222: Navigating Perimenopause and Beyond: A Guide to Women’s Health with Dr. Shieva Ghofrany

Welcome to The Wealthy Mom MD Podcast, a podcast for women physicians who want to learn how to live a wealthy life. In this podcast you will learn how to make money work for you, how you can have more of it, and learn the tools to empower you to live a life on purpose. Get ready to up-level your money and your life. I’m your host, Dr. Bonnie Koo.

Hey everyone, welcome to another episode. So over the next few or several podcast episodes, not necessarily in a row, I’m going to be featuring some of the amazing speakers that we’re going to have at the upcoming Money and Wellness Conference February 20 to 23rd at the beautiful Four Seasons resort in Oahu. That’s the main island where, well I shouldn’t say main, but that’s the island that has Honolulu and that’s the island that most people are familiar with. 

And so I wanted to showcase some of the topics that I haven’t talked about on the podcast or haven’t had guests about. And obviously I hand-picked these speakers, so I find them wonderful and I think what they have to share is so, so valuable and might be topics that you may not have heard of. 

And so today my guest is Dr. Shieva Ghofrany. I hope I pronounced her name right. And she and I met a few years ago and then recently reconnected because I was specifically looking for a speaker who could talk about women’s health. And as you know, nobody really talks about how we can take care of ourselves, optimize our health as we get older. And none of us were taught this in medical school. 

Now, some of you may be aware that there’s a lot more awareness around perimenopause and menopause, and I’m so glad there is because all of us are going to go through it. And what does it even mean? Like the only thing I knew about menopause was that it happens in like your fifties and that your period stops and you get hot flashes and that sucks. And hormones are bad. 

When I was in medical school, it was all about that WHI study that basically said, hormones are bad. Do not take it, you will get cancer. And that has been such a huge disservice to women. In fact, I would say a whole generation of women got gypped. 

And so this education is so important, and not just that, just understanding how our bodies change and what we can do about it. And this topic just goes hand in hand with Peter Attia’s work, his book called Outlive about just being proactive with your health instead of being reactive. 

We’re going to discuss what perimenopause is, what menopause is, when does this actually start? What does it mean? How are we going to feel and other things that we need to keep in mind. Like most of us kind of know, because we’ve sort of heard that as we get older, our bones get less dense and that we lose muscle or sarcopenia. And so that means we need to do something about it if we don’t want to have too much of that, which has its own consequences. 

And so we’ll be talking about that, what you can do about it. And then also how hormone therapy is something you should really know about and then understand the risk and benefits. 

Now, I want to share that I am in perimenopause. I started skipping my periods last year, and I was kind of surprised because prior to that I was clockwork every 28 days. And so I remember when I skipped my first period, I was like, oh, it’s not a big deal and whatever. Like I didn’t think much of it. But then like, obviously I knew that was a sign of perimenopause, but I didn’t really think much about it because I wasn’t having any symptoms. 

But the more I dove into the topic, the more I realized that maybe I do have symptoms of perimenopause, namely the effects of declining estrogen. And one of the things that I noticed in my blood work is that my hemoglobin A1C has been creeping up despite not really having any diet changes. I had gestational diabetes, by the way. 

And my lipids were creeping up. My lipids have always been really good. My LDL is generally 100 or less and my HDL has always been on the high side, I think close to 80. And the last panel I got, it was very different. And so I’ve learned that these are consequences of declining estrogen levels.

And then I thought about, or rather I just read about all the other symptoms that are kind of vague and can be attributed to a lot of things, but it could also be contributed to perimenopause, including mood, including brain fog. Now, I haven’t experienced brain fog, but I definitely have noticed that my brain isn’t the same. And it’s even hard for me to describe what I mean by that. 

But taking that all together, when I saw a menopause expert, she’s a GYN who did some additional training, because many physicians, and namely many gynecologists, simply did not have this training. I heard that they got like one day or a week of anything about menopause. And so there is a society that does additional training. And so those GYNs do have the information to really explain things and offer treatment. 

And so I met with one a few months ago and I started hormones. Namely I have an estrogen patch, it’s like a tiny little thing. And I take a progesterone pill at night. And so the hope is between that, between continuing lifting heavy, making good food choices, that things will move in the right direction. 

I also got a continuous glucose monitor, or CGM, as of today, the day I’m recording this intro. Anyway, I just started my second, I don’t even know what you call it, my second patch. And each patch lasts for, I forget, around 10 days. And honestly, it’s been really eye-opening and frankly depressing to see how my blood sugar reacts to certain foods. As a Korean, I did hear that rice can be really bad for your blood glucose. And it was, I don’t even want to tell you what the number was, it was so high. 

There are ways to decrease the blood sugar surge with rice. Apparently if you refrigerate it overnight or even freeze it, it changes the starches so they don’t get digested so quickly. And then I also saw this thing about cooking it with coconut oil. I’m not going to do that because I definitely don’t want rice that tastes like coconut oil. 

And then people have said, just substitute cauliflower rice. If you’re Asian, that is just no. I mean, maybe I’ll mix some in, like a quarter to whatever, because obviously that provides some fiber and vegetables. But like the thought of having to replace cauliflower, like it’s just like, I don’t know, part of me is like, certain things you just got to enjoy. 

And I don’t want diabetes. I never want to get on insulin. And so I am doing what I can to be proactive about it. 

And these are things that all of you need to understand about our bodies. And so Shieva is going to be at the Live Wealthy Conference. I am so excited for the attendees to get this education that is so needed and just hard to come by. So here’s my interview with Shieva, I know you’ll enjoy it. 

Bonnie: Welcome to the podcast, Shieva. 

Shieva: Thank you, Bonnie, I’m so excited to be here. 

Bonnie: Yeah, I’m so excited about this topic and we’ve had so many offline discussions, but why don’t you go ahead and introduce yourself? 

Shieva: Well, I think you are younger than me, but I always joke at some of these podcasts that I am not only the hair club president, but I’m also a member. I don’t know if you’re old enough to know that club. 

Bonnie: I do know what that is. Yes. 

Shieva: I mean, I kind of joke like if you’re old enough to be perimenopausal or postmenopausal, then you might be old enough to know that. But I say that because as an OBGYN for 25 years, I understand things, of course, clinically and medically. 

And then as the woman who went through six miscarriages and three babies and endometriosis and HPV and weight loss surgery, and then ovarian cancer with a smattering of perimenopause and then surgical menopause from my ovarian cancer surgery, I feel like I really have seen so much of this from the lens of what it’s like to be a patient and a woman, and a woman who, even though I have all the data and knowledge, you really don’t know some of these things until you’ve kind of adjacently experienced them. 

And so it’s really helped me, I think, with the language and understanding how to get into the mindset of it. So I love talking about all these subjects, but especially perimenopause and menopause. 

But yeah, essentially, I’m an OBGYN who still practices obstetrics. I am about to launch my telehealth menopause practice. And I have an online platform that right now is called Tribe Called V, but in the near future will be switched and will be called womaning.com, because our premise is giving people preemptive knowledge. 

Bonnie: I love that word. 

Shieva: And we say womaning is hard, but learning about perimenopause, for example, shouldn’t have to be. I can’t say perimenopause is not hard, but I can say learning about it and trying to manage it shouldn’t have to be as hard as it is. 

Like you and I know, you’re a very educated doctor, and yet you as an educated female physician still had a little bit of struggles finding the right person, right, and getting through perimenopause. And it just belies the point that people don’t learn any preemptive knowledge about this, regardless of their education. 

Bonnie: Yeah, it’s kind of important as a woman to know this. 

Shieva: So important. 

Bonnie: But people don’t talk about it. 

Shieva: Yeah, exactly. Well, I like to talk about it, so I’m glad we’re doing this. 

Bonnie: Yeah, because I think it’s something, you know, my audience is predominantly women. And it’s like I am so grateful that there is a heightened awareness around these topics because every woman will go through this. So this is not about perimenopause, but you know how all of us, our eyes change and we become more, you know what I’m talking about? Like starting to need reading glasses. 

Shieva: Yeah, we get more farsighted. Yeah. Yeah, that is actually a little bit part of perimenopause, meaning it goes along at the same time and age typically. 

Bonnie: Yeah. So I didn’t know that everyone went through it, I only thought some. And then when the ophthalmologist said, no, no, no, everyone goes through it, I was horrified. 

Shieva: Well, it’s funny you say that, when I had my third baby I was 41. I was about to be 41. And I’m in the hospital holding her and I’m like, she’s so cute. And I was like, oh, oh, I joked, I have to put on readers to see my infant. And then that was when I realized like, oh, I’m all at once postpartum and probably on the brink of perimenopause or within it. 

The good news is, as I keep saying, all this stuff is natural and normal. And we also get to say, sorry nature, screw you today. We’re not going to take it lying down. We’re going to try to help ourselves and make ourselves feel better. 

Bonnie: Yeah, this is such an important topic because it’s not just – I think when women hear perimenopause and they’re younger, they might think it’s not relevant. But again, it’s going to happen. And the more information you have and to be proactive about things. And then there’s things that are recommended specifically for peri and meno, but some of those habits, like lifting heavy weights, should really occur when you’re younger. 

Shieva: It really should, yeah. Protein intake. 

Bonnie: Let’s talk about protein because actually today I was asking ChatGPT, and maybe you could help me figure out how much protein I actually need per day. Why is protein intake so important? Let’s talk about sarcopenia and how it’s coming for all of us. 

Shieva: Well, because we naturally just start losing muscle. Like sometimes, I mean depending on the data you read, like in your thirties you start losing muscle. And then as you and I talked about before we started recording, as your hormones change, you also become more insulin resistant. 

So you not only need muscle to strengthen your bones to decrease the risk of osteopenia and osteoporosis, which is where our bones are getting less dense and more prone to fracture as we get older, which is a big risk for women. But in addition, if you become insulin resistant, that’s also going to increase your weight. And as you get more insulin sensitive, you can build more muscle, and muscle helps the insulin resistance. So it’s a cycle. 

So for all those reasons, you need to lift heavy weights, which is the polar opposite of what I learned in the seventies and eighties. 

Bonnie: Oh my God. It was all about – Yeah. 

Shieva: Aerobics and skinny, right? So we were restricting calories and making ourselves small. Now we really want to encourage women to lift weights, heavy weights, to strengthen your bones. And that also builds muscle, which becomes more insulin sensitive. And we want to eat protein because without protein, you won’t be able to build muscle because that’s the building block. 

And so it’s hard to say how much, because that’s even controversial. Like a lot of things you and I are going to talk about, unfortunately, there’s data on both sides of the map, but I would say there’s very few definitive data points. Like I will listen to experts in the field who vary from like a person of mine in your frame should eat anywhere from 70 grams of protein a day, upwards of 120 grams of protein a day and anything in between. 

So I tend to try to, like theoretically I try to hit 80 or 90 grams a day. And I will tell you that I hit that maybe two days a week, because it feels like a full-time job. So rather than do it exactly based on your kilos and whatever formula you decide, like 0.6 to 1.2, I think it’s easier to just say in general, like if a woman is hitting 70 plus grams of protein a day, that’s pretty good. 

But then here’s the other part of this, I think that you and I as physicians can tell people exactly all the perfect things to do. Avoid alcohol, make sure you’re drinking enough water, make sure you’re taking your supplements, make sure you’re doing weight bearing, make sure you’re getting sleep, make sure. There’s a point at which it’s going to make us crazy to have to do all those things. 

So I like to kind of generally know about these things and teach everyone about it, but also hold that loosely so that we’re not increasing our cortisol with the stress of like, I didn’t have enough protein, you know? 

Bonnie: Yeah. Well, it’s also like our perfectionism can get in the way. It’s like, yeah, it’s like these are ideal, but very few people are actually going to do it. Yeah. 

So I was asking ChatGPT, because someone actually told me today, like if I’m trying to build muscle, then I need 150 grams of protein. And that just sounded really, really high. I mean, maybe. 

Shieva: I mean some will say that, but then other people would say, you know, yes, if your kidneys are really healthy, they can withstand it. But at the same time, can your kidneys really withstand it? And also like 150 grams of protein, I actually genuinely don’t know how you would actually have a life otherwise, because the amount of time it will take for the volume, unless you’re really intentionally putting extra protein powder in every single meal, for example, it just seems like a lot. But I’m not a fitness expert, I will say that. 

Bonnie: Yeah, in fact when I asked ChatGPT for 150, it was a little insane what they wanted me to do. But 90 grams actually feels really doable because when I did ask ChatGPT and I basically fed it like, this is how much protein I want, here are the types of foods I eat. Like, I actually like a lot of different things. I’m pretty flexible. But it was very reasonable and it helped me get a visual of like, okay, this is the type of food I need to eat to get to that level. 

And so I definitely have modified my diet. So for example, I was in Greece over the summer, so I really got into the Greek yogurt bowls and that’s a great source of protein. 

Shieva: Amazing. So much, there is so much. And by the way, for those of you out there, I just discovered this because I am very lactose tolerant of cheese, but very lactose intolerant of milk and yogurt, but now that brand Fage, F-A-G-E – 

Bonnie: Oh yeah, that’s what I use. 

Shieva: They have a lactose-free Greek yogurt and it has 17 grams of protein in it. So I actually will put that in a protein shake if I can. Or you probably know this, cottage cheese, an amazing source of protein. Tuna, one can of tuna has like 37 grams of protein in it. So there are definitely ways to do it, you just have to be strategic. It’s hard. 

Bonnie: You can’t just, like you have to kind of plan ahead for the protein. Yeah. So, okay. And question, like, why do we lose muscle? 

Shieva: Oh my gosh, that’s such a good question. We don’t know exactly. I mean, again, partially it could be the hormone changes, the insulin changes, estrogen really helps support muscle, right? And just the idea that maybe it’s also lifestyle related. As we’re getting older, we’re just naturally getting less active, right? 

Plus the stretch of time when you’re in your thirties now is when many women are actually getting pregnant. So getting pregnant, and if you nurse, ironically two things that are so good for our body, quote, unquote, and so natural, but they actually do deplete our body of a lot of the nutrients that we need. And so that can also increase the chance of sarcopenia and then osteoporosis and osteopenia. It’s a big challenge to be a woman, right? 

Bonnie: Okay, so tip number one is get more protein and lift heavy weights. Okay. 

Shieva: And lift heavy weights. 

Bonnie: Yes. Okay. So speaking of like, obviously there’s so many effects of declining estrogen, but maybe I’ll just use myself as a case study. So I started, as you know, hormones. And the reason why my gynecologist who does have sort of additional meno, we should say that a lot of GYNs don’t actually have knowledge and training. And some of them will just say like, I don’t do hormones. I hear that a lot. 

Shieva: Yeah. Well, and I think what’s good to know for the audience, who might largely be doctors, I don’t know. So OBGYN training, which is four years, gets very little. I mean, back when I did it 25 years ago, we started getting a lot of training in hormone replacement because I was pre WHI study, that big study that talked about hormones. 

Bonnie: Yes, yes. 

Shieva: And so I was lucky that I got training and that our residency director cared about it enough. But most residencies after that get like one to two hours of menopause exposure and training. 

Bonnie: Isn’t that crazy? 

Shieva: It is crazy. It is actually crazy, right? So there should be a separate kind of fellowship. And so nowadays, a lot of general OBGYNs, again, through no fault of their own don’t fully know it. Plus the data has really changed. Even in the last three to five years, the data has radically evolved and changed. 

Plus, as you know, we’ve got 15 minutes per patient and you cannot do one and done with menopause, which is why now there is a big crop of doctors and nurse practitioners who are learning on their own through menopause society in different ways. And then they’re doing this either through telehealth privately, but without insurance, which is good and bad, right? Like I think I wish it was more democratized, but this is the world we’re in. 

Bonnie: More accessible, yeah. The reason why I went to see her was like, yeah, I have been missing periods. Like I had like three in the past year. And I wasn’t having anything obvious, because like even in medical school all you learn is hot flashes, really. And so I wasn’t having that and my sleep was fine. But I did notice I feel like my brain doesn’t work as well, but then I’m like, well, is it peri or is it the fact that I’m an entrepreneur and I’ve become more ADHD because my days are just a little different and I’m spending a lot more time like being creative and imagining. And so my brain does feel different. 

I got labs done after, but then a full cholesterol panel, hemoglobin A1C, I had gestational diabetes and like all that. My cholesterol has been creeping up, it’s always been very low. My hemoglobin A1C has been creeping up. And at first I was – And my diet hasn’t really changed significantly. And so I think these are things that are a result of declining estrogen. 

And so I’m lifting heavy, taking walks and stuff like that. And so it’s like, I’m trying to optimize because I don’t want – Who wants diabetes? It’s like a horrible disease and wreaks havoc on the body in many ways. So we started it and it’s, you know, so I’m on the patch and then the progesterone pill at night, which looks like candy. I’m sure you know, it looks like little balls. 

Shieva: Yeah. So it depends on which generic brand. I have two bottles in my cabinet. One looks like little balls and one looks like little footballs. 

Bonnie: Yeah, why are they shaped like that? It’s just kind of funny. 

Shieva: I don’t know. I know. It’s just the gel, it’s a gel cap. So that’s the way it is. 

Bonnie: It is kind of fun-looking, like I wish all pills were kind of – 

Shieva: Right. They look more like candy, I know. So how do you feel? 

Bonnie: I don’t really know how to measure, you know, I don’t know how to measure, except the fact that I did get my period yesterday. 

Shieva: Yeah. Which by the way, so this is where, I don’t know how much you want us to go through like the basics. In other words, the hallmark of perimenopause, as you and I know, is that your hormone levels are fluctuating, right? 

So they’re not, it’s not like being post-menopausal, which is once you’ve had a year with no period. That means you hit menopause and everything after that is postmenopausal, that’s where you have no estrogen and progesterone. And actually your testosterone has already started to decline a decade ago. 

When you’re perimenopausal, which is that time that leads up to menopause, which can last 10 plus years. So anyone listening, you could be in your mid to late thirties to early forties and already be perimenopausal and have very regular cycles, but subtle changes. Like you touched upon, sleep disturbances, maybe hot flashes, maybe mood changes, maybe brain fog, maybe ovulation pain. 

Bonnie: Let’s talk about mood changes because I think people don’t talk about that. I’ve read about how depression and anxiety can get really bad when you’re peri and how getting on hormone replacement therapy is like getting on an SSRI. 

Shieva: Yeah. Well, and this is where I think a lot of us in this space don’t want to say everyone should be on hormones, but we recognize that this period of time in our late thirties to mid fifties, especially nowadays, many of us are, like maybe we’re having children. So maybe we’re older and perimenopausal as well as being postpartum. We’re maybe taking care of our parents. We’re having careers. So it’s a stressful time. 

Yes, we might truly have depression and anxiety, and maybe you really need an SSRI. But you might have exacerbated depression and anxiety because of your hormones. And maybe the hormones are going to help you just as much, if not more than the SSRI according to data, with the added benefit of protecting your bones, for example, in addition to maybe protecting your brain, maybe protecting cardiovascular health. 

And I say maybe because as you probably know, the data on cardiovascular health and brain health, I would say is pretty definitive, but the menopause society has not yet endorsed estrogen as a way to prevent it because there’s data on both sides of the map. 

But I think a lot of us feel like, why are we throwing SSRIs at people and all kinds of other medications when we could be using hormones, again, judiciously and not in every single woman, but safely and judiciously? Because the preponderance of data at the very least, if it doesn’t say it’s going to help your brain, cardiovascular health and all the other things, it at least says that it’s relatively healthy for almost all women. 

Even if we can’t yet say a blanket statement, it’s going to decrease dementia and decrease cardiovascular health, because those are the two things that many people want to believe it is helping and many people want to say it’s not helping. So that’s where the controversy still lies. Whereas hot flashes and bone strength, we know definitively it will help those. So those are kind of the two broad camps. 

We know that there’s definitive data it’ll help bones. It’ll help hot flashes and night sweats. I would say we don’t yet know definitive data on cardiovascular and dementia. Despite all that, we have definitive data that it is likely not harmful. And that’s really important, right? The safety of estrogen and progesterone when it is, nowadays most of us use bioidentical and not synthetic forms, there’s amazing safety data. 

And that’s not what we had 25 years ago or 22 years ago when WHI study came out. That’s why we’re going to be talking about it more and people are going to hear about it more. And there’s still so much misinformation out there. 

Bonnie: It’s so funny. I was like, aren’t I too young for this? So let’s talk about the age range for peri, because I think people think it’s something that happens after their fifties. 

Shieva: Yeah. 

Bonnie: Because I think people in their thirties might be like, oh, this isn’t relevant to me right now. 

Shieva: Yes. And listen, I say this all the time, I never want to make it like, you know you could be perimenopausal. But the truth is if you’re 35 to 40 and you are all at once, very healthy, still able to get pregnant, getting your period, but again, maybe a little schvitzy at night, maybe a little sleep disturbance, again, all those little things we talked about, you might be perimenopausal. 

Now here’s the good news, do you have to know it? You actually don’t. It’s not having any major health impact yet on you, other than it’s good to weight train, it’s good to eat protein, it’s good to be generally healthy. But isn’t it nice to know it so that when you start going through these things, you don’t wake up drenched in a pile of sweat thinking there’s something dreadfully wrong with me. 

So the preemptive knowledge of understanding that menopause is defined by a year with no period on average to about age 51, but it is literally a minute, like a day that you’ve had a year with no period, that is menopause. Everything after you are postmenopausal. 

Bonnie: What if a year goes by, but then you do get a period a few months later? 

Shieva: At what age? 

Bonnie: Oh, is that the – I don’t know. 

Shieva: Well, and here’s where it matters because I wish we could be definitive about all of it. If you were 51, you had a year with no period and then you bled, you are definitively postmenopausal. It is likely nothing dangerous, but you have to be evaluated with an ultrasound. 

I would personally say that at any age, but I’m more concerned of a 51 year old postmenopausal female bleeding after a year, than like let’s say you were 45, 46. Strictly speaking, you did not go through early menopause if you went through menopause at 45 or 46, because that’s within the normal age range of menopause, which is on average at 51, but it could be anywhere from 45 to 55. 

Bonnie: That’s good to know, because I bet a lot of people who are 45 might be thinking they still – I mean, nothing wrong with being 51, it’s not that far after. But I think there’s a lot of people in their early forties and mid forties who are just thinking like, oh, I don’t have to worry about that. 

Shieva: I don’t have to worry about it, right. And again, they don’t need to worry, but the problem is when they think they don’t need to worry and then they have symptoms, then they freak out and they do worry. That’s what I keep saying to everyone. 

Like my sister and I, I always laugh, she’s two years older. I’m 55 almost, she’s 57 almost. And all those years in her forties when she would be like, I’m really hot. I’m really sweaty. I couldn’t sleep. My vulva hurts when I have sex, all those things. I would say to her, you know, I think it’s – And she was like, if you say perimenopause one more time. And I would joke like, oh, now I call it the other P word because it became this like dirty word where she – 

Bonnie: P word, yeah. 

Shieva: She was like, if you tell me perimenopause, like in her mind, I was telling her that she’s old. And I’m like, I’m not saying you’re old. 

Bonnie: You know what? 

Shieva: Yeah?  

Bonnie: That’s really important because I think there is a stigma. 

Shieva: Yes, and there shouldn’t be. We should all at once say, this does not mean you’re old. This objectively means there is a stretch of time leading to menopause where your hormones are predictably unpredictable. Meaning I can tell you when someone says to me, what could happen in perimenopause? My answer is anything could happen. 

You might have normal periods and then suddenly stop your period altogether at 51. You might have months where it sucks. You might have months where you feel great, and anything in between. So as long as you know that, you can be less scared and less anxious and you can get help. 

But I think so many people still shy away from the conversation because, you touched upon it, there’s that stigma that once you’re in perimenopause, you’re on the brink of menopause and you must be old. Or women mistakenly think that perimenopause, for example, at 42 implies that they’re going through early menopause, when they’re not. 

You can be perimenopausal for that decade, still go through menopause at 51, which is again, normal and natural. But that doesn’t mean you have to take it lying down. You still get the opportunity to say normal, natural, and I’d like to treat it. We’re living into our nineties now, right? Like you and I were supposed to be dead at 52, 53 back in the day when we were hunters and gatherers. 

So now we’re living longer, which is wonderful, but we’re living longer with chronic illnesses. So we have the opportunity to treat ourselves well, feel good, and make sure that we don’t develop those chronic illnesses. And that’s where I think it’s really valuable for people to be mature enough to listen to the data, listen to the history, listen to the knowledge so that they’re not blindsided by it. 

Bonnie: I mean, it’s all about being proactive. I’m sure you know about Peter Attia. 

Shieva: Yeah, very much. 

Bonnie: And just it’s all about being proactive. And I think there’s, thankfully a greater awareness about like, yeah, it’s less about living longer, although that’s great. But it’s like, how do we live longer and feel great? Like he calls it health span. 

Shieva: Right. Health span, yeah, exactly. And I think when you talk about that with people, even those people who might be listening who don’t know who Peter Attia is and don’t have access to that level of either knowledge, or I always joke, like I don’t have a grass fed bison farm in my backyard to be able to eat all the grass fed bison I want like Peter Attia does, but there’s so much that – 

Bonnie: Wait, does he? 

Shieva: Yeah, I think so. I think he has his own bison. I could be wrong. Someone should fact check, but I’m pretty sure he mentioned that in one of the things. God bless him, like if I could – Well, I don’t want to live on a farm, but if I could afford my own grass fed bison all the time, I would. 

I think my most important nugget I would like to teach all women to really democratize this is learn the definitions of perimenopause, menopause, and what postmenopausal means. Learn what is normal and natural. Learn the simple ways you can fix it where you don’t have to spend millions of dollars, where you can literally get regular hormones from the pharmacy. 

You don’t have to go to someone fancy. You don’t have to do all kinds of injections. You don’t have to buy the latest green juice. You literally have to eat good quality food, which means less processed food, less processed sugar, and move your body more and lift weights. So it could be that simplistic. And you could also do even more than that if you want. 

I do think we’re starting to overcomplicate things a little bit in this space, because now we have access to all these other abilities to really – 

Bonnie: Oh yeah. 

Shieva: And that’s what I want to try not to do too often, right, for the people who can’t or don’t want to. 

Bonnie: In many ways it’s like the simple things, again, are like adequate protein intake. And it’s something that women should do earlier in life because I think, you know, obviously you and I both have a lot of friends who are women. And so a lot of my friends are physicians, they’re highly educated, and a lot of them are – Well, you know a lot of physicians don’t take care of themselves. And what I mean by that is like exercise and stuff. We’re not lifting weights. 

Shieva: Right, or sleep. We’re not getting adequate sleep. I mean, and our system is not cut out for it, right? Like many of us, you and I, I mean, at least for me, when I was 29 to 34, I was a resident. I was getting the worst sleep of my life. And then I was an early attending. So had you said to me at the time, lift weights, sleep more, I would have been like, when and how am I doing that? Like, who’s taking care of these patients? 

Bonnie: But our friends are older and so like, I’ll just be like, are you lifting weights? Like one of them is an avid runner. I’m like, but you need to lift weights. And I think people just don’t understand how important it is. 

Shieva: I know, yeah. I think that no matter how much, for example, you and I think everyone’s talking about menopause right now, right? It’s getting such a moment. Like you look every other day in the New York times there’s an article. And yet day after day, I see it on Instagram, women write to me and they’re like, but I thought hormones caused cancer, but I thought vaginal estrogen is really bad for you. Things that I’m like, again, what is everyone Googling? If they’re not Googling this, like, how are they not hearing it? 

But I think that the truth is, no matter how much our silo is focusing on it, the average person out in the world, I mean, they are truly worried about other things, as we know, the price of eggs, right? Like they are not able to hear this information or digest it or know it. 

So I’m hopeful that in the next couple of years, we’ll be able to get this basic stuff to be much more mainstream and get the doctors who are taking insurance. God bless them all, including my practice, we still take insurance. But I hope that we all find the time to be able to help women with it because they need it. 

Bonnie: This is where I think just encouraging my friends, like following people like you, Kelly, Marie – 

Shieva: Mary Claire Haver. 

Bonnie: Yeah, because that’s how you can start getting educated and learn a bit, you know, read some books on it and stuff like that. So I think that’s a great start. And this is also why I’m so excited that you’re coming to our conference, because I know it’s going to be such a great value add and women are going to, I know they’re going to be so grateful to have learned about this now versus just being like having no idea what to do. 

And again, it’s going to be doctors and most doctors don’t know anything about it. So I just wonder, like if doctors don’t know anything about this, how do we expect the public to even know, right? 

Shieva: Bonnie, this is what I say, and you have a son, so I don’t know if you’ve thought about this yet. But this is what I say a lot, no matter the age, demographic, race, religion, socioeconomic status and education, right? Like the most educated physicians, who one would think knew their OB GYN health, they don’t get access to their OB GYN health knowledge, right? 

Like you were a dermatologist, so you didn’t get access to the OBGYN health knowledge. And no matter how educated you are, you are of the highest education in our country, right? But you didn’t get to learn about it because your teachers didn’t know. When you were in medical school, they didn’t teach you about it. Dermatology residency didn’t teach you about it. And even your family members would not have necessarily known. 

So it is, I always jokingly say, sadly, that it’s the great equalizer, OBGYN health knowledge, which is actually the most important thing in a way to us, right? We didn’t have access to as women. Like I was a daughter of a pediatrician. She was amazing. I didn’t know about my own HPV until I found out. I didn’t know about my own endometriosis until I had a massive ovarian cyst with it. I didn’t know about the number of pregnancy losses I was going to go through, my ovarian cancer, right? 

So it is sad that education itself still hasn’t even seeped into OB GYN health. So I’m thrilled to be talking to all the doctors, for example, in February. But I still feel like, how is it possible that as women, we still haven’t gotten to learn about our own health? And this is really a fault of the system. Like we have to fix this somehow. 

Bonnie: Unfortunately, I wish you and I could just say, hey, these are the three symptoms of perimenopause and then leave it at that. But it could be so many things and a lot of symptoms are vague. So actually when I was talking to a friend about, because I didn’t feel like I was having perimenopause symptoms except the fact that I was skipping periods. And I was like, yeah. 

And then they’re like, well, what about brain fog? I was like, I don’t know about brain fog. But then I just said my cholesterol, like the labs were just showing, and I don’t necessarily feel that different. Like I still sleep great. 

Shieva: Right. Right. Well, and that’s a good point. Yeah. I mean, so you – Okay, so I would say this, there’s so many points we could do. I’ll try to pick a couple of basics because this could be like five hours of us discussing it. 

Bonnie: Yeah. 

Shieva: I think that, like I said, first and foremost, I want women to know the definition of it. I want women to understand and not be angry at their doctors that their doctors don’t know it. So they might have to go to their doctor saying, hey, I’m 48 years old. I’m missing my period a little bit. I’m not having hot flashes and night sweats, but I know it could be perimenopause. 

Or I’m missing my period and I am having hot flashes or night sweats or mood changes or brain fog or more weight around the middle or more hair on my chin or less hair on my head or decreased libido or more acne or more ovulation and breast pain. These are all like very common symptoms. 

And then there’s less common symptoms, burning mouth, you know, people describe all kinds of skin changes. So there are a variety of symptoms, get to know what they are. I mean, if you overall are doing okay, then at least just knowledge of the basics is good. 

There’s certain lab tests that you should have done. And I still think that women should see a primary care doctor every single year. And that means they would have their cholesterol checked, their thyroid checked, their blood count with their iron levels, ideally, because these things can all fluctuate once you get through perimenopause and being postmenopausal. 

And as long as those are okay, then you get to decide, do I want to treat perimenopause or not? I don’t think we’re yet at the point where we can safely say every woman should be on hormone replacement for prevention of everything. Meaning I’d like to say that, but our societies don’t allow us to say that. 

What we can say is hot flashes and night sweats and osteoporosis prevention are distinct reasons why people can be put on hormone replacement. And then there’s a variety of other things that many of us agree there’s enough data that it probably is worth it because it’s not unsafe. 

The challenging part for women in perimenopause is that, like I said before, it’s predictably unpredictable. So trying to fix, like in your case, you’re on a patch of estrogen, which is bioidentical, meaning you got it from the pharmacy, but it is the type that mimics your own hormones. And you’re on a pill of progesterone, which is hopefully helping sleep, even though you don’t need it. 

But trying to control your hormones when your hormones are fluctuating is hard because these hormone values are still lower than, for example, birth control doses. So one thing that is now coming out of this movement to teach people about menopause and perimenopause is I can’t believe some of these doctors are still putting perimenopause patients on birth control pills. You’ll hear people say this and they’ll kind of really malign doctors putting women on birth control pills to fix perimenopause. 

Bonnie: Is that wrong? 

Shieva: No, and that’s what I was going to say, I think that is an unfair statement, meaning perimenopause is more easily fixed by birth control doses because birth control doses are supra-physiologic. They’re higher than our normal doses, they shut down your ovaries. They make you not ovulate, which means all those fluctuations even out. So that’s a benefit. 

Now, they’re not bioidentical. They are synthetic, at least in our country, and there are side effects and risks. So with the benefit of making life even, there come risks. So if instead I put someone on HRT doses, I’m using bioidentical, which is technically safer, and lower doses, which are technically safer, but it’s not as easy to control her symptoms. 

You, for example, as an educated woman who has the time to think about it, might decide that that’s better for you. But there are a lot of other women who, regardless of their level of education, their means, whatever, they don’t have the time to kind of screw around with different doses of the patch and the pill and things like that. They don’t necessarily have a doctor they can call. They really might be served best by being on the birth control pill. 

And so I really would personally kind of stand against all of my, I will say sisters, because it’s mostly females in our space, who are swinging the pendulum the other way and really maligning the birth control pill. Because again, the birth control pill, yes, has negative downsides, but also has some positives. 

So I think what’s important for people to hear about and learn is, there’s no one way to fix this. There are multiple different ways, and it’s got to be a process and you have to, unfortunately, have some patience within the process, and listen to a few different sources to really understand all the different aspects of it, which sucks, right? 

It would be so much easier if it could be one and done and I could just say, everyone go on the pill, it’s easier, or no one go on the pill, it’s easier. But the answer to all of this is, it depends, right? 

Bonnie: Yeah. When do you think I would see improvement in blood glucose and cholesterol? I’m assuming that takes time. 

Shieva: Yeah, but I would say, honestly, we know just in general with most of these types of hormonal things, which obviously cholesterol and blood glucose fluctuate with hormones. So I would say two to four months, I suspect you’re going to notice an improvement. 

Now, here’s the truth. If someone said to me, if I only do the estrogen patch and progesterone at night and I don’t change my diet or exercise to increase insulin sensitivity, am I going to notice an improvement? The answer is, we don’t have great data. You might improve a little bit, but it’s not like, you still have to do the work, which you’re doing. So I would say two to four months, you’re going to notice some improvements. 

Is it going to be dramatic enough where you don’t ever, for example, need a statin? Hard to say. Some people, yes. But we also, and you probably know this, some people synthesize cholesterol, and some people absorb cholesterol from their diet. And people fall into two different groups, and we don’t know which group you’re in just based on your cholesterol level. Like that’s kind of second level testing that people sometimes need to do. 

But again, as soon as two to four months you might notice an improvement, especially in your A1C level, right? 

Bonnie: Maybe I’ll just recheck it. 

Shieva: Do it right before the conference. Yeah, do it in February before the conference and then we’ll see. 

Bonnie: Yeah. Because my hemoglobin C went from, it was like 5.9 last January. And then it went down to 5.5 because I was doing some modifications. And then a month ago it was 6.0, and it’s never been that high. And the CGM, it’s like, again, it’s been depressed. Rice is just insane when I eat, right? I don’t want to tell you how high it got. I just was like, holy cow. 

Shieva: Have you experimented with, and again, I think the data is like pro-con, about making the rice, freezing it? 

Bonnie: Oh, maybe. I haven’t done freezing, but I did refrigerating. 

Shieva: The resistant starch, yeah. 

Bonnie: It still went up pretty high, but it was nowhere near it. It was a lot less. 

Shieva: Less. 

Bonnie: And honestly, I don’t even eat rice that often. I mean, I am Korean, but there’s weeks where I go by not having it. So, it’s not like, but I’m never going to cut it out. Everyone’s like, oh, you should switch to cauliflower rice. And I was like, no. 

Shieva: Well, and here’s the thing, that’s what I mean. You know, I always joke that I literally had weight issues as far back as I can remember, since I was like six or seven years old. But I always say, I wonder is it all the food I was eating, or was it the self-flagellation over all the food I was eating, right? 

I think of course you have to generally eat healthily. But if you’re so obsessed about how you’re eating and how you’re lifting and how you’re doing, again, that cortisol stress response is going to affect your glucose far more, probably, than enjoying the rice and eating the rice and giving good energy to that rice as it’s delicious and you eat it. 

How was your fasting glucose with your CGM? 

Bonnie: It’s in the, actually, let’s look. I have the aura ring, too. So, I just feel like I’m gathering all this data, which is fine. Let’s look at it. The CGM is wild. I’m like, this is crazy. So, is this like right when you wake up? Like, when do you actually? 

Shieva: Well, I mean, it depends. Like, listen, because you have a CGM, you can say right when you wake up. If you didn’t, you probably would do it within a half an hour of waking up before you eat, right? So, give me both. What’s the difference? Tell me what it is. 

Bonnie: It’s funny because at 6:16 it was 89. I think I got out of bed more like 6:30, which was 82. But then 6:26, it’s 102 and then it’s 90. But yeah, it’s under 100. 

Shieva: Listen, I will tell you this, as OBGYNs, we’re a little bit more finicky, probably, than your primary care because we’re used to what we would have considered, like do you remember when you were pregnant? 

Bonnie: I had gestational diabetes. 

Shieva: Right, and so you would have been instructed that you needed your fastings to be below 90 to 95, and your two-hour postprandials under 120. I know. And so I will tell you that I do think that those numbers are actually what you should try to – I’m not an endocrinologist. 

Bonnie: Oh, I was told 140. Like, I’m in trouble if it’s really, again, I think right now I’m just what I call the data collection. I’m not judging. But then I get to experiment. So again, today I had rice that was refrigerated. And then again, like being mindful of protein. Do you know what the seaweed wraps are that Koreans eat? 

Shieva: Yeah. 

Bonnie: The crispy seaweed. So I had that, just making little rice sushi rolls. So, I had avocado, I had canned salmon, and I had a hard-boiled egg for the morning. And I just was eating that as little rice rolls and just kind of experimenting. 

So, it still went up high. It was like 180. But it was over 200 when I was eating fresh rice. And so I’ll just keep experimenting, like just different combinations. 

Shieva: Do you like pasta? 

Bonnie: I do. I don’t eat it super often. 

Shieva: I know, because I have to say, pasta is like my – I’m Iranian, so I should love rice. I actually do not care. If I never have rice again, I’ll be fine. I love pasta. And I hate all these alternative pastas, except that I just found edamame pasta, which is just edamame. That’s the only ingredient. And I swear, it tastes like spinach fettuccine. And I put some butter and olive oil – 

Bonnie: Is it in the refrigerated section? 

Shieva: Nope. It is dry. And I order it from one of those big companies that sells us everything. It comes overnight. And it’s got 25 grams of carbs, but 25 grams of protein. 

Bonnie: What? 

Shieva: And it’s literally only edamame. That’s the only ingredient and it’s so good.

Bonnie: You know, it’s interesting, I’m not gluten intolerant and I’m not gluten-free, but I do try to reduce my gluten intake. So I buy the Jovial blend or this Andre. And I feel like it’s pretty good, but edamame, I’m going to – 

Shieva: Oh, you’re going to like this better. I’m telling you, it’s so good. It is so good. And yeah, I think, listen, I do think it’s good to decrease our processed carbohydrates, right? Like red rice, pasta, and sugar that are processed. It’s always ideal to – 

Bonnie: So what brand? I see Explore and the Only Bean. 

Shieva: What is the one? It’s like a navy blue, I’ll look and see. There’s two different brands, I’ve ordered both and they taste the same. 

Bonnie: The Only Bean is a green packaging. Explore is kind of like more neutral. 

Shieva: Okay, the Only Bean, I’ve had that one. And then I like, I’ll tell you the one that I liked slightly better just because of the size of the noodle, that black one, yeah, the blue one, Seapoint. That was my favorite one. 

And I’ll tell you another topic that unless you have other questions that we could talk about quickly. I mean, not really quickly. We’ll make it quick, but there’s a lot of stuff to discuss. It’s vaginal estrogen. Vaginal estrogen. 

Bonnie: Let’s talk about that. 

Shieva: So people with vulvas, so our vagina, our vulva and our urethra, which is the hole we pee out of, for those of you who don’t know, is very sensitive to estrogen and actually a little bit to testosterone, but very, very sensitive to estrogen. And so that means that three different times in our lives, we will be very estrogen deficient and we will be affected by it. 

One is if you’re pregnant and then nursing. So during nursing, your estrogen levels are really low because your prolactin level suppresses ovulation, very low. This is why postpartum, if any of you have tried to have sex after your six-week visit, when your doctor was like, hey, you can have sex. It will hurt because your vagina and your vulva are less elastic because you’re essentially in an estrogen depletion state and vaginal estrogen will really help. 

The second time is if you’re on combined hormone contraception, like on the pill. 

Bonnie: Wait, question, can you do vaginal estrogen postpartum? 

Shieva: Absolutely, I prescribe it. 

Bonnie: Oh, I didn’t even know that was a thing. 

Shieva: Oh yeah. See, this is why. And don’t even get me started because there’s a whole reason why I can tell you why you wouldn’t know it’s a thing, because your doctor didn’t have time at your six-week visit to talk about it. 

And then the second time is during the birth control pill. If you’re on prolonged birth control pills, some women, because they’re on estrogen for the pill, but it’s a steady dose and it’s a synthetic dose and it antagonizes the estrogen in our vulva and vagina. And again, it can hurt. You can take vaginal estrogen then. 

And then the most notorious time is perimenopause and most likely postmenopause. Perimenopause is potentially less for many women because they still have estrogen, but their estrogen levels are fluctuating. But postmenopausally, the data would say like 30 to 50% of us have symptoms. But really, if you actually asked women directly and asked them the symptoms, I guarantee it’s more like 70 to 90% of us. Because even for example, recurrent urinary tract infections, that is a symptom of estrogen deficiency. 

And rather than taking antibiotics multiple times, especially if you’re getting recurrent urinary tract infections after sex, if you actually just use vaginal estrogen, you would enjoy sex more. It would hurt less, and you actually would not be getting urinary tract infections recurrently, for most women. 

Bonnie: So how do you actually apply it? It’s like a gel? Let’s just talk like – 

Shieva: Yeah, so there’s a cream. I know, I wish I knew we were just definitely going to talk about it because I have like my bag of tricks. But there’s a cream, there’s a ring, there’s a tablet, and there’s like a little gel cap torpedo. And that’s all estrogen. Then separately, there’s also vaginal DHEA, and that converts into estrogen and testosterone. And that’s a little suppository. 

I personally actually think that while the cream is not the easiest, I think it’s the most impactful because, as you can imagine, remember I said it’s the vagina, the vulva, and the urethra. So if it’s just the tablet or – 

Bonnie: You’re able to spread it around. 

Shieva: Yeah, the cream, you can smear it all over the place. So what I tell my patients when I prescribe vaginal estrogen, I tell them three things. A, it might not be covered by your insurance because your insurance does not give a dang about your dry and inelastic vulva and vagina. So you might have to pay for it. But nowadays on like Cost Plus Pharmacy and all these other online pharmacies, you can get a big – 

Bonnie: Are you talking about Premarin? 

Shieva: Premarin is the brand, or Estrace is the other brand. Most of us use Estrace because it is the bioidentical form, but now Estrace is generic. So it’s estradiol cream. So I prescribe the tube. I tell them it might not be covered, but you can get it online for about $30 for a big tube. 

Second, the package insert will tell you that it causes cancer, stroke, heart attack, blood clots. 

Bonnie: Oh, great. 

Shieva: They are misquoting actually the systemic hormone data, meaning the hormone data that they put on like the old Premarin boxes that are oral formulations. They’re putting it on the vaginal cream. It is absolutely safe, even for people who have had breast cancer. There’s multiple, multiple, I mean thousands of studies supporting this. 

The third things that I tell them is when they say, well, how long do I have to use it? You got to use it as long as you want to use your vulva and vagina either for sex or just for comfort. Someone will say, well, I don’t even want to have sex, but when I’m like spinning on my Peloton, it’s irritating because their vulva and the vagina become less elastic and then it gets irritated. 

Or again, nursing home women will get recurrent urinary tract infections. And as you probably know, this is a big source of concern. If they all had some vaginal estrogen that they put inside, it would help. 

So you get the applicator. Most of us start with a half a gram or a gram twice a week. I tell patients start with the applicator because then you know how much you’re using, but after two or three times, because it’s usually twice a week, twice a week regularly, then you can toss the applicator because it’s annoying because you have to wash it, and eyeball half a gram to a gram. 

A half a gram is about the size of a strip of toothpaste. And you put it literally, like if this is your vulva, you put it all around the outside, up into your vagina, smear it all around. You cannot mess it up. And it’s so valuable. Like if we gave that one intervention to all women, that alone truly would revolutionize so much. We would decrease UTIs. We would decrease pain, discomfort, all of it. 

Bonnie: I mean, obviously I knew it existed, but I was just like, I don’t really feel like I need that right now. 

Shieva: Yeah, and you might not. You might not need it now, but all of a sudden, let’s say in one, two, three, five years where you’re like, huh, I just got my second UTI, I want you to remember this conversation and be like, I’m not going to keep going on antibiotics to prevent the UTI. I’m going to actually use vaginal estrogen to restore my vagina and vulva to what it should have been. 

Bonnie: Oh, let’s talk a little bit about testosterone. 

Shieva: Okay, so here’s another nugget. And I think you know the answer to this, but if you don’t, don’t be embarrassed because most people don’t. Do we as women have more testosterone or more estrogen in our system? 

Bonnie: I think I know the answer because I follow people, but I bet most people will say the wrong answer. 

Shieva: Yes, so what answer do you think it is? 

Bonnie: It’s testosterone, right? 

Shieva: Yeah, women have more testosterone than estrogen. We still have less testosterone than men, but more testosterone than estrogen, but we have gendered hormones, right? Which we shouldn’t have. We’ve said testosterone is a male hormone and estrogen and progesterone are female hormones. But in fact, men also have estrogen, it’s just in different levels. 

So because of that, estrogen and progesterone have gotten a lot of attention. Not enough, but a lot. Testosterone really has been ignored and only kind of looked at as like, oh, you only need that if you’re trying to build muscle like a bodybuilder or, oh, you people are trying to use it for libido. 

So as of right now, the only indication that is kind of sanctioned by our governing societies, like menopause society and ACOG is hypoactive sexual desire disorder, which means if you have been diagnosed with that and you have less spontaneous desire and low libido, then your doctor can prescribe testosterone. Though in their defense, they might not know how, they might not have been taught. And it is technically a controlled substance because it’s off-label for women. 

It is not an FDA approved indication for women. So even though we know scientifically it’s okay to use, we have to prescribe it to you, if we’re using a commercial pharmacy, off-label. So we end up having to do things like give you a one month male supply that will last 10 months for a female, because we use about a 10th of the dose of what a man would use every day because, you might know this, testosterone is frequently prescribed for men. 

Like frequently FDA approved, multiple formulations, not even a question. For erectile dysfunction, I shouldn’t misspeak about erectile dysfunction because I don’t treat it, but it is up to 40% of people will have erectile dysfunction, which means it’s a pretty common thing. 

Bonnie: Is it like their perimenopause? 

Shieva: But they call it dysfunction, right? Whereas in our case, they’re like, oh, it’s natural. Perimenopause is natural. But in their case, we call it dysfunction. 

Bonnie: That’s fascinating. It’s like, of course. Yeah. 

Shieva: Of course, so they get treated. So testosterone, you will hear more about it, thankfully. Hopefully one day we will have a female formulation. Right now your options are get it from the regular pharmacy through your doctor or your menopause clinician. But again, they’re giving you what is technically a male dose in a one month supply, or they might prescribe it through a compounding pharmacy. There are people doing injections and pellets. I would personally say I don’t think there’s enough data yet to do that safely. 

Bonnie: I thought aren’t pellets like not a good thing because you can’t really control the dose. 

Shieva: Yeah, I think it depends who you ask. I would personally say that I don’t feel like I need to prescribe pellets for my patients or use pellets because so far I’ve been able to mostly help them and control them with these FDA approved like estrogen and progesterone doses and off-label uses of testosterone. So I would not use them myself or for my patients or my sister, for example. 

Do I think there are some clinicians who are very judicious in using very, very low doses? I do. Like there’s some doctors in the space that I love and I trust and I believe that they are being judicious and using very low doses. And the reason why they use it is they say that it is more convenient because you get the pellet put in. 

And just for everyone to know who’s listening, a pellet is this tiny, tiny little what it sounds like, a pellet, that’s being put right basically underneath your skin, like at the top of your buttocks. And it’s slowly releasing testosterone or estrogen. And our concern with it is, as Bonnie said, you don’t know exactly how much the person is absorbing. And once it’s in, you can’t take it out. 

Bonnie: So that’s the part, you can’t adjust it. 

Shieva: So to me, because it is not FDA approved and untitratable, and the majority of the data, even if it looks good, is by the companies who sell it. So I personally, unless they come out with really good – 

Bonnie: It sounds kind of horrible. Can’t take it out. Can’t adjust the dose. You don’t know what you’re on. It’s like, why would you do that? 

Shieva: Well, and again, I’ll be equitable and say this, I’ve seen some terrible, terrible side effects from it. I’ve also had patients who claim that they feel great on it and I believe them, but I still would personally say we can achieve you feeling good, yes, with a little bit more titration, but through more studies. 

Bonnie: That just seems like it makes sense to do that. Sensible. 

Have you heard the drug Addyi? 

Shieva: Yeah, of course. 

Bonnie: What are your thoughts on that? I had never heard about it until two weeks ago. 

Shieva: Yeah, I will tell you this, here’s another nugget for y’all to know. Female libido, do you know how many drugs there are for female libido? 

Bonnie: Is that the only one? 

Shieva: There’s two. 

Bonnie: Two. 

Shieva: There’s Addyi and Vyleesi and then off-label testosterone, right? But there’s two FDA approved drugs. Do you know how many drugs there are for male erectile dysfunction? 

Bonnie: A gazillion. 

Shieva: 27 or 28. Multiples more, right? 

Bonnie: Because people don’t care about women. 

Shieva: Because people don’t care about women because we are taught –  I mean, there’s so much we could talk about that. So yes, Addyi is a pill that you would take every day that theoretically can help with spontaneous desire. And I definitely have patients who think that it’s worked a lot. And I’ve had other patients who don’t think it works a lot. It actually might have a little bit of a beneficial effect on weight as well, so that’s good. 

Bonnie: Oh, yeah. I’ve heard that too. Yeah. 

Shieva: Yeah, because it works in the central nervous system. And so I think it’s great. And I think that the founder, Cindy Eckert is – 

Bonnie: I heard her speak. 

Shieva: Oh yeah, she was at your conference, right? 

Bonnie: At the conference. Yeah, at Lead Her.  Yeah, it was, I mean it was just amazing.  

Shieva: She really cares. And she cares and she has done an amazing thing. You heard her story, how she sold the company and then bought it back. And then Vyleesi is an injectable that you could use twice a week, so eight times a month. And that’s right before you’re about to have sex. And it can help with, again, spontaneous desire, orgasm, things like that. So I do wish we would have more. I really do. 

Bonnie: Yeah. Well, she started the talk with asking, how many know about this medication, like the pink pill? And I don’t think it was more than 50%. She’s like, how many of you know about the blue pill? Everyone. 

Shieva: Right. Oh, everybody. God, how would you not know about the blue pill? Because it’s all over, there’s commercials all the time for erectile dysfunction. Like many women come to me saying, there’s something wrong, I don’t want to have sex, it must be menopause. 

And here’s the honest answer I would say to all the people out there, menopause certainly can exacerbate it and perimenopause can exacerbate it because we’re tired, because we’re stressed, because we’re not getting sleep, because of all those things. 

But also one of the biggest indicators of whether or not you have spontaneous desire, meaning walking around wanting to have sex, as opposed to when you’re in the act, once you start having sex, are you able to get lubricated and be excited and then have an orgasm? The answer is most of us, once we’re in it, are okay, but we don’t have spontaneous desire anymore. 

And the biggest indicator is length of time in your relationship, which is why you and I have divorced friends who are our age, they are having rampant sex because they have spontaneous desire for their new partner. 

And that doesn’t mean, I don’t say that to advocate for everyone cheating or getting a new partner. But I say it to audiences of women. 

Bonnie: I mean, it makes sense. 

Shieva: It makes sense. And that’s why I think, at least if we know that, then we can strategize. Now that I’ve said it, I want you to think of the people you know in your life who probably have the best relationships with their long-term partners, probably strategize things, whether or not they realize it. 

They’re doing things to keep themselves excited. They’re maybe listening to erotica. They’re using vibrators. They’re talking about it with their partner. They’re keeping that feeling alive, not in a way that they needed to when they were younger, because when they were younger in a new relationship, that just happened. 

They’re doing what people who exercise a lot do. I don’t love to exercise, but once I’m in it, I’m like, this is great, I’m going to do it again. And then tomorrow I’m like, I don’t want to do it again. 

Bonnie: Oh yeah, I rarely feel like doing it. 

Shieva: Right, but I could do better mindset work and decide that I want to be that kind of person who really loves exercise and work on it. And we could do the same thing for sex if we were taught that, but we’re not. So we end up just, as I joke, we just end up sucking it up and doing the labor of love or letting our sex life really dwindle. 

And instead, we could help ourselves either with medication or mindset or both and with vaginal estrogen. 

Bonnie: Do you feel that if partnered married people are not having sex, is that an indicator of something bad about their relationship? 

Shieva: You know, I really, I will say this, I think it very much, like most things in medicine, very much depends. Right? I think that I have friends, patients, family members who have beautiful, really deep relationships that are very fulfilling and they have very little or no sex or they have not penetrative sex, but they have oral sex and they touch a lot and cuddle. 

And I know other people who are having regular sex with their partners and they have very damaged relationships. So I really do think, I hate the term sexless marriage, you know there’s a term sexless marriage? 

Bonnie: Yeah. 

Shieva: And I think the truth is this, for many couples the lack of sex is because their marriage is damaged, right? And because they haven’t worked on it and because they’ve let all of that go by the wayside. But I don’t think it means every couple that doesn’t have sex has a bad marriage. 

I think you two get to decide together. Like are we not having sex because we love each other, but we actually have decided we don’t want to, for whatever reason we don’t want to. But we otherwise are connecting emotionally and maybe even physically in other ways. Or are we not having sex because we’re avoiding each other and maybe it hurts and I didn’t go see my doctor and maybe you have erectile dysfunction and you’re too embarrassed and maybe I hate you because you snore too much. 

I think anyone who says it is a sign of something wrong, I think men who are not having sex regularly probably have either a medical condition or maybe you’re seeking sex outside of the relationship because I think most men, their testosterone levels don’t tend to wane as much as ours do. So when I say medical condition, because we’ve determined that erectile dysfunction is a dysfunction and not natural, I would say those men could get help. 

Bonnie: That’s fascinating. I never heard that.

Shieva: Right. Right, so I could look at it both ways. I could say, hey, it’s natural because 40% of men go through that. I think the data was, I think, we should check me on this, 40% by age 65, which means it’s somewhat natural. But since we’ve labeled it dysfunction, if a man goes through that and because there is shame attached to it for men, they really should seek help because they can get help pretty easily. 

Bonnie: I’m assuming it’s also covered by insurance and cheap. 

Shieva: Of course. I mean, it was covered by Medicare even. 

Bonnie: What? 

Shieva: Yes. But they should also make sure that their female partner is getting help because the last thing you want is him to be getting the blue pill when you haven’t gotten your vaginal estrogen and maybe your pink pill and your mindset, because then you’re just forced into a really incongruent relationship, which I do think is what happens for a lot of people. 

Bonnie: I bet Addyi is not covered by Medicare. 

Shieva: Oh God, it’s not covered by any commercial insurance. It’s like, I think it’s about $99 a month, which is very worth it for people who want to use it, absolutely. But not covered. 

Bonnie: All right. Well, we could talk about so much more, but I think we covered a lot of topics. And for those listening, I hope this has been really informative and piqued your interest to, I was going to say it’s coming for you like it’s a bad way. But it’s going to happen, so be informed and be proactive. 

Shieva: Yeah. And it’s not all bad, there’s many good aspects to it in many ways. 

Bonnie: Okay. Well, thanks so much for being here. How can people find you? 

Shieva: Thank you. I’m mostly on Instagram at Dr. Shiva G, which I like. 

Bonnie: Can you spell that? 

Shieva: D-R-S-H-I-E-V-A-G. So Dr. Shiva G, V-A-G is in the last part of it, so I love that. So that’s on Instagram. And then right now our website tribe called V, like Victor, like vulva, vagina, tribecalledv.com, which will be in the near future switching to womaning.com where we are going to help, I keep saying that we want to help decrease your anxiety by increasing your knowledge about your OBGYN health because womaning is hard. 

Bonnie: Yeah. All right. Thank you so much for being here. 

Shieva: Thank you, I appreciate it. 

Bonnie: That was an amazing episode. I hope you enjoyed it and got so much value. And I hope this inspires you to maybe follow who I consider the thought leaders in this. So obviously there’s Dr. Shieva and then Kelly Casperson and Marie Claire Haver. And it also keeps that information fresh so that I know it reminds me to make sure that I’m doing what I can to stay on top of my health. 

So if you love what you heard, then I encourage you to grab a spot at the Live Wealthy Conference, February 20 to 23rd in beautiful Hawaii at the luxurious Four Seasons. Spots are going fast and I don’t want you to miss this chance. 

Now, and I’m not just seeing this, but I’m not sure I’m going to do this conference again. And people have asked me why not? If you know anybody who has planned a conference, it is a ton of work and the costs are so high. Like the AV, we got an updated quote and it was almost double, like $70,000. And that’s not even including our videographer. 

And so between that and just all the time it takes for my team to plan this, I’m just honestly not sure I will do it again. I’m actually thinking I’m going to move to smaller retreats. There’s a Paris retreat that I’ve been wanting to do. And so that’s where I am right now. And so this is your chance to come to possibly the last Money and Wellness conference, and go to wealthymommd.com/conference to learn all about it and to save your spot.

Hey there, thanks so much for tuning in. If you loved what you heard, be sure to subscribe so you don’t miss an episode. And if you’re listening to this on Apple Podcasts, I’d love for you to leave a review. Reviews tell Apple that this podcast is, well, awesome. And it will help women find this podcast so that they too can live a wealthy life. And finally, you can learn more about me and what I do at wealthymommd.com. See you next week.