Today we had a question for our cell Doctor forum. Welcome. Today is June the second, and we are answering questions regarding protocols, not so much research or sell. Doctor forum is regarding protocols and questions about marketing, and less about the current research, which we do on Tuesdays. And this is a common question, although the details vary, the common theme is has to do with combining our plate rich plasma procedures with hormonal therapies. So I'll read the question, use that as a jumping off point and some of the nuances that have to do with that idea of combining those two therapeutic strategies. So the question was, I have a client's husband who's calling to get information for his wife. She is a 52 year old with ovarian failure. She's been to every provider, from medical to acupuncture with no help. They told her, since she did not start hormone replacement therapy soon after failure, that there is HRT would not help. Therefore, I suppose HRT would not help. He's looking for testimonials for similar patients, and I told him that I would do research so many things in this question. So let's take let's start with the last sentence, because it's the easiest looking for testimonials, for similar questions, if someone is really over interested in before and afters or testimonials, both of which are easy to fake, we know that they get faked. You can look at many before and after pictures and see where people are faking them by changing the lighting, changing the angle, smiling versus not smiling. If you want to make your filler look wonderful, take the before picture not smiling and just make it so that in the after picture there's some activity of the facial muscles in the form of a smile, even if it's not a complete showing your teeth smile, and the after will look better so it gets done. And there has been papers written about it. We all see it, and some days I long for the back in the 70s when it was considered unethical to have before and after pictures, because it was making a promise that you may not be able to keep. Now I don't really think that's as far as you should take it, because you need some degree of before and after pictures to show people what it is you're doing, not for every procedure, but for many. For example, if you're treating acne scars, you you would have legitimate pictures that show some resolution, but they should have the same lighting, and you would think people would notice, but they notice what they want to believe. And it's just is cheating. I think you really are better off not showing your best before and after pictures when you're doing something subtle, like we are doing with our PRP procedures, if you're doing breast implants, that is not subtle. If you're doing liposuction, that is not a subtle thing. And before and after pictures are necessary. If you're doing Labiaplasty, I think you should have before and after pictures so people get a really good idea about what a labia looks like that is asymmetric and extensive enough that it hangs out of the bathing suit and becomes painful to ride a bicycle and do other things just wear blue jeans. The degree to which you're changing things is very dramatic. When you're doing fillers, it can be dramatic. Same thing with toxins and our PRP procedures, but I still think you should attenuate. You should scale back some so that you're not over promising. Always under promise. It's cliche, but most people are afraid that they won't get business if they don't over promise and try to wow people, the people who are so that's what I'm getting out if they're asking for you to wow them with a testimonial. Always already feel like this may be someone who is going to be hard to please. Now the so what do you do? It's in the last part of that sentence, you present to them research in realistic numbers. What we're really doing with all of our medicine is playing this the odds. We're playing the odds. Wait just a minute, making sure you can hear me. Okay, good. So you can hear me. Sometimes I think I'm talking and I'm talking to myself. So just making sure the technology is working. So the when you do anything antibiotics, when you're doing surgeries, it's usually implied, but it's all sometimes it's plain and it's not implied. But we're always playing the odds that were given to us in previous research. So we know that with birth control pills, there's. Still, I think I may be remembering this wrong, but I think there's still, like a 1% chance you could become pregnant while you're on the pill, and bumps to about 10% if you're using condoms and practicing the rhythm method. So those are the odds, and we we base our therapies on that, not on what any one per particular person told us. And there are you can buy. If you don't believe me, just go to Fiverr, go online and Google around a little bit, and you'll find where you can buy yourself followers. You can buy testimonials for your book on Amazon. You can buy 10,000 followers on Twitter. And testimonials are easy to fake research, not so much. So the way to answer this person is, first of all, realize that's a red flag. He's looking for a testimonial, and instead give him numbers and research, which I'm about to give you. One other thing before we get into the science that's useful to know from a marketing and running your practice standpoint, is that this is extremely, extremely common. The husband is calling to get information for his wife. There's two ways you could look at that. One way could be that the wife is disinterested and she has no intention to try to make anything any different, and she may not want to have sex with her husband because he's abusive, and she is happy being postmenopausal, or she's happy with her love affair with a UPS man. We don't know what's going on, but for multiple reasons, it will often be the husband who's looking to find information for his wife, and the most I gave you the most negative, which would be that the wife has no interest in having any sexual relations for social reasons, from because she's distant from her husband and doesn't even want to attempt to make things better, either because of their incompatibility or her affection for another person, she may be ready to file for divorce and go live somewhere else, we don't know. But the other good reason that could be happening, and this is also very legitimate, is that the the wife is despondent and has learned helplessness, but would like to regain her vitality and her sexuality and the creativity that's associated with that and the intimacy that comes with it, but she has become disheartened and is not out looking with as much purpose and determination as her husband. Now, the other negative way to approach that is that you think that, and this is a real, real attitude that's out there. It's useful to know this, is that there are those who would say that everything we're doing with hormones for women, with our O shot, with our lasers, our radio frequency devices. It's shocking to see the attitudes of physicians, of physicians that claim that we're just treating the wife either to take advantage of her insecurity, to make profits, or to somehow trick her into making an available place for the husband to put his penis. And if, and I think it's so important to know about this, I'm going to stop and show you something regarding a an article that I wrote for Medscape, just to show you that the shocking the shocking the shocking attitudes that people have regarding sexuality and treating it in women. It's it's just an all you have to do. I'm going to pull this up so you'll show you. Give me a second, because there's, I think just answering the science part of this without looking at the social part is doing you a disservice. And these ideas snuck up on me in the beginning when I first, for example, when I first came up with the OSHA, and I thought, wow, this is so dramatically helpful to women. I'm going to go down and be able to buy a postage stamp with my picture on it, and, and I'm only slightly joking, and then it was the exact opposite. I had extreme anger. From as far as I could tell, every major sex therapist on the planet was angry at me, and I thought, What? What did I do? Well, I'm going to show you the attitudes that are out there, so hold on to share something else with you. And knowing this, it's okay that this is a thing. We can't change the world, but it's you should know it so that you can deal with it and counter it with positive, useful, truthful information. Here
we go. I.
All right, here, right? This is an article that that I wrote for Medscape regarding how the gist of it, and I'll put the you know, go ahead and put a link in the chat box in case you want to read it later. But the gist of it is that there's a lot more research out regarding men and their sexuality and how to treat it than there is for women, and that part of it is the women of productive age reproductive age are an orphan population in that it's hard to conduct clinical trials for fear of the complications that might happen should the woman become pregnant during your trial. So I talk about how we have now 30 ish or so, FDA approved drugs and devices to help men with sex, and we are up to, I think, three now, FDA approved drugs for women. Two of them are psych drugs, and one of them is DHEA cream, that I think is just a roundabout way to try to give testosterone. I know dhe DHEA has its own benefits, but it's it's nothing like what we have for men in the in both numbers and effectiveness. So you would think that's the gist of the article. So now let's look and see what physicians have written about this article. These are doctors. Okay, here's a doctor that says, I'm going to go out on the limb, the title and the opening observation of the Newsweek magazine article do not equate to a need for drugs for women. Now the Newsweek article they're referring to is in this article, I referenced the cover of Newsweek when about the time 50 Shades came out, and the title of the article was exploring the sexual revolution. And the gist of it was that women are now. They're demanding that we take care of them. They want to have sex, and they want to have it in a healthy way, even after they pass menopause and there and however, they want to celebrate it, and they want doctors who will take care of them. The revolution of the 60s was that because of the birth control pill, women became free to have sex without fearing pregnancy. But now the new revolution is they want to be able to have sex in a healthy, creative way, and they want us to take care of them. So let's, let's go back to the comment and let's so you can see this is a doctor doesn't say if he's an MD, but they're, they're all to be able to comment on this website, you have to register as can't be a lay person or to be able to comment. Anybody can read it, but you can't be a lay person to comment. So ironically, on Valentine's Day, this physician says that the opening title observation do not equate to a need for drugs for women. Women needs to access to drugs to give, to enjoy the sexual revolution. Give me a break as a foundation student and graduate of the New Castle University School of Medicine. Okay, it's a physician. I can say the only formal lecture theater training I received was graphic and video educational female sexual health. It was not a one on one on how girls and women need drugs to have a fulfilling sexual life? Okay, so let's just stop right there and think about it. So somehow that's incompatible. What about the drugs for men to have a sexual life? In other words, we're not going to treat it with medicines if there's a problem. And so doesn't equate to us doing everything we know to keep us healthy sexually. Why doesn't that not equate let's disregard the timelines of sexual development, work life, child, birth, mothering, and the myriad of other impacts and the needs, and focus on what this article suggests. Do some or many women need drugs to be sexually competent and happy? It's like asking whether men need a huge Johnson and the ability to satisfy to achieve their personal sexual goal in life. Well, no, it's not. You can have to have you can have Viagra, or you can have RP shot, or you can have a vacuum device, or you can have a penile implant because your wife wants to have sex, because she wants to have sex, and you want to have the intimacy of that. Do you see how uninformed and like did this person ever talk to a man who was trying, who had just got a divorce because he can't have sex with his wife because he's impotent or has premature ejaculation, and now she's married another man lives in another state, and he has to get on an airplane to go so his children, he's got nothing to do with the size of his penis. This is the most stupid, ignorant comment, and it's coming from a physician. If this doesn't make you want to go change the world and educate your colleagues, you should not do the O shot. This should make you angry. This is a physician. This isn't a sixth grader. This isn't a stupid college I. High school football coach talking about sex in the locker room. This is a physician. Seems medicine would like to feed and maybe profit from another exploitation of women. Have we harmed our real women enough lately? In other words, you don't want us to try to figure out how to help a postmenopausal woman go take your MD degree and put it through a shredder and get a job selling. I don't know what you need to sell. I don't know what you need to do, but this is a comment, and if you don't believe me, read them over and over and over again. Here's another one. Doctor I'm not convinced. I have to be careful about what I write next on Medscape, where they'll block my comment. I perceive a culture bias in this article that makes it unacceptable as a scientifically valid argument. Really just thought, is this not societal, and what is it to do with medicine? Well, it has everything to do with medicine. Women have two psych drugs for their brain. They have one little, wimpy DHA cream for their vagina, and it hurts to have sex, and they want to have sex after they have menopause, which often happens in their 30s, and now their husband, in his 30s, wants to have intimacy, and so does she? These are doctors saying this bullshit. These are doctors saying this bullshit. Okay, I'm sorry this makes me angry. But so back to this question, if you're not aware of that, and this is not the exception, this is the rule. It's not the rule in our group, because in our group, you're dealing with people who understand sexuality, the importance of it, and they have the courage to think about it, to offer treatments for it. But it's not the rule in medicine, not by any means, that attitude of wanting to help women. And is it any wonder that women can't have a conversation with their doctor? If your doctor has this attitude, does it surprise you that only one in two women ever have a conversation with their physician about sex, and then, even when they attempt it, the doctor changes the subject after the first question, when this is what your colleagues think? I don't know where this comes from. It just is shocking to me when I read these comments, and most of them are of that nature or something similar. So back to the question. You flip back over here and show you, because if you don't know this, think when you deal with your patients and your colleagues, you'll be blindsided the way I was. Let's see. Okay, so back to this question. The husband is calling to get information for his wife, but it might very well be that he truly loves his wife, that he adores his wife, and he's sad because she feels broken. I just traded a car that had one little scratch in the back fender, and it bothered me. I didn't lose sleep over it, but it bothered me. You can have a little something with your car that you don't even spend that much time in. You can have a but if you have a major something with your body, like one of your if your sexual organs are not working, then that can bother you in spite of the ignorant comments of your colleagues. So anyway, so she's 52 years old with ovarian failure. She's been trying every provider, from medical to acupuncture with no help. And is that a wonder? Because if she's talking to the doctors we just quoted, they're blowing her off. And if she finds a doctor who actually understands the medicines, if she prescribed, if they prescribe Flibanserin, it's on a good during the research, at average one extra sexual encounter per month. And does that mean she's going to have better orgasms? No, she's just going to want it one extra time per month, and the other is likely to cause, okay, it's a decent drug, but it's likely to cause nausea. And now she's got to take some Zofran or something to keep from vomiting when she's trying to be romantic, or she can take the DHEA cream, which is maybe helps with the dryness dysprunia A little bit, but that's going to be about it. So what's the doctor got to offer her if he's not or she's not doing what we know to do, and he's waiting for the tail to wag the dog, because this is what where we get to the second part of this question, they told her, since she did not start hormone replacement therapy soon after failure, that's not going to help her. And of course, anyone who's routinely offering testosterone to women. Know how stupid the uninformed, these are not stupid people people. They are just uninformed because the tail is wagging the dog. And what do I mean by that they're waiting for an FDA approved testosterone that's paid for by insurance and that they can write it on label for women, and it just won't happen. One study showed that 91%
of children who were in the hospital were prescribed at least one off label drug. And why is that relevant? Because children are also. An orphan population in that it's very risky to conduct clinical trials, so the pediatrician will leverage the research that's been done for adults, and then they'll write it off label for children, as we do for testosterone for women. There are multiple studies out now that showing that testosterone attenuates the autoimmune response. It helps with things like rheumatoid arthritis and lupus. It also helps with depression. There is no evidence. The latest studies show that it does not increase your risk of breast cancer. I mean, look at female bodybuilders if you just want a practical look. They their breasts become atrophic because they're you actually you can block the estrogen, down regulate estrogen receptors, and it's been shown over and over again to help libido an orgasm. And yes, it helps years after, even if it started years after menopause. So it's an uninformed provider, which isn't surprising, who probably has a not so good attitude about even taking care of women. Can you believe that's a physician saying we're but somehow, let's just reverse it and say, oh, when you're given Viagra to men, you're just taking advantage of their insecurities to wanting to have sex with their wife, and you, you should just let them age gracefully with their limp penis, so that even if the wife is still virile and wanting to have sexual relations, he's completely inadequate to do anything with his genitalia. If you just, I mean, if you just flip the the sex gender in the article of those comments, it comes across as stupid, so yay for this. This came from one of our providers. Now how? Back to the final crux of this, and I'll wrap this up because it's 30 minutes of me ranting about something that's dear to my heart. I started doing hormone replacement for women, and 26 years ago, in the year 2000 and have treated 1000s of women and gone through some of political bullets in the early days, 23 years ago, from medical boards, and I've had just about everything in my office, DEA, the IRS, the Medical Board, the pharmacy boards, everybody Now, many, many, many people are doing what I did 26 years ago, and there's less. There are fewer arrows that come your way, but they're still out there from that group of people that I just showed you, representatives of with those comments. And if they're waiting again, if they're waiting for the FDA approval, it won't happen. But if they're waiting for research, there are stacks of it. A landmark study came out just the past year or so, two years ago, showing there's no increased risk of breast cancer when prescribing testosterone, but we're still modifying drugs that were that are own label for men, and that will keep most of your colleagues from ever prescribing them. That's what I mean by the tail wagging the dog. The FDA or insurance telling you how you should decide to do things. When you have a person in front of you, and you have a stack of research showing that what you have in mind is supported by that research. There's a whole science. And I'll put links to this article when I send it out with the email about the whole idea of off label versus own label, and how many manufacturers of medications know that their medicine is being used off label and that but they're not motivated to do the research because of The complications that come with orphan populations of children and women of the childbearing age. And so they reap them. They reap the profits, and the doctors who write the prescriptions and their patients reap the benefits, but it will likely never be on label for certain indications, for certain populations and and so the short answer to this question is, yes, you should offer her hormone replacement therapy or offer her testosterone. But more this is not as simple as, say, learning to do an O shot. I think learning to do hormones properly is not a one day course. To do it properly, you really should sign up for one of the companies that or organizations that offer classes in this, and I started doing it, like I said, 26 years ago, by just basically reading everything that was out there and going to a 4m meetings. And back when they were some one of the only organizations and age management medicine group, which is also another group that offers courses, and they're my favorite now, AMG age management Medical Group offers courses in hormone replacement therapy, and because everything moves, for example, when you give testosterone, you. Increased thyroid binding globulin. If that person is taking oral thyroid replacement, you'll need to go down on the dose, because they're free, thyroid will go up when you give them testosterone, you'll get elevated somatomy and C levels when you add testosterone, some of it will aromatize to estrogen. But yet, people need estrogen to be able to think, and if you'd block their estrogen too low, even in men, that's associated with dementia, you should always check prolactin levels, and you need to know their LH and the FSH levels to know kind of where they are. And it's not, it's not like doing a residency in internal medicine, but it's to really become safe with it and effective with it, I think is at least a few weeks of study in a properly designed program. And barring that, I think you should find someone in your area to write the prescriptions and do the blood work to make sure that at least thyroid, estradiol, testosterone and DHEA are thought and prolactin levels are thought about and adjusted with everything else in mind. Or when you move one, know you're going to move the others. And when you do that, I don't care if she had menopause when she was 30, and she's now 65 she will still see benefit. And if her problem is decreased libido and or anorgasmia or decreased orgasm, I think that the hormone replacement is more important than the O shot. So could you do them both at the same time? Of course, you could do the O shot. Full effect is 12 weeks. You could do some blood testing. The blood tests are back in a week or two. You can start your hormone replacement therapy, and the same thing you I tell people, you'll start to feel different at about six weeks. Three to six weeks, and your family will start noticing your behavior is different. You seem happier, more energetic, by the 12th week, and your full change in your body takes about three to four years. That's why most women who show up obese at 40, they're usually about four years post menopausal. Now they've gained 40 pounds, but they didn't gain the 40 pounds in a week. They gained it over the past four or five years. And the same thing, when you fix their testosterone level, if they're exercising and eating right? They'll become more lean and healthy in appearance, but it'll be over three to four years after you change things. So the short answer to this is yes, she should have hormone replacement done by someone and measured and done in a very personalized way based on her lab testing, redo blood tests, replace it, do more blood tests in six weeks, adjust things as needed, and then you're following up with with blood test and adjustments every six months or so, depending on what's going on with her. And she also gets a no shot with some benefit. But if, if she just has to pick one and she hasn't had hormone replacement, you would do that. But absolutely, if they have the means and the time, then you do everything at the same time. Could doing research, yeah, you could do one next, trying to get someone well who's not feeling well and their relationships are broken, they want to feel better yesterday so you can I usually like to do everything that's safe and then back things off as I'm able. Another warning, and then I'll shut this down. It will happen with almost all of your hormone replacement therapy patients, because there's not immediate feedback. At some point, you will put them back together, and they'll be having wonderful sex and intimate relations, and their creativity is better. Their thinking is more clear. They're sleeping better or left off progesterone that needs to be checked too. So anyway, their thinking will be more clear, and their sleep is better. And then
they'll think, Oh, I'm not sure I need all this, and the cashier at the health food store, or their sister, who's still 30 pounds overweight and lives by herself and hates men and women and just not even doesn't really know what she's thinking about, talking about is what I'm trying to say, well, tell your patient that really she should get this supplement that she bought at the health food store, And she won't need all those hormones that are going to make her ears and her breasts fall off. And so your patient will buy the hair of a dog mixed with garlic and start taking it every morning and stop your hormones. The thing is that just like it took 12 weeks or so for things to kick in, it'll take 12 three to four months before, she'll start to feel not so well again, and she won't associate it because she stopped the hormone six months ago. She won't put the two together, and so she'll show up at your office eight months later and say, you know, I'm not feeling so good. Do you think it's because I stopped the hormones you were giving me? You. And you'll have to very patiently say, yes, that garlic hair of a dog, stuff you were taking wasn't helping you. You thought it was helping you because you were reaping the benefits of the hormones for 12 weeks after you stopped taking it, that's what tricks them saying, Oh, I stopped all my testosterone. I'm still feeling great taking the hair of a dog mixed with garlic, and I don't need that anymore. And so they think they found a supplement to take the place of your stuff, because it takes that long. Remember, hormones are messengers, and they act at the cell membrane to change protein synthesis and and to change general metabolic milieu of your of the cell. And when you stop them, you don't all the proteins that have been made don't immediately go away. So there's this tapering off of effects. And because of that, they think that their little supplement is doing everything your hormones used to do. So you you warn them about it, and they'll still do it. And when they show up you, you have to re educate them, and that's why follow up is so important. You have. You're giving people hormones. You got to bring them back in and talk to them, I think, at least every three months or so, and make sure they're still doing what you're doing. And if they've stopped it, you warn them where they're headed, so that they they come back. And I think that's it. That's all the questions we had. If you have questions for me or for the group, you can raise your hand or put them in the chat box and I'll answer them or get others to help us answer them. I don't see any questions, so I'll I'll put the papers to back up what we talked about with the email that goes out. And hope you guys have a great week. Thank you for being on the call.
