Brittany (00:00)

Hey there, good afternoon. Brittany Meeker, nurse practitioner at Thrive. I am with the amazing Dr. Bimisa Augustin, who I get the privilege of working with every single day and is an amazing mentor, but also too, she's here to really help clear the confusion and empower women with the facts and the hormone therapy knowledge base. And just to kind of trump some of those studies that are making hormone therapy discouraging for the benefits and outcomes that it does provide. Dr. B, introduce yourself.

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Dr Bimisa Augustin, DNP (00:32)

Hi, I'm Dr. Bimisa Augustin. I'm a doctor of nursing practice. Been in practice now for a little over 20 years. I don't want to age myself. And yes, I am a very much so perimenopausal woman, okay? So I understand what a lot of women are going through and also too understand the fears because in the beginning, before I started, I would not prescribe hormones either, but I opened my mind to different things and I learned a lot and here I am. It's nice to be with you, Brittany.

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Brittany (00:59)

You, too. And I want to really dive into perimenopause like you mentioned. Why is it so confusing? Why is it so overlooked?

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Dr Bimisa Augustin, DNP (01:08)

Well, it's overlooked because of the fears, you know, of what these hormones have caused in the past, right? So in a lot of cases, a lot of practitioners will say, well, you just have to live with it, but you don't because it's decreasing your quality of life, right? So a lot of these symptoms begin. Okay, it can begin in the mid 30s, right? But I've actually started seeing women that are younger that are starting to have these symptoms like in their late 20s. So if you have a young, vibrant 20 something year old coming into your office saying, I'm having hot flashes, then guess what? If you're not thinking outside of the box, you're basically gonna say, okay, nothing's really wrong with you. Just, deal with it. So it is overlooked because it was so taboo. It absolutely is. And a lot of people don't really understand what it is, like to go with it, go through this. I would say especially men, they definitely don't, it's those women that are living in that body and their quality of life is affected that, are being overlooked.

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Brittany (02:03)

I think it's interesting too when we have these patients present to us at such a young age. It's like, well, what day of the cycle are you on? When are you noticing these symptoms? And it kind of dawns on them. Well, I don't even know the correlation with my cycle and these symptoms, which speaks volumes. It's so important to know, are we in that follicular phase, that luteal phase? Where are we at with ovulation? Is it happening later? Because it's very common in our luteal phase to kind of notice a lot of these night sweats for younger women. Depending on what they're experiencing. And I think it's important to know too, with estrogen fluctuations in perimenopause, can exacerbate a lot of mood disorders. And given your specialty in mental health, I imagine you see a lot of SSRIs and benzos getting prescribed for these symptoms. And it really is the baseline of a hormone dysregulation. Now I love a good band-aid, but I like to rip it off too. And I find that with these prescriptions, they are very helpful, but it's not getting to the root cause of why it's happening further. And what's unfortunate too, and I'm sure you see as well, like perimenopause, them having like more joint pain and chronic pain and sometimes feeling like when they work out, they can't recover as quickly. So it's just very unfortunate that with the sleep disruption, feeling during the day more moody, they're having more pain. It's also just kind of a band-aid of kind of things that we place that are not fixing the root issue, which is so unfortunate because they're so young, right? It's like as time progresses, it gets worse.

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Dr Bimisa Augustin, DNP (03:32)

Also don't realize that their thyroid is playing a big role in how they're feeling as well. Even in irregular periods, their thyroid is definitely playing a huge role. Studying functional medicine has taught me to look at the symptoms along with the labs being an added value.

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Brittany (03:51)

Right, right. You love that thyroid.

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Dr Bimisa Augustin, DNP (03:55)

Love it.

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Brittany (03:56)

You love the thyroid and I have learned to love it too. And that's super taboo, right? With the thyroid ranges, you never want to go too high, too low. It's always this scarcity of putting them in like this hyper or hypo, you know, outcome. And it's really the fact of it takes weeks and months to ever get there. But the range never is enough to really support what we need those, those ranges to be to begin with. I'm curious too, with patients you've worked with and they bring their labs to you and it's kind of like they were told everything looks good, everything looks normal. What do you educate them about the early signs and what to look at when it comes to labs?

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Dr Bimisa Augustin, DNP (04:36)

Okay, so I do let them know lab values are added, but the first thing I do is I ask them close ended questions. I will ask them, hey, do you have mood changes? Mood swings? You just want to punch everybody in the face all of sudden, and they just look like, oh, rainbows and butterflies, right? And then I will ask them, brain fog. Do you have that? Yes or no? How about sleep issues? Talk to me about your sleep. When they go through all of this and I'm like, okay, now let's look at your labs. And then we see the progesterone won't even register. some of the labs are lower than 0.5. So guess what? You have a progesterone deficiency or their testosterone is in that quote unquote, lower end of normal range, right? And they're an athlete or something like that. And their testosterone is let's say 15, might not work. So that's where that brain fog and the fatigue is coming in. They feel like they're losing muscle mass. basically I do look at the symptoms first. I ask the questions about the symptoms first and then we put them together with their labs and boom, there's your beautiful picture.

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Brittany (05:25)

No, and that's super helpful too, just for the approach of what they've experienced before because Academy, well, you've heard of A4M, I imagine, right? The American Academy of Anti-Aging. I love it. It's delicious. I eat it up. And I'm actually kind of brought back some data for us to like explore with everyone listening. And it was fascinating to me, the study of low testosterone being, you know, increased risk of depression, especially in women. And that as we transition through this perimenopause phase or even young athletes, right, that they're really depressed, they have low testosterone levels. So again, conventional medicine will focus on other options. But again, the labs will be, this level is good, but we know that the free direct testosterone has more of an outcome than just the total. But we're always focusing on the total testosterone, which is kind of a reserve bank. But I find that really interesting too. And even about the WHI study, I mean, that's really why a lot of patients I imagine of yours too, I know mine, is this going give me cancer and hormones aren't good. How long do I have to be on this? What's your feedback on the WHI study? Because it's quite fascinating.

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Dr Bimisa Augustin, DNP (06:41)

So if I can say this, the WHI study was BS, okay? A small study sample. Older women that were already predisposed, It scared the heck out of everyone. Everyone. There's no real justification why patients can't go on hormone therapy if they're not synthetic. And that was another thing. There was synthetic hormones involved. And I would say also too higher doses. A little bit of these hormones can go a long way. You don't need to just throw someone on a large dose of these hormones and expect for everything to be okay. Because to be honest with you, I wouldn't. I did not like the study at all. It did absolutely, absolutely scare everyone. It scared everyone.

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Brittany (07:18)

Right. A hundred percent. And I want to say too, like A4M really spoke on it and had a lot of detail. And just from like my review of that is, is yes, it was synthetic hormones. It was Provera, Primarin. And the biggest takeaway was it wasn't the estrogen that caused the symptoms. And we're looking at symptoms of the risks of blood clots and things like that. Because like you said, it was an older group of women. They had more comorbidities than expected, smokers, all the things and then they were placed on synthetic hormones. And so as these issues were happening, they stopped and said no hormones for anybody, but it was more of the synthetics, not so much the bioidenticals. And so when we look at this specific drug, Provera, it was considered the primary source of the concerns by the Women's Health Initiative, the WHI study, but its distinction missed the fact that it said all hormones, not bioidentical hormones, which is a total difference. And so I think what we think of as hormones is really we're replacing your hormones. We're not doing that. We're supplementing it because your body is getting more of what it's lacking naturally in the sense of it knows how to recognize it. So I always think that the WHI study is quite fascinating, but it was debunked in 2013. And so now there's more light on it was more of a synthetic issue and not so much of a bioidentical issue. So those, those blinders were on for a lot of providers. Again, I think it's important to kind of look at the recent studies of what that looks like. Estrogen, right? So we think of the WHI study being concerned of hormones and treating hormones, especially estrogen. And so there's been a big fallout of the fear around estrogen. What's your feedback on that.

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Dr Bimisa Augustin, DNP (09:01)

I like estrogen. estrogen is more so like the loud twin. I like it. It does help with vaginal dryness because of the atrophy of the vaginal wall. It does help with libido, absolutely. It does have some properties where if it's balanced enough, women can actually lose weight and maintain their sexy figure. I like estrogen I would use progesterone a little bit more to be honest with you but I do like adding estrogen especially with those postmenopausal women those women are just now starting to go through menopause and these symptoms are horrible because of the fluctuation of estrogen and that hormone I am very conservative with I mean literally to the point where if you're going to use it daily, we start out at 0.3 or 0.5 and then we work our way up from there as needed. But it's a very, very good hormone where you only need a small amount in order to make a difference.

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Brittany (09:45)

100%. I love your comment on it can help with weight loss. That was one of the things the study said is, aside from women, if we look at men who are on testosterone and the bro science is what they call it is it's estrogen blockers for these men, but they'll have these big muscles and these big bellies and it's because they have no estrogen and now they're growing a belly similar with with women, right? If our estrogen starts getting low, we recognize this belly and we're like somethings off here and it's usually the fluctuation of estrogen and she mentions like like you said it's a fat burner it could really shut that abdominal area and make weight go down but I also love from the science standpoint further of when you do supplement really with bioidentical estrogen is what it can do for the heart like if you have pre-existing cardiovascular disease there's not a negative effect on heart attacks and outcomes it actually decreases the risk of death. It's interesting too that when you replace estrogen before the age of 60 or within 10 years of menopause, you're going to have a reduction in coronary artery disease and death. And so it does a lot for the risk of Alzheimer's that we hear about. And also when we look at, stopping estrogen to begin with, there are some times like that study, you think of the WHI study where these women were on hormones and come to find out it was debunked on what some of it did, but really the bone health of it, right? Because estrogen is going to reduce the bone reabsorption, maintain the density, and testosterone does more of the strength.

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Dr Bimisa Augustin, DNP (11:23)

Yes, and there are studies that do show that there is a correlation between a decrease in testosterone, Alzheimer's, dementia, and Parkinson's disease as well.

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Brittany (11:32)

100%. I love estrogen. What are your thoughts? You know, estrogen alone, when it comes to the hormone relationship therapy and breast cancer risk. I mean, we understand that there's a relationship between hormone therapy and the breast cancer risk. What is, what does that look like?

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Dr Bimisa Augustin, DNP (11:49)

So that's why I always prescribe progesterone along with estrogen. And like I said, I do tell my patients that, estrogen is the loud twin, progesterone is the quiet one. Being that estrogen is so excitatory, you need something that's going to balance that and kind of calm it down. And that's where progesterone will come into play, right? Oftentimes my estrogen prescriptions are a little bit well the doses are lower and the progesterone I will say the balance is a little bit higher, you know just a little bit, I do have some that are way higher but just a little bit so that way it can kind of alleviate some of those estrogen dominant symptoms, because putting women on these hormones that they've never had supplementation before, all of a sudden they're like, oh my gosh, I'm nauseous or my breast hurt. What is going on? Well, it's a little bit too much estrogen. So what we're going to do is kind of calm that down, change the frequency of the use, instead of daily, drop it down to every other day or every, every two days and add a little bit more progesterone just to give it that nice balance. You have to find that sweet spot. There's a lot of back and forth with titrating these these meds a lot in the beginning.

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Brittany (12:52)

100%. And so with those being bioidentical, what's the difference with bioidentical and synthetic?

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Dr Bimisa Augustin, DNP (12:59)

So bioidentical, they are structurally identical to human hormones. So you can put them side by side and they're gonna almost look the same, They're often better tolerated. They have fewer like side effects compared to the synthetic hormones. That's pretty much, that's all I know. That is all I know. It was only a few times that I did give synthetics and I was just like, okay, this is not for me. So every since then, all these years I've been doing bioidentical. I myself am on bioidentical and I don't have any side effects and I love them.

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Brittany (13:29)

Right, yeah, I agree. I'm on them too and I have no side effects. Again, you're my amazing provider that takes care of me and does all the things. Yes, but I would have to say with that being said, I think communication between us is huge and I say that for patients that are listening with fear.

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Dr Bimisa Augustin, DNP (13:36)

Hey, you are mine.

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Brittany (13:47)

or unsure of facts, that it's always helpful to speak to a provider and get those questions addressed. And even those who are listening, having open discussions with your provider who you may want to talk to hormones about that there's a big difference between synthetics and bioidentical. And I think of synthetics as a way that can make your hormone production not only be depleted, but puts you in an induced menopause. I mean, let's go into the Mirena. There's nothing wrong with the Mirena in the sense of maybe why you possibly got it, but you're not cycling at all. And so you're more in like a medication induced menopause, which is causing a lot of the symptoms. So while we do work with patients who are on birth control measures, the goal is like, let's please just rip this off and really funnel through this and kind of see a more clear picture. So what would you say is different from birth control pills with hormones symptoms? I mean, how are they different and how do you approach that?

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Dr Bimisa Augustin, DNP (14:24)

Okay so the difference is birth control suppresses okay oftentimes it's suppressing your estrogen all right. We don't suppress anything. The thing is if there's any dominance there especially with estrogen we're going to balance it with progesterone. Give you more progesterone so that way you're not prone to those hot flash symptoms like you suppress it you're going to have hot flashes. Hello, vasomotor. And most of them are like my gosh i gained so much weight on this even depo, and i'm like because you're not producing any estrogen. You're not cycling. So, I mean it's patient preference if they want to stay on it absolutely you can and we can give them more progesterone okay while they're on their birth control but it will birth control pills lower the efficacy so you can get pregnant, so that's a lot of education that we have to do for patients that want to stay on birth control. I don't necessarily try to talk them out of it, but I will definitely educate them and tell them, hey, it might be a good idea for you to come off of these, especially if you're having those symptoms, those side effects from, the birth control. But if they don't, I'll work with them.

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Brittany (15:40)

100%. And I know you're all about the liver with bioidenticals, with birth controls, we always want to keep it on the liver, especially with how hard it can be on the liver to process all of that. And I find too, going further with like patients with polycystic ovarian syndrome, which is more of an estrogen androgen dominance of the system. It's kind of like a one, one pill fits all. It's spiralactone and here is a progestin based birth control. I love that, obviously our approach as providers is tailored made for patients, but I'm curious too, like if a patient has PCOS, how do you approach that if they're on birth controls and what's your approach for it?

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Dr Bimisa Augustin, DNP (16:20)

So women with PCOS, they can benefit from hormone therapy as well. They absolutely can. Especially when they're experiencing sleep issues, mood changes, things like that. You don't necessarily put them on, testosterone because of the androgen overload already, but we could benefit from progesterone or DIM. And DIM is not, a hormone. It actually helps to modulate estrogen. So there's herbal supplements that can definitely help these women out. and progesterone again. I can't say it enough.

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Brittany (16:48)

I think we're even in an article on progesterone and it's like Brittany, we're just talking up progesterone. I mean, Lord knows you have me on it. I'm obsessed, but I think it does a lot for that luteal phase for skin, hair, sleep. There's a lot of layers to it I feel like we hear menopause for hormone replacement therapy, but like you said in your practice too, there's a lot of younger women that are having to be on hormones. So would you debunk that hormone therapy is only for menopause? What other groups of people would benefit from it?

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Dr Bimisa Augustin, DNP (17:18)

Absolutely not just for those women that are menopausal. It's PCOS, women with endometriosis, surgical menopause, absolutely. Okay, and it's getting younger, all right? Women that are just having mood changes, test their thyroid, see what's going on, instead of throwing them on, antidepressants, which can suppress your hormones as well. If you're suffering from low libido. Testosterone is great for that, right? Progesterone, poor sleep, joint pain. So all these women can, benefit from hormones. And another thing, joint pain along with I would say muscle cramping or muscle pain or muscle loss. You're seeing big, big, big results when it comes to women that are, being put on testosterone.

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Brittany (17:57)

I think I love testosterone. I think that's probably my number one fave. It's really big right now too, because we're in this epidemic of the GLP-1s and the Tirzepatide and Ozempic and the weight loss is phenomenal and it's great and it's decreasing inflammation. But where there's subcutaneous tissue, there's muscle and our hormones need the muscle. And so we find that hormones are getting depleted. Testosterone like muscle strength, endurance is getting depleted because of the GLP-1. So it's not uncommon for those on, GLP-1s that are affecting testosterone levels and hormone levels because you're depleting a lot of fat, but where fat is there's muscle and so that can, our hormones need muscles and things like that. So very helpful for that group of patients is getting the testosterone replacement. Now, again, it's not just for men, right? We need testosterone and so many women will feel the difference and I thought it was fascinating. So there was a clinical practice study where 87% of people had a decrease in depression symptoms after receiving androgens like testosterone. And so I thought that was interesting as well because androgen decline after the second baby is associated with increased depression in women. So after the second baby, testosterone is dropping. We're seeing depression, but when you replace it, it's better. What are your thoughts on looking at the emotional and cognitive benefits of testosterone?

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Dr Bimisa Augustin, DNP (19:23)

Usually when a patient presents to me in my clinic in there and they're sitting here, they're upset crying, they don't know why. First thing I will say is have you ever had your hormones tested? No, like no okay, let's take a look at some things and see what's going on. I see more women I literally just had a 31 year old with a testosterone level of a four. Everyone thought she was bipolar. She would have moments where it was just, I cannot move out of bed. I am so sad. I am so sad. Do you know what, I only took one, about one month of trochee use and complete 180. Complete 180. No longer is it, you might be bipolar or I'm sad, and they're trying to, admit me into the hospital. Totally different. So I think that is very important to find the underlining cause before throwing anyone on any medications that could have terrible side effects.

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Brittany (20:11)

100%. I mean, even opioids, right? That's a big thing for chronic pain management. Again, those who are prescribed it usually does need it, but it has a direct lowering effect on testosterone. While if you give more testosterone, that can actually help with chronic pain management. So I think it's fascinating that that one hormone alone is not just focused on men, but what it does to mental health, bone health, right? And so it's really good to know that.

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I mean, even if we think of the vasomotor symptoms of hormones and like the benefits of what they do, what does that support look like long-term? Because obviously I've seen your labs and you're thriving on what the hormones are doing for you. What else does that look like?

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Dr Bimisa Augustin, DNP (20:59)

So it's reducing not just my risk, but every other woman that's post-peri-menopausal or post-menopausal. Reducing the risk of cardiovascular disease, okay, absolutely. Inflammation, all right. So women that are 10 years post-menopausal, it reduces that risk of coronary artery disease as well, big time. Like I said, I mentioned before Alzheimer's, any cognitive decline, reduces that risk. Dementia, Parkinson's disease. I mean, there's just so many benefits to this hormone therapy. Not just, bone density. That's another thing. Everybody thinks, I don't want osteoporosis or osteopenia, but there's other things that these hormones are beneficial for.

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Brittany (21:43)

Right, 100%. I think it's wild to like, we look at the correlation, like when we were in our young 20s and teens, we could jump out of bed and stay up late and have the energy for all the things and have late nights and like, obviously libido was great, but as we get older, that declines and I don't think at all for a second with all the research that it's not a coincidence that our hormones are declining, but now we're higher inflammation, cardiovascular disease, Alzheimer's, like it's all tied in and no one's really looking at the depths of that. I mean, even with how estrogen protects the heart and brain and just like looking at the role of it from a vascular standpoint. Estrogen being an antioxidant helps with increasing nitric oxide production, smooth muscle cell relaxation. The loss of it, low estrogen leads to increased cholesterol levels, increased LDL, the bad cholesterol we don't want high. But then also too, testosterone declines. We're looking at more of that arterial stiffness and heart disease. And it's all interrelated, but also too, just looking at notes of references. There was a 2023 review that showed that 30 to 50 percent of reduction in Alzheimer's risk when hormone therapy was started early. Now what's early? The perfect scenario is perimenopause or 10 years within menopause of no cycle. So it's better to start it early like when our perimenopause phase, right? But up to 50 % of women over 50 will have an experience of a hip fracture or some sort of fracture, which hormone therapy can change that trajectory. I think too, there's research that shows as we get older, men and women are increased of a hip fracture and that can even lead to death because then we're immobile.

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Dr Bimisa Augustin, DNP (23:28)

Yep, absolutely. All cause. Mortality.

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Brittany (23:29)

Something that we could replace. Like, right. It's wild. It's so wild. What steps can women in their 20s and 30s take to really help support their hormone health now?

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Dr Bimisa Augustin, DNP (23:42)

Now especially younger women, that vitamin D is a hormone. Hello, heart healthy, brain healthy, and especially bone health. It will help with K2. It will help your body naturally utilize the calcium that's made from the D3 and pull it into your bones to make it stronger. So that's the first step, And then after that, just keeping an eye on your labs and paying attention, being in tune to your body so that way you'll know, okay, well, this is different because I always do tell my patients too that our bodies are a luxury vehicle. Any little thing that goes wrong, a light is going to go off. So you have to be in tune to the differences that your body is experiencing. Number one, would say vitamin D and then start from there.

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Brittany (24:23)

I love vitamin D and it is a hormone. It's like this big stuff. It's in like the supplement category, but it is a hormone and it affects our immunity and our bones and our depression. I mean, I think what's wild too is that reference range of D3 is from 30 to a hundred. And if it's over a hundred, it's toxic. There's research that shows you need it over a 70 to decrease the risks of colon cancer, breast cancer, inflammation, immunity. And I have patients that are like, yeah, my D3s, like a 30, you know, it's within range. I'm like, we're going to start that. Let's time out real quick. Time out. we need it doubled. So I love the D3 and that's a big, big important part to focus on. Also too, just looking at, the hormone health being foundational to fertility and mood. I wanna focus on, like you said, labs is that the concept of a normal reference range is really problematic. And I feel that the normal reference range is a range based off of expectation for your age, right? So it's not a normal range of optimized, it's normal range of a bell curve given your age and what the expected level should be. So whenever you see labs and it looks normal, it's expected for your age. But who the heck wants a level for their age group? I don't. I mean, that's why we get tired when we get older. We don't need to be average. We need to be like improved. Thank you, Dr. B for always keeping me in those higher ranges. But I think it's important that those labs are just a guide and that like you said, closed statements with questions. You want to answer these closed-ended questions and get answers, you know, and find out that way versus just getting labs and only focusing on the labs.

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Dr Bimisa Augustin, DNP (26:07)

Absolutely, absolutely. For me, it's all about optimization. You definitely optimized me. I mean, you're a 46-year-old woman. And yes, I do not mind telling my age. I do not. Being 46 and my testosterone level is literally, I think you read it last time, it's like 100. I am happy. I am happy, happy, happy, happy, OK? My life is great. So I'm perfect where I am.

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Brittany (26:28)

And like you said, each patient needs different things. And I feel like the takeaway is to really include your provider in a lot of these concerns and questions you have. Supplements like DIM for women, calcium glucurate is another good one that helps metabolize it more through the gut. And there's so many different supplements, even for women that are concerned about hormones. The supplement range D3 is a hormone, but we can put that in the bucket of supplements to consider DIM, calcium D-glucurate. Probiotics, right? Our gut is huge. I know you're big on leaky gut and all things gut and liver. I'm not sure if many are aware, but if you're not having daily bowel movements, you're really just reabsorbing those toxins your body are trying to get rid of. So that's why sometimes when patients start on hormones, they have those quick, sensitive responses, because ideally they're not metabolizing through them as expected. So again, communication is key. So where can listeners go fill out a quiz and learn more about all the details we touched base on?

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Dr Bimisa Augustin, DNP (27:39)

Thrivelab.com for one, it will have the self-assessment, fill it out and then a director patient care will call you and walk through the steps and you'll come on with that with a provider and make the decision, you know, if you want to join or not. Believe me, you'll like us. We're all fun.

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Brittany (27:55)

So thrivelab.com, fill out the self-assessment. Dr. B, thank you so much for your insight and passion and the details and depths of your testimony, your patient's testimonies and your knowledge base of all things hormones.

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Dr Bimisa Augustin, DNP (28:08)

Thank you. It's been a pleasure.

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