Ep. 167 – Let’s Talk About Human Optimization: It Starts with Improving Your Metabolic Health with Dr. Jaime Seeman

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: I am so excited to have Dr. Jaime Seeman. She is a total badass. She’s an integrative medicine, OB-GYN, she’s a wife, a mom, she’s Mrs. Nebraska. She also was on the Titan games. She just got back from vacation and carved out time out of her busy schedule to connect. So, I’m so excited to have you here. How was your vacation?

Jaime: Thanks for having me. Seriously, it’s such an honor and I love the work that you’re doing. My vacation was so wonderful. I live a crazy busy life and vacation was always one thing that my husband and I could use to really unplug from the world. We still tried in 2020 but this was the first big family vacation since the pandemic, and we went to the lake, and we had an amazing time. We got sunlight and got out on the water. We did boating, which is totally my vibe. I love either totally relaxing on the beach or doing something physically active. So, it was a wonderful, wonderful vacation and we made lots of memories, which is what it’s about.

Cynthia: Absolutely. Well, I’m glad that you were able to get away. I too feel like in many ways, everyone’s lives were put on hold. During the peak of the pandemic, we actually were in Montana. I was there on business. So, all of us went and we had a great time just hiking and being away, disconnecting as much as possible. My kids, they’re teenagers, but they were completely appalled with the fact that they we had very spotty Wi-Fi in the hotel, and they were like, “Oh, my God.” I’m like, “This is actually a good thing. We should not be so connected all the time.” So, I know your daughters are a little younger, but there will come that time when they become woefully preoccupied with technology and I always tell them that I feel in many ways, there’s been both a blessing and a curse during the pandemic, lots of togetherness, but also they’ve been more connected to technology, because in many ways, that’s the only way they’ve been able to interact with friends. So, I’m glad that things are feeling like they’re getting back to some degree of normalcy. But I would love for you to share with the listeners. I really enjoyed getting to know a bit about your background. I know you were raised by a nurse mom, but did you always know that you wanted to become a physician or is that something that came a bit later in your trajectory?

Jaime: There’s no physicians in my family. My mother was a nurse, but early in her career, got into hospital administration and left bedside nursing, helped start this surgical center. She was the breadwinner in our family, and the leader of the household per se, and I’ve always looked up to my mom. She’s one of the really biggest role models in my life. But I loved band aids, and I love blood, and I loved all that stuff as a little kid. My mom always tells the story, I was about three years old, my brother was five years old, and we had this injury happen in my parents’ house. We nailed heads together and my mom had to take us both to the emergency room and they shuttled me off in this room. They didn’t want me to watch my brother have to get these stitches. We both needed stitches in our heads. I went back in the room and I’m like, “Can I have a mirror? Can I watch or who is this [crosstalk]?”

Cynthia: [laughs]

Jaime: So, that was really me. I was very much infatuated with the human body. My mom thought that maybe I would go into nursing like her, but she also saw a lot of my personality traits and thought maybe I would be a teacher. Then, I don’t really remember how old I was, but I’d expressed to my mother, my interest in medicine and just in health care in general. She was the one that really said, “Listen, if I had to do this all over again, just knowing you as my daughter, I would have just went to medical school and became a physician, instead of going to nursing school.” That was the first realization as a little girl that I could be a doctor. People tell you this all the time like, “You can be whatever you want to be,” but there’s no doctors in my family. I’ve never really had these figures to look up to.

But clearly, my mother believed in me and so, I was on this like pre-med track, and I went to college, and I was going to get an exercise science degree. I showed up on the first day of college and they said, “We’ve eliminated the program. You’re going to have to choose a new major.” I was like, “Oh, my gosh. Now, what do I do?” Just these feelings of self-doubt like I’m never going to get into medical school. So. I chose a biology degree just because I felt like that’s what everybody in medicine did. Then just started to have this moment of internal panic. What am I going to do when I get out of college have the biology degree if I don’t get into medical school? Luckily, I started to have a change of heart and thought I would completely pivot and go into broadcasting and the colleges of nutrition and exercise science ended up merging faculty. It was a blessing in disguise the entire time because my undergraduate degree is in nutrition and exercise science. Now, sitting where I am now in this chair, it was such a valuable piece of my education because it was way different than a lot of my friends that got their biology degree and that really only understood that basic science and not a lot of the things that truly matter in medicine.

Cynthia: Oh, I love that story. I think that it probably preemptively gave you an advantage over many of your peers because as I talk about very openly, whether you’re a nurse, or a doctor, or a PA, we get little to no education about nutrition. I actually had to go back and do a functional nutrition program, and that completely lit me up because most of what you’re taught is completely contrary to actually what will embody health and longevity. So, you went to medical school, you had this nutrition and exercise science background. I know that you played college-level sports, which I think is just incredible. You’ve mentioned in several of your interviews that when you got to medical school, which obviously is incredibly intense, things really changed for you. So, do you think that it was at that point in time that your eating habits changed? Was that the increased workload and stress level? Because for anyone whether you’re aware or not aware, medical school is just incredibly intense than all consuming. So, I would imagine that was quite a lifestyle shift for you on so many levels.

Jaime: Yeah, here’s this transition in my life where I’m going from being a collegiate-level athlete, we’ve got these nutritionists– I was a college kid. I wasn’t eating perfectly. I’m not going to lie. I had some alcohol and things like that. But I have this huge shift in my life, where I’m going from being forced to be very physically active to now being suddenly very sedentary, sitting in the classroom for multiple hours per day tests every single Saturday, I’m in library. We didn’t have children at the time, but it was definitely a shift downward in physical activity. I had this trouble with maintaining my weight. I had just completed this nutrition and exercise science degree. And what we had been taught, you say it’s a blessing, I don’t know. Things I was taught was like limit sodium, eat low fat, count your calories, it’s just salt and saturated fat that cause heart disease. So, all I really understood at that point even with a nutrition degree was just eat less calories and move more. This was like during the P90X rage. So, I decided, find a couple medical student friends, let’s start doing these P90X videos, and I’m just going to count my calories. was literally can remember a moment, I was counting goldfish and pretzels that I was like, “Okay, this is what I’m allowed to eat while I study at the library, this amount of goldfish or pretzels.” I was able to maintain my weight okay, and sure, P90X was great.

But then, my husband and I really wanted to start a family. We didn’t want to wait until my medical training was completed. So, we decided third year of medical school to get pregnant. We had trouble getting pregnant. I was diagnosed with polycystic ovary syndrome or PCOS, and was missing my periods. I had come off years of birth control. So, I really had no idea what was going on with my cycles. I had to start metformin, and then my doctor ended up offering me Clomid to try to get pregnant. Luckily, I was able to get pregnant the first month of the medication, but what I was doing from a dietary perspective is, I was really trying to eat a very low-calorie diet because I thought, all I’ve heard with PCOS is that if you lose 10% of your body weight, you can restore ovulation. So, I said I’m going to try to lose 10 pounds, and so I was working in a really small town in Nebraska at the time on a rotation, and I would go to the hospital cafeteria, and I would go to the salad bar, and I would get iceberg lettuce, and put cottage cheese, and sunflower seeds on it. That was literally what I ate for a month straight. I lost some weight and I got pregnant.

During my three pregnancies, I ended up having three pregnancies. They were all 23 months apart. My girls are all 23 months apart. But luckily, I didn’t have trouble getting pregnant with the second two. But during my pregnancies, I failed my glucose testing. After my first baby was born, I was diagnosed with hypothyroidism. After my third baby was born, I was still on thyroid medication and I was diagnosed with prediabetes with a very normal-appearing BMI from the outside. So, gosh, looking back now and knowing what I know now, it all makes sense, but I didn’t know back then what I was even doing, Luckily, I had three pregnancies, luckily, I have three very healthy babies, but holy smokes, it’s just crazy to think back at the advice I was given and how I ever got through it all. [laughs]

Cynthia: No and it’s interesting to me, I didn’t know until we started trying to get pregnant that I probably had very mild PCOS that had been masked by being on oral contraceptives because I was one of those people that they put me on oral contraceptives because my cycles were irregular. They’re like, “Oh, this will fix that.” So, being 17, 18 years old, that sounded fantastic. I can control my menstrual cycle. [crosstalk] Exactly. If I don’t want to have a period that month, I can just start my new pack of pills, fantastic. But not until we started trying to get pregnant did we realize that I probably had mild PCOS, and much to your point, not every person with PCOS is obese. You can be slender, you can be small. So, what are some of the misnomers that people have about PCOS? For the benefit of listeners who may not be as familiar with what this is, I know a lot of listeners sometimes are focusing on the other, the reverse puberty changes that are happening. But for the benefits of listeners, let’s unpack what PCOS is, so they can better understand how that can impact ovulation, how that can impact infertility, how our diet really feeds into developing this? Obviously, there’s some genetic susceptibility because it wasn’t until I had to go on Clomid to ovulate that three or four of my aunts were like, “Oh, yeah, we have to take Clomid to get pregnant with our children. I was like, “Why is no one talking about this?” It’s almost like no one wants to mention this because it’s just not PC.

Jaime: Yeah, well, first of all, PCOS is a really poor name for the disease and I’ve been coming up with new naming trends that I keep hoping will stick. But so many patients come to me and they’re like, “Oh, I’ve got a cyst on my ovary. I think I have polycystic ovarian syndrome.” The ovary’s job, it’s makes, every single month, a certain number of follicles are stimulated by the pituitary gland and this follicle pool, eventually, one of them will become a dominant follicle. It will oscillate in a perfect world, it will become a corpus luteum, and then it will regress and go away. So, the ovaries job is to make cyst up to 2 to 3 centimeters in size, very normal.

But the clinical features of polycystic ovarian syndrome, the criteria for diagnosis is essentially threefold. So, you need to have either no periods at all, we call that amenorrhea or you have you’re skipping periods. We call that algomenorrhea. So. you’re only having maybe six periods a year, where you have really, really, really prolonged cycles. The second criteria is either serum levels of high androgens. So, high testosterone, high DHEAS, or you have clinical signs of hirsutism. You don’t even have to draw the blood. The woman will come in and she’s got really dark hair growth on the face or on the chest down into the navel, maybe it extends down her legs, past the vulva, or maybe she’s got problems with acne or other androgenic features. We tend to see this on athletes, I was a three-sport athlete. I’m very athletically inclined, I build muscle easily. So, I fit that phenotype very well.

Then the third criteria is polycystic ovaries. If you do an ultrasound, you can actually see a ton of these little follicles that are trying to develop, but they don’t. And you see this clinical feature of what we call a string of pearls around the ovary. So, it all depends on how big they are and how many there are in there. We don’t have to necessarily get into that but essentially, you need two out of three criteria to get the diagnosis of PCOS.

But you touched on something, I had a little bit of PCOS. It’s such a spectrum. We have patients that are skinny, all the way to patients that are obese. We have patients, it’s real subtle, maybe they have a little bit of elevation in testosterone the periods are a little off, all the way to women who are completely amenorrheic. They’ve got like a full beard and all the other downward manifestations, PCOS. But at the root cause and you hit on it we don’t know. There’s definitely things we don’t know. There’s some genetic susceptibility. If your mother had PCOS, and you’re a female born to her, you’re more likely to PCOS. So, God bless my three children, my three daughters.

[laughter]

Jaime: Here is the book, I’m going to write about your life. At the root of all of this is insulin resistance. It’s not necessarily overt peripheral insulin resistance. It’s not all these people have diabetes. Some of them can pass the glucose tolerance test, but essentially what’s happening is, this insulin is driving increased androgen production from the ovaries. The androgens get aromatized into estrogens. It is inhibiting this feedback loop into the pituitary gland. So, we see disturbances in FSH and LH secretion. Then, it’s inhibiting ovulation. So, no egg is released, which means no progesterone is produced, which is this predominant estrogen state. So, these patients don’t have periods. When they do have periods, they’re extremely heavy, they have higher rates of infertility, they have other estrogen dominance syndromes, they have an increased risk of metabolic disease, including cardiovascular disease and diabetes long-term. Many of them tend to be obese, but not all of them are. The skinny PCOS phenotype is much harder to treat my opinion. Because I think there’s probably a lot more genetics that play there.

But it’s interesting when you look at the literature on PCOS that some of the mainstay treatments, like I said, when I would pull up the literature, it said, tell the patient to lose 10% of their body weight. It’ll restore ovulation. While there, you can lose weight a lot of ways. You can lose weight on a McDonald’s diet, or a Twinkie diet, or whatever it is. You can lose weight a lot of ways, but that’s not really helping at the root cause and I, of course, found that out because I got pregnant and then I went back to eating all this crappy food, and I got gestational diabetes. So, when we think about what the treatment should be for PCOS is nutrition should be the absolute number one treatment. It is very simple. If you remove dietary carbohydrates from the diet, we reduce levels of insulin secreted, which means that we can help bring down the androgens, restore the ratio of FSH to LH, restore ovulation, restore progesterone production, and things tend to get better. They tend to lose weight, they ovulate, they can get pregnant.

In my clinical practice, I’ve been able to get a lot of PCOS patients pregnant without the use of medications like metformin or Clomid, or Femara. But when you really look at the literature, it’s like they want to put these patients on birth control pills, if they’re not trying to get pregnant. Because it just makes the problem go away. It protects the endometrium, it protects the uterus, it can help with some of their androgen symptoms, and so, there’s just all sorts of reasons why they shouldn’t go on them, but a lot of patients just get put on birth control pills. If they need birth control, that’s one thing. I’m a fan of contraception. You should have the ability to plan your pregnancies. Then they look at other treatments of the androgen symptoms. So, of course, it’s very distressing as a woman to have acne or hair growth. So, there’s some things that you can do on an aesthetic level of spironolactone, which you don’t want them to get pregnant on that. So, you put them on both birth control pills and spironolactone. But the problem is, it might make some of these things better, but then at some point, they want to get pregnant, and now, you’re back to square one. They come off the medicine, and we haven’t actually fixed the problem.

For me, I’m just so passionate about it. Not only because that was me, when you can put yourself in the chair where the patient is and really understand, how they feel about the situation. I think you have another level of empathy. But when we think about pregnancy, the influence of epigenetics and the fact that the recommendations that I make to a pregnant woman influenced her baby’s DNA, and then her baby’s DNA, and so, we’re talking about for generations to come. Because high androgen exposure and pregnancy has an epigenetic influence. So, I’m just real passionate about it, because that conversation isn’t happening, I want women to always feel empowered that they have so many choices to make that could really profoundly impact their long-term health.

Cynthia: Well, and I think it’s so important. Obviously, I’m at the other end. We’re done having babies. We have teenagers at home. But I think how different things could have been for me as a teenager and a young adult before I was ready to have children, had I known what I know now. I love that you are so proactive, because I think that really makes a difference. I think I feel like this generation is asking more of their health care professionals that they want to look at things a little differently. Someone was asking me the other day, how many years I’ve been on oral contraceptives. I said, probably from 17, and I got married when I was 32. When I said, so that amount of time, because you get to a point where, yes, it’s very convenient not to get a period and then you just get accustomed to, I had horrible PMS, and I probably actually didn’t have terrible PMS, but I had terrible PMS symptoms while on oral contraceptive. Never felt better when I stopped.

Assumed that the fertility switch would just switch on, and that’s a whole other misnomer that people assume you go off oral contraceptives, you’re going to be able to get pregnant immediately. There are a lot of people who don’t, they end up at– This persistent amenorrhea issues that I had before. We’re just exacerbated. So, I’m so very grateful that there are healthcare professionals like yourself that are challenging the more common notions that we had about a lot of these issues. So, you went through this infertility period, went on to have three healthy pregnancies and three healthy babies. At what point after you’ve been diagnosed with gestational diabetes, and you’re a new mom, probably in residency during all of this, did you start putting pieces together about nutrition? When did all of that start to come together for you personally?

Jaime: Well, after my third daughter was born, I had a big tragedy that happened in my life. I lost one of my best friends in the middle of her pregnancy. We were actually both pregnant at the same time. She passed away during my third pregnancy. So, I went on to deliver and was just in this really low part of my life, and I knew with my previously failed glucose testing, my father is a normal BMI diabetic, and his parents were both normal BMI diabetics, and then come to find out now later in life, my mom has prediabetes. So, I definitely knew that from a genetic standpoint I was very susceptible. I was the one that actually advocated to check my hemoglobin A1c and found out I had prediabetes. I had never checked my blood sugar’s outside of pregnancy or anything like that. I couldn’t figure out why I had hypothyroidism. I was trying to read about why people get postpartum hypothyroidism. But I was tired, and I didn’t feel good, and I just thought really this is what life is like, when you’re a busy mom, and you’re a doctor, and I just had this sense of burnout, I had watched my friend get failed in the medical system. We couldn’t save her life. So, it was really March of 2015, I decided that I was going to live my life differently. I was going to get rid of my diabetes, I was going to get rid of my hypothyroidism, and I was going to do it through nutrition. I’m like, “Dude, I have this degree. I’ve a medical degree. If I’m going to ask my patients to do these things, I’m going to walk the walk and talk the talk. I’m going to figure this out for myself first.”

I set out, I said, “Okay, eat whole foods.” That makes sense to me to eat the whole thing. So, I started The Whole30. Then, I realized I like cheese. [laughs] I tried to transition into paleo. I was like, “No, I really like cheese.” [laughs] So, in early 2016 is when I adopted a ketogenic diet, and I didn’t really know what I was doing. It was forefront of when keto became a hot new thing. But the weight started to come off. It was like the fog started to lift. My thyroid function improved, my hemoglobin A1c normalized, and I was sold. I’m like, “This is incredible.” But in the medical world, people were like, “You’re promoting the ketogenic diet.” People were saying like, “You should have your medical license reviewed.” [laughs] I was trying to share openly about it. It was right when I started my social media just because I feel like there was another woman out there that was in my position, and I’m the doctor, and I’m supposed to know all this, and I’m just figuring it out in my career. I’ve never looked back. There’s been variations of my diet. I’m much more animal based now than I was prior. There’s definitely new literature that’s come out. I’ve incorporated intermittent fasting at times just with my crazy lifestyle. So, there’s definitely been different variations, and I’m not zero carb by any means. I’ve fluctuated back and forth with adding things like squash or sweet potatoes. Now, that I’ve reversed my insulin resistance, the goal for me really is just metabolic health. I check my markers very regularly, and I think that’s the endgame, is it’s not zero carb forever when you have insulin resistance. It’s teaching your body, how to burn both fat and glucose as a fuel source, so that you have more metabolic flexibility.

At the end of the day, it’s just how you feel and function best because my Fit and Fabulous brand is really– You can’t be filling other people’s cups if your pitcher’s empty. So, when you take care of yourself, when you eat right, when you’re sleep right, when you move right, you have energy to go out there and impact the world, and do all the amazing things that you want to do, and you named off things that I’ve done in the last couple of years, which is great. But they were all really a product of me changing the controllable things in my life.

Cynthia: I think it’s so important for anyone that’s listening and feels like I’m x age, and it’s too late, or because I’m in these circumstances, I can’t do this, I tell people openly, my whole background in medicines, ER medicine and cardiology, talk about the sickest of the sick, and I just got to a point where all I did was write prescriptions every day, lots of prescriptions, sometimes, 10 or 15 per patient. I kept saying it all starts with food. My cardiology colleagues who are supportive of me, would poo-poo me. They’re like, “Oh, this is cute.” Our nurse practitioner really likes to talk to people about food and I kept saying, we’re missing the boat. It all starts with food. The food that we eat impacts our health pervasively. What I found ironic with all the cardiologists that I worked with and all the MPs were all very thin. All of us worked really hard to make sure we were making good food choices. But then, what we were telling our patients oftentimes was completely the antithesis of what was keeping us relatively healthy.

On so many levels, I love that we’re seeing all these shifts for metabolic flexibility and most recent statistic I read was, I think it’s 88% of Americans are metabolically unhealthy. So, that means 88% are either obese or overweight, and that means that there’s 12% of people out there that remain able to–their body’s able to utilize either fats or glucose as a primary fuel source depending on what their needs are. I just think that we’ve really conditioned our patients in many ways to ask for prescriptions, instead of doing– and it’s the hardest work. The hardest work is the lifestyle peace, and better-quality sleep, and stress management, and getting physical activity, and lifting weights. That is much harder in my opinion than just prescribing a medication, but that’s what we’ve conditioned. Both the pharmaceutical industry and our training, it’s just very pill focused. It’s like the symptom is managed by a pill, and I’m like, “Well, if we dig a little deeper, there’s more to it than that.”

Jaime: Well, I think that it’s hard for me to look at my colleagues in medicine and blame them, because first of all, there’s a lack of education about nutrition and some of these things in standard medical education. But the way that the medical system is designed, the way that we get paid, the way that we make money for our practice, or the hospital, or whoever you work for is by seeing more patients. So, the way that clinics are designed is that patients are in a 5-, 10-, 15-minute slot at most. So, they come back with their hypertension and their diabetes, and there’s no possible way for you to do that amount of education in that amount of time. So, you have to rely on these ancillary services, and then I’m sending them to a nutritionist that literally got the same degree that I did, that was told to eat low sodium and low fat, and that’s going to prevent their heart disease.

So, it’s really the way that our medical system is designed. It’s okay to take care of chronic disease. Here, take this medicine. Okay, add this medicine. Okay, do this, do that, do that. We mean while, but we’re not really fixing these things. We’re just putting band aids on it. So, I get it. It’s not sexy. We’re asking for patients to have a level of personal accountability when it comes to these things, but it’s not an easy fix.

Jaime: Yeah, and I want to be really clear. I left clinical medicine five years ago, when I have nothing but respect for my peers. I agree that sometimes, we’re in a losing situation, because the current medical model is not designed for most providers to be able to practice the way that if they want it to be able to sit down and talk about nutrition or talk about lifestyle, because they’re just not given the amount of time to be able to do that. There’s a lot of cognitive dissonance, frankly, about the nutrition science that’s being done and applying it to the current medical paradigm. So, I always say like, “I have nothing but respect and admiration,” because especially, in the last 18 months, the medical community has borne the brunt of this pandemic, so I never want to sound unappreciative or ungrateful, because they’re doing a lot of hard work right now. I want to be really clear about that.

But let’s pivot a little bit, because I think one of the other key areas that I feel is oftentimes really neglected is when women are– and I know you’re in the thick of things as a OB-GYN, women have, they have menstrual cycles, they’re dealing with contraception, they have pregnancies, they have babies, and then women largely may be done having families, and then they sail or not so much into perimenopause and menopause. So, I didn’t actually know what perimenopause was until I hit it like a wall. I always am very open and honest, and just say that I’m a trained medical professional, and I knew very little to nothing about this time period. How do you think we’re doing a different/better job educating our patients about this transitional period when maybe their periods are waxing and waning, the hormones are fluctuating, they may start experiencing more challenges with sleep, weight gain, energy issues? How are we doing things differently than probably 20, 30 years ago?

Jaime: Yeah. Perimenopause, essentially what’s happening in a woman’s body is that, a woman is born with all the eggs she’ll ever have in her lifetime. She’s born with over a million and then 400,000 by the time she starts menstruating, but then you only release a couple hundred in your lifetime. As that pool of eggs gets lower, so every single month, it’s like asking 20 people to come to the party, and only one of them’s supposed to come to the party. But then eventually, the brain is yelling at the ovaries and only two people want to come to the party, and then no one shows up. What’s happening is that pool of follicles gets smaller, we’re seeing these very erratic estrogen levels during perimenopause, like psychotic is how I describe it. Then when you don’t ovulate on the month, you don’t ovulate, there’s no progesterone production. Now, this is a natural, natural phenomenon. Where the medical system is failing these women is they’re like, “Well, this is natural. Just embrace these changes.” Like embrace aging, or some people don’t realize it’s perimenopause. They’re having anxiety, they’re having depression, they’re having insomnia, they’re gaining weight, they’re becoming insulin resistant, and all these things are creeping up on them, and that’s perimenopause.

Years ago, we used to really look at women and think that hormone replacement was such a good thing. It would prevent the chronic diseases of aging that happened after menopause, because once women officially go through menopause, which is the clinical definition is 12 months with no periods, we start to equal men as far as cardiovascular risks. Because as we lose estrogen, we start to deposit more visceral fat around the organs, we become more insulin resistant, our brain doesn’t function as well, we have an increased risk of dementia, our bones start to weaken, we start to increase the risk of osteopenia and osteoporosis. So, we used to give a lot of these women hormone replacement therapy, and women definitely did feel better. Then these trials came out, the WHI trial and a couple others that really scared a lot of people away from using hormone replacement therapy. Now, we’re seeing the pendulum swing the other way. But what we’re not really acknowledging in this situation is that there are things that women can do. I always talk about these five pillars, which are nutrition, movement, stress, sleep, and environment. All of these things can have an effect on how we go through this transition, how we feel during this transition, because if you’re coming into perimenopause with a backpack full of bricks on your back, it’s going to make it really hard.

Cynthia: [laughs]

Jaime: We have a woman that’s she’s optimizing everything, and yes, this is happening, but could these patients tend to feel better? So, hormone replacement therapy is certainly this individualized thing that should be taking into account a woman’s history, and family history, and their small risks associated with it. But I’m a huge fan of hormone replacement therapy in my practice, and I wish more women talked about perimenopause and menopause, because I find very commonly that women will say, “My mom never talked to–” I’ll say like, “How old was your mom?” “I don’t know. She never talked about it. My aunt never talked about it. No woman in my family has ever talked to me about this.” So, they’re just having to ask their girlfriends, “Hey, what are you feeling? Oh, you feel the same way. Okay, this must be perimenopause.”

The other hard part is that these patients will come in to their doctor and be like, “I think it’s my hormones. Can you check my hormones?” Doctors are like, “We shouldn’t test them. It doesn’t matter.” The reason is because it’s really hard to test hormones. Because from morning to night, from Monday to Tuesday, from Monday to Monday, from the first of the month to the next to the first of the month, hormone levels fluctuate. It’s all over the place. So, when you’re just drawing blood one time at 3 o’clock on Thursday afternoon, it’s just telling you what they were at 3 o’clock on Thursday afternoon. Then of course, there’s people that do saliva testing, and urine testing, and there’s different ways, and there’s pros and cons to all of them, but it’s hard to actually test. So, we have to go by clinical symptoms and how patients feel. We have to acknowledge that some of these lifestyle things can make a huge impact on this natural period in a woman’s life.

Cynthia: Yeah, and I think that, on top of this which compounds that there’s a lot of shame as women are making this transition, and I just say this, because I’m paraphrasing hundreds of conversations I’ve had with women, girlfriends, family members much to your point. My mom’s a nurse. My mom never had a conversation with me about any of this. From my perspective, there seems like there’s this shared shaming. People are afraid to get older, they’re afraid to no longer be fertile, because I don’t know what they necessarily anticipate that looks like for them somehow, they’re concerned to be old. I’ve had women use this terminology. So, I have to sometimes give myself grace when I’m talking to women understanding that there’s so many variables that impact their comfort level having these discussions. I agree wholeheartedly that the way that you navigate perimenopause successfully or not into menopause largely is impacted by your sleep quality, your interpersonal relationships, the foods that you choose to eat, and this is where I say all the time, what we ate in our 20s and 30s may no longer serve us in our 40s and 50s.

For me personally, when I slammed into the wall of perimenopause and someone, I’m sure good naturedly, they said to me, “Well, you’re 44 years old. So, why don’t you gain 5 or 10 pounds? You’re 44 years old” and so, hearing those kinds of things, I kept saying, but if this isn’t normal for you, and you’re not changing anything like why is this happening, and even for myself with all the knowledge that I have. So, for many people, I find that they have to pull inflammatory foods out, maybe dairy no longer agrees with you, maybe gluten, or grains, or alcohol is a good example. As I was making that transition, I’ve never been a big drinker. But if I had alcohol, I would for sure get a hot flash when I would go to bed and I would for sure have a horrible night of sleep. So, I would say to my husband, as I was trying to explain to friends, I just don’t drink anymore, because it’s not worth it. I’d rather get a good night’s sleep. But we’re not having those conversations which makes it even more challenging.

What I do find interesting and I was actually just talking to my realtor today, and she is menopausal, and she said to me, “I am on hormone replacement therapy.” I was like, “Great.” “My sleep is horrible.” I was like, “Well, do they have me on progesterone?” She was like, “No.” “So, what do they have you on?” she was like, “Premarin,” and I said, “Okay.” I was like, “Let’s have a sidebar conversation when we’re done with all these other things.” But I think there’s so much misinformation about, as you mentioned, hormone replacement therapy, synthetic versus bioidentical therapy versus– they’re even people, there’s like the Wiley protocol, which that was one of the questions I got to ask you. There’s so much flux, and some of its good information, and some of it’s not that people don’t know how to make good decisions. I think if we’re not proactively having those conversations with our patients, I know that you are, but I think there’s probably other providers that may not be proactively doing that, it just makes for more ambiguity, uncertainty. People are like, “What in the heck is going on with my body? Where did this come from?”

Jaime: Yeah. Hormone replacement therapy, there’s so many providers that have been scared away from using hormone replacement therapy based on old data. Now, that’s been refiltered through and the WHI trial in particular is what scared a lot of people away because there was an increased risk of breast cancer in the patients taking estrogen and progesterone. Not in the estrogen-only arm, it was actually somewhat protective in that arm. But now, the thing about it is that, these were synthetics that lives equine estrogens. They essentially come from horse urine.

Cynthia: [crosstalk] thanks. [laughs]

Jaime: There’s never been a good trial looking at “bio identical” and a lot of people, how you think of it as like a lock in a key. If you’ve ever used the wrong key in a lock that’s not supposed to go with that key. Sometimes, you can get it to turn but maybe it’s not sending the right same signal. Now, there’ll be people that argue that it’s the same downstream effect. There’s also a misconception that all bioidenticals are compounded. No, we actually have bioidentical FDA-approved prescription options. So, there’s tons of ways that you can replace hormones. Now, they’re safer methods. So, one of the things that came out of the WHI trial was risk of blood clot and stroke. Now, most of the women in these trials were older, they weren’t good candidates, they were obese, a lot of them were smokers. When we look individually at a woman and who’s a good candidate, there really is clear evidence that there’s this golden window of opportunity, and it really tends to be within 5 to 10 years of menopause, tends to be this golden window of opportunity where you can make an impact on long-term health, reduce the risk of dementia. There was a trial just a couple of years ago showing that, and it was a group of women in Utah. Reduced risk of osteoporosis, osteopenia, cardiovascular disease, you name it.

But the American Menopause Society comes out with these statements that still scare a lot of people away. When you look at the data that they use to make a lot of these recommendations, they really cherry pick a lot of data. It’s like recording a podcast earlier talking about salt and saturated fat, and you take whatever it is. Salt, there was a lot of cherry picking of data. The seven countries study with saturated fat. The same thing has happened with hormones. They took 13 studies that were convenient for them that gave them the message they wanted, and they really ignored a lot of other well-designed studies and clinical experience comes with this too. I can just tell you that women feel significantly better. It can make a huge impact on quality of life. Although for some women, there is a small risk of some of these things, we really have to balance quality of life with that.

So, back to the blood clot risk, we’ve never seen that with transdermal estrogens, meaning given through the skin or sublingual or subdermal therapies. Vaginal estrogen therapy. really is honestly my personal opinion that almost 100% of women should be on vaginal estrogen therapy. It’s very safe even for people with breast cancer. I have so many breast cancer patients whose oncologists have scared them away from using very low dose estrogen therapy in the vagina. I’m telling you right now that, if men’s penises shriveled up when they went through andropause that 100% of them would be on some cream on their penis to fix this problem.

Cynthia: [laughs]

Jaime: But it starts to affect women’s relationships that increases their risk of urinary tract infections, pelvic discomfort, atrophic vaginitis. So, I’m a huge fan of estrogen therapy for almost everybody and then systemic therapy is certainly just very individualized. But you’re right. I’m totally making a presumption about this person, you were talking about earlier that was on estrogen only therapy. Maybe, she’d had a hysterectomy, so she didn’t need progesterone. But there is still sometimes a place for progesterone supplementation, for sleep, for anxiety, there’s things that micronized progesterone can really help with.

Then of course, androgen replacement in some of these women is another controversial topic, and now certainly needs to be done by a provider that understands what they’re doing, because overreplacement of androgens can give women a lot of side effects that they don’t like. Dark hair growth, acne, and things like that, but testosterone replacement does have its place in sexual function, and bone health, and muscle health, and those types of things. So, there’s lots of ways to replace it. I’m a huge fan of it, but you just want to find a provider that’s well read, and comfortable, and has a lot of experience doing it.

Cynthia: Yeah, and it’s really unfortunate. I have a colleague that went through estrogen positive breast cancer treatment. She’s also a healthcare professional. I’ve had these roundabout conversations, “Maybe we need to find you a new GYN to talk about the vaginal estrogens,” just based on what– I’m certainly not a specialist. But based on what I’m reading, because the vaginal atrophy symptoms can impact not just the woman, but also their interpersonal relationships, their significant other. I was horrified to learn that, it’s like you use it or lose it, meaning, if you go through periods of time of you have painful intercourse, you avoid having intercourse and lubes aren’t working, and you get to a point where you just abstain from having sexual intercourse with your partner that you get– from what I understand, and you can let me know otherwise, you can get significant structural changes to the vaginal orifice that are going to be permanent. So, someone said that it’ll actually shorten and this atrophy. I think part of it’s the loss of estradiol that impacts the lactobacilli that normally live there. So, there’s like a domino effect that can occur. So, really encouraging people to have those conversations, even if you’re embarrassed or uncomfortable. Have those conversations with your healthcare provider so that you can get properly treated, so that you’re not in a position where you’ve just decided like, “I’m just going to be celibate for the rest of my life,” because I think that having sexual activity, having sexual intercourse with your partner is really an important part of your relationship.

I say that as my friendly PSA, because I have had so many women talking to me about this recently, and I keep saying, “Go back and have a conversation with your GYN or your midwife so that you’re addressing this and not waiting five years to when you get to a point where, it’s just too painful to even consider–” or the other piece of it. I see a lot of women doing these laser therapies. I don’t know if you have any opinions about that, I’m sure you get to see the impact of women that probably come to you after the fact. But I probably would err on the side of wanting to use intervaginal estrogen before I would consider laser therapy, and I don’t know if you have an opinion, but there were several questions that I got. That was one of them.

Jaime: Yeah, estrogen therapy. There’s also androgen therapy you can use in the vagina that aromatizes locally to estrogen. So, there’s vaginal DHEA, but what happens when you lose the estrogen is, you lose the cells that line the vagina, lose their plumpness, they become pale, they become thin, they become dry lack of lubrication, and you’re right. We can see the shortening of the vagina, we can see a decrease in the size of the opening of the vaginal introitus, so sometimes that can make penetrative intercourse uncomfortable or difficult. So yes, it is a use it or lose it. Sometimes, in these situations, women have abstained, maybe, they’ve had the death of a partner, and now, they have a new partner, where sometimes we send these women to use vaginal dilators or pelvic floor physical therapy so that they can reinitiate those sexual relationships. It is such a taboo subject, some providers don’t feel comfortable talking about it. Patients don’t feel comfortable bringing it up. I find a lot of patients unless you directly ask, and I’m one of those people that always ask about sexual function. Can you have an orgasm? Do you have problems with dryness? Do you have pain with intercourse? If they say, “I’m not having intercourse,” is that by choice or is that because there’s a problem? You really want to tease these things out, because sexual relationships are normal and healthy. They’re part of a woman’s health.

There was a study I came across recently looking at the number of orgasms that a woman has in a week or a month or a year, and having to per week reduce a woman’s mortality by I can’t remember the percentage off the top of my head, but it’s a normal part of women’s sexual health. So, you brought up these other, what we call, vaginal rejuvenation therapies, and what these therapies are, there’s a couple different ones on the market. One is a CO2 laser which essentially delivers a level of heat to the vaginal epithelium that creates these little microdefects. Just like people use CO2 ablative lasers on the face, it stimulates the fibroblasts to make these columns of collagen underneath the vaginal epithelium. It can help slightly with some of the atrophy symptoms, the low lubrication, and just the plumpness because of the collagen production that underneath that surface epithelium. Then, there’s another device on the market that uses radiofrequency, monopolar radiofrequency with a cryogenic cooling aspect to it at the same time to make it comfortable for the patient. But once again, it’s really the same idea but it does get a little bit deeper into the tissue by delivering this heat source. It stimulates the fibroblasts to make collagen.

There’s trials looking at mild urinary incontinence symptoms, vaginal dryness, healing of poorly healed obstetrical wounds, just generalized vaginal laxity, but it all just depends, especially, when it comes to vaginal laxity. Everybody thinks you’re going to get this treatment is going to tighten up the vagina, when you were 20 or 30 or something-

Cynthia: [laughs]

Jaime: -but they had children and there’s damage to the pelvic floor. There’s different layers we’re talking about here. There’s vaginal epithelium, there’s connective tissue and muscles, and so it doesn’t correct all of those things. Now, there’s other modalities out there that target that. There’s one that targets the musculature. It’s like a chair that you sit on that helps contract those muscles, and it brings blood flow to the nerves and the blood vessels in the muscles. There’s a newer one that uses soundwave technology, very similar to the technologies for men with Gaines wave that targets the clitoral tissue with sound waves to help work on that neovascularization, and just repairing some of the damage to those nerve endings that can happen with time. So, there’s a boatload of modalities out there.

The unfortunate part is a lot of these are cash pay procedures. So, you’ll see them in a lot of med spas, they get oversold. The benefits get oversold to a lot of women, and I’m not saying that they do. Some of them really do have benefits. But unfortunately, these are services that fall in the world of Botox, and if you can’t afford them, you can’t get them. But vaginal estrogen therapy is safe and effective for many women. I’d like to say it’s cheap and effective, but the coverage on formularies sometimes is really bad, the cash pay can still be really high. It’s not a well-covered service. It’s just sad for really women and women’s health across the board, because hormone replacement therapy is not well covered.

Cynthia: That’s really a shame on so many levels, because I think back to and I’m going to date myself, Viagra came out on the scene when I was a new nurse practitioner. The joke was we could never carry enough samples in the office. So, I worked for cardiology practice. So, we had clinic and then hospital time, and the joke was all the male cardiologists that were middle aged and older were the ones that were taking the samples home. So, if we can get Viagra coverage or Cialis coverage, we should be able to get hormonal support coverage for sure.

Now, I want to be respectful of your time, but I did get some questions. They were all over the place. People were asking, “Do you use the DUTCH in your clinical practice?” This is a dried urine and saliva test that some healthcare professionals are using now. You mentioned earlier that, hormones are challenging to test for because they fluctuate hour-to-hour, minute-to-minute, day-to-day. Is this something that you’re using in clinical practice right now?

Jaime: I do use it, but not for everybody. For certain situations where we’re trying to tease things out. Like I said, if we do serum testing, it’s a snapshot in time. The nice part about DUTCH testing is, we can do cycle mapping, where we look at estrogen and progesterone production over the course of a cycle. Okay, that can be helpful. I like the salivary component for cortisol. Not necessarily for the other metabolites of– let’s not look into metabolites, but not for estrogen, and progesterone, and androgens, but I like it for cortisol. The inaccuracy with some of the urinary metabolites is that, there can be some genetic influence of how you spill those metabolites into your urine. So, anytime we find something on DUTCH that looks inaccurate, a lot of times back it up with serum testing, clinical signs and symptoms before we say like, “Oh, my gosh, look at this. This is so off.” But I think it’s a good test as far as looking at the overall picture of like, “What’s going on with their cortisol? How do they metabolize their estrogen?” which I think is something I never thought of when I was going through training.

There’s different pathways of estrogen metabolism, and there’s so many different things that can affect those pathways. If you have somebody on hormone replacement therapy, want them metabolizing their estrogen, it’s a hormone called use it and lose it. You want to use it, you don’t want to hang around. You don’t want it to get reabsorbed. So, there are different aspects of DUTCH testing that can be helpful, but it’s not for everybody, and it doesn’t always give you all the answers. Sometimes, you need additional tests to put all the puzzle pieces together.

Cynthia: Now, I think that’s a great answer. Next question, low carb, and keto, and thyroid health, because they’re still this, what I perceive to be old science that you need a certain amount of carbohydrates in order to get healthy T4 to T3, so inactive to active thyroid hormone conversion. What are your thoughts on that?

Jaime: Yeah, it all depends on what the reason is that you have low thyroid function. Insulin resistance by itself can cause hypothyroidism and it can be this vicious storm. I just did a post on it literally just a couple days ago if anybody wants to go check that out. But there’s a lot of other co-factors required. You need adequate iodine. You definitely need adequate selenium, which is one that people don’t think about or talk about. There’s lots of other cofactors involved with thyroid. Now, where I think a lot of the misconception comes is that people will say, “Oh, the patient went on a low carb diet and their thyroid hormones dropped.” Now, of course, I’ve had the luxury of being able to test myself a lot, especially with the history of hypothyroidism and I’m no longer on thyroid medication. My thyroid has corrected with a low carb diet. Well, I think the root cause of hypothyroidism was my insulin resistance, and I fixed that and suddenly my thyroid got better.

Now, weight loss in general, weight loss across the board will cause a reduction in thyroid hormone. This is the body’s protective mechanism. Through nutrient sensing pathways, it’s sensing that there’s less calories coming in. So, I’m going to conserve energy, I’m going to turn down the motor a little bit. Just diets across the board, if you’re in a calorie deficit, you’ll see a lowering of thyroid function. Now, when we look at the studies that have been done on low carb and ketogenic, Jeff Volek and a few people have published thyroid data on patients participated in these trials. We do see reduction in free T3 in people that are on low carb diets and so people [unintelligible [00:50:58] that’s because you need carbs to convert to T3.

What we don’t see and what I haven’t seen clinically is a concomitant rise in TSH or thyroid stimulating hormone. If they’re truly hypothyroid with low free T3 levels, we should see this rise in TSH. The brain should be saying, “Hey, we need more thyroid hormone,” but it’s not. A lot of them don’t tend to have hypothyroidism symptoms. They theorize that as insulin sensitivity improves, which happens on a low carb diet. Thyroid sensitivity improves, so like the level of the nucleus of the cell, where T3 interacts, there’s probably an increase in thyroid sensitivity. So, I have no problem with patients who have disorders. Once again, you have to know, is this autoimmune in nature, is this a nutrient deficiency, is this because of their insulin resistance, and so you want a provider that can tease that out? But it’s certainly a misconception and I have no problem with it. We have to monitor.

Cynthia: yeah, now, and it’s interesting, because I always say this one size fits all doesn’t necessarily take into account bio individuality. I love that you address the co-factors for healthy thyroid production, because that is oftentimes overlooked and missed, because automatically people are going to “Oh, you need medication. You need medication.” Instead, let’s look at their magnesium, let’s look at their iron like looking at all these other pieces of the puzzle. I did have a couple questions about and it’s interesting. These come and go the Wiley protocol. I’m sure you probably know your answer to this. For anyone that’s not familiar T. S. Wiley is, I don’t even know if I call her a scientist. She’s just an individual that believes strongly and fervently that women should cycle till they die, and to stay on a therapeutic enough hormone to continue having menstrual cycles, etc. So, I would say on the fringe of hormone replacement therapy, definitely an outlier.

Jaime: Yeah, I don’t use that. I’ve seen patients that have been on it. I think one of the advantages of being in menopause is that you’re in steady state. Come on, every woman knows what those ups and downs on those roller coasters feel like and they’re not fun. Yeah, I don’t use that my practice. I think I have an optimal range that I’m looking for with estrogen, and progesterone, and testosterone replacement. It’s different for each woman. We use clinical signs and symptoms to figure out what their optimal ranges, and I’m more of a fan of steady state. Now, depending on how you’re replacing it, you’re always going to see peaks and troughs anytime you’re using some sort of medication. Plus, I just think that the level of titration of some of these things, people are busy, we’ve got lives to lead.

[laughter]

Cynthia: [crosstalk] titrating.

Jaime: I’m okay [crosstalk] an advantage of being a menopause.

Cynthia: Exactly. And lastly, there’s a woman asking, she’s in menopause, she knows that she’s concerned about sarcopenia. So, she recognizes there’s this muscle loss with aging. She’s already osteopenic. She’s eating really healthy, she’s doing strength training. Does she have to be on bioidenticals? She’s said I recognize that I’m not being treated by Dr. Seeman, but in a general feeling, if you’re five years into menopause, not on bioidenticals or not on hormonal replacement therapy, you know you’re already osteopenic and doing all these other things. If she’s trying to avoid being on by phosphates or any of the bone building medications, are there ways around this or is she eventually going to need to probably consider hormonal replacement therapy?

Jaime: Yeah, there’s certainly lots of personal risk factors that could be at play. Genetics, hf she’s been thin, if she’s ever smoked, when she went through menopause like how long her years of estrogen exposure were. But really, when it comes to postmenopausal bone health, there’s really three things that I talk to patients about. The first one is adequate protein consumption. Protein helps build strong bones. Bones aren’t this magical substance. They’re a type of connective tissue. Then, the calcium comes in and solidifies that and hardens that. We’re right. We do lose bone health as we age, but adequate protein consumption can help with bone health.

The second one is resistance training. It has to be something that actually placed the stress on the bones. Now, you can do that with resistance bands. That’s the cheapest, easiest way to do something from home, if you’re afraid of using weights, or dumbbells, or something like that. But unfortunately, like yoga, Pilates, some of these other very low-intensity exercises, don’t put enough stress on the bone. So, protein resistance training.

Then, the third one is hormone optimization. Depending on how old this patient is and depending on what their level of osteopenia or osteoporosis, it’s not an FDA-approved indication for hormone replacement therapy, but I’ve still used it in patients. I still have patients that have been on it for that reason. Yes, a lot of the osteoporosis medications can come with really horrible side effects. They’re not magical by any means. From my perspective, adequate protein consumption, resistance training, and optimal hormones, and it’s never too early to start. You should start worrying about this in your 30s, and in your 40s, and in your 50s, and not when you get to 65, and you’ve ordered DEXA and they’ve got osteoporosis already. When it comes to hormone replacement, a very important thing for everybody listening in to understand is when we’re talking about osteoporosis, cardiovascular dementia, hormone replacement therapy is better at prevention than it is at reversal. So, once you get to 65, 70 years old, you can’t just start estrogen and think these things are going to be reversed. It’s so much better at helping prevent it when you’re in that golden window, which is 5 to 10 years from menopause.

Cynthia: Well, thank you so much. I know that our conversation today will be truly invaluable. Let the listeners know what’s next for you. I know that I’m really grateful I’m going to be seeing you in a couple weeks out in Omaha, but what are– You’re starting a podcast, which I’ve already listened to a couple episodes. They’re amazing. How can people connect with you? What’s next?

Jaime: Yeah, I’m super active on social media, mostly on Instagram. I can’t be on all the channels. I don’t have time for it. [laughs]

Cynthia: [laughs]

Jaime: You can find me @doctorfitandfabulous on Instagram, Doctor Fit and Fabulous over on Facebook. I’ve got a YouTube channel. I just started the Fit and Fabulous Podcast, which has been two years in the making. You totally understand the time consumption of this because I do work full time in clinical practice. So, I’m a full-time OB-GYN, and I’ve got three daughters. Yes, Keto Summit Omaha is happening in which is an incredible event here. This is our second year having the event right here in Omaha, Nebraska. It’s August 19th and 20th. Cynthia’s going to make the flight out here. I can’t wait to hug you in person, but it’s going to be a wonderful event. Then ,the days after Keto Summit, I’m doing a 54-mile walk from the Capitol in Lincoln up here to Omaha to raise money for homeless veterans. So, those two events are happening simultaneously. Then all at the same time, because I can’t just do one thing at a time. [laughs]

We’re opening a new business here in town called Upgrade Performance Institute, which is this incredible space that is resistance training focused. We’ve got a gym, we’ve got a DEXA scanner. So, we can actually see how much muscle, and bone mass, and fat mass people have. We’ve got IV hydration, and peptides, and antiaging modalities. I’m not leaving my clinical practice, but I am the medical director over there, and I’ll be helping a lot with nutritional consult. So, it really will expand my ability to help people with that because when I’m in my OB-GYN practice, I want to be doing gynecology and taking care of my obstetric patients, and I’ve just been bombarded just even locally in my community helping people with insulin resistance and nutrition. So, this is going to be a great avenue to help more people.

Cynthia: Oh, I think that sounds amazing. What a blessing you are to your patients and to your community, always giving of yourself to others. I will make sure that we include all the links to your website, and your social media, as well as your podcasts. Thanks so much for joining us this afternoon.

Jaime: Thanks, Cynthia.

Presenter: Thanks for listening to Everyday Wellness. If you loved this episode, please leave us a rating, and review, subscribe, and remember, tell a friend. And if you want to connect with us online, visit the link in the show notes.