Dr Louise Newson [00:00:02] Hello. I'm Dr Louise Newson, and welcome to my podcast. I'm a GP menopause specialist and founder of the free balance app. My mission: to break the taboos around women's health and hormones, shining a light on the issues we've been too afraid to talk about, from contraception, sex and testosterone to menopause related addictions and beyond. We're covering it all. I'll also be joined by experts and inspiring guests, sharing insights and real stories, as well as answering your questions and tackling the topics that matter to you the most.  

Dr Louise Newson [00:00:42] Today on the podcast I've got with me, Dr Felice Gersh, who's dual accredited from the US. She's a gynaecologist, so OB-GYN trained, but she's also trained in integrative medicine. We really do unpick about hormones, especially oestradiol, but we also talk about why it's so hard in the US, especially, to get natural hormones, and how easy it is to get synthetic hormones, there's lots of conversation that's really great in this podcast.  

Dr Louise Newson [00:01:14] So, Felice, you're here in real life, because last time we did a podcast remotely, I can't remember how long ago, but it was a while ago, because I remember I was sitting in my husband's study and talking about heart disease and hormones. And you know, you're one of the few people I can really geek out with. I can really talk on a cellular level about hormones, which is great, but now you're in real life. You've been to my house, you've been to my clinic, and now you're here in the studio.

Dr Felice Gersh [00:01:39] Well, you invited me to come, and I just jumped at the opportunity. It's like, this is so fun. And yes, we can talk about everything, and we are so aligned. It's just fantastic.  

Dr Louise Newson [00:01:50] It’s great because tomorrow we've got a conference, and you're coming to speak, and you spoke, we have monthly meetings for all our clinicians. And you came and spoke, and it was just brilliant. Because as you were talking, lots of them are WhatsApping me to go, Oh my goodness. How did you meet Felice? She's brilliant. She's so knowledgeable. Because, I think in medicine, and I'm sure it's the same for your training in the US, but certainly in us, we're just taught, this is a condition, this is the treatment. Ask no questions. And as you know, I've got a pathology degree as well. So, I did three years as an undergraduate, then I took a year out and did a pathology degree. And it was then that I really learned about cell processes, and I really learned about very basic things, about receptors, about our immune system, about mitochondria, the powerhouse of our cells. And it was really such an interesting time. And I was saying to my husband, who's also got a pathology degree as well, I forget that lots of people didn't do that degree. They don't have that knowledge. They don't have that basic science. So, if I'm stuck in medicine, and I've always done it, if I'm working why has someone got raised blood pressure? I will go back and work out, how do the kidneys work? What's happening? What's happening with their different processes that are going on in their body? But if you don't have that basic knowledge, it's really hard to move forwards, isn't it?

Dr Felice Gersh [00:03:13] It is, and a lot of it, honestly, I had to acquire by doing a lot of my own reading and research, because I went to school a long time ago, and I am so into exactly what you were saying. Mechanisms, what's happening at the cellular level. How is this working? Because only then can you really think it through and think independently and not just do what like, here's the protocol, follow the protocol, and without even thinking, not mindfully, like working it through, like, why is this the protocol? How did it get established? Does it even make sense? Is there a better way? So I think that's what both of us have been striving for, looking for, are there better ways and not being stuck in established protocols without, like, thinking them through and looking at the foundational pathways and mechanisms and so on, which makes it so exciting and really fun trying to figure out how a woman's body works, for example.  

Dr Louise Newson [00:04:15] And it's so true. I mean, you've been a gynaecologist and OB-GYN for many years, and then you've sort of reinvented, re-educated yourself quite a few times on your professional journey, haven't you?

Dr Felice Gersh [00:04:28] I have. I call it my different chapters. So, there was a chapter when I did 1000s of deliveries. I was just a prolific surgeon and always learning and different techniques and working with new medical devices, some of which were horrible, and now are off the market, thank goodness. And then when I moved on from doing obstetrics and lots of surgery, I went back to school, and I did a two-year fellowship in Integrative Medicine at the University of Arizona School of Medicine, and really took a lot of other courses in functional medicine. Learning about mitochondria, and never looked back. So, I just say that I have what I call my expanded therapeutic toolbox.

Dr Louise Newson [00:05:08] Which is amazing

Dr Felice Gersh [00:05:09] It makes it so much easier to practice, too, when you have more resources to draw from to help your patients. And it really is. I love my new chapter, educating, traveling, writing, writing papers, and I'm still a clinician, though I work every day. When I'm in my office, I'm working every day, which I think, like we talked about this earlier, keeps us really grounded and really understanding what it means to take care of patients. So many people make recommendations about patient care, and yet they're not even seeing patients, and haven't for many, many years.

Dr Louise Newson [00:05:46] I totally agree. And you know, being a doctor is such a privilege. Seeing patients is the best part of the job, but it does keep it real, and also, individualisation of care is so important. So you might know all the biology, all the physiology, all the pathology, and then you have a real patient who has real you know, they have different diets, they have different stresses, they have different things going on in their lives. And individualization of care is so crucial. One of the things that I, there's lots of things I respect you for, Felice, but one of the things you were saying the other night, it just makes me realise how strong you are, and when we're talking about health of women, hormonal health, I think you have to be really strong to stick to your principles when you know you're right. So you were saying to me the other night about the mesh. So some of people might have heard of the mesh repairs that were, now been taken off market, but these mesh for gynaecological surgery, and you were going to train other people. So you were taught how to do the mesh. And so that's quite a privilege, being selected to be a teacher. And then you were taught. And then what did you do?  

Dr Felice Gersh [00:06:53] I said, no way this stuff is going to harm women, just feeling it and looking at it. And the kidt, they had blind with trocars like these, like pokers that you would blindly poke to establish like the try to secure this mesh into the tissues. And it was a synthetic material that was really thick and harsh and putting it into really fragile, delicate tissues, I said this is going to erode, which it did. And so I was taught on all these different mesh kits from many manufacturers, and I said, I'm not going to use it. I absolutely won't use it. So I walked away from the opportunity to train and use it, and I said, I'm going to use native tissue repair. Sometimes I'll use bovine or a cadaver fascia when I really need to, but I'm not going to put all this artificial tissue and implant it permanently into women's delicate tissues. And that was a good decision, because there were many, many lawsuits, many women were harmed, many women live with chronic pain and disability, and many really tragic stories, and many, you know, just sad tales, and it was finally taken off the market. And this is part of, really what I am scrutinising. So I used to be, once upon a time, an early adapter of new pharmaceuticals, like I know about it. I'm like, so trendy. I know about everything, but now I'm really not. I look at it and I want to know everything about the drug. How does it work? What's the mechanism? And there's always collateral issues. There has to be, because you can interfere with an enzyme pathway or a peptide. You can't and then think it's only going to work in one part of the body, because everything has multitasking. There's not one thing that's in one place, doing one thing, and sometimes you have the same peptide, for example, doing different things simultaneously, you'll have high levels in one part of the body, low levels in another part. So, I'm very cautious now.

Dr Louise Newson [00:08:52] Yeah, which is so interesting, and it's the same US and UK with the meshes. You know, it was a massive scandal, actually. And Chris Harding, who's been on my podcast before, he has taken out so many meshes. You know, it's awful, but it's very hard in medicine, if everyone says, well, yes, no, come on, let's do it, let's do it. And its sort of a bit of a mess with the hormones in that it's sort of gone the other way, really, that people are now scared of natural hormones, which really worries me. And in fact, my mother, who's not a medic, said to me a few months ago, Louise, I think you need to talk more about what hormones are, because most people don't even know we have hormones in our body. And I thought, oh, bless mum. I'm sure they do. And actually, she's probably right. You know, years ago, the first medical writing I did was about breast cancer, and I was supposed to be writing about tamoxifen for women. And I spoke to my mum, and she said, people don't know what cancer means. And I went, oh don't be ridiculous, mother. And I said, okay, I'll ask a few women. And the women I spoke to had had breast cancer, many for several years, and they'd said cancer means death. I said, what? I said, Well, what about chemotherapy? No, that means hair loss. They didn't know. And as medics, we use all these words and we forget that people don't know. So, when people talk about hormones, they often think it means breast cancer, because they think it's HRT equals breast cancer. They don't think about hormones such as insulin, they don't think about thyroxine. They just think about hormones. And I got a message today from someone in Brazil to say there's a big campaign against testosterone in women in Brazil by the gynaecologists and endocrinologists, because they're so cross that people are talking about testosterone.  

Dr Louise Newson [00:10:32] And I think, goodness me, there's a lot more in life to be crossed about than a natural hormone. So we've got in a mess I think that is becoming really hard to unpick, and it's gone on for over 20 years since the WHI the Women's Health Initiative study came out. And just to be clear to people listening, this was using synthetic hormones. They've been chemically altered, and we can talk a bit more about that in a minute, but they're not the same as unnatural hormones. The data went to the press far too early. It hadn't been analysed properly. The headline was, it causes breast cancer. It causes heart attacks, terrible. HRT prescribing was about 40% of menopausal women in the US. It was about 30% of menopausal women in the UK. Now fast forward, we've got natural hormones. We know there are plenty of benefits to our future health, symptom control, so forth. In the UK, it's less than half. It's 14% of menopausal women. And in the US, some of the figures of the licensed HRT or MHT menopause hormone treatment is like, 1.8% like, it's fallen off a cliff. Everyone's scared, aren't they?

Dr Felice Gersh [00:11:39] Well, in my practice, it's extremely high, but from what I'm reading as well, it's under 5%. And that's the 5% is women, like, in their 50s. You go 60 plus…

Dr Louise Newson [00:11:52] It’s nothing.

Dr Felice Gersh [00:11:53] They don't even have data, but it's going to be very minute percentages. And that's very sad. I mean, we're both very sad about that, and we're both like, really publicising, banging the drum to help women to understand that all hormones, the word hormone is also misused. It really drives me crazy too, because they use the word hormone and they apply it to what technically are endocrine disruptors or xenoestrogens, like they're not ever found in nature, in a human, ever, and they actually interfere with real hormone production or distribution, degradation, elimination in some fashion, with a receptor function. And they're different, and yet they're all put into the same bag as if they're all the same when they're really night and day different, and how they, in so many ways. And of course, that's the whole really tragedy of the Women's Health Initiative, the way the data, which was misunderstood in the very first place and wasn't anywhere near as terrible as they made it out to be, not even close, but it has been applied to different products, to our own natural bioidentical hormones. And it's not a fair comparator, and you're it's like totally a different product.

Dr Louise Newson [00:13:11] So, we were talking in the car yesterday about how you chemically alter something, and it can make such a huge difference. And I use the graphite pencil lead. And compared to diamond, it's just one bond different. They're made of carbon. But you used a great analogy as well.  

Dr Felice Gersh [00:13:25] Well, mine was water. So water is H2O and if you just make a little change and you turn it to H2O2, that's hydrogen peroxide, you wouldn't want a glass of that. So that's and I said, like you're molecularly like doing your analogy, I'm doing elemental but, you know, you make the tiniest change, and it's completely different from something that's life sustaining to potentially life ending. I mean, a poison from something that's wonderful. So we have to really understand that, that these are different molecules. And if we had a little, you know, whiteboard, we could draw, you know, the molecules, they're not the same. And of course, they have different effects on the receptors throughout the body. And I just wish we could just walk away from that Women's Health Initiative, like, shut the door, lock it, bolt it, and never look back. But it won’t.

Dr Louise Newson [00:14:20]  So why is it, especially, like it was a US study. It was a billion dollar study. It was probably the biggest study that's ever been done on women's health, but it still showed that women who took hormones, HRT, had a lower risk of bowel cancer. Why are we not? Why aren't there sort of grown-up people out there saying, actually, this was the wrong study. It was the wrong type of hormones in the wrong type of women given to the you know, like and the results actually were badly reported. I don't understand why we keep going back in time.

Dr Felice Gersh [00:14:47] Nor do I why we and you're right, there actually were shockingly beneficial effects that were very minimised, for example, in the group in their 50s, it showed a 30% reduction of all cause mortality. There's no pharmaceutical that lowers your risk of dying by 30% from everything overall. I mean, so and yet that wasn't talked about. And like you said, colon cancer was reduced, and bone health was dramatically impacted in a beneficial way, and that is really a very leading cause of morbidity and mortality in women, is everything related to muscular, skeletal health. And yet that was downplayed. So the benefits were ignored and the negatives were completely misconstrued. In fact, the whole thing about it increases myocardial infarctions was dropped, and the issues with strokes and dementia was related to the extra, really high increase in clotting from using the conjugated equine oestrogens, which increased clotting, spontaneous clotting risk 400% so not too small, you know, shabby of an increase. So if you increase clotting, then yes, you're going to increase potential strokes. And microvascular clotting can cause vascular dementia. I mean it’s not hard to explain.

Dr Louise Newson [00:16:15]  And also, the synthetic progesterone, because the progesterone they use was, is not a very nice progesterone at all, with oxygen, progesterone acetate.

Dr Felice Gersh [00:16:25] Two thumbs down.

Dr Louise Newson [00:16:26] Yeah, totally. So, so it isn't a surprise, but I don't know why we're just translating that, if you like, to 2025, when we've got natural hormones. But when I started HRT nine years ago, I was 45 so if I went to go and see a doctor even today, if I was 45 which I'm not now, but if I was age 45 going to see an average US doctor with some hormonal change, am I more likely to be put on the contraceptive pill or hormone replacement?

Dr Felice Gersh [00:16:56]  Oh, by far, more likely on the contraceptive pill, absolutely. And in fact, the pills are used up until it's supposed to be for lower risk women, but I've seen women on blood pressure medications and have insulin resistance, but presumably lower risk women up to the age of 55, and that is the preferred US approach to perimenopause.

Dr Louise Newson [00:17:22] And why is that?

Dr Felice Gersh [00:17:23] That, plus some antidepressants like we were talking about.  

Dr Louise Newson [00:17:25]  Yeah, so if I had started, we can't go back in time, but if we did, and I was in US and didn't see you, I hasten to add, another doctor was given contraceptive now that is synthetic. That's the graphite or the hydrogen peroxide or whatever you think so it's synthetically manufactured, so it's going to block my oestradiol receptor, it's going to block my progesterone receptor. It's going to stop any testosterone I have working in my body, pretty much. And it's also going to increase my risk of heart attack, stroke, cancer, only small amounts. But then, if I went to go and see you, age 45 and you gave me natural oestradiol, natural progesterone, natural testosterone, if I needed it, then there isn't a risk of clot, there isn't a risk of stroke, there's a lower risk, you say, 30% of mortality, probably at least it will reduce inflammation in my body, like you can tell me, on a molecular level, how those hormones work, because I've had them in my body for years. We know how they work, don't we, but I don't understand, like, why, as a doctor, would you give me something that's more risky, not you, but a doctor?

Dr Felice Gersh [00:18:32]  Right. It's just pervasive lack of understanding. And after the woman's health initiative came out, and it just created just a furore, and fear, it was unbelievable. I was in practice at the time, and I begged my patients to stay on hormones. I was so opposed to these widespread negative conclusions about the use of hormones, and about half of my patients stayed on hormones, and about half of them didn't. Some of them started having terrible symptoms, and then ultimately, a year two, three later, came back to me, but some didn't. Some came back 10 years later and said, I wish I had never gone off the hormones, but I couldn't convince them. The fear was so powerful. And after that, the newer doctors and the studies say that currently, 80% of medical practitioners would be nurse practitioners, doctors and so on. 80% of them were not in in the midst of practicing, what, medicine, maybe some of them were in the beginning of training, but they weren't actually practicing medicine 23 years ago when the Women's Health Initiative came out, and the education that followed since then has been marginal to zero. So they know nothing. The doctors, nurse practitioners, who are currently in practice, were taught nothing, literally, and what they were taught was all negative. And many of them just don't seem to have the curiosity that you'd like to have them have to go and learn it on their own. But they're not, they're like and then they're just embedded in this institutionalised medical practices that are all in the US. Most of the doctors are employed now working for big entities that create protocols, and they the protocols are hostile to hormones, and they're very limiting, or some of them are bending a little bit now, a little bit of softening.

Dr Louise Newson [00:20:31] But it takes a while.

Dr Felice Gersh [00:20:32] But it's still the FDA in the US, the only use that's approved for hormones, for vaginal for now called genitourinary syndrome of the menopause, which does not have a level that's enough to get absorbed and create any systemic benefits, so it's a local effect. And the other is just for prevention of osteoporosis, which almost nobody actually does. It's like even the endocrinologist never even think of it because they're still afraid. And the other is suppression of the night sweats and hot flashes. That's it. There is not any medical society that's advocating for hormones, for cardiovascular health, neurological health, musculoskeletal health, other than not you know, looking at muscles and joints. None of that is happening. And so when you're protocol driven and you're only using for FDA approved use, but off label use is totally legal, so it's not like you're breaking a single law to say you want to use it for something beyond this limited use.  

Dr Louise Newson [00:21:38] And it's the same here. MHRA, exactly the same. You know, it's licensed for menopause, not perimenopause, for flushes, sweats, prevention of osteoporosis, which, by the way, affects one in two women. So, you know, eve 50% of women will be a lot better than we're doing now.

Dr Felice Gersh [00:21:51] Or more.

Dr Louise Newson [00:21:55] But I used to write a weekly column in a GP, it was a magazine, but it was gave free to every GP in the country. So, I used to write an evidence-based column once a week for them. And I found some of them recently, and I found the ones from 2002 and I actually found some that I written in 2001 so pre WHI and I'd written about HRT, about the benefits for bone and heart, and, you know, all the things that we knew then and then in 2002 I said, oh, this WHI study had come out, but actually, there's no big deal. Doesn't show us anything that we didn't know already. Still really good for bone protection, really good for symptoms. But I was in my little bubble then I was just working in general practice. There was no social media. I didn't really like really wasn't paying much attention to outside what was going on. And my patients just carried on taking HRT because they knew the benefits. They understood. They said, oh, well, this risk of breast cancer is there is really small, but I've got all these other benefits as well. Why can't women have a choice? Like, why is it like you're saying the endocrinologists don't like using these hormones? Or, why is some doctors saying have contraception? Why can't women decide what they want when they know it's better for them. And you know, one of the things you said to me a while ago on the phone was, we know that eating fruit is really good for us, and no one will disagree that eating fresh fruit is good for us. So do we limit it? Do we say to people you can only eat fruit for a few years? Because, you know, do you remember saying that? And I thought, that's great.

Dr Felice Gersh [00:23:21] I always try to drive home the point in a way that's simple and really clear. And I think that what is happening in the US is, what's driving the increase in interest in hormones, and even prescribing of hormones, is the groundswell of women. It's not from the top down, it's the bottom up. And what this is creating in the US is a business driven model of hormone prescribing, which actually has some benefit, but it's actually makes me very sad in a lot of ways, because these new, like a lot of online like dispensaries for hormones, they're driven by business people. They're not started largely by anyone who has a medical degree of any kind. These are business driven. They see that there are a lot of women who want hormones, and the medical establishment isn't providing it, so they're creating these online dispensary companies, and they're hiring different people to then prescribe who don't really have a foundation, like we talked about, how does the cell work? What is this doing? They really don't have that. They're just given these little protocols. They're given like, this is what you prescribe. There's not the individualisation that we talked about. They're not monitoring levels. They're responding to symptoms that when they develop from the treatment, but they don't really know what to do either, and they're trying to give the very smallest doses to try to have the fewest problems. So they're not about optimisation at all, and this is what many women in the US are now turning to. Because they go to their own gynaecologist or family doctor and they're told, no, this is going to give you cancer. How could you even think of it? They're still back in this old wrong thinking. So they feel I have no options, so they turn to these online companies, and then they get what I call a whiff of oestrogen and a little bit of progesterone and never testosterone, because they can't do that online, and so it's something. So sometimes I like to think it's better than nothing,  

Dr Louise Newson [00:25:29] It's better than nothing, but it's not ideal at all so.

Dr Felice Gersh [00:25:31] Not even close to ideal. But this is what's happening in the US, and it's all business, financially driven, but the impetus is coming from the groundswell of women wanting hormones, not from the doctors educating from the top down, and the educational, you know, environment in medical schools and post grad work is still really limited. They're not teaching so when the professors don't know they're not teaching anything, it's really said.

Dr Louise Newson [00:26:04] It is the same. It is the same in the UK, it is a lot led by women, which it shouldn't be. And so many women are not listened to. They're underserved. So one of the things is, you know, online, lots of people trying to lose weight, they're going to these GLP drugs, these GLP ones, these drugs that supposedly will transform everybody. We've seen a massive surge globally in these drugs like as ozempic. I'm very cautious as a doctor, like you, I've seen a lot of drugs come and go. I want to know, how do they work in the body? What are their potential for harm? What are their potential for benefits. What are their long-term outcomes? What else can we do first before we're giving some drugs that's new to the market, people are just getting them, like Smarties, really. online, which I have a worry, because it's not individualising care. There's lots of reasons why people put on weight, and there's lots of things we can do, but we know during perimenopause and menopause. It's a metabolic problem. We've spoken about it before. People will often put on weight. They'll put down more adipocytes, which will produce oestrone and inflammatory type of oestrogen. In my mind, maybe I'm too simplistic, so I'm keen to hear what you know like in my mind, I will always balance someone's hormones first I will look at their nutrition, I will look at their exercise. Wait for everything to have an effect before I'm even thinking about any other drugs. I mean, I don't prescribe these drugs anyway, but I wouldn't recommend them first line, because oestradiol, just explain, has some really beneficial effects, doesn't it on our metabolism?

Dr Felice Gersh [00:27:38] Oh, it's huge. Well, everything in the female body is designed, whether you want to have babies don't want to have babies, it's designed for reproductive success. And it turns out that metabolism is critical for reproductive success. So, if, think of metabolism, it's the creation, utilisation, storage, distribution of energy. So, it's critical for any organism to have intake of energy, also known as eating, that matches the needed expenditures of energy, creating heat and running all the machinery of the cells and so on. So, it's all finely tuned, and there's these different hormones and peptides that are all interconnected, and sort of like the Yin Yang, you know, like there are hormones, neurotransmitters, peptides that are involved in reducing appetite, and there are others that are involved in increasing appetite, and they're all under the modulation effects of oestradiol. So, I always think of oestradiol as the hormone of metabolic homeostasis. So, to keep things working smoothly and right, when you lose your oestradiol, the systems that are involved, mostly in the hypothalamus of the brain, become like offline. They're not working properly.

Dr Felice Gersh [00:29:00] So the hormones and peptides that are involved in nutrient sensing and the master clock that triggers the control of the circadian rhythm, which is very involved in metabolism, they all kind of start becoming drifting, so you don't have things quite right, so you don't have proper appetite regulation, and because the circadian rhythm goes off, so women often will have the change in their cortisol production. They'll have more at night when they should, like, lose their appetite and want to go to sleep so they feel energised at night. But the takeaway is that oestradiol is key to regulating all aspects of metabolism. So, without it, you lose your appetite, control, proper control of storing and burning fat, glucose, transport, all these things. So absolutely, the first thing is to get women properly hormonal. Own balanced and get their nutrition, all of that together, and only then start thinking of adding pharmaceuticals.

Dr Louise Newson [00:30:08] Which is so important for people to know. There's so much that we could talk about. You will have to come back another time, but just to finish, three take home tips, I would like to know your three top reasons for considering oestradiol?  

Dr Felice Gersh [00:30:23] Well, I would say that number one has to be brain health. No matter what the condition of your cardiovascular system is, if you don't have a functioning brain, forget it.  

Dr Louise Newson [00:30:34] It’s irrelevant.

Dr Felice Gersh [00:30:36] So, oestradiol is neuroprotective. That's another whole podcast we could do, but the bottom line is, to have proper mood and cognition, you need oestradiol. So that would be number one. Number two would be, actually the musculoskeletal system, such an underplayed organ n system that you know in terms of muscle and joints and bone for not just locomotion, but these are they create kinases. They create like myokines from muscle, they create hormones. Bone makes hormones as well that help control cognition and fat burning and glucose control. So, the musculoskeletal system would be my number two. And number three, the cardiovascular system, because you have to have proper vascular health in order to properly nutritionalise and oxygenate. But I'm going to throw in one more. I just can't stop! The immune system.

Dr Louise Newson [00:31:34] Indeed. Well, that's the basis of everything.

Dr Felice Gersh [00:31:47] Exactly. I can't leave out the immune system, because we have to be able to repair. We have to be able to fight off pathogens. So, you know, if we could just go on, I just love oestradiol.  

Dr Louise Newson [00:31:47] Very good. What a great way to end. You'll have to come back for more, but I'm because you've come so far, I will allow you to have the fourth one. So thank you so much, Felice, it's been great.  

Dr Felice Gersh [00:31:56] My pleasure.  

Dr Louise Newson [00:31:57] Thank you.

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