Ep. 156 – Mysterious Effects On Hormones & Intermittent Fasting: Tips for Optimizing Estrogen Metabolism with Dr. Stephanie Gray

Presenter: This is Everyday Wellness, a podcast dedicated to helping you achieve your health and wellness goals and provide practical strategies that you can use in your real life. And now, here’s your host, nurse practitioner, Cynthia Thurlow.

Cynthia: Today, I’m so excited to have Dr. Stephanie Gray. She’s a fellow nurse practitioner, a functional medicine provider, who helps men and women build sustainable and optimal health and longevity so they can focus on what matters most to them. She helps women in midlife, who feel their bodies have betrayed them step back into their bodies by restoring optimal hormone levels, so, they can regain their sleep, figure, mood, and feel amazing again. She is known for keeping hormone replacement therapy sexy, safe, and effective. Welcome, Stephanie. It’s such a pleasure to have you.

Stephanie: Thanks for having me on.

Stephanie: I have to tell you I get dinked all the time, because I don’t have enough nurses on the podcast. The biggest problem I find is, nurses don’t want to come on the podcast.

Stephanie: What? [laughs]

Cynthia: I find it even– Yes, it is a challenge. I think it’s maybe it’s our training, we were meant to be sometimes a little bit in the background, not front and center, and-

Stephanie: Sure.

Cynthia: -so, this will check at least one box for the year. Thank you so much for agreeing to come on. But I’d love for you to touch on, what brought you to being so hormone focused. I know based on previous conversations that you did some of your graduate education in this area in particular, but I know that listeners would love to hear about your journey, obviously, started off as a nurse, and kind of progressed to being an NP. But what got you interested in hormonal therapies?

Stephanie: So many things. Where do I start? Well, like you mentioned-

[laughter]

Stephanie: -as nurses, thankfully, we’re trained to appreciate the whole body. We’re taught the bio, psychosocial, cultural, spiritual, self, it’s something that we need to treat in totality. As a nurse, I thought, “Okay, I want to be able to prescribe medications at some point and get patients off drugs.” I actually thought of going to chiropractic college, because I thought that may be a good fit. I think I would have made a good chiropractor, but I’ll refer out those problems. Doing some of my graduate training in nursing homes, I saw a lot of incontinence, and I realized the number one reason for admittance to long-term care facilities was urinary incontinence.

Cynthia: Mm-hmm.

Stephanie: I learned the art of, which we don’t have to get into today, of pessary fitting, and I was trained to fit patients with pessaries to help with prolapse and whatnot. Long story short, I found there were nonsurgical, nonpharmacological options for urinary incontinence that helped patients regain some dignity and remain in their homes. I thought there has to be the same approach to every other condition. How do I get that training? I did become a nurse practitioner, and I sought out that training. I did the advanced fellowship through American Academy of Anti-Aging Medicine. Long story short, I’ve started my own practice. One way to get patients feeling better very quickly was optimizing their hormones. That’s where I decided to– that’s where I got the training to build my practice, which interestingly, also implies to urinary incontinence, because you don’t want to have a lot of estrogen deficiency in that area, or you can leak urine. So, that amongst my own personal journey. I have a long history of infertility. Thankfully, I, now have a beautiful almost two-year-old, but once you know of-

Cynthia: Amazing and beautiful.

Stephanie: -but I also have my own personal just health journey that led me along the route of learning functional medicine, which involved optimizing my hormones, and maybe we can go into more that later, but it was my personal story, and then, also just figuring out actually, I need to help patients. How can I better do that? Nursing was a step in that direction for me, but I needed to get through graduate school, and do a little additional training so that I had the rights that I needed to help patients the way I knew I needed to.

Cynthia: Well, I’m so glad that you have that additional training because, even though, all of my background as an NP was cardiology and ER medicine, so I’m that adrenaline junkie. I liked the really sick, on-the-brink patients. It wasn’t until I left clinical medicine almost five years ago, it’s hard to believe, that I started my own practice, that I started to have a healthy amount of respect for the endocrine system, and for our brains and how there’s this delicate orchestration between our brains, and receptors, and glands, and hormones. Now, I bow at the temple of the hypothalamus-pituitary axis, which for anyone who’s listening, this is contained in our brains, but it orchestrates all of this communication and traditional western medicine, I want to be really clear. I’m allopathic trained as it’s [crosstalk]

Stephanie: Me too. Yeah.

Cynthia: We both are, but there’s a piece of the puzzle that’s really missing. Root cause determination and management for chronic and preventative health can’t be underestimated. We’re both functionally trained, and for me, I was so humbled, when I started to realize I was like, “Oh, my gosh, we were chasing a symptom, but really, we needed to look upstream, and why weren’t we thinking that way?” Certainly, for full disclosures, I’ve been very honest and open about my thyroid journey in the last five months. Back in September, Nature-Throid, WP Thyroid were removed from the market, because it was determined that there weren’t the appropriate amount of dosage of medication and some of the prescriptive medications, and so for many people, they were thrown to the wolves to deal with, okay, are we going to do compound in medications, are we going to do Armour, or are we going to do synthetic–? [crosstalk]

Stephanie: NP-Thyroid, I’ve put a lot of patients on NP when that happened. [giggles]

Cynthia: Needless to say, five months later, I finally might have gotten the right pieces of the puzzle put together, but the reason why I’m sharing this is that had I not known what I needed to document, my providers might not have really listened to what I was saying, and I think about so many lost opportunities, not just for women, but also men who are feeling off. What kinds of conversations would you encourage people to have? What are some of the signs of hormonal imbalances in the body that may tip people off that it’s not just in your head, weight gain is not just because of COVID? I think a lot of people just keep attributing it to that, and I said it could be way more than that, but what are some of the symptoms? When you’re just scratching the surface, when someone comes to you as a new patient, what are some of the first things that you nuance for them to help them understand what’s going on with their bodies?

Stephanie: Well, speaking to women in midlife, which is the majority of my patient population, now, that we see about everything, maybe we’ll start with low thyroid symptoms. Patients will have that weight gain. Especially, weight gain, that just shows up one day, even though, they didn’t change their lifestyle, their diet-

Cynthia: Great.

Stephanie: -hair loss, dry skin, I tell patients everything slows down. The memory, the mood, the energy, their growth, the nail growth, your bowels, everything slows down. Those are symptoms of low thyroid. Through our conventional training, we’re taught to look at TSH and maybe T4. But we weren’t taught to look at free T3, reverse T3, thyroid antibodies things that functionally trained providers look at. To their credit, conventional docs, they’ll run the basic tests, and half the time they tell the patients you’re normal, but many times patients don’t feel normal. So, I’d encourage the listeners, if you’re having those symptoms, which are really just a handful of the symptoms, to dive deeper, find someone who will comprehensively assess your levels and interpret them appropriately.

Also, for women in midlife, even starting in the 20s and the 30s, I see a lot of low progesterone. I see patients with infertility which is, like I mentioned, what I was struggling with. Heavy bleeding, irregular cycles, anxiety problem sleeping, a lot of patients just wake up, and they have either fast heart rate, they’re waking up in the middle of the night just feeling something’s off, and they go to their doctor, and they’re put on an anxiety medication or sleeping medication, which may very well help, but that’s a band aid approach. That’s not getting at the root cause of the problem. Many of those patients do need progesterone. That’s usually the first hormone to go. Stress will rob you of progesterone. This last year, everyone hasn’t been maybe more stressed than normal. A lot of my patients’ levels are showing it. Their levels are lower than they’ve been. I say stress is the biggest hormone hijacker. It really is. So, those are some low progesterone symptoms.

Low estrogen can lead to, as I mentioned earlier, urinary incontinence. It helps tighten the skin. It helps minimize wrinkles, because of its benefit to collagen production. Low estrogen can lead to vaginal dryness, hot flashes, night sweats, memory fog, even bone density issues, and depression. Estrogen is most like serotonin, that calming, happy neurotransmitter. Progesterone is most likely GABA. We need both. We need serotonin and GABA support. A lot of women will start to have those, we call them vasomotor symptoms where they get blushing, whatnot. That can be due to low estrogen. Even testosterone is important in women. I’ve seen women as young as in their 20s with zero testosterone, which is a problem. But again, usually it’s midlife that we’re seeing those levels start to dip. Low testosterone can lead to poor mood, motivation, drive, libido, or energy, or muscle mass. Back to the weight gain thing, a lot of women are like, “Gosh, I’m going to Cross-Fit. I’m working out aggressively, but I don’t see the muscle gain that I used to have.” They just feel something’s off that they’re just not right. They don’t feel as well as they used to. Testosterone is most like dopamine, that other happy neurotransmitter. We need all of the above. [giggles] So, if you’re listening and you have any of those symptoms, you could be experiencing some hormone decline. How do we know if you have that? Well, look at your labs, and compare them to your symptoms, and then decide what we’re going to do to improve those levels, get you feeling better.

Cynthia: I know one of the questions that I was asked because I like to pose on social media who I’m interviewing to get a gauge a sense of where people’s questions go.

Stephanie: Yeah.

Cynthia: One of the questions that I got was, I’m perimenopausal. We know that’s the five to seven years preceding menopause. People were asking, is it appropriate for me to go on bioidenticals, I think they were speaking specifically to estradiol, or progesterone, or testosterone, and not so much the thyroid, I think that was separate.

Stephanie: Sure.

Cynthia: Well, obviously, without looking at labs, but do you have a governing philosophy? I would imagine you’re never too young for some hormonal support. That’s probably what I’m moving towards. But it sounds their particular provider said, “Oh, we’re going to wait till you get through menopause before we do that.” I said, “Why would you do that?”

Stephanie: Would you wait and suffer?

Cynthia: [crosstalk] need that. Right.

Stephanie: I think you know where my answer is going. But I think that question may be posed, simply based on her already talking to her doctor. The misnomer is that you can only take hormones 5 to 10 years. A lot of patients are told, okay, I’ll put you on this estrogen pill or whatever their doctors giving them. But they’re told, okay, you can take the short-term, and then I’m going to pull you off of it. I think some patients think, well, maybe I’ll wait until my symptoms get really bad before I’m going to be limited with how long my doctors could treat me. Maybe I’ll wait. I have to differentiate it. I would agree with that statement that hormones should be used short term if they’re synthetic. From my perspective, never. Synthetic hormones should never be or used only in short term. That does not apply to this person’s question being bioidentical hormones. When would they start taking bioidentical hormones? I’ve taken them, I’m in my 30s, so you can take them. I’ve started patients on them as young as 20s. Yes, you can start taking them earlier in life, and you can continue them essentially forever.

Hormones aren’t dangerous. They don’t cause cancer. Synthetic hormones are dangerous. I don’t recommend synthetic hormones, but we can’t translate the risks from synthetic to natural. That’s what a lot of conventionally trained doctors do unintentionally. They’re unaware. They’re not trained the differences with synthetic and natural. To answer your question, “Why wait, don’t suffer?” Yes, get on. If you need them based on your symptoms, and your labs, get on them sooner rather than later.

Cynthia: A little segue into the menopausal females question. Her question was, do you like– and I can probably guess the answer to this, but I said, “I will ask Stephanie regardless,” Bi-Est and Tri-Est, what are your feelings about those and pellets? Are you a fan or not?

Stephanie: Yes, I’m a fan of pellets. I think I’ll answer that question, then we’ll go back to the Bi-Est and Tri-Est.

Cynthia: [laughs]

Stephanie: Pellets are subcutaneous hormone implants. They’re about the size, I would say a little skinnier than a Tic Tac, but they’re like a little grain of rice almost. They’re not as thick as a Tic Tac, but about that size that can be implanted into the fatty tissue on the lower or back upper bottom area. Listeners might be thinking, “Well, why would I put [laughs] hormones there?” But believe it or not, this is what I truly believe is one of the safest ways to receive hormones. As you go through menopause, what is happening is your ovaries are essentially shriveling up, you might not want to hear it, but they’re shriveling up and throwing in the towel. There will be a day that is their last. Pellets are like having fake ovaries. They’re having a C team. Well, your ovaries are A team, adrenals are your B team, and pellets are almost having a C team on board, that your body can draw from when needed. They’re released on cardiac output.

When you’re working out, when you’re stressed, your heart’s going to beat harder, faster. Blood’s going to flow pass these hormone implants, bring some of that testosterone or estrogen into the bloodstream at times you needed them, and then less times, you don’t need them. They’re very convenient, because you’re not swallowing a pill every day, they’re just there upon what your body can draw from. Also, because they’re in that tissue, they’re cleared by the kidneys. They actually don’t go through your gut or your liver at all.

Cynthia: Okay.

Stephanie: That’s where hormones get all the bad hype. When you’re taking something by mouth, it’s going to have to be metabolized, and we think the risk with cancer, and the risk with clots, and whatnot happens in the liver, and so, if we can bypass that by putting the pellets in an area of the body that they’re clear to the kidneys, we thus are then bypassing those risks. Hormone pellets, yes and for because I think they can be administered very safely. They’re very convenient. Even for men, men can get those testosterone pellets. Instead of nasty, unsafe injections, they can get pellets as well. So, pellets are a great option for estrogen and testosterone. They’re not an option for progesterone.

Let’s talk about the Tri-Est, Bi-Est question. Tri-Est, trio, T-R-I, is standing for three estrogens, estrone, estradiol, and estriol. Estradiol is the hormone that’s available in the pellet, but there are two other estrogens, estrone and estriol. What was used in the Women’s Health Initiative study that scared doctors and patients away from estrogen was conjugated equine estrogen. Essentially, it was a mix of E1 and E2 and given orally. It was literally horse urine. If that’s the study that showed the risk of using oral, horse urine, well, I’m not going to use oral horse urine in my patients, and I’m not going to use E1. Tri-Est, when I started my practice, I used not orally, but topically. Compounding pharmacies could compound E1, E2, and E3 but I have since not been prescribing E1. Years back through my training a lot of doctors were like, “Let’s not give E1 anymore,” That was more of a dangerous estrogen, why give it? To answer that individual’s question, I don’t give Tri-Est. I do give Bi-Est. Not in the pellet because only estradiol is available in the pellet.

Estriol, which is E3, we have E1, E2, E3, so E3 is very safe estrogen. It’s wonderful back to urinary incontinence again, vaginal dryness. Many times, it can be compounded, to be used in a vaginal troche or vaginal cream or compounding pharmacies can combine them to be applied topically elsewhere in the body. I don’t have patients with topical hormones on the upper half of the body period. Don’t put hormones on your wrist or on your arm. That upper lymphatic chain could pull those hormones into the breast. We don’t want more estrogen getting pulled into the breast, but below the belly button, on inner thighs, where there’s fatty tissue there, you can apply a topical combination of estradiol and estriol, which is known as Bi-Est, or Bi-Est can be made into oral capsule, which again, oral estrogens, or a sublingual lozenge or troche, which you can put under your tongue. But you can see how complicated this can be, that you really need to find a provider who for you, based on your levels can assess that you need estriol, if you need estradiol, and then determine the appropriate way to optimize those hormones for your health in longevity.

Cynthia: That’s really interesting. Even as an NP, I did not know all of that about the pellets, but I never prescribed pellets, and it really only been since I moved into this other space that I’ve gotten a little bit more acquainted with that. I would imagine that there are, and I want to say this without judgment, I think that there are absolutely positively providers out there that know a little bit without knowing a lot and there are absolutely positively people that will reach out on social media. I’m sure you get it as well who are just desperate, because they know something’s off.

Stephanie: Right.

Cynthia: Either they get put on oral bioidenticals and they gain a bunch of weight, because it’s going through the liver for a second pass, or they’re not on an optimized dose for them or their bodies because there’s no one size fits all philosophy for sure.

Stephanie: So many of these patients get put on hormones without ever having levels tested too, and that’s a pet peeve of mine. When I started practice, I feel like, “Gosh, I’m just picking up all the pieces, all these train wrecks come to me,” because like you said, they may have been put on oral estrogen alone with no progesterone, when they probably needed progesterone in the first place without having any levels tested to confirm they needed estrogen.

Cynthia: Right.

Stephanie: Just because I said earlier if you have hot flashes, you may need estrogen, maybe you don’t need estrogen.

Cynthia: Mm-hmm.

Stephanie: Don’t just go on a hormone without confirming that via labs or things can get a little messy.

Cynthia: Well, and it’s interesting to me because the hot flashes piece can be blood sugar.

Stephanie: Totally, stress.

Cynthia: It can be– yeah, your macros. Exactly. I remember the first time, I ever had a hot flash, I remember I was folding laundry and it was the middle of the summer and I looked at my husband and I said, “I don’t know what just happened.” But for me at the point of life that I was, it was because I tend to be low carb, but I think maybe I had some wine. Wine is a given. If I have wine [crosstalk] a sweat.

Stephanie: Yep.

Cynthia: Let’s unpack some of the reasons why people can actually have those hot flashes while we’re touching on this, because there’s this misnomer that it’s all related to estrogen loss, but it can be related to so many other pieces of the puzzle that I think are really critical, and nutrition is absolutely one, stress management, sleep quality all things that a lot of people are just are not talking to their patients about but are just as important.

Stephanie: Or even just sticking with your right on all of those, I agree. Sticking with hormones for a moment, you can have hot flashes again with low progesterone or low testosterone. I have some women who for whatever reason, they have family history of cancer even though I would be comfortable giving them estrogen, they say, “Nope, staying away from it. Not taking it. I’ve made up my mind.” We give them testosterone and their hot flashes go away. Testosterone is also great for night sweats. What if your thyroid’s too high? That could cause hot flashes also. So, it’s just important to have all of the labs comprehensively assessed and find a provider that’s going to test, not guess, because just guessing things could go wrong. I find many times hot flashes on my patients are caused by sugar. Sugar, sugar, sugar, sugar. Sugar is the devil. Most addicting substance on earth can cause all kinds of problems in our body.

Many times, just having patients modify their diet, getting that sugar out, inflammatory foods. For me, even gluten can cause hot flashes, because gluten makes my heart race. If I haven’t had it in, I don’t know eight years, but I’m not going to go back. Even if I have cross contamination, my heart’s going to race, I’m going to get warm and hot. A lot of additives and foods like MSG, different artificial whatever you want to call them, flavorings, colorings, additives, those also our bodies essentially don’t like, and we can then react by having hot flashes. I think we mentioned a lot of reasons why that can happen, but–

Cynthia: If you’re listening to this and you’re having hot flashes, those are some things to consider. What’s really interesting to me is, I just started integrating continuous glucose monitors into my practice, and I myself was wearing one. I’m very aware because I intermittent fast. When I’m getting close to when I’m going to break my fast, I generally get cold. It doesn’t matter how physically active I am or how optimized my thyroid is, that’s just my sign. It’s like, “Okay, you shouldn’t break your fast.” So, it was very interesting for me, even though I’m a low carb or even though I don’t eat junk, I don’t drink alcohol, I’ve gotten really boring in terms of my nutrition, but I was telling my husband, I had two times, one time was there were plantains that were fried and coconut oil, and they just sea salt– [dog barking]

Then, one other time, I had a little bit of white rice that was added to a salad, and so I just had like two or three bites, and my blood sugar went above 150, and It had been within controlled within a normal variance for two weeks. I was saying, it’s amazing to see the things that will offset your blood sugar. Could be things that are benign and not unhealthy, but for your body, your N of 1, definitely your body is letting you know that doesn’t work for me at all.

Stephanie: Back to the benefit of testing, right? Would you have known that? You probably would, you’re so in tune with your body, but would you have known that rice was triggering it had you not been wearing the continuous glucose monitor? Testing is just very helpful.

Cynthia: Absolutely. I know that we both enjoy using the DUTCH, but what are some of the– When you’re looking at a new patient, let’s just say a middle-aged female, because we’re ultra-special. [giggles] These are gently the women who all of a sudden maybe they’ve never had to see someone regularly. All of a sudden, they’re like something is off. What are the normal battery of tests you like to use? The DUTCH is a dried urine and saliva test, very special test. I know that you have to find a provider like yourself or me that can interpret the test. But what are some of the other labs you’d like to look at it? If someone’s coming to you just feeling hormonally off, they’re not feeling like– they’ve gained weight, they’ve got brain fog, they’re just not feeling like themselves.

Stephanie: The DUTCH test is the Cadillac. It’s the best test, love it, recommend it to almost every patient. But depending on how many other tests we’re running on that patient, it could be cost prohibitive, because it is more expensive. Blood testing for some people is covered by insurance. Some people with a high deductible, blood testing just ends up being cheaper, and depends on the patient. Typically, I would recommend starting with bloodwork. If a patient is cycling, then I do recommend hormone labs to be tested one of days 19, 20, or 21. Now, that’s in a regular 28-day cycle. That’s about a week after ovulation. Again, if the patient is cycling regularly. If you’re not, then we have to just decide when to do the bloodwork, and it probably doesn’t matter. One of those days, we want to test progesterone. I like to test estradiol, also estrone, not just estradiol, but estrone and testosterone. If nothing else, get those sex hormones, just get a baseline.

I do still look at FSH, which is more looking at the brain, back to what you were talking about earlier, if the brain is sending the signal to the ovaries to send out the hormones, that can be beneficial and helpful too. If you’re going to get bloodwork done, you can get thyroid labs done also at that same time. TSH, free T4, free T3, reverse T3, thyroid peroxidase antibodies, and thyroglobulin antibodies. Usually, I’ll recommend an iron and ferritin, because some of these patients are borderline anemic too. If you can at least get some blood testing done, awesome. Great start. If your provider will go above and beyond that, and do more saliva cortisol testing, do the DUTCH test, that’s even better. The benefit of this urine, this DUTCH test that you’re alluding to, is that we can then see how the body is eliminating estrogen. That can only be seen in the urine. Blood’s not showing us what you’re eliminating, blood is just showing what’s floating around in your vein literally that day.

On the urine, we can see how the liver is breaking down estrogen and eliminating it. We don’t want estrogen to accumulate in your tissues. We want it to bind to the receptor, like in a parking lot, to park appropriately, do its job, and then get out right. [giggles] Estrogen, if it hangs around too long, can cause cysts, fibroids, heavy bleeding, can lead to eventually– doesn’t cause, but could feed an existing cancer. It’s really important if you have family history of breast cancer, if you’ve had it, if you have these fibroids and cysts, if you have endometriosis, some of these symptoms suggestive of poor estrogen metabolism or estrogen detoxification to do the urine test. I really am selective based on the patient and their budget like which tests I’m going to run.

Cynthia: Well, I’m sure that they appreciate that you’re sensitive to that, because one of the things that can happen in this functional space is that there’s a lot of tests. Not all of them necessarily need to be run all the time, and I’ll have people that have worked with someone else, and then they bring their milieu of tests and I’m like, “Okay, I wouldn’t have interpreted that way,” but okay, let’s-

Stephanie: Right.

Cynthia: [crosstalk] -go through this and dive into it.” We know we’ve got these different tests, and then from the test, we can determine how best to support the individual, and one of the things that I find really fascinating about thyroid, just touching back on that again, is you’ve mentioned checking in iron, checking a ferritin, but all these cofactors for thyroid making sure that your body knows how to convert inactive to active thyroid hormone. You think about iron, you think about magnesium–

Stephanie: Selenium, zinc. Yeah.

Cynthia: Absolutely. Iodine, I know is very controversial. Actually, I think it’s Dr. Alan Christianson just wrote a book, and my understanding from friends who’ve had an ability to check it out first, they said he feels very strongly that iodine is the reason why we have so many thyroid problems, and I know there are other schools of thoughts. I know iodine is obviously one of those things, vitamin D, and folate and B12, I know are all really important as well. If you have a provider that’s willing to– As you say, do the Cadillac, do the bigger workup, and make sure that there’s not another contributory issue, because I’ve just find that thyroid is oftentimes that missing piece in some other ways.

Stephanie: Yeah.

Cynthia: I have a lovely woman I’m working with, and her healthcare provider was only really willing to do a TSH, which her TSH was 5.2, which already told me something was off, and only did a total T4, which was a little bit off. I encouraged her to do more labs, and it turned out she had Hashimoto’s. She had an autoimmune thyroid issue and sure enough, she needs medication. So, I scooted her off to a functional medicine person in her area, but I think the big takeaway from sharing this information is that if you can’t find a person that’s able to do the workup that you need to be able to figure out what you specifically need support with, that there are lots of providers out there that can definitely fill in those gaps for sure.

Stephanie: You’ve just got to find them. Yeah, if you’re going to have brain surgery, you’re not going to go to a cardiologist, you’re going to go to a brain surgeon. If you’re going to have a baby, you’re going to go see OB-GYN, or maybe midwife, whatnot.

Cynthia: Yeah.

Stephanie: So, if you need your hormones optimized, you need to go to a hormone provider, literally. Not even just an OB-GYN, many OB-GYNs don’t even test hormone levels anymore. You need to find someone who’s trained in functional medicine, that TSH being that high, that TSH I think in her case, obviously, the higher the TSH, the lower the T4, T3 usually. So, those are inversely related. One of my mentors, Joe Collins, taught me TSH stands for too slow to help. By the time TSH is high, T4 and T3 may have been low for years and that patient has struggled, because all their doctors tested as a TSH for years. It’s slowly climbing up. Well, by the time it’s high, they’ve lost hair, they’ve gained weight, they feel lousy, they’re depressed and have no energy. So, you’ve got to find someone who can test levels comprehensively.

Even back to iodine, like you mentioned, I think there are these strong opinions on iodine, but I think it varies based on person. What area of the country were you born in? Where do you live now? What’s your diet? There’s not just a blanket answer that iodine is good or bad for thyroid. I think that approach has to be personalized, and I talk a little bit more about that in my book, Your Longevity Blueprint, in Chapter Six, I talk all about hormones, and I talk about what the discussion we’re having today, talk about sex hormones, about thyroid hormones, and even iodine.

Cynthia: It’s all super, super important. Now, let’s pivot and talk about, I got questions about osteoporosis and osteopenia.

Stephanie: Sure.

Cynthia: People saying, I’m doing all the things. I’m doing weight bearing exercise, I’m lifting weights, I met a healthy weight. My grandmother was osteoporotic. I’m osteopenic. So, what can I do if I don’t want to– if I’m not ready to go on hormones, and I don’t want to use, I know there are prescription medications that are out there that address this. They all have side effects, and so one woman very kindly said, “What are my options behind doing all the other things I’m doing? My diets dialed in, I do this walking every day, I lift weights, I’m doing all the things, but I’m still osteopenic.”

Stephanie: Yeah, I get this all the time. I see a lot of women in this situation. Saw one yesterday. I have a lot of patients who are 100 pounds. They’re small women. They have small frames. [laughs] Yes, they should be doing weightbearing activity. So, please do that. The sad part of the matter is your peak bone density was built back in your late 20s and early 30s. You’ve lost that window, you’re not going to build a lot of bone density by exercising. That will help you maintain it’s going to help you keep your balance, your flexibility, and your strength, so you don’t fall and suffer the downside of osteoporosis and osteopenia. But there are things that you need to help maintain your bones. Back to the medications you mentioned, so one class of medications that is available is the bisphosphonate medications. These are things like Fosamax, Boniva, if you’ve heard of those, which have their own list of side effects. Those are not going to help you build bones either, but for many patients, will hold them steady. But they can almost make your bones a little more fragile.

There’s a nutrient that’s been shown to be equally as effective as those medications, it’s called strontium. I use a lot of strontium in my patients. Now, that’s not a nutrient we can test for earlier you’re alluding to cofactors that are important for hormone production. We can test for those. We can test for magnesium, calcium, all the nutrients. We can run a nutritional analysis. Look at vitamins, minerals, amino acids, antioxidants, omegas. Even for someone with hot flashes, maybe she just needs to get on some fish oil and a multivitamin. If her nutrition is poor, sometimes just a little bit of supplementation will give her the cofactor, she needs to make a little bit more hormones so that she’s not symptomatic. But with bone density, strontium is very important, as is vitamin K too. A lot of patients have had calcium, maybe magnesium, maybe vitamin D, but I don’t want to say downside, but the caution with that is that, if you take too much calcium, and even too much vitamin D, you get kidney stones, right?

Cynthia: Yeah.

Stephanie: I’ve had them, and they’re not pleasant, and I don’t wish them on anyone. What we want for those women who are having bone density issues, and actually for everyone, is we want the calcium that you’re exposed to in your diet, hopefully, you’re eating green leafy salads, whatnot. If you choose to take a calcium supplement, we want to make sure that that calcium is ushered into your bone matrix. Vitamin K2 has MK-7, that’s the form I recommend to my patients, is the usher that directs the calcium into the bone matrix. Calcium and magnesium help the calcium get absorbed into the bloodstream, but then all bets are off. There’s no telling where that calcium is going to go. It could form a kidney stone, it could form a bone spur, calcify your arteries, whatnot. What you really need is vitamin K2. If you’re a woman who’s having some bone density issues, take magnesium by all means, high-quality form, a well-absorbed form, I have lots of blogs on this on my website. Take D3, get your levels tested, but K2 and strontium are nutrients that can be very helpful.

Then, hormone replacement therapy. I offer all forms. I meet my patients where they’re at, but specifically, sounds silly, but the pellets even testosterone, not just estrogen or progesterone, but testosterone can really actually help you build bone density. I’m not talking about just holding steady. I think the average improvement in patients after two years on testosterone is an 8.3% increase, which is incredible. I have had patients come into my practice with osteoporosis now have normal bone density. They have actually improved points, percentages. It is incredible. It sounds too good to be true, but when the DEXA scans come in, I show it to my staff. I’m like, “Look, look, look. See, her bone density- [laughs]

Cynthia: Now, [crosstalk]

Stephanie: -is improving.” Isn’t that’s exciting for these patients?

Cynthia: Now for a female, if she takes testosterone, are her options only the pellet, or do you also do cream administration?

Stephanie: Yeah, like what I said, I will offer whatever the patient wants. She’s nervous about side effects– Let’s say she had PCOS earlier in life, and so she thinks she doesn’t need testosterone now. She actually may. She may need it now, but she may not– She may be fearful of the side effects like hair growth, whatnot, oily skin. We may start her on something more conservative, like a topical gel or cream, or a sublingual lozenge, but the research on bone density improvement is primarily on pellets. All the hormones can help, I should say that most significant improvement is with pellets.

Cynthia: I think that’s fascinating. Oh, I can’t wait to– I’m going to be so excited to share on this podcast. Now, I think it’s important for people to understand that there are bioidenticals, and they need to understand what that is versus synthetic medications. I know you had touched a little bit about Premarin, but I think it would be helpful to be able to differentiate so that people understand what they’re advocating for when they go to see their healthcare provider.

Stephanie: Yeah. The difference between bioidenticals and synthetics is the molecular structure. I have this all outlined literally in my book also. I show the molecular structure of the horse urine, and then the estrogen your body makes. They’re different. That’s why you don’t want to take the horse urine. You want to make something that’s equivalent, or ideologically identical, that’s where term ‘bioidentical’ or ‘natural’ comes from. What that means is that hormone that you’re taking, should fit into your hormone receptor, like a key fitting in a keyhole and therefore, not have side effects, because your body recognizes it as natural. It’s same concept as why we want to eat organic and not chemical-laden food. Our body doesn’t know what to do with those chemicals. How do we process that? How do we eliminate it? It adds to our body’s toxic burden. With hormones, we want something our body’s going to recognize, it’s going to bind our receptor and not cause harm.

The synthetics have a different– literally, even for men, with the testosterone replacement therapy options. They have a different molecular structure, they’re not going to bind like a key fits in a keyhole. They’re going to bind partially, so patients get some benefit, but they have more side effects. You want to take what’s biologically identical to what you’re making. If the hormone name is medroxyprogesterone acetate, or levonorgestrel, or a progestin, those are not the same words as progesterone. You literally only want to take progesterone. If your birth control or your hormone replacement therapy does not say progesterone spelled in that fashion, it is not natural, it is not bioidentical, it is synthetic. Same with estrogen. If your estrogen patch says estradiol, it is Estradiol. If it says something else like conjugated equine estrogens or whatnot, it’s not bioidentical. So, you really want to look for those words on your prescription. Estradiol, progesterone, testosterone, that’s what you’re looking for.

Cynthia: I think that’s an important distinction. I always say the more you know, the better you can do for sure. I got a couple questions about women, and this always frustrates me. When someone says, “I had a hysterectomy five years ago, but I’m not in menopause.” I’m like, “Okay, did they take your ovaries?” Okay, you’ve been in menopause, [crosstalk]

Stephanie: [crosstalk] that was surgical menopause. [laughs]

Cynthia: Surgical and biological, so two very different things. Biological being when your body no longer is– You’re no longer having cycles for more than 12 months.

Stephanie: When the ovaries say we’re done. [crosstalk]

Cynthia: Throw in the towel.

Stephanie: Yep, yep.

Cynthia: Throw in the towel. When you’re in perimenopause, very likely you are getting much closer to that point. You might not even be ovulating month to month. Then, you have women oftentimes who are offered surgical removal of their uterus and/or their ovaries, and there’s no discussion with the patient to say, “Hey, guess what? You’re going to be in menopause.” There’s literally this disconnect. I cannot tell you how many patients I’ve talked to, and it upsets me, because they didn’t realize they weren’t told. It was just assumed, the surgeon assumed that they knew this, and I always say never assume, because most patients are scared and frightened when they get to a point where they need surgery. They may not have been processing all of that. Let’s talk a little bit about those that had surgical removal of their uterus and/or ovaries, and what that represents for them. Obviously, they very likely also need hormones, especially if they’ve had their ovaries taken out.

Stephanie: Gosh, I want to unpack that because there’s about five points I want to make. I don’t know if I’m going to remember all of them. Let me go back to first. Ideally, we would have patients who need a hysterectomy find a functional medicine provider to prevent the need for the hysterectomy. If you’re having heavy bleeding and you’re anemic, I get it. You’ve lost a lot of blood, you feel like crap, you’re probably just going to do what your surgeon says and have a hysterectomy. But maybe you needed progesterone. Progesterone can minimize that heavy bleeding. Maybe you had high estrogens, which are the proliferative hormone which cause the uterine lining to thicken and then your body’s bleeding. Your body’s not making a mistake. It is bleeding for a reason. So, you had a hormone imbalance that led to the hysterectomy and having a hysterectomy doesn’t correct underlying hormone imbalance. It maybe got rid of the bleeding, or the fibroids, or the pain, or whatnot. There’s no going back in time, we can only go forward. But a lot of patients think, okay, that hormone imbalance or the problem is fixed. It’s really not fixed. You just had a surgery, which is one of the two tools conventional medicine has, drugs and surgery, which helped you.

But moving forward, I agree, those patients deserve to have their hormone levels tested, if nothing else, even for bone density. A lot of patients say, I don’t have menopausal symptoms, I don’t have hot flashes, I’m fine. I don’t need hormones. They may to preserve bone density or to preserve memory. Maybe they have a family history of Alzheimer’s, or to help with cardiovascular function. I’ve been in practice slightly 12 years now. I’ve tested hormone levels, pre-hysterectomy, the day after hysterectomy, a week after hysterectomy, months after hysterectomy in patients who got their ovaries removed or not had their ovaries removed, it is fascinating patient to patient, the differences that we see. Some patients the day after the hysterectomy, hormone levels are zero.

Cynthia: Wow.

Stephanie: They will plummet.

Cynthia: Wow. I bet you they feel terrible too.

Stephanie: They do. Without testing any levels, some patients are fortunate enough that their doctor will give them a hormone, it’s usually estrogen, which they may not need, but only estrogen. I’m trying to think of all the things I wanted to unpack with that statement, but it just goes back to having hormone levels tested to see what you need so that you age gracefully.

Cynthia: Well, I think one of the other kind of misconceptions is that I’m seeing more and more women in their 40s go into menopause earlier, and I’m sure that can be from a constellation of different things. I have women who are 55 and insist they’re still getting their periods, which I find fascinating.

Stephanie: [laughs]

Cynthia: But I think somewhere in between there needs to be this conversation, because I know when I hit the wall of perimenopause in my early 40s, I will never forget it. I happen to just be seeing my GYN coincidently on the first day of my period, she was like, “Oh, my God. Your period is so heavy.” I was like, “I was just telling you this.” She said, “Well, we can put you on hormones,” and she’s referring to synthetic.

Stephanie: Birth control, probably, yeah.

Cynthia: But put you on hormones, we can do an ablation or if you want. You’re done having kids will just take your uterus and I was like, “No, absolutely, positively not.” If you’re listening and you’re a woman that’s in this period of– sorry for the pun intended, in this time period of your life where you’re having very heavy periods just know there are more options than synthetic hormones, ablations and hysterectomy is that there are absolutely providers out there who would love to be able to help you balance your hormones like Stephanie and avoid having to have a surgery, because I’m of the belief system. I never want another surgery unless my life depends on it. I had my appendix out two years ago against my– there were no choices. I had [crosstalk] ruptured. Let’s pivot a little bit and talk about what are some of the things when you’re working with middle-aged women ways that we can optimize estrogen metabolism? What are some of the foods or tips that you like to interject into your work with them?

Stephanie: Sure. If we haven’t done any testing, we haven’t done the DUTCH tests, there are just some general recommendations I can make across the board that usually benefit all patients. If we’ve done the testing, then we can more personalize what that individual needs. But without doing the testing, one group of vegetables that is very helpful is the cruciferous vegetables. We’re talking cauliflower, bok choy, kohlrabi, kale. Not spinach, but the vegetables that if you cut the stem, there is a crux or a cross, those are the cruciferous vegetables. I tell my patients every single week, go out and at least get a head of cauliflower or broccoli or whatnot, and go through at least one about two of those every single week. Those help your liver clear out excess estrogen. Estrogen from the environment. I live in Iowa, so there’s herbicides and pesticides literally floating around the air here. Even from auto exhaust, roll down your car, you’re inhaling those fumes, those chemicals can also impact your hormones, your estrogen. You can get estrogen from plastics these days, from fragrances, from personal care products. Estrogens are everywhere. They’re even in our water system, so many people flush their birth control in them. [laughs]

Cynthia: [crosstalk] you should be flushing it, you should be consuming it or taking it to your pharmacist. [crosstalk]

Stephanie: Yes. [laughs] But research has shown, literally, water systems don’t filter out estrogen. All these women that are on hormone replacement therapy, are on birth control, even if they’re not putting their birth control down the toilet, their pee is going down the toilet, and therefore, estrogens are getting into our water systems that, yes, our children are drinking. No water systems filter out that estrogen. Very scary for the future considering I have a son. Some vegetables that will help are those cruciferous vegetables. Anytime I say this or comment on this, somebody in the audience like, “What about my thyroid? I’ve heard I’m not supposed to consume goitrogens that those green vegetables are going to counteract my thyroid.” You would have to eat a ton of these vegetables raw daily.

Cynthia: Four or five cups is what I read, because, of course, [crosstalk] down that rabbit hole.

Stephanie: Yeah.

Cynthia: [crosstalk] how much? There the fiber would fill you out– [crosstalk]

Stephanie: You would be so gassy.

Cynthia: [laughs] You wouldn’t be able to do it.

Stephanie: Speaking of gas, if you can’t tolerate the vegetables, if you’re on a low FODMAP diet, I’ve had SIBO, I’ve had fructose intolerance three times in my life, I’ve been very low FODMAP where I couldn’t tolerate broccoli or cauliflower. Thankfully, I can now. But if you’re someone that’s in that boat, which we won’t go down that rabbit hole right now.

[laughter]

Stephanie: If you’re in that boat, you can take an extract of those cruciferous vegetables called DIM, it’s diindolylmethane, I can never pronounce it. That’s what my doctorate focused on. Literally, nutrients like them to help facilitate estrogen metabolism for purposes of reducing breast cancer, but I believe the majority of the estrogen-driven cancers come from poor estrogen metabolism. What do we do to reduce our risk? Eat the vegetables, lots of them, or take that supplement DIM. What else can help is B vitamins. B vitamins help with a process called methylation, which we can test on that fancy DUTCH test, but without having tested it at many patients who have MTHFR genetic variants, are formed isolators. Usually, patients tolerate these very well. Some patients for them, they feel very jittery on the Bs. They feel, they get anxious or it’s too much, and in that case, they’re probably overmethylating, and it’s and that’s too much for them. But if patients can tolerate Bs, especially if they’re on a diet, that they’re not eating a lot of meat, they may be very low in B vitamins, so taking a B complex daily can be helpful in the morning because it’s energizing, not at night.

Then, antioxidants are lastly very protective when we think of estrogen metabolism. There are markers on the specific– There’s a specific marker on the DUTCH test that can lead to breast cancer. The way that we protect patients against that, that marker oxidizing leading to DNA damage, which leads to cancer is to take antioxidants. Things like resveratrol, glutathione, N-acetylcysteine, all those things can be very beneficial, and swing odds in your favor from a cancer risk reduction, make the hormone replacement therapy you’re taking more safe, or just help you in general, if you have heavy cycles, or cysts or fibroids or whatnot. All those nutrients can be very helpful.

Cynthia: Oh, that’s such a helpful bit of information. I think that people really forget that estrogen metabolism is the key on so many levels, and I’m sure that you have the same reaction from some of your patients, but women will have been constipated for years.

Stephanie: Mm-hmm.

Cynthia: That’s one of the ways that we package off excess estrogen as we–

Stephanie: Eliminate it. Yeah.

Cynthia: Exactly. I said so, if you’re not having a bowel movement, anyone that does–

Stephanie: That’s a problem. [laughs]

Cynthia: Once or twice a day, you need to have a conversation with your functionally trained provider to find out why, because it is not normal, and I don’t want anyone listening to think that it is. I always say it’s just a symptom of anything. It could be as benign as you need more support with emulsifying, breaking down fats and we’re such a fat-phobic culture on so many levels that trying to talk to my middle age to beyond patients about this, and I’ll just say, “It’s okay. Yes, you can have those fats. We’re not anti-fat. We’re not low fat, we want to have healthy fats, and we need to help our bodies break them down.”

Stephanie: Yeah, I agree. You’ve got to poop every day. If we plugged the exhaust on a car for one day in the car would explode. But then we think we can just hold in our waste for days? No, that’s not good. Not good.

Cynthia: A very good friend of mine, she’s actually a physician. She said, adults are much like babies. They need to poop and sleep. I said, “Oh, my gosh, that’s so brilliant,” because if most of us slept through the night and had a bowel movement every day, we would have a much easier way of living for sure.

I know that you have this super busy practice. What’s next for you? I know you have an amazing podcast, which I’ve been fortunate to have been a guest on, and [crosstalk] for next week.

Stephanie: Yes, thank you for coming on. Very popular episode. [laughs]

Cynthia: Oh, thank you. I can actually see your book behind you. But tell the listeners what you’re up to, how best to find you, where are you on social media.

Stephanie: Sure. My clinic is the Integrative Health and Hormone Clinic. We’re in Hiawatha, Iowa. That website is ihhclinic.com, and then yeah, as you can see, my book is Your Longevity Blueprint, where I really just introduce the audience to functional medicine. Today, we unpacked hormones and what tests are available, but guess what? There are advanced testing options for every organ system in your body. It might be your gut, we were talking about, your genetics, there’s your cardiovascular system, there are tests for everything available. I unpack that in my book where I’m comparing how we would maintain our home to how we should be maintaining our body. You can learn more about the book at yourlongevityblueprint.com, which is also the name of my podcast that you were on. Then, we’ll also offer– Listeners, today 10% off if you use code, THANKS10, at the website for the book and the supplements that we talked about today. I would say what’s next for me, hmm, I did create, of course, the Your Longevity Blueprint course, but I am working on a PMS mastery, a perimenopause mastery and a menopause mastery course which I’ll launch hopefully this quarter.

Cynthia: Oh, sounds fantastic and so sorely needed for sure. I feel like I did a whole TED Talk talking about perimenopause, but it was [crosstalk] I felt like there was such little information and no one prepared me. I’m like, “I’m a healthcare provider. How can we expect our patients to be prepared if we’re not even having conversations about it?”

Stephanie: There’s just so much to know, and so yeah, check out my website. Also, social media, it’s Stephanie Gray A-Y, DNP, and you’ll hear when those courses are available.

Cynthia: Awesome. Well, I can’t wait to help support you.

Stephanie: Thank you so much for having me on the show.

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