Hormone Myths with Cassie Milligan

Bree Allred: [00:00:25] I how do I know I'm a good [00:00:50] candidate for hormone therapy? Cassie Milligan: You're a woman. Bree Allred: I'm just kidding. You're like, "There you go. [00:00:55] Everybody can be a candidate," Cassie Milligan: right? Really anybody, because when... Like I said, it's not just your sex [00:01:00] hormones, right? So even, I mean, even with women that have had [00:01:05] cancer, breast cancer, ovarian cancer, like you can still be a good candidate for hormone [00:01:10] therapy. It's just we do it different. Mm-hmm. It's not like, oh, you get a hot flash, you just have to [00:01:15] ride the wave. We really focus on maybe just giving more of like an estriol instead of an [00:01:20] estradiol to help with some of those symptoms. So really, I mean, I [00:01:25] see 18-year-olds, 20-year-olds that come in and they're like, "My cycle's [00:01:30] off. What's going on?" It doesn't mean that they have to have hormones, but I'm [00:01:35] checking hormones, and like thyroid and adrenals, because I feel like [00:01:40] even our 20-year-olds are so overly stressed that their adrenals can be off- Yeah [00:01:45] and it will throw off their cycles or whatever. So like I said, [00:01:50] like men and women, right? Like both. If like most [00:01:55] most people can be good candidates for HRT. Bree Allred: Okay. Let's talk black box [00:02:00] warning just a second. Cassie Milligan: Okay. Bree Allred: So we've seen estrogen demands, [00:02:05] shall we say that, increase now that people are like, "You mean I don't have to deal with all of this?" Isn't Cassie Milligan: that Bree Allred: funny? But [00:02:10] let's kinda talk about that process. Like there was one study, what data was pulled from that study- Cassie Milligan: Yeah ... Bree Allred: why [00:02:15] it created the black box warning. Yeah. So a- and then why did they lift the black box warning? Cassie Milligan: Yeah. So it [00:02:20] was the Women's Health Initiative back in the early 2000s. Ugh. The way that the study was presented [00:02:25] was actually presented incorrectly. So what the study actually found is [00:02:30] actually women that were given estrogen, they actually had a decreased risk [00:02:35] in cardiovascular disease and cancers. What they found is, on a [00:02:40] basic level, the, when they were using synthetic progesterone and [00:02:45] synthetic estrogen together is what was causing- these [00:02:50] cancers and cardiovascular disease that whole- Your Bree Allred: body doesn't like the fake stuff, really? Cassie Milligan: Wild, [00:02:55] right? Yeah, so that was debunked actually in [00:03:00] 2024. There was, like, a huge, like, research study of, [00:03:05] like, 50 million women or something like that where yeah if you are [00:03:10] getting optimized with bioidentical hormone replacement [00:03:15] therapy, your risk of cardiovascular disease goes down. Your actual risk of breast [00:03:20] cancer goes down. The risk of osteoporosis goes down. We have these [00:03:25] hormones in our body- Right ... right? And so just making sure that they're bioidentical. I kind of explain [00:03:30] bioidentical is the hormone fits identical into the [00:03:35] receptor that it's attaching to, in the body. So it's [00:03:40] identical, right? So making sure that you're getting the right amount of hormones. You don't wanna [00:03:45] overdose. You don't wanna underdose. It's like this really fine line, right, that [00:03:50] you're gonna benefit from. Yeah. So the FDA removed the black box [00:03:55] warnings, and all of a sudden everybody's like, "Oh, now I can have estrogen," which is kinda wild, right, just 'cause [00:04:00] it was on there. Yeah. But I don't know if you watched the FDA, like, [00:04:05] where they had the round table last July. But there were many [00:04:10] practitioners that talked about how they would have these patients come in, and they [00:04:15] would recommend, say, an estradiol cream And the patient would [00:04:20] go and pick it up, and they would get home, and they would open up the, the [00:04:25] insert, and it would say, "Black box warning: This can cause cancer and heart attack," and they would [00:04:30] throw it in the garbage. And that is such a disservice to women. I feel like we've really had a [00:04:35] disservice- Yeah ... for many years. And now that they've removed it, [00:04:40] everybody wants Bree Allred: estrogen. Everybody's like, "Let's do it." Yeah. So do you feel like there's actually a short- a shortage right now, that people are struggling to [00:04:45] get it? Cassie Milligan: So with the patches, yeah. It's getting better. I have women [00:04:50] calling the clinic and, "You sent my patch to this pharmacy and they don't have it, and I'm calling all these [00:04:55] pharmacies," because, like, I understand the importance- Bree Allred: Yeah ... Cassie Milligan: of getting your patch, right? I feel like it's [00:05:00] getting a little bit better. I think we're catching up. I think there really was a shortage. I don't [00:05:05] Bree Allred: think they realized- Well, they've been prepping for about a Cassie Milligan: certain amount ... Yeah, I don't think they realized, like, how many women [00:05:10] are gonna want- Yeah ... like, their estrogen patch, right? Yeah. And the patches are great. Like, [00:05:15] I have really good success with estrogen patches, but there are other ways to get, to get estrogen. [00:05:20] So if someone's like, "I can't get the patch," like, I will prescribe a cream for them. Bree Allred: Yeah, [00:05:25] like, there's things that you can do differently and then- Yeah ... seeing if your body absorbs well- Cassie Milligan: Yeah ... Bree Allred: through the skin or [00:05:30] do you Cassie Milligan: need... I don't do estrogen tablets. Okay. I don't do tablets. Tablets have to [00:05:35] be absorbed in the gut. Even estradiol, tablets can be bioidentical. [00:05:40] So when estrogen has to be absorbed in the gut, sometimes it will push it down the [00:05:45] proliferative pathway- Mm which can kind of lead more to, like, a cancer kind of [00:05:50] disrupting kind of the gut and it, it does affect kind of your, your estrogen [00:05:55] receptors. Yeah. So- So Bree Allred: the mode of delivery matters Cassie Milligan: for Bree Allred: individual- Totally ... people, and that's a [00:06:00] discussion you should be having with a provider. Cassie Milligan: Yeah, absolutely Great. Bree Allred: There's different [00:06:05] modes of how you can get hormone in your body. Cassie Milligan: Yeah. Bree Allred: So what are the delivery methods that are the [00:06:10] most common? And are there certain ways you recommend versus others- [00:06:15] Yeah ... to get those hormones? Cassie Milligan: I just wanna like preface this, because I know that a [00:06:20] lot of people are like, "I want to do this as naturally as possible." Mm-hmm. And [00:06:25] there is a place for like nutrition and gut health when it comes [00:06:30] to hormone replacement. Yeah. Right? When you don't have hormones, like you can eat as [00:06:35] many carrots as you want, you're not gonna get hormones. Does that make sense? Yes. Like the purpose of the [00:06:40] diet and like the kind of the nutrition side of things is making sure that the hormones are [00:06:45] still being processed correctly. So if you don't have estrogen, I need to [00:06:50] give you estrogen, and then eating your cruciferous vegetables are gonna help push it down [00:06:55] the methylation pathway. Bree Allred: Yeah. Cassie Milligan: So like yes, there is a place [00:07:00] for a holistic piece of HRT, but there's also a place for [00:07:05] replacement. Yes. Does that make sense? Bree Allred: Yes. Cassie Milligan: So I just wanna like start there. Yeah, like clarify [00:07:10] there. Bree Allred: I wanna start there. Yes, 'cause that's an important piece. Cassie Milligan: There is a very important piece. And yes, like [00:07:15] when you're younger, like really focusing on kind of the gut and, and that [00:07:20] piece is really important, but as you get older and your hormones start to decline, like the only way I can replace them [00:07:25] is replacing. But the gut and nutrition is very important piece to help with regulation [00:07:30] Great. So I wanna start there. Done. Okay. The other [00:07:35] piece... So yes, there's different modes of how we can get hormones. With [00:07:40] estrogen a patch, a cream, a pellet, some people do tablets. I [00:07:45] never say anything like people are doing anything wrong. If they do a tablet, it's just not like the [00:07:50] way- Your preferred method of how you prescribe it ... It's not my preferred method. Yeah. Mm-hmm. With the estradiol patch it only [00:07:55] comes in an estradiol, right? When you do like a cream, I can do like a [00:08:00] biased cream, so I can give you the estradiol and estriol that we talked about. Mm-hmm. That is really [00:08:05] important to help support your beta receptors that help like kind of turn off cancer [00:08:10] genes. That's what I would give to like a breast cancer survivor- Breast cancer person is like a [00:08:15] biased. And then a pellet. You can do estrogen pellets also, estradiol pellets. The pellets [00:08:20] you insert every two and a half, three months for women. It just slowly releases that estradiol [00:08:25] throughout kind of that, that period. So that's kind of estrogen [00:08:30] Progesterone you can get in a capsule, you can do as a troche. So [00:08:35] troches go underneath your tongue and absorb underneath the tongue, or you can do a cream. [00:08:40] People benefit from creams. It's totally fine. I don't see the sleep [00:08:45] benefit with a cream. And I don't see the systemic benefit of [00:08:50] supporting your brain, your gut. Bree Allred: Mm-hmm. Cassie Milligan: It does help balance the estrogen. Yeah. Yeah. The [00:08:55] progesterone troches or the progesterone capsules. Now, there is something called a Dutch test, that's dried [00:09:00] urine I do offer. It's just expensive, so I don't give it to everybody. But if I'm giving [00:09:05] someone progesterone and they're not seeing the benefits maybe with a capsule, like the Dutch test does [00:09:10] tell me like what pathway you benefit from more, what, what [00:09:15] pathway you like push towards. Um, and some people need a troche versus a capsule. Bree Allred: [00:09:20] Okay. Cassie Milligan: Absorbing it in the mucus membrane as opposed to the, in the gut. So that is one. [00:09:25] Testosterone can come in a cream, injections, [00:09:30] or a pellet. I actually can do testosterone troches just kind of low dose troche [00:09:35] if, someone doesn't wanna do injections. I don't do a lot of injections on women. Like, I have some [00:09:40] women that are like, "Hey, I feel better on this," and that's so great. Mm-hmm. And, and I'll do the in- the injections for [00:09:45] them. But yeah, so testosterone pellets are great. Again, it would go with [00:09:50] the estrogen, if you need it, and then a cream. Women do really good with cream. Now, for [00:09:55] men, men usually wanna do it an injection, and that's totally fine. The reason why I don't do injections as much [00:10:00] in women is because the the dosing is really hard. Bree Allred: Yeah. ' Cassie Milligan: Cause you don't wanna get a man dose, [00:10:05] right? So, I do try and get it compounded so that it's a s- a lower concentration so they don't [00:10:10] have to do as high of, like injection. Yeah. Well, I guess it's as low such a small [00:10:15] amount- Bree Allred: That you're like, am Cassie Milligan: I Bree Allred: even- ... injection ... Cassie Milligan: actually? Yeah. Am I injecting this at all? Yeah. Yeah. So yeah, men and [00:10:20] women can both get, you know, the testosterone in injections. Mm-hmm. So that's for women. [00:10:25] Men really don't need progesterone or estrogen. So even if they're low on estrogen, it's usually 'cause they're low on, [00:10:30] they can be low on testosterone. So as I boost up their testosterone, it will start converting some to [00:10:35] estrogen. Okay. So they get the estrogen support. So I don't give estrogen to men, but I do give them testosterone. [00:10:40] Bree Allred: Nice. Cassie Milligan: Yeah. Bree Allred: Okay. That's a great kind of overall thing there. Let's [00:10:45] say who may not be a good candidate? Like, who are people that you're like, "I am not prescribing [00:10:50] hormones for you"? Do you feel there's anybody that you would say [00:10:55] that? Cassie Milligan: Yes, there are people that I would. If I drew their [00:11:00] labs, for instance, and someone's like, "I have no libido. I [00:11:05] have no sex- like, no libido. Like, my, my motivation sucks." Like, they're [00:11:10] very pushing, like say, my testosterone's low, and then I draw and it's really high. Like, [00:11:15] they're not getting testosterone. We've gotta look deeper. No. Right? Some, some [00:11:20] women that have, like, a really extensive history of breast cancer, I [00:11:25] will be very cautious. Like, we have a conversation about even [00:11:30] estriol. Bree Allred: Mm-hmm. Cassie Milligan: Estriol cream. It is something that needs to be, like, [00:11:35] vaginal estriol cream if you do have, so it's not such a systemic, right? Yeah. It's gonna support the [00:11:40] vaginal health. I do have some women that really struggle with progesterone, so [00:11:45] I, I don't... I mean, progesterone's great. But some, some women just [00:11:50] don't do well with it, and so I, you know, I wouldn't prescribe it to them- [00:11:55] Yeah ... if they've had an issue in the past. Bree Allred: Yeah. Okay. So it's like very open [00:12:00] conversations of like, "Okay, let's see what we can do" Completely open. And- Cassie Milligan: Yeah ... but- I'm not gonna push [00:12:05] hormones on anybody. So I have the conversation, risks, benefits, [00:12:10] and they get to decide. Bree Allred: Which is how it should be- Yeah ... instead of like, "No, you're not getting that." [00:12:15] Cassie Milligan: Yeah. No. I, we just keep an eye on them, right? Mm-hmm. So it's very... I mean, [00:12:20] my plans are very individualized. So- Yeah ... I always tell my patients, like, "I'm just your guide [00:12:25] through your journey. So I give you these recommendations, and you get to decide. Is this what you wanna [00:12:30] do? Great. If not, there's always, you Bree Allred: know-" Yeah ... " Cassie Milligan: something else I can help you with." But... [00:12:35] Bree Allred: Are you having conversations, say, with somebody's oncologist if you're trying to recommend- ... [00:12:40] different things, or do you allow the patients to do that? Cassie Milligan: Oh, yeah. I definitely allow the patients to [00:12:45] have conversations with their- Okay ... oncologist. Yeah. But you're Bree Allred: not often ca- calling Cassie Milligan: the oncologist- I haven't really called like- to be [00:12:50] like, "Hey- Yeah ... Bree Allred: let's have a discussion" Cassie Milligan: I, like, in all honesty, I [00:12:55] haven't really had a lot of really, like, high-risk patients. Mm. If [00:13:00] it was like, for instance, if someone had breast cancer yesterday, like I'm not putting them [00:13:05] on hormones. Bree Allred: Yes. Cassie Milligan: Right? So it's gotta be like they've gotta be like [00:13:10] w- through the breast cancer, through all of that for at least a, at least a year [00:13:15] or two before I would say, "Yeah, let's do, let's do like hormone replacement therapy." [00:13:20] Yeah. So if someone comes in, I guess that would be like someone I would say no to is- Yeah ... if they have. Bree Allred: And [00:13:25] then if... I would probably just argue this one for you too, that it's like if you're on an estrogen blocker, [00:13:30] you're probably not gonna- Yeah ... do well with an estrogen cream You... Yeah. Yeah ... at all. It's like- Exactly ... no, we're blocking the [00:13:35] receptor. Like, like- You're not gonna do that ... you can't absorb it, so you're not a good candidate. Yeah. Cassie Milligan: Yeah. [00:13:40] 100%. Yeah. Like, there's a... If you're on the tamoxifen- Yes ... is that what you're talking about? Yes. Yeah. We're not... There's no point. [00:13:45] Bree Allred: Yes. Cassie Milligan: Right? And even in men, right? So here's the thing with men, though. So prostate cancer, [00:13:50] right? They say it's a big increased risk if you give them testosterone, but if you actually [00:13:55] keep their testosterone optimal, it decreases the risk of prostate cancer. [00:14:00] So someone who has absolutely has prostate cancer, yeah, like I'm not gonna give you [00:14:05] testosterone. But I want to give men testosterone that is low [00:14:10] or not optimal- To keep them at a lower risk of prostate [00:14:15] cancer- Yeah ... with optimal testosterone. Makes Bree Allred: sense. But I think it's just maybe the monitoring [00:14:20] component is what's missing- Oh, yeah ... in our standard medical system- Mm-hmm ... per se, that it's like they don't have the [00:14:25] time to maybe- Yeah prescribe these and monitor these and- Cassie Milligan: Yeah ... Bree Allred: and do every- or insurance isn't covering the [00:14:30] labs, or- Cassie Milligan: Yes ... Bree Allred: different things there that it's like, "Yeah, we're just not gonna give Cassie Milligan: you that." We're just not gonna give you that. Yeah [00:14:35] and they don't look at labs on an optimal level, right? Yeah. I explain this to my patients. Like, [00:14:40] I get the system. I know it's broken. I get it, but when [00:14:45] that provider draws your labs, they're in charge of those labs. So if something's really [00:14:50] funky, then they have to sit down with you and have that conversation. So the more labs they draw, the [00:14:55] longer their visit needs to be, and they don't have that time. And so they're just gonna draw the most basic [00:15:00] labs- Mm-hmm ... and they're gonna say, "You're fine." And it's not that they're doing anything wrong. That's just what [00:15:05] they've learned, right? And within the system that they are a part of ... and within the system. Yeah. Like, that is what, like, [00:15:10] insurance-based practice does. It really... They... It, it's a sick model, so they're not gonna treat you [00:15:15] until, like, your labs are completely out of range. Yeah. Bree Allred: No. So let's talk about hormones' effects [00:15:20] on vaginal health specifically, and then I'll kind of talk a little bit about how the pelvic floor may [00:15:25] respond to those changes as well, and how- Yeah Some of these things get crossover. Oh, [00:15:30] 100% they get crossover. Yeah. Yeah. So what do we see happen in the vagina as our hormones are [00:15:35] changing with age? So as your estradiol goes down, so estradiol actually helps [00:15:40] with moisture in your vaginal canal. So as that declines, right, you're gonna have [00:15:45] more vaginal dryness. Cassie Milligan: It can actually atrophy if you don't have enough moisture. Which [00:15:50] when you're thinking of atrophy, we talk about, like, muscles, right? Right. It's like they get thinner, and it's- Yes ... kind of that same idea. It's, the [00:15:55] skin gets thinner. Yeah, the skin gets thinner, the muscles get thinner. Sometimes they get less elastic- [00:16:00] Yeah Bree Allred: is a good description. Maybe it's like- Right ... they're kind of, like, stiffer tissues as well. Right. So when we're [00:16:05] talking vaginal atrophy, a lot of people are like, "What does that actually mean?" What does that mean? Yeah. And it's like, yes, it's- And then, and when it gets [00:16:10] kind of thinner, this is where you can have, like, kind of your organs start to kind of [00:16:15] shift down- Mm-hmm Cassie Milligan: right, and, and push on things. Yes. So this is where you step in and, like, help with, like, that pelvic [00:16:20] floor therapy. Yes, exactly. So they very much go hand in hand [00:16:25] together. Um, so putting someone on an estradiol cream vaginally is [00:16:30] really going to help support that vaginal canal and help- Yes ... give it the kind of the [00:16:35] moisture that it needs. And the collagen. Mm-hmm. So it, it actually [00:16:40] helps with, like, collagen stimulation to help make that pelvic floor and [00:16:45] that vaginal canal just a little bit stronger, right? Bree Allred: Yeah. It functions better. [00:16:50] The muscle bulk is better. Yeah. The tissue health and elasticity is better. Cassie Milligan: [00:16:55] Right. Bree Allred: And when we're talking about vaginal atrophy, we cannot leave out, like, intercourse related symptoms- [00:17:00] Yes ... right? Like- So many ... so, so many women that are... And we can even talk this too a little bit with women that are [00:17:05] breastfeeding. Mm-hmm. Because estrogen levels are a little bit lower, which helps with milk production. Right. [00:17:10] Right? So I'll see these symptoms oftentimes in this post-men- or postpartum, [00:17:15] not postmenopausal- Period, yeah ... but this postpartum period, especially if we're breastfeeding as well. Cassie Milligan: Yeah. Bree Allred: But [00:17:20] they're, like, it's sandpaper. It, like, feels like things are gonna rip- Yes ... versus stretch. Yes, Cassie Milligan: it's [00:17:25] Bree Allred: so painful. It's like, it's painful. Mm-hmm. And sometimes we do get micro tears because of the tissue health- Right ... not [00:17:30] being good as well. Cassie Milligan: Yeah, yeah. And that's also, like, a progesterone Bree Allred: thing. Cassie Milligan: Mm-hmm. Right? And [00:17:35] so, like, after you have a baby, your progesterone levels can go down also. Yes. So like [00:17:40] everything's just kind of declining. So just giving postmenopa- I'm post-menopausal [00:17:45] Postpartum. Bree Allred: Post, we're both doing that based on like our- Yeah ... previous conversation here. [00:17:50] Cassie Milligan: Postpartum women, Bree Allred: progesterone- Cassie Milligan: Yeah ... will actually help, help with that. But also testosterone. Mm-hmm. [00:17:55] Testosterone helps with like the muscle building, right? So to do kind of a low dose [00:18:00] testosterone cream will also help with that, like the support of the vaginal canal. Yeah. [00:18:05] Especially like post- partum. Bree Allred: Yes. Postpartum. Bree Allred: So just, and like [00:18:10] people that are in this postpartum period could draw a lot from this conversation if you're having- Oh, Cassie Milligan: yeah ... Bree Allred: symptoms like this [00:18:15] as well. Cassie Milligan: Yeah. Bree Allred: There were, are oftentimes, and maybe I'll have to recommend, like, more thorough, but a lot of times [00:18:20] I'm like when I look in, when I'm doing a pelvic exam and I look at vaginal tissue, one of my [00:18:25] telltale signs is, like, there's a bright red urethra that looks like a bullseye surrounded- Yes by pale white [00:18:30] tissue. The pale white tissue. 'Cause people ask, like, "How can I, how can I tell?" And I'm like, "Your tissues are white- Right ... [00:18:35] when they should be pink." Cassie Milligan: Yeah. Bree Allred: And then it's like if it's really bad, we get this, like, bullseye appearance on [00:18:40] your urethra. Cassie Milligan: Yeah. Bree Allred: That people are like, "How can you tell?" And I'm like, "You need to talk to somebody about estrogen [00:18:45] cream." Yeah. Because I can't prescribe it, but I have great relationships with people that it's like- Yes ... "Okay, these people need [00:18:50] this." Cassie Milligan: Yes. Bree Allred: And it can be- It's great ... hugely helpful, and doing a cream helps with a [00:18:55] little bit more localized uptake, and not as much- Correct, not as Cassie Milligan: systemic ... systemic. Bree Allred: Yeah. To where it's like we're getting it, [00:19:00] it goes through the skin and gets resistance and kind of sits- Yeah in more localized tissues, so [00:19:05] can be a very safe option. Cassie Milligan: Oh, yeah. Mm-hmm. For Bree Allred: postpartum- Cassie Milligan: Yes ... Bree Allred: with breastfeeding where [00:19:10] you're not getting a big systemic uptake- And you- ... for breast cancer survivors, for women that are a little more [00:19:15] concerned with- Right ... systemic estrogen. Cassie Milligan: And you can do Estriol. Yeah. So that [00:19:20] Estriol cream that we keep talking about, right? So we have actually three estrogens. We have estrone, [00:19:25] estradiol, estriol, and estriol's just kind of a weaker estrogen, but it [00:19:30] really helps support that also. Bree Allred: Yeah. Cassie Milligan: Mm-hmm. Bree Allred: Which is great. [00:19:35] Pelvic floor muscles, if something's painful, we also can get a muscle response that goes into a [00:19:40] protection mode- Mm-hmm and makes it so that it's like, oh, no, even sometimes with, okay, we [00:19:45] got a cream, things are feeling a little bit better, but it still hurts. Cassie Milligan: Yeah. Bree Allred: And it can be because it's a [00:19:50] muscle issue that's in a guard and protect mode now that it's been- Cassie Milligan: Yeah ... Bree Allred: in that- Cassie Milligan: In that Bree Allred: [00:19:55] state ... in that position or state. Yeah. So it can kind of perpetuate that, and it can be... So even if you're like, "Okay, my tissue [00:20:00] health is doing better, but I'm still having pain," that's often where pelvic floor therapy can come into play. Cassie Milligan: [00:20:05] Yes. Bree Allred: And then other symptoms, are prolapse, are genital organs- Yeah ... sitting [00:20:10] lower in the vaginal canal because of the tissues losing elasticity, losing [00:20:15] bulk, losing support factors, and it can be a huge issue. Cassie Milligan: Yeah. Bree Allred: And then we also [00:20:20] talk about, like, there's the genitos- genitourinary syndrome of menopause, [00:20:25] right? Cassie Milligan: Mm-hmm, Bree Allred: yep. And oftentimes it will get shorted to, shortened, goodness, I can't talk anymore. Shortened to [00:20:30] GSM. Mm-hmm. And this is where it's like we see increased urinary incontinence. [00:20:35] We see the bladder not being as happy. Sometimes we'll be seeing bowel changes [00:20:40] even along with that as well, but- Yeah ... we're talking about urinary symptoms that it's like, yes, I'm going to the bathroom all the time. I'm [00:20:45] having to wake up at night to go to the bathroom. Yep. Urgency is super high, and I can't control it, [00:20:50] or stress incontinence where it's like with impact or surprises or- Yeah, [00:20:55] sneezing sneezing, that you're peeing. Yep. Yeah. And the Estriol, [00:21:00] the Bi-Est cream, Estradiol cream, Estriol cream, any of those will be really [00:21:05] beneficial for that. Some women also get increase in yeast infections as they go through the menopause- Or [00:21:10] UTIs ... or any UTIs I will see those as well, 'cause it's that environment. Yep. Yeah A lot of it that it's like, oh, that's off [00:21:15] 'cause it's not got great moisture. It's not good with barriers. It's- Cassie Milligan: Yes ... Bree Allred: kind of weak and [00:21:20] torn, micro torn tissues that can Cassie Milligan: make a difference. And I would say not just [00:21:25] hormones there, like, doing a really good, like, probiotic one that [00:21:30] is specific for, like, vaginal- Mm-hmm Bacteria, vaginal health. Do you have a favorite that [00:21:35] you recommend? The one that I have at the clinic is an Ortho Biotic Women's. It's through the Or- [00:21:40] it's through Ortho Molecular, that is the brand. Is great. I have a lot of women [00:21:45] that, like, if they had, like, an odor or something, the, you know, they just feel like they're, it, it, the [00:21:50] imbalance is off. Mm-hmm. They're getting yeast infections, even, like, UTIs. Adding in that probiotic [00:21:55] is really beneficial. Bree Allred: Yeah. Cassie Milligan: A lot Bree Allred: of different ways. Your body needs good bacteria. Cassie Milligan: Yes. [00:22:00] It does, and it needs the right balance- Yes ... of good and bad, right? We have good and bad bacteria, but we just [00:22:05] don't want the bad bacteria to over, overdo the [00:22:10] Bree Allred: good, Okay, we're gonna do kind of some rapid fire questions. I just wanna put this more into a [00:22:15] scenario so that women can maybe recognize themselves a little bit more, and just give us real basics. I [00:22:20] know there's probably a lot more, and we're not saying give away your treatment plan or your secrets especially- [00:22:25] 'cause, like, it's individualized. But- Cassie Milligan: Yeah Bree Allred: let's take me. I'm a 43-year-old woman. Cassie Milligan: Okay. [00:22:30] Bree Allred: I've gained, doing 15 pounds. Mm-hmm. I wake up at 3:00 AM, [00:22:35] and I feel exhausted, I've got brain fog, I can't word find stuff [00:22:40] anymore. I'm like, I feel... Doing like- Mm-hmm ... saying something and I'm like, " Cassie Milligan: Uh..." Yeah. Or [00:22:45] like, "I Bree Allred: know that's a spoon." Can't find the word. But I can't say it. Yes, but I can't say it. Cassie Milligan: Yeah. Yes. Bree Allred: Yeah. Maybe her libido's [00:22:50] changing just a little bit. She's not wanting sex as much anymore. She started leaking during [00:22:55] exercise or being like, "Oh my gosh, I can't make it to the bathroom in time. I just don't feel like me."[00:23:00] Cassie Milligan: Mm-hmm. Bree Allred: Do you... But she comes into your office, like what medical things are you gonna recommend? [00:23:05] What... I don't... Like, if they're even looking, whether they come see you or somebody else. Cassie Milligan: Yeah. [00:23:10] Bree Allred: What is their little bit of a map of like, okay, what do we wanna do? Yeah. Where do we [00:23:15] start? What questions maybe should I ask to, to get things going in the right direction?[00:23:20] Cassie Milligan: Well, and that is like a big part of my initial consult, right? Mm-hmm. My initial consults are about [00:23:25] an hour to an hour and a half. So I... Like, when you go to a doctor, like how long do you see the doctor? If I- [00:23:30] 20 minutes ... have an MA. Bree Allred: 20 to 40 maybe if you're lucky. Like if Cassie Milligan: you're lucky- Yeah, if you're lucky you'll get 20 to 40. You might be in the [00:23:35] office for that long, but the actual doctor you'll see about eight minutes. Bree Allred: Mm-hmm. Cassie Milligan: Um, so [00:23:40] there's a lot of questions. Like, yes, you have all of these symptoms, but I do [00:23:45] basically go from head to toe and ask even deeper [00:23:50] questions. A lot of your symptoms are definitely perimenopausal. Like I can... I mean, I could [00:23:55] probably pinpoint what is off just by what you're telling me. Bree Allred: Mm-hmm. Cassie Milligan: But that doesn't [00:24:00] mean that you need all these hormones. So absolutely I have to check [00:24:05] labs, right? So I would never give anybody hormones without checking labs at least. But [00:24:10] yes, that is something that I would definitely have to check because you can have all of those symptoms [00:24:15] with just a low ferritin. Bree Allred: Yeah. Cassie Milligan: Right? You can have those symptoms with... Yeah, maybe it [00:24:20] is just your testosterone is really low. But what you're telling me is like your [00:24:25] adrenals are off, you don't have enough estrogen, like your progesterone is too low, your testosterone's [00:24:30] too low. But when I... Yeah, I would have to... I would definitely need to check those labs. You always Bree Allred: need to [00:24:35] assess and not guess. You're like- Yes ... "Okay, here's my guesses." And I will often tell people, I feel like [00:24:40] medical practitioners, we're detectives, and we're- Yeah ... kind of like, "Okay, here's my signs." Mm-hmm. [00:24:45] "And then I'm gonna go gather the evidence and the data that-" Yeah "... tells me exactly what we need to know." Mm-hmm. And [00:24:50] sometimes that data is gathered by like, "Okay, we got enough evidence to go down this path. [00:24:55] Let's see how your body responds to it and see." Cassie Milligan: Yep. Bree Allred: You know, it's like this hypothesis, [00:25:00] and we're doing a scientific test- Cassie Milligan: Mm-hmm ... Bree Allred: to get the outcome and the data to be like, "Was my [00:25:05] hypothesis correct?" Cassie Milligan: Yes. Bree Allred: So moving there- Yeah ... where you're like, "Okay, we go down these little different paths and see-" Yes "... where [00:25:10] we go." Cassie Milligan: Yeah. Absolutely. Just the... The moment that I walk in, I am [00:25:15] thinking about all the different possible diagnoses. Bree Allred: Yeah. Cassie Milligan: Right? And then just getting even [00:25:20] deeper into those questions that I'm gonna be asking, and a little bit deeper.[00:25:25] And then when I pull in the labs, it does help me be like, "Oh yeah. Yeah, this is... I, [00:25:30] I figured this would be off." Mm-hmm. And sometimes like we said in the beginning, sometimes it's not off [00:25:35] and I'm like, "What?" And- Okay, Bree Allred: hold on. Cassie Milligan: Yeah, yeah. Bree Allred: Let's reevaluate. Go back to [00:25:40] the drawing board here a little bit. What have I missed? Yeah. Yeah. Cassie Milligan: Yeah. But- Yeah. Well, [00:25:45] focusing on, yes, your symptoms, drawing those labs, kind of taking a deep- [00:25:50] a deeper dive Bree Allred: And then maybe trying some, a few things that you're looking into as far as- Cassie Milligan: Yeah. So [00:25:55] say like your actual hormones- ... bloods, hormones or- ... were off, right? Mm-hmm. Then I'm very conservative [00:26:00] the way that I do hormones. I start very low, and then we slowly go up. So, you [00:26:05] know, if, if everything is off, then we're gonna start really low and kind of slowly taper up. [00:26:10] Great. Like, I think it gives people a great place to start, where it's like- Yeah ... okay, it's worth a conversation. [00:26:15] Mm-hmm. Seeing what things are kind of our primary concerns, getting labs and data to support [00:26:20] that- Yeah Bree Allred: and then trying a treatment. Yep. Yeah. Great. Thanks for that. Okay, we're gonna do some rapid fire [00:26:25] questions. Oh, man. Okay. So I'm gonna give you a symptom. Cassie Milligan: Okay. Bree Allred: And I want you to [00:26:30] tell me whether hormones can be involved... Sorry, hormones could be involved, and what else you [00:26:35] would want to investigate. Okay. Okay? So just real quick, like one to two, like are hormones [00:26:40] involved, or what else would you investigate? Cassie Milligan: Okay. Okay? Weight gain. Both. [00:26:45] Okay. Are hormones involved? And I would also do investigation. Bree Allred: [00:26:50] Okay. Brain fog. Cassie Milligan: Again hormones or would I dig [00:26:55] further? Bree Allred: Yeah. Cassie Milligan: When it comes to mental health, just putting [00:27:00] that out there- Mm-hmm mental health is just as important when it comes to hormones. Bree Allred: Great. Love that. [00:27:05] 3:00 AM waking. Cassie Milligan: Hormones. Bree Allred: Okay. Anxiety. Cassie Milligan: Hormones. [00:27:10] Bree Allred: Low libido. Cassie Milligan: Hormones. Painful intercourse. Hormones. [00:27:15] Bree Allred: Hair loss. Cassie Milligan: Hormones. Nutrition. Okay. Hormones, nutrition. [00:27:20] Okay. Bree Allred: Love it. Cassie Milligan: Fatigue. Hormones. Bree Allred: Urinary [00:27:25] urgency. Cassie Milligan: Both. Hormones and look further. Bree Allred: Okay. Joint pain. [00:27:30] Cassie Milligan: Hormones and look further. Bree Allred: Mood swings. Cassie Milligan: Hormones. Belly fat. And [00:27:35] mental health. Yeah, belly fat. Hormones, but when I say hormones, not just sex hormones, adrenals. Okay. [00:27:40] I just very much- Bree Allred: Belly fat ... belly fat. Cassie Milligan: Yeah. Bree Allred: Okay. So the point is, not everything [00:27:45] is hormones. Cassie Milligan: Yeah. Bree Allred: And hormones can contribute to a lot. Cassie Milligan: Yeah. Bree Allred: Okay. All [00:27:50] right. Myth busting really quick. Cassie Milligan: Okay. Bree Allred: I'm too young for perimenopause. Cassie Milligan: No. Bree Allred: True or false? [00:27:55] False. Okay. My labs are normal, so my symptoms can't be hormonal. [00:28:00] So false. Hormone therapy causes breast cancer. Cassie Milligan: Ah, false. [00:28:05] Debunked. Yes. Bree Allred: Bioidentical automatically means safer. Cassie Milligan: False. [00:28:10] Bree Allred: Okay. That's why I think a big myth that people- Cassie Milligan: Yeah Bree Allred: misconstrue. Cassie Milligan: Yeah. [00:28:15] Bree Allred: Testosterone is only important for men. Cassie Milligan: Ugh, false. Yes. Bree Allred: Weight gain after [00:28:20] 40 is inevitable. Cassie Milligan: Mm, I mean, true and false. Bree Allred: There [00:28:25] is some truth, but it's like- Cassie Milligan: There is some truth ... you have body changes that happen. There is some truth to that, yeah. Yeah. But also, [00:28:30] like, there's some untruth to that. It doesn't mean that everybody's just gonna, like, gain all this weight. Bree Allred: Mm-hmm. Yep. [00:28:35] Um, painful intercourse is just part of menopause. Cassie Milligan: False. Bree Allred: Yeah. Leaking [00:28:40] is just part of having babies. Cassie Milligan: Listen, that's false because I have some women that [00:28:45] are like, "I can jump on a trampoline. I had five kids." Bree Allred: Yeah. " Cassie Milligan: I've never had anything like [00:28:50] that." Bree Allred: Yep. Cassie Milligan: Lucky. That's Bree Allred: like... Yeah. There's genetics, there's- Cassie Milligan: Yeah ... Bree Allred: how your body heals, whether [00:28:55] you're exercising, all of those things. Yeah. Yeah. What do you wish that every woman knew before she entered her [00:29:00] 40s? Cassie Milligan: [00:29:05] Ooh. I would say that[00:29:10] I think it's going back to, like, how we have been treated as women, that, like, [00:29:15] just 'cause you're aging doesn't mean we have to go through this. Bree Allred: Yeah. Cassie Milligan: We can go through [00:29:20] perimenopause and menopause very gracefully helping support those symptoms. So, like, [00:29:25] not just feeling like, "Okay, I'm turning 40, now my whole life is, like, ending"- Yeah [00:29:30] like, and I just have to ride the wave. Bree Allred: Yeah. What's something women are commonly told is normal [00:29:35] that makes you think, "No, we need to look deeper"? Cassie Milligan: All the things that we've talked about, [00:29:40] like not being able to sleep at night, the, the word recall. Bree Allred: Mm-hmm. Cassie Milligan: Um, [00:29:45] the vaginal dryness, the decrease in libido, um, the waking, [00:29:50] uh, like, literally everything that we've talked about today. Bree Allred: Like, we need to look further. Cassie Milligan: [00:29:55] Absolutely. Bree Allred: Yeah. Cassie Milligan: It... Just because, like, people think it's normal does not mean that it's [00:30:00] normal. Bree Allred: Yep. Common is not normal, people. Exactly. Okay. If someone is [00:30:05] listening today and thinks, "She's describing me"- what are the first three things that you [00:30:10] want her to do? I know it's hard, right? 'Cause it's individual when you're looking at this whole [00:30:15] profile, but if you had to generalize that, what would you say? Cassie Milligan: I would say look for someone [00:30:20] that does hormone optimization not just, "Hey, I'm a [00:30:25] hormone expert," that they really have that optimization piece- Mm-hmm ... 'cause, like, normal's [00:30:30] not optimal, right? That would be one big thing. When you go to that [00:30:35] practitioner, hoping that they listen, and not just [00:30:40] say, "This is life," right? Yeah. Like, ride the wave. So, you know, [00:30:45] finding that practitioner that will listen. Bree Allred: And if you're not there, try again. Yeah. That [00:30:50] sounds discouraging, but it's like if you haven't found the right one, keep trying. Cassie Milligan: I'm not for everybody either, [00:30:55] right? Yeah. So you know, if the way that my approach is not for you, I'm not offended by [00:31:00] that. I want you to feel better. Yeah. I want you to feel optimal. So finding that [00:31:05] practitioner that's right for you is perfectly fine 'cause you want that [00:31:10] person to mesh- Yeah ... with you. I would definitely say making sure that that practitioner is [00:31:15] listening to you. And you know, checking [00:31:20] deeper, I guess that's kind of more of like the functional side. Bree Allred: Mm-hmm. Cassie Milligan: Just making sure that [00:31:25] they're looking at you as a whole As opposed to, like, individual organs Yeah 'cause they all [00:31:30] should be working together. Bree Allred: Which is great, and that's one way I love our medical system. I [00:31:35] al- I'm like, it's still one of the best out there. Cassie Milligan: Yeah. Bree Allred: It really is, but there are its limitations, and I think [00:31:40] some of that is everybody's become so specialized in their field- Cassie Milligan: Yes Bree Allred: that they forget to be like, [00:31:45] "Oh, there's, like, other things that-" There's other organs that do work ... work with, together. That it's like, "Oh, I'm a GI [00:31:50] specialist. Oh, I'm a bladder specialist. Oh, I'm an OB. Oh, I'm a hormone [00:31:55] specialist." Hormone probably does better because it's a systemic delivery. Cassie Milligan: Yeah. Bree Allred: But just those ideas of like, [00:32:00] yeah, these individual areas do work together. Cassie Milligan: Yes. Bree Allred: And looking at, it's like, okay, let's see how this is all [00:32:05] interacting. Cassie Milligan: Yeah. Bree Allred: That's one thing I feel like sometimes they get to physical therapy, and it's like we're the one that's like, [00:32:10] "Oh, you have GI symptoms" Cassie Milligan: All the things. ... Bree Allred: painful intercourse, and and all of these practitioners have [00:32:15] been trained to treat them- Individually separately and individually, and it's like- Yeah ... there is some value to that, but when you put it [00:32:20] back all together, it's like, oh my gosh, we're missing a huge component because everybody's been missing- Yes ... the other [00:32:25] people's piece. Cassie Milligan: Yeah, 100%. Yeah. And working together. Like I refer people [00:32:30] to primary care all the time. Mm-hmm. I refer people to cardiology. I refer people to physical [00:32:35] therapy. It's not like I'm just gonna do everything. No. No, no. Like, there, I [00:32:40] refer people to mental health specialists. There's a big piece in our mental [00:32:45] health and wellness. Bree Allred: Yeah. Cassie Milligan: I do explain to people I'm not against [00:32:50] traditional medicine necessarily. I'm against the the dysfunction of [00:32:55] it. Like, it's only a sick model. And I explain to my patients when they come [00:33:00] in for their initial consult, my clinic is Eastern and Western medicine that have come [00:33:05] together because there is a place for both. Bree Allred: Yeah. Cassie Milligan: I can't optimize you only on this level and only on [00:33:10] this level. There is that come together- Yeah ... piece. So it's not [00:33:15] that I'm completely against that, that healthcare. There's places for it, [00:33:20] but I don't feel like everything should be pushed to a medication, [00:33:25] everything should be pushed to the sick model. Bree Allred: Yeah. Cassie Milligan: There is [00:33:30] a place for this kind of Eastern medicine model too that like come together. Bree Allred: I love that. [00:33:35] Yeah. Cassie Milligan: What does feeling like yourself again actually look like? Uh, uh, [00:33:40] again, everybody's different, right? But I will say it's really fun to see people come [00:33:45] in and be like, "Oh my gosh, I feel so good. I'm sleeping." [00:33:50] Like, I- I... "My memory is better. My libido's great," right? [00:33:55] So feeling like myself again is really individualized- Yeah to, [00:34:00] like every person is different to what they feel is, I feel like myself again. [00:34:05] But I will say it's their energy's improved, their sleep. Sleep is so [00:34:10] precious. Their sleep is better. They're waking up rested. Their libido's back- Yeah ... you know? Like- [00:34:15] Yeah ... their husband loves Bree Allred: the- It goes back to that knowing, right? That like- Cassie Milligan: Yeah ... Bree Allred: I'm at [00:34:20] home Cassie Milligan: here. Yeah. Bree Allred: I'm at home here, and I know that it's like versus, "Ugh, something's off." [00:34:25] Cassie Milligan: Like- Something is off, yeah. Bree Allred: Yeah. Versus like, "No, I feel like myself again." Cassie Milligan: Yeah, 100%. "I Bree Allred: know I'm back [00:34:30] to me. I'm in, I'm at home in my own body again." Cassie Milligan: Mm-hmm. Bree Allred: I love that. Okay. [00:34:35] Thank you so much- Cassie Milligan: Yeah ... Bree Allred: for coming. Like, so much good [00:34:40] information, and I know that you have like hours more that you can talk about. So much, so I appreciate you coming. Talk about it all [00:34:45] day long. Yes. It's amazing. So what I love about this conversation is that we're normalizing [00:34:50] what's not normal. Cassie Milligan: Mm-hmm. Bree Allred: Right? That has been normals, normalized [00:34:55] basically. It's like, "Oh, well, you're just a woman." Cassie Milligan: Yeah. Bree Allred: Like, enjoy the wave, right? Yeah. Ride the wave, figure [00:35:00] it out. We're actually normalizing that it's like, no, that's not normal, and you can actually do something [00:35:05] about it, again. Cassie Milligan: Yeah. Bree Allred: And I know that there's so many women out there that it's like, "Oh my gosh, thank you. This is so [00:35:10] helpful. It helps me at least understand my body and different modes or options that I can take to starting to [00:35:15] get down that road of feeling like myself again." Cassie Milligan: Yeah. Awesome. Bree Allred: So thanks for joining us [00:35:20] for this episode of Healing at Your Core. If you're interested in working with Cassie, we'll have her information in the show [00:35:25] notes, and we hope that this brings you along to your journey to getting to the [00:35:30] core of your issues and really helping heal from the inside out. ​[00:35:35] [00:35:40] [00:35:45] [00:35:50] [00:35:55]