank you very much. I just needed a little primer, primer, primer, both of them. So Dr. Shepard, can, do you mind if I switch gears on you and just take us in a different direction? Okay. So one of the conversations that we had, and I want to say it was with Dr. Stacey Sims, we were talking about, Listen, we've talked about the types of exercise we should be doing, we women folk. We've talked about that up one side and down the other. We know we need resistance training. We know we need muscle. We know that we need to be eating protein. It doesn't mean we're all doing it all the time, but the knowledge is there. Okay, we know this. But there is a little bit of confusion about whether zone two exercise is good for you or bad for you. Now I have my own personal take. And I don't mind sharing it because I think we all know that I got my doctorate from Google University. So please take it for what it's worth. I do zone two all the time. I also do resistance training. Zone two, I do because I love it. And I enjoy it. And I enjoy competing in triathlon. I don't do it because I'm trying to achieve some sort of outcome, which is the way that I experienced zone two exercise back in the day. Now I do it because I love it. I have been cautioned against it. And then I have also been told no, that's a great thing to do in between weight workouts. I need to know Dr. Shepard's take, and maybe you should define zone two since I didn't do that. But can I have your take, please? Because podcast fam, Dr. Shepard, we're going to be shallow for just a second. Dr. Shepard, she's a sight to behold. She's gorgeous and tall and athletic and fit and over 35. Very over 35, mind you. 35 plus like 12. So I need to know from your professional and completely aesthetic standpoint, what's going on with Zone 2?

Dr. Shepherd: You know, Zone 2 really is, the training really is this hot topic. Should we do it? Should we not? But when we really look at what it actually is, it's generally known as this like steady, conversationally paced exercise. I guess you could say endurance. And I think we do go through phases in society where something is not important anymore, right? Like if egg yolk is great, or it's not, right? We go through those. So when we talk about zone training, we really mean how are we breaking down our training intensities into heart rate or power ranges and using that as a model for the specific training plan or workout that you're doing. And so when we think of the structure of zone two, it really is relatively something that is easy and long and 60 to 70% of what we would think of our max for 45 minutes or more. But the difference of what we've seen specifically with weight training and muscle buildup and what we go through biologically with the decline of estrogen in midlife is that now there is more of an emphasis really to push more towards muscle building, building up our muscles, which would then impact our bones. And the reason we do that is because there's such a significant decline in muscle mass and lean muscle mass as we start to age, namely because we're aging. But two, because of that decline in estrogen. So again, that's a lot of reasons why we place the emphasis on that, because we know that is just kind of really coming out of the picture very quickly, it's really trying to escape. And so we have to find a way to really boost that where it can boost the functionality and the ability for us to have skeletal muscle because we know that is going to impact bone and bone health. And we know that women typically, as they start to age and get into their 60s, 70s, 80s, because of the decline in skeletal muscle is really why you have an increase in chronic disease states, but also decreasing bone strength. And that's what do most women have when they're in their 70s and 80s. They typically fall, break a bone. And we know the morbidity and mortality that comes when women do fall and break a bone. So again, it doesn't necessarily mean I think that if I had a woman who, or a patient that was like, you know, I really enjoy my zone two and I don't want to do weight training instead of me, you know, kind of criticizing or telling her not to do zone two is saying, how can we allow you to do zone two, but add a little bit extra in instead of starting the conversation and we need to eliminate. And I think that really defeats people sometimes is when we. come with more of an elimination factor rather than how can we enhance or add to something that you're already doing. I'm just glad that that person is moving, because movement to me is key. And so I will take zone two, and maybe try to sprinkle a little power training, strength training in there. And then over time, because the real thing is the habit, what is the habit that you're forming? And how is this going to improve your longevity, but movement is key, I would say first movement is key, then we can slice and dice that really means.

ELLA: This is such a useful perspective. And I want to respond again, as a lay person and make a couple of observations based on what you're saying, because I love your take. So for example, for me personally, as someone who enjoys zone two, what I'm hearing you say is, it's a matter of priority. So if you had to prioritize a movement, if you have the privilege of being able to choose, by the way, like your schedule will allow for you to do a variety of things or whatnot. If you have the privilege of being able to choose, You need to prioritize some resistance training, some weight training, if you want to age the way that we're here to talk about.

Dr. Shepherd: Okay. I think prioritization of the specific type of conversation that we're having and what we see with estrogen, right? We're really focusing on the emphasis of estrogen, how it's important and how it impacts your body. Yeah. So I would definitely agree with the way that you just worded it.

ELLA: There's also some debunking to be had here. Because remember, of course, we are of the generation that cut our teeth on an hour and a half of cardio or pop a tape in the VCR to aerobics or something. And the goal, it has to be said, nine times out of 10, was to change our bodies and to take up less space. And so for me, a lot of this zone two conversation is useful to say, hey, if you're moving, as you said, That's already a check in the right column, right? Movement, absolutely fabulous. Number two, if you're moving for the joy of it or because you're doing something that you love, that hits very differently. And to me, I even think physiologically it hits differently than if you're thinking that at age 45, an hour of cardio is going to do any of the things that you think it's going to do for you. Like it's just a reprogramming in my mind.

Dr. Shepherd: Am I being clear? Yeah, you're being really clear. And also, I want people to change the concept of where they are currently with their workouts, their eating, their habits, and change that to how do I want to show up later on in life? And if you're able to really sit down and answer those questions, a lot of times it makes it easier or less stressful to have to think, what are the things that I kind of need to change in the scope of the things that I was just talking about eating, exercise, movement, I kind of say it's the same thing as finances, I would never tell anyone, you know what, when you retire, you should start going ahead to save money, then no way we would say, hey, in order for you to do really well later on, let's really make some impact now. So that we have some reserve or we have something that's going to, you know, help us in the future. And the same thing goes for exercise, exercise and resistance training and weightlifting. That's really where you're going to get bang for your buck. later on in life and you can be so happy that you actually did that and did the work beforehand.

ELLA: We are investing in our muscles. We are investing in our musculoskeletal strength. We are investing in injury avoidance. I mean, the list goes on. Okay, I really, really like that framework. I have a question. What would you tell 30-year-old us, Dr. Shepard, if you could sit her down right now? What would you tell her to do, pay attention to, to not do?

Dr. Shepherd: Yeah, I would say that as you know, I believe that 40s is really when we start to change the conversation of who we are, how we feel, how our body chooses to respond, like when you wake up in the morning, or even kind of the endurance that you have. We just don't have as much as we had in our earlier decades into our 30s. So I believe the 30s should be kind of this introduction of when my 40s come, I really want to be strategic with it so that when I do reach menopause in my 50s, that I'm well prepared. I think before we have kind of I say this again, it's kind of like a screencast, we I've cast it as this horror, this horrible movie that is like, you know, people just jumping out all over the place and dragons and you're like, oh my God. The men apocalypse. Yeah, the men apocalypse. Exactly. And so people were like, oh my gosh, I don't have to think about it. I don't have to talk about it. And they feared it. Instead of us saying, hey, you know, this comedic love story of the second half of your life is coming up. How are we going to, how are we going to prepare to show up at the cafe so we can sit down and just enjoy that chapter of our life? Are me cute with menopause. Yes. I'm like the conversation would change just in your thought process. This is coming and it's not so horrible, but I know that if I do these things, the transition can be. a little bit more manageable, it can be a little bit more pleasant, and I'm going to work on those things in my 40s.

ELLA: Dr. Shepherd, I am scared. I have dozens and dozens and dozens of hours of conversations like this that empower and, in this case, knowledge is power because you can proceed differently. But I am scared. Is it possible to do right, to do well for yourself 80% of the time? We're not robots. Is it possible to be okay through the latter years of perimenopause and the transition through menopause? Like, do some people have that experience relatively unscathed?

Dr. Shepherd: Yeah, I have seen a lot of them. I have met these people. I think because we have started to change that conversation, but I do believe that people who maybe didn't even really mean to do it, who did some really good work earlier in their life without realizing that they were impacting their, you know, kind of future years really don't have the same experience. But a lot of times they don't know why. And I'm like, well, the investment was made, even though you didn't really know it. And now as you're starting to go through this hormone decline, your body is kind of showing up for you in a way that you didn't know. And so that's why I say that it's so important, the lifestyle factor of what we talk about, and what we've been talking about today is so very important, because it's the small things, right? It's the small things that add up into the outcome that I was looking for. And that's why I'm saying that the habit forming and the habit installation through our latter 30s throughout our 40s really can dictate and shift what we're going to see in that transition. And I really wholeheartedly believe that.

ELLA: Dr. Shepherd, are the core habits that you lean on then, do they come down to the big rocks that we have talked about many times before? So quality sleep, nutrition density, if you will, prioritizing protein, resistance training. If you're at zero, then 10%, 20% is great. If you're at 10%, then 30% is great. Like in other words, start where you are, use what you have and do what you can. not hacking your body, not stressing yourself out, paying attention to cortisol so that you're not fighting an uphill battle the entire time, mindfulness practices. Dr. Shepherd, is that what we're talking about when you talk about habits? And is there anything that you want to get on the table that I did not mention?

Dr. Shepherd: No, I think those are all really good. Again, I think what you listed were options and what people can, you know, pick and choose on what they would like to put on their plate. Again, because it can seem overwhelming initially when you list all these things and you're like, oh my gosh, these are all the things that I have to change in my life in order to have this good outcome. And so I think that the ability for people to at least look at it, like, right, you're presented with these lists or items of things that you can do. is saying, what do I think that I can implement into my life based on the way that I flow, the way that I live my life, what conveniences I want, what I have access to? That's how you really should approach it. Even patients that I see today, and I'm like, oh my gosh, there's this laundry list of things that we need to go through in this visit. And here are all the things that need to be changed. No, I'm like, okay, which one's priority right now? Which one can we chip away at? Which one are you not interested in at all? Because that conversation may change in a year or two, you know, there has to be fluidity in the conversation, or else we're never going to have them do what we want them to do. And I think people's experiences of how these symptoms or how these kind of obstacles show up in their life is the experience and the journey that they're going to go through. But being able to present From the beginning, what's going to happen, which is the education, then also the options of how they can impact their life is them taking ownership into this midlife perimenopause and menopausal transition.

ELLA: Yeah, and I've said it before, this show's been on the air for nine years or something, and I've said it before, I will say it again, Dr. Shepard, I'd never even heard the word perimenopause when this show launched. Never even heard it. So just the very fact that we're having this conversation, to me, is major, major progress, and also creating this community, this sisterhood of resources and conversations that, frankly, it's too soon to take that for granted. It did not exist, again, a handful of years ago. So thank you very much for clarifying another phenomenon that we engage in sometimes. And that is that we think future us is going to do everything and do everything perfectly. I talk about the concept of future us a lot. I'm a big fan of starting with present you. And looking at what dials can you change in your life today that work for you, a slight degree of a change, not some big, massive, catastrophic change in your life, and just continuing to learn and turn a few dials, and then maybe learn a bit more and turn a few dials. And what I'm hearing from you is that it's worth it because there are, in fact, at least two women who have pursued, but more to come. In all seriousness, thank you for showing us what's possible.

Dr. Shepherd: Yeah, I think the possibilities of what you can achieve and accomplish, I think are the most important parts of this because many people are defeated before they even start the journey. And so if we can step back and allow people to understand exactly how they can show up in their own abilities or disabilities, that's really where we're going to get more buy-in from the full collective of women instead of saying, Every woman has to do it this way. Every woman has to look this way. And I think for many years and decades, rather, we have seen how society, how culture has tried to label and place women in a certain box. And we're really moving away from that. And I think that is even more important for the perimenopausal phase, which is why this is like kind of the thing that I love to do, which is why I wrote a book, Generation M. And this is what I want women to see that it's a lifestyle, evidence-based lifestyle.

ELLA: Okay, well, you're clearly coming back on the air to talk about Generation M. I have one more question for you before we wrap up today, Dr. Shepard. And this one is an interesting take that I know very little about. Ozempic, Wagovi, these semi-glutides. Semi-glutide, semaglutide I'm hearing, which I don't like. I like semi-glutide. You can stick with that one. GLP-1 is the way some people recognize this, but the commercial names are the Azempics of the world, the Mugovies of the world. These are controversial when it comes to weight loss and whether they're good for you over the long term. That's not what I want to talk to you about. What I want to talk to you about, Dr. Shepherd, is that I'm reading more and more that microdosing these GLP-1 drugs can have extremely beneficial effects on women in perimenopause and menopause. Now, I have not researched this, I am just throwing the topic at you based on a little bit of reading that I've done, because I would very much like your take. What's news here? And what should we be aware of?

Dr. Shepherd: Yeah, so when you look at that whole menopause transition, and even in the perimenopausal phase, 70% of women experience waking, right. And that probably is one of the highest complaints that we hear from women is just that all of a sudden, no matter how much physical energy that they're expending, they start to see this increase in weight. That has to go with again, the estrogen receptors and where they are all over the body. So your adipocytes, which are your fat cells, just a fancy name for fat cells, you have estrogen receptors on that. So when we have a decline in estrogen, that really is going to significantly increase how fat is or fat mass, but also the migration of it. And so that's why you start to see decrease in muscle, right? So you're going to have an increase in fat mass, decrease in lean muscle mass, and also the migration of the fat going from more of our hip buttocks area to more of the abdomen area, which is typically where you start to see that weight gain and shift in our in our shapes. So we talked about metabolics and how our body likes to change more to an insulin resistant type of body as we start to see a decline in estrogen. So in addition to the fat cells being impacted by decrease in estrogen, now we have these metabolic changes happening internally with insulin and glucose. And that's why when we see our GLPs, which really does impact that communication between insulin and glucose, that's why you start to see that it actually is impacting the metabolic portion of menopause, which already biologically is happening with our increase in fat mass, but also our insulin resistance increasing.

ELLA: Are you using this therapy in your clinic?

Dr. Shepherd: I do have patients on this. I think that when we look at our GLPs, whether it's for the treatment of obesity, right, where people come in specifically for them trying to decrease obesity, but then you do have patients who are like, from a perspective of insulin resistance, or the inability, you know, when I check their hemoglobin A1Cs, which is kind of like a lab marker for increase in glucose, those things start to happen even if they're not really doing anything that's causing it. So when we look at the studies at how it actually is improving cardiovascular outcomes, it's decreasing weight, it's decreasing the patient from being insulin resistant. These are all factors that are going to improve longevity, quality of life, and also having women not have to necessarily do so much work and not have the outcome they're looking for for some of these things.

ELLA: When you're talking about these longer term benefits, including in the general sense, longevity benefits, health span benefits, is this still macro dosing? Or is it micro dosing? Or is dosing even am I even running down the right road here?

Dr. Shepherd: So the macro dosing, micro dosing, it's kind of like how is it being distributed? How much dose are you on? Most people, when they're looking for fat loss, you're going to be at kind of like those higher levels, right? People who have maybe sustained weight or maybe don't have an obesity issue and they're really on it for whether it's fasting glucose or lipid profile, blood pressure measures, etc. that's when you can start to decrease the dose because they're more on a maintenance dose in order to just kind of like keep everything chugging along at a low lying level, not necessarily we're looking for big impact. So the I would say the key message for all of this is you really want to go to a provider that truly understands that metabolic side and the longevity side of what semaglutides can offer in addition to weight loss. But you really want to have conversations about if you do decide to stay on a semaglutide on a macro dose level or a long term factor, because you want to make sure that the interventions that you're being managed properly and that you're looking at it in a holistic or holistic fashion of overall health. rather than just saying I'm trying to lose weight. So I think long term what we will see is that this is going to be something that's going to be implemented more into how are we treating people outside of diabetic or the obesity when we're decreasing those risk of cardio metabolic diseases. Just one more thing, cardiovascular disease, leading cause of death among women, right? You can take all the cancers you want. And cardiovascular disease is still going to outweigh as far as death for women. So when we start to see a medication that can actually decrease the risk of that, and cardiovascular disease mortality, then you know, we're definitely on to something.

ELLA: I appreciate that primer primer so much because I am only just starting to see this class of drugs in a completely different light. Now I'm not I'm not out here to promote or advocate for but I do want to create literacy. And I do want to create awareness so that women know what to go ask a professional about. So I'm very grateful to you for that. And what I'm hearing is that I need to do a whole show on that topic. So I will put a pin in that for now. I want a copy of your book. I want to have you back on the air after it is released in October. And for today, Dr. Shepherd, I am so grateful to you. Thank you so much. Thank you.