00:00 – Dr Tim Hlavinka: I’m seeing so many patients with these really refractory UTIs who have all the symptoms of
00:05 – estrogen deficiency. I’m keenly looking for a POI. Melissa: Hi. Welcome back to the Live UTI Free channel.
00:12 – My name is Melissa and this is a follow up interview with Dr. Tim Hlavinka. After our last interview with
00:17 – Dr. Hlavinka, we received many questions about the role of hormones in contributing to recurrent UTI pre-menopause.
00:23 – So, in part one, we’ll discuss primary ovarian insufficiency or POI, which occurs when the ovaries stop functioning
00:30 – as they should before the age of 40. POI and recurrent UTI may be linked. If you haven’t seen our first interview
00:36 – with Dr. Hlavinka, check it out. If you enjoy these videos, think they’re important, and want to support what we do, don’t forget to subscribe and tick the
00:43 – bell so you’ll be notified of our new content. Thanks again for joining us on this journey to making change in women’s health.
01:02 – Today, I’m joined by Dr. Tim Hlavinka for a follow up interview. Dr. Hlavinka is a urologist, as well
01:08 – as being an expert in sexual health and women’s health. He has an extensive background in providing support to recurrent and chronic UTI patients and is very active
01:15 – in our community. So thank you once again for joining us to answer the questions that we’ve gathered from our audience.
01:22 – Dr Tim Hlavinka: Of course, I’m more than glad to do so. Melissa. Thank you for everything you do for the community. You’re instrumental in getting my message
01:31 – out to all the patients I’ve helped over the years, and I cannot imagine that the community and the world
01:40 – is not a better place without your activities. And we all thank you, I’m sure.
01:46 – Melissa: Oh, that’s very kind of you to say. And I think we organized – Dr Tim Hlavinka: It’s accurate.
01:52 – Melissa: We organized this interview because we had some follow up information that we wanted to share. So I want to jump straight into the topic of primary ovarian
01:59 – insufficiency or POI. And it’s also called premature ovarian failure. So it would be a great place to start
02:06 – if you can explain what those terms mean. Dr Tim Hlavinka: So, this is a condition that has been
02:13 – known for a long time and had several health
02:20 – conditions, diseases, genetic abnormalities, for which it was well recognized and
02:28 – quite understood to the mainstream medical community, any
02:35 – primary care or OB GYN knew how to diagnose this based on those. And I’m not going to go into those because
02:41 – you can Google that and you can see what those causes are. But for practical purposes, for our community
02:47 – and for the patients I see, this is almost solely due
02:52 – to hormonal contraceptives. And it is something that’s been recognized for a long time in research on sexual
03:03 – issues, particularly libido. And because of that, there is a new genetic marker that’s being developed that
03:10 – actually looks at variations, genetic variations in the androgen receptor in women that predispose them.
03:17 – And about 7% of women worldwide have this androgen
03:22 – receptor abnormality, which means 1 out of every 14 women is predisposed to having
03:31 – this happen. Now, why have we not done more work on the estrogen receptor, which it would seem like that
03:37 – would be the the more fruitful [Inaudible]? Well, quite
03:43 – honestly, the clinical trial with 25 patients with the control group was an OB GYN, Andrew Goldstein,
03:51 – who’s a genius, who was seeing women for low libido
03:56 – due to the pill. And because of that, it seemed more fruitful to go down the androgen receptor to look for
04:04 – abnormalities. And that’s quite simply just sort of the aha moment that led to this. The good news is that
04:10 – he has exposed, us, the medical community in the world since our organization is international, to this incidence.
04:19 – I will say that at the women’s health meeting three years ago, four years ago, there was a single abstract
04:26 – presented that kind of introduced the possibility of this being more important than we knew. The next year
04:33 – there was a panel with a discussion with 3 or 4 lecturers. And the following year there was half a day spent on
04:40 – this. So the way to determine if the women’s health, medical
04:48 – community and organization, professional organization, is proactive about these issues is to see how rapidly
04:56 – they adopt these new diagnostic algorithms to see whether
05:02 – or not this is causative or potentially causative for you. And my recognition of this is just basically of
05:10 – a perfect storm from seeing a lot of women for sexual dysfunction, from oral contraceptive use. But really,
05:17 – any hormonal contraception can do it for any length of time. I think Dr. Goldstein found that contraceptive
05:25 – use for as short as six months at any time in your life, even if you’ve been off them for years, can predispose
05:33 – you to this. So there’s something that must happen to alter that receptor permanently in a number of women.
05:41 – Now, I don’t have a handle on how many of those versus the ones who can easily reverse it. We’ll get into
05:46 – that more in a minute but the bottom line is that this is something that for my practice, I have to look for
05:55 – it because I’m seeing so many patients with these really refractory UTIs who have all the symptoms of estrogen
06:02 – deficiency and estrogen replacement is helping them. So, I’m keenly looking for POIs. And I think POF is
06:14 – a overkill. I mean, you want to give women hope that if they have this insufficiency, it’s not failure because
06:21 – failure typically means that you’re not going to recover. Now, is that to say that in some patients it’s not
06:27 – recoverable? Again, we’ll go into that in more detail in a minute. But for 98% of them, they can recover
06:34 – ovarian function. And I think we’re going to go through a few sort of scenarios in a moment. But that’s why
06:42 – POI is so important. And another contributing factor
06:48 – is Covid. There was a study that showed 6% of women, even 6% of women, asymptomatic, who either had mild
06:58 – or zero symptoms with their Covid but were diagnosed positive, antigen positive, on the PCR test had ovarian
07:06 – – attacked the ovaries and caused premature ovarian insufficiency. Now, this is recoverable again as well.
07:14 – But that’s not – there’s not a lot of time to study after this. So I don’t know if I’m [Inaudible] all
07:19 – those women or if – I’m convinced it’s the perfect storm of stress, Western diet, Covid and oral contraception,
07:31 – hormonal contraception, I should say. Hormonal contraception that that is sort of a perfect storm that’s led these
07:37 – patients to me that they’re sort of the – the infections,
07:42 – both – I call them genitourinary infections now, they become a marker basically for POI and sort of a clinical
07:51 – sign. So, that’s a long answer. But I think it’s critical to
07:57 – how important this is and I’m seeing it all the time now. All the time.
08:02 – Melissa: Are you seeing symptoms of POI in very young patients that are similar to those symptoms experienced during menopause?
08:09 – Dr Tim Hlavinka: Absolutely. I used to say my youngest patient was 21. Now, I can’t say that because I have
08:15 – a teen, a 17 year old whose mommy started her on contraceptives.
08:22 – I’m sorry, parents, I shouldn’t say mommies because that’s not always women that start [Inaudible]. That’s
08:27 – a parental decision at age 12 because she started her period at age 11. So at 17, she’s in sort of, not full
08:36 – blown menopause, but definitely ovarian insufficiency. It’s not at all uncommon to see women in their mid
08:44 – 20s now with this. It used to be – we kept ratcheting down the age group. We would see patients in their
08:50 – mid 30s, early 30s, and those didn’t raise an eyebrow. Now, quite honestly, patients in their 20s don’t raise
08:57 – an eyebrow in my clinic. They’ve just sort of become part of what we do to determine what might be a cause
09:03 – – causative. Melissa: Can you tell us more about the link that you’ve seen between POI and recurrent UTI, and how common
09:11 – you think POI is as a cause for recurrent UTI in younger people? Dr Tim Hlavinka: It is so important right now that any
09:18 – woman of any age with refractory UTIs is considered to be POI until proven otherwise. And because it’s
09:26 – mainly a clinical diagnosis, and we’ll get into the sort of other tests that you could do. But since it
09:35 – is a clinical diagnosis, it’s important to make sure that you suspect it. And obviously I am now all the
09:42 – time, and then you test for it. But if you suspect it, even if tests don’t corroborate and you treat and
09:49 – that’s the most important thing, because these young women are acting, for all intents and purposes, as
09:56 – that they have a hormonal deficiency. And typically it’s an estrogen deficiency and estrogen replacement,
10:02 – be that either topical or systemic is what’s required
10:08 – to to solve the problem. There is a group of patients for whom I suspected – I am never
10:18 – able to prove it because they don’t really have any signs or symptoms other than the fact that they can’t
10:23 – get rid of their UTIs. And I sort of treat them accordingly at this point and see what the outcome is.
10:30 – Melissa: So how do you test for POI? Dr Tim Hlavinka: Clinical suspicion and physical exam.
10:36 – Very, very important to do a physical exam. So many young women come in and there’s no way that a provider
10:43 – would suspect that they have any signs of estrogen deficiency because they look so estrogen replete everywhere
10:49 – else but without doing a very careful pelvic exam,
10:54 – including most important thing is visual inspection
11:00 – and tactile contact with the tissues to see the tissue
11:08 – character and to see whether or not there are signs of menopausal changes, otherwise known as genitourinary
11:15 – syndrome or menopause, GSM for short. So we won’t have to spend hours saying that word. But seeing signs of
11:23 – GSM in these very young patients. But they almost all have, Melissa, I will tell you, if you look carefully,
11:30 – even at something as subtle as vaginal dryness, a thin epithelial
11:35 – layer, loss of the rugae, the sort of the coarse
11:40 – wrinkles in the vagina, atrophy of the labia. You know, all these things can
11:48 – be signs of estrogen deficiency, but you got to look for it. In most of them, it’s pretty obvious, unfortunately
11:55 – and others have missed that. Then we do labs. Labs don’t have to be confirmed. I try to do labs at a certain
12:03 – time of their cycle if they’re cycling. If they’re not cycling, you just do random labs and see. You rarely
12:09 – get the full blown elevated FSH and LH that classically
12:15 – is a test for menopause but what you can see is subtle abnormalities in the hormonal pattern. Occasionally,
12:23 – you have to do like a luteal phase and a ovulatory phase to be able to see, I’m sorry, ovulatory phase
12:30 – and a follicular phase, excuse me, to see whether or not there’s subtle differences. And that’s diagnostic because you should have wide
12:38 – – in a normal menstruating woman, you should have fairly wide swings in hormonal levels and if they don’t vary,
12:48 – that’s one thing. But really, even subtle abnormalities like an elevated SHBG
12:55 – or just a slight free testosterone, decrease in borderline low free testosterone. An estradiol that really doesn’t
13:03 – do much, sort of a blunted ovulatory peak of estradiol
13:08 – and testosterone. Things that I’ve looked at over the years that I suspect from this and any hormone abnormality
13:17 – at any time during the cycle is, pretty much in my clinic, diagnostic of POI. Now, there is some research
13:26 – into something like anti-mullerian hormone that’s not widely available. I’m looking in to start using that.
13:34 – I honestly think that’s the way to go because it seems to be more sensitive. Inhibin B, these are lab tests
13:42 – known to the fertility specialist. And they’ve been looking at these for years, but they do seem to be
13:51 – adequate markers for, I should say, very precise markers
13:58 – for potential POI. I’m looking at using these, but just so I can be complete until your client’s state
14:06 – of the art information. Those are things that their provider might suggest and I’m looking into starting
14:13 – getting those. Melissa: Speaking of fertility, is POI something that impacts fertility or the ability to conceive and pregnancy
14:21 – itself? Dr Tim Hlavinka: Absolutely. Many of these patients are seeing fertility specialists.
14:32 – So, many of the young ones, pregnancy is not a consideration, so I’m not going to say it’s a very frequent
14:39 – issue, but definitely I’ve seen a lot of patients for infertility. And unfortunately, sometimes it’s not
14:49 – something – how should I say this? If they can’t have intercourse, they have so much vaginal dryness and
14:56 – atrophy that you can’t even get your pinky digit in for the pelvic exam. It’s pretty obvious why they’re
15:04 – not getting pregnant. So, I just recently had a 25 year old who was like that, who had seen six gynecologists
15:11 – and a fertility specialist who, I don’t know what they were seeing on exam, but it was obvious to me as soon
15:17 – as I pulled back the drape and I didn’t even need to do an exam. She’s thankfully, thankfully better. So.
15:27 – Melissa: So when you do identify POI, what is your approach to treatment? Dr Tim Hlavinka: It depends upon the patient’s
15:35 – clinical presentation. I typically treat the most severe symptoms. Most of the time there are multiple. It would
15:43 – be something like infertility, recurrent UTIs, vaginal dryness, pain on intercourse. Typically, that’s how
15:49 – the patients present. So, you get sort of a multifactorial
15:55 – treatment. This young lady, I sent her to the pelvic floor physical therapists, after a few weeks of aggressive
16:02 – intravaginal hormones, it was pretty clear that she was not going to respond quickly because she also had
16:10 – hot flashes, night sweats, all of that. She was in menopause, and six gynecologists and a fertility doc
16:17 – could hear those symptoms and look at her exam and not put the two together is quite frankly, appalling.
16:25 – And I ain’t that smart, as we say in Texas but, you know, it was there. It was obvious. So, my point being
16:34 – is, I treat them very aggressively if they have lots of symptoms like she does. And really, I think I need
16:41 – to jump on it, I’ll start them on systemic hormones. And then obviously very aggressive intervaginal hormones
16:49 – and sometimes labial hormones if they need those as well, which she did. And thankfully, within 18 months,
16:57 – she started cycling again. I weaned her off the hormones, and she’s pregnant now, so I’ll Melissa: – Amazing.
17:03 – Dr Tim Hlavinka: Do a pat on the back on that one. Melissa: How does that type of systemic hormone treatment differ from a birth control pill?
17:11 – Dr Tim Hlavinka: So, what I do is I – it’s actually much – so a birth control pill is and this is of course
17:20 – the yin yang of oral contraception and any hormonal contraception.
17:29 – But oral is the worst because of how it impacts our liver metabolism of hormones and affects the ovarian
17:37 – and adrenal production. So, the bottom line is that
17:43 – when you take an oral hormone, it’s just the tiniest amount of estrogen and progesterone to make you regular
17:53 – and stop you from ovulating. So in many women that’s okay. They do okay. But all oral contraception, even
18:01 – the very low, low, low dose E + P alone or even just
18:07 – the low, low estradiol pills, they tell your body you
18:12 – got enough, just the right amount, so you don’t ovulate. But for many women, that’s not enough systemically
18:18 – or in local terms. I have seen, mid-20s young woman
18:25 – with osteopenia and she didn’t even have a family history of bone density
18:33 – issues. So, I think it’s the receptors. And we’ll get into that in a little bit more about why I think this
18:40 – is happening. But for me, that’s the diagnosis and that’s the problem with the pill, quite honestly. It
18:48 – sort of achieves its goals by fooling your body in a way that’s not healthy for many women.
18:56 – Melissa: Mm-hmm. So when someone starts on POI treatment, how long does it usually take for them to respond?
19:03 – Dr Tim Hlavinka: Typically, there’s very little response for several months, which is very frustrating for the patients because they want some instant results. And
19:12 – I understand that. And I tell them it’s going to take potentially 18 to 24 months to get back to normal.
19:18 – This lady responded in about 14 months and was pregnant at 18 months. So I’m thrilled about that. But it’s
19:25 – not short term. Now, there are those that say I should be using HCG, which is the fertility injection, but
19:33 – it’s just so expensive and it’s out of – it’s like $2,000 for a six week course of it, and you might need
19:39 – it for a year and a half. So, and there are some discounted compounding pharmacies that make
19:47 – HCG. And I’m considering that in the most severe cases. But then you get into sort of, what’s the term for
19:55 – that hyper – multiple pregnancies. So,
20:02 – that’s the issue with using HCG. So I like the way I do it because it gives the patient what they need
20:09 – at first just to make their symptoms better. And then, you know, for the majority of them I’d say 90% of them,
20:16 – Melissa, they do return to function eventually. Can I get them back sooner with HCG? Well, I typically
20:22 – have reserved that for the ones that haven’t responded to the regimen that I’m using. And then that gives
20:29 – me sort of that salvage potential. Telling them, look, you got to spend, you know, 8 to 10,000 dollars. because
20:37 – there’s nothing else we can do. Melissa: Mm-hmm. And do you typically recommend that treatment for POI continues into pregnancy?
20:45 – Dr Tim Hlavinka: The problem is, is that we don’t know what it’s going to do to the pregnancy, so it pretty much has to stop. I do, most of the time, convince
20:54 – the obstetricians to let them at least continue the vaginal DHEA if they’re on that. I will say that when
21:02 – the estradiol level starts to peak, like at about the second trimester, most of them get better. Now, sometimes
21:09 – they don’t completely get rid of their UTIs, unfortunately.
21:15 – But the other menopausal symptoms, obviously, improve simply because the systemic estradiol levels are very
21:23 – high. They can be 5000 at peak in pregnancy. Melissa: So it’s this kind of treatment you’re talking
21:29 – about people improving once they’re on treatment, is there a point where they can stop treatment forever
21:35 – and their body will then recommence producing what it needs to? Dr Tim Hlavinka: Yes, yes. I don’t really have a handle
21:42 – on a percentage of that, but it’s a fairly high percentage. Many of them do have to continue vaginal estrogen treatment.
21:51 – It’s almost like once the receptors have been upset because there’s not enough hormone circulating that
21:58 – they like to grab on to and do their tissue health, sometimes it’s lifelong. Sometimes it can be intermittent,
22:05 – like they need to use it three months a year. And that’s all they need. Quite variable in terms of that.
22:13 – Melissa: Okay. This topic does come up quite a bit in our community, because it’s not something that clinicians tend to do, treat women in their 20s and 30s with hormonal
22:21 – replacement therapy or vaginal estrogen. Do you think it’s safe for women at that age to use these types
22:27 – of treatments? Dr Tim Hlavinka: If I didn’t have it, I’d have to quit.
22:33 – It is the single most effective thing I do is [Inaudible] estrogen and topical
22:41 – estrogen and testosterone to the external genitalia. To me, there’s so many cases of women for whom that has
22:51 – been game changing and they’re upset because 90 days later, they’re still getting infections. But then all
22:58 – of a sudden, once you get the vaginal epithelium to its healthy state, things really do turn around. So
23:05 – it’s definitely safe, underutilized and essential in
23:12 – my practice. Melissa: And now are there other hormonal imbalances pre-menopause that can influence UTIs?
23:20 – Dr Tim Hlavinka: Mm-hmm. Well we know now that cystic
23:26 – ovarian disease can be endometriosis. All of those which typically because of either the condition or
23:34 – hormonal condition itself. And I need to correct sort of a common misconception out there among providers
23:41 – about PCOS that and this is my own thinking about polycystic ovary
23:48 – syndrome. Well, you got these big cysts on there, and they’re causing it. No, it’s actually they have multiple
23:55 – small cysts that are in various stages of the ovulatory cycle that are little independent hormone factories.
24:04 – And because they can produce pretty much anything they want, you can have all these imbalances. So the key
24:12 – with PCOS and my view is to treat what you’re seeing, seeing what the symptoms of it is [Inaudible] or, you
24:20 – know, and androgen, hyperandrogenism, hirsutism,
24:28 – facial hair, hair loss, things like that – libido. Treat the symptoms because you really don’t know what
24:37 – sort of minor hormone factory those little cysts are doing. There are certain hypothyroidism, diabetes,
24:46 – like I said, Covid, pro-inflammatory conditions. There’s a whole host of things that can cause this.
24:54 – Melissa: Do autoimmune diseases such as Hashimoto’s limit the body’s ability to fight UTIs?
24:59 – Dr Tim Hlavinka: I’m convinced that that’s the case simply because I see so many patients with autoimmune disease,
25:05 – connective tissue disease, rheumatoid arthritis, Sjogren’s. It’s lupus. Patients on immunotherapy for those conditions.
25:16 – So to me, and if you talk to the functional medicine doctors that they – that’s what they’ll tell you. It’s
25:22 – pretty much part – they treat it as systemic inflammation. And they feel like
25:29 – any inflammatory – even an infected tooth or a joint
25:34 – that’s infected or – I mean, that’s an obvious case. So, there is something like that. But any kind of chronic
25:40 – source of inflammation, dental caries, it’s chronic
25:46 – sinus infections. You know, these are the kinds of things over through the years, I’ve seen this sort of commensurate – somebody came in. One of my patients had a flare up of his sinusitis.
25:58 – He was going to come in for a flare up of his prostatitis. I can almost guarantee you. It was just part and parcel.
26:03 – And it didn’t, even before the antibiotics might have been started. That would have caused the resistant organism to emerge. So this is a pattern I learned
26:11 – early on. So the problem is, is that the immune system is pretty complex and there are limited things that
26:20 – can be done from a improvement standpoint, but we should all be – many of my patients are already doing that,
26:28 – quite honestly, Melissa, they’re smart. They know that they’ve got to keep their immune systems healthy in order to fight this. But obviously, vitamin D, vitamin
26:36 – A, things like that, those are things that we can do
26:41 – to keep our immune system strong whether or not you take some other supplements. That’s something that
26:48 – I don’t really feel comfortable answering because I rely on my functional medicine providers to do that
26:54 – for our patients. And they do an excellent job of evaluating and boosting the immune system.
27:01 – Melissa: What about for patients that do have endometriosis or estrogen positive breast cancer? How would you treat
27:07 – them in the case of POI? Dr Tim Hlavinka: So, I have been able to have almost
27:13 – all the breast cancer oncologists agree to give intravaginal hormones, depending upon what is their receptor status
27:23 – and things like that, and of course, their disease status. I mean, someone who’s progressing, we wouldn’t do this, but, even some of them really demand it because
27:32 – their quality of life is so poor. And we measure estradiol
27:37 – levels. At first, I had to bring these poor ladies in every week to get an estradiol level to prove to
27:43 – the breast cancer oncologists that they were not having systemic elevations of their estradiol. And ultimately,
27:52 – they realized that that was never the case, that you can treat – and I use a dilute concentration, not the
28:00 – kind of typical one gram of a 0.1% solution. I typically use a very much – a lower 0.01 and about a quarter
28:07 – gram three times a week to kind of and then we measure hormones to see what measure of estradiol levels to
28:13 – make sure they’re not absorbing. So almost all of them will let me do that. Now, those are the cases where
28:18 – there’s really concern or if the patients do have systemic
28:23 – absorption, then almost all of them allow me to use intrarosa or intravaginal DHEA compounded. And quite
28:31 – honestly, at the last meeting I went to and I’m looking forward to going next week, getting an update, there
28:36 – was pretty much equivalent to intravaginal estrogen, beta estriol estradiol combination. So that intravaginal
28:45 – DHEA using the same things to the epithelium at the same time and to the same degree that the estrogens
28:53 – are. So that’s a very exciting new finding. Melissa: And is intrarosa something that’s available
28:59 – on prescription only? Dr Tim Hlavinka: Yes. Yes. Now I use a compounding pharmacy
29:05 – to make the intravaginal DHEA suppositories because I can use twice the concentration. I went to
29:13 – a presentation last year where the principal investigator was telling us how wonderful it is. I showed these
29:20 – slides of before-and-afters of vaginal epithelium biopsies. And, you know, these women’s health providers were
29:27 – oohing, aahing and all that stuff at how much it had done to the woman’s vaginal epithelium, how much benefit
29:33 – it had. And afterwards, I ask him as a sidebar because
29:38 – I knew he wouldn’t talk about it during the presentation, I said, well, you know, it comes in 6.25, 12.5 and
29:46 – 25 micrograms. Did you decide – why did you decide to come out with 6.25? He goes, well, we found they
29:53 – were all equivalent. You know, it’s like, right. No way. There’s no way that 25 micrograms is going to
30:00 – be the same as 6.25 micrograms. So I use 12.5, mainly
30:05 – because of concerns about the production from the compounding pharmacies, and because I find that that works better
30:12 – than the 6.25. So that’s what I typically do. Daily 12.5mg in intravaginal, intrarosa, I should say intravaginal,
30:21 – intrarosa. Sometimes doubling the dose can be effective if they can get a hold of intrarosa at reasonable prices.
30:28 – But 12.5 micrograms of DHEA vaginal suppository daily.
30:34 – Melissa: Okay. That’s good information. And we talk a lot about estrogen to support frequent UTIs. But there
30:40 – are a number of people in our community that have reported that they only experience symptoms at times in their cycle when the estrogen would be higher. Do you have
30:48 – a theory for why that might happen for some people? Dr Tim Hlavinka: It’s confounding. And I do have a theory.
30:56 – Yes, I have a theory. Do I have science behind that? And research? No, because it’s one of those – it’s
31:02 – one of those clinical circumstances, Melissa, where, you know, that it’s the hormonal flux that’s causing
31:10 – the issue. And I see this and sort of discern this from the menopause
31:16 – patients, menopausal therapy patients that I have where I can give us the same dose of a hormone replacement
31:23 – therapy month after month after month and there variation in response is significant. Is that an absorption phenomenon?
31:33 – Well, I will tell you that I’m now giving injections for this to try to avoid the trauma of hormone pellets
31:41 – that a lot of patients are getting here in the US, and other places as well. That’s very invasive. I always
31:50 – tell my patients before I’ll do that for you, and the next time you go to your provider, who’s doing that
31:55 – for you, because I see a lot of these patients that aren’t doing well, watch the YouTube training video.
32:00 – I had to watch for it and see if you’ll get the procedure done. Once you see what’s being done to your backside, you won’t go back. I will tell you that. It is really
32:08 – a brutal procedure. Now, it’s effective and keeps a lot of women very satisfied for 12-14 weeks. And I
32:14 – get that. But I’m doing the same thing almost about two weeks less duration of benefit with the combination
32:21 – of estrogen and progesterone, testosterone as an injection. It’s got to be in the buttock because it’s just – you
32:28 – need to have enough muscle mass to absorb this and keep it in place for about 10 to 12 weeks so that the
32:34 – patients are getting benefit. I’m up to 35 patients. And I’m happy to say that this
32:39 – has been a game changer for them. They’re very happy with it. They don’t have to rub the cream, worry about
32:46 – absorption and things like that. Many of them are able to come off their intravaginal therapies just because
32:51 – the systemic estradiol levels are good enough. So, that’s sort of an innovation that I’m doing right now.
32:58 – But even in those patients, they’ll vary. The ones that are still kind of having an irregular menstrual
33:03 – cycle sometimes will have that. But in most of the patients, it regulates them so well that they stop
33:11 – having these sort of cyclical symptoms until dose is wearing off. So to get kind of a long answer to I think
33:20 – it’s a receptor alteration. I think at varying times during the cycle, there’s receptor alterations. We’re
33:29 – going to find one day that this is genetic abnormalities and receptors and that those change in a hormonal environment.
33:36 – And so, not only will a given receptor have a given genetic predisposition for having problems, it may
33:43 – be a different response at different levels of the cycle and different hormone levels in a woman’s body.
33:49 – And that’s the best answer I can give for that. Melissa: Yeah. Well it sounds like a – Dr Tim Hlavinka: It’s an observation that is [Inaudible]. Melissa: It would be an interesting area to do some more
33:55 – research in, given how many people do report that. And related to that topic is people who are on hormonal
34:01 – replacement therapy and say they react to the estrogen and that it seems to cause bladder symptoms. In
34:07 – that case, do you adjust treatment or do you think it’s a matter of time before those kinds of symptoms
34:12 – dissipate? Dr Tim Hlavinka: I try to adjust treatment towards symptoms
34:17 – and many times you’re playing off side effects. In this case, obviously hair loss or where you don’t want
34:24 – it, and hair growth where you don’t want it. And that’s a balance between estradiol and testosterone. You can
34:30 – almost always achieve that by dose adjustment but for
34:36 – a lot of patients, they need more androgen to get their libido where they want it to be in their energy but
34:43 – then that creates androgen side effects. And as you increase the estradiol, then it starts to cause the
34:49 – same symptoms that you are. So it can be a fine tuning. And I always say, look, I never can – I’m never going
34:56 – to get it perfect, but I will get it right. That’s what I say about when we try to do these hormonal adjustments.
35:02 – Melissa: And we do focus a lot on estrogen when it comes to hormonal therapy. How do you use testosterone or progesterone in that kind of approach?
35:10 – Dr Tim Hlavinka: So this one is highly controversial in my view. There are a few – one school of thought.
35:17 – A lot of the functional medicine doctors and naturopaths, they feel like a woman needs progesterone. Progesterone
35:25 – is a critical hormone throughout life. Although I’d say just like the others, it ebbs at menopause. In
35:33 – women that still have a uterus, I always use progesterone, obviously, to keep from bleeding, to keep the endometrial
35:39 – lining, the lining layer, the uterus, minimal and so it’s not too stimulated, over stimulated in
35:47 – any kind of pre-malignant changes. So, that’s pretty much essential, but I try to use the lowest dose possible
35:56 – to achieve that and to regulate not bleeding and are having if they’re still cycling to not have heavy periods
36:06 – or long periods. Having said that, there are some women for whom things like sleep. If they have menstrual
36:15 – – premenstrual migraines. Those that are pretty much
36:20 – have anxiety, anxiety is a big part of their symptomatology
36:26 – at various phases of their cycle, then I will offer them more progesterone. But these women that are [Inaudible]
36:33 – 200, 300, 400 mg of oral progesterone, because they’re getting pellets and their estradiol levels are still
36:40 – very low and their testosterone levels are through the roof but they’re symptomatic because this is raising
36:47 – your SHBG. 100% of my patients on any form of oral
36:52 – hormonal therapy are there – all of them has raised their SHBG 100%,
37:00 – have an elevation of their SHBG because of that. So you’re poking holes in the bottom of the bucket
37:06 – that you’re trying to fill and it can make it very challenging, but it’s also a very common source of
37:11 – referrals for me because they’re not happy with how they’re doing and they’ve heard about me. So, the progesterone,
37:19 – I think is something that’s variable for those providers that say it’s essential and should be given. I would
37:24 – say yes, that’s fine as long as you avoid the side effect, which can be – I mean, it’s also feeling like
37:30 – [Inaudible] in your premenstrual syndrome. That’s when the progesterone surges. It’s also something that can cause weight gain and bloating. And to me,
37:42 – it’s an essential factor in the sort of weight gain that women have experienced after starting hormone
37:50 – replacement therapy. And, but obviously that’s very, very bothersome to women. Early on in my career, I
37:59 – found out what it means to change dress sizes when women would gain five, ten, fifteen pounds after hormonal
38:06 – therapy. And that’s not a insensitive male comment. It’s the reality of the fact that I did not recognize
38:15 – how much this impacted their weight and weight is obviously
38:20 – something that we all need to work on and maintain a healthy weight. And anything that contributes needs
38:27 – to be looked at as a factor and altered as much as possible.
38:33 – Melissa: Definitely. And do you think progesterone could cause UTI symptoms in some people?
38:39 – Dr Tim Hlavinka: I do. I do because it can be relatively hypo ovarian. In other words, it can – if you give
38:47 – progesterone or you give too much, it suppresses. Particularly if it’s oral, it suppresses. Now you can get progesterone
38:54 – in cream. A lot of people feel like the topical progesterone is not as effective. They do all these fancy tests
39:01 – to see all the different progesterone and their metabolites and all that. I’m just a lot more simple than that
39:07 – with those issues. And I find that avoiding progesterone
39:13 – as much as you possibly can is the best alternative. And just letting the estrogen and testosterone, estradiol
39:21 – and testosterone be what you vary. Melissa: Mm-hmm. Some people do report issues with estrogen
39:27 – therapy too, especially vaginal therapy, especially like chronic yeast infection. And is that something
39:34 – that gets better over time with that kind of therapy? Or do you have to also dial back the treatment?
39:40 – Dr Tim Hlavinka: In my view, it is very important to get proper compounding agents. The standard pharmaceutically available agents are often
39:58 – not good for my patients simply because they’ve already had issues with vaginitis. They’ve already been on
40:04 – – they’re already hormone depleted so much that it’s just the agent, the carrier is what it’s called, that
40:12 – may be reacting to estrogen. Any hormone, when you
40:17 – have a deficiency, looks like a foreign substance to our tissue. And you can react in an inflammatory
40:24 – pattern, in an inflammatory manner at first, because
40:29 – the receptors don’t know what to do with it. It’s kind of passing into the tissues in very high concentrations.
40:35 – And again, it’s a pro-inflammatory state when we have a deficiency and we treat. So the goal in those patients
40:41 – is to start with a very, very hypoallergenic base and
40:47 – use a very low concentration and a very small amount. Just say like I was saying, the other – for the others
40:55 – is to start with a quarter gram of a 0.01% in a base that’s very well tolerated by most patients.
41:02 – And then try that. Sometimes, they’re still very sensitive. There are a number of women for whom we just can’t
41:09 – get it right. I can’t figure out the combination or how to do it. Pretty much, they’re rare, perhaps 5%
41:16 – or fewer women where we just can never get the estrogen in the vagina to do what we wanted to do. But I will
41:23 – tell you, almost all of them can tolerate intrarosa. All of them. Almost all of them can tolerate the intravaginal
41:29 – DHEA that seems to be the whatever they’re putting in those suppositories. If you get a good compounding
41:34 – pharmacist, it seems to be something that’s holding them from – I should say, preventing them from having
41:41 – that kind of reaction. Melissa: Yeah. It’s interesting. We did get a few questions about how to do dosing for suppositories or pessaries,
41:48 – depending on which area of the world you’re in. So some people have been told to use a hormonal pessary
41:53 – as well as a probiotic or prebiotic pessary every day. So how do you use those if you have to use both every
42:01 – day? Can you use them at the same time, or do you have to separate them somehow? Dr Tim Hlavinka: I believe that those can be kept in place. I don’t know
42:11 – that you need to remove the hormonal rings or hormonal pessaries, and use the therapies. Theoretically, there
42:20 – could be some drug interaction that prevented absorption. But since these are indwelling typically and they have
42:28 – a sort of a slow release, it’s very unlikely that they’re going to impact the absorption of both agents, in other words, cause one
42:37 – to not let the other one be effective. Now, I don’t have pharmacokinetic data on that. I don’t have 2 or
42:42 – 3 paper to quote, to say that that’s the case. But from a practical standpoint, I will say one of the
42:50 – things that just, Melissa, it’s just these – a lot of women come in and they’re putting
42:56 – like five things in their vagina, three times a week. And, you know, they’re every minute of every day, they’re
43:03 – thinking about putting something in their vagina. And it can be – it’s got to be maddening to think that you have to focus that much on that part of your body
43:11 – just to be able to have a quality of life. So what I try to do is I try to minimize that and see what’s
43:17 – essential and what’s not. How can we wean off something? Pretty much everything has got a term. I wouldn’t call it short term, but, you know,
43:28 – most things that I recommend don’t need to be done more than 3 or 4 months, in order to get efficacy.
43:35 – And then you wean off to see whether or not you still need it. Melissa: Is that the same case with DHEA or intrarosa?
43:43 – Dr Tim Hlavinka: So, most of the patients have such refractory
43:48 – conditions that I’m reluctant to do that. Again, it’s only been a year where I’ve really [Inaudible] to intravaginal DHEA as kind of a – I wouldn’t say go
43:59 – to, but for the patients, for all the patients that aren’t tolerating estradiol or estriol or combinations
44:06 – intravaginally, I’ve gone to that. It’s only been a year where I’ve done that, and so there aren’t that many that can or have weaned off it to be able to give
44:15 – you a proper answer to that. Melissa: Mm-hmm. Okay. With the case of intrarosa or
44:21 – vaginal DHEA, can you use that at the same time as a probiotic? A vaginal probiotic I should say.
44:27 – Dr Tim Hlavinka: Yes. Yes, yes. You can. Melissa: Okay. And last time in your interview, we had this question a couple of times from people
44:33 – who watched the first interview, you mentioned a prescription probiotic and a vaginal prebiotic to use during antibiotic
44:40 – therapy. And people would ask you if you could share the name of that. Dr Tim Hlavinka: Mm-hmm. So not to be teasing or to be
44:48 – coy, actually a lot has evolved since that time. And one of the things that evolved is that the standard
44:57 – generic, proprietary brands, you can [Inaudible] multiple chain pharmacies in the United States, not abroad,
45:04 – but in the United States, the CVS, Walgreens, they typically all have their proprietary brands of prebiotics
45:12 – and probiotics that are actually very good. They’re encapsulated, they’re enteric coated. They are multiple organisms and very high counts
45:27 – such that you’re getting really for a very – it’s a cost factor. In order to get those, they typically
45:33 – were very expensive and didn’t have the greatest shelf life. So, now in the US, I’m converted until all the
45:41 – patients just go to Walgreens and get their best proprietary brand out there that’s got the most organisms, and
45:49 – the most colony counts to be able to use. And that’s been as effective as any,
45:56 – particularly from a standpoint of the patients that really are going to be on long term antibiotics. That’s
46:01 – been essential. Melissa: Okay. Dr Tim Hlavinka: So I’m not teasing. It’s just that this has kind of changed. Melissa: Yeah. It’s a good update. It’s been a few years
46:07 – since we last spoke. You also mentioned in that first interview that you have an information sheet that you share with patients about vaginal health, and we had
46:15 – a few requests about whether you could share that with our community. Dr Tim Hlavinka: That’s going to have to be something
46:21 – that’s going to be – you’re going to have to update, because I don’t really have that in a form right now. I’m working on that. I hope to get that out soon, but
46:29 – hopefully that will be updated and you can put that on your website as soon as I come up with it.
46:35 – Melissa: Yeah, that would be great. Before we move on to UTIs and sex, which is a topic that we have covered
46:40 – previously, we did have a question about whether there’s an association between UTIs and hormones for males.
46:47 – Dr Tim Hlavinka: UTIs and hormones for males. We guys get so lucky with this. We have so many more asymptomatic
46:55 – – most of the time we’re the asymptomatic carrier that’s causing the infection as opposed to suffering from
47:00 – this but there really doesn’t seem to be even in our patients, for instance, that are on this testosterone
47:09 – depleting therapies for prostate cancer, that doesn’t seem to predispose them to more chronic prostatitis
47:15 – or chronic UTIs. In men, I will point out that when there’s an infection, I’m convinced it’s everywhere.
47:22 – The classic for women is women are getting chronic UTIs. Well, most of the time, they’re cystitis. In
47:29 – men, when we get an infection, it goes all over the male ductal system, the prostate, the bladder. So that’s
47:35 – why more aggressive treatment needs to be done to eradicate those. But they do seem to be spared the hormonal depletion
47:43 – issue. Melissa: Thanks so much for watching. I hope you found part one of this interview helpful as we explored the
47:48 – impact of hormonal imbalances pre-menopause and how treatment may help reduce the frequency of UTI. If
47:53 – you’d like to learn more about this or related topics, be sure to check out our other videos or head over to liveutifree.com for related articles. And don’t
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