Ask Me About Hormones

01/28/2026

In my 15 years of prescribing testosterone to Men, I have not had a single clotting event that I am aware of. Please read the previous post on erythrocytosis and polycythemia.

As the prevalence of male hypogonadism (HG) has increased, more patients are prescribed TRT. TRT may be associated with an increased risk of deep veno…

01/28/2026

Testosterone and Hematocrit

Polycythemia and erythrocytosis are terms that are often used interchangeably—even by clinicians—but they are not the same, and the distinction is clinically important.
• Erythrocytosis is a laboratory finding
• Polycythemia is a disease or syndrome
They should not be used interchangeably.
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1. Erythrocytosis — bone marrow is normal
An increase in red blood cell (RBC) mass above the normal range due to appropriate bone-marrow response to external stimuli.
Measured by:
• Hemoglobin (Hb) > 16.5 g/dL
• Hematocrit (Hct) > 48%
Reactive (Secondary) Erythrocytosis
Driven by external factors, not by intrinsic bone-marrow disease.
Common causes include:
• Testosterone replacement therapy (TRT)
• High altitude exposure
• Obstructive sleep apnea
• Smoking / chronic hypoxia
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2. Polycythemia — bone marrow is pathologic
A clinical syndrome characterized by increased RBC production due to intrinsic bone-marrow disease.
Polycythemia Vera (PV) a myeloproliferative cancer
• Clonal bone-marrow disorder
• Uncontrolled RBC production
Dysfunctional platelets
• Creates a baseline hypercoagulable state
📌 Patients with PV can develop DVTs and other thrombotic events even when hematocrit is “normal,” because clot risk is driven by clonal platelet, leukocyte, and endothelial dysfunction—not blood thickness
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01/14/2026

Possible side effects of progesterone

🌙 Common Side Effects (most are expected effects)
Sleepiness / sedation
Grogginess or “hangover” feeling (especially morning after)
Dizziness or lightheadedness
Vivid dreams
Mild brain fog early on

👉 More common with oral dosing due to neuroactive metabolites (allopregnanolone).

😵 Less Common but Seen
Headache
Bloating or fluid retention
Breast tenderness
Nausea
Constipation
Mild low blood pressure symptoms

😔 Mood-Related Effects (subset of patients)
While progesterone is calming for most, a minority experience:
Low mood or emotional flatness
Irritability
Worsening depression (rare, but real)

🩸 Menstrual / Hormonal Effects (cycling patients)
Spotting or irregular bleeding
Temporary cycle disruption during initiation

01/14/2026

What does progesterone do?

🧠 Brain & Nervous System
Calms the brain via GABA-A receptor activity (anxiolytic, anti-panic)
Improves sleep quality, especially deep sleep (↑ slow-wave sleep)
Reduces irritability, rumination, and PMS/PMDD symptoms
Neuroprotective and anti-seizure properties
Supports cognition by reducing neuroinflammation
👉 This is why many patients feel “calmer” or sleep better within days.

❤️ Cardiovascular & Vascular Effects
Does NOT increase clot risk (unlike synthetic progestins)
Neutral or favorable effect on blood pressure
Supports healthy endothelial function
Does not blunt estrogen’s cardiovascular benefits

🦴 Bone & Muscle
Works with estrogen to support bone formation (osteoblast activity)
Deficiency is associated with bone loss, even when estrogen is adequate
🔥 Inflammation & Immune Modulation
Anti-inflammatory
Helps counter estrogen-driven inflammation when estrogen is unopposed
May be beneficial in autoimmune-prone states

🩸 Uterus & Breast
Protects the endometrium from estrogen-induced hyperplasia
Promotes normal cellular differentiation in breast tissue
Synthetic progestins increase breast cancer risk; micronized progesterone does not

⚖️ Metabolic Effects
Supports insulin sensitivity
Does not worsen lipids (unlike many progestins)
Helps regulate cortisol rhythm and stress response

😴 Sleep & Circadian Rhythm
Shortens sleep latency
Improves sleep depth
Reduces nighttime awakenings
Especially effective when taken at night

01/09/2026

What a great turnout today!!! Sorry I ran over BUT I had sooooo much to say! Stay tuned for seminar highlights

12/23/2025

BHRT, when:

• Bioidentical
• Properly dosed
• Individually monitored

does not “add hormones,” but restores physiologic communication between cells, mitochondria, brain, bone, and cardiovascular tissue

12/23/2025

Identical Twin Comparison: BHRT vs No BHRT

Baseline (Early Adulthood)
• Same genetics
• Similar early hormone production
• Comparable metabolic rate, bone density, cognition, and cardiovascular risk
As aging progresses, hormonal divergence becomes the dominant variable.
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Twin A: Uses BHRT (Physiologic, Optimized Dosing)
Expected Long-Term Outcomes
Metabolic Health
• Preserved insulin sensitivity
• Lower visceral fat accumulation
• Better lipid particle size and mitochondrial efficiency
Bone & Muscle
• Maintained bone mineral density
• Reduced fracture risk
• Higher lean muscle mass and strength
Brain & Cognition
• Improved synaptic plasticity
• Lower risk of neurodegeneration
• Better mood stability, sleep quality, and stress resilience
Cardiovascular System
• Improved endothelial function
• Lower arterial stiffness
• Reduced inflammatory markers when properly dosed
Reproductive & Urogenital Health
• Preserved vaginal/urethral tissue integrity (women)
• Improved libido and sexual function
• Reduced genitourinary syndrome of menopause
Skin, Hair, Aging
• Increased collagen production
• Improved skin thickness and elasticity
• Slower visible aging
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Twin B: No BHRT (Natural Hormone Decline)
Expected Long-Term Outcomes
Metabolic Health
• Increased insulin resistance
• Higher visceral adiposity
• Greater risk of metabolic syndrome
Bone & Muscle
• Accelerated bone loss
• Sarcopenia
• Increased fracture risk
Brain & Cognition
• Higher risk of depression and anxiety
• Cognitive decline over time
• Increased dementia risk (especially post-menopause)
Cardiovascular System
• Increased arterial stiffness
• Higher LDL oxidation and inflammation
• Greater cardiovascular event risk after menopause
Reproductive & Urogenital Health
• Vaginal atrophy, urinary symptoms
• Reduced libido and sexual satisfaction
• Increased recurrent UTIs
Skin, Hair, Aging
• Rapid collagen loss
• Skin thinning and dryness
• Accelerated aging phenotype
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Why This Comparison Matters Clinically
This twin model demonstrates a critical concept:
Aging is not caused by time alone — it is largely driven by hormonal decline and loss of cellular signaling.
BHRT, when:
• Bioidentical
• Properly dosed
• Individually monitored
does not “add hormones,” but restores physiologic communication between cells, mitochondria, brain, bone, and cardiovascular tissue.

12/23/2025

I saw a new patient this week. Usually, my discussion about the benefits of hormone therapy takes some time, so I was prepared to give my usual spiel. As I began, she stopped me and said:

“I want hormones. My mom is an identical twin. She took hormones; her sister did not. My aunt is a metabolic disaster, while my mom not only looks younger but is thriving.”

12/17/2025

Not many prescribers have taken the time to truly learn how to optimize hormones—and not all hormone treatments are the same.

So what’s the difference?

1. Hormone Replacement

Primarily addresses symptoms
Uses the lowest doses needed to reduce discomfort
Often involves minimal or no ongoing monitoring
Little personalization in dosing, timing, or delivery

2. Hormone Optimization

Restores physiologic balance, not just symptom relief
Personalized dosing, timing, and delivery methods
Requires regular monitoring and adjustment
Focuses on long-term health goals, including:
improved mitochondrial function
enhanced brain and cognitive health
bone strength and growth
improved cardiovascular health
improved muscle strength

Replacement treats symptoms.
Optimization restores function and resilience.

12/16/2025

I think we should change the medical terminology surrounding perimenopause, menopause, and post menopause. These terms are confusing and, in some cases, misleading. The term post menopause, in particular, implies that women are “done” with the process, when in reality this is often the period of greatest vulnerability to hormone dysregulation.

A more effective and clinically meaningful approach would be to shift the focus away from age-based labels and toward whether a woman—or a man—is hormonally balanced and optimized. This framework allows both younger and older individuals to receive appropriate hormonal evaluation and treatment aimed at optimizing health, function, and long-term well-being, rather than waiting for symptoms to escalate or milestones to be crossed.

12/10/2025

ALL women for their 40th birthday, should be prescribed progesterone. Adequate progesterone can help reduce fibroid growth, regulate abnormal periods, and improve insomnia, anxiety and mood swings. This can significantly ease the transition through perimenopause and into menopause.