Tom Rountree (00:01.518)
Hey everyone, welcome back to the podcast. Today we have a really special guest. I think it's very important for people who may be suffering from perimenopausal problems or menopausal problems. Today we have Dr. Anthony Kiel, MD. He's a director of EvoMD, which is actually where I work. And it's a direct primary care practice located in Cape Girardeau in Jackson, Missouri. He earned his medical degree from the University of Missouri and completed his residency.
and Family Medicine at Southern Illinois University in Springfield, Illinois. And he also holds a bachelor's degree in mathematics. He began practicing medicine since 1999 and became a doctor out of a desire to help other people, combined with his strong interest in science and mathematics. Eventually, he shifted his practice to hormone-based therapy, which is actually the topic of this episode, when he discovered their profound effects.
Dr. Kiel also enjoys spending time with his wife Angela, their children, riding motorcycles, hunting, and operating heavy equipment, which we'll likely get into during this episode and have a fun time with it. So Dr. Kiel, welcome to the podcast.
Anthony Keele, MD (01:16.461)
Thanks, Dr. Rountree. being on the opportunity.
Tom Rountree (01:20.974)
So I was thinking maybe we should form this podcast a little bit around the Women's Health Initiative study since I think that since that study came out roughly in 2002, it's kind of given a lot of pushback to using hormones in practice and kind of that it's really been put of a kind of a blockade on physicians using it practice. But recently,
I know the FDA kind of reversed or kind of put a more lax statement around their black box warning around using hormones. So can you kind of tell me a little bit, I know you graduated in 1999 and then you were a family practice physician for a while, is that right?
Anthony Keele, MD (02:12.131)
Yeah, I mean, technically I'm still a family physician. I still do a wide range of things that most family physicians do. However, I was initially in practice in Illinois for a few years. And then in 2002, I had the opportunity to come back to Cape Girardeau, which is my hometown. anyway, so I did normal family practice for several years and basically, a lot of family medicine.
is you're treating hypertension, diabetes, high cholesterol, things like that. And I began to, I had a very busy practice, but I wanted to focus more on prevention. And one of the areas that I felt like was a good opportunity for prevention was in hormonal placement therapy. It's one of those things that most doctors tend to treat things that they're taught in residency.
And hormone replacement therapy is something that is not, uh, you know, it's taught very well in either medical school or in, in residency. And I, not just where I went to residency, but it's kind of a general thing that they just don't teach you a lot. Uh, but all you get is basically during, you know, your gynecology rotations or, um, you know, they talk about doing mostly, um,
birth control and a little bit on menopausal women. But they don't tend to teach the range of hormone therapy that includes both men and women.
And actually what got me interested in, I went to a conference in 2005 and there was a guy there that had trained at a place called Syngenogenics Institute. And he was actually a psychiatrist and he had stopped doing psychiatry and was only doing hormone replacement therapy. So he was giving a talk on DHEA. So I listened to his talk and I found it interesting that he was no longer doing psychiatry, but he was doing hormone replacement therapy. So I went up after the talk and I talked to him for about 30 minutes.
Anthony Keele, MD (04:22.691)
And he kind of told me his story and how he got into doing that and where he had trained. so then I decided to check out the Syngenogenics Institute. I read a lot of their online papers and some of their information that they had, and it was kind of cutting edge. So Syngenogenics, a guy named Alan Menz was kind of a pioneer in the US as far as broad hormone replacement therapy in both men and women.
So they had a continuing education training course. And so I ended up going and doing the training course, which involved about 40 hours of online study and testing. And then you end up doing a full week hands on in Las Vegas, where their facility is, their headquarters is. So I did that. And then that really got me interested in. And the other thing too is at the time,
I was about 50 pounds overweight and was really busy. Wasn't exercising. And so basically I took all the stuff that I learned through this continuing education program.
I did my own hormone testing for myself and kind of looked to see where my levels were and how I felt. so I use kind of the tenants that they in their approach to hormone placement therapy and I applied it to myself. also kind of changed my, my appetite or not my appetite, but my, my eating habits and began to exercise more. And I lost 50 pounds at eight weeks.
And I felt fantastic. And of course, you know, when you're a doctor and you know, patients are typically come to see you maybe every three months or something. you know, patients would come and then three months later they would come back and you look completely different when you've lost that much weight.
Anthony Keele, MD (06:15.871)
And so of course, everyone would know, well, what are you doing? Whatever you're doing, I want to do that. So that's how my hormone replacement therapy practice began. So I always tell patients that I was patient zero for what I call, I ended up calling it the optimized living program because
To me, doing hormonal placement therapy, you're improving your life, you're improving your vitality. That's kind of the point of it. And so that's how I kind of got into it it grew from there.
got to the point where I was seeing about 100 patients a day and then decided to hire a couple extra people to kind of split the workload out. But yeah, so that's been pretty much my focus for the last 20 years.
primarily doing that. I was basically the first person in this part of Missouri that was doing home replacement therapy. were some clinics up in St. Louis, there's a couple places down in Memphis, but nobody in this area was doing it. The other thing is back in time when I started doing home replacement therapy, it wasn't really well known and it wasn't really popular. And so I got a lot of pushback from area providers who thought the stuff I was doing was just crazy.
However, now 20 years later, it's much more well-known and it's much more popular. Now, providers who used to tell patients that what I was doing was nuts, now they refer me patients. It's been an interesting shift over the last 20 years. But to get to the topic we want to talk about today, is primarily,
Anthony Keele, MD (08:02.785)
hormone placement therapy for perimenopausal and menopausal women. A lot of the, you know, a lot of the...
Kind of the hype recently has been about the FDA's removal of the black box warnings for estrogen replacement. And how all that kind of got started was you mentioned the Women's Health Initiative. When that was a series of clinical studies that were initiated by the National Institutes of Health beginning in 1991. The studies actually went for about 15 years. But yeah, as you mentioned in early, think it was 2002, they began publishing results
Tom Rountree (08:19.982)
Thank
Anthony Keele, MD (08:42.071)
their studies. The problem and there's been a lot of you know ever since those came out there's been a lot of discussion on the quality of the study and a of the you know a lot of the criticism has been about that they basically they skewed their study to older women
Most women were over 60 and so there's a large number of patients in their 50s who go in through menopause and they were, you know, because it was skewed to patients over 60, then you know that's where the criticism is that because you know that's where the health benefits if you actually go and look at that subset.
Tom Rountree (09:06.687)
Mm-hmm.
Anthony Keele, MD (09:33.212)
Basically what ended up happening because of the way the women's health initiative was done that they, you know, the initial, when they initially looked at the, some of the results of these studies, it looked like that women on hormone replacement therapy and they were looking at estrogen and progesterone is what they were specifically looking at. It looked like it was actually harmful to women. They were trying to say there was like an increased risk of heart disease in women. They were on hormone replacement therapy versus ones who were not.
And so, know, for a long time after that study came out in early the early 2000s, you know, basically the last 23, 24 years, a lot of providers have been very reticent to prescribe estrogen replacement therapy for women having menopausal symptoms.
And the reason is, is they were afraid that if they, you and a lot of providers would even tell women, hey, don't take this, you know, it can harm you. can increase your risk for having a heart attack. It can increase your risk for breast cancer, you know, and all these other things. Now, but on the other hand, there were people that were saying, hey, you know, there are good benefits for estrogen replacement. You know, it improves bone mass. It can help with mood. It can help with sleep.
treat the symptoms of what we call climacteric syndrome, which basically is the constellation of symptoms that women have when they are going through menopause. One of the things I, you know, I do a lot of education with patients about, you know, what is menopause. And so basically, you know, what I like to explain to patients is, is, you know, it's not like you wake up one day and now you're in menopause.
Menopause is a process and often for a lot of women it can take anywhere from three to five years. you know, kind of the progression of what happens is most men and women, and we're primarily talking about women today of course.
Anthony Keele, MD (11:46.5)
begin to experience hormonal decline usually in their mid-30s. And the rate at which the hormonal decline occurs is determined by your genetics. So it is true that not everyone ages at the same rate. And all the physiological and physical changes that we think of, you know, from the time, say, you're 30 to the time you're 60, right, there's a lot of physical changes, a lot of physiologic changes that occurred in that time. For the most part,
those are mediated by hormones. So what happens is that at a certain time, based on your genetics, usually 35 to 40, your body begins to decrease the production of certain key hormones. And as that happens, you begin to have these changes, changes in your skin, muscle atrophy.
your metabolism tends to slow down. And that's why we see a big surge of obesity in patients in their 30s and 40s because a lot of times their metabolism is slowing down, but their calorie intake doesn't decrease to maintain that proper ratio of how many calories and how many calories you're burning and that sort of thing.
So, and then that's also too when people begin to experience other symptoms of hormonal decline like mood swings, decreased libido, problems sleeping. Sometimes patients will develop what they call brain fog, things like that. They just don't feel as good as they did in their 20s, right?
Tom Rountree (13:30.676)
Yeah, I've run into that a lot actually. Like they come to me and they'll say, well, I have brain fog. And I'm like, it's such a generalized thing. And it took me a while to realize that it's very hormone related. Like, especially psycho. The other one was chronic UTI. In fact, my first kind of run in with that, because I did a year of OBGEN with using estrogen therapy was for chronic UTIs and it fixed them.
Anthony Keele, MD (13:44.493)
Yeah.
Tom Rountree (14:00.936)
And I would get pushback from like usually it was the patient's relatives like their son or something like they would ask me. So I would have to send them the studies that show, hey, it doesn't increase their risk of cancer at certain ages. In fact, it may even help some cancers. But yeah, I ran into that brain fog definitely.
Anthony Keele, MD (14:24.099)
Right. you know, patients that, and then specifically what happens to women at some point they're, you know, they're decreasing levels of estrogen progesterone. And then you have also other hormones like FSH, LH, those that basically control the menstrual cycle, right?
Those levels begin to fluctuate and as that happens they begin to experience menstrual regularity. So some women have, you know, they'll go three, four, five, six months with no period. Sometimes they have really heavy periods. They don't have, you know, then they stop waiting two, three weeks and they do it again. So there's a, you know, the wide range of stuff. And then they begin experiencing what I like to call, you know, it's kind of classically known as climacteric syndrome. So those are the, like I said, the constellation symptoms that women
experience and not all women experience them. There are women who just for whatever reason don't experience menopausal symptoms and then there's women who experience them so severely that it basically incapacitates them. It makes them hard for them to work. It makes them hard for them to do their functions because they're having such you and the ones you classically think of of course are hot flashes or hot flushes where they just they're sitting and all of sudden they just feel like
they're just burning up, So, you know, a lot of times they want to run their air conditioners even in the wintertime or, you know, in the summertime they want it 60 degrees outside, you know, in the house or whatever. And they're freezing out their husbands or their families or whatever. So you have that, you have nightswets where they wake up in the middle of night and they're soaking wet or they soak the sheets or whatever.
And then the other one, big one are mood swings. And a lot of times with mood swings, you see also, you know, decreased libido. You see irritability, you know, where they begin to experience problems with relationships with their children or their spouse or, whoever. And it's just, you know, and they just have almost like a change of personality.
Anthony Keele, MD (16:32.355)
And those symptoms usually begin occurring. So in general, most women go through menopause somewhere between the age of, 42 and 52 is most common.
Some women go earlier, some women go later, it just depends. But prior to actually going through menopause, and to define menopause, it's either an FSH, so FSH is follicle stimulating hormone. So that's the hormone that your pituitary gland below your brain releases that basically stimulates the ovaries to do their things. So if your FSH once it goes above 23, you're considered to be a menopause, or if you have 12 consecutive months with no period.
Now, a lot of women end up having, say they have endometrial ablation or they have hysterectomy. so that part doesn't work. So a lot of times they don't really know, they just start having these symptoms unless somebody does blood work and checks their FSH and says, yes, you have that. But when they begin experiencing these symptoms, sometimes they're very mild, sometimes they're more severe. what I do when I see those patients, and a lot of times what happens,
Tom Rountree (17:25.87)
you
Anthony Keele, MD (17:42.774)
But again, and I think it is because of a lack of training, a lot of doctors just don't know what to do with a patient. They don't know what levels to check. And if they do check some hormone levels, they don't know what to do about it. know, so hang on just a second.
Tom Rountree (17:57.368)
Sure,
Anthony Keele, MD (18:09.443)
Sorry, I had to lift the dog. Anyway, providers don't know what to do with these patients as far as how to treat them. But when I end up seeing these patients, so I do a comprehensive hormone panel and we're checking estrogen, progesterone.
Tom Rountree (18:10.894)
Letting the dogs out.
Anthony Keele, MD (18:32.483)
But we also are checking testosterone and DHEA and things like that and there's a lot of hormones Basically men and women pretty much have the same hormones. It's just that they have different levels of those hormones
And so, you know, and actually testosterone is one that a lot of people, you know, don't really think about in relation to women because testosterone is very important in women as well as in men. Women obviously don't have the same amount of testosterone. They're about about 10 % of typically 10 to 15 % of what a guy would have. But it does a lot of very important things in them. And as they began to go into the perimenopausal state, their testosterone is decreasing as well. they some, lot of
the symptoms of the fatigue and the slow metabolism and the trouble sleeping. Sometimes a lot of that can be contributed to testosterone deficiency as well. So we check these hormones and then basically we treat them. And there's different ways of treating estrogen placement therapy. can do pellets.
which you can do testosterone and estrogen pellets and I do pellets in the office. We do those about every three months. We can do injections. Most women for when you're replacing estrogen, you can do a shot either once a month or every two weeks and that's plenty. We can do oral estradiol. We can do creams like topical creams sometimes are compounded.
And then there's also like, you know, estrogen patches and things like that. So when you get into these different treatments, you know, one of the things a lot of patients, you know, sometimes we'll ask about is the difference is, you know, they say they want a natural product, right? And yeah, I know you and I, we kind of talked about this. So.
Tom Rountree (20:29.804)
Yeah, yeah, I've heard that a lot.
Yeah, we did.
Anthony Keele, MD (20:37.729)
when patients say, hey, you know, is that a natural product? And then I like to have a discussion with them. It's like, okay, what they're wanting to ask is, is it bio identical? That's what they really want to ask.
but they don't know what terminology to use. So I often explain to patients, okay, so here's the difference. So when you're looking at hormones, ideally, if you can, you want to supplement with something that's bioidentical. And bioidentical basically means that the molecule or the substance that you're injecting in your body or taking orally or topically or however you're getting it.
right, is the same as the molecule that your body naturally produces. And the reason that it's important is because if it's bioidentical, number one,
it doesn't have to be metabolized to the liver through what's called the third, you know, the third path system where you basically take something, you take it to the liver and you break it down, right? And because when that happens, you've got these metabolites. Well, sometimes you have an active and inactive metabolite, inactive metabolite can cause side effects or cause problems. So, bioidentical is better in that way. Plus two, you're not likely to have any kind of allergic reaction or you're not likely to have any kind of side
effects from using it. So you know bioidentical you know so I like to use bio when we're talking about estrogen replacement I like to use bioidentical estradiol as an injectable or we also have bioidentical as oral pills. Some of the commercially available products are not bioidentical. They are derived from you know other sources.
Anthony Keele, MD (22:22.595)
And then the question about natural. So bioidentical can either be a naturally derived product, say, for example, like NP thyroid or or armored thyroid, which is derived from thyroid glands of pigs. Right. So it's a porcine.
And then so natural this means that you know, it's some substance is naturally occurring Whether in humans or an animal or some plant source or something like that and then synthetic means that it's you know manufactured Biochemically in some production facility, right?
Tom Rountree (23:06.744)
Yeah, in a plan or something like that or, yeah.
Anthony Keele, MD (23:10.039)
But just because it's made synthetically doesn't mean it's not bioidentical. So there's a lot of bioidentical stuff that's manufactured synthetically. And it still works. in my mind, I would rather have something bioidentical that's manufactured synthetically than something that's not bioidentical that's available naturally. I think it's going to do better.
Tom Rountree (23:33.068)
Mm-hmm.
Anthony Keele, MD (23:36.176)
and in my 20 years of doing this, it works a lot better. then, going back, so the whole deal with going back to the Women's Health Initiative. So the whole problem was they did this study, they reported the results prematurely before all the data was properly analyzed. they began to, so they basically came out and were...
telling women that if you use estrogen replacement therapy that you can get breast cancer or you're going to have a heart attack in your 50s or whatever. Man, let's see, I gotta look dumb again.
Anthony Keele, MD (24:25.315)
So, you know, you're going to have all these negative effects. And so you had proponents of estrogen replacement therapy, and then you had people that were basically scared women saying that, hey, you know, you don't want to use these or they're going to cause a problem. And so there was this, you know, this conflict in the medical community. You know, what do you do? So some.
you know, women who were going through menopause, they're having symptoms, they're not feeling good. They go to their doctor and their doctor says, well, it's just a natural part of life. You got to live with it. You know, it should be better than two or three years. And then you had other providers like myself that, you know, was like, okay, you know, if you're having these symptoms of menopause to the extent that it's causing you a problem.
then we can treat it. but I also, you know, it's also important, just like whether you're treating high blood pressure or diabetes or whatever it is, you know, I always like to explain to patients, you know, there is no perfect treatment. There's, there's pros and cons to everything. And you have to, when you are going to treat a problem, you have to look at, you know, the risk benefit. So what are the risks of taking the medication or the treatment and versus what are the benefits? And if you're, you know, if you feel like the benefits
fits, outweigh the risks, and that's a good treatment. And that's the way I approach hormone replacement therapy. when I see new patients, women who come in and they're having these symptoms, I ask them, is this something that's bothering you on a daily basis? Is it impacting your life? Is it keeping you from doing certain activities or whatever? How is this affecting you?
And then the other question I ask them is like, OK, well, we can treat it, but here's the ways we can treat it. And are the symptoms bad enough that you're willing to do this treatment? Right. And then, of course, you you got to review their history. know, do they have an intact uterus or not? Because that affects if you're given a master gen, they have an intact uterus. You have to give them a regressor on to. But.
Tom Rountree (26:24.78)
Mm-hmm.
Anthony Keele, MD (26:39.011)
And then you basically have to design a replacement program for them that's going to fit their needs. And we have a lot of different ways we can do it. Some work better for some patients. sometimes cost is a factor and inconvenience. Is it a daily pill versus a shot every two weeks? Or pellets, which is every three months. So you have to look at all those different things.
Tom Rountree (27:04.62)
Which one do you find is the most kind of popular?
Anthony Keele, MD (27:10.531)
Shots are still the most popular. We do, like I said, it's a bio-genicul estrofile injection. Typically, I usually start women on it every two weeks and that seems to do really well. And then the second...
Tom Rountree (27:28.814)
And how do they, yeah, go ahead, sorry. I was gonna say the second one.
Anthony Keele, MD (27:34.244)
It's what's called an IM injection or an intermuscular injection. And usually they like in their shoulder. It's a really small, it's like typically it's about a quarter of a milliliter, 0.25. So it's a really tiny injection. We use a small needle and most women will, they'll self inject at home. And then we have some patients who aren't comfortable injecting themselves. They'll come to the office and the nurses will inject.
Tom Rountree (27:46.722)
Mm-hmm.
Anthony Keele, MD (28:00.676)
So that's the most common. The second probably most common would be oral. So estradiol tablets, which they typically, you know, there's different doses and they'll typically take those every day. And then third would be the probably pellets. Like pellets are growing.
So pellets haven't been around, the type of pellets we're using now haven't been around as long as the other forms. So, you know, it's like with anything when you have something new, it takes a while for it to kind of get out there. The other problem with the pellets is cost. So when I, you know, I'm educating patients about their treatment options, it's all about, you know, cost versus convenience. And I tell patients pellets is all about convenience. You know, you come in
the office takes me five minutes put the pellets in and you're good for three months you have to do anything else the problem you know but compared to the the pills or the shots it's much more expensive so we charged we charge $250 every three months for the pellets to do the pellet procedure whereas three months of estrogen shots is about 30 bucks
Tom Rountree (29:05.345)
Yeah, yeah, convenience, yeah.
Tom Rountree (29:18.026)
Mm-hmm, mm-hmm. Yeah, that makes sense. Yeah, yeah, yeah.
Anthony Keele, MD (29:19.811)
to the 20 bucks. yeah, but I have a large, know, I have a pretty good, pretty good number of female patients who come every three months and get their pellets put in, because that's what they want to do. And they're more concerned about the convenience than they are the cost.
Tom Rountree (29:37.73)
Yeah, and I kind of wanted to go back a little bit. And I wanted just the general, you the audience to know those who are interested in research, there's a couple of trials that actually came out that reinforces your statement about how there's a lot less risk or cardiovascular risk, especially in the younger, you know, population. Those trials were called the KEEPS and ELITE that came out in 2010, 2013.
that really kind of put that a little bit more to rest that there's a lot less cardiovascular risks associated. And even also, like it kind of undermined the assumption that hormone therapy increased cardiovascular risk basically.
Anthony Keele, MD (30:18.37)
Right.
Anthony Keele, MD (30:29.475)
Right. And again, the problem with that is the women's health initiative, when those studies began to be, you know, discussed and the results released. again, the problem, of the big problems with is they released a lot of their results prematurely. Um, and, what happened was, cause you know, you had this large study with, uh, there was about 160,000 women, um,
Tom Rountree (30:46.094)
Mmm.
Anthony Keele, MD (30:56.579)
but it was skewed to more, so was patients aged 50 to 79, but the majority of them were over 60 that they had in the study. So there was a,
So it skewed the results to the older patients. Where they really saw the benefit though was in the younger patients, the women who were just going through menopause. But what ended up happening was it created a scare. And then all, like I said, everyone was scared to give patients these hormones because they're gonna cause them to have breast cancer or they're gonna cause them to have a heart attack or whatever. And then as these other trials came out later,
They totally contradicted the results that were published of the first trials, but because the damage had already kind of been done, they weren't as popular and so as widely promoted or distributed as the initial study.
Tom Rountree (31:49.646)
Accepted. Yeah.
Anthony Keele, MD (31:52.972)
because after the women, the WHO studies came out, that became the standard. That's what everybody talked about when they were talking about hormone replacement therapy in women, menopause. You had these studies later that came out and said, that's not right. It's a good thing for them. The other thing that happened too is in the last 20 years since that stuff came out,
Tom Rountree (32:14.498)
Mm-hmm. Mm-hmm.
Anthony Keele, MD (32:21.601)
They've, you know, we're now able to do gene analysis. And for example, the whole deal with the breast cancer, right? It wasn't about giving them estrogen. you know, it was a, there's a term for it. you know, basically, we now know that women who get breast cancer for the most part is because they have a mutation of BRCA1 or BRCA2. And we can actually test those genes, right?
Tom Rountree (32:49.09)
Yeah. Yeah.
Anthony Keele, MD (32:51.683)
And so it was it's called I think it's called lead time bias is what the problem was but what was happening is
and I had this discussion with patients a lot because they're asking you know if you talk about okay I'm having these symptoms I'm you know I want to you know I want to fix my symptoms but I'm worried that I'm gonna get breast cancer right so I explained to patients look the the thing about breast cancer you know the reported incidence of breast cancer in United States is about 12 % so basically one out of every eight women will have breast cancer in their lifetime and we know
The reason that is is because that's the prevalence of those gene mutations. BRCA1 and 2 is about 12 to 13 % in the population in the United States. So if you have that mutation, you are more likely to have cancer. The association with hormone replacement therapy though is, one of the things, if a woman develops breast cancer and they take it out, one of the couple tests they do, they look for,
estrogen receptors and progesterone receptors on the cancer cells. A lot of breast cancers are estrogen, they're either receptor positive or negative, but there a lot of them are estrogen receptor positive. What that means is that if you are giving
a woman, let's say they're in menopause, they have very low estrogen or no estrogen, and you're giving them supplemental estrogen, there is a slight risk that because those cells are estrogen receptor positive, that giving them supplemental estrogen can make the cancer grow faster. So that's the real... The problem is they made the association that because women were getting estrogen,
Anthony Keele, MD (34:47.893)
So the cancers were showing up faster. during the period, looked like they made the thing, they did a cause effect. They're taking estrogen, they got breast cancer.
Tom Rountree (34:51.091)
Right, right, yeah.
Tom Rountree (35:00.012)
Mm-hmm.
Anthony Keele, MD (35:00.331)
No, they got breast cancer because they got breast cancer. They had to be on estrogen. So there's lead time bias. So the tumors grew faster and they showed up faster on self breast exam or mammogram or whatever, how they were discovered. Right. So that was one of, that's one of the issues. And so that's why I tell women like, look,
If you have this gene, there's a good chance you're going to get breast cancer. Now we can test for the gene. Unfortunately, it's a fairly expensive test and a lot of insurance companies don't cover it. But we can test for it. And I tell them, look, if you have this gene and you take estrogen, you're probably going to get breast cancer. If you take estrogen, it's going to show up quicker. But on the other hand,
Tom Rountree (35:50.146)
Mm-hmm.
Anthony Keele, MD (35:51.734)
I also, you I see that women who are taking estrogen replacement therapy tend to be more health conscious. So they do monthly self-press exams. go and get a mammogram once a year or whatever, get their over four year. So they tend to pay attention. And so, you know, I've been doing this 20 years and I've had maybe...
Anthony Keele, MD (36:25.251)
10, 15 women maybe in that period of time that actually got breast cancer. And none of them, yeah, I mean, I think I've probably treated an excess of 5, 6,000 patients over that time. And I've had 10 or 15 of them that got breast cancer and none of them died from it. There was all stage one. So it was diagnosed, they it removed. Some of them were put on,
Tom Rountree (36:32.224)
Out of thousands and thousands.
Anthony Keele, MD (36:55.235)
like tamoxifen, know, or remadex, you know, suppress estrogen. But a couple of them got radiation therapy or whatever. But I have not ever had a female patient get breast cancer and diaphragm.
Tom Rountree (36:58.306)
Mm-hmm.
Tom Rountree (37:12.226)
I think it's also important to point out that once they get on this therapy, their energy comes back, they're probably lot more active, and they're actually probably engaging in things that actually decrease their cancer risk. So if they're exercising more because now they have more energy, if they're eating healthier, because it kind of goes hand in hand, but if you're being treated,
with something that is supposed to improve your lifespan and your quality of life, then you will likely go and start exercising and doing all these other things that actually decrease your cancer risk.
Anthony Keele, MD (37:49.504)
Exactly. Right. And that kind of goes back to, you know, I mentioned at the beginning of the talk, you know, one of the reasons I got into doing this was I was looking to be more proactive in patients' health and not, you know, most of what I was finding I was doing in family medicine was reactive. Patient comes in, they're overweight, they're not exercising, they're not eating right, they have high blood pressure or
they develop diabetes or they have high cholesterol or whatever. So we're treating reactively to some problem that patients develop. Whereas I found over the last 20 years by treating, aggressively treating patients when they begin to experience a hormonal decline, right? And we haven't even touched on the other health benefits of hormonal replacement therapy.
like for example testosterone and some of those things.
lowers blood pressure, it lowers cholesterol, it improves cardiac output. So, you know, they're less likely to get congestive heart failure. And, you you just mentioned one of the big things is if you can take a, you know, a typical say 40 year old female, right? Who got some kids at home, you know, kids are in high school or college or, whatever. Or sometimes you got 40 year olds now with little kids, right? They got five, 10, five, 10 year olds, something like that.
So if they're experiencing a little decline, they're not sleeping good. They're tired all the time. They don't feel like going to the gym. You know, they, just are kind of dragging through life and you can take that person. do the testing on them, figure out what they're low on and then, kind of my, my, optimized living program is basically we do a series of blood tests, a comprehensive blood panel, and we compare their numbers to patients who, know, a typical patient who's in
Anthony Keele, MD (39:48.566)
their 20s, right? And the other thing that I look at when I'm assessing hormones, right? And I have, again, this isn't something else I talk to patients a lot. If you look at, let's say you measure someone's testosterone level, their estrogen level, right? There's the lab normal, right? The lab says, okay, you know, and I always tell patients, lab normals are based on what's called 95 % confidence interval.
So if you take a hundred random people and you measure a value, where are 95 % of those people going to fall? Right? So that's what lab tests are based on. The problem is from a clinical standpoint, just because you're in the quote normal, doesn't mean that you feel good. And what we find is, that patients, especially for hormones, if you're in kind of that top third of the normal range,
And that's what I call, and that's why I call it optimized living because that's the optimal range for testosterone for DHEA, for vitamin B12, for vitamin D, for estrogen, progesterone, all these different things, growth hormone that we can measure. And so, a lot of times, a lot of the patients I'm treating,
their levels are quote normal because they're in the lab normal, right? And that's also too why a lot of patients who are having these symptoms, they'll go to their primary care provider or whoever, gynecologist or whatever, they'll get the lab tests and because the test values are in the quote normal range, the doctor or nurse practitioner or whoever will say, hey, your levels are normal. You don't need anything.
Tom Rountree (41:14.85)
Mm-hmm.
Anthony Keele, MD (41:36.95)
anything. But from a clinical standpoint, if you take a patient who is at the, you know, in the lowest 30 % of the lab normal and you treat that patient and push them into the upper 30 % of the lab normal, they feel better. And, you know, it's easier for them to lose weight because their metabolism increases, their blood pressure increases.
Tom Rountree (42:01.366)
Mm-hmm.
Anthony Keele, MD (42:02.785)
They have more energy. They sleep better. know, they just things are overall better. It, you know. Right. Yeah, and that's a, that's a thing that, you know, I think a lot of, you know, people when I initially started doing this 20 years ago, they were thinking of that. was taking patients and, and like, you know, for example, the, you know, the guys that.
Tom Rountree (42:08.738)
So, yeah, they're still in the normal range. They're just in the upper normal range.
Anthony Keele, MD (42:30.327)
the bodybuilders or the power lifters or whatever that are taking anabolic steroids.
And really what they're doing is they're taking compounds which are broken down testosterone in their body. So they ended up with a super physiologic of really, really high testosterone level. Right. And because they can make them stronger, they can grow muscle faster, but also has a lot of deleterious effects. And so they were assuming that I was taking normal patients and making them super normal or super physiologic.
Tom Rountree (42:46.445)
Mm-hmm.
Tom Rountree (43:02.56)
Right, super physiologic, yeah.
Anthony Keele, MD (43:04.449)
Yeah, all I was really doing is and other people that do, it's actually called anti-aging medicine or age management medicine, doctors that focus on that. All we're doing is we're saying, okay, if you look at the lab normal, right.
Tom Rountree (43:14.028)
Mm-hmm.
Anthony Keele, MD (43:23.882)
from a scale, say, one to 100. Where do you fall in that range? If you're above between 70 and 100, you're probably not coming to see me because you feel good, right? But if you're in the 20 to 30 % of that level, you're going to have symptoms. And so then all we're going to do is we're going to try to take you from the 30 % range and move you above 70, right?
And that will generally fix your problem. And so that goes back to the whole preventative thing. If I can take someone who's 35 and is getting to experience the hormonal decline at the beginning, and I can supplement their hormones, get them up, they are not going to experience the negative things that they would potentially.
So you can potentially prevent that heart attack that they would have had at age 55 or age 60 or whatever, or you can prevent them from becoming a diabetic. Right. Or you can prevent them from developing numerous other problems. Um, you know, or, you know, joint, joint, joint problems, right? If you're a hundred pounds overweight, there's a good chance you're going to have problems with your knees. You have arthritis or other degenerative problems from, being overweight.
Tom Rountree (44:33.784)
Mm-hmm.
Anthony Keele, MD (44:48.201)
So really what I do, that is the focus of what I do is trying to basically wherever patients are at in that spectrum is to try to optimize their hormones so that by doing that, they're able to better manage situations in their life and they're more energetic. It's easier for them to lose weight.
And a lot of times, you know, if you feel good, you're sleeping good, you have more energy than, you know, exercise is easier. Um, I have patients all the time that come in that they're a hundred pounds overweight. They're exhausted. You know, they're like,
I come home from work, I lay down on the couch and I take a nap for an hour. And then I try to get up and fix something, eat or whatever like that. They just don't want to go to the gym because they're tired all the time. But once you fix their hormones, now they're leaving work, they still feel energetic, they're gonna go to the gym. They're gonna go, you
And those are the patients who are going to lose weight, their blood pressure is going to come down. know, one of my favorite things of doing, you know, a lot of people worry about diabetes, right? And diabetes, you know, is again, you don't wake up one day and you're diabetic. It's a, you know, the average patient takes 15 years to become a diabetic. It starts with insulin resistance. And the majority of like type two diabetics in the United States is because of
obesity. So it's like a catch-22, right? You gain weight and you develop insulin resistance and that makes your insulin levels go up and you gain more weight and your insulin resistance goes up and up and up and and finally you're producing so much insulin that your insulin receptors begin to fail and now you have high blood sugar and then that begins to affect all your other organs and stuff.
Anthony Keele, MD (46:42.755)
So a lot of patients who come to me for hormone replacement therapy have all these other problems and I can fix the other problems by fixing their hormones. And you know, we address the other things as well, but you know, one of my favorite things and I've done this hundreds of times in last 20 years, I love when I cure diabetics. And a lot of people think that once you become a diabetic, you're always a diabetic. Well, it's not true. You're a diabetic.
at least you know for the type 2 diet bags you know adult onset diabetes it's typically because you've got insulin resistance and those patients typically tend to be overweight well if you lose weight the insulin resistance will go away the diabetes goes away so if you're on medication for diabetes and you lose weight it goes away you don't need a medicine anymore so I like yeah I like when I am able to
Tom Rountree (47:35.384)
Yeah, yeah, definitely.
Anthony Keele, MD (47:41.603)
reduce someone's weight, reduce someone's insulin resistance where they no longer require medication.
Tom Rountree (47:51.342)
So if we can, I want to just to clarify earlier, you had talked about treating women, like perimenopausal or menopausal with the hormone therapy. And does it improve their flushing and their lack of sleep? I just kind of want to hammer that home a little bit because I think it's very important that people understand that
Anthony Keele, MD (48:17.655)
Yeah.
Tom Rountree (48:21.89)
Well, I'll let you talk.
Anthony Keele, MD (48:25.197)
So, yeah, so what brings a lot of female patients in in that age group, in the 40s, early 50s, whatever, is because of severity of their symptoms, right? They're having hot flashes, it's interfering with their work, it's interfering with their activities at home, they're having night sweats, they're waking up at night just soaking wet and having to change their clothes, stuff like that.
and they're having the mood swings. You know, they're having weight gain. They're having trouble focusing at work. You know, there's the brain fog. We mentioned that earlier. So these are all symptoms that are bad enough that it's affecting their, their life. Right. And they, they want it fixed or, you know,
Tom Rountree (49:08.144)
And typically, this is like, I'm trying to think about like a case study a little bit, like maybe they're like 40 or 45 or 45 to 50, is that kind of what we're looking at?
Anthony Keele, MD (49:19.447)
Yeah, so in my experience, most women begin to have these symptoms about three years before they go through menopause. And that's what they call the perimenopausal phase, right? You're having symptoms of menopause, but yet you're still having periods somewhat. Maybe they're irregular. if you do the blood test, the FSH is below 23. But they're still having symptoms.
You know, it's to the point it is affecting their daily life. So a lot of providers, if they have that patient come in, if they do blood work or whatever, they're going to say, okay, well, your levels are okay. They're not going to treat it because they're basing it on a blood test. Well, I, you know, am of the opinion that if, if symptoms are bad enough that they're affecting your daily routine, right?
Tom Rountree (50:03.278)
Mm.
Anthony Keele, MD (50:18.029)
then that can be treated and it should be treated. Now, giving a woman estrogen or progesterone, is that going to prevent you from going through menopause? No, they're still going to go through menopause. It's just you're blunting that process because they're not having those symptoms. The other thing I do, patients I'm prescribing estrogen replacement therapy to or any kind of hormone.
Tom Rountree (50:37.795)
Yeah.
Anthony Keele, MD (50:47.427)
You know, we do serial blood tests because one, we want to make sure that we're giving them, you know, the amount of medication, whether it's the shot or pill or whatever is putting them into a healthy level. But also to, you know, if a woman say is 40 years old and has been experiencing these, you know, and you know, most women they'll put up with it for a while. So it's like a typical patient. You've mentioned that, you know, a case study.
So a typical patient, let's say, you know, it's a 42 year old woman who's been experiencing hot flashes and nights sweats for, you know, six to 12 months, right? And initially they were wanting twice a week. They'd have one last 10, 15 minutes. Now they're having two or three a day, right? And they're having trouble sleeping at night. Uh, they're waking up two or three times a night, just soaking wet. They're having multiple hot flashes during the day. Um,
you know, they're having some mood swings, a lot of them, especially, you know, if they're in a relationship, they begin to experience a decrease in libido. And now they're not interested in having sex. And, you know, if their partner is still interested in having sex, now that becomes a, you know, a conflict in the relationship, you know, you know, one partner wants to have wants to have sex more than the other one.
And so now that becomes a, you know, it becomes an issue. Yeah, they've had relationship problems and, know, like I have women all the time who tell me like, you know, five years ago, my husband and I or my boyfriend, whatever, you know, whatever relationship they're in, you know, they would want to have sex two or three times a week or three or four times a week. And then.
Tom Rountree (52:20.226)
Big relationship problem. Yeah.
Anthony Keele, MD (52:45.311)
Now it's like they don't care about it at all. So, but their partner hasn't changed a bit. And so they, you know, now that's where that conflict comes in. So if you supplement their estrogen, you know, you can fix that. can fix that problem.
Tom Rountree (52:48.909)
Yeah.
Tom Rountree (53:04.174)
Right, right. And I kind of want to give some context. I was, when I did Ob-Gyn for, I did it for a year and then I switched to FamilyMed, one of things we would do is change the oral contraceptive pill based on the estrogen that it had. And in order to try and fix their, you know, their perimenopausal problems. The problem with that is that you cannot fine tune an oral contraceptive pill.
Anthony Keele, MD (53:25.187)
Right.
Tom Rountree (53:32.972)
you know, it's given to you. Like this is the amount of estrogen and if you want to go to the next one, it's maybe this slightly different amount of estrogen. just don't, you it's not something that you can actually fine tune. So with the injections, you know, you can actually titrate it to actually an optimal dose. And also ACOG has come out, American College of Obstetrics and Gynecology has come out and saying, hey, yeah, this is actually
Anthony Keele, MD (53:43.427)
Right.
Tom Rountree (54:02.594)
beneficial to treat women with hormones around this stage of their life.
Anthony Keele, MD (54:09.239)
Right. Yeah. So.
Anthony Keele, MD (54:16.311)
Yeah, I mean, when you're going to treat estrogen deficiency, know, you ideally you want to use something that is titratable and you know, you can follow the blood tests and whatever, but specifically for estrogen, for me, it's more about clinical clinical results. Right. So I, and the other thing too, just like with any medication, you know, you want to, you want to start low and go, you know, start low and go slow. Right. So I try to get
Tom Rountree (54:44.526)
Yeah.
Anthony Keele, MD (54:45.187)
the lowest and I want to use the lowest possible dose that gets the results that we want. And so a lot of times I'll tell women that, we're going to start this hormone replacement program. You know, I always tell them, I'm like, hey, you is you want to, you want to think of this in terms of about a three month period. So it's not that we're going to fix you day one, but over the 90 days, you know, we're going to, um,
Tom Rountree (55:05.39)
Mm-hmm.
Anthony Keele, MD (55:13.091)
And I've been doing it long enough that probably 90, 90, 95 % of patients, the dose I put them on initially will fix their problem. But I, know, the other thing is important as regular follow-up. So typically I see a new patient, we've done the lab testing and all the tests that we do, and we're going to supplement them with, you know, X, Y, and Z, right? We do that for a month, have them come back in.
And then we talk about it like, okay, a month ago before we started, let's say for example, the patient is going to do estradiol injections, right? She's going to do an injection every two weeks. So I would have given her one in the office. She did one at home two weeks later. So she's had two injections. So we'll talk about it and we'll say, okay, before we started this, you were having two or three outflashes a day. You're having nights with at least two or three nights a week. And it was...
You it was affecting your mood and your libido and all whatever. So, you know, where are we at now? And my goal is with estrogen replacement therapy specifically, my goal is to have zero hot flashes, zero night sweats. And that's for the most part pretty easily attainable. You know, and like I said, I'd say 90 % of patients with it, start the dose, I start them on with the estradiol injection and they come back in a month that they have, they've had not.
You know, usually they'll tell me, hey, you know, this is great. I feel so much better. You know, I'm sleeping through the night now. I feel more rested during the day. You know, my mood's improved. I'm not getting into arguments with my spouse or my kids or, whatever. And so they are seeing a positive change in their life by giving them a shot. Right. So.
Tom Rountree (56:42.61)
wow, yeah.
Tom Rountree (57:07.084)
Yeah, and they came in for a couple of symptoms, but then they come back saying, hey, you fixed all these other things as well.
Anthony Keele, MD (57:14.049)
Yeah. And that's the thing. You know, I see that all the time. A lot of people, because the other thing too, as I tell patients is like, look, you didn't wake up one morning. This is the way you were. This is a gradual process over many months or sometimes years. And so your body, you know, when things begin to change, you, it's such a, you know, it's a, it's such a slow change that you kind of get used to it. And it's not until, like you said, they come back in a month.
And like, yeah, they came because the hot flashes, night sweats, but all these other things have gotten better too, right? And so once you change it, now they realize, wow, I didn't, and I'll hear it. They tell me that a lot. The patient, female patients will say, hey, I didn't realize how much I was struggling in these different areas until we fixed it. And now, you know, all these different aspects of my life have gotten better.
And so to me, you know, that's one of the big things about about medicine. You know, our goal is to make patients lives better, to make them healthier, to make them, you know, you know, and one of the things we talk about in anti-aging medicine is it's what's called the the vitality curve. Right. So what happens is in a normal person as your levels.
your hormone levels begin to decline, your vitality curve goes downhill. So, well, when you start replacing their hormones, it either goes up or at least levels off. Right. And so, in medicine, you know, we have all these really great procedures and medications and different things that we could do and all these different aspects, you know,
Um, you know, say in the heart or in diet treating diabetes or heart disease and all this, we can fix a lot of different things. But the problem is, is, is you can make, we can make people live for a long time. But, um, if their last 40 years of their life, they're, they, they don't feel good. They're miserable. What's the point. Right. And so I see that is, you know, one of the big reasons of.
Anthony Keele, MD (59:38.916)
for what I do is, okay, yes, we can do a heart cath or we can do whatever procedure to make you live longer, but we wanna make sure that your quality of life is good. And so I see doing a hormone replacement therapy as improving quality of life. And that's the whole point of it.
Tom Rountree (59:59.854)
Yeah, I think you're right because the other thing is that people come in and they'll tell me, well, hey, doc, I'm exercising, I'm eating right, but I still just have these perimenopausal symptoms. And I kind of want to let people know that, your body has these hormones that are essentially just going away. there's nothing you can do.
Anthony Keele, MD (01:00:15.373)
Right.
Tom Rountree (01:00:28.662)
You can't out exercise it, you can't out nutrition it. These things are just simply disappearing over time and they're slowly disappearing over time. And so that's why they're experiencing these symptoms. And I don't want them to beat themselves up thinking that, I'm not exercising enough each week. It helps with the symptoms, but it will not get it as far as hormone replacement there.
Anthony Keele, MD (01:00:32.312)
Right.
Anthony Keele, MD (01:00:56.151)
Yeah. And, you know, there's a huge market in supplements, right? All these different things, know, vitamins and minerals and other like peptides and things that people will take. And, you know, I feel like they have their place, but without actually supplementing the hormone itself, you're not generally going to fix the symptoms by taking something else. So you have to fix the
Tom Rountree (01:01:02.518)
Mm-hmm.
Anthony Keele, MD (01:01:25.987)
what's causing the problem in the first place and not just, you and with, especially with the internet and, you know, all these, there's, you know, yeah, there's a lot of people that are following. Yeah, a lot of, and a lot of stuff, you know, some stuff's okay. Some stuff's good, beneficial, but there's also a lot of bad information out there.
Tom Rountree (01:01:40.174)
influencer gurus. There's a lot of them out there.
Anthony Keele, MD (01:01:54.98)
And a lot of, you know, and I, it's what I always tell patients is, um, you know, you have to look at, you know, whoever you're listening to or trying to get advice from, you need to look at their, what's their motivation. Are they representing some supplement company and there's their, they're wanting you to buy their products. Right. Um, and so they're basically using your health as a sales pitch.
sell some product.
Tom Rountree (01:02:26.592)
Yeah, yeah, and it's one source, it's their source of income. it's, like, that's what I tell people, like doctors, we have multiple different diseases we're treating, you know, multiple ways to treat them, but these other influencers are like one thing, you know?
Anthony Keele, MD (01:02:37.858)
Right.
Yeah. I, right. And even in, in medical stuff, you know, one of the things that's really become popular is this whole, the whole med spa thing, right? even in Kate, you know, there's six or seven med spas anymore. And I ended up seeing a lot of patients who've gone to these med spas and, know, nothing against them,
Tom Rountree (01:02:54.776)
Yeah.
Anthony Keele, MD (01:03:09.347)
at least the ones around here are all for the most part of staff with nurse practitioners. And my issue with that is a lot of times the nurse practitioners, what they've done is they've gone to a weekend training program. Like for example, the Bio-T training program, they've gone to a weekend training program where they've had, you know,
two days of education. The first day they educate them about hormone replacement therapy and human physiology and all this stuff and how that works. And then usually the second day, they're talking about selling products, right? And so I have patients all the time that basically go to a med spa or one these little hormone clinics and they'll have a...
Tom Rountree (01:03:51.807)
Mm-hmm.
Anthony Keele, MD (01:04:03.491)
Battery of test done and then they're put on a whole bunch of different some hormone stuff But also a lot of supplements and they're told well you need to take this this and this and you know Hey, you know all this stuff is you know, it's it's $500 a month, right these different products and so For a lot of patients, you know, they're gonna feel better because there's they are getting the treatment but where the the difference comes in
and go into one of these places where it's patients who are like, see, is if they have a problem, right? Because, you know, let's say 90 % of patients are gonna, you know, so what they're doing is they're learning a treatment algorithm, right? You do these tests, if the value is this, give them this, if the value is this, give them this, right? And then a treatment algorithm. But they don't really, they don't have the knowledge and the experience.
Tom Rountree (01:04:39.286)
Yes, yeah.
Anthony Keele, MD (01:05:03.167)
if things don't go the way they're supposed to, right? So a patient comes back in a month, well, they're having a problem and well, they don't know what to do with it. They don't what to do about it. And so, you know.
Tom Rountree (01:05:16.566)
Yeah, I have a specific case where I found basically sustained high blood pressure leading to chronic kidney disease, you know, across three different lab values that I'd seen come from these types of spas. And I would, and I ask, say, hey, are they looking at that and are they treating it for you? And the answer is almost always no, because they're so limited in their breadth of experience that
it doesn't even register on their radar very well. So, you know, I think it's, like you're saying, it's important to be cautious whenever you're visiting these places, going to.
Anthony Keele, MD (01:05:56.452)
And I tell, you know, I have patients who, who, you know, sometimes I see, but they also go to one these other places for whatever. And if that's what they want to do, it's fine. But again, I always caution the patient. I'm like, look, you know, this is all they do. So their whole stick is all their complete source of income is based on whether we can, you know,
pellets in you or whether we can give you shots. And then we have these, all these different supplements. Well, we make money off and sell them the supplements. So we want you to take all these supplements. And so I see patients all the time that are basically taking a whole bunch of different products that they probably really don't need. but the reason they're taking it is because whoever told them to buy it.
Tom Rountree (01:06:35.768)
Mm-hmm.
Anthony Keele, MD (01:06:54.027)
or prescribe it to them wants to make money. And I tell patients like, look, know, EBO, for example, is a membership driven thing. They pay a monthly membership. so, you know, my motivation is not.
We, you know, I don't put patients on stuff just to sell a product. you know, I try to be comprehensive about it. Also too, I've been doing this for 20 years and I have a much greater experience dealing with problems and being able to solve problems for patients because yeah, I mean, unfortunately, you know, there is, like I said earlier, there is no perfect treatment.
Tom Rountree (01:07:20.313)
Mm-hmm.
Anthony Keele, MD (01:07:42.372)
Occasionally patients who are put on estrogen have an issue, right? So one of the most common issues that you see in women that are taking estrogen replacement is, and I mentioned earlier, one of the big questions you have to, you know, that you want to understand before you start a patient on estrogen is do they have a uterus? Do they have an intact uterus? And so, you know, it's very important to get that history. Okay, if you had a hysterectomy,
Tom Rountree (01:08:03.758)
Mm-hmm.
Anthony Keele, MD (01:08:10.509)
You did have hysterectomy, why'd you have a hysterectomy? Was it, you know, did you have uterine cancer or were you having a heavy bleeding or you're having fibroids or pain or, know, what was the problem? Endometriosis, you know, whatever. And so you want to know, did they take the uterus out? Did they leave the ovaries? A lot of times in pre-menopausal women who get a hysterectomy, unless they need to take the ovaries out for some particular reason,
A lot of times they'll take one ovary out and leave one so that they're still producing estrogen, progesterone, testosterone, DHE, all the hormones that the ovaries produce. Sometimes they'll take them all out. I see that frequently too, patients who, they were 30 years old, had a complete hysterectomy and they weren't put on anything. Now, 10, 15 years later,
They have low testosterone, low estrogen, low progesterone, low DHA. I mean, they have low everything. And they're overweight and they've got pre-diabetes and they've got high blood pressure and their cholesterol's bad and all these things have gone wrong. And a lot of it was because somebody took their ovaries out and didn't educate them on the importance of supplementing those hormones, right?
Tom Rountree (01:09:32.622)
I think it's strange how if you take the thyroid out, they will definitely be put on hormones. Like they will, you know, for sure. But you're right, I've seen ones where they've had a complete hysterectomy and there's no, like, there's no hormone, you know, replacement for that.
Anthony Keele, MD (01:09:38.561)
Right.
Yeah.
Anthony Keele, MD (01:09:50.274)
Right, right. So I think that's a, you know, and I've seen that many, many times. But again, you know, one of the big things that happens, okay, so you ask the patient if they have an intact uterus, all right. Well, if they have an intact uterus and you give them supplemental estrogen, then you run the risk of stimulating the uterine lining. And so, you know, you'll have a
Let's say you have a menopausal woman, she's 55 years old, she hasn't had a period in six years, and she's having horrible symptoms. She feels bad. So you're going to fix her symptoms, but at the same time, she's got an intact uterus. If you give her estrogen without giving her progesterone, two or three months later, she's going to come back in or call and say, hey, I'm spotting. And that's because you gave her estrogen.
But you stimulated that uterine lining, but you didn't give her progesterone, which stabilizes the line. Right. And so I kind of approach that two different ways. Some women I'll just give daily progesterone too. And even then there's a small percentage of those women who are getting estrogen in whatever form they're getting progesterone to protect the uterus. Still sometimes three or four months or a year or two years down the road, they start bleeding and then you got to figure out, why are they?
Tom Rountree (01:10:50.134)
Mm-hmm.
Anthony Keele, MD (01:11:13.955)
bleeding. So either you need to increase the progesterone or you need to decrease the estrogen or some women, you you just need to take uterus out or do an endometrial ablation and, you know, ablate the lining where they can't bleed anymore and so it won't proliferate. So, you know, that's a that's a pretty common situation that happens in women who getting estrogen replacement is they'll have bleeding. And so if you're going to supplement women with estrogen,
You need to know how to fix it if they start bleeding. You need know what to do about it.
Tom Rountree (01:11:50.766)
Yeah, I think that's important because even though these specialty clinics, they don't deal with the problems that they create. And that's a big thing because if you don't deal with them and you're just like, now you need to go to OB-GYN or something, then it's kind of like the patient is stuck, they're in limbo sometimes, they're afraid.
Anthony Keele, MD (01:12:03.008)
No.
Tom Rountree (01:12:19.414)
and they don't even maybe have answers for it.
Anthony Keele, MD (01:12:21.586)
Well, yeah. Well, and then what happens is so they have a patient who's having, let's say bleeding issue, right? So they go see the gynecologist. Well, the first thing a lot of times the gynecologist does is just takes them off all of it. They're like, you just need to stop all the hormones, right? Well, you stop the estrogen and you stop the, you you stop the progesterone. A lot of times, you know, three or four weeks down the road, the bleeding will stop because you no longer stimulate the, like the ureter.
But at the same time, now the patient's back to square one. Now they're having all the flashes and the night sweats and all that again. But because the gynecologist said, well, you you shouldn't take that because you have bleeding. So now they don't know what to do. So the place that the med spa, the whatever, nurse practitioner or whoever gave them stuff in the first place, now they've had a convocation problem.
They went to see somebody else to try to fix the problem and they were taking off everything. So now they're scared to take hormones because they think hormones are going to bleed. but I have lots of patients that, you know, that's happened to, and I just explained to them, like, look, you haven't had any estrogen for four or five years and now you're getting a little bit of estrogen. Your uterus is, is, is for whatever reason, your uterus is sensitive to it. So we can.
Tom Rountree (01:13:24.824)
Yeah.
Anthony Keele, MD (01:13:46.348)
still fix your problem and keep you from bleeding. There's a process that we can do to take care of that and I do that all the time. I a lady last, well actually I two patients last week that I was dealing with that situation that they were having bleeding.
You know, you just, got to, you got to, and a lot of it too, you know, patients, women who haven't had a period for five years, they don't want to bleed. They don't want to spot, but you have to explain to them, Hey, you know, this happens sometimes it's, it's nothing bad. Um, you know, a lot of times they're worried that they've got endometrial cancer. And like this, I this patient last week, again, I've treated thousands of women and I've never had a case of endometrial cancer ever. And, but.
Tom Rountree (01:14:24.066)
Mm-hmm.
Tom Rountree (01:14:35.128)
Right. Right.
Anthony Keele, MD (01:14:44.611)
you know, multiple times a year I'll have female patients on estrogen replacement therapy and having, you know, vaginal bleeding. And you just figure out what, you know, for the most part, it's pretty easy to figure out what's causing it. And, you know, it's simply a matter of, usually just simply a matter of adjusting the doses of the medication they're on. You know, like said, lower the estrogen, you can increase the progesterone. If that doesn't work, then you get a pelvic ultrasound.
Tom Rountree (01:15:06.798)
Mm-hmm.
Anthony Keele, MD (01:15:13.983)
and you look at their, you know, do they have something funky in their ears? Do they have a couple big fibroids now that's making them more prone to bleed? Or also you want to look at, you know, what's the thickness of the urine lining? So typically,
Tom Rountree (01:15:29.196)
Right, right via ultrasound, yeah.
Anthony Keele, MD (01:15:31.585)
Yeah, you can, I mean, they measure it and they tell you the number. And so if it's abnormal, then the next step is, you know, need an endometrial biopsy. You're to do that anyway, because you want to make sure that, you know, it's not, they don't have a endometrial hyperplasia, which, you know, a precursor to endometrial cancer. And then you're going to do some kind of definitive treatment because if the hormones are beneficial for them,
Tom Rountree (01:15:33.986)
Mm-hmm.
Tom Rountree (01:15:48.6)
Mm-hmm.
Anthony Keele, MD (01:15:59.032)
but they're having a side effect. Well, we can fix the side effect. I saw this lady that I was dealing with. She was having bleeding. I increased her progesterone. had her stop the estrogen and she was still bleeding after two weeks. So got an ultrasound. Intermittual lining was normal, right? But she's still bleeding. So I said, well, you know, she wants, I said, do you want to stay on the hormones? She goes, yeah, definitely. They've changed my life.
And I said, okay, well, you want to stay on the hormones. We got to fix the uterus problem. So I referred to like gynecologists for an endometrial ablation where they go in and basically burn. you know, I mean, you know, but the lining of the uterus where it can't proliferate. So problem solved. And it's, you know, that's an outpatient procedure. Um, you know, pretty well tolerated and it's much less invasive than going in and taking the uterus out. So, and now somewhere.
Tom Rountree (01:16:40.844)
Yeah, yeah.
Tom Rountree (01:16:55.34)
Mm-hmm. Mm-hmm. Yeah.
Anthony Keele, MD (01:16:57.731)
Basically, they've got an abnormal uterus, it's enlarged, or they've got fibroids or whatever. Those women typically end up getting hysterectomy. They'll go in, outpatient, do a laparoscopic assistive adenomysterectomy.
And then most of the time those women go right back on hormones because it's, you know, it's benefiting them. And once the uterus is gone, you ain't got to worry about it
Tom Rountree (01:17:30.734)
Yeah, yeah, it's profound change in life for them. So much better.
Anthony Keele, MD (01:17:34.338)
Yeah. So like I said, that's difference. If you're going to treat hormones, you need to know what to do if there is a problem. And that's why sometimes I'll tell people, that's kind of the difference of me treating a patient with my years of experience and my knowledge versus somebody who went to a weekend course on how to treat hormone replacement or how to do hormone replacement.
Tom Rountree (01:17:59.534)
Yeah, knowing that nuance is the difference between the patient having a good life or not. That nuance is extremely important in medicine for sure.
Anthony Keele, MD (01:18:08.994)
Right.
Anthony Keele, MD (01:18:12.297)
It's also the difference between, you know, and a lot of it, a lot of times, you know, patients, you know, they're going to base decisions on what they're told. So if they're having a problem and someone says, hey, this is terrible. You should never take hormones again. You know, it's going to cause you to have this problem or whatever. You know, they basically are going to be too scared to do it.
But at the same time, if you have a provider who says, okay, yeah, yeah, we're having an issue. Here's what's causing it. And here's what we're going to do to fix it. And you're getting a benefit from the hormones. So you can continue to get a benefit. We just need to fix the problem. Right. So it's all about it's, you know, how the patient reacts and how the patient looks at the, at the situation is, is wholly determined on the
Tom Rountree (01:18:49.71)
Mm-hmm.
Anthony Keele, MD (01:19:09.389)
perspective and the outlook of whoever's talking to them, the provider. And so that can make a huge difference on whether that patient ends up staying on the hormones or whether they stop it. And now they spend the next five to 10 years having these terrible symptoms that are negatively affecting their lives.
Tom Rountree (01:19:19.638)
Yeah, and how they perceive it.
Tom Rountree (01:19:34.83)
Yeah, I think that's a really, really, really good point. Well, I think we had a really good conversation on this. And I really appreciate you talking about it because almost no one, I mean, finding the solution to perimenopausal problems is sought after by, you know, thousands of women, but the solution is not very apparent and it's not out there in the world. So I really appreciate you talking about this.
Anthony Keele, MD (01:20:04.813)
Right.
Tom Rountree (01:20:05.07)
And I think we can definitely have maybe a follow-up podcast on testosterone and other hormones. I think it'd be really good to talk about it. But appreciate you talking about this one. And is there anything you wanted to add before we let our listeners go?
Anthony Keele, MD (01:20:14.701)
Sure.
Anthony Keele, MD (01:20:29.089)
Yeah. So, mainly what I would say is, is, you know, home replacement therapy is a very beneficial thing. can, it can dramatically change your life. And so I would just encourage patients, you know, we're talking about female patients here, but I would encourage female patients, who are beginning to have these symptoms, the hot flashes, the nights with the mood swings. you know, there's another thing we get it. We didn't really get into very much, which is called.
dyspareunia or pain during intercourse, which is another really common complication of estrogen deficiency and something I treat frequently. But I would just encourage patients that they're having those symptoms, get tested, talk to your doctor, ask them to do an FSH test on you. It's an easy blood test to do. like I said, if you're over 23, you're in menopause. Or if you're close to it,
you know, if you're 1920, you're pretty close to menopause. You're probably going to go with menopause in a year or so. But if you're having these symptoms and you go to your provider and they try to, you know, act like it's nothing that's important or it's something that should be treated, then what you, you know, I would encourage you to seek out a provider that does hormone replacement therapy because, know, if you're in that percentage of women who are going to have these symptoms long-term,
To me, it doesn't make any sense to just suffer with these symptoms of estrogen deficiency for years and years and years when there is safe treatment that can fix your problem and not only solve those issues but have other positive health benefits for you in the long term and maybe prevent you from having some serious...
issue or complication down the road. you know, like I said, it's all about, you know, being proactive when you begin to experience these problems, get it checked out and find someone who, you know, deals with this situation on a record basis and is going to be proactive about helping you feel your best.
Tom Rountree (01:22:47.074)
Great. Thanks so much, Dr. Keel, for this conversation. I'm looking forward to definitely our next one.
Anthony Keele, MD (01:22:52.886)
All right, thanks.
