"If Only I Had Seen You Sooner...": The Conversation We Don't Have About Prevention and Surgery

A conversation about prevention, surgery, and what comes before.

There’s a moment in medicine that stays with you, when you realize a patient has reached a point where surgery is needed, and you quietly wonder:
Could this have been caught earlier?

Surgery saves lives.
This is true.

But it’s often not the beginning of the story.

It’s the moment we enter the story.

What happens before that moment?

Subtle symptoms, shifts in the body, changes that don’t quite make sense--often dismissed, normalized, or missed.

In this podcast conversation, Dr. Lorna Brudie and I explore when surgery is truly necessary, what patterns we see before patients reach that point, where prevention fits into modern care, and how we might begin to see patients sooner.

This isn’t about choosing prevention over surgery. It’s about expanding the window, so we can understand the body earlier, before it has to speak louder.

What if we listened sooner?

What if we looked deeper?

What if we connected the dots--before the diagnosis?

Transcript

Mary Louder, DO: Welcome to the Dr. Mary Louder podcast. Today we have a very special guest, Dr. Lorna Brudie She's an osteopathic physician like myself, and she's trained in both oncology and gynecology, which is a very unique combination. We're going to be talking today about functional oncology and how the root of cancers can be metabolism. And I think this is a really important discussion to have. So welcome and listen in to the conversation that Dr. Brudie and I have together. Enjoy. Well welcome to the Dr. Mary Louder Show. My guest today is Dr. Lorna Brudie She's an osteopath like myself. She's from, New York College of Osteopathic Medicine out on Long Island out there. And she is a gynecologic oncology specialist. So. And currently she serves as the medical director for Excel Medical. Welcome.

Lorna Brudie, DO FACOG: Thank you so much for having me. Good to see you again, Mary.

Mary Louder, DO: Yes, you as well. We met at a conference recently, and we just hit it off because we're kind of kindred in our approach to things. One of the things that I would say as a patient, it would your, you know, the specialty that you have oncology plus gynecology, we don't really go there for fluff and stuff. It's usually something's up and, you know, as a patient, it's a little more nerve wracking. The stakes are a little higher. It's not like, well, let's just kind of see. So from your perspective, and both you and I have had a very long and storied career. And so we've got a lot of experience to, to speak from. We kind of arrived when we began talking, the statement was, if I had seen you sooner.

Lorna Brudie, DO FACOG: Yes.

Mary Louder, DO: So hearing that and even thinking that from your specialty, in your experience, what does that mean to you?

Lorna Brudie, DO FACOG: So if I could have a tagline, that's what my tagline would be. If, if, if I had only seen you sooner. You know, I, I would see these women in advanced, advanced part of my career. I'd be in the operating room prepping patients. For, for, for the surgery. And I would be thinking to myself, how did we get here? Was there something that we missed along the way that we could have prevented this cancer? And these were mostly endometrial cancer patients. So endometrial cancer patients are usually morbidly obese, have hypertension, have insulin resistance or pre-diabetes or diabetes, and then are susceptible to endometrial cancer. And I always thought to myself, if we had only intervened sooner, maybe these ladies wouldn't have wound up on my table. So what what we are learning more is that this is a metabolic cancer. This is due to metabolic dysfunction. Right. So hormonal imbalance, inflammation. And had we done something ten years sooner, perhaps this woman wouldn't have developed cancer. And to me, taking that thought process, that's how I look at patients now. Not can I take care of your disease and you operate on your cancer. It's how do I prevent you from getting cancer? Right. And what can I do decades before before you get there?

Mary Louder, DO: Right. Okay. So the endometrium, I think we don't give it enough respect. I think, you know, if you think about how much the lining of the uterus goes through every day to get to the to start from the beginning of the cycle, which is the day you begin bleeding to the next time that you begin bleeding. It's one of the most dynamic organs in our body. And it--

Lorna Brudie, DO FACOG: It absolutely is.

Mary Louder, DO: Yeah. And it almost functions more like a transducer where messages come in, go out, come in, go out. But it's multiple types of hormones, multiple types of messages that come. So, you know, and I mean, do you think it's only estrogen and progesterone influence on the endometrium or is insulin there, any other cortisol, anything else that we need to know that's maybe being discovered lately about this?

Lorna Brudie, DO FACOG: I'm sure there are inflammatory markers.

Mary Louder, DO: Mhm.

Lorna Brudie, DO FACOG: I'm sure they're inflammatory markers that are in playing, that are playing a role because we, we are seeing some early data, especially with endometriosis, that the endometriotic implants, the fluid that that is sitting in the pelvis due to the endometriotic implants, show inflammatory cytokines. So they're using Glp's to treat some patients with endometriosis to decrease the inflammation and the pain. So I definitely think it's more complex than maybe we were taught originally. So I think I think more has to be looked at from that, from that perspective.

Mary Louder, DO: And do you think there's a lot of research on this?

Lorna Brudie, DO FACOG: Not a lot. I would not say a lot. Because everyone's very focused on estrogen. Progesterone.

Mary Louder, DO: Yes. Those guys. Gals.

Lorna Brudie, DO FACOG: But I think, you know, I think I think the inflammation, inflammation plays such a key role. Right. We go back to adipose tissue, the fat, especially visceral fat in that. That's where all the bad stuff happens, the inflammatory cytokines. And that heads us down the road towards cardiovascular disease, diabetes and cancer. So I don't think we're we're looking at inflammation as much as we probably need to, because if we target that and the insulin resistance that goes hand in hand with it, if we're targeting that, we can be preventing disease, chronic diseases.

Mary Louder, DO: Right. So when we've got in, everybody's talking about inflammation. I had someone, you know, want to come and see me. And they said their inflammatory markers were normal, but they're sure they have inflammation. So, you know, so my question is a couple things on that. A what are the markers that were measured? B what makes her think that in terms of what symptoms she's experienced and C where did she get her information from. Right. Because right now everything is about inflammation, this inflammation that. And I only say that because that's exactly what's, you know, out in the news that's out on the with the influencers that's out with social media is everything's inflammation. Um, and, you know, I'm not sure that that's exactly accurate. I mean, what are your thoughts on that?

Lorna Brudie, DO FACOG: I think you have to look at a lot of different markers, right? It's not just showing up and saying I have inflammation, right? I mean, it's, it's kind of taking the whole, as we were taught as osteopaths, taking the whole patient into perspective, right? I think the inflammatory markers are important, but they may not tell the entire story. I think a fasting insulin level is very important because that's going to show signs of change before a fasting glucose changes or hemoglobin A one C becomes concerning. So that's what I'm looking at because I'm looking for insulin resistance.

Mary Louder, DO: Right. So the canary in the coal mine as it were, could be insulin versus blood sugar or hemoglobin A1C.

Lorna Brudie, DO FACOG: I think that's a fact.

Mary Louder, DO: Okay. And so and if, if most of the, well, a lot of the research has pointed towards male patients. They don't have a uterus.

Lorna Brudie, DO FACOG: True.

Mary Louder, DO: And so-- thanks. And, and I mean.

Lorna Brudie, DO FACOG: Small small anatomy lesson. Small anatomy.

Mary Louder, DO: Exactly, exactly. This is what happens when a paradox get together, right. Two docs get get into medical humor. But I think the important thing is, is we can't translate some type of medical research for both men and women. We have to take them distinctly by themselves.

00:07:54 Lorna Brudie, DO FACOG: Very true.

00:07:55 Mary Louder, DO: Okay. So we get into this concept of what estrogen dominance is it that or is it really a problem with progesterone?

00:08:03 Lorna Brudie, DO FACOG: So I never looked at things coming from the GYN world. And I know that estrogen dominance term is out there everywhere. I can't say that that's my favorite term. I look at it as a progesterone deficiency, right? Because yes, you may be dominant in something, but what's missing? It's the progesterone, right? So when we when we categorize these women as estrogen dominant, I think of that as the PCOS patient polycystic ovarian syndrome. Right. So those women are usually not all the time are overweight. So they have extra extra fatty tissue where you're getting conversions into estrogen. Then they're having abnormal periods. There's not enough progesterone being made. It's it's kind of a cycle and a vicious cycle of events that's going on right there. There have high androgens. The testosterone, the androstenedione. They have high androgens causing issues like oily skin, acne, facial hair and hair in places that they don't want it. Right. So that's not just estrogen dominance, right? That's that's also androgens are being driven up in not a good way, right at baseline. And they're deficient in progesterone. So they're not cycling appropriately. So I look at it as progesterone deficiency or insufficiency. And these women need progesterone.

Mary Louder, DO: Okay. Interestingly, the the testing that we do, you and I both do is the DUTCH testing. I then bounce that against a hormone panel of DNA. And what I find is sometimes and I'm pointing back up the chain is when I'm doing this by pointing that way, is that DNA doesn't. Uh, their DNA shows a deficiency in even steroidogenesis the creation, the synthesis of progesterone as a hormone. And I, for one, am one of those.

Lorna Brudie, DO FACOG: It's so interesting, right? Because it's not just, oh, you're deficient, it's what's happening behind the scenes. Right, right. And I think you especially being so inquisitive, right. You it's we want to get to the root cause what is actually happening? What is driving this issue? Right? We can't just put a Band-Aid on everything. We have to figure it out. And I think that's sometimes where traditional medicine kind of gets, gets tripped up, right? Where we put a Band-Aid on things. We, we throw a medicine at something rather than figuring out, hey, why is this happening? Where is this coming from? And I think these tests are so it's, it's just extremely interesting to me to find out really the mechanics of what's going on hormonally, not just production, so to speak.

Mary Louder, DO: Right. So I have seen recently in someone's labs, not mine, I will full disclose that. But they had, they didn't have a high amount of progesterone that was synthesized. Right. So they've got low, low coming in. Then on their estrogen side, they had normal patterning for production of estrogen. Normal patterning for going through one, two and three phases of detoxification or biotransformation which is great. Didn't really get tripped up with methylation. Didn't really get tripped up with COMT or sulfation. But then I found that their GI tests showed that they didn't clear it very well. And so that would mean and they had some adipose um and had visceral fat which has its own inflammasomes, which is actually a thing. And so then we found that she was just recycling the higher estrogens and there wasn't progesterone coming through. So and she just wasn't eliminating the progesterone. And so my treatment wasn't in her, you know, and she was seeing other physicians. And their solution to having some of the lining was to give her--

Lorna Brudie, DO FACOG: Throw progesterone at her, right? When you didn't fix it, when you didn't fix the problem. And that's, that's where I think in gyn, we don't go that distance. We stick to the standard tests we're looking at. Yes, levels are going to fluctuate during cycles and and whatnot. They should be pretty stable, decreased of course in menopause. But we're looking at static levels so to speak. We're not looking again at the mechanics. And I think it's very interesting once you start diving into the root cause and the mechanisms behind, like you just said, not clearing estrogen. Okay, so she's not clearing it. She's not making enough progesterone. That means she's going to be at risk for endometrial cancer, but she's going to show up at, you know, at my door with an endometrial cancer because no one could fix the actual root cause of the problem.

Mary Louder, DO: Right? Exactly. Exactly. And when I first started working with her, she was in tears. This was a few months ago because she was just so confused, didn't know what to believe or think. So what would make her cause to believe me? I said, we're going to find you and we're going to put you at the center, and we're going to figure you out by doing your DNA, your Dutch and your GI map. And she has come through that. And then we also treated some PTSD around that, to be honest, and also her stress level in work. And so in doing that, she has come through with flying colors and her symptoms are markedly different.

Lorna Brudie, DO FACOG: That's amazing.

Mary Louder, DO: Yeah. And so and it's been four months. Not long. Great. Yeah.

Lorna Brudie, DO FACOG: That's awesome.

Mary Louder, DO: And so and she'll be due for a biopsy again in about three or four months from now. So and I'm anticipating it being a total different thing.

Lorna Brudie, DO FACOG: Yeah.

Mary Louder, DO: So this message of everywhere you turn, it's estrogen. We need more estrogen. You lost your estrogen, which problem? You lost your estrogen. You need to have your estrogen back. Do we? I mean, honestly, are we supposed to? What do you think?

Lorna Brudie, DO FACOG: So since since since you bring that up. You know, I do think about things a little bit differently now. And I think medicine is heading into at least what we're doing. Bio individuality. It's not a one size fits all. Right. You have to look at the person just like you said their their DNA. Other other sequencing other testing. And that's what I'm learning. And it's, it's so funny to be a gyn and oncologist, have been in women's care for twenty seven years and continuing to learn something new in a way that I know can help women. And my major goal prevent cancer, right? So it's it's eye opening. And I always say as a physician, I'm learning something every day and I learn from you. I learn from my colleagues, I learn from the people that I teach. I, I think you have to continue to learn because medicine is constantly evolving. We want to do the best for our patients and we have to keep up.

Mary Louder, DO: Yeah. I think that that's really, really true. And I think when patients come to me, one of the things they say all the time is I've asked my doctor for help and they just don't know what to do or they don't want to. And I'm not sure it's a don't want to. I think it's more they don't know what to do.

Lorna Brudie, DO FACOG: Don't know.

Mary Louder, DO: Yeah. And I find that they lack curiosity. I find that concerning. I will just put it in that category concerning. And that even makes me curious about why they lack curiosity.

Lorna Brudie, DO FACOG: Let's, let's also put it this way. I, you know, we, we we've been doing this for a long time. Medicine is tiring.

Mary Louder, DO: Mhm. It is.

Lorna Brudie, DO FACOG: I think we reach a point of burnout. We reach a point of burnout. And sometimes we reach a point of saturation. Right? How much how much more can I take in?

Mary Louder, DO: Mhm.

Lorna Brudie, DO FACOG: Right. And and I think it happens to all of us at some point, you know. And we, we have to recoup and recover from that and keep moving and keep trying to learn and keep doing the best for our patients.

Mary Louder, DO: Mhm.

Lorna Brudie, DO FACOG: I, I have to say I'm, I'm, my own health issues, I've dissected my own, my own labs and whatnot, and I've had to dig deeper myself.

Mary Louder, DO: Yeah, I have too. And I have, you know, usually when I, I think, yeah, I do think that, you know, I've, I've presented to my own physicians in a certain way that they go, oh, we're so glad that you've taught us something today. And I'm like, I'm the patient, not the doctor, you know. But it's true. I've had to dig to find my own answers, and I'm, and I've decided I'm actually okay with that. Because in turn, what that's allowed me to do is to help patients more and also to understand their frustration of.

Lorna Brudie, DO FACOG: Absolutely.

Mary Louder, DO: Getting answers. Yeah.

Lorna Brudie, DO FACOG: I feel the same way.

Mary Louder, DO: Yeah, I think so too. So let's, let's kind of wander into what are the gynaecological cancers? What do we need to know if we want to be metabolically healthy? What do we, what questions do we need to ask? What tests do we need? What extra tests, if we can call them that? How would you guide us towards that?

Lorna Brudie, DO FACOG: I think it's yeah, I think I think it's important first of all, to see your gynecologist every year for pelvic exam. It doesn't mean you need a pap smear. Pap smears are are triaged differently, right? Depending on prior results and prior history. So it doesn't mean you need to pap smear every year to show up for a pap smear every year. But you need a pelvic exam every year. As I always told my patients, you need somebody looking and you need somebody feeling right to make sure that we're not missing anything. And then I think we have to look at the whole patient, see where they are metabolically it. I was testing, but kind of out of what I should have been doing because it to me, the primary care should be looking at the fasting insulins, um, getting the people with the hemoglobin A1C is treated and not just saying, we'll see you back in six months and check it again. Right. It to me these were warning signs. And then you also have the hormonal imbalance, right? That these perimenopausal women, of course, the PCOS women too, and our menopausal women showing up with not feeling right and again, being dismissed, saying that's normal for your age. that that's that's how it goes. Or I can't offer you anything. 

Lorna Brudie, DO FACOG: So I think it's important to be, not just getting your pap smear and your pelvic exam. Of course, we want to do some breast screening. I know there's controversy now over the mammogram and whatnot. It's there for screening. That's what we're using for breast cancer and a breast exam. but we also have to be looking at thyroid. We need to be looking at lipid panels. we should be looking at apo-b levels. Lipoprotein little a, I think it's important if you have a family history of cancer, cardiovascular disease, things that we can test for genetically, do the genetic testing. Because if you have a mutation, whether it's for a cancer or for something for some other condition, it's going to put you into a different screening category than the average patient, right? So we could preemptively help you if, you know, in my case, I was screening people for the BRCA gene, right. Or some other other genes, Lynch syndrome. Right. How can how can I help you not get cancer? Right? Because some of your relatives did. And that's why you're here. 

Lorna Brudie, DO FACOG: So I think I think we have to be looking again preemptively like you do the the DNA screening, looking at hormones. Of course people colonoscopy in the right age group. So we, we have to take the traditional screenings, but we also have to think about the patients who have family history of cancers and diseases and focus on getting them tested for mutations. You know, funny funny thing, I was listening, um, this this past weekend was the Society of Gyn Oncology's annual meeting taking place in Puerto Rico. I, I stayed home, um, because I had work to do, of course, but I listened to, I listened to the meeting and one of the, one of the discussions was about if we leave the DNA testing up to us as physicians, we don't always get, you know, or up to the patient. We don't always get as good of a result unless we're on top of them saying, hey, you need to get this done. And the outcome was better, you know, more patients showed up for testing when we really expressed the importance, hey, you need to get this test done rather than, hey, you. You know, someone, someone may have this gene mutation in your family, you know, go home and think about it. 

Lorna Brudie, DO FACOG: So it's important for us as physicians, I think, and I always felt this way, is to educate our patients, right? I could never make the decision for my patients. There were some patients who chose not to do surgery or to not to elect to do treatment, which is fine. They're the one in control of their lives. But I think it's really important for us to educate patients so they know all the options, all all the alternatives, and they can make the decision that's right for them.

Mary Louder, DO: Yep. I agree with that fully. And just even knowing and having something presented to them instead of like, well, I didn't even know that existed. So I think that that's super important. Um, okay, I want to go a little bit different direction. Post menopausal women breakthrough bleeding, they get put on birth control. Which--

Lorna Brudie, DO FACOG: Ugh.

Mary Louder, DO: Tell me, talk to me, doctor. Talk to me.

Lorna Brudie, DO FACOG: I, that's that's yeah, always, always interesting when I would see that, right. So they would come to my office and on birth control and at age, you know, fifty seven oh, I just started bleeding. So, not the right hormones. Right? So anyone who came to me with abnormal bleeding who was in menopause, we, we were always taught that's endometrial cancer until proven otherwise. So recommendation would be for an ultrasound of the uterus to measure the endometrial lining endometrial biopsy. Okay. Whether that's in the office or a DNC in the operating room, synthetic hormones. And, you know, who knows what they're being put on. The majority of birth control pills that we've used were always a combination, right, of the, the conjugated equine estrogen and a progestin. Right. 

Lorna Brudie, DO FACOG: So synthetics, very few people used a mini pill, which was progestin. Progestin, only very rare. Um, so not the right patient to be putting them on a birth control pill. That's not what birth control pills are used for. Birth control pills were used to shut down ovarian function completely so that the ovaries were not making their own hormones. And you were giving a woman a set dose of hormones, their monophasic and triphasic pills, meaning different doses right throughout the month, but giving them a set dose of hormone so that they would, when you stop them, they would have a period. So it was it was an induced period. That wasn't even a period that that was due to the fact that we're giving you, we're giving your body hormones that, you know, we know you need something, it recognizes that it has a hormone. And then we're going to stop the hormones so that your uterine lining sheds, right? That all man made. A man made period. That is not the right way to go for a menopausal woman, right? 

Lorna Brudie, DO FACOG: So, that pains me to, to think about that. Number one, I'm no longer in, in the place where I'm using synthetic hormones. They, I, I use them in, in my past, in my past life, right? Throughout the years. But in the place that I'm at now, I would never consider putting a postmenopausal woman on a synthetic like that, for multitude of reasons without making sure she didn't have an endometrial cancer. So no, no room or place for that.

Mary Louder, DO: Yeah. It's interesting because that woman is still at some level, I have to try to think through the hormone process, but I've had women show up with that or an IUD and they go, I don't know, ever when I went into menopause because they, you know, totally shut down and don't even have a, an induced period, which to me just makes me like a little freaky on the inside, to be honest. Because I'm like, that's not what that organ was meant to do for decades. You know, shut down and not be at all, uh, cycling. And I find it curious that, um, I mean, what do you how do you think those women are at higher risk for endometrial cancer or, um, gynecological cancers or less risk if they hadn't been cycling? What's the research show?

Lorna Brudie, DO FACOG: So technically they should be at less risk from endometrial cancer standpoint, if they were on a combined birth control pill because it keeps the lining thin. Okay. Same thing with a progesterone secreting IUD. We we use that in patients who were not good candidates for surgery who had endometrial cancer or pre-cancer. So that was to keep the lining thin. So there is a role. There is a role for that, however caveat, right, which I only learned probably within the last decade, the combined birth control pills that we've been using. Slight increased risk of breast cancer. Right from the synthetic progestin.

Mary Louder, DO: Yes. Right. So progestin.

Lorna Brudie, DO FACOG: And.

Mary Louder, DO: Progesterone.

Lorna Brudie, DO FACOG: The blood clotting.

Mary Louder, DO: Yeah. Progesterone and progestin are not the same animal.

Lorna Brudie, DO FACOG: No. They are chemically completely different. Right. That progestin the the synthetic form of what they thought was progesterone right there making it act like progesterone, but would act differently on receptors in the body, like the breast. So we'll go we'll we'll walk into the Women's Health Initiative here. Right. Where they used, right, they they used premarin and they used prempro. So synthetic hormones. And what they found was slight increased risk of breast cancer in the group that had the progestin, you know, and funny enough, my senior year of residency, I, we had to do, you know, whatever your thesis was and present it. So I was at the University of, I was at the University of Kansas, and they did. They had a study. They had participated in a study, the Hope study, which was health osteoporosis. It may have been progestin estrogen study. 

Lorna Brudie, DO FACOG: Okay. So I took those patients. This is before the Women's Health Initiative. So probably like two years or so before the Women's Health Initiative or right around there. I took all the women at University of Kansas had their mammograms. I double blinded a radiologist, and I had him read all the mammograms. And I didn't publish this data. I should have. All the mammograms of the women who were on the combined with the progestin all had dense breasts, and abnormalities were the ones who were controlled and who were on the Premarin only did not. So I already knew. Then the progestin and I reported this. This was in my presentation as a as a senior resident, that this was the data showing that the progestin is causing abnormalities in the breast tissue.

Mary Louder, DO: Yes.

Lorna Brudie, DO FACOG: And then Women's Health Initiative comes out, you know, um, showing now it wasn't statistically significant, um, which is good. And then they did long term data looking that there was actually a reduced risk of breast cancer in the estrogen only arm. So those women who had hysterectomies, they only put them on the estrogen, reduced risk of that, reduced risk of overall mortality and actually reduce risk of mortality and incidence of breast cancer. So we learned a lot from that study. It ruined women's health care for twenty three years. But, um, we certainly learned a lot.

Mary Louder, DO: Yeah. What do you think about, unopposed, so if you don't have a uterus and you're going into menopause and you want to go on bioidentical hormones, hormone replacement therapy, do you give them progesterone or do you not give them progesterone?

Lorna Brudie, DO FACOG: I do, I do because of all the benefits of progesterone. So, it's it's apoptotic. So it's going to kill breast cancer cells, though, of course, the kind of progesterone that we use, the bioidentical. Killing breast cancer cells. So protective there. Helps with, mood stability, sleep, calming effects. So it just has so many benefits that I wouldn't ignore it.

Mary Louder, DO: Yeah. So I shortened the answer. And I always said to people, well, I don't believe they took the progesterone receptors out of your body when they took your uterus out.

Lorna Brudie, DO FACOG: Ah, that's a good one.

Mary Louder, DO: Yeah. Because you've got, you've got progesterone receptors in your brain. Bones, heart, breasts. Where else? Gut has them. So, you know, and I think I, that there's some uh, receptors for hormones for sure in the, what's the endothelial lining, the lining of the blood vessels. And we're finding that the lining of the blood vessels are actually a hormonal receptor type organ as well.

Lorna Brudie, DO FACOG: Yes.

Mary Louder, DO: So we might arrive back at another conversation about ten years from now, saying everything's a metabolic disorder, right? Or everything's a variation on the theme of metabolism.

Lorna Brudie, DO FACOG: I think that's a true statement.

Mary Louder, DO: Yes, I do too. So trying to think here now, how else to pick your brain? Because this is so important for for women to understand. I think the controversy is out there of, you know, you do need this. You don't need that. Bioidentical hormone, in my understanding, and please correct me where I'm wrong, means that it can be synthesized in a lab. It can be a synthetic man made hormone, but the receptors literally matches the human receptor. Is that correct?

Lorna Brudie, DO FACOG: It's bioidentical. So it's the same structure as what we make.

Mary Louder, DO: Okay.

Lorna Brudie, DO FACOG: The majority of them, majority come from plants. Okay. So, you know, majority of them do. But but it's it's chemically similar to the hormones we make.

Mary Louder, DO: Okay. So where. So they come from plants. So they. So walk me through. How do they even. Where do they come from?

Lorna Brudie, DO FACOG: Yams.

Mary Louder, DO: Yams, okay. And soybeans, stuff like that. Right. Okay. And so then that phytoestro-- phytoestrogen chemical looks biologically identical to what the human estradiol E2 actually is. Okay. Gotcha. So the fact that, um, we use the and that can come in a patch, that can come in injections, that can come in topicals, trochees, things that melt under your tongue. The other controversy that people pick on is the first pass concept through the liver.

Lorna Brudie, DO FACOG: Mhm.

Mary Louder, DO: So let's take a pass at the first pass. Or do you want to pass on the first pass.

Lorna Brudie, DO FACOG: No, I so, so I, I may be unlike, uh, you know, other folks that you speak to. I'm a huge proponent of oral estradiol. So I think, I think where there's controversy is that there may be one or two studies, few studies that say, oh, slightly increased risk of estrogens, meaning mixed bag, increased risk of blood clotting. So the only safest, the only safest estrogen is transdermal estradiol. Well these studies are not purely oral estradiol. They're estradiol mixed in with conjugated equine estrogen and some other estrogens. So I don't think we can fairly say oral estradiol is bad and causes blood clots. So that's that's number one. I think that's a misnomer. Where I'm careful is with a patient I know has a thrombophilia right. They have factor V Leiden. They they have they have family history. They themselves have a personal history, right. Because we know statistically, if you had a clot, you're likely to have another one, right? Regardless of what you're taking. Right. 

Lorna Brudie, DO FACOG: So but it's going to get the hormones are going to get blamed for it. So I think you have to understand the literature where I also have an issue and I see a lot on Instagram is transdermal estradiol, like all over the place. Safest estrogen, right? Okay. You can get high blood levels with a transdermal formulation. However, you're not going to get the cardiovascular protection that you would from an oral estradiol. So even though you may have an elevated level, it's not necessarily going to give you cardiovascular protection. You may get bone, you may get vasomotor symptom relief. Um, but and you're, it's definitely going to help local tissue if you're using it vaginally for GSM, right? Genitourinary syndrome of menopause, but you won't get the cardiovascular benefits.

Mary Louder, DO: Why.

Lorna Brudie, DO FACOG: Because it's it's not first pass. So people get, people get duped. And this is how I train people. Don't think because you you have someone on a patch and they have a level of over-- I like over seventy five for an estradiol level. If I'm looking at a regular lab. Okay, not not going into your DUTCH testing mechanics. Right. But if I'm taking a lab, right, therapeutic, if I'm looking over seventy five and that's for men and women, um, if I have a level, but they're on transdermal, they're not getting all the cardiovascular protection. So you may get bone, you know, brain maybe, you know, but you need, you need the oral for the cardiovascular bone and brain.

Mary Louder, DO: I did not know that.

Lorna Brudie, DO FACOG: Mhm.

Mary Louder, DO: I can go home now. I've learned something.

Lorna Brudie, DO FACOG: No, I told you, we learn something new every day.

Mary Louder, DO: Seriously? I did not know that.

Lorna Brudie, DO FACOG: Uh- Huh. So I think people get tricked and, like, it kind of annoys me when I watch all this stuff on Instagram because I'm like, do you really know the literature? You know, it sounds great. Sounds great. You're putting everyone on a transdermal patch, but they may not be getting all the benefits that they could be from an oral estradiol.

Mary Louder, DO: Okay. When a person takes a troche, troche, trochee, all of the same thing. I mean, seriously, is it really just only absorbing through the mucosa or are they getting their swallowing it?

Lorna Brudie, DO FACOG: I think a mixed bag there. Right. Because I know when I was using a sublingual progesterone, I was falling asleep because I was swallowing my saliva. So I couldn't take that right. So there has to be some kind of incorporation orally there, right. So I don't know. I don't know what the data really is on, on the trochees. But I would imagine if you're swallowing some of it, it's going into the bloodstream differently than a mucosal absorption.

Mary Louder, DO: Yeah. And I have seen that come through on metabolism more the first pass and then, you know, where they've got the challenges with phase two. And then we see it bump over to, you know, sixteen hydroxy, um, or four hydroxy estrone versus the two hydroxy. And then so, and I have changed it over to transdermal. And then that goes away, you know, and I have seen that and I have seen with transdermal be able to build bone, I have built bone with transdermal. Plus you put other components in there and, and rest assured, if, if, if hormones were the only issue, we wouldn't need micronutrients. We wouldn't need to understand our macros. We wouldn't need to understand our microbiome, right? If it was only hormones. So we've got to make sure that we put everything, everything together for that patient.

Lorna Brudie, DO FACOG: I agree with you. You know, that's why I think this whole metabolic component is so important, right? Because I can balance someone's hormones. They still may have insulin resistance. You know, they may have other components or like you said, nutrient deficiency, micronutrient deficiencies, right? That I can't correct with hormones. So as I'm, as I continue to practice and continue to learn, there's so much more that goes into this. Than, than just one piece.

Mary Louder, DO: Yes. And I think, you know, as I've seen and put our, our menopause program together, mastering midlife menopause and beyond, what I've done is I've targeted more of the metabolism in general. And in doing so by getting all of the hormones, insulin, um, DHEA, you know, looking at just the patterns across and, and then how they're connecting and collaborating. I found that if we manage metabolism first and then we add or adapt the hormones for estrogen and progesterone thereafter, and testosterone, I have a better result. It's just a smoother transition in and out. Sometimes we need, as you know, we don't need as high A doses. We certainly don't have the side effects that people talk about of the maybe the intolerance or disturbance or, you know, and I make them kind of earn some of their hormones back.

Lorna Brudie, DO FACOG: So how are you, how are you starting patients?

Mary Louder, DO: Um, usually I start them with a detoxification because they often need that. And then we look and understand our phases one, two and three. And I start by optimizing three, two and one. I reverse it that way and make sure that the gut is getting rid of stuff and you're stooling and there's good short chain fatty acids and which creates, you know, different biomarkers and things like that, and butyrate and things like that. So you've got good digestion, good signaling and good cell health.

Lorna Brudie, DO FACOG: I think I think the gut's underrated also.

Mary Louder, DO: It is. And then I can pull hormones through because if we can get those then we can get the liver, as we say, dumping or biotransforming or detoxifying. Then that's going to open things much easier than whatever I need to kind of dance through with, you know, phase two, whether it's the Comt variant or methylation variant or sulfation, or oftentimes they have a deleted glutathione and people say, oh, don't give them glutathione. Give them cysteine. And you know, glycine. I'm like, good luck with that. If it's a deleted gene, they aren't going to make it. So you've got to give them the glutathione.

Lorna Brudie, DO FACOG: Can't give them the precursors.

Mary Louder, DO: Exactly. Because it's it's it's just dumping into the black hole. And so I give them glutathione and all of a sudden they go, oh, I like that. Or in methylation, I don't use a high dose of B's at all. I use a lot of choline, zinc, magnesium, because those things are the micronutrients that make the B vitamins. It's like the raft for the B vitamins. You know, if you want a visualization for those B vitamins to work and the methylation pathways to function better, and I find people more deficient of choline than they are of B vitamins per se.

Lorna Brudie, DO FACOG: Interesting.

Mary Louder, DO: Yeah. So they all of a sudden you get choline. They're like, oh, things are starting to oh, I feel better, I feel calmer. I think those things are moving because often you give B vitamins and they go, I can't handle them and too much. It's too, you know, I vibrate, I get jittery, I can't, I can't focus and it's because it's just too. And the B vitamins I think are a lot of them are too strong. They're the strength of the B vitamins. The dosing is just high.

Lorna Brudie, DO FACOG: Mhm.

Mary Louder, DO: So it's too much of of a good thing. So, and it's, it's probably my osteopathic teaching where I go an indirect approach, right? With some of like what we did with osteopathic manipulation, you could directly treat the lesion or indirectly treat the lesion. And if I indirectly treat some of the, the biotransformation pathways, they go, oh, thanks, that just took the pressure off. I think I can work now. So it's I think it would be it was something that when I learned it, I just saw it because I had patients who didn't tolerate it. And I'm like, there has to be a way through.

Lorna Brudie, DO FACOG: It's I find those pathways so incredibly interesting and like, just keep learning every single patient, you just keep learning something new.

Mary Louder, DO: Yeah. So, well, this has been absolutely fascinating. I think the, the information here is vital. It's critical. And I appreciate how clear, how clearly you've given us really good points to understand. And, and I, I hope really educate our listeners so they have, can ask a lot better questions and know and just not go in and take whatever's given to them. You know, in this phase of life, because I think it does make a huge difference, uh, regarding outcomes.

Lorna Brudie, DO FACOG: I do too, I do too, I enjoyed speaking with you. And like I said, I, I always love speaking with you because I always learn something from you every time.

Mary Louder, DO: Oh, well, thank vice versa today. I mean, that was great. So. Well thank you. And we'll have you come back after, you know, after a time because I think this is going to be I think we're going to see some things evolving. And I think it'll be really important to see what's next on the horizon for, because we're having a big push of hormones right now. So I think it's going to be interesting to see some months down the road of what the fallout of some of this is, which is, you know, kind of borders on a bit of misinformation, so to speak.

Lorna Brudie, DO FACOG: So definitely, definitely, I agree with you. Well I'm excited. Thank you for having me. It was a pleasure.

Mary Louder, DO: Yes. Thank you.