The Zone of Chaos | Casey Stumpf | Ep. 466

Okay, got the red smoke. Gun runs north and south, west of the smoke, west of the smoke. Okay, copy, west of the smoke. I'm looking at danger close now. Come on, win it, baby, give it to me, I need it. You're clear and hot. Copy, clear and hot. I can hear the hangover in your voice. Give us a quick walkthrough of your evening. Listen to you, you sound older and wiser. Yes, I am older and wiser. Are you still shit-faced? No, no. You sure? I'm positive, yeah. Performance will be the determining factor. Okay. How big did you go? I was pretty big. It was one of my good buddies, so. So it was a wedding. Did you guys go beer or did you go harder? Harder, yeah. They had open bar with whatever you wanted. What'd you go with? Tequila Sprite. There's a name for it. Isn't that a Paloma? Something along those lines? Maybe. I'm not sure. Okay. It was good, though. It was a good time. It was a good time. You know, I'm not quite sure, yeah. That's a good question. Good answer. Okay. These are the easiest episodes for me ever, because I'm just going to ask questions and honestly struggle to even comprehend what you're saying as the answer. You said you had some things you wanted to start with, though. Yes, props. Not necessarily props. I'm thinking you said things like, oh, yeah, yeah. The problem is, though, I can't. Michael, it's Jude. Oh, dude, those are sick. The problem is, these are readers. I know. I was trying to pop the lenses. We couldn't get the lenses out. I have my hot pink ones, but I only need those if I can see. Man, okay. I have a. These are dangerous to wear. Why? I mean, I could probably see something right here, but beyond that. No, no, no. That's just for reading. All right. If I could have popped the lenses out of these, I would have worn these the entire episode. And then I have my champagne prop. Yep. We'll put that there. Oh, fuck. Do you know what it is? I think so, yeah. Okay. Well, that's. Michael, do you know what it is? Do you know what this is? It looks like a wishbone. It does. Yeah. Yes, it is. Is it? Now, you guys have, like, a theme in here, very dark manly. I brought this nice silver one. I don't know where we'll place it in the, you know, but it goes with the theme. Oh, does that. We'll give that to Michael as a parting gift. Yeah, we'll. Because he's quitting. Yeah. That's your parting gift. Thank you. Because, Michael, you are a pussy. Really. Truly. Well and truly. Yes. I thought for, like, a holiday, you could do, like, paint this section red glitter. Oh, God. It could be a Christmas tree ornament. Yeah. Well, I'll share at the end, Michael, what that is. Okay. I'm excited. Have you figured it out yet, is your mind? I have some ideas. I have some theories. Hmm. Yeah. I bet you do. Patches. Why is there a patch shortage? Oh, goodness gracious. And this is a nightmare. Absolute nightmare. We're talking estrogen. Estrogen patches. Okay. And it's multifactorial why it's a problem. So, before the Women's Health Initiative, like, 25% of women were using hormones. What is the Women's Health Initiative, and when did that kick off? That study started in 1991, but they published the results in 2002. That's when they come out and said, oh, estrogen's going to kill you, you're going to get breast cancer, and you're going to get heart disease from it. These were the black box rings or black labels. Right. So, this hormone that we have had in super high levels in pregnancy and puberty, they're like, this is going to kill you. So, all of a sudden, they just stopped prescribing. So, we had 5% of women maybe on patches or hormones in general. Then, we have in July of 2025, FDA is like, this could be life-saving. Yeah, no shit. Like, we're not dying from estrogen. So, November, they removed black box warning. Prescriptions doubled in that time frame. Okay. So, you have patches. For hormone replacement, patches make up about 44%. So, women can get their estrogen in a patch, in a gel, a pill, a ring. There's lots of ways you can get it, but patches, just set it and forget it. Easiest to do. Okay. Especially if you have a condition. If you're a female who's got a clotting disorder, you can't take estrogen by mouth. There's other risk factors. You can't take it orally. So, all of a sudden, you've got a manufacturing supply chain set up for 5% of people using patches, right? And then, you and I talked about, well, we need the FDA. Why isn't the FDA saying there's a shortage? There's a pharmacist group. They're the ASCP, and they are kind of got their finger on the pulse. They're seeing what pharmacies are short on. They're seeing what's coming out of hospitals. They have a real-time, like, accuracy of where our shortage is. And they're like, yes, we have a problem. The FDA just recently, a huge advocate that I love is Kelly Kasperson. She's great for women's testosterone. Reach out to FDA. They said, oh, not to worry. We have a supply. There's not a shortage. Total gaslighting. I will say- Why would they say that when people are struggling to fill their prescriptions? I don't know if they're just not tracking it, the metrics. So, I spend, you know, I get text messages from my patients throughout the day. Half of them will be, I can't find a prescription. I can't find a patch. So, what do they do? So, we, I don't have time to call pharmacies. They're like, well, do you know what pharmacy? I don't have time to call pharmacies. And by the time you get to this pharmacy, it could be out. So, Amazon used to be a pretty good source. When I heard Amazon was running out, I'm like, oh, we're in trouble. We're in trouble if Amazon's running out. Mark Cuban's got Cost Plus drugs. His generics are great prices, but when those run out, the patches were costing like 200 bucks a month. What was normal before 200 a month? Like, you cash price, maybe 30 bucks. Insurance, some people can get it cheaper, 10, 15. So, I was digging into this after you and I had the conversation. If the FDA said, yes, this is a true shortage, we could pull in compounding pharmacies. That's the trigger for them to be able to compound and help out. Yeah, but that's such a dirty world because we were talking about that when it comes to peptides and how they're trying. Was it the geopolitics? GLP-3, Reta-Trutide, they're trying to label it as a biologic so it can be pulled out of the compounding world. There's too much of a gnarly economic fight going on there. 100%. It's a band-aid, but if you have women who are finally feeling better or want help and now they can't get their hormones, then that's a problem. So, if the FDA said, yes, there's a shortage, then the compounding pharmacies could at least try to pitch in. That happened with Ozempic and Terzepatide. They had that mass upkick. Compounding pharmacies got to start making it. Then they caught up with supply and they had to stop. As we know, there's still pharmacies compounding it. But that would be huge for the FDA to trigger it. Now, the problem, the scary thing is that they think it's going to be two to three years until this shortage is fixed. So, there's tons of orders, back orders. They're generic meds. There's a low profit margin. There is no monetary incentive. So, we're in a pickle. The next episode is brought to you by Ethos, a question for the audience: How often have you thought about life insurance, the fragility of life, and the difficult decisions that can come at the end of life, whether it is unexpected or even if you know that it's coming? For myself as a person, when I was in the military, there was life insurance associated with that. I gave it almost no thought because it was part of the sign-up process. After leaving the military, I had a gap in even thinking about life insurance again because, you know, life goes on, no pun intended. It just wasn't something that came up or that I thought about often, even though I had three young children. And it probably wasn't until they started getting a little bit older, purchased a few houses along the way, and got to a place in life where you realize, man, this is complicated enough while I'm here. I don't want it to be even more complicated when I'm not. I don't want to have to worry about what's going to happen to me and my family, or leave my family without the tools that they need in the unlikely or untimely event that that happens. This brings us right back to Ethos. They make getting life insurance fast and easy 100% online. You can get a quote in seconds, apply in minutes, and get same-day coverage. There's no medical exam. You just answer a few simple health questions, and you can get up to $3 million in coverage. Some policies are as low as $30 a month. Ethos has a 4.8 out of 5 stars on Trustpilot with over 4,000 reviews. So take 10 minutes and get covered today. With life insurance through Ethos. Get your free quote at ethos.com/cleardhot. That's E-T-H-O-S dot com slash cleared hot. Application times may vary. Rates may vary. And the Trustpilot rating is current as of June 1st, 2025. So where does that leave people? Literally calling on their own? Yep. Calling on their own. And then here's another problem. So you were feeling good, let's say, on one brand. OK, we can get you this brand. If it's a generic, the generics only have to have 80% to 125% of the active, right? So there's a bell curve of what they can produce. What's the non-generics? What do they have to have? They're supposed to have-- that's supposed to be 100% guarantee you're getting this. Right, you're getting this guaranteed. So now if I move someone to a generic, what I'm seeing often is they're like, Casey, my symptoms are back. I don't-- I'm having hot flashes again. Just put another one on. That's what-- MacGyver Medicine. I'll tell them that, cut one in half. I mean, I've got women looking like pin the tail on the donkey sometimes just to get where we need to be. So that's the patch option. Okay. So we're hunting patches, but it's going to be yours probably to fix it. So what do women do? So you can do estrogen gel, which you can put on your skin. It's an everyday, which I like because the brain likes steady state. I mean, the patch would, I guess, be everyday too, but it's just attached to your skin. So you're not doing anything every day. So there's a patch that's either wear it once for the whole week. There's a dual acting patch twice a week. So you wear one three days, take it off for the next. So either one week or twice a week. The gel I like though, because it's steady state. Problem, it's usually non-formulary. It's more expensive. I don't know what that means. It means that insurance is denying it for a lot of women. So I can't get my patch. So we go to a gel. They're saying, Nope, that's non-formulary. We're not covering it. It's definitely pricier, right? So they're denying it. So then we end up with another problem. There's a ring, vaginal ring, you know, kind of like my bracelet. You put it inside, wear that for three months. That's about 300 bucks. Okay. So the options there, and then there's the oral estradiol. It's cheap. It works. It's good. You and I talked about this though, for if you work with a provider, who doesn't understand what happens when you take that by mouth, it goes to the liver, the sex hormone binding globulin increases. That's the protein sucks up the testosterone, free testosterone. So say I have your testosterone optimized. You're on an estrogen patch. We have to switch to oral. I'm going to drop this free testosterone. So the brain fog can come back. The depressed mood, everything just like what happened? Yeah. It's like a stereo. One thing, again, you specialize in this. I don't. But even in my own, it's not hit a button and everything is fixed. If you improve your sleep, you might have to adjust what you have going on. If you mess with your diet, you might have to adjust what you're going on. It's a stereo equalizer. And it seems as if you move one, you should expect that there's going to be moving at all times. Yeah. And especially route matters, how you take your hormones matters. So those are the big, I think more people are going to have to go. Oral estrogen can be like nine bucks for a month. That doesn't sound bad. It doesn't sound bad. But if you have like a clotting risk factor, so it technically can increase your risk of clots because it goes through the liver and activates the clot. So general public and a thousand women, one to two are going to get blood clots. You're just going to, that's just the statistics take oral estrogen that goes to about two to four, but that risk goes up. If you're older, if you're obese, if you're smoking, uh, have the clotting disorder. So there are. There are some people who can't take it. All right. Were there any other, I know there was some baseline issues you wanted to cover. Was the estrogen patch the only one? Well, I'm curious your take with your background to this screening of testosterone. What do you mean? My back, the military background? Yeah. Uh, in the military. I wish I had a baseline. I mean, I wish I could at least know. I didn't have a baseline until I finally went years ago and got tested for what my levels were at the time, but I don't know what they were in my late teens, twenties, thirties. Well, I'm assuming just your, what, how they had you guys operating and not good sleep, it would have been low. I mean, maybe, but that's a hypothesis. We don't know some people tolerate it better than others. And some people, as you know, kind of have higher levels of testosterone to start with some have lower. So I don't know where I w I have no idea where I was. I don't think first off, correct me if I'm wrong, it's just another box you check on what you're going to test anyway, and they're drawing your blood as it is in the military, probably annually, if not biannually, why would you not just check that box? And at least you have an ability for a pathway for this is where you are now and twice a year, once a year, you get that. And then when you leave and you're later in life, at least you can look backwards and say, this is where I was and this is the difference. Well, I think it's great. I mean, we know like the same for men, if you're like, okay, we're going to cut your balls off and hold on. Who's saying that? That's menopause for women, right? Okay. Cut your balls off when they don't have balls. I'm saying for men, I'm giving you the equivalent, like, this is what I feel. Like, balls are gone. You're, you know, you're not sleeping, you're obese, you're depressed, you have no muscle mass. That's what happens to you. Like, it's just men go like this. I think they should be screened where my problem is, is it's not clear in the Pentagon's response has been like, it was written for service members. So, but they're not saying what they're going to do for women. And they're not going to say if they're going to help women. Oh, that's because they don't know. Don't worry. The lack of guidance just means they have it. They haven't thought their way through it or their answer is, I don't know. So, I think that that's where I'm curious to see. Well, here's the thing, though, too. It made headlines. Right. I would love to see what it looks like. Right. In execution. When are they going to start this? How are they going to roll it out, even for the guys? What's their threshold going to be for the introduction of hormones? What's the. Right. Well, and that's the thing. Okay. What number are they going to use? When I did some research. I don't think they have any. They think maybe 300. Okay. Because. Because the endocrine society says if you're below 300 for men, right, we have a good standard for women for them to use. But then what will they do? At this point, I think that the headline was exactly what it was. The headline. Yeah. That's a PR victory. And I'm not saying it's. I would like to see that done, at least from a screening perspective. The headline is easier than the mechanics of getting something implemented inside of the military. The reason you're not able to find the guidance, my guess is. Oh, it's not there yet. They don't have it yet. No, no, no. I was just curious your thoughts. I don't see how testing and getting as many metrics as possible as early as possible in your career has any downside other than the military. Here's an example. When we were doing parachute testing on the tandem systems, they brought out G meter, like the gravitational forward force load indicators. Okay. And I forget the exact G load that a pilot takes on an ejection seat ride. But I think if you get two of those, you're done flying to ejection seat rides, which honestly, if you have to eject twice, I'm going to say there might be something, you know what I mean? Like you have the worst luck ever, ever, or maybe piloting wasn't your thing. I don't know. We were routinely breaking those devices. And so instead of finding devices that could accurately measure the G load, they just said we're good. Because if you identify a problem, who's responsible for dealing with the long-term consequence of that? Right. So. So would the military own that replacement then the rest of their life, if they identified it during active duty? I don't know. Or if they identify an active duty, if this is where you start and you do 10 years, this is what you could likely expect or 20. It's like how long they fought the agent orange. This is a horrible analogy, but how long did the military fight paying people for the things that happened because of agent orange and exposure? Decades. Why? Because it's expensive. And they also would have to admit culpability and liability. Yeah. So what if. If you start doing all this robust testing and it is determined, oh shit, regardless of who you are, where you come into this at, this is what you can expect. And this job actually destroys your endocrine system. And you might have TBI type issues and you might be dealing with post-traumatic stress. Do you have to disclose that up front? Does that become the new recruiting poster? Or do you just realize that every person that does that, it, you know what I mean? It's this, it turns something from being very opaque to a little bit more clear. And in my experience, sometimes the military doesn't. They don't like it being that clear. Well, maybe it'll go nowhere. Perhaps. Again, the headline is easier than the implementation. Yeah. Maybe it goes nowhere. So we'll see. Okay. Um, were you surprised by the response from me coming on in March? No. Why would I have been surprised? Well, I think, you know, you're, most of the people you interview are probably mostly male, mostly not topics. Or men reach out than women do. Mostly not topics. I mean, that's what I'm trying to get at. I think that's what I'm trying to get at. I have to say the response, and we've talked about this, was just amazing. You know, it didn't show. Well, here's why it didn't surprise me. Before we had talked, you explained to me the number of providers that there were versus the number of people who are likely going through this. Yes. So when you explained the math, no, there was no surprise at all. Because again, just in the messages that we got, which, I mean, I can just start reading through these things, but the theme is, I'm in the forest by myself. I don't have a machete or a compass. I'm stumbling around. Sometimes I hear some whispering advice from over here, but then it conflicts with this advice over here. I'm hiding in a closet. No, that's the men. My feed is full. It's hilarious. There's this Australian dude. He'll do things. Oh, no, I know who he is. Yeah. He's like, I can't, I'm not even going to try the Australian accent, but he'll do the sniff test where he'll set up the camera and his wife's over there and he'll just, usually he gets tired. He's at three and she loses her shit. Yeah. It's hilarious. Yeah. My feed is about 50%, probably because I'm watching these things and laughing my ass off. But yeah, guys hiding in closets, making videos. This other guy, he's like, guys, I, I really screwed up yesterday and I need to do better. I, I went upstairs. I, you know, I can't believe. Yeah. And I don't blame the women for where we'll go over that in a second, but I think the surprising thing was. These women were calling and be like, my husband sent me, my husband were like, I don't know if you can. can see the metrics you just figured this out yet it's probably not best if the husband pitches this conversation to the woman like hey you're acting real fucking weird maybe you should go talk to somebody that doesn't go well no but it was my husband sent me the podcast you know and that was just the engagement of men helping women in their health arena i think you mean the engagement of men helping themselves navigate life yeah trying to survive women hey i always tell my girls like listen my job is to keep you out of jail i know when it's gonna happen we talked about you know crazy murder stories last night i'm like it happens in this phase of your cycle i know this is when i'm gonna go to jail that's what i got out of your slide show presentation the zone of chaos this is when you kill right here i mean yeah so no it didn't surprise me at all the same thing will happen with this it's uh it's shocking the the math just it doesn't work well well i was 75 million women either in perimenopause menopause post-menopause so the three phases and i'm like well how the license or the certificate i have is the mscp which is my certification the board test i took estimate currently right now 4100 of us yeah the math doesn't work on that yeah i mean of course there's other providers who are doing this you don't have to have that title that just shows that i my commitment and sitting for the exam yeah uh do you want to dive straight into questions what do you want are there any questions that you want to or are there any other uh blanket um i think i think another surprising thing too that came up since you and i talked like the military thing was surprising to me but just the uh funding for women's health like we have the issue of the pat shortage right we know that's a problem our funding's getting cut dramatically so i just we have all these women your like women's health okay funding like for example alzheimer's cases two-thirds of them are female really yep why is that well we don't know exactly why and it's not just that we live longer we think it's something to do with the estrogen there's a big study going on right now because you end up killing your partners yeah yeah um so if two-thirds of cases of alzheimer's cases are women the funding for women and that is only 12 percent of alzheimer's research so these don't make any sense it doesn't and it's this way across the board for women's health for um research for funding for menopause is one percent of all funding who's making these cuts where does the money well well the nih nih is only does like six percent of the researchers other funding besides the nih but we are disproportionately and then we're getting cut and so we've got all this going on now we've got more buzz more people talking about it celebrities have moved you know things are moving now but the funding is going to be cut and so we've got all this going on now we've got more cuttings cutting so there's one person who is donated more for women's health she just um put another 215 million in melinda gates she's contributed 600 million for female for midlife health for women when you say that where does the money go where does she who does she cut a check to well i don't know exactly who like so i'm part of the menopause society and i was at their convention last year and they said oh we got 10 million is that a cool logo the menopause society michael look up menopause society logo let's get some it's not it's not they need some flair it's a misbranding opportunity yeah so they announced that we got 10 million so a lot big thing for her too is uh education see look weak i know it's not i would have like a dagger with a ghostbuster symbol on it and a guy running away um big thing that she's putting money into is education which is what we need we have to have it taught in medical schools we have to have we cannot do unless we start getting teachers and providers helping we're still in this problem that makes sense so yeah we've i'm so grateful for her but she has outfunded the whole government system for women it sucks that they're going in the wrong way yeah i don't want to steal the nih's ability though to fund gain of function research on bat coronaviruses though okay you know because that worked out pretty well for us the last time all right um should we go right into it yeah hold on i had a couple people okay my wife is 43 and was on hrt and feeling good then got diagnosed with breast cancer and has gone through treatment including chemo and upcoming mastectomy and then some radiation it sounds like hrt her hrt provider won't work with women post-cancer treatment i was wondering if casey has any insight on hrt which is a term i'm sure we'll use hormonal replacement therapy after cancer specifically for this person's wife her cancer is a non-hormone reactive form her oncologist recommended she stop the hrt during treatment which she has he also stated there is a good chance the chemo will put her in menopause anyway is hrt post-cancer treatment possible and still beneficial or detrimental there's a lot there but yeah and i actually you know i think unfortunately you and i saw mom die of cancer you watched mom die with cancer i came back about 10 days before she died but we saw her quality of life up until and so you have these breast cancer survivors who go through hell to live right they go through treatment and then sometimes their quality of life can be hell on the other end now breast cancer is tricky in the fact that there's so many types is it estrogen receptor positive is it there's so many different kinds is it dcis and they can tell levels of definity in that yeah yeah it's all okay and pathology you can see these so on my because i actually had special training for treating breast cancer patients okay you know i have a passion for helping women who are told no no no no especially breast cancer they're told nope you're done okay just go just go like go just like live your best life but you feel miserable you know the treat you survive treatment but now this is gonna look cruddy yeah that sucks now there are some cancers if it is er positive that means there's a receptor on the breast tumor that responds to estrogen and i'm going to be really clear estrogen does not cause breast cancer we know that there's not one study because you'll hear that oh my my mom had breast cancer i can't take it no if you have this er positive breast cancer receptor you give it estrogen it can feed it it's not going to cause it but it'll make it grow okay so there are some cancers it's a no you can do other things but a hormone negative receptor has a lot more opportunity options non-hormone reactive exactly so it wasn't fueled by estrogen wasn't fueled by progesterone so they should be able to down the road they can vaginal estrogen for everyone across the board we've talked about that right um so saving that area but then there's a medication called do of a which is someone like this you could do so it especially your dcis patients there's studies on this actually using do of a for part of helping with lowering the tumor and then there's a study on this actually using do of a for part of helping with lowering the tumor burden so it's estrogen but then it has a serum on it so it protects the breast tissue and it protects the uterus so there's a you just have she's got to find a provider no is not the answer you got to keep searching god that's rough when you're going to the provider hoping that they have the answers that's why you're going in the first place well and the oncologists they think in this lane right they they're here to try to keep you alive but i i mean also i saw with mom too she's like she was a shell of herself and she was like she was like she was like she was like and they're like here you want to do another round of chemo i'm looking at her going she's like using a walker or holding on to me to walk in here and you want to also what kind of bullshit false choice was that basically what they said was do you want the cancer to kill you or the chemo to kill you she would not have survived another round of chemo no no no no i know but they offered it why well that's kind of you know i love you know working in hospice and oncologists they have a great role right they have a role but some times i see them just looking at the disease and not seeing the whole person yeah like where's the quality and breast cancer patients get a short end of the stick sometimes with hormones so you've got a um i want to highlight for breast cancer survivors dr corinne men she's the biggest advocate for women how do you spell the last name m-e-n-n okay so they should start following her she had breast cancer herself she's a ob-gyn she's a huge advocate looks into all the that's who i studied with and she's a huge advocate for women and she's a huge advocate for women and she's a for breast cancer um post-treatment so she'd be a great one for them to follow what's the best hrt regimen for perimenopausal women that still has her uterus and any differences in someone that has had a hysterectomy and this is where i think we have to change the story so people will be told the gaslighting and health care is horrific so do you think they're intentionally doing it or they're repeating the last thing that they were taught and not continuing education well i think there's two things the first thing is that they're not continuing education and the second thing is they're so busy seeing patients they don't have time to be curious i think the reason i ask is i think intent matters i don't think that there's a whole fleet of machiavellian doctors out there trying to gaslight women well well i think i had one patient who went in and told her male provider hey you know my sex drive is gone and he said you should pray about it listen we're talking about a community that is comprised of individuals there's a bell curve as we all know in life and even on the highest performing team there's a bottom 10 i think though that most doctors are not going to be able to do that because they're not going to be able to do it and i think that's the problem with the doctors are they're doing their best to help each especially if they specialize in one thing, you take a step outside of that and their knowledge becomes very general. You take a step outside of that, it becomes very hypothetical. You take a step outside of that and they're like, I have no idea. I don't think they're, I mean, gasoline, I understand the term now based off of previous business partners, but I mean, I don't think the doctors are being dicks. I think, like you said, they're time compressed. They don't know, but they remember the last thing that they were probably taught and that might've been 30 years ago. Or taught at all. Yeah, and that's not to remove the burden from them. Obviously, it's still their job to do the best that they can, but I also don't want to make this, hey, all male doctors are out there trying to screw over women patients. I'm not, this could be male or female. But the common things, because I just shared about this, it often will take women four to five providers to get to me, right? And they're told, you're too young. Oh, you're still having periods. You don't have hot flashes. You're too old. X, Y, and Z, why you don't qualify. Well, we just talked about the math. There's a reason why it takes them. Right. I don't think intentionally people are trying to do harm, but what it feels like to a female, if you go in and you're in tears and you need help and you're told you're fine when you're telling them, I'm not fine, I'm falling apart. Yeah. So what was the question? It was best HRT regimen for a perimenopausal woman that still has her uterus and any difference in someone that has had a hysterectomy. So perimenopause is where we got to start. We're not, I don't want women waiting like me that did the crash and burn. I want to see, women starting hormone therapy early. We know that that's better for bone, brain, heart. That could be age 35. You know, I don't like to put a label on it. If you're not feeling yourself, which usually starts looking like I'm not sleeping well or my mood is off, right? My husband, what was it? The sniff test? Like the sniff test, the Aussie guy. If he's. Oh yeah, he sniffed three times and eventually his wife would be like, what the fuck is wrong with you? Right. If this is starting to rear its head. She's going to lose her shit. Not your typical presentation. If you're 33, 34. Okay, we can help that. So perimenopause is going to be all things. Estrogen, progesterone, and testosterone. All three. But it's finding the recipe for everyone. Everyone's got their own recipe. There's some great telehealth companies, but they're kind of time constraint. And then perimenopause is this dance. You have to find a provider who knows how to move with it. So we'll find their sweet spot and then the hormones move again. And then we're shifting. Okay. You've got to shift again. So you've got to find someone knows how to dance with you through it. I also feel like you have to be for my own. I think I've been on TRT now for, I don't know, just under two. I don't even know. But if you're not also intimately involved in your own journey, and like I just asked you like, hey, can you get my blood work ready to go? If you're not somebody who is going to actively have your hands on the steroid equalizer as well, it's not going to go well. I think the other person has to be intimately interested and involved in the process as well. No, I agree. And I think this came up in a lot of the questions was, well, what blood tests do I need? Yeah. First, those are treatment difference between uterus and post hysterectomy when it comes to best HRT regimen for perimenopausal woman. So post hysterectomy, they would say technically you don't have to have progesterone. You have to have progesterone if you have a uterus to protect the endometrial lining. Estrogen can make that lining build, which could cause cancer. Progesterone protects that. So like I was told, I don't have a uterus. They said, oh, you don't need progesterone. Progesterone. Bullshit. What we know now on progesterone, I will take it the rest of my life. So progesterone helps with mood, sleep, bone density. So for me, there's no difference. You get all three. What path were you going to go? The testing. The lab testing. And I think this is women want help and they're just like, fine, just give me a lab test. Give me a lab test. I don't feel right. I feel crazy. Something's not right. Give me my labs. They'll go get their labs. They'll see a provider who maybe doesn't understand this arena and they'll be like, you're fine. You're fine. Everything's fine. Just sleep more. Exercise more. Meanwhile, they're dragging on the couch. They're not sleeping. So I think that they can really run into some trouble hanging their hat on. I just need labs. I think specifically, though, what labs should they be looking for so they can get the right pieces of information to take it to a provider? So is there a generalized lab you can request? No, there is no lab test for perimenopause. And that is why I need an hour. My initial intake with people is an hour. And I'm listening. I'm listening. And I'm like, OK, in my head, coming up with a plan. Insurance model isn't set up for that because estrogen and progesterone and perimenopause is that zone of chaos, that up, down, up, down. So I could check you four times in one day. It's going to look different. And and they're going to fall within range. So you see a provider and be like, this is fine. It's more how the fluctuations, that chaos is creating the symptoms. Where does testosterone treatment for women specifically play a role in which problems and what product does she prefer? So testosterone is a test you could get. You could get that test. Again, though, you have these arbitrary normal ranges, right? As you're answering this, I'm going to go to the IG page because there was a question somebody specifically asked about a level that they wanted your input on. So go ahead. Well, I'll speak to what I feel best at. So they can't, you know, back in the 90s, they tested 500 women and said, this is the range or the lab will give a range. So that range on some labs, I've seen a normal range the bottom number be a two, two as normal. Nine is normal. That is crawling. You're dragging. You are just not feeling yourself. So in testosterone, men and women, just tick, tick, tick, tick, tick. It just goes down. It just decreases. So I, myself personally, I feel best between 120, 130. That's my range. So this is going to go right into your question here. My hormone doctor likes me. It's 60 for TRT. I feel that is low. Also, what are your thoughts about GLP-1? I work out and eat healthy, but I have a hard time losing weight. I'm 52 years old and have weight training since last year has been hard on my body. Do women have more tendon tear during pre or during premenopause? So yeah, so 60 TRT for you, you're saying that would be low. I wouldn't feel good at that. And there's a few caveats on that. It's OK, here's a lab test. But how does the person look in front of me? All right. Do you have brain fog still? Are you still irritable? Do you feel, is your mood not the best? Do you not feel like yourself? Are you having more problems gaining muscle mass, right? If you're still saying, I've got all these things in your 60, let's bring this up. Let's try a little higher. What if she's on oral estrogen and what's circulating in the blood is really low? So, you know, this is one, treat the person, use the lab just as a, you know, a reference. Pairing the HRT, I'll use the broader term, and GLP-1. There's a lot of misconceptions about GLP-1. I had somebody ask me the other day, I think it might've been on the show as well. No, it was on the show, asking essentially what my thoughts on it and if it's cheating or, I think it was just my thoughts in general. And my answer was, I mean, it's a tool that can be abused like anything else. It's also not you, new. It's been around for a long time. 20 plus years now. Yeah. And if, you know, I think the comment came from the super heroin chic, idea that some people see, which I think those people are probably not weight training and doing all the other things that you're supposed to be doing. No. Yeah. Which I would say that probably doesn't work great. But I think again, in an HRT model for somebody who is 52, what would your general thoughts be on a GLP-1? They work beautiful together. So say you just, we'll use Terzapotide. Say you use Terzapotide on its own. Is that a one? Two. A two? Dual acting agent. And then RETA is a three? Three and some on GLP-1. So if you use, if you use Terzapotide on its own, you have some, some improvement. If you add in the hormones, even better. Because midlife insulin resistance goes up. The menopause muffin top shows up. So if you combine the hormones, beautiful. And why I love testosterone even more for this, because those GLPs are going to pull muscle. You got to be actively involved. It's going to pull fat, but it's going to pull muscle. So my patients, they have to eat the protein. They've got to do the weight. But what is here? Bring in testosterone. It's going to help build muscle. So those two together great sweet spot. Can you talk about the difference too in how you use the GLP-1s? And this is again, my broad understanding, a micro dose versus some of what I'll consider to be the macro doses for pure weight loss. Well, and that's like a trigger word these days. What is? Oh, micro dosing. Some people are getting really upset with people using micro dosing. So let's say Terzapotide, a starting standard dose Terzapotide for weight loss is 2.5 milligrams. And then if you're using their pens, it goes 2.5, 5. You know, you can't do these conversions. We're using Terzapotide, not. But say it's starting dose for weight loss is 2.5. I like to start depending if it's male or female. Females, one and a half to two. Some men will start at two and a half. So because we just, we need to get things moving. But I may only take them up to three, which wouldn't be micro dosings. A true micro dose would be, you know, less than a milligram. Per week. Correct. Which you can, you can do. You can, now your rings are coming off, right? Your, your clothes aren't in a tight, the puffiness people get. Yeah. So, and the health benefits, there was just this huge study that just came out on over a hundred thousand women and they had 30% decreased risk of breast cancer on them. There is some fascinating, I think you and I have talked about this for maybe the first time you were on, the long-term, when it comes to the cognition protection against neuroprotective. And again, this isn't, it's a macro dose, but the smaller dose that you're talking about. - Yeah, because it's lowering the blood sugar. sugar in the brain. It's lowering inflammation. We don't have great trials on that. We're just looking at observation, but I think it'll lead that way. The question two was on the testosterone formulations. There's no FDA approved testosterone for women. There's eight for men, but none for women. Do you need a specific testosterone for women or can one of those eight satisfy? Well, so what we have to do is go off label, which a lot of medications we use off label, you know, to include the GLP ones we were just talking about. Yeah. GLPs too, I like for pain management. So what we do is we have taken male formulation. So you can get test and gel and these little packs and you're supposed to make that last like seven to 10 days. Well, it's alcohol based, so it can dry up the effectiveness change. And now a lot of pharmacists are saying, nope, this is for men. We're not giving it to women. You can't write it like that. So we've got a barrier there. Okay. So then it's, then there's other pumps that you can use, but what if one pump is different? There's too much variation and I want you to use a pea size or an edamame. Maybe your edamame looks different than mine, right? There's too much variation. So I prefer compounding because I can control each click that is comes out of the cream. I can control the dose on that. And what if I want to fine tune it? What if I want to bring someone up maybe 10, 20%? I can dose that in a compounding cream being, oh, a pea and a half, use a pea and a half. But again, the pharmacists too, a lot of them are saying, no, they won't give it to women. I'm 54 and still having my period regularly. I just want to be done. However, everyone says how great it is for my skin. What's going on? I've been in perimenopause for over 10 years. She's probably talking about that. She still makes her own estrogen. I don't know. Yes. So low estrogen, dry skin, crepey skin, itchy skin. That's why you'll see. I actually just came up with the pharmacist I work with, with a E3. So we took Estriol, copper, NAD. I haven't released this yet, but when I get home next week, we're going to put it out there. We came up with it. So it's like a lower dose estrogen for the face with copper and NAD on it. Yeah. But for this person's question, she's been on this ride for 10 years. Sounds like she wants it over. I don't. I feel like there's an eject button. Any advice though? She's loving her skin. Wasn't she loving her skin? She doesn't say she's loving her skin. She says, however, everyone else says how great it is for my skin. So everybody else is complimenting her on her skin. She's got to be close. So the median age women go through menopause is about 51. But is the reality you're on the roller coaster until the roller coaster comes back to the ride end or the get up? Yes. Like four to 10 years. More on vertigo and menopause. I don't remember us talking about this. Yeah. So I'll see this one often. Like women will go, I had this and I didn't even realize it because, you know, not having the uterus. I didn't, we went on a Disney cruise and for two months I came back and I was like, Ooh, just spinning, spinning. Well, I didn't know. You had none of those issues before the cruise? No. Do you think it was some of the movement? A hundred percent it was, but I think it was exacerbated by the fact I was in perimenopause. I didn't know it. So the fluid in the inner ear, you have these crystals and think of like seaweed. These, they move together. They should do this and match, right? And the brain moves, they should match. So sometimes they can be like this, cause vertigo. We got to have enough fluid in here to make it move smoothly. That makes sense. So the inner ear is definitely, if you have low estrogen, it affects the inner ear and the fluid. I had one patient who debilitating vertigo, couldn't get out of bed, went and saw Ian. T doing all the uplifting maneuvers, doing meds, nothing work. Let's get her on some estrogen. She's working again. She still has some vertigo, but she has now she's actually like getting out of bed and working. Damn. So ENT, ENT will miss that, that it's hormone related. Should me or my doctor run labs on my minerals to see what I might be deficient in before prescriptions. Secondly, specifically for progesterone. That's true. And when does progesterone knock me out? I'm, I'm so sleepy in the AM when I take it. And in parentheses, 100 milligrams of bioidentical. Okay. So I would never say like vitamins trump what hormones will do. Now we got to look at the big picture. Cause I think people miss that. Vitamin D would be a must. You're taking that. Yes. Yes. D3K2. Yeah. Vitamin D is going to be a must. Because everyone's low, even in California, right? Everyone's like, Oh, I'm in the sun. They're notoriously low. You've been up here in the winter time. Oh, I know. Sun comes out from 9am to 1030am. So vitamin. Days that aren't overcast. Vitamin D is a hormone. Misclassified is a vitamin when during the rickets time, but it's actually axohormone. So super, super important for mood and energy. So vitamin D is a must. B12 when that's low, brain fog. Sluggish, low energy. You see how these overlap. Yeah. So you have to, it's not just hormones. It's looking at the big picture. So it'd be vitamin D. You can look at your zinc, your magnesium, your folate, your B12. You could look at those. The second part, why does progesterone knock me out? I'm so sleepy in the a.m. when I take it. A hundred milligrams of bioidentical. So progesterone, I would say for people, 50% of my population of women love it. 25%, 30% of them love it. Yeah. 30% say, I don't notice much, but I have a uterus. I have to take it. And the other 10, 15 are like, I hate this. So we call that progesterone intolerance. So when you take progesterone by mouth, it goes to the liver. And one of the byproducts of the metabolites is it ends up raising the GABA in the brain. So think of mother nature Xanax, hence 50% love it. They're sleeping better. Their anxiety has come down. But you've got 10 to 15%. 15% where it can be more anxiety, too sleepy, headaches, reflux. You have to think outside of the box how to protect the uterus if they have that. Someone like that, I would move the dose up earlier. Like what if you took it at dinnertime and see if that comes off. Oh, sleep through it, you mean? Right. So move it up and see then if you're not as groggy in the morning. Yeah. Sounds like they're taking it in the morning. No, you would take progesterone at night. It's meant to be taken at night because the side effect of it. Is it makes you sleepy? Oh, well, there you go. Shows you what I know. If I start taking TRT/HRT, can I ever get off of the therapy or am I stuck taking it for the rest of my life? This is a very common question. So the old saying was you should only take it for five to 10 years. That's what they said. Right. When you're supposed to fear the hormones your body made and then what you hit 60, got to stop 60. We're done. Just crash and burn. That was that was what it was like a great carnival ride. That was what it was. At 60, you needed to come off. Again, this is an individual journey and you have to find a provider who can weigh the risk and benefit for each person. If you're doing well, have no side effects. I mean, I'm going to die with that testosterone in my hand. Be it an injection, a cream. I know how awful I am off of it. Why would I stop? I mean, what's dad? He doesn't be 80 now and he's still clicking away. We don't have time to dedicate. An entire episode to the current status circus that is. I was I just did a speech in Scottsdale and the man who ran the organization is a touch older than dad. Still, day to day operations, crushing it, not showing up at the house with no shoes on. That was yesterday, Michael. He just he rolled in with he rolled in with linen pants. Linen pants, no shoes, left his phone at the house, came back. I mean, you get to interface with him. Yeah. So I think it's an individual journey. Do you have to take it the rest of your life? No. But do you you know how you feel on it? Most people feel 60, 70 percent better. We know when you stop taking it, the bone, heart, brain protection goes away. How much do you think? I mean, let's say we're halfway or, you know, around the lap of life on our track. How much do you think there will be an innovation or how much have you seen in evolution in the delivery mechanisms of these things? Like, even since I've started paying attention to it, I remember the first time I ever heard the term GLP one. And then it's like GLP to GLP three and getting this news from Instagram. But, you know, people are the newest GLP five. So obviously they're continuing to push forward with all that stuff. Testosterone just seems to be testosterone. Same with estrogen, progesterone. Do you think they'll get any more sophisticated and complicated in a good way with the treatment and delivery mechanisms? Or is that just it is what it is? Like if you're on testosterone, you're going to have a cream or an injection or an oral. That's just going to be. I mean, it's working. Yeah. I mean, but the horse and buggy was working for a while, too. I mean, that goes back to like the theory of like people say the pellets are better. Right. To me, that seems like a pretty high level of commitment because once those suckers are in there. Now, I told you. that I don't know their name, so I'm not going to say it here, but there's a medical place here in Kalispell, mismanaging women completely on pellets. How so? Like the women I'm taking over. What does the mismanagement look like? That they are dosing them so high that like one girl, she was five months post injection and still had a testosterone of 400, which is a male range. Yeah. So tell me what you think it was five months ago. And that makes it really hard for me because these women are used to living. This high. But you also, what can you really do? You have to wait for that roller coaster to come back. Holy cow. Yeah. Okay. So you might be on it for the rest of your life is the answer to this. I think it's a personal choice. If you have no contraindications to it. Yes, you could. I mean, this is an area of medicine. Actually, I'm going to look into is using hormones for like hospice patients and a life. That's my next journey. Okay. Here's a question. I completely don't understand. Well, using why? Wild yam cream to support progesterone, grow a uterine fibroid or help balance hormones to prevent its growth. Yeah. And I saw this. You understand that? I do understand it. And I looked into it. And so with AI these days, there's some great things where there's apps I can use that pull data, right? It pulls all the data from trials that I've ever done. So I put this in there because. What's your preferred tool? I open GPT. Where do you go Claude? Open evidence. Oh, it's the medical. It pulls the databases of the research has been done. You know, I don't know everything. So I said, all right, I don't know. Let's see if I eat 10 pounds of yams. What's going to happen there? So I looked, the yams do not have cream. Oh, this is wild yam cream. So no, I'm saying I understand these words, but I'm this sense. Well, I'm telling you, women are desperate. Women are desperate. They can't get help. So they are seeing things on the internet. They are. Oh, this, this influence. I said that they are going for it. I get it. You feel awful. You want help. No. So yams are not going to trigger estrogen or progesterone. There's been no clinical studies that show any link to fibroids. So I actually dug into that one because I found that interesting. Is DIM, D-I-M, necessary to combat the side effects of testosterone supplementation, especially for those of us on higher doses, dosages? I don't even know what DIM is. That's a male, correct? Who asked? This is Skitch1974. Let me click on the profile. I'm going to think it's a- It's a picture of somebody's eyeball. I haven't, the first name though is Heather. So I'm going to say that's a- Huh. Okay. Because I'll hear that often. In the modern era, I'm not going to say what it is. I don't know how they're living their life. So DIM is made up of like cruciferous vegetables, your kale, your broccoli. DIM, cruciferous. Oh. Are those yams? No. Okay. So it is, there's not good strong data or evidence on this, but it is thought to help with some of the conversion of testosterone to estrogen. Okay. Because there's this fear. I see it in my men. Oh, Casey, I've got to be on aromatase inhibitor. I'm like, why? You need estrogen just like I do. So if you block estrogen, it's going to affect your bone, brain, and heart. You need it. You do not need to be on aromatase inhibitors. Is your estrogen going to go up if I give you testosterone? Yes. And maybe it goes red and goes to high. You're not wearing a B-cut bra these days. Yeah. Just the A-cut. That's accurate. Sure. Right? So you're watching for that. You're watching for men who develop breast tissue. Titties. Middies, if you will. Yes. You're watching for, I'm just crying at every, like a Hallmark commercial. I'm falling apart. Some of those commercials are tearjerkers. Sure. But it's like. You fucking throw puppies in there? What are you supposed to do? Just like. Shh. So there's this fear of bumping up estrogen. It's rare that you're going to see it be in a range that you need to do anything about it. That's really. So for women, you don't even move the needle. So say, like, I have breast cancer survivors that were estrogen sensitive. So their receptor was positive, right? If I give them testosterone, there's a fear of how much of this am I going to move to estrogen? Am I going to trigger potentially down the road? I tell them the risks. They're miserable and want to try it. They can send their life away. That's your journey. But I track their estrogen. I'm not seeing it move. And women get a tenth of the dose as a male. So if a male, if I bump their, say, their estrogen up, say, even 10 points, that would be one point for a woman. You're not going to see it. Do I think that supplement's necessary? No. And the data's not great. All right. But check out the EMs. Yeah, the EMs. What does she, meaning you, recommend as top resources? Top resources for women to learn more about navigating perimenopause. It's hard. I think so many women are experiencing issues related to hormone changes, but they don't know where to start. Or maybe a checklist or tracker of things to do that you, this is a homework project for you. This person is saying maybe you could make a checklist. Actually, that would be a good product for you to sell. Well, where is it? On my computer. Oh, it's doing a great job helping your people on the internet. Trying to reach. Un-fucking-believable. You can only do so much, you know. Resources for women. Where do you start your journey of information? Clearly, Instagram influencers. Yes. I mean, I'm happy to share my tracker. The problem is, even if they track it, if they go see a provider who doesn't know the Serena, then what? Right? Well, that's the second part of the journey. I think this question speaks to where a lot of people are at. But I'm saying this as somebody who hasn't gone through this journey. They don't know where to start. Right. So the provider might actually. Right. Be the second step. This is legitimately, where would you push people for education or point them to and not push? Right. The tracker could help. What you do with the tracker is, it gives you some agency over what's going on, right? Well, 100%. And my patients who come see me, they get a copy of my tracker. And I highlight on this because I teach them how to navigate the hormones. Like, you're going to go up on estrogen here. Send me these trackers so I can gauge how you're doing on them. So we look at about 25 symptoms on the tracker I use. Now, for education. Heather Hirsch has the perimenopause survival guide. Dr. Mary Claire Haver has the new perimenopause. Kelly Kasperson, the menopause movement. All these are providers who I train with. And I'm lucky enough how, with internet now, that once a month we do ground rounds. So I get access to these people and we run hard cases together. Do you have any books that you would recommend? All three of those people I just mentioned. Yeah, those are all three books I named. Any good podcasts specific about this stuff? All three of those. Okay, so there's a variety of mediums. All right, that's a good starting point right there. Asked my wife if she has questions about perimenopause. Her response was, when does this shit stop? Remember? Four to ten years. But here's the thing. It doesn't have to be awful. And I think, for me, this has been the most rewarding medicine. I'll have women come in. They look like a shell of themselves. You've seen, there was a few comments on there from people of just how life-changing this can be. Who have seen me. And it doesn't have to look like this. It actually can look very high-functioning and like yourself again. So it doesn't have to. I'm going to rehydrate. Michael, any more thought on this? I'm just taking it off to rehydrate here. I do it. Say it. I think. Have you been doing research behind the scenes back there while we're talking? I actually haven't. I feel like it's something that goes into. The vagina. Oh, it goes into it. Yeah. So it's like you could buy. Michael's so shy. You could buy one of these at the. You're still going to play rugby when you go to Missoula or no? Yeah. So he can travel with this and educate. Is that what, did I get it right? So you think you buy this. You think that's a toy? Like a sexual tool. No, no, no, no. Like, like something like an, actually that's too big. Cause I was thinking like an IUD or something. Okay. He thinks like a birth control. Yeah. Okay. This is, this is no, I appreciate your honesty because this is most, most people can't name what this is and I'll, we'll talk about it at the end. Yeah. I, that's what I was thinking. And then I thought about how small an IUD is. And I was like. First off, that's your next ear piercing. That's what that is, Michael. Okay. Please talk about how this kind of therapy can help women who have had hysterectomies. I know so many women who have had one, but there's no push to have them seek treatment for the horrific hormone issues. They'll have, because of this surgery, please cover this exclamation, exclamation. Okay. So there, you have to say, is it a total hysterectomy, which they take the ovaries and the uterus out, or is it a partial like I had? So this doesn't clarify. Well, I can speak to both. Okay. So a partial is what I had. They left my ovaries, took the uterus out. Why do they decide to do one over the other? Maybe they had a concern for like BRCA, right? Genetic risk of ovarian cancer, something like that. Okay. What's the benefit to a partial versus a complete? So like myself, I left my ovaries. Okay. So if you do a total, come out of the operating room, full menopause, you're in it. Yeah. And a lot of women aren't replaced. Now, if I was a surgeon and I was doing a total hysterectomy, I'd have an estrogen patch on prior to surgery. So they're getting hormones and they leave. Now, if you're like myself, they left the ovaries. I still wanted my hormones. Jones. no uterus. The problem is a lot of women don't know is this group here goes into menopause about four years early. The blood flow isn't going to that region as much anymore. You don't have a uterus, so the ovaries die sooner, which is why when I was 47, when I started figuring things out, I was like, there is no way. I'm too young. No one had explained to me. So totally different. If you have a total hysterectomy, everything's taken out. Everything should be replaced post surgery. If you have a partial like myself, you've got to track those hormones. But again, that's where perimenopause comes in. And I want people starting hormones early. So the answer to that is you got to start hormones early. Okay. Any suggestions for women who have PCOS? My wife suffers from it and has all the usual symptoms. Okay. Okay. Okay. I don't claim to understand PCOS or women, but some suggestions would be helpful. Thank you. So PCOS got rebranded this year. What is PCOS? Well, PCOS stands for polycystic ovarian syndrome. It had kind of a narrow, like how you were diagnosed. An ultrasound, you had to have 20 follicles. A ring of pearls was the standard classification. And missing periods, irregular periods, it affects fertility. They renamed it just two months ago to PMOS. So the polycystic ovarian syndrome is no longer a thing. What did they rebrand it as? They rebranded it as PMOS, which is more of what it actually is. It's more metabolic. So polyendocrine metabolic ovarian syndrome. Yes, it involves the ovaries, but it's also, you see a ton of insulin resistance. So you could be my size and, still have it. Because most of the time, a lot of people think, oh, insulin resistance, that they're really overweight. But you could still have insulin resistance, be smaller, having irregular periods. These people tend to have more acne on their jaw, more facial hair. They can have hyperpigmentation of their neck and armpits and groin, which is interesting. This hyperpigmentation is a sign of insulin resistance. So this, like I would ask women, I'd be like, do you, is your arm, are your armpits darker? And they would be, yes. And then I'm like, Hey, you have insulin resistance without a lab test. So odd expression of that. Well, it's the hyperpigmentation that comes with it. So what someone like, if they have that known diagnosis, one of the biggest things I've seen help is the GLPs. Interesting. Yeah. So the GLPs bring down the insulin resistance, bring down the inflammation with it can actually help cycles become more regular. So that is a sign of insulin resistance. For my PMOS girls, one of the biggest things and progesterone. So in PMOS, they tend to have more androgen. So their testosterone levels normally run higher. It's the pathology of what's going on in the ovary that they kick out more testosterone. This is another one. I think a lot of people on your side of the table, meaning women will probably resonate with most insurances won't cover. Testosterone treatments for women because it's not approved by the FDA. At least that's what I have been told by our insurance. Is there a press to get FDA approval? We are in Southern California. This is actually somebody who could probably work directly with you and are out of pocket for my wife's treatment. Have you seen any progress on this? Is there, it's just a hard block depending on your provider. It sounds like where this is an insurance. Remember I said men have eight FDA approved. Well, that's kind of where I was curious. I was like, well, I don't know. I don't know. I don't know. I don't know. I'm curious too with the military where it pulled in like all service members. I'm like, Hey, what are you going to do for women who we don't have an FDA approved military tend does, does in medicine tends not to work off book. They don't, they, they have a pretty narrow lane. You have to stay in for medicine in military medicine. They do. Maybe your experiences are slightly different than mine. Did you see him going off book? Maybe, well, maybe in your arena that they would. When you're isolated and well away from. The rest of the large machine in the military and they're just like, here's a dish of whatever you want. Treat your symptoms. Very different. But like say Camp Pendleton was like, Nope. Oh, you should talk about your experience. I mean, so you're saying this because somebody who worked as a practitioner at the Camp Pendleton, I was going to say Marine Corps hospital, but I feel like it was a naval hospital. You have, you got to fall in these lanes. You could prescribe, you know what I mean? As very rigid of what you could, you could do there. Does this basically leave it to being out of pocket? If you find a provider, they make a decision. But boom, your insurance isn't going to cover it. Is there other avenues that you have heard of that have been successful or is this writing a check or a card obviously? Rare that you're going to find insurance cover it. There is, it's indicated for hypoactive sexual disorder for women, HSDD, hypoactive sexual dysfunction. Is that too much or too little? It's saying that you have a low sex drive for at least, low sex drive for at least six months. And it's distressing. Okay. That is the only indication for testosterone for women right now. Repeat that exact verbiage. So maybe somebody could say that in front of their doctor. What was it? HSDD. Yeah. That is. But what are they supposed to say how they're feeling? I have had no desire for sex in the last six months and it's causing me a lot of distress. Okay. That is. Not saying what you should do with those terms, but. That's the only clinical indication. Now we know it helps with brain fog, with mood, depression. And you, I'll ask you that in a second. Muscle mass, feeling like yourself again. Had you noticed, or if you can remember any change in mood on your testosterone journey? I struggle with this one because I'm pretty flatline. I don't have high highs and I just generally don't have low lows. And it's not me trying to be like that. I just don't know if I naturally have high highs and low lows. I mean this, you know, are you open to sharing where you were prior to us starting? What do you mean? Your levels? Do you remember what they were? Right at 300. Okay. So that's where with the military saying, Oh, if it's 300 and less, we can go. Something like that. Six. Yeah. 306. 306. Yeah. Which is to me for a man, crawling. Barely. I don't know if I would describe, I mean, I'm, I have no problems talking about my own. One of the first things I did actually was talk about it on the show because I just want to be transparent. Yeah. And also I don't want people to think that there's this, this magic button that you can hit. I don't think I've ever suffered from depression. And I have to say that though, based off of how horrendous I've heard some other people describe, their experiences. And what I can say is I don't think I've ever felt that. But again, if I have lower highs and shallower lows, that would be a relative term for me. You know, I certainly have my good days and my bad days, but for me, the biggest difference that I have noticed is my ability to feel like I am rested versus constantly, you know, the gas state, Hey, 50 miles till empty light is on in your vehicle. Yeah. But it, it also hasn't been drastic and we're still, you know, two years into this, the last time I had my blood checked, I was like, whoopsies, that's a bit too. And I was feeling it too. I'm like, I don't like the way, and I've been honest about that too. Yeah. So this will be the first check after lowering that dosage down. Well, lowering it, but the frequency is different. No, it was always Monday, Wednesday, Friday. Yeah. I don't think I've ever deviated from that. Oh no, I did because you were doing two. Well, you were at some point you were doing twice a week. Oh yeah. I think I did play around with that a little bit, but I mean, that's the thing I'm trying to figure out what works best for me. Some people inject every day. I just don't think I would enjoy that. Some people just be like, if you're a diabetic, okay, here's my little shot. Yeah, but I'm not diabetic. So I don't think I would enjoy that. Okay. Well, I ask about the mood because, you know, Jason working for the fire department, I take care of a lot of firefighters. And the penis gets them in usually, Oh, something's wrong with the penis. That's usually why they'll come in. And then I'll ask them, how are you feeling? And they're like, Oh, Casey, I feel great. My mood is better. So it's so good for mood is testosterone and it's downplayed, I think. That's why I was asking if you noticed it. I personally noticed a big difference. In Jason? No, for myself. I won't speak for him. For myself. Yeah. Well, you could speak for what your perspective was as a spouse. I'd have to ask Leah. To be honest. I mean, I, I mean, objectively, how good are we at rating our own? Well, I can feel it. Oh, the resilient. Oh, I mean, cause I was in the shits before I fixed this. So I know. You've been crazy for the vast majority of your life. But now it's a fun crazy. Is it though? Yeah. Yeah. But I do want to speak to that. The optic on where you're viewing it from probably depends, but I do want to speak to that though, because I think, and you've seen this in your arena and it's really unfortunate is suicide. Yes, but however, comma, it's way more convoluted than you think. than this person served in the military and killed themselves. I am, the more I talk with people, the more I dig into, and this isn't true of everybody, but I will say that there is a growing cohort that seems to fit with this. There is this conversation of this person was in the military and killed himself, therefore it is because of their military service. - Right. - The number of people that I know of now who had the epitome of traumatic upbringings before going into the military, and it absolutely makes sense to me why they would pursue that job. If you were bullied and you wanna smash bullies, guess what's a great place conceptually to be able to do that. But if you don't deal with that before going in and then you have a job that gives you another full bag of stuff going out, and I have heard that the culture in the community is changing and the drinking aspect and culture of that is way down, spectacular. That was not the case when I was in, and that is not to put a finger on the military and lay blame or anything like that, but it is, shit, you were around, it is a drinking culture. We worked hard, we partied hard, and it can be managed, but not as well by everybody. So you layer on those some years of that, exposure to blast, exposure to trauma, you get out and then most people will go home where they were from, so isolation from the community, then they'll isolate from everybody, dive deep, and again, these are broad general statements that don't apply to everybody, dive deeply back into whatever coping mechanism that they were using before and end up making decisions that are horrible. Is that from your military service? I'll say corollary, not causal, but there's this 22 a day, which is a horrible number, and I'm not saying that it's not tied, but I have just, and now the conversations I've had with people, it's such a deeper, more nuanced issue. - My guess is their testosterone was also low. - There's probably that as well, too, because again, if you look at concussive blast exposure, all of those things, like that's all very real in what it does to the brain. - 100%, well, and I was just saying, too, you've unfortunately had lost too many friends from death by suicide, but I think this can be a very scary arena, and I think women need to be validated that it is documented, it's biologic, it is not their fault, it is not from too much stress, that that zone of chaos is what causes it, but the suicide rates go up by seven times for women in perimenopause. And mental health diets go up seven, you know, huge increased risk of suicide in perimenopause. And the screening guidelines, as a provider, there's two screenings we use, one for anxiety and one for depression, it's just across the board. Any provider would use these. It's a PHQ-9 and a GAD-7. They're kind of missing the mark of what can happen in perimenopause. So I see this all the time, Leah and I were talking about it, how many women, she knows, here's an antidepressant, here's an antidepressant, right? Where you're missing, the root cause is the hormones of this chaos. So maybe they're gonna feel a little better, but then they can feel flat, and just ugh, and the sexual side effects that are already stressing them out. So I think for perimenopause, women really have to advocate for themselves with mental health of looking at the hormones for supplementing, replacing those for mental health. - So here's a question that goes right into that. My wife's doctor does not deal with testosterone at all. The other two meds have done wonders for all her symptoms so far. Why are some providers hesitant to deal with testosterone? And I'm gonna add to that, what do you do if your provider doesn't deal with testosterone? Do you have to go find another? - Michael, can you pull up the Ishwish organization? So the Menopause Society, he pulled up, that's great for hormones, but just because you do, you're an MSCP doesn't mean you know testosterone. So Kelly Casperson is who I trained with, and I've been working with him for over a year now. And I've been working with him for over a year now. period tracker on your phone you're saying men should get a period tracker 100 oh this is so we know when to play hide and seek yeah 100 you get a period tracker yep and you put it on your phone michael that one um slide that had the the dips and things remember and i'll teach the men how to so this is how this is survival 101 survival 101 you get a period tracker okay and you start tracking it so you've got day 14 day 12 to 14 if men think they're gonna have sex highlight that with stars that's gonna be your go days 12 to 14 that's gonna be it if you think you're gonna get the end of the period 12 day one is when the period starts so day one usually on the apps it has like a usually has like a drop of blood or something and day seven is where it would end usually usually some women shorter or longer okay look at 12 to 14 see the heart that blue line is estrogen that estrogen helps with sex drive this is when women feel their best what's lh uh luteinizing hormones the brain okay so that's things peaked at like the mid point between 13 and 14 if you think you're gonna have a chance at all it's gonna be day 12 to like 14 that's it you're screwed the rest of you taking notes here okay so estrogen is that blue it spikes and ovulation it comes down okay the pink in the back you'll see like day the luteal phase is the back half you'll see the progesterone climbs climbs climbs climbs climbs estrogen is also climbing even it looks purple because it's overlaid okay day 21 there's no pregnancy it crashes that dump is the hiding that is you've got your mres in the closet at day 22 21 you got your mres you got your snacks you got your breathing no sniffing no sniffing no chewing no that was one of the other ones too he goes guys i no chewing i messed up again i chewed my food no suggestions no so basically what you're saying is from day 21 through day seven day 21 to 28 it resets at day one so j21 to if it's everything is still looking low over on the up to day yeah but we're at the back end here of the cycle so you can track when the hormones will dip but this is honestly if a female has a provider who's working with them in perimenopause my goal is they don't feel that dip i bring women's hormones up progesterone and estrogen up in that dip so they don't feel that so that crash isn't happening so that that is where i come into play now if you have a partner who isn't this is when you're camping in the car you know right here it's really sad though if you think look at that you get women get maybe two to three days out of the month where they have energy feel better on managed hrt what do you think you could increase that to as opposed to two to three days unmanaged do you think you could gain a couple more days like what are we looking at i can get oh the women i work with it's night and day it's weeks like yeah sure you have a few days that aren't your best but right even there are women with headaches and migraines that dip right there in the luteal phase the brain is super sensitive to the dip so i can get i can control headaches and migraines most of my migraines are in the luteal phase and i can get a lot of headaches i can get most of them under control with hormones here's a good question when does perimenopause start and how can you tell it's starting and do you find a provider when you start to notice symptoms or should you find one before what's a good strategy for this so the most two common things that women complain of perimenopause not being able to sleep you can relate to that and um change of mood the irritability right the just not feeling like myself so they say could be 35 but to be honest if you feel start feeling those i don't care what age you are like i have patients who are 83 you know i was talking to her when we were up here my 83 year old cute patient like it doesn't matter to me your age just get help but for perimenopause if you're just not feeling like yourself i would get help would you start researching it before you feel like you're getting to that area so you know where to go you have a plan sure i mean you could go the hard part is like where do you go right 4100 of us who have the certification um so on the menopause society they you can search by uh your location it'll pull up and then dr mary claire haver who i recommended she is probably the she has the largest platform for women's health right now um she also in her books has a list of providers too a couple people have referenced menopause what is that yes menopause what is that a well the technical term is andropause but that's boring okay so i like menopause well same like thing that you will see like for men go through it their hormones dip they tank they lose they don't have energy the brain fog the mood lack of muscle getting that adiposity they start gaining weight so i find when i work with men and women if i only bring up one you get this disbalance so it's best if you can bring up two okay any advice for hormone replacement and treatment for addison's patients which i don't even know what addison's is so addison's has to do with your adrenal glands adrenal glands look like a little um kidney bean that sits on top of your kidneys okay and it produces it's important for like cortisol um so they actually for addison's you have to take cortisone or a steroid the rest of your life you just sort of affect sleep mood energy so you have to deal with the addison's in addition yeah but it doesn't like preclude you can do anything with that so just because you have addison's you can still do all of the other hormones since menopause my hair is extremely dry and brittle this is a hard one what is the most effective way to improve the health and moisture of my hair this is a hard one is it okay this is a huge complaint and a lot of women i will see will blame it on testosterone or glps which can be a thing you'll see women who have a lot of testosterone who have a lot of testosterone who lose a lot of hair on glps really but here's why i think it's happening if you're not eating if you're not getting your protein that your your body sees it as a stressor so it dumps the hair now it's not immediate it's three to four months usually after you start it but if you look at women you probably haven't done this elder women tend to have like hair thinning in the temples or the part here gets whiter okay and we just lose a lot of hair it's just across the board so it's super frustrating and i think of hair for women this is our crown and it just starts to thin as we age regardless so estrogen can help testosterone some women are really sensitive to dht so when you especially by skin if you put testosterone on your skin increases the dht which can make hair fall out okay so one way around that is you can do injections plus or minus info on using salt palmetto pumpkin seed oil neutrophil i don't know if you've ever heard of them they're a popular company that does hair supplements about yam cream no no yams and andy's rubbing yams in his hair i'm just trying to genetically have good hair dad's is out of control what do you mean it's a real force he still has some which is impressive at his age it's impressive that it's all over the place at all times but i mean yeah um so that for optimizing estrogen is huge if you're on glps you have to eat right how many people do you see that'll just they just don't eat they just rely on the shot are do you think some people are taking glps because they don't want to eat as much i mean it is an appetite suppressant i think it's and for um alcohol abuse there's studies nicotine like there's yeah like a lot of people who are taking glps because they don't want to eat too much and so if you're on glps you're not going to eat as much and so if you're on glps you're not going to eat as much body image issues could play a role in here and if they just stop eating you're going to dump your hair oh that makes sense yeah slight divergence here what's the best supplement for prostate health so there was this the traverse study came out there was for men saying that testosterone was going to cause prostate cancer so kind of like okay estrogen causes breast cancer right that was the big concern we know that that is not true there was this concern oh does testosterone cause prostate cancer and the traversed trial showed that the data doesn't support that so taking testosterone yes it can bump your psa number your prostate number we trend that your provider should be following that that's one of the metrics or the little things in the reports yeah if you live long enough for a man you're going to get prostate cancer it just it grows so there are some things like sal palmetto again not great data on it to help protect prostate health pumpkin seed oil but the there are actually some people who are using um even after prostate cancer they're giving back testosterone and not showing recurrence michael this one's for you totally off topic hey andy has anyone ever mentioned to you that michael looks like mark zuckerberg just saying there you go just wanted you to feel included people are thinking about you thank you uh let's see what else here covered that one we've actually made Quite a dent in these. a couple questions about over-the-counter testing for perimenopause but like you said i don't feel like that's effective yeah kind of answered that one it's gonna if you took it four times in a day it'll give you different answers so it seems like you treat the symptom a lot more than uh not menopause yep there's a yam cream one again what was your friend's question that came through last night oh i think we answered some of them but i'll go back over there let me see if there's any more in there what is what is best an older and an older woman who hasn't been treated but is now having frequent recurrent utis do you know the answer to this cranberry juice no it's the vaginal estrogen oh what i know the answer we did it last time oh so jason you know he on his pair on his medical aids especially where he works a lot of older people and it's a lot of elderly women who fall i'm like and i ask him where did you find them in the bathroom and the reason why for elderly females don't have to be elderly that utis and women as you get older make you confused you know it's not the young girl who's got to sit on the toilet who's peeing all the time have pain they get confused okay what happens an older female gets up she's confused goes to the bathroom she falls she breaks a hip so vaginal estrogen will save lives i tried to get jason to tell people at the calls that cpr for the vagina was vaginal estrogen he said that was too much i i don't think that the san diego fire department is going to sign off on that level of no but he has been really good at telling like she needs vaginal estrogen because it will decrease the risk of utis which decreases hip fractures which decreases death okay so vaginal estrogen everyone be on that even active breast cancer patients can be on vaginal estrogen how does stress everyday stress in parentheses and also the big life events affect our female hormones divorce family trauma life death is there a big difference for men versus women and this is a very different question how do women who have had no sexual experience get doctors to hear us to get our hormones checked our bodies properly checked and to hear our concerns i think i actually responded to that person well guess who's calling should we answer no we should not hi dad if he was in here hi dad oh let me talk about my testosterone and what's going on now he studied for days to be able to say it correctly because i had mocked him so incessantly my my testosterone i'm on my testosterone dad oh oh are the fans wanting do the fans have questions for me um i don't think sexual activity in any way should dictate if a woman gets help right like i actually i don't and maybe this is my reading it wrong no how do women who have had no sexual experience get talked are they saying earlier in life or someone later in life who just was not interested in sex i'm trying to understand where this lands maybe they've never had sex okay right i don't think your sexual history should be an indicator if you feel good the rest of your life no i think they're completely independent yeah yeah and so i to be honest if you saw a provider and that was their question and that was their hard stop next provider uh trauma trauma is actually really so trauma rears its head and perimenopause and so i do what's called and women because they're traumatized yes the men are yes from the we need to focus on perimenopause from a man's perspective we're the ones who are suffering here oh i don't doubt it yeah i mean i've been very open that jason and i almost got divorced during this time i mean i it was pretty fun i don't doubt it but so i do what's called trauma-informed care so in my intake questionnaire actually have men yep it's on the men's page too it's on the men's page too but for the women i actually have a trauma history and it unfortunately seems to rear its head in perimenopause is that bumping the suicide road or is that bumping the suicide road i don't know i don't know i don't know i don't know i don't risk also potentially but trauma that a lot of women have stuffed and buried rears its head in perimenopause men and women i mean i think just for maybe for mammals not dealing with your traumas it's not a great strategy you can either deal with it or it's going to come deal with you at some time probably at your lowest points and then yeah what are your uh i think we covered all the questions which is good what are your thoughts i'm going to shift a little bit to peptides and i ask this because depending on what you how you're algorithm for people out there listening is what you're looking at it's a wild ecosystem out there do you think that and i've i can't say i have deeply dove into this but have read some stuff where a lot of these peptides especially from large online influencer platforms being sourced from china which uh and i have seen some people who are the opposite spectrum of the influencers who are buying some of these and testing them and holy cow oh yeah and they're not scrubbed well and if some of them contain way too much some of them can nothing yeah nothing everything in between i know your stance on peptides you're pro-peptide as i am myself but again it's a tool but you also you have to be so careful where you're getting your information from and then also the product itself so do you think that this ecosystem of really large platforms really promoting this is this net positive or net negative are you yet to be determined because if you're like jabbing stuff you don't even know well they're making money these influencers with no medical background are making money off of this right and i go oh look at some of these going you don't even know what you're talking about and what if someone just goes to a peptide and we're actually missing the root cause right yeah and i get it people are desperate and if you're scrolling on instagram oh for fifty dollars that's a red flag well you can make it worse and this is where i understand organizations like the fda wanting to say we need to regulate this but also at the same time i don't like how their arms reach from big pharma who's trying to regulate it as well because they see how massive it is and try to cut compounding pharmacies out but also what's the the lesser of two evils having some level of quality control and yeah it might go under the the realm of big pharma which i'm not advocating for or you're ordering something from overseas and you don't know what's in it and you're just hoping for the best i don't you know live your life however you want to right but maybe not everything you see on instagram is going to be the same but maybe not everything you see on instagram is going to be is the best idea i've had since i've been practicing three four patients now become peptide distributors like they're selling peptides interesting where are they sourcing them from that's the thing i'm like where your sterility reports where's the purity reports where are you getting getting them from because there are compounding facilities in the there are and so that thing you you know you're friends with brigham and he's a big advocate of this and the fda i think it was six that they just said we'll go in front of the panel they did not get approved they said okay we'll put these in front of the panel to see the next step is to see if the fda will approve them for compounding the only one i recognized in that was the bpc 157 tb 5000 combo that one was in there there were some other ones but i didn't recognize the other ones yeah i don't know them all off the top of my head i knew which ones they were but um i don't know them off the because then what happens you start having adverse effects too right from these people and then other or organizations can be like see they're bad they're bad one triggers the other one so it's it's you're choosing between i don't want big pharma involved in control of peptides which are naturally occurring and i think big pharma has shown they've done some amazing things and then also they operate off of bottom line i get it i'm not yeah i understand what that is and i don't want to interface with it as much as possible in my personal choices i don't want to choose not to do that i do like what bring them scott going on i do like the idea that there are ways outside of just big pharma where you can go through providers and the cool thing about bring him is he's vertically integrated we're talking about the founder of ways to wells but he knows where it's coming from the issue is it's shop now button and yeah it'll show up but i mean what is it well saying you can buy the glps online you know for through the influencers too you don't know what you're getting so i think that that's we're going to run into a problem i don't know be more effective at regulating that or throttling that if it would be the platforms itself or it would be neither of those are great options because then you're talking about censorship as well too i mean peptides have a role insulin's a peptide bacitracin you put on your skin is a peptide people are using peptides and they don't realize they're using them they've been around for insulin was like 1920 a long time it's it's the like you said the wild west of people going crazy with it i know one thing that we didn't cover that came up by selling a couple questions is thyroid there was thyroid questions on there thyroid so thyroid uh it's a little butterfly sits in front of your neck and it regulates the speed of your body your metabolism your sleep your energy so if it gets sluggish it looks like perimenopause so it would be good if someone you could get a thyroid panel that's not just a tsh that's what people superficial scratch the surface you want to know your storage form in the tank what's free circulating is this for men and yeah do you have that in my blood work yeah okay so all i know is that when i'm getting my blood drawn i just they keep going and i say please leave me some for the drive home also where's the nearest orange juice dispenser but well i think it's because of the lab company which is crazy the same panel that you get drawn i draw in my clinic it's three tubes so their explanation was is because we ship this one here and we ship this here their processing is not in one place i feel like if my what is it hematocrit hemicrit if it was high after no no you're good you're just gonna say i feel like my biannual blood work is doing my that's why because they ship out i draw the same in clinic and it's three tubes man they just keep going they lay it all out before i'm just like i don't know how much of the hydraulic fluid we have in here but save me some yeah so thyroid's a big thing and people will oh my thyroid's low it can feel the same perimenopause hypothyroidism low looks the same and feels the same but you've got to do a deep dive in your thyroid labs too because they can overlap and if someone's on thyroid medication and does oral estrogen you have to increase your thyroid medicine this is where it really you've got to find someone who knows this dance right even if you dial all this stuff in but your lifestyle metrics are just trash yes are you basically pissing into the wind and that's huge for me i have what are the i always pronounce this wrong what dad makes the rocks oh the uh what are those called karen karen's karen see i always say it wrong karen so i use that karen's rock karen so i have one in my office and i use it to teach and the bottom rock is sleep and the next rock is exercise and the next is nutrition and i tell my patients if you cannot get these stable i can't even build on top you know because so many people i get it they just make me feel bad i'll just inject right i understand why they are feeling that way and why they want it to be yeah the light switch but that just isn't the reality no but i teach to that we have to focus on sleep we know for alzheimer's if you don't sleep your risk goes up heart disease everything sleep is key which is really hard for a lot of people um so that was a question i'd also have people do deep dive on lipids not just your standard cholesterol triglyceride do the lipoprotein a you know it will be so doing all those would be on there how close do you think dad is to getting in a home michael's like do i get an opinion on this yes michael you can you're welcome you're part of the family well i don't know any good ones i don't think that he'll listen to this because he can't figure out how to listen to your podcast did you know that what yeah i said oh did you listen there's some podcasts you've done and i said oh did you listen well how do i do that how do i did you know michael the chinese hacked him too he's been hacked by the chinese they did a real thing that he said no what's the real thing he really said that he was no no he really said that what's the real thing is jason born of electronic devices aka my dad somehow went into his settings and changed the language to chinese which i'm gonna assume is actually a bitch to undo especially if you go back yeah you'll know where this if you can't read mandarin it's pretty tough so he convinced himself that because of his intelligence value to near peer adversaries that china had hacked his phone yeah so where would you go if you thought your phone had been hacked or you needed help with your apple device where would you seek help for that i mean probably i don't even know actually the internet first of all so now that's that's a no-go he can't get online so so instead he went to his cell phone provider verizon yeah and demanded that the person that he encountered fix his phone so they factory reset his phone because they're not tech people they're there to sell you a plan yeah um he has no contacts save in his phone yeah they did a factory reset that sucks he's got one but it's not anybody in his family yeah and uh so he'll just he has convinced himself well i know the numbers that are important to me he doesn't even have me saved as a contact no no we are doing we are being very responsible children and we did his advanced care life directives which everyone should have right i'm a huge advocate for talked about what you were going through with him so people can think about this a huge advocate like working like what i saw in the er what i have to deal with with people not having their wishes working in hospice and people not having it spelled out right so i don't care even you should have it like we should have it oh they used to have us update our wills yeah well there's not really an advanced care directive but like in everyone should have it where do you want cpr or not it's the pulse form do you want cpr yes or no what kind of care do you want do you want full care yes i want to be intubated i want a ventilator give me everything all that stuff's good but if somebody if if a nine like say you stroke out at a restaurant somebody calls 9-1-1 how are they going to know that if you don't yeah if you don't have it right most of the time people will put this on the fridge fire goes in and they're looking on the fridge that but i mean you're at a restaurant right so then what happens is you hope you've had a conversation or you're with someone and they'll be like call the call the person who is their health care proxy that's why you and i have to each have a copy of this as the 9-1-1 responding personnel they're calling you to say no they're doing full code they're doing so they're going to be doing a lot of the things you might have asked right and that's there's but say you and i are there with them yeah then you can be like no you know but otherwise yes what they have to do is they have to run a full code until they get to somewhere where it says otherwise to stop you just can't do that did i ever tell you i had to do the heimlich on dad one time i was there yeah and you said keecy keecy my dad and i'm like you're bigger than me dinner roll it was yeah in his mouth and didn't want to say anything i was sitting across the table looking at him he's over there yeah and andy's looking at me and he's looking at me i'm like i'm like the nurse handle your shit look at me i'm time like i'm not gonna be able to do anything to this large man full on had to go god i looked him three times it came out just like in the movies too and it came out at a fucking dinner table he ate that roll by the way he cut it after yeah that was at a thanksgiving dinner that's awesome yeah how long ago was that years yeah well over a decade ago but yeah yeah the journey never ends with that one yeah so so healthcare proxy proxy for everyone yeah but then yeah if number one gets called they're probably going to violate those things and that's all right you just you have to like if i'm in that shoes i don't know your wishes i'm gonna do my best to save you right and you just do that and then when they go to the better medical kit first if you're gonna save people oh i know it's pathetic have you shared your story of no i'm not going to talk about that okay yeah that's that's that yeah irrelevant okay all i'll say is this if you actually want to be useful and helpful you need tools and knowledge and understanding how to use them yeah i have tools just not as good of tools as yours and don't go co-black co-black helps no one i don't know what that means it means you're fucking you're physically present but not mentally aware of what's going on you're overwhelmed by the circumstances you're dealing with oh i don't run into that situation well if you're ever out in town you're going to have to be in town and people are not used to seeing relatively traumatic things they'll be standing there oh yeah no no and you can look at them they have the apple squirrel wheel of death that's code black you're code black physically present mentally checked out i mean call me weird but i love those situations you know i love your emergency room you know i mean the craziest one was working on the damn airline with carter when we were flying to brazil for eight hours working on that guy yeah that was the most expensive you hadn't been on board do you think they landed the plane they wanted to land the plane and i was like i've got a tour to go on vacation i have a i have got to get to brazil part of their handing you medical devices and providing bedside care no carter said i i was like carter's like mom i've seen you do this so many times i'm just gonna play my video games you know and i'm working you know a cheap airline we're on a guy who speaks he stopped budget shopping airlines i know your poverty mindset is disgusting korean guy speaks no english kind he had passed out diaphoretic they haul him on to the the four-seater you know seat haul him there his other friends are korean hand him all these these pills i'm like don't take these pills i don't know what they are how is he even going to take them he takes a handful of pills in front of me he just had stents play so i'm like great we've got a heart situation they bring me this bag of like you know for fluid there's 250 bags right 250 so tiny i'm used to leader bags oh yeah the 250 bags are there's turbulence i'm like carter this is how carter assisted me i'm like carter get me my readers because i can't see to start an iv what gauge needle did you have i didn't need i'm working in another country i'm just like let me see i think i started with a 20 oh that's not bad no but we're used to have us practice 14s fuck that yeah so yeah let's do ivy training we're out of 18s and 20s here's some soda straw 14 gauge needles well you guys your your acs would be able to oh does it make it feel any better when a soda straw is puncturing your vein no it does not so yeah here we are and we're right over panama and they're like can't we need to land the plane i was like give me 30 minutes i'm like i've got to get on this little tugboat with carter in the amazon what did you learn from this experience oh it was great we had a great time life was saved so the whole there's like 500 people on the plane i get him stabilized did he eventually come back to it yeah he was stabilized and then i said do not pull your line out because all i had was 250 bags i had to keep just changing them out we land and he's so mad rips the iv out is bleeding everywhere so the paramedics show oh it was a hot mess but carter goes mom i just gave you an air clap because i've seen this before perfect i love it just unfazed yeah yeah well yeah there you go have advanced medical directives and uh you know don't take a fistful of pills on planes maybe that's after a stent and you've passed face like face plant on in the aisle yeah yeah they had nothing they had they didn't have i got a blood pressure cuff yeah passed up it was like where am i third world people are passing up the medical tools they had in their own carry-on to help me someone passed me up a blood o2 sat i had someone passed up their blood pressure cuff it was crazy well it was crazy yeah well how can people get in touch with you oh well and i have to say too you're the reach of this you and i talked about this of that lady in south africa right of you opening up this platform to potentially a way to help another country who doesn't have help in this arena once i hit upload i have no control it's fascinating to see how the internet works like that right but even like me getting the opportunity to speak with her and in real time seeing what south africa had and her excitement and if that leads her excitement to teaching other women right that's what we need it's going to be a grassroots effort it's going to take too long for my age to catch up right so it's going to be women teaching women and so i thought that was amazing um to work with her so currently i'm licensed in california montana but what i had saw happen is you know people crying miserable throughout all the united states and i'm like do you have a desire i mean not that it could happen overnight but do you have any desire to increase the number of states that you are would you say registered in licensed you have to have a license um so and then there's just me right i'm solo provider and i love talking about that that's a scaling problem right well and that was the thing you know i'm very fortunate i'm very fortunate in the growth that i've had i'm very fortunate in how people trust me i am very different personality than they're used to and they either like it or not right but i think my results speak for itself and people can relate to me but what happened was it's just myself so i have decided to train other providers to work under me so i can help more people and then in the rest of the united states i'm doing coaching so are you going to increase the states you're licensed in or keep it i don't know i mean honestly i've had patients of people who have been licensed in and i've had patients who have been licensed in and i've had patients who have been licensed in and i've had patients who have been licensed in and i've had You get the silver one. You get the silver one. Oh, hell yeah. That's awesome. Take it on tour with you in rugby. I will. Actually, honestly, Michael, it's the best parting gift from the show ever. I feel like your life, you are ready to now go on the road and teach others what you have learned. Yes. Very knowledgeable. Oh, look, and teach on the rugby tour a yoni massage. It's spelled Y-O-N-I. Before we get completely off the rails, we're going to go ahead and wrap this up. It's not off the rails. No one talks about this for women. What is it? What's a yoni massage? A yoni massage involves massage of all the tissue. You can have a conference with Michael afterwards. Yeah, I just looked it up. Yeah, look it up. Listen, I'm here to educate both men and women. That's great. Spectacular. So. All right, we have to get back because I'm sure Carter is already pacing, waiting for Huckleberry Day. Huckleberry Day. Is that what we have? What are we doing? Going to Whitefish? Yeah, it's Huckleberry Day. Have you ever heard of Whitefish? Have you ever heard of this, Michael? Huckleberry Day? Is this like a fair or a- It's a festival in Whitefish. I think I'm going to let you guys explore that on your own. I have limited, if not any interest at all, on Huckleberry Days. We'll see if dad shows up in his linens. Dude, no shoes. Shows up at the house, no shoes. Powerful. Like, just barefoot. Just a fucking hot mess. Mm-hmm. Yeah. Tucked in shirt. His shirt was tucked in. The zipper was up. Yeah. I'll give him credit. Which actually that is rare. Yeah. Yeah. Just that the zipper was up. Yeah. And one of the pant legs wasn't soaked in urine, so that's a positive plus. All right.