Managing Symptoms in Perimenopause

This week's GameChangers is a conversation about managing symptoms and age-related health effects through perimenopause, menopause, and post-menopause. Help patients through this time with evidence-based choices inlcuding medication, supplements, and lifestyle.
 
The GameChanger
Perimenopause is not a diagnosis, but a natural part of reproductive life which should be managed with evidence-based strategies.
 
Guest
Anna Garrett, PharmD, BCPS
President, AnnaGarrett.com
 
Reference
Going Mad in Perimenopause? Signs and Solutions
AARP (What Doctors Don’t Know About Menopause)
EWG's Shopper's Guide to Pesticides in Produce
EWG's Skin Deep
4 Reasons Why Menopausal Women Should Lift Heavy Weights

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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Differentiate between perimenopause, menopause, and post-menopause by describing the potential physiological changes.
2. Identify common symptoms in perimenopause and evidence-based medication, supplement, and lifestyle recommendations

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-182-H01-P
Initial release date: 06/03/2024
Expiration date: 06/03/2025
Additional CPE details can be found here.

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Transcript

Speaker 1: 0:08

Hey, ce Plan members From CE Impact, this is Game Changers. Today we are talking about perimenopause and I'm really excited to have with me Dr Anna Garrett. Dr Garrett is a PharmD from the beautiful UNC Chapel Hill and is a board-certified pharmacotherapy specialist with over 20 years of experience. She's also a certified intrinsic coach, which I'm excited to ask a few questions about that today. And when it comes to our topic for today, which is perimenopause, she literally wrote the book. It's titled Perimenopause the Savvy Sister's Guide to Hormone Harmony. Welcome, dr Garrett.

Speaker 2: 0:47

Thank you.

Speaker 1: 0:48

I'm so happy to be here. Well, we are happy to have you. I am so excited to talk to you today. This is a huge topic. I remember listening to a podcast about a year ago I think it was maybe the New York.

Speaker 1: 1:02

Times Daily, and it was titled Menopause is Having a Moment. I is, and I've used yeah, I've used that phrase a lot, because I think it's exactly what's happening. Menopause is having a moment, and I think it's truly for good reason, which we'll get into. But, most importantly, we talk about how, as pharmacists, we can advocate for appropriate symptom management We'll talk about that today as well as using hormone replacement therapy for prevention of other aging conditions. So it's an important part of women's health that all pharmacists should be aware of. So, before we get into it, could you tell us a little bit about yourself and how you narrowed in on the scope of this for your pharmacy practice?

Speaker 2: 1:41

Well, I will say that my career path has been anything but linear, so that's how we all are, I think I know I started out as an infectious disease specialist believe it or not, straight out of my residency, and then I worked at various hospitals. I did some medical writing and my last I call it my last real job although this is a real job for sure was at our local hospital in Asheville and I was the manager of our wellness program, which meant that we offered a lot of disease prevention services in various areas. And so that is what led me into the intrinsic coaching certification, which basically means I have a health coaching certification through this company that teaches intrinsic coaching, which basically is helping clients get to a new piece of thinking, like in 10 or 15 minutes rather than a whole big long session. But when I was doing that, I knew that I wanted to have my own business, because I wanted freedom and flexibility and to be able to help patients and clients in a different way than we were doing in the hospital. And so I I was going to just have a health coaching business.

Speaker 2: 3:07

And then I was like well, but I've got this pharmacy degree and it took me a long time to get it, so I need to do something with that. So I visited a compounding pharmacist in North Carolina and sat in with her on some hormone consultations, and by the time I left that day, I knew that was the. Those were the two pieces I wanted to put together, and so I started that in 2011 and it's been been a journey ever since, also not linear, but it's a lot. Really enjoy what I'm doing.

Speaker 1: 3:40

Yeah, I love that and you know, kind of, before we get into the clinical topic, I'd like to talk a little bit more about that. So I love that you, you know kind of narrowed in on the things that you're passionate about and what made sense and and you've had such a successful business and I know you have lots more to do in that space so that's so great and I hope that we can all kind of learn from that to sort of you know, listen to what, what speaks to us and and where we can really add value. So that's so great and I hope that we can all kind of learn from that to sort of you know, listen to what, what speaks to us and where we can really add value. So that's so great and took a huge risk of you know kind of focusing on that and having your own business and, like you said, it's definitely probably more than a real job, right?

Speaker 2: 4:19

Well, only, a business takes a lot of time, and in 2011, nobody was taught. Menopause was not having a moment in 2011. So it was just, you know, there were maybe three or four people who really were having anything to say about it, and ever since then it's, you know, ramped up and up and up and so which is great, I'm very, very happy to see women being served in a way that helps them have a better quality of life throughout their lifespan. But there and there's so much information, misinformation still out there, and doctors haven't really gotten on the 2024 train of hormone therapy yet. They're still in 2002. So that's still a big challenge.

Speaker 1: 5:09

Yeah, absolutely, absolutely. I have a little bit of a personal experience with that. I wasn't going to talk about this, but I guess that leads into it. I had a hysterectomy for preventive reasons many, many years ago and I remember talking to my doctor about it because we have a history of osteoporosis in our family and you know I was worried about the dementia component and so I really wanted estrogen or hormone replacement therapy and it took like six months to convince this physician that that is what I wanted and at the time it was like Premarin. That's all the evidence that's out there. Because of your risk and you know I mean I think he was very conservative because I do have some of that risk, but it was it was hard. It was hard to advocate for myself and I remember thinking and talking to people about it if I wasn't a healthcare provider or professional and, you know, knew how to do my own research about it and have my own idea of where I wanted to be.

Speaker 1: 6:03

I knew what my outcome was. You know, I'm not sure that I ever would have kept advocating for it and gotten that to happen.

Speaker 2: 6:12

So I think you're right, we still have so much more to do. Well, and I, as part of my business, I teach women how to advocate for themselves. You know, right down to giving them the same the language to use with their doctor, and you know your. Your situation brings up an interesting point, because I feel like the conversation about hormone replacement, if you're having a full hysterectomy, needs to happen before you have the surgery, so that everybody's on the same page, because the last thing you want is to come out of surgery and all of a sudden it all hits the fan because you haven't had that conversation and your doctor isn't on board, and there are plenty of those doctors who aren't on board.

Speaker 2: 6:53

I had not a similar situation, but even for my own health, I couldn't sleep and so I've gone through many iterations of sleeping stuff. But I wanted to try estrogen, and every woman in my family, except for me, has had breast cancer. Well, estrogen doesn't cause breast cancer, but I had to go to my doctor with the book estrogen matters and say here is what is in this book you know you can take the time to read it or not and she a hundred percent knows that I know what I'm talking about, and so she let me try the estrogen patches, and it was absolutely life-changing for me.

Speaker 1: 7:35

Well and good for you for advocating, and hopefully now she learned, you know, for other patients as well, I think it's it's just taking so education takes so long. I think we get an idea in our head and you know, of course, with that doctor, because of the risk and he didn't want to be responsible for that, he was actually a gynecology oncologist, so that was, you know. I think he had other things in mind. But, yeah, knowing the language and I think that's a really good point Like that conversation should have had it happen preventatively, and I didn't even think about that. I never would have considered that. So I guess I'm glad I brought that story up because that could have saved quite a bit.

Speaker 1: 8:14

We won't go into that part of the story because that is a whole other thing, but it is. I think you know doing that ahead of time. That takeaway is really important. I love that you brought that up. I think the other thing is you know that that I've learned in learning more about this is perimenopause is not a diagnosis. It is different than menopause. It lasts for what? Four to 10 years. I guess you probably know the stats better than I do, but I mean it can really be a big chunk of our adult lives, and so it's really important that we advocate for what's important to us for quality of life. So so can you talk a little bit about that as well?

Speaker 2: 8:56

Oh, absolutely so. Perimenopause is that five to? It's actually an African-American women. It can last up to 14 years, studies have shown. But it's when it's that period when your hormones start to shift, and so the first thing that happens is your progesterone goes down and then estrogen begins to run the show, which causes all kinds of things that can be really vague so lack of sleep, weight gain, anxiety. So lack of sleep, weight gain, anxiety, fatigue. So it's some very nonspecific things that don't just make you sit up and go. I must be in perimenopause.

Speaker 2: 9:35

It is enough to send you, for some women, to your doctor and you're highly likely to come out with a prescription for antidepressants or birth control pills, neither of which are going to fix what the underlying issue is, which is that you have a progesterone deficiency and as you move through menopause or through perimenopause, your estrogen levels will start to fall.

Speaker 2: 10:01

And you know, if you're lucky, they end up, in tandem with your progesterone levels, at a low level and you aren't experiencing a lot of symptoms. But for women who live in the United States or other industrialized countries, this is a little bit of a problem, because we're exposed to so many chemicals that act like estrogen in our bodies and sit in our estrogen receptors, that you can be symptomatic long into menopause. And if you couple that with weight gain, well, what women don't realize is that fat cells make their own estrogen which can continue to contribute to this estrogen dominance picture. So women can continue to experience symptoms of hormone imbalance into menopause. So menopause is one day of your life. It's the day that marks a year since your last period and then everything after that is post-menopause. So you know that may sound like splitting hairs as far as the language goes, but I think it's important for people to understand you know where they are and to use terms correctly, as they're talking to friends or you know healthcare providers or whoever.

Speaker 1: 11:22

Yeah, I think that's a really good distinction, because I feel like I have read and listened and watched a lot on this topic and I've never heard it explained that way, and so maybe we should be saying perimenopause is having a moment, because truly, like you said, that's that's really where I think it is. I've never heard it explained that way it is.

Speaker 2: 11:45

I've never heard it explained that way, but that makes total sense. It makes total sense to me and the whole hormone replacement, which is now, I think, technically called menopause hormone therapy I'll probably never remember that, but that discussion becomes more important in post-menopause, whereas in perimenopause there are so many things you can do that don't require hormone therapy. Yes, you may require progesterone replacement, but there are very few women that I've seen or helped that have needed estrogen in perimenopause, unless it's kind of on the tail end, because perimenopause is characterized by really high estrogen levels and so that's what causes the weight gain and the crime scene periods and breast tenderness, and all of that because that's the estrogen signaling your tissues to grow, grow, grow, which creates all this havoc. And so women in perimenopause, especially early on, don't need estrogen replacement. They may very well need progest, is your like.

Speaker 1: 12:55

So what is the standard recommendation for somebody who comes in, Because I think the antidepressant statement that you made earlier I think that is happening a lot. I hear of a lot of people say, oh, I got put on the antidepressant for perimenopause symptoms. So so can you talk a little bit about like, what is the recommendation when somebody comes in with those symptoms, Like, where do you start as kind of a rule?

Speaker 2: 13:34

Well, so there's an argument on both sides of do you test somebody's hormones, and so my viewpoint is going to be a little different than the one I talk about first. Society will say you don't need to test hormones because they fluctuate so much. You know, they change from day to day. Well, my reaction to that is what lab tests do we do? That does not change from day to day. If you take a diabetic and say, hey, stick a finger on each hand and compare the readings, they're probably going to be different, and so we still use that information to make clinical decisions, right? So any lab tests we use to make clinical decisions, and so what I'm looking for because I do recommend testing hormones is on day 19 to 21 of a cycle, I want to see what the relationship is between estrogen and progesterone, because then that will help me decide. Does this person need to be on supplemental progesterone?

Speaker 2: 14:52

A lot of doctors just go by symptoms, and so you know you give somebody progesterone, they get better or they don't. But there's a lot more to progesterone. They get better or they don't. But there's a lot more to progesterone than just putting on some cream or taking an oral capsule. Not everybody responds well, especially if, if, like let's say, their cortisol is is very, very low. So there's a lot of nuances to it and doctors don't get taught any of this in medical school. Lot of nuances to it and doctors don't get taught any of this in medical school. So AARP did a study, probably six years ago, and published it, and it was called why your Doctor Can't Help you in Menopause. And so they surveyed all these residency programs OBGYN residency programs to see what was being offered as far as hormone education, and only 20% of the programs had any education about hormones, and of that 20%, most of it was elective. So I know I've kind of gone down a rabbit hole and I'm getting ready to come back. So no, it's, it's so interesting. So we've all been well, not all of us, but a lot of doctors have been told oh, just give somebody an SSRI, because that, will you know, help with hot flashes and anxiety, and some of them do. But the thing about it is you don't have a Zoloft or a Paxil deficiency, you have a progesterone deficiency and that can easily be taken care of. And with the SSRIs, the problem is that they're extremely hard to get off of. So Effexor is commonly used for hot flashes, but it is really really hard to get off of and it can take up to a year to taper it down. To get off of it.

Speaker 2: 16:41

When somebody comes in with the full-on menopause symptoms, the usual approach is to give them a form of estrogen. So I am a fan of topical estrogen preparations. I really like the estrogen patches just because they're so easy. And then if someone has a uterus, you need to add progesterone. The old school thinking is still that well, if you don't have a uterus, you don't need progesterone. Well, you have progesterone receptors all over your body and so you can really benefit from progesterone as far as anxiety and moods and that kind of stuff sleep, even if you've had a hysterectomy. So I think the tide is turning a little bit more on that, because women are starting to advocate for themselves as far as adding in progesterone after a hysterectomy.

Speaker 1: 17:37

As far as adding in progesterone after a hysterectomy. So what is the recommendation, because you mentioned that so post-menopausal, how long do you see people on this therapy?

Speaker 2: 17:51

So up until 2017, the recommendation was to do it for no longer than five years, but then the North American Menopause Society put out a new set of recommendations that said women can be on hormone replacement therapy as long as they have a need for it and I haven't read the one that came out recently, but there's a body of evidence that is mounting. That basically is you know, protect your bone health, protect your brain health, protect your cardiovascular health, take care of your. You know hot flashes and all that and stay on it as long as you want. So I, you know, I tell people somebody's going to have to pry my patch out of my cold dead hand.

Speaker 2: 18:46

You know as long as there's not a reason to stop it. So with topical preparations there are not a whole lot of side effects. One thing that does come up sometimes if it's not dosed properly, is a woman will start bleeding again, and then that requires a whole work up for uterine cancer, because postmenopausal bleeding is not normal, and so you definitely want to get that checked out. But that can also be a result of having your estrogen dose be too high, because that'll stimulate the growth of the uterine lining and then cause it to shed.

Speaker 1: 19:27

Yeah, that makes sense. So you mentioned, you know, until forever, like if you want to be on it forever until you shouldn't, until there's risk. So I know, like kind of going back a little bit, the Women's Health Initiative is, you know, sort of what got us into this mess in the first place, and you know, I mean it's data that we have on the day. You know we can only, you know, looking back, it's like that's what we thought and so you know that's okay, but now that we know more, we need to do better. So, in that vein, what are the risks? Like what should we be worried about in some patients? Because you know, we know now that the cardiovascular risk it does not outweigh the benefits of taking them. So when?

Speaker 1: 20:10

you say like until they shouldn't like. What are those things that we should be worried about?

Speaker 2: 20:15

Well, the biggest one that comes to mind and this question is being asked more and more often is the guidelines say that you should start hormone replacement within 10 years of menopause and before the age of 60. Well, if you look at me, I was 59 when I went into menopause, but I started them anyway because I was not 10 years out from menopause. And you know, but I started them anyway because I was not 10 years out from menopause. So the question that's pretty central right now is is it ever too late to start hormone therapy? And so I am friends with somebody who knows more about the literature than I'm ever going to hope to know, and what she says is the risk of starting estrogen after 10 years of menopause is that if somebody has plaque in their arteries and you start estrogen therapy, then the arteries become more elastic, which can potentially allow a plaque to break off and cause a stroke. So if somebody is in that category, then having a more extensive cardiovascular workup before starting, which would include a carotid ultrasound, a coronary calcium score and then a measurement of LP little a and that helps you further define that particular woman's cardiovascular risk, and if all of that looks good, then you are probably okay starting it.

Speaker 2: 21:46

Um, you know, there's still. There's still a lot of questions about women who have had breast cancer. Um, should they be on hormone therapy? And there actually are a number of studies out there that show that estrogen does not increase the risk of recurrence. Now they don't get same kind of press that the women's health initiative got, but they are out there.

Speaker 2: 22:11

And then you know, with progesterone, well, well, let me finish with estrogen. So with oral estrogen preparations there's still a risk of heart attacks, blood clots and strokes, because that first pass through the liver changes the clotting factors and can increase the risk of blood clots and all those other events that go along with that. With progesterone, the biggest risk is that you give it to somebody that's got severe PMDD premenstrual dysphoria and there's no way to know whether somebody's got a receptor issue or not till you give it to them and it makes them a lot worse. But a lot of physicians and other health care providers don't know about this receptor alteration where basically the shape of the receptor doesn't allow the progesterone to do its job, and it makes that patient much, much worse when you give them progesterone as far as the PMDD goes. But you're going to know that in the first month. So there's also questions.

Speaker 1: 23:21

Is there a? Oh? Sorry, I don't mean to interrupt. Is there a pharmacogenomic test that can you know? We have so many more of these things that are guiding therapy. Is there? Anything that you could know to prevent that. Or like what's the percentage of people that that would even apply? Maybe it wouldn't even be cost effective.

Speaker 2: 23:41

It's a minuscule percentage of people. Okay, I don't know if there is a test to figure that out for progesterone. I know that there are a lot more genetic tests that are coming. Well, it's already on the market. But so the ESR, snp, the estrogen sensitivity receptor SNP, I don't know the details, but and I'm, but I'm going to learn very soon about how you use that, that particular SNP, to decide if somebody's a good candidate for, for hormone therapy.

Speaker 1: 24:18

Yeah, interesting. Okay, sorry, I didn't mean to cut you off. I think you're going on to the next point you know I think about. There's so many of those things that are genetically related that you know we're just gathering. That's what's so exciting, is we're, you know, learning so much more that you know we wouldn't have to wait for that, you know, to happen, but we could actually, you know, have that guide our therapy. So I'm always interested to know if that's available. One of the things you talked about was toxins and foods to stay away from. Would you mind talking a little bit about that and the things that impact estrogen that we could talk to patients about?

Speaker 2: 24:58

Sure um, so toxins are almost impossible to escape. So of course, there are the pesticides that are on our food. Um, so that's why we, you know, have the list of the dirty dozen um on. Uh, what's the website? Um yeah, environmentalworkinggrouporg has their dirty dust. Strawberries are always at the top.

Speaker 1: 25:26

So uh, right, right, raspberries are my favorites.

Speaker 2: 25:30

We've got plastics, um, that are everywhere. We've got phthalates that used to be in water bottles but still exist in other places, and so those things, um, and things that are found in lots of cosmetics and the environmental working group has a list of those two Sunscreens are a big one as well that act like hormone mimickers and don't allow our endogenous estrogen to do its job correctly because the receptors are blocked. When it comes to foods processed foods tend to exacerbate symptoms. Alcohol is a big one for exacerbating hot flashes and interrupting sleep.

Speaker 2: 26:17

I try to buy grass-fed, organic meats In Asheville. We have lots of access to that, but not everybody does and not everybody has the budget for it. So just trying to eat as clean as humanly possible and staying away from I tell people to stay away from additives they can't pronounce because they're probably not good for you. I know that doesn't specific foods necessarily, but things like flax seed can be very helpful. So ground flax seed, sprinkled in yogurt or whatever, can be helpful for some estrogenic symptoms. So there's there's a lot of ways you can take care of yourself.

Speaker 1: 27:01

Yeah, I feel like you know, sometimes when we talk about this, and I think maybe this is why maybe you say, like SSRIs are easier to prescribe than it is to figure out, like what the doses are. And you know I think that's part of it is there's no like set right wrong. You know there's no objective data necessarily. Every person is a little bit different and you know it takes a little bit more time. So I guess, as we, you know, as we kind of start to wrap up this discussion, because we could go on forever, I have so many questions.

Speaker 1: 27:31

We'll have to do this again, but you know what are the key things. I guess you know, as a pharmacist, when you've got somebody who says, you know, I feel like I've been perimenopausal, I'm having these symptoms, you know what should I do next? Like you know, are there kind of some like guiding principles that you know, 10 years before maybe your mother had menopause, you know, really start thinking about this preventatively, you know, look at your, you know your osteoporosis risk and you know some of those things like what are? You know, are there a set of five things that we should all remember that we, you know it's a good place to start with patients sometimes Cause I think it's so sometimes it can get so overwhelming that we just, you know, get prescribed an SFRA.

Speaker 2: 28:20

Well. So the way I practice it's like a three-legged stool. So it is lifestyle is the foundation, and then supplements if they're needed and then hormone replacement if that's needed. You have to clean up your lifestyle. If you're having symptoms, I mean, there's just, there's no way to out supplement a crappy lifestyle. And getting into your lifestyle means addressing stress first, because stress raises cortisol. Cortisol is the only hormone your body needs to live and your body will make it at the expense of all of your sex hormones. So if you don't get stress under control, you're, you're really missing the boat. Um, the next thing is sleep, and I know people are going to say, yeah, but I'm in perimenopause, I can't sleep, and I'm like at least provide the container to try to get eight hours of sleep a night. Um, clean up your diet, eliminate, eliminate or at least moderate alcohol use and you know, for perimenopausal women, wine is kind of like your go-to right To like manage.

Speaker 2: 29:34

Coping mechanism and I literally have had clients where I got them to stop drinking and everything went away Everything hot flashes, insomnia, the whole thing. And it's a very powerful step to take and it's really, really hard to take. So I say clean up those things you know. Work with a health coach if you need to, to provide some accountability and some education and have somebody to hold your hand to, to provide some accountability and some education and have somebody to hold your hand, and then from there supplements can be very helpful. So if somebody's in early perimenopause, Vitex or Chaseberry is a supplement that can really help balance estrogen and progesterone. Magnesium can really help with sleep. Fish oil is great for any inflammation. B vitamins, because we don't get enough B vitamins normally. And if you're on hormone replacement, you definitely need that because hormone replacement depletes Bs. And then from there you have a conversation about hormone therapy and not everybody wants to go that route and that's fine.

Speaker 2: 30:44

Back to lifestyle. I forgot exercise. And how can we forget about that? Because there's studies that show that exercise cuts down hot flashes, preserves bone health and keeps you out of the nursing home. So you know, doctors are telling women they don't need to have a bone density scan until they're 65. I'm like the horse is out of the barn by then. I tell people at 50, because once your estrogen drops, your bone density just drops really dramatically and and you want to be able to jump on that if you need to, and I'm one of those people, so I lift weights yeah, estrogen. So those are my, my strategy.

Speaker 1: 31:25

Yeah, I think, if nothing else you know from like, you see the data on the piece of paper and it's like, okay, I need to lift weights.

Speaker 1: 31:33

You know, so I think it's kind of one of those health coach strategies, like if you, you know, if you want to be able to be strong, you have to, you know, start that early. So that was one thing that changed for me. You know, I knew I needed to, it's like, okay, I know I need to lift weights and I need to do that. And then when you see it on paper and it's like, okay, I need to maintain, you know, my bone density, so that's the way to do it, so it that can be really powerful just to get people to kind of move on that I think.

Speaker 2: 31:57

Well, and I reversed osteopenia with lifting weights. So, um, it took. You know it took three years, but I still did it. And I started when I was 50 and I'm 64 now, and so I'm still doing it three days a week. So, cause I'm not going to?

Speaker 1: 32:16

Right, right. The last thing you want to do is fall and break a hip. Yeah, that's what I'm trying to prevent. And so, when it comes to HRT, then if we, you know, when you get to that third leg, starting on when you're in perimenopause, what's your recommendation?

Speaker 2: 32:34

there. So for perimenopause, my general recommendation is for progesterone. It comes in creams over the counter, so that's available to everybody. The oral capsules work much better for sleep, just because of the way it's metabolized. And then, when you get into menopause, an estrogen product whether it's a topical estrogen product, whether it be a patch or mist or gel or compounded cream plus progesterone again either capsule or cream. And then in menopause it's important not to forget about testosterone. So you don't hear a lot about testosterone in women because there's no commercially available products. But for maintaining bone health and muscle health and just your drive, testosterone can be a really powerful addition to your hormone regimen. So some people like to do the injectable, some people prefer compounded cream, and those are the two easiest ways to do it.

Speaker 1: 33:43

Okay, great. So I think that makes it easy, like that, you know, like just choose along the way and where you are, and I think if we can do that for prescribers you know a pharmacist can do that for prescribers here. You know, here's what we recommend from the drug therapy standpoint and to be an advocate, like you said to you know, encourage women to go into their provider with this. Like these are the things that you know I want to make sure I'm addressing as an education and advocating for themselves. I think that's really great advice.

Speaker 2: 34:18

Well, and a lot of women say, well, how do I find a doctor who actually knows what they're doing about with hormones? And I say, go ask your compounding pharmacist in town, because they know who knows what they're doing. So that's a great. That's a great great point.

Speaker 1: 34:35

Yeah, that's a really great point. Okay, well, this has been so good. Like I said, I think we could go on and on, but I know we have a time constraint, so do you have any last last parting words? Or I guess, what's your, what's your biggest thing that you want to make, pete?

Speaker 2: 34:54

make sure people know about this topic to know that they don't need to suffer, that there are so many things that you can do to help yourself, and there are providers out there that can help and it may not be your doctor, so don't hesitate to look in the pharmacist world or the chiropractor world. There are people that are very, very well trained to be of assistance with hormone imbalances and just overall general health naturopaths. So there's lots of people out there, and if you're not comfortable with your doctor, then if they're dismissing you and making you feel like it's all in your head and that you just have to suck it up, go find another doctor, because that is not true. You do not have to suck it up.

Speaker 1: 35:47

Yeah, yeah, really great point. And I think you know you have an amazing practice that I know you take patients from all over the country, so I think you're a really, really great resource and I would just encourage particularly pharmacists in the community. You know, know who those providers are and and and put it out there I mean I have. So I'm in this age group so I have a lot of friends that ask me these questions and so I know if they're asking me they are wanting a pharmacist to tell you know they just need a resource. So even if you know you've got a sign that you put in the pharmacy, ask me about perimenopause. I think just the more we can talk about it and advocate for it and then you can help those patients to know what next steps to take.

Speaker 1: 36:31

I think you could position yourself as a really great resource in the community. And then also knowing where to send them for more whether it's providers or the compounding pharmacist or whether you do that compounding so really making ourselves known that we know this drug therapy space and we can help to provide some advice to patients I think is great. So thank you for all of the work that you're doing. I think your business is amazing, and who knew you know 15 years, or however, however long you've been doing this that it would be having a moment and that you'd be having such an?

Speaker 2: 37:06

impact on your life.

Speaker 1: 37:08

So so very cool. I'm sure that's rewarding every day for you.

Speaker 2: 37:11

Yeah, it is. It's a lot of fun. Yeah, so great.

Speaker 1: 37:16

Well, that is it for this week. Thank you so much, dr Garrett. I really loved this conversation and hopefully we can talk more, maybe on another topic, because I know there's so much that you're doing and that we can share with people. So that is it for this week. If you are a CE plan member, be sure to claim your CE credit for this episode by logging in at CEimpactcom and, as always, have a great week and keep learning. We'll talk to you next week. You.