Ep. 334 Hormone Insights: Advocacy, Trends and Tips for 2024 with Esther Blum

I am delighted to reconnect with Esther Blum today. She joined me once before for Episode 264, one of the most popular podcast episodes for 2023. 

Esther is the bestselling author of many books, including See You Later Ovulator. She is a registered dietitian with a thriving virtual practice specializing in helping women balance their hormones, shed stubborn body fat, and address the root causes of their health issues.

Today, Esther and I discuss the state of hormones in 2024. Our conversation covers lazy medicine advocacy, meno-washing, and meno-care, and we explore uncommon symptoms associated with perimenopause and menopause and methods for obtaining testing. Esther also shares her recommended supplements. 

You will love this engaging and insightful conversation with Esther Blum!

“Progesterone is a game changer for inflammation and swollen joints, especially the hips, knees, and fingers.”

– Esther Blum

IN THIS EPISODE YOU WILL LEARN:

• How safe is hormone replacement therapy?
• Why hormone testing and monitoring is essential 
• The importance of prioritizing romance and connection in a marriage
• The benefits of pelvic floor therapy
• How working with compounding pharmacies can reduce the cost of hormone replacement therapy
• How to work with doctors to address hormone imbalances
• Some uncommon symptoms of perimenopause and menopause
• How dietary changes and probiotics can improve focus and brain clarity 
• Hormone testing and menopause management 
• Esther recommends supplements for adrenal support during menopause

Connect with Cynthia Thurlow

• Follow on Twitter
• Instagram
• LinkedIn
• Check out Cynthia’s website
• Submit your questions to support@cynthiathurlow.com

Connect withEsther Blum

• On her website
• Instagram
• Get Esther’s 14-Day Metabolic Menopausal Meal Plan

Esther’s Books

Esther’s book, See Ya Later, Ovulator!, by Esther Blum

Cavewomen Don’t Get Fat, by Esther Blum

Eat, Drink, and Be Happy, by Esther Blum

Previous Episode featuring Esther Blum

Ep. 264 Peri/Menopause are a Natural Function of Aging: See you later, Ovulator!

Transcript

Cynthia Thurlow: [00:00:02] Welcome to Everyday Wellness podcast. I’m your host, Nurse Practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

[00:00:29] Today, I had the honor of reconnecting with Esther Blum, who had one of the most popular podcasts with me of 2023, Episode 264. Esther is the best-selling author of multiple books, including See ya later, Ovulator! She’s a registered dietitian and she maintains a busy virtual practice where she helps women balance hormones, lose stubborn body fat, and treat the root cause of her health struggles. Today, we spoke at great length about the state of hormones in 2024 including lazy medicine advocacy, menowashing, Menocare, and so much more. We reviewed uncommon symptoms related to perimenopause and menopause, ways to get testing, and some of her favorite supplements. I know you will love this conversation as much as I did recording it.

[00:01:23] Welcome back my friend. I’ve been looking forward to this conversation.

Esther Blum: [00:01:27] Thank you, Cynthia. You know I adore you. I’m so excited to be here. 

Cynthia Thurlow: [00:01:30] Aww, likewise. And so obviously, one of the most popular podcasts from 2023 was our discussion. My community loves you. I thought we could talk about the state of hormones for 2024 because I am probably much like you across social media, in your DMs, in your emails, women are still struggling to find competent, good information about their bodies, about perimenopause and menopause, about HRT. And one common theme that keeps coming up for me is women saying like, “I’m so excited.” I just found this new NCERT, GYN, NP, midwife, PA, etc. And this is what they prescribed me for hormone replacement therapy. I was like, “Great, what did they give you?” And then I realized it’s actually not HRT, it’s actually oral contraceptives. And I’m curious if this is a theme that you have been seeing, do you feel like there’s still this degree of misinformation? I have to believe it’s well meaning, but prescribing perimenopausal women or menopausal women who would be better served with getting hormone replacement therapy to try to convince them that oral contraceptives are the same thing, I think is duplicitous.

Esther Blum: [00:02:41] It is. And often I’m going to call it out for what it is, which is lazy medicine [Cynthia laughs] on one hand, it’s lazy medicine. It really is egregious on one hand and on the other hand, it is that doctors are taught to fear hormones. Even though the FDA has approved the use of bioidentical hormones, those bioidentical hormones still have black box warning labels on them. Even though the pill and oral contraceptives, oral synthetic estrogens, have a documented higher risk of stroke and clot and transdermal estrogen does not. Doctors are still terrified to prescribe it even though the pill is estrone and synthetic estrogens and transdermal is, if you’re getting biased estriol and estradiol and if you’re getting the patches, estradiol-

Cynthia Thurlow: [00:03:39] Yes. 

Esther Blum: [00:03:39] -it is still so much safer and so much better than the pill. It’s like a micro dose. It’s a fifth of the dose of the pill.

Cynthia Thurlow: [00:03:48] Yeah.

Esther Blum: [00:03:49] So how is it that a dietitian and a nurse practitioner are sitting here talking about this and it’s not given to women? This knowledge is not given to women in medical offices. This is what makes me bang my head against the wall, but also gets my ass out of bed every morning. [laughs] We got to change this. 

Cynthia Thurlow: [00:04:07] Yeah. Well, and it’s interesting to me, my mom’s generation, our mom’s generation, they were really impacted the most by the WHI, the Women’s Health Initiative, which I know we’ve talked about extensively on this podcast multiple times. But that generation of women were largely taken off of all of their HRT. And my mom will openly talk about what happened to her. She started having terrible pain, arthritic pain in her hands and her feet. She was prescribed Vioxx in lieu of being taken off of estrogen. And then there was the whole debacle about Vioxx, these COX-2 inhibitors. And I think a lot of women were dealing with brittle bones, chronic inflammation and oxidative stress, poor quality sleep, dry vaginas, which I know we’ll talk about. And I just think, in a lot of ways, we have chronically underserved women in middle age. And my hope and my intent, and certainly our voices, the voices of a lot of our colleagues on social media, hopefully, we’re helping to amplify, allowing women to have good information to make good decisions. 

[00:05:10] And for every woman listening, listen, I understand you may decide not to take HRT, and there is no judgment on our part. We just want you to be able to make a good decision based on your risk factors, based on your health, with a qualified practitioner that’s going to be able to honor your needs. And that’s really clear. One thing that I have been surprised by is how much gaslighting persists over another topic when women want a baseline of their hormone levels. And I acknowledge hormones are chemical messengers. Hormones, for a lot of us may change day to day, hour to hour, depending on where you are in this perimenopause journey. But I’ve had more people come back to me and say, “My healthcare practitioner said it is useless to test hormones.” What are your thoughts surrounding this? Do you think this is improving? Do you think more women are advocating for themselves and that’s why they’re seeing more pushback? What are your thoughts? 

Esther Blum: [00:06:06] Yeah. I don’t think the testing is improving because again, doctors who are not trained in functional medicine don’t understand that you can do a saliva test and look at your tissue saturation of hormones. You can do a 24-hour urine collection, you can do a DUTCH test, and guess what? Blood is still accompanying all these tests. So, okay, your hormones may be fluctuating up to 30% on any given day that is absolute truth. However, your baseline hormone fluctuations can still be tested. So if you’re fluctuating now, in six months from now, are you still fluctuating or have those numbers come down? Each of us can tell when they’ve come down because guess what? Sleep takes a hit, irritability comes back, brain fog, no endurance at the gym or to work out, no energy. We start to get where depression and anxiety kicks up. 

[00:07:03] So we know our bodies. And there are plenty of doctors that just put women on hormones that are like, “Fine, we’re just going to put you on it.” And they don’t test, they treat symptomatically. I certainly am not one to let perfect be the enemy of done, but you should know your levels. It does help, it does matter. And I think especially because you have to have your hormones at a certain baseline to prevent bone loss, to prevent cardiovascular risk, to prevent loss of gray matter in the brain. So, specificity is helpful. But if you tell me, “You know what, my doctor put me on it and has it monitored.” I’ll be like, “Okay, I’m still grateful you’re on hormones the end of the day.” And now let’s get you some testing. 

Cynthia Thurlow: [00:07:48] Yeah, it’s interesting, I just interviewed Dr. Lisa Mosconi, who was so lovely. And for anyone that’s listening, that podcast will be out in March around the time of her new book coming out, The Menopause Brain. And she is this acclaimed, well-respected brain researcher, and she was kind of talking about how she became interested in aging brains and how little research in 2016 had been done on aging brains in women. And she said, “I just could not believe the lack of research.” So, she is now creating a whole catalog of information. And I’m actually going to go to New York to get my brain scan, because I want to know what is going on in my brain. And to your point, we know that we need our estrogen levels to be at a certain level to help protect our brain, our heart, our bones. 

[00:08:36] And I think on a lot of different levels, that whether it’s serum testing or otherwise, and stay tuned for what Dr. Mosconi said about being able to test for estrogen levels in the brain this is kind of cutting-edge technology. To me it was really interesting that even brain health researcher was saying, “I think it’s important to have a sense of what those levels are, so at least we have something to gauge against.” And so, I agree with you wholeheartedly. I want to pivot a little bit and talk about another hot topic is that menopausal women don’t have sex. And I don’t say this to be tongue-in-cheek. It is really a lack of understanding. Like, outside the United States, vaginal estrogen is available over the counter. I’m going to say that again, vaginal estrogen outside the United States, there are countries where you can go into your pharmacy and you can pick up a tube of vaginal estrogen, whereas here, I believe, it still has that black box warning on it, and yet it’s one of the safest things. It’s not a systemically absorbed product. 

[00:09:36] And I think for a lot of women out there, even in the latter stages of perimenopause, and especially if you’re a thin woman, you’re going to have less estrogen stores. You are very likely going to have that terrible terminology. They call it genitourinary symptoms of menopause. I mean, GUSM, I mean, what a terrible or the senile vagina, as Kelly Casperson calls it. [Esther laughs] Not that she calls it, but she was reminding me that that was a term that had been used in her presence and so she thought that was terrible too,-

Esther Blum: [00:10:03] Terrible.

Cynthia Thurlow: [00:10:04] -senile vagina, but how many women don’t realize that they don’t have to live with these symptoms and that there is a fairly easy fix and tie into that urinary tract infections, incontinence, leakage. I mean, these things don’t have to be normal. How many of my cardiology patients, I’m sure you probably saw them in the hospital too, they were on these powerful anticholinergic drugs to address their overactive bladder when probably what they needed was some vaginal estrogen, which is such an easy way to prevent chronic UTIs to deal with all these symptoms. I know you had an amazing reel [laughs] when you’re talking about the speculum and what women go through. 

Esther Blum: [00:10:43] [chuckles] I grabbed my grill tongs, yes. And I watched my mother. I mean, I took her to the doctor to get Botox injections in her bladder when all she needed was vaginal estrogen. And she was also pulled off her estrogen with the Women’s Health Initiative study. So regarding vaginal estrogen, the Framingham nurses study looked at women for 18 years on vaginal estrogen. There was no change in serum blood concentrations of estrogen. And even now, oncology doctors are getting hip to saying, “Hey, you know what? Even if you’ve had treatment for ovarian, uterine, breast cancer, like this is a quality-of-life issue. We don’t want you to atrophy.” And so, it is incredibly safe. It does stay localized. And if you are still wary though, of using vaginal estrogen, you can certainly use vaginal DHEA, which has the same effect on rebuilding collagen in the vaginal walls.

[00:11:39] And by the way, when you apply this all ladies, you should put it on the clitoris and the urethra because clitoral atrophy is a very real thing. Now, my buddy, who we know, our girl Suzanne Fenske, also taught me that she has her patients apply topical oxytocin to the labia and the clitoral area to really enhance sexual sensation, arousal, pleasure. Because a lot of women with clitoral atrophy, this is why they are turning to vibrators, because they need a stronger sensation than just penetration or even oral sex to actually achieve orgasm. So that’s why there’s like three engine speeds on those lovely devices, because some women truly need a really strong sensation to do it. But the good news is there are solutions out there now. Yes, you do have to get oxytocin compounded, you have to get DHEA compounded, and you have to get testosterone. You can also use, like, vaginal testosterone along with estrogen. Those are more compounded. 

[00:12:46] But there are bioidentical estrogen creams, like Estrace, that you can get FDA approved through your insurance at your regular pharmacy. And that can help with libido, okay. But also, what we forget about libido with women. This is like the coolest thing. Orgasms start in the brain. And women, I mean, that’s why you can have orgasms in your sleep, just like men can ejaculate in their sleep. But women can have orgasms in their sleep. And that brain connection, that connection with our partner is actually really important. And I think a lot of women lose their libido in midlife because they’ve been married probably on average, 20 years, maybe 30 years, and it’s like, “Same old, same old. Let’s just do the five-minute quickie. We’re exhausted. We just put the kids to bed. We know we want to do this, but then we have to get up the next morning for a meeting.” There’s, like, no time for romance right now and you can always change the time of day in the morning or scheduling it.  I love to tell the story of my parents. Like, Wednesdays and Saturdays were their “naptime,” and we were like-

[laughter]

[00:13:56] -at my mom’s funeral, I told that story. The rabbi was, like, blushing furiously, and I was like, “Spoiler alert, guys. We knew you weren’t napping.” They had a stack of Playboys and Playgirls in their bureau that we all knew about. And my mom was an amazing needle pointer and she had two pillows that I still have hanging in her closet, like these old needle point pillows. One said, “Sex cures headaches,” and the other one said, “A hard man is good to find.”

[laughter] 

Cynthia Thurlow: [00:14:24] Progressive. I love it. 

Esther Blum: [00:14:25] And they were married well over 50 years, so I think you have to make it a priority in your marriage. I think for a lot of us, myself included, physical drive has definitely decreased, and I’m on full hormone cocktail from topical to vagina, and still, it’s like, “I have to make the effort sometimes.” I don’t always feel arousal, but once it gets started, I’m like, “Okay, yeah, right. This is good. This is all good.” But we really have focus on our connection with our partner. 

Cynthia Thurlow: [00:14:57] I think that’s such a good point, Esther. I’m so glad that you brought that up. And a couple things just touch on. Oxytocin intravaginally or placed on the clitoris, that is a new one. I have actually intranasal oxytocin in my refrigerator that I haven’t yet tried. It just arrived. I’m super excited to try it. But oxytocin is one of these hormones that is involved in orgasm and bonding and all these other things, but it helps decrease cortisol, so if you’re, like, super stressed, this is why sometimes the things we don’t think we need to do when we’re stressed are actually the things that are going to be most helpful. So just to understand that interrelationship with oxytocin and having an orgasm can help reduce cortisol. So that’s certainly powerful. 

[00:15:39] The very first physician that I worked with that did HRT and this is a very patriarchal comment that I’m going to just say what he said to me. He used intravaginal DHEA that was compounded. He called it “jungle juice.” And I used to always chuckle. I was like, “I think you need a different name [Esther laughs] that may appeal to you as a dude.” But as a woman no that’s-

Esther Blum: [00:15:58] Yeah.

Cynthia Thurlow: [00:15:58] -yeah, just call it vaginal DHEA, and we’ll just go with that. I look forward to interviewing Susan on the podcast later this year.

Esther Blum: [00:16:04] Yes.

Cynthia Thurlow: [00:16:05] I also think about over-the-counter options, like Anna Cabeca’s product that she’s designed herself, that there’s no junkie fillers, DHEA, coconut oil.

Esther Blum: [00:16:13] The Julva.

Cynthia Thurlow: [00:16:14] Right. And she always says clitoris to anus. So it’s important to be making sure that you’re using Julva or any of these topical applications and understanding that it’s not just the vulva, the vagina that need the replenishment of these hormones. It’s that it’s this entire genitourinary system. And I find for a lot of women, they start getting a lot of itching and just discomfort. And so, if you’re having those symptoms, please know that there’s a solution. Sometimes you have to see a specialist. There are these, I always say, GYNs that are also urologists, very, very specialized. I saw one once because I had this chronic UTI pattern that we couldn’t seem to break. And I remember thinking he was the most kind, thoughtful person I’d ever met. I just kept thinking; you really have to like women in particular if you’re working in this occupation. So kudos to the GYN urologists that are out there, because that is a very, very, very, very specialized area of medicine. 

Esther Blum: [00:17:11] It is. And, you know, it’s funny. I’m glad you had a good experience. I went to a GYN urologist because I was peeing, like, seven times a night and didn’t understand I had pelvic floor dysfunction. So, he did an exam. He’s like, “Oh, my God, it’s like cement in there. [Cynthia laughs] Zero bedside manner.” But he was like, “You’ve got to get pelvic floor therapy.” So I found a lovely pelvic floor therapist who I fondly call my vagician, my hope [Cynthia laughs] and I think that is another huge piece. I always say, like, “Hormones alone don’t do the heavy lifting. If you have a weak pelvic floor or a weak saddle, you need to do strengthening and stretching exercises. If you have a tight pelvic floor, you need to do stretching, strengthening, but also releasing the trigger points in the vaginal walls.” 

[00:18:04] There are wands you can use that you gently insert in the vaginal walls and you press against the trigger points to release them. Because a lot of us, we store, we clench like, we’re in [unintelligible 00:18:20] Kegels if you’re type A like me and you’re not going to pee your pants, but you’re also not going to empty your bladder. The other extreme, when you’ve got the weak pelvic floor, right, that’s when you’re leaking. When you pee, sneeze, or cough, or jump. So, either way, pelvic floor therapy is, it’s PT for your vagina. And the good news is orgasms are PT for your vagina too.

Cynthia Thurlow: [00:18:38] Oh, yeah. That is important.

Esther Blum: [00:18:39] They really are if you’ve got a weak pelvic floor. Now, some women also can’t achieve orgasms because their pelvic floor is so weak. They can’t poo or pee properly because their pelvic floor is so weak. So the good news is all fixable. Takes a little time and consistency, but it’s really all fixable and can dramatically change the quality of your life. I mean, I was peeing seven times a night when I went to my first urologist GYN. And after pelvic floor PT, we got down to, like, one to two times a night, which is such a game changer. But again, nobody’s talking about this. Like, I would go to my GYN and say “I’m peeing all the time.” She was like, “Well, stop drinking water after four.” There was nothing, no offering, no internal exams. And I was like, “How are there not pelvic floor PTs in GYN offices? This should just be part of the practice.” There’re also laser therapies that you can do too to tighten the vaginal canal. Oh, boy. There’s MonaLisa, I believe, and ThermiVa are two commercial names that you can look at, and you are given a topical anesthetic. The treatment lasts around three minutes. You have to go a couple times a year. And it’s pretty simple to do so many amazing, exciting options you can do, which is great.

Cynthia Thurlow: [00:19:58] Yeah. No, I think the option piece– what’s interesting is pelvic floor therapy is standard of care in most other countries. Like, I’m going to keep saying this standard of care in most other countries that as soon as you are done delivering a baby, you go to see a specialized physical therapist for pelvic floor therapy. Number two, if you’re going to use a laser near your vagina, please make sure you go through a clinician. I think there’s a lot of these well-meaning wellness centers, antiaging centers, and you want to make sure the person that is utilizing those kinds of devices on such a delicate part of your body is actually someone who’s aware of the anatomy, physiology and is being really– Because I’ve had friends that have had mixed reviews with these. I’ve never actually done it, but if I needed to consider it, I would be going to a clinician, because I do think that it’s important or someone that’s working within a clinician’s office so that you know this individual has specialized training, because there are women who’ve been burned, because they are working with someone who doesn’t know what they don’t know. And you and I both know what that means. 

[00:20:58] And sometimes people can end up having an untoward event. But yes, it’s good that there are options. And it’s not like if you do vaginal estrogen, you can’t also do pelvic floor therapy. It’s almost like a platter. You can take what you need and put back what you don’t need. But knowing that there are options and you don’t need to suffer needlessly, I think is a really important point. Now, one thing that I’ve been reading about, it doesn’t impact me because all of my hormones are compounded, but there appears to be an HRT shortage. And it’s not just unique to the United States, it sounds like it is happening outside the United States. And if you’re listening, it’s probably the standard therapies, the things that are covered by insurance, that tend to be inexpensive. So probably the patches, the oral progesterone, which is dirt cheap, I don’t fully understand or appreciate is it can’t possibly be that demand has risen so rapidly that these pharmaceutical companies can’t keep up. I’m curious to know, because I’m sure there’s never been a Viagra shortage. 

Esther Blum: [00:21:52] Well, amen to that. Yes, absolutely. It is interesting. Right now I believe the statistic is a whopping 4% of women are using HRT. That’s it.

Cynthia Thurlow: [00:22:03] Here in the US. 

Esther Blum: [00:22:04] What I have learned in 2023 was that compounding pharmacies, we really have to protect and support and give money to compounding pharmacies. Because the FDA is in the midst of making four different hormone cocktails for women. That’s it. I don’t know even if that is patch and Prometrium, I don’t know if they’re going to be topicals versus vaginal. I don’t know exactly what those cocktails are going to entail. But certainly, if pharmaceutical companies can make a buck off of this menowashing, as it’s called. [Cynthia laughs] Menowashing, then they’re going to do it. I wonder if it’s due to– There are a lot of online companies popping up now and I wonder if that is causing a search. Like women, they go to their GYN and perhaps they’re gaslit. So they’re like, “Okay, there’s a myriad of online companies doing this where they can get access to a doctor, they pay a monthly fee and they get hormone prescriptions.” I’m not really sure where the shortage is coming from. I know in the UK it’s really wicked because Dr. Newson has blown it all out of the water, God love her and Davina McCall also, it’s great. 

[00:23:18] So I’m not really sure, why? but I would say this, it’s interesting too, insurance doesn’t always cover. Like, I got a DM from someone saying her insurance is going to charge her $500 for her monthly estrogen. And I said it’s going to be cheaper for you to go to a compounding pharmacy at this point. So the cost differential is a true thing. I do not want to dismiss anyone’s challenges financially to accessing compounded hormones. However, understand, often it’s for a three-month supply. So you may hear a number and say $90 for a prescription of estrogen. That’s a lot. But understand it’s $30 a month really, so a Bi-Est cream. So do what you can. Work with compounding pharmacies. What’s a cheaper way to make it? What’s the least expensive form you could do for me? Try and work with your pharmacist that way. Or say, if I buy in bulk, will I save money and try and get it done that way? 

Cynthia Thurlow: [00:24:19] That’s really helpful information. And I think for a lot of individuals over the generic progesterone works just fine and for a lot of people it does. And it’s like $5 or $9 a month. So, it’s really inexpensive. The estrogen patches tend to be pretty inexpensive. I think for every individual it’s really determining what do you need, what’s the right dosage for you, where are you? Unfortunately, testosterone, there’s no FDA approved. testosterone for women so that does have to be compounded, which I know a lot of physician voices in particular in this space are speaking out against this and saying women need testosterone as well. And so, I get all my stuff compounded. But having said that, there are lots of different ways and talk to the pharmacist. I find even for myself, every once in a while, my kids will get prescribed something that’s outrageously expensive, and I’ll talk to the pharmacist and say, “What’s the workaround? Or is there a way to do this less expensively?”

[00:25:14] And actually, we found for my older son, who intermittently has eczema, there’s a product that he’s now on that is expensive, but if we buy three months’ worth, which it takes him an entire year to use it, it’s ridiculously inexpensive. And so, I think that having an honest conversation with what’s your budget? What can you afford to spend? What I do find interesting is, again, in countries HRT is covered. And I think that as our voices continue to be magnified and we’re doing more advocacy work, I would not be surprised if at some point there is some type of required insurance coverage for HRT. Whether it’s the standardized stuff that you just pick up at the pharmacy or a credit towards the compounded options. I think consumers are going to a large enough wave coming. I think women much like oral contraceptives, back in the day when I used to use those, they were never covered by insurance, which to me was ridiculous. But then again, I’ll make up the point that Viagra gets covered, which tells you that there’s definitely [crosstalk] some patriarchal things that go on within insurance companies. But my hope and intention is over time, that we cover women’s needs at their younger ages and at older ages, so that everyone get access to options. 

Esther Blum: [00:26:28] Well, let’s talk about, well, A, the birth control now, you can get it over the counter, basically may not be covered, but you could get over the counter. But B, the testosterone workaround for now is that you can ask your doctor for what the version that gets prescribed to men at just a 10th of the dose, and that can be physiologically more compatible and covered under insurance. So for now that’s an option for women, but I think it’s tricky. 

Cynthia Thurlow: [00:26:56] Yeah. And it depends on the clinician, because I’ve had the experience where GYNs were like, “No-”

Esther Blum: [00:27:02] Right.

Cynthia Thurlow: [00:27:03] -and here’s the other thing. You have to have a DEA number. So some clinicians no longer have DEA numbers because they’re not prescribing drugs that are controlled. And so, they literally cannot prescribe testosterone-

Esther Blum: [00:27:14] Yes.

Cynthia Thurlow: [00:27:14] -And they’re now monitoring prescriptions very closely. I had to talk with Dr. Pam Smith. And she was talking about how and this is the segue into talking about pellets, the fact that she’s seeing so many young women having cardiovascular complications from being on pellet therapy, because their testosterone levels are way super therapeutic, way beyond where they should be for a woman, and how she’s seeing young women that are coming in with heart attacks and other types of complications. And so now the DEA is very carefully monitoring testosterone prescription supplementation. In fact, the last time I got my testosterone, my Dr. Hartman, who everyone knows that’s who I go to, he had written my prescription one way and the pharmacist had interpreted it another way. And it was this back-and-forth conversation with the pharmacy, because they were like, “We’re sorry to let hairs over this,” but because of all this internal, external scrutiny that’s going on around testosterone, we have to be extra conscientious about clarification. 

Esther Blum: [00:28:11] That’s right. And I heard doctors talk about that too. And yes, it’s a real problem, the pellets and the injections. I have seen very few studies on pellets. And I went up to the bio rep at A4M. I said, “Where are your studies? Where’s your clinical research?” She said, “Oh, we don’t need clinical research. We have thousands of people who’ve gone on it.” I’m like, “That’s still not a controlled trial.” I can tell you in my client population, I’ve had one or two people who’ve done well on pellets. Everyone else, it has been an absolute disaster where they gain 10 pounds overnight. They are so enraged, they have lost hair on their head and grown it from their chin. And their libido is so out of control. And you can laugh and be like, “Oh, your partner’s really lucky.” But after a point, it’s like, “It’s really actually not fun or funny.” And then the worst part is they get to wait a full six months before that is flushed out of the system. So why do you need physiologic doses in your 50s, you don’t? And most of you have not had physiologic doses [chuckles] even in your 20s, you don’t. 

[00:29:25] Number two, only about 20% to 30% of women actually need testosterone repletion in menopause. And this is, per Dr. Pam Smith, this is not my statistic. But about 50% of women don’t need it at all. It’s really not like– some women have testosterone that is too high. And so, you really do want to be very careful about inserting a pellet. And again, I’m like, “Show me more research. Even if there are a couple of studies done, that is just not enough.” And I don’t think clinicians are trained. I think patients are getting them through medi spas versus a real clinician. And I’ve also seen pellets where it’s everything. It’s testosterone, estrogen, progesterone, all in one. I’m like, “No, no, no.” So the beauty again of transdermal or compounded oral is you can tweak the dose the next hour, the next day. It’s really easy to change your results and tweak, and it’s much more couture versus off the rack, right. Now, FDA-approved-

[laughter] 

Esther Blum: [00:30:35] -bioidenticals are off the rack. But you can still make them couture if you have a patch where the dose is too high. You could talk to your doctor about cutting it in quarters, cutting it in half. If you have a peanut allergy, you’re taking Prometrium, which is in a base of peanut oil, and you can go to the pharmacy and say, “Can you please put this in some olive oil or just remove the peanut oil or remove the dyes and can be done.” So you really can work the system, which is great, which is why I’m so excited, like you’re talking about all this in the podcast, because women need to know. I am going to write an eBook on this, like just an essential guide to hormones of like, what do you need to know? Hundreds of studies in the back to show your doctor. Because doctors are terrified, a lot are terrified and not to this day, not even taught meno care in medical schools. So, imagine and it can feel really uncomfortable to confront a white coat about this. I don’t really like confronting my doctors that my choice is just to leave and find a functional doctor or practitioner. But let’s say you want to work the system, because you’re like, “These are my resources. I’m not going out of insurance to solve this problem.” 

[00:31:46] You can really say to your doctor, “You know what, I’ve read the studies, here they are, I’ve got 100 in the back of my book too. See ya later, Ovulator, right, I’ve read the studies. Let me try for three months. I’m willing to take the risk. I’ll sign a waiver. I’m not going to put any risk on you. Please let me try. I’m not sleeping. I’ve got a family history of dementia. I’ve got a really weak pelvic floor, and my quality of life really needs an upgrade. Can you please partner with me?” It’s really hard for a doctor to say, “No,” when you’re putting it like that because it’s not threatening putting it all on you. And you’re coming at this thing, I would see even if you’re not a clinical researcher, most of us are not. But you can be like, “Dude, I’m telling you, I’ll do the heavy lifting. Just please write me the prescription, please and open the door that way.” And that doesn’t feel confrontational, but it can absolutely get them to say, “Yes.” Now, again, if you can, you should really be with someone who is going to monitor you because a lot of doctors will just say, “Okay, here’s your hormones, bye.” And then you’re still going to be the one leading the charge, which you should not be responsible for your own medical care, but at least get your foot in the door until you figure out your next steps and take it from there. 

Cynthia Thurlow: [00:33:07] That’s such an important point. That’s why I’m always such a huge fan of advocacy, education, empowerment, so that any woman that’s listening knows that they don’t have to suffer and that they can have those conversations. I mean, unfortunately, I would imagine most, if not all of us have been gaslit at some point and use it as an opportunity to say, “Okay, I’m going to ask my girlfriends who they like going to or as you mentioned very appropriately, there are now telemedicine options. And I oftentimes like to talk about Joi. And we have a relationship with them that if I have someone who can’t find a physician or a nurse practitioner or PA or midwife in their area, that will fill in the gap and people can get access to the things that they’re looking for.” 

[00:33:52] Let’s pivot and talk about some of the uncommon symptoms that women get in perimenopause and menopause that no one thinks are attributable to sex hormones, but interestingly enough are. And so I’m going to start with frozen joints because I have a girlfriend that I went to high school with who called me a couple of weeks ago and saying, like, “I’m very physically active and I just woke up one day and my left shoulder is completely frozen.” 

Esther Blum: [00:34:19] Yeah.

Cynthia Thurlow: [00:34:20] And so, understanding that in and of itself can be a sign of low estrogen. It can be the sign of an autoimmune condition. It could be a sign, which is probably all the above of some inflammation. We know 70% of autoimmunity occurs in women. Really starts to escalate a bit when we’re in perimenopause and menopause. Do you see a lot of frozen shoulders in your patient population?

Esther Blum: [00:34:41] I don’t, but I see them in my girlfriends. And they’re having sports injuries and tears and just, yeah, the frozen shoulders. And they’ve never been to a chiropractor in their life. They’ve never understood. And I’m like, “Dude, it’s the hormones. It is low estrogen and it can be low testosterone.” 

Cynthia Thurlow: [00:35:01] Yeah.

Esther Blum: [00:35:02] And by the way, people who are overusing testosterone in their younger years, can have wicked joint issues by the time they’re older. There’s no synovial fluid left. So, yes, frozen shoulder is a big one. Itchy nose, itchy ears, and itchy skin is another one that I’m like, “Again, fluid changes, neurological changes are another big one.” And I just want to give a shout out to anxiety and depression and ADD, because those changes in brain biochemistry are not only due to a drop in estrogen, estrogen plays a primary role, but testosterone and progesterone also play a tremendous role in cognition, in mood, in memory, learning. Like, they all work on different compartments and different pathways in the brain. And certainly, a progesterone deficiency is going to leave your poor dopamine receptors and your GABA levels just so hungry, so thirsty for more hormones. And again, this is why it gets really tricky when doctors are putting women on IUDs and birth control for treating as a menopausal treatment, because those two products contain synthetic progestogens, which do not hit up the GABA receptors in the brain. Only bioidentical progesterone will hit up the GABA receptors in the brain. 

[00:36:38] So let’s say you’re on the pill and the IUD and you started it in perimenopause or after kids, and you’re like, “I don’t want to upset the apple cart. I don’t want to go off it.” I have plenty of clients who add in bioidentical progesterone while that IUD or even is in place or while they’re still taking the birth control pill, you can still add in and stack up bioidentical progesterone and testosterone on both of those products. And then when you’re ready to take out the IUD or stop the pill, you add in bioidentical estrogen. So, hormones are really an incredible thing. And as for the ADD, also, a lot of women are being prescribed Adderall, they’re being prescribed Zoloft. Just because you’re in perimenopause doesn’t mean you suddenly developed ADD. It just means your brain biochemistry needs to be addressed and your gut biochemistry needs to be addressed. 

[00:37:37] We have massive gut changes in perimenopause. The lining of the small intestine changes with the decline in progesterone and estrogen. So foggy gut or leaky gut? I should say leaky brain. So when we really work on optimizing gut function of healing that gut wall, cutting back wine ladies, cutting back alcohol, which is going to just, like, keep poking holes in that leaky gut, cleaning up your diet, getting in probiotics, getting in red polyphenols, your cherries and your berries and your cranberries, which will also help support preventing UTIs and fiber, of course, all of that builds a really healthy gut microbiome, which will also support that really nice focus and clarity in the brain. 

Cynthia Thurlow: [00:38:29] Yeah, it’s interesting. You bring up a lot of good points. I’m actually interviewing Dr. Gundry this afternoon, talking about his new book, and he talks a lot about, specifically you know, he calls them the gut buddies. But the interrelationship between polyphenols and short-chain fatty acids and how that influences the gut microbiome vis a vis, like estrogen, so the estrobolome, which I know my listeners are familiarized with. It’s unbelievable how many changes occur in the gut microbiome just related to the shifts in estrogen. I’m down like a nerdy, like a very, very nerdy [Esther laughs] pathway right now learning about this, and I’m like, “It’s humbling how much changes.” Other things I wanted to mention are vertigo.

Esther Blum: [00:39:08] Yes.

Cynthia Thurlow: [00:39:09] I’m seeing a lot of vertigo. Vertigo is dizziness.

Esther Blum: [00:39:10] Oh, yeah.

Cynthia Thurlow: [00:39:02] I saw a ton of it in cardiology, most of it benign, occasionally these things that are not benign, but common to see that within a low estradiol state, ringing in the ear so tinnitus, this is something I started experiencing and never, ever, ever did the ear, nose and throat specialist, who is amazing, ever say to me, “Oh, by the way, because of your age, it might be that low estrogen is driving some of your symptoms.” So that’s been interesting to experience.

Esther Blum: [00:39:37] Yes.

Cynthia Thurlow: [00:39:37] I know that we talked a little bit about bladder urgency and incontinence and those kinds of things. But the other big overarching theme is pain, chronic inflammation. 

Esther Blum: [00:39:46] I was going to say, yes.

Cynthia Thurlow: [00:39:48] How many women have chronic pain, whether they’ve been diagnosed with fibromyalgia, which to me is really a sign of something else that hasn’t been picked up. I think fibromyalgia is like when all else fails, we don’t know what else to diagnose you with. That’s what you get, it’s a real diagnosis. But I’m just saying, I think there’s oftentimes something else that’s at play.

Esther Blum: [00:40:06] Yes.

Cynthia Thurlow: [00:40:06] But the chronic pain piece, for a lot of women is debilitating, because if you’re in chronic pain, you’re not going to move your body, you’re going to struggle to do normal activities of daily living. You’re probably not going to make the same food choices because you don’t feel good. You may get dependent on medication. And I think, without jumping off onto a tangential conversation, I think in this day and age, when we are dealing with an opioid crisis, I think women are still being overprescribed certain types of medications that can lead to other issues that they have to deal with. So the chronic pain piece, which in many ways, I can’t tell you how many women have just gone on an estradiol patch and all of a sudden their knee pain goes away, their shoulder pain goes away, the chronic ankle pain they’ve been dealing with, the physical therapy that has gotten them nowhere. And I’m not in any way saying that I don’t believe in physical therapy, I do. But if the reason why you’re having all these aches and pains is the changes to the sex hormones, I think that’s quite significant. 

Esther Blum: [00:41:05] Yes. And partnering with that, again with the changes in your gut. I have a lot of my clients, even if they don’t have a leaky gut or a gluten sensitivity on the tests, I’m like, “Just ditch gluten or grains for three months or dairy, and we do some elimination dieting to really see.” And then when they reintroduce it, they’re like, “Oh, my God, my joints were so inflamed. I had a gluten exposure and I was so inflamed after that.” So again, often our guts write checks that our bodies cannot cash after a certain point in midlife, and it really warrants addressing for sure. But the hormones, yes, I agree. I mean, the progesterone too, it is a game changer with that inflammation and those swollen joints, especially like the hips and knees and the fingers, I see, like, a lot of women are like, “My hands are so puffy, my joints really are swollen and achy and on hormones,” they’re like, “Wow, it’s just tremendous.” And again, people say, “What are the benefits of hormones?” We can list 1000, but under the umbrella of quality of life, it is that simple. We all deserve exquisite menopause care. Why are we shortchanged in this department? It really doesn’t make sense because let’s face it, ladies, we’re the ones who get the shit done anyway. [laughs] So you better be supporting us so we can run the world as we do right now. 

Cynthia Thurlow: [00:42:35] Yeah. No, such a good point. And one thing that I found interesting is there are now some over-the-counter tests. So women are always asking me, “How do I know where I am? Am I close to menopause? Am I still in perimenopause?” Especially for the women that have IUDs or they’ve had an ablation, they’re not getting cycles every month. I just learned about, [chuckles] remember Clearblue Easy, which was a pregnancy test. 

Esther Blum: [00:42:56] Yes.

Cynthia Thurlow: [00:42:57] There’s now a Clearblue Stage Indicator testing that will give you multiple day testing of your FSH. And for some individuals, there’s actual research behind this, but it’s an over-the-counter test that you can pick up and test in your urine. What could potentially be going on, which I thought was really, really interesting. And for anyone that’s listening, what is the FSH? It’s follicular stimulating hormone. It’s a hormone that’s excreted in the hypothalamus, but is a chemical messenger/hormone that is telling the ovaries to release an egg. And so, as we’re getting closer and closer and closer to menopause, that number starts to go up, and it actually will go up at an accelerated pace as our estrogen levels are starting to plummet. And so, if you get a blood test with an FSH greater than 25, you’re there. If you do this home test and I have no affiliation with this, I just kind of stumbled upon this as I was preparing for this podcast, Clearblue Stage Indicator testing. That’s another thing that you can look at. 

[00:43:56] And I learned from Dr. Jolene Brighten about the anti-mullerian hormone, AMH, which is a measure of ovarian reserve or primordial follicles and she has some really interesting information on her website. She has an actual graph that kind of looks at what are the ranges we expect to see at certain stages of our lives, obviously peak fertility. You want the number higher, but after the age of 45, it might be less than 0.5 ng/mL, so really teeny tiny amounts, but it’s that measure of ovarian function. So if you’re trying to get pregnant at 45, it’s going to be a whole lot harder than it was at 30. And that’s a function of many factors. But I thought that was really interesting. Are there tests that you’re also looking at when your ladies come to you and they’re just curious, where am I on this perimenopause, menopause journey? 

Esther Blum: [00:44:42] No, those are it. And then I, of course, look at the DUTCH test, which won’t tell your egg reserve, but it’s going to tell you, again, I don’t recommend doctors ever, and no doctor really does. But I don’t recommend you prescribe hormone dosages based on the DUTCH. But it gives you a really nice overall picture of what your hormone production is like. Again, if you’re on the pill or IUD, you’re not going to have a true baseline. But it also looks at, what I love is it looks at how hormones move through your liver. So, your phase 1 and phase 2 detox, it can pick up some subclinical hypothyroidism, looks at your HPA axis and your sleep, whether you’re deficient in B6 and B12, a glutathione, a melatonin. So it can be another really helpful test. But I want to know, how accurate are those Clearblue Easy tests? Like, what’s the accuracy? That’s what I want to figure out. 

Cynthia Thurlow: [00:45:38] Yeah, I didn’t. So last night when I was looking at– Because it was another clinician who had brought it to my attention. So that was the first rabbit hole I went down. There is actual research on it and it appears to be fairly accurate. And I thought, yeah, with five tests you’ll get a sense. So, if you’re someone that’s in the middle of perimenopause, it’ll probably be not as accurate as someone that’s probably at the tail end of perimenopause. Having said that to me, for someone to be able to go to the store and buy a test to get a sense of where they are, when their doctor says to them, “I’m not going to test your FSH, there’s no point in doing that.” And I say all the time, I think the first time I had my FSH tested, it was like 50. And I was like, “Oh, okay. I know for sure there’s no question where I am,” [laughs] but my provider had no problems ordering it. But for people that are listening, they might get some pushback. 

[00:46:26] And so maybe this is a way to circumvent kind of that traditional modality. But there’s also DirectLabs, Own Your Labs. Those are two companies; I have no affiliation with either of them. You can go and you can order your own labs. Now, the challenge when you order your own labs is that you then need someone to interpret them if you don’t know how to do that. So that’s always the kind of sticky wicket that you deal with. But I think for a lot of individuals, they like having a sense of what’s going on. They want to be proactive. And so an FSH is certainly a standard test. The AMH, depending on your provider, that may be something they’re not as familiarized with. But if they’re a GYN or they’re doing medical endocrinology, or they’re functional or integrative in terms of their approach, they probably are ordering those on occasion. But certainly, the Clearblue product is something you can buy over the counter. And I think for some people, they’re curious. They want that information sooner rather than later. 

Esther Blum: [00:47:17] Yeah. And power to the people. I applaud these companies for at least putting our own health into our own hands if we can’t get it from our practitioners. Yes. 

Cynthia Thurlow: [00:47:28] Any last words on things that you’re using supplements that are new to you? Anything that you’re finding is particularly efficacious for your patients and clients? I always feel like there’s always something new that I’m kind of playing around with to see if I like it. 

Esther Blum: [00:47:43] Yes, I’m really excited. I’ve actually just gone through my third iteration of producing supplements that I will be putting out this year in 2024. Based on the thousand or so DUTCH and GI MAP tests that I’ve seen and people who I’ve treated and what comes up the most. What are the most commonly prescribed supplements that I’m using to help women on HRT or help women who are not detoxing their hormones well, but want to start HRT? So, let’s give a shout out to our gorgeous glutathione girl. Glutathione, it’s the liver’s most potent antioxidant. It is used to help treat Lyme, mold, long COVID, but it also helps estrogen move through the liver beautifully. And we produce less of it as we age. We definitely need more. And it is so energizing, like no one takes glutathione and feels more tired [chuckles] unless they have a very high toxic burden and it’s too much detoxing at once. But glutathione is a wonderful overall systemic antioxidant. It’s something I believe everyone should have exposure to. 

[00:49:01] And then, of course, I love the adaptogenic herb ashwagandha. So adaptogenic herbs really build your body’s resilience to stress. They’re not meant for you to take, so you can take on more stress. They are meant to help rebalance, especially that beautiful HPA axis, that hypothalamic-pituitary-adrenal axis, which really is a good barometer to stress and hormone status. So when our stress is really high and our adrenal output is low, we can have a very low cortisol curve. But in the absence of hormones, we can also have a very low cortisol curve. So as women go on HRT, often it is paired with adrenal support to really push them up the hill, and then the hormones help them stay there. But in that transitory time, we do need adrenal support, because in menopause, what most people don’t realize is the ovarian production of hormones winds completely down, and it’s almost like a switch is flipped, and the adrenals all of a sudden say, “Hey, I’m going to hand these over to me. I’m going to handle your hormone production now and just puts out a very small amount of hormones.” 

[00:50:19] So if you go into menopause stress, which, please, who isn’t? We have aging parents and teenagers simultaneously, and our careers are often taking off because we’ve paid our dues long and hard, or we’re having, like, a midlife reinvention where we’ve been home with the kids and then say, “What’s next for me?” So it’s really great. Ashwagandha really helps support your adrenals as you go through these transitions. And it’s a wonderful sleep support as well if you find you’re on hormones, but you’re still waking up a lot, and you can wake up a lot with a low cortisol curve or a very high nighttime cortisol curve. So ashwagandha really helps balance that out. 

Cynthia Thurlow: [00:51:00] No, I love those. I think it’s important for people to do some degree of experimentation. I always say, “My biggest experiment in progress all the time.” And for me, I think one of the most important products that I’ve probably used in the last year is TUDCA. And so initially, people come to you and it’s an acronym for a very long word that I’m not going to attempt to say it [Esther laughs] because I will probably mangle it. But TUDCA, initially, I started taking it to help with detoxification support, help with biliary support. And then I was reading an incredible article talking about the role of TUDCA in brain health, because there’s this interplay between our enteric second brain, which is our gut, and the brain. And so for me, I think TUDCA has been one of these products that I use sparingly and only in people that it’s appropriate for. But I think, for me, has really been instrumental in helping to heal my gut, which has been a long road. It’s almost five years since I was hospitalized. It’s hard to believe. It feels like it’s gone by like that. And yet I’m realizing that I think it’s honestly taken probably four and a half, five years to get my gut back to a level of homeostasis.

[00:52:04] But as we’ve mentioned today, as we’re making this transition from perimenopause into menopause, there’re a lot of changes that go on. There are a lot of things that change and shift. They don’t have to be negative. And certainly, I think you and I both live a life of transparency, sharing the funny things and then sharing the things that we’re frustrated with, and finding ways to adapt and to find a reframe, which I think is so helpful. Please let listeners know how to connect with you on social media, how to get access to your books. And you mentioned you’ve got a resource that you’re working on for your community. When do you think that will be available? 

Esther Blum: [00:52:38] Oh, my gosh, I hope soon. It’s just been a labor of love. And so hopefully by the end of Q1 for sure. So come hang with me on Instagram @gorgeousesther, and my website is estherblum.com. And if you would like access to my 14-day Metabolic Menopausal Meal Plan, you can go to estherblum.com/recipes and grab two weeks’ worth of meal planning so you don’t have to think about ways to really optimize your lean muscle, optimize your body composition, but also not overstress your digestive system. 

Cynthia Thurlow: [00:53:17] I love it. Thank you again, my friend. 

Esther Blum: [00:53:18] Thank you.

Cynthia Thurlow: [00:53:21] If you love this podcast episode, please leave a rating and review, subscribe and tell a friend.