Not Just Hot Flashes: What a Doctor Wants You to Know About Hormones | Dr. Laura DeCesaris (Part 1)

In this week's episode, Laurie is joined by Dr. Laura DeCesaris, a functional medicine practitioner who specializes in women’s health and wellness. Dr. Laura teaches women in perimenopause and menopause about their bodies and brains, so they can make better decisions for their health and leverage their hormones to live their best life.

In this episode, we primarily focused on hormones. We start by discussing what happens to women from a physiological perspective during perimenopause and menopause. From there, our conversation shifts to all things hormones: different types of hormone replacement therapy, the difference between bioidentical and synthetic hormones and why you should care, annual tests that you should be requesting to establish a good baseline of information so you and your care provider can easily spot changes, lifestyle shifts that will support our hormone health, and more.

If you’re someone who is not a good candidate for HRT, you’ll want to listen in because we talk about alternatives for you, too.

Because I had so many questions for Dr. Laura, this is the first of two episodes with her. We continue our conversation in next week's episode, which focuses on gut health, brain health, and the top 3 things midlife women should prioritize to feel and show up as their best self.

LINKS + MENTIONS:
FREEBIE: Discover the Top 10 Techniques Used by Busy, High-Performing Women Around the World for Optimal Health, Hormone Harmony and Longevity

Labs List:
Hormone panel, Lipids panel, CBC panel, Metabolic panel, Fasting Insulin, Vitamin D, Thyroid panel

Dr. Mary Claire Haver

Cynthia Thurlow, NP

Connect with Dr. Laura DeCesaris:
www.drlauradecesaris.com 

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Transcript

SPEAKER_01:
Whenever I've asked, who would you like to hear from on the School of Midlife podcast, there is one answer that invariably comes up. A medical practitioner who treats menopausal women and who understands hormones. And look, I completely understand your interest in that conversation because it's not easy to find that combination. I know, I have personally been looking for a while now. But miracles do happen. I had the pleasure of meeting Dr. Laura DeCesaris earlier this year at a business conference. We were literally sitting right next to each other, and we've been trying to find a date for this conversation ever since. She is a functional medicine practitioner who specializes in women's health and wellness. She teaches women in perimenopause and menopause about their bodies and their brains so they can make better decisions for their overall health and leverage their hormones to live their best life. Because I had so many questions for Dr. Laura, this is the first of two episodes with her. In this episode, we're focused primarily on hormones. We start by discussing what happens to women from a physiological perspective during the menopausal transition. From there, our conversation shifts to all things hormones. So different types of hormone replacement therapy, the difference between biodentical and synthetic hormones, and why you should care. annual tests that you should be requesting to establish a good baseline of information so that you and your healthcare provider can easily spot any changes, some lifestyle shifts that will support our hormone health, and more. If you're someone who is not a good candidate for HRT, you'll still want to listen in because we talk about alternatives for you, too. I'm telling you, this is an episode you'll want to download and listen to again right before your next doctor's appointment. And you'll also want to listen in next week when I continue this important conversation with Dr. Laura. In part two, we'll focus more on gut health, brain health, and the top three things women should prioritize to feel and show up as their best self. Let's get started.

Welcome to the School of Midlife podcast. I'm your host, Laurie Reynoldson. This is the podcast for the midlife woman who's starting to ask herself big life questions like, what do I want? Is it too late for me? And what's my legacy beyond my family and my work? Each week, we're answering these questions and more. At the School of Midlife, we're learning all of the life lessons they didn't teach us in school. And we're figuring out, finally, what it is we want to be when we grow up. Let's make midlife your best life. 

Laura, I am thrilled to have you on the School of Midlife podcast. This is something that my listeners have been asking for. It's going to be a great conversation. Before we dive in, though, will you just please introduce yourself? You've got such a varied background, and I wouldn't want to not introduce you in the way that you see fit. So tell us a little bit about what you do, how you started, all the things. Catch us up on the background.

SPEAKER_00: Of course. Well, I'm so excited for this conversation, too. Ever since we met at Girlfriends of Business last year, I've been excited for us to connect more and chat about hormones and everything else for midlife women. So it's going to be a great conversation. Yes. So I do have a very varied background. I am a functional medicine practitioner. I currently run a health hormone and high performance consulting company that serves primarily midlife women, most of who are entrepreneurs, business owners, executives, busy moms. women who have a lot going on and like it that way but also want to feel and show up feeling their best day in and day out and not kind of sacrifice their well-being for their career, for getting to have all these different aspects of life that they that they would like. I didn't always know I wanted to go into this. Actually, when I was younger, I wanted to be a marine biologist, much like every other elder millennial who grew up in the Lisa Frank era realized that really was not going to be as quite a fruitful a profession as I wanted. And I got really interested actually in genetics and studying cancer. My mom, her identical twin, and my older sister all got diagnosed with thyroid cancer within like a year of each other when I was in high school. and I just was really fascinated by the connection between that. I went off to Cornell University, got myself a job the first week of school in a genetics lab, and promptly found I hated doing research. It was really lonely. Every PhD student I talked to was like, don't do this. You need more socializations. I'm like, okay, I better better find something else to do if I don't want to be by myself going into the lab at midnight all the time. So obviously some sort of patient interaction career was kind of next for me. But something really critical happened at the time when I was trying to figure out, do I want to pursue an MD? Do I want to look into osteopathy and get a DO? What other options for me are out there? When I was trying to figure that out when I was a junior in college, I actually got diagnosed with a thyroid disease as well. I got diagnosed with Hashimoto's disease, which is an autoimmune thyroid condition. And when I went to my then endocrinologist and kind of said, like, what do I What do I do? What's going on? I'm 21. I'm supposed to feel like at the prime of my life, and instead I'm tired and overweight despite dieting and exercising, and I feel like crap, and I can't remember anything from my classes." And he pretty much said like, oh, he said, to be on medication for life. This is just your life now. And maybe because I'm a little stubborn, I was like, I'm 21. That can't be the answer. It can't be like this forever. And so my mom, who was into functional alternative medicine before it was as mainstream as it is now, she's like, no, no, come home. You're going to go with me and see my functional medicine practitioners. roll my eyes, like, okay, all right, we'll do whatever she says. And that woman changed my life. I went in for this appointment, she knew just by like, looking at me and like poking different areas and asking me questions. She could tell all these symptoms that I was having that I didn't even share with her. And she helped me understand how they were connected, how, you know, stress and not sleeping and constipation and the weight were all related to my gut and to my hormones and And no one had ever pointed that out to me and that if I actually fix some of these things, I could actually send that Hashimoto's into remission and have a much different life. So with her guidance, I did just that and decided like, Hey, this is what I want to do. Like this lady is, I think she was like 65 at the time and she just loved showing up to work every day, which was just, I think, so refreshing to meet someone who loved their job. after that many years in it. I was like, yeah, I'm going to do whatever she's doing because this is really cool. She's really happy. She has to interact with patients all day instead of being alone in the lab. So I literally did exactly what she did, which was first go to chiropractic school, which I found out was not exactly functional medicine, but it taught me a lot of really cool things about structure and function of the body. Got me really into things like weight training and just more athletic pursuits that I am just ever so grateful for. But from there, I also got my master's degree in applied clinical nutrition, and I did two postdoc programs with the Institute for Functional Medicine and the Academy for Anti-Aging Medicine. So I got my fellowship with both of those programs. I don't know what I'll study next, but I'm probably not done with school quite yet. But that's kind of my educational background and how I ended up doing what I'm doing now.

SPEAKER_01: so impressive and you have accomplished so much at such a young age and how incredible to figure out what it is you wanted to do so early on and have that really guide your path and still light you up and do something that you love. I don't want to spend too much time here, but can you explain to the listeners the difference between functional medicine and how it differs from, say, conventional medicine, particularly as it relates to treating midlife women?

SPEAKER_00: Absolutely. And I want to preface this by saying that functional and conventional medicine are often pitted against each other, and that's really not how things should be. They're really meant to compliment each other at the end of the day, conventional medicine, which many people just know as healthcare has medicine is kind of, you know, you have your primary care physician, you have a bunch of specialists that you go to. If you have symptoms in a given area, typically they diagnose you with a disease or a condition. And they give you an appropriate treatment, which is typically medication for the most part. There's nothing wrong with that. Conventional medicine is fantastic for emergency care, for infectious care, obviously for addressing major issues. But where it tends to fall short are in areas like hormone health, like addressing chronic inflammation and chronic illness, like helping women figure out, hey, why am I anxious and not sleeping and gaining weight? And I feel like crap. And I don't want to go on five medications to manage each of those things. So functional medicine then kind of takes a step back and starts to look at everything from more of a whole systems point of view. It's a little more preventative. It's a little more proactive. It's a little more personalized. So rather than basing it on an algorithm that ends with a prescription, it says, hey, this woman across the table from me what happened in her life that led her up to this point, age, let's say, 48, feeling the way she feels? What was her childhood like? What has her diet been like? What are her stressors? What is her day-to-day life and routine? What is her mindset and relationship to stress and to her health? And so it kind of starts looking at all of these different areas of really daily habits, things that we do every day, and how they can be contributing to our health or our lack thereof. It may use different types of labs. It may use therapeutic nutrition. But really, it's meant to treat the individual in a way that's very simple and sustainable and doesn't just address the symptoms, though, of course, we want people to feel better more quickly, but also sets them up for long-term success by getting to the root of those issues and addressing things from the foundations.

SPEAKER_01: I said I didn't want to spend too much time here. But now that, what role does genetics play in all of this? You talked about healthy habits, you talked about lifestyle, but you also talked about your mom and her sister and like there's definitely some familial connection here. So I'm interested in the role of genetics.

SPEAKER_00: Yeah, so best estimates, genetics, are maybe like 10% for most people. So it can be relevant because, for example, I shared a little bit of my family history. I know that there's something genetically there that makes us a little more prone to conditions that affect the thyroid. It's clearly there. So does that mean that I'm destined to get thyroid cancer like the other women in my family? Not necessarily, but what it does tell me is that that's my blind spot. So you better believe that I am continually staying up on thyroid blood work, thyroid scans, doing everything I can to support that organ as best as I can, probably more than your average person, because I know that that's a risk factor for me. Same if you have a family history of diabetes, of cardiovascular disease, of mental illness. You know that those are areas that maybe you're a little bit more prone to experience issues in if you're not supporting them well. There are some amazing functional tests that we can do genetic screening, not in the sense of how most people understand genetic screening, like going and looking for genes related to cancer, But looking at someone's genomics, looking at their genetics and kind of what they might be prone to in terms of their stress response, in terms of their detoxification ability, in terms of their hormone metabolism. So it can kind of tell us again, like, what is this person's blind spots? What are the areas that we really want to dial in nutrition and lifestyle and be proactive about keeping tabs on these things with annual labs? But overall, it's a small percentage. And I say that because I don't want people to be like, oh, it's my genetics. There's nothing I can do about it. You absolutely can. Eat whatever I want.

SPEAKER_01: And just as that is how I'm going to end up. Final question on that. The tests that you talked about, are those typically covered by insurance? women decide to go a more functional medicine route versus conventional, are they typically coming more out of pocket for testing and care?

SPEAKER_00: There are some great companies out there, like Aruba Health is one, RUPA, that people can use their HSA or Flex accounts or their FSA accounts to purchase those lab tests. But most of them are not covered by typical insurance. I figured. Unfortunately. Right, unfortunately.

SPEAKER_01: Okay, turning the tables now. Let's focus on what I said. Laura, will you come on and talk about hormones? And so let's focus on that now. It used to be that we never talked about menopause and certainly not paramenopause. I mean, that just, you know, we had no words or language around what happened up to the point where we stopped menstruating. So for those of us who don't have a medical background, could you give us a primer, I guess, on what goes on in a woman's body when she is going through perimenopause? And I understand that I'm probably asking you to explain at least a semester, maybe an entire year's worth of material here, but I think that's part of the issue is we have, we experience these symptoms you know, hot flashes, brain fog, anxiety, weight gain, but we don't know why. So we don't understand really what's going on physiologically in our bodies. So could you help us understand that? We'll start with the easy questions first.

SPEAKER_00: Absolutely. When you said that, I'm probably asking you to summarize a semester or a year. All that went through my head was, I wish most schools, whether you're in conventional medical school or even functional trainings, unless you're someone who is pursuing education in menopause and perimenopause, you probably won't get much education in those areas. So just for all of you midlife women out there listening, remember, you get to choose your doctors. You can hire and fire accordingly. So ask the questions when you're setting up those appointments. Hey, does this person have training for perimenopausal or menopausal women? are they up to date on most current guidelines? You've got to advocate for yourself in general in today's world, but especially as a midlife woman. So kind of doing your due diligence and checking into the background of the practitioner that you're looking for, I think is really, really important. So what is perimenopause exactly? And it's interesting because before we hopped on, I was almost thinking, I wonder what age range her audience considers a midlife woman. Well, here in the US, life expectancy for women is 78, which puts the, if my math is correct, puts middle of life at 39. So really, we're talking here mid-30s, 40s, 50s. That's really a big a couple of these two decades here is kind of this mid-lifetime, which also happens to be when perimenopause can happen. Perimenopause is usually about the 7 to 10 years before a woman hits menopause. And menopause, I will say, is a moment in time. There's a lot of, I think, confusion with this terminology here. The definition of menopause is when you have officially gone 12 months without a menstrual period. Before that, you are perimenopausal. After that, you are postmenopausal. The average age where that menopause, that moment in time, happens is 51, but it can happen anywhere from 45 to 55. So perimenopause, if we take it back, that 10-year spread, in some women, that can actually begin in their mid to late 30s. So, we can start getting these hormone changes pretty young, I think. I mean, maybe because I'm 36, maybe that's why I think it's pretty young. But I can tell you my hormones are already different than they were when they were 30. I already know things are changing. So, it's that women don't have to wait until they're 50 to start looking at some of these things. They should actually start being super proactive in their mid-30s and understand what their baseline is to set them up for success going into the next two decades of life so that you know what those changes are. are. And typically, a couple of things happen in this perimenopause window. So ultimately, over time, as a woman eventually hits that menopause day, our primary female hormones, estrogen and progesterone, they're going to decline with time. They're going to decrease. but they tend to put up a little bit of fight on the way out. And this has to do with a lot of the communication between the brain and the ovaries, meaning it's not this slow, gentle decline, especially where estrogen is concerned. It's kind of all over the place, ups and downs, peaks and swings, peaks and valleys. And that is what is responsible for a lot of the symptoms that women experience, like hot flashes, temperature changes, changes in executive function, brain fog, weight changes, period changes. It's because these hormones are not as consistent and regular as they were when we were younger and the brain is trying really hard to figure out what's happening and it's kind of sending signals like, not enough estrogen, let's go make more, or too much estrogen, let's stop making it. And instead of having, again, that nice smooth pattern, it's kind of all over the place. Additionally, when we think about what women in their late 30s, 40s and 50s, just where they're at in life, we have families growing up, we have women reaching higher points in their career, maybe grandkids are coming along. The stress levels tend to be a little different than they were when we were younger. higher stress levels, right? And of course stress, long-term stress, further exacerbates this hormonal change issue that's going on here. It can tank a hormone called progesterone, which many women might have heard of in relationship to fertility, but it's also important for a lot of other things. It's important for sleep. It's important for a sense of calm and ease. And how many of you who are midlife women all of a sudden develop sleep issues and find you're like anxious and irritable for the first time in your life for no reason? A lot of the time it's because we're all of a sudden missing this progesterone because we've compounded the impact of age-related loss of progesterone. with years of accumulated stress that's further causing a decrease in that. And then that sets us up for an imbalance between estrogen and progesterone, worsening some of these other symptoms like weight changes, like issues with blood sugar, like that little bit of fluff around the midsection that seems like it popped up overnight at some point in your 40s. So things are changing a lot. And I think the temptation for a lot of women is like, Where did this come from? I'm doing all of the things I've always been doing and they're just not working anymore. And it's because we're applying, you know, nutrition and exercise and lifestyle that worked really well in our 20s and early 30s to a completely different physiology. manual, like two types of cars, like whatever, whatever comparison you need to make. But essentially we need to realize and recognize that as all of these hormones shift, so too does our nutrition and our exercise and our self-care and our stress management. We have to change those and change the way we look at it to kind of reflect these internal changes that are going on. So much. It was a lot. I did my best to summarize it.SPEAKER_01: No, you did a fantastic job. It's as someone, I mean, I'm in my 50s now and damn this would have been good information to have, you know, 20 years ago or even 10 years ago. So I'm glad that we're finally starting to have the conversations. So now that we know what we're up against, and I'm not sure that that's the right way to put it, but can you speak about some different options we might have for women to optimize their hormones and feel their best? Or maybe we're not even there yet. Are there steps that we need to do in between?

SPEAKER_00: I think the best way to look at this is there's a couple of shifts that have to take place. And I know the tendency for most of us is to be like, and this is just what we've grown up thinking in our conventional health care system is, oh, yeah, this is happening. So like, where's the pill I take for that? And absolutely, things like hormone replacement therapy can be super beneficial, specifically in this perimenopausal window, but especially when they're done alongside lifestyle changes. We always know people get the best results when they're doing both. unfortunately, there is no like one magic pill that's going to magically make a person feel better. But if we get the blueprint right for each woman, and if they're a good candidate for something like bioidentical hormone replacement therapy, it can drastically change the quality of life. So I also want to make a comment that if you're listening to this, and maybe you are closer to your 50s or 60s, the thought of hormone replacement therapy probably scares the crap out of you. Because you grew up in a time when a study called the Women's Health Initiative came out in the early 90s, which basically scared the crap out of every healthcare practitioner when it came to prescribing hormone replacement therapy. It was a very poorly designed study in hindsight that has been debunked many times over, but essentially what came out of it was people said hormone replacement therapy causes cancer. So many women who were going through these changes were not given that as an option. We know now that that's not the reality. And there's a difference between synthetic hormones and bio-identical or body-identical hormones, which are closer to the way that our hormones look. We know that things like synthetic progesterone, we want to stay away from that. We know that that actually does not have good health outcomes. That is typically what carries with it risk of increased cardiovascular disease, of stroke, of things that we do not want. It's also called MPA, if anyone has ever come across that. bioidentical progesterone, bioidentical estrogens, have actually found to have the opposite effect. They actually help preserve cognitive function, decrease the rate of dementia and Alzheimer's, which women are three times more likely to get than men after menopause. Isn't that bananas? It's crazy. So crazy. Yeah. So crazy. And that's because estrogen does have a very protective effect on the brain. And we really miss it when it's gone. But bioidenticals can also help with preserving bone density. They can help with those vasomotor symptoms, which are things like the hot flashes, like the night sweats. And generally, they can give women a better quality of life, especially when they're done alongside healthy lifestyle changes. When we look at the lifestyle side of things, I think the biggest thing that midlife women can do is start making the best nutritional and exercise choices to keep their blood sugar balance. Not to throw another hormone into the mix, but when all of these hormones are changing for midlife women, for perimenopausal women, what also happens is we lose something called insulin sensitivity, which is what we need to keep our blood sugar at a healthy level. So if we lose insulin sensitivity, what happens is basically we don't respond as well to the food we're eating. We get blood sugar swings more. And this feels like energy up and down all day. This feels like food cravings that you never really had before. This feels like waking up at 2 or 3 in the morning and you're not sure why. This looks like sudden weight gain usually around the middle, no matter what you're doing. A lot of the things that women tend to deal with at this point in time. And so starting to look at our nutrition and our exercise and say, hey, instead of trying to just like lose weight, instead of trying to change my appearance, how do I work on this internally to keep my blood sugar as healthy as possible? There's so many cool things you can do now to even measure that if you're a data-driven woman like myself, right? You've probably seen people wearing little continuous glucose monitors on their arms, or there's little finger tests. But you can actually see how you respond to different foods, to different types of exercise. I would say the biggest trends for midlife women that they could do is seriously increase their protein intake. Watch the alcohol. I know nobody wants to hear that, but as we age, our alcohol tolerance as women gets worse and worse. And really, it's only going to exacerbate all of these hormone changes that we have, especially if it's at night before bed. Almost a guarantee that it's going to interfere with your sleep. So those are the two biggest things. You're like, I have experienced this.

SPEAKER_01: You talked about energy, food cravings, waking up at 2 a.m., weight gain, alcohol intolerance. I have all of those. So yes, I resemble everything you're talking about. OK, a couple of things to unpack there. You talked about being a good candidate for HRT. So how how would women know if they're a good candidate for hormone replacement therapy?

SPEAKER_00: Yeah, so my favorite way is there's lots of different ways to test hormones, right? There's blood tests, there's saliva tests, there's urine tests. There's one urine test in particular, it's called the Dutch test. The value of this test is it looks at how a woman metabolizes estrogen, meaning estrogen is metabolized through the liver, there's two different phases of it, and there's a couple of breakdown products, little sub-estrogens, we'll say. There's a two, a four, and a 16 estrogen metabolite floating around in all of us. we can actually see using the Dutch test which metabolism pathway a woman favors. We want estrogen to be metabolized down what's called the two pathway. It's the healthy anti-inflammatory pathway, good things. We don't want it going down the four pathway, which is inflammatory, linked to DNA changes, higher risk of cancer, estrogen related issues. If we run a Dutch test and we see a woman preferentially metabolizes down that four pathway, she's not someone who I'd want to introduce any sort of exogenous estrogen into the mix because her body's not doing something really healthy with it. So even that's just like a one-time screen to figure out how this person metabolizes it, I personally feel that information is so valuable for anyone that's considering any sort of hormones. Obviously, if you also have a family history of hormone-related cancers, that's something to consider as well. Probably would be a good candidate for that. A lot of that is specifically tied to estrogen, though. Doesn't mean that you wouldn't be able to utilize other types of bioidentical hormone replacement, maybe a progesterone, maybe even testosterone. But understanding how a woman metabolizes these hormone pathways brings to light which things will be the most beneficial for her and if she's a good candidate for them.

SPEAKER_01: So I need a little bit more understanding between bioidentical hormones and synthetic hormones. And maybe it's just, could you explain the difference between the two? Maybe how they work in our systems? And are there Are there names or like trade names or prescription names or something that people could recognize so that we can understand? Are we dealing with bioidentical hormones? That's hard to say. Or synthetic hormones?

SPEAKER_00: Sure. So synthetic hormones, the most common are like primarin is the big one for estrogens. And if we break down the name of it, primarin, it's actually pregnant mare urine. It's made from the urine of pregnant female horses because it has a whole bunch of different kinds of estrogens in it.

SPEAKER_01: And named by a man, I'm sure.

SPEAKER_00: who can make this really simple, right? That's one. Or in terms of the progesterones, MPA, which is medroxyprogesterone or Provera are some of the brand names. These are synthetic hormones. MPA in particular, I mentioned earlier, is one that has not been linked to some great stuff in studies, would not recommend. Synthetic hormones, they look different than the hormones our body makes. So ideally what happens is get a big dose of those and the body converts some of it to a usable form. So it's dependent on the body being able to do something with it, being able to convert to a form that's usable. Versus a bioidentical hormone, which are actually just named for the hormone. So it's bioidentical estradiol for estrogen, bioidentical progesterone for progesterone, keeping it very simple. These have the same molecular structure as the hormones that our body makes. So what's going into the system is what the body what the body already makes. So a little bit simpler for the body to utilize and respond to at the end of the day.

SPEAKER_01: So why would anyone use a synthetic hormone?

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SPEAKER_00: Typically, so that was what was developed first, and that's still usually the standard of care with any conventional practice. That is what is owned by pharmaceutical companies, to be honest. Bio-idemicals you typically have to find through a practitioner or a compounded pharmacy. That's honestly, I don't consider myself a conspiracy theorist, but I actually can't come up with any better reason other than one is owned by pharmaceutical companies and one isn't. To me, that's probably what it is. I think we're going to see changes over the next decade where bioidenticals are going to be, they're already more available than they used to be even five, 10 years ago. So we'll see how that changes over the next decade as well. Some of it is also just a study lag, you know, and when we read studies on things, you have to remember by the time something comes out and is published in the study, it's usually been in the works for like two, three decades. Sometimes that information is already out of date by the time it's published. So right now it's 2024. We're still working with some stuff from the 90s, from the early 2000s, whereas seeing like longer term impacts of bioidenticals, some of the newer therapies, we probably just don't have that yet.

SPEAKER_01: Interesting. When most of us outside of the medical field think about hormone replacement, it seems like we only think about estrogen. And you have talked about estrogen and progesterone. We haven't talked about testosterone, although I do know some women who take some of that. And you've touched on this briefly, but why Can you, can you go a little deeper on why is estrogen so crucial for women's health? And what, so we've got the benefits, but then are there risks that go hand in hand with estrogen therapy?

SPEAKER_00: Yeah, so in my mind, they're all important. I'm not sure why. I'm guessing because so many people associate estrogen as the primary female hormone. That's why it gets the most attention. And we do know that estrogen, I should say, the loss of estrogen that women experience in menopause, we know that it's directly correlated to the increase in disease risk that women experience post-menopause. in every field from cognitive decline and brain health to cardiovascular health to metabolic health and blood sugar to bone health and muscle loss. So people focus on it for a good reason because we know that estrogen receptors in the body are widespread and without it, our disease risk does change really drastically later in life. It does. However, I think the other hormones are just as important. Actually, If we look at the amount of hormones in our body as women, we actually have the most testosterone relative to the other hormones, which we don't always think about. So testosterone is really important. And it is important for holding on to our muscle and our bone. It's important for vitality, for libido, for all of these other things that really do impact quality of life. So it is something that's important to pay attention to. And progesterone, especially when a woman is still having a cycle and perimenopause, it's essential to counterbalance that estrogen, right? It's all about their relationship to each other. So in my mind, it's important to look at all of them, not just one of them, and kind of see, well, how are these operating individually, but also in relationship? to each other. Someone may have high estrogen but low testosterone and progesterone. So we have to kind of look at, well, how do we re-regulate the ratios between these things? Whereas another woman may come in and have, maybe she's had PCOS when she was younger, she has elevated testosterone but really low estrogen and progesterone during perimenopause. Those are going to be different experiences and different treatment approaches for those two women who are both in the same stage of life. So that's where that bio-individual piece

SPEAKER_01: comes into play. And I would assume also when we're talking about bioindividual, there are some challenges in getting hormone therapies right or dialed in for each individual. Is that correct? And what does that process look like?

SPEAKER_00: Absolutely, and there's a lot of different forms of these hormones too, right? People can take them orally as little capsules, they can be injected, they can be patches. So whenever I'm working with a client who she's like, hey, I'm interested in bioidenticals and I work with a third party company that does bioidentical hormone replacement for them and I say as we go into this I want you to approach this with curiosity and understand that we may have to try a couple of combinations out before we find the one that's a perfect fit for you. Some women respond really well to transdermal or patches Other women do really, really well with oral forms of it. It completely depends on the woman, on her history, on how she metabolizes things. And then we have to play around with dosage and frequency. So it is a little bit of a, I guess, an art as well as a science at figuring out what works for each woman. Sometimes people get it right the first time. Sometimes they have to try things out for a little bit, figure out what meets their needs where they're at.

SPEAKER_01: If you take, say, estrogen in a patch, would you also take progesterone in a patch or not necessarily?

SPEAKER_00: Necessarily. Progesterone, for example, is often taken as an oral form, oral micronized progesterone. A lot of women do really well taking it at night just because, again, it can help with sleep, with that anti-anxiety, that calming feeling. But they may still do a transdermal estrogen, a patch. And maybe they do once a week a testosterone injection if they have low testosterone as well. So you can kind of mix and match with the different ways to apply these things as well.

SPEAKER_01: to be mindful of your time but you're just a wealth of information and I certainly want to serve the listeners as well. I will say I've talked to a lot of women whose doctors refuse to work with them to balance their hormones. Like they also refuse to write prescriptions for HRT. They'd rather write them a prescription to address their symptoms like high blood pressure or high cholesterol or anxiety or depression. And I would love to hear your opinion on… It seems like more and more women need to advocate for themselves when it comes to seeking care. And it seems like what I think I'm hearing you say is, if you've got a doctor who says, that is off the table, we're not going to do that, then you need to go find another doctor. But I would love to hear your opinion on How can we advocate more effectively for ourselves when it comes to our healthcare and midlife?

SPEAKER_00: And I have to say, I always feel, I don't know if feel bad is the right phrase, but I always have empathy for medical doctors in today's conventional system because I'm pretty sure they didn't choose to go to medical school, spend that much years and so much money educating themselves to basically be ruled by insurance company algorithms and have like the threat of malpractice hanging over their head at every second. So I've met a lot of doctors who I think are super burnt out and they just feel very boxed in by what they can do for people.

SPEAKER_01: And I don't think- And of course you've got the Monday evening quarterbacks who are just diagnosing themselves on the internet and like, well, and then I think we should do this too.

SPEAKER_00: Right. I imagine you spend all that time in school and they're all of their postdoc fellowships and residencies. And then someone comes in with their stack of Google papers and is like, I know better than you. And granted, not every doctor's in that case. Like, I think we've all encountered there's there's people in every profession, I think, who are just ego gets in the way a little bit. But I think there's a lot of great practitioners out there who just feel a little stuck in what they can do to help people. Either it wasn't part of their education to get into hormone replacement or The clinic that they work for has just set things with insurance companies in place, and this does not fit that model. Even now, when women who are menopausal are going in for care, I think it's only 10% are offered any type of prescriptive therapy. And amongst that, it's typically for antidepressants to address menopausal symptoms that are coming from hormone changes. Why do you think that is? I have no idea. It's very frustrating to me. I think, again, it came from just the way that care algorithms were set up, fear of hormone replacement, some common symptoms as we lose that estrogen in the brain are anxiety and depression and things like that. So unfortunately, it's become a hallmark of certain areas of our health care system that if you don't feel your best, let's just change your brain chemistry so you don't have to think about it quite so much anymore. Not that those medications- Just be more positive. Right? Yeah, just relax. Just relax. Don't stress about it. Not that those medications can't help some people. I don't want to come off as anti-medication. I think it's been helpful for a lot of people. But I think there's a lot of women being underserved by only focusing on that and not being told to talk about their options. So if we're going to advocate for ourselves, I think some of it is, again, if we're starting with a new doctor, hey, I have a question, like, is this physician trained in menopausal care? Like, are they trained in education around hormone replacement therapies, I would like to know my options, kind of like get a feel for what's happening ahead of time there. I think women can also expand their options, you know, maybe you do want to look towards a DO, maybe you want to look towards a naturopathic position. to complement your care from your primary care provider, people that have done more training in some of these areas and may be able to talk you through different options a little bit more. To me, the biggest red flag is when any practitioner, I don't care what their credentials are, doesn't have the time to sit down and talk through options with you. Even if they disagree with what you want, if they don't take the time to explain why that is and make sure that you feel comfortable and have an educated discussion about it and instead they just brush you off and kind of brush an idea off, to me that's a sign that either they just don't know what they're talking about or their ego is getting in the way and no one deserves a practitioner of any sort who shows up bringing that kind of stuff to the table. So sometimes it does mean being brave enough to be like, well, I would like to talk with someone about these options and I'm going to walk away because this person isn't willing to do that. Or maybe it's just taking the time to ask your provider and be like, hey, can we talk about this at my next visit? Like, I know that we haven't really talked about hormone options before, but I'm feeling really poorly. I have questions. I would love to talk things through with you and know your opinion. I think you'd probably be surprised. That might go a long way with certain providers to say, wow, okay, this person really just wants to have a conversation. They're not just going to show up and be angry at me and yell at me. But if you've been on the receiving end of behavior like that, I would get out of there and find a new person. Absolutely. It has to be a mutual respect and it has to be a partnership in your health, especially in this phase of life. It can't be that authoritative doctor-patient relationship. You have to be on equal footing talking through this transitional phase.

SPEAKER_01: If women are looking to make a change with their health care provider, are there certifications for menopause? Or is there a directory somewhere of providers who focus on menopause? Or, like, where would they start?

SPEAKER_00: Yeah, two places come to mind, and I'm happy to give you links afterwards. And I'm sure there's more than this, but these are two that come to mind. One is there's an amazing physician out of Texas, Dr. Mary Claire Haver. Many women have probably seen her content. I know that she has started putting a directory together of practitioners who are trained in her methods specifically for menopausal women. So that's one. Another one is Cynthia Thurlow, who's an incredible nurse practitioner. She is an expert in intermittent fasting, particularly for midlife women. But she has also put together a directory of practitioners who do prescribe bioidentical hormone therapy and are well-versed in perimenopause and menopause. So those two areas, I think, are great starting places for people to look. And I'm pretty sure it's nationwide, practitioners on those. It's not just in their home states. So I can find both of those links for you.

SPEAKER_01: What? That would be great. And we will we'll drop them in the the links and mentions clickable links for those, which will be fantastic. What are the, are there rules about, I'm in Idaho, we don't have a great track record of preserving women's rights in the state of Idaho. You probably have read that more and more family practice doctors and OBGYNs are actually closing shop and leaving the state because of some of the legislation that's come down. Can we, if we are in, I'm gonna call it a menopause, practitioner desert, I don't know what else to call it, but can we create relationships online with practitioners who are in different states? Can they write prescriptions? How does that work?

SPEAKER_00: So there's a couple of different avenues you can go here. And one, again, we talked earlier about, hey, I want to pursue the hormone replacement side of things. And I also want to pursue the lifestyle support side of things. So for example, myself and plenty of other health consultants like me, we work across state lines, but we're really focusing on patient advocacy, on figuring out what's going on, on supporting someone with nutrition, with lifestyle, with figuring out what they need. But there's similar third-party companies who, what they do is they handle prescriptions. So they are a linked network of providers in different states. So that when you come in to see them, they say, hey, what state are you in? And they link you up with an appropriate provider. That's still all usually done virtually through telehealth. to help get you what you need. So for example, I partner with a company called Joy Women's Wellness. Essentially, they are a telehealth company that does bioidenticals, they do peptide therapies, things for healthy aging as well, but they have practitioners licensed in every state. So when I'm working with a client in California or New York or Minnesota. I know that no matter where they are, when I set them up for a consult with Joy, if there's someone who's interested in hormone replacement therapy, they'll be taken care of with a state bounce. So we can kind of partner on their health that way. It's almost like having a little care team in your corner. So there are more and more companies like that coming out to help women get access to these things.

SPEAKER_01: So if someone was working with you, then you would, and you're not in the state where they live, then you would reach out, make a referral to a doctor, and then the care transfers to them? Or you were talking about a team, so does everybody stay on deck and we all, we're all trying to solve the same issue? Or how does that work?

SPEAKER_00: Typically depends on the client. A lot of the times if I'm working with a woman and she, she admittedly also needs help with nutrition, she's other stuff going on. We found out her guts a mess. She's got crazy stress levels. She wants the educational piece. We keep working together. And then it's just an adjunct like, Hey, in addition to what we're doing. I'm also going to set you up with Joy Women's Wellness. I want you to have an educational consult with them about their bioidentical hormone replacement therapy because companies like that, that's kind of what they deliver. They're not necessarily supporting and coaching and all of these other aspects of life. Sometimes it's done at the same time or maybe I'm finishing up with a client and we got really great results, but she's like, hey, I want like I want to do some aging peptides. I want to do some bio-idemical hormones to help with sleep or performance. Maybe after her care is over and that comes up towards the end of the conversation, we do transfer care over. It completely depends on the person. What are aging peptides? So I hate the phrase anti-aging peptides because I think that phrase anti-aging is just so stupid. Because we're all going to do it. And aging is a privilege. It is a privilege.

SPEAKER_01: The alternative is you don't age and you don't get to do anything else. So why wouldn't we want to?

SPEAKER_00: And I don't want to age gracefully. I want to age actively and vibrantly and feel my best for all of my years. So peptides, a little bit of an offshoot of hormone replacement therapy. Peptides are little tiny molecules that sometimes the body makes them in small forms. Perhaps the best known peptide right now is GLP-1 agonists, also known as Ozepic, those sorts of things. But they're things that can just like help our body work a little bit better. So for example, there's skin peptides that can help with skin aging. There's peptides that can help with gut repair and healing. There's peptides that can help with energy levels and cellular health. So it's kind of just like a deeper layer of performance supplementation to help people function at their peak.

SPEAKER_01: I want all of that. So we talked a little bit about if you are going to a new practitioner, kind of some of the things that you should vet ahead of time. Are there certain tests? We talked about the Dutch test. We talked about a blood test, some other tests. If we are going in to establish a relationship with a new provider, and we're in that late 30s, 40s, 50s, early 60s age group, which I understand is a very large range, are there certain tests or exams that we should have or to have a baseline to kind of understand where were the areas that we could improve upon, maybe where our blind spots are.

SPEAKER_00: Yeah. I would be happy if you would like, I can share with you my annual lab lists that I run on myself and all of my clients. So that way people can basically take it and ask their doctors for it. There's a couple of things that I think just for a baseline once a year that you can get run in terms of a blood test. We're going to look at things like we can look at your hormone levels, your sex hormones. We can look at your thyroid. We can look at your cholesterol, your triglycerides, also called the lipid panel. We look at something called a CBC, which looks at our red blood cells, our white blood cells, tells us a lot about like iron levels, immune system. We run something called a metabolic panel. This looks at things like your fasting blood sugar and your electrolyte levels and your liver markers. I think people should run fasting insulin every year. You usually have to ask for that one extra. What else do I like to run? Let me think what else is on my little lab list. Those are the big ones. I also run vitamin D just because so many women are deficient in it. I run like red blood cell magnesium because again, so many women are deficient in it. But I'll give you the whole lab list that I typically recommend just as a baseline, like a women's wellness panel. This is what you should get run at least once a year and figure out where you are. For my clients, I typically recommend that alongside a gut microbiome test once a year. This is an at-home stool test that tells us what's going on in your gut. Because the gut really is the foundation of our health, and if the gut is off, it can impact our hormones, our mood and our mental health, our weight and our metabolic health. our detox ability, everything else. So at the bare minimum, I have people do a women's wellness blood test and a gut test every year. Are there other tests you can run? Sure. Some of it depends on like your personal history, your personal preference. But I think those two, if most people stay on top of those year after year and kind of be like, hey, where do I need to focus my time this year? Like what's happening in my body? You'll be amazed at how much better you can feel and how much it will streamline your nutrition, your exercise, your supplements, so that you're not needlessly taking a bunch of stuff just hoping that it works.

SPEAKER_01: We're going to come back to gut health, but let's wrap up hormones if we can. I mean, I know that it's still going to Hormones touch everything. So if you're not a good candidate for HRT, because I understand that some people have medical history that they can't do it. There could be other reasons. But could you walk us through some other non-hormonal strategies that women can use to alleviate the symptoms of perimenopause? Absolutely.

SPEAKER_00: So let's put these in a couple of buckets and we'll start with nutrition. Nutrition can be an incredibly therapeutic tool if you let it, right? So we chatted earlier about looking at our nutrition from a way that keeps our blood sugar balanced. This can look like increasing your protein. And it looks like something that I call an ideal plate design, which means when we eat, we want to look at our plate. We want to make sure it has protein. some healthy fat. This could be like olive oil or avocado or nuts and seeds. And then we want it to have fiber, ideally in the form of brightly colored fruits and vegetables. It can also be soluble fibers like oatmeal, like whatever you're looking at. But those three components tend to help keep blood sugar very balanced and hormones happier versus a big plate of carbohydrates alone. which will tend to be a little difficult for the body to handle. So from a basic standpoint, they are delicious. They are. And you could still have those things, but what I tell my clients are is if you're going to have the big bowl of pasta, you have it with protein and you eat the protein first. Try and blunt that blood sugar spike a little bit. Your body will thank you for that later. I would never totally remove someone's delicious bowl of pasta from them.

SPEAKER_01: Not all heroes wear capes.

SPEAKER_00: So we can start with simple things like that. I think most women, and we have to think, again, in this perimenopause and menopause age, again, I mentioned earlier, we tend to start losing muscle mass as we age as well. So our protein needs actually further increase because we lose muscle more quickly as we age. So this goes hand in hand with increasing strength training, which is bucket number two, exercise, but increasing your protein intake Adding in resistance or strength training, I think these are really big keys at combating some of the hormonal changes that are happening. Strength training we also know improves testosterone levels, helps with libido, with energy levels, with holding on to muscle. It helps with managing our stress hormone cortisol. So I think some of the best thing women in perimenopause can do, and if you are a boot camp or orange theory junkie, like don't come running for me, but start doing more strength training and more like walking and sprints as your cardio versus the hour long elevated heart rate classes all the time. You can still go do those once a week, but you don't need to do them five days a week. It's not going to be favorable to your hormone profile in this stage of life at the end of the day. So those are some changes. And then we can also start looking into supplements or natural things that affect some of the symptoms that we're experiencing, right? Things like maybe hot flashes or weight changes or some of the mood changes. There's been herbs that have been studied for years and years and years that specifically help with some of these menopausal symptoms. Things like black cohosh is a big common one. You'll see that in a lot of like menopausal supplements to help with hot flashes and things like that. A lot of great research behind that one at helping modulate hot flashes, black cohosh and blue cohosh. There's a few that are like that, that you can take a look at in terms of herbal therapies, which again, for women that can't do hormone replacement, it's another good option just to offset some of those symptoms that are happening. There's a ton of things if you're a woman who's more experiencing some of the brain-based symptoms, like maybe you're more forgetful, memory loss, maybe your mood is changing. So now we can look at things that help support brain chemistry. L-theanine is an amino acid that has a very calming impact for the women who Maybe you're tired at night, but your brain doesn't quite shut off. You're wired. You're a little anxious. That can be very calming. You can also look at things like nootropics. Maybe you're still working and you're like, man, my brain just does not fire the way it used to. This is a class of supplements that help improve cognitive performance. They increase blood flow to the brain. They can kind of just help with offsetting some of that impact of the loss of hormones on the brain for women. We can also look at lifestyle tools, like if anyone's ever heard of biohacking, things like the sauna and the cold plunge, we can actually use these really strategically too to help with menopausal symptoms. So what we find actually is when women cold plunge earlier in the day, and if they're going to use a heating modality like the sauna, doing that later in the day, that actually helps a lot with temperature regulation. You might be thinking, hey, I get hot flashes at night. Why the heck would I want to go into a sauna at night? Well, when the body heats up, it signals the brain to start cool down mechanisms in the body. So if we use the sauna later in the afternoon, the evening, it's almost like turning on the body's internal cooling mechanisms and bringing the body temperature down, which is what we want to happen for optimal sleep. So you can use those later in the day, get a good little cold shower earlier in the day, and that can help with some of the temperature regulation side of things, too. I know that was like a lot, but just some things that people can start looking at.

SPEAKER_01: That is fantastic. I still have, I want to talk about brain health, I want to talk about gut health. So we're going to wrap this episode right now, and then we're going to pick up this conversation in the next episode. Yay.

Thank you so much for listening to the School of Midlife podcast. It means so much to have you here each week. If you enjoyed this episode, could you do me the biggest favor and help us spread the word to other midlife women? There are a couple of easy ways for you to do that. First and most importantly, if you're not already following the show, would you please subscribe? That helps you because you'll never miss an episode. And it helps us because you'll never miss an episode. Second, if you'd be so kind to leave us a five-star rating, that would be absolutely incredible. And finally, I personally read each and every one of your reviews. So if you'd take a minute and say some nice things about the podcast, well, that's just good karma. Thanks again for listening. I'll see you right back here next week when The School of Midlife is back in session. Until then, take good care.