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Exhausted, Foggy, and Ignored: The Hormone Conversation Every Woman Deserves with Dr. Lara Williams

Sarah Boyles Season 3 Episode 15

In this powerful episode, I interview Dr. Laua Williams, a practicing OB/GYN with extensive training in functional, restorative, and integrative medicine. We dive deep into how our medical system often misses the mark when it comes to hormone testing, fatigue, and perimenopausal symptoms.

Dr. Williams explains how lifestyle, cortisol levels, iron levels, sleep quality, and stress responses are often overlooked and why progesterone, not estrogen, is often the missing piece.

If you've ever been told you're fine but feel anything but, this episode is for you.

For more information on Dr. Williams:

https://www.oregonclinic.com/our-team/lara-williams/#



Timeline:

00:30 Introduction to Dr. Lara Williams

01:07 The Journey to Integrative Medicine

01:48 Challenges in Traditional Western Training

02:16 Exploring Alternative Medicine

02:49 Combining Functional and Restorative Medicine

03:17 The Importance of a Holistic Approach

03:35 Addressing Training Gaps in Gynecology

05:02 Hormone Testing and Replacement

05:25 Case Study: Treating a 44-Year-Old Patient

05:59 The Role of Lifestyle in Hormonal Health

09:43 Understanding Cortisol and Stress

12:12 The Impact of Sleep and Lifestyle Choices

17:24 Iron Deficiency and Brain Fog

18:59 Addressing Urinary Symptoms and Urea Plasm

18:57 Patient Case Study: Urea Plasm

20:16 Functional and Integrative Medicine

21:28 Hormonal Imbalances and Treatments

28:42 Menopause: Symptoms and Testing

32:30 Testosterone Therapy Considerations

36:17 Empowering Women in Health

 Hi there. I'm here today with Dr. Laura Williams, who is a physician. She's a fellow of the American College of Obstetrics and Gynecology, but is also a fellow in functional medicine, a fellow in restorative medicine, and a fellow in integrative medicine. So she has a very unique skillset. So I just wanna check, I I got all of that, right?

Correct. Yes. Okay. And do you just wanna speak to that for a second? How that changes your viewpoint from the average GYN and the average GYN training? I feel like, you know, you have such a different skillset than what I have. 

Well, it's it came about in a really unique fashion because I was so frustrated because I was about 10 years into my career, and you get to a point where you're, you know what you know, but you also know what you don't know.

Yep. 

And I kept getting questions, and I would have patients come in with lists of supplements and homeopathy medicines, and they would be doing acupuncture and. I felt like my treatments could only take them so far. But I was also watching that the treatments that they were receiving outside of my practice were only taking them so far.

And so I kept having questions about what happens when you merge the two? What happens when you bridge over? And so there are. It's hard to bridge over because in the traditional Western training, we are really well trained in disease management and I don't know any other field that is as well trained in disease management as we are, which is critically important to understanding.

Y you have to pivot in certain places is because, you know, if you don't do YX will happen, but we. Don't have the skillset to help prevent some of X. Like, we know what to do when X happens, but we don't know how to prevent it. So I, because I had so many questions, I started down the road, so I started with acupuncture because I was personally receiving acupuncture.

And so I decided to get training in that, and that led me to homeopathy training which I had no understanding about it. You know, I grew up in Texas, they weren't using homeopathy. And then I, with that, then I was like, oh, there's this. Functional medicine piece. And then there's this restorative medicine piece.

Those both look interesting from different directions. And my sister was having fertility problems at the time and she had decided that they were not gonna do IVF and they weren't gonna do other things. And so I decided to double down on the restorative and functional medicine and see if I could figure out how to help her get pregnant.

My niece is now seven and and then that led me to a master's in integrative medicine. And getting board certified in that. And then I did another acupuncture and homeopathy course somewhere in there. But it was, I look back now and I'm not sure how I did it because it's the definition of insanity because the, it's a lot.

It's a lot. But what I love about what it's given me is it's given me a lens, a different lens to look at things through. And so I, because I'm looking at both sides of the aisle it really does provide a different lens. Which I'm very, very grateful for. 

Yeah. And I think that's true. You know, sometimes when patients come in with supplements, I can only tell them if I think that supplement is gonna hurt them, but not if it's actually going to get them to where where they want to go.

Right. So there are definitely holes in our training, but I also don't know anyone else that has the training that you have. I think you're. Unique, right? Yeah. I mean, is there anyone else? There might be one person. 

I don't know. I don't know that there's anyone else who's done all of the things that I have done and who's a practicing ob, GYN.

Like I think a lot of people decided to go this direction and dropped the obstetrics and the, I didn't drop the obstetrics because I think those are the patients who often need it the most. Like those are the people that you need to know if the. What they're doing is gonna harm their pregnancy and so much because that's a non-controlled market.

I'm watching a lot of people, there's a lot of direct to consumer marketing. There's a lot of Dr. TikTok and Dr. Instagram now. Yeah, I thought that I would like, I like Dr. Google better than somebody. I actually like Dr. Google better than Dr. TikTok and Dr. Instagram. Way better. And I hate Dr.

Google.

There's something about influencers that make people think that what they're saying is correct, right? Even if it is not correct, it's really hard to gauge what's right and what's not right. Except for by number of followers, which isn't, you know, isn't a great metric, 

right? 

I wanted to talk to you about hormone testing and hormone replacement.

'cause I think you have a, just a unique view on it. And I was thinking that the easiest way would be if I kind of gave you scenarios, examples of patients, and then you can tell me what you would do in that situation. Does that sound reasonable? 

Yeah, totally. 

Okay. So if you had someone come to you who was 44 and had a couple of kids and was having symptoms like brain fog, UTI like symptoms, but negative cultures, having a lot of irritation, what would you do with that patient?

I mean, would you treat them, would you put them on hormones? What tests would you do? Would you say no, you're just fine. And send them out of your office? Which I know you're gonna say yes, no, 

100%. So that is, that's Monday for me. I think I saw several of those folks on Monday. So I look at them holistically.

So the first thing I want, I wanna point out is, and I point out often is the ovaries are not responsible for everything. We, because Western doesn't consider so many other avenues, it is often laid, oh, she's 44. This must be her ovaries. It can be, there are people who have premature ovarian insufficiency.

There are people who go through premature menopause. But that does not tend to be the case 95 plus percent of the time. So the first thing I'm looking at is I'm asking about sleep because most 44 year olds are not getting an average of seven hours of sleep a night. And you have to, like, the brain data says you need seven hours of sleep.

When they talk about, you know, hormones and Alzheimer's, like sleep and Alzheimer's are right up there. And I would actually probably argue as. Being discussed more right now. But sleep is something that you're responsible for. And what I find is that when we are talking about lifestyle, people push back.

Like I have people all the time that be like, well, my sleep is fine, and then I actually have them get something to measure it, and it's not, and it's not an average of seven, it's a minimum. So I ask about alcohol consumption. There's a reason that so many celebrities go dry in their forties. It's because that sugar load.

Hoses, women in our forties like it, a hundred percent does, and it doesn't get better with age. It's not like all of a sudden you rebound in your fifties and now can drink like you could in your thirties. I'm also looking at what are you doing? Like, what's your stress level during the day?

Like I look at women. All day, every day who are get up they go to the gym or they go exercise and then they get their family out and then they go to work. And then they're fielding phone calls from family members because they have a sick parent. And then they're all the afterschool sports and then dinner's at eight o'clock at night.

So I ask the big stuff, but then. And usually there's air there's usually lots of work that can be done there. And then you have to look at them holistically. So when I test them, I'm checking to see where their iron is, where their vitamin D is where their thyroid is. Thyroid conditions are hormonal conditions that we often don't pay attention to in in the forties.

And then I will, I do check hormones because I've had too many people. I had one come in who was like, I was told I was fine. And she had the real classic picture for premature ovarian insufficiency, and she did. She has it. But I like to check where we know we have data, which is cycle day one, two, or three.

Like I also have a 44-year-old who will come into my office who wants to know she can get pregnant. So we know where Fertile Labs are because we have millions of women to compare to. So I go after where we have comparison. And I'll just get an FSH and an estradiol. And that's, that we know what that's supposed to be.

You're, you know, in your fertile years, your FSH is supposed to be below 10 and your estradiol is supposed to be below 60. If those numbers are showing something different, then we need to look at other stuff. And then the next place I tend to look is i'll, I will check testosterone because I usually wanna get a baseline of where folks are.

I, I check A-D-H-E-A one of the stress hormones, and then I will actually check the stress hormones. I will get a four point cortisol and. In your patient that you're describing, about 98%, 99% of the time, there's something wrong in their four point cortisol because we know what happens in our mid forties.

It's the level of responsibility has not waned. The number of tasks that are added to the daily list have increased. We're usually in the thick of it with our families our families of origin plus our families of that we've created like it's. It's a lot and we're so used to just managing it, handling it, that we just keep managing and handling it and not pausing to say, should we be managing all of these things?

So if the cortisol level's high, then what do you do? I. In that situation so 

cortisol levels usually hide in these women in their thirties. So the way that I think about cortisol is the first thing that happens. And anyone who's ever been in there knows exactly what I'm talking about. It goes up and it is, ugh, man, I've been there.

You can get by on four hours of sleep. You're still rocking it. You can, you are crushing it. You can keep taking on more and you keep rubbing up. Sometimes you're, you stutter up a little bit. Sometimes you're feeling a little stressed. But overall, you're doing okay. Then the body says, look if we keep producing that amount of cortisol, we're gonna fry the brain, your most important asset.

So it starts to downregulate, so it starts to turn down how much cortisol, and they used to call it adrenal fatigue, but it's not a good name because the gland doesn't fatigue. It downregulates. Cortisol is the first hormone that comes off the cascade. So it starts with cholesterol, progesterone, and then cortisol.

So cortisol comes off in front of estrogen, comes off in front of testosterone, so it is one of your master hormones. And so if you're down regulated, I describe it as. You can occasionally go 80 on the freeway in a true emergency, but otherwise you're gonna be stuck at the speed limit 55. You cannot go over 55.

Sometimes you can't go over 40 just depending on the day. And there's no rhyme or reason. Those patients tend to be lots of brain fog fatigue that seems outer proportion like we all know when we didn't sleep well. But some days they'll be like, I just, I don't have it today and I don't know why I don't have it today.

And then in Western, in basic society, we're taught when we were tired. You just work harder, right? You just push harder. You have more caffeine. You have, because you're not getting as much done. You gotta get up earlier. You stay up later because you're not as functional as you were when you could get by on that four hours of sleep and crush it.

And then you start getting weight around the middle. Like a lot of people start getting more achy. They start really turning down. And then the final phase is what I call down and out. Like you're just in the bottom. You can't go over 25 on the freeway. It, and it feels awful. It's the worst I've ever felt like I've been a phase three, not once, but twice because I didn't listen the first time.

I didn't make the changes in the pivots that you have to, if you can't pivot somewhere else, like I can't get a ectomy. So I need to protect sleep beyond protecting sleep. And I don't go out in the evenings. I don't drink I don't do things because I can't compromise my sleep. And so the first thing I do with folks is.

I figure out what, where the problems are. So Apple Watch, Fitbit, or Ring. I love those devices. I'm not a technology fan, but I love it to help figure out where your issue is. Most women, it's sleep, it's fragmented, it's going to bed too late. It's scroll it's doom Scrolling on Instagram.

TikTok like, oh yeah, I got into bed at nine, but I went to bed at midnight 'cause I was scrolling. I actually on one of my one of my CME things, it was what has more impact on sleep, alcohol or blue light? And I was like, oh, it's alcohol. It's blue light. I got the question wrong, which is why I remember it.

And I thought, okay, I know the impact alcohol has on sleep. We've all done it. We've all woken up, and especially in my forties, you wake up at two o'clock in the morning with

you're wet, you're,

sweating or you're

don't feel your best. That glass of wine that never bothered you before.

Now you know, you wake up and you're tired. You were really fragmented over the night.

And so it's, so looking at sleep,

that's one of the first things like do you have a partner that snores? Are you in a room that's dark enough? Are you in a room that's cold enough? Do you still have dogs, cats, kids that are in bed with you?



And then the other one that's been really interesting is. I had a couple people who sleep data. I was coveting like it was so pretty. But their stress during the day data was never came out of the absolute maximum range. And so they were recovering at night, but they weren't being able to break up their stress during the day.

And everyone thinks of stress as, oh my gosh, I'm so stressed out. And I tell people it's an adaptation response. It's when your body adapts, like in this lovely Oregon weather, when we start off at 48, we end 85. That 40 point adaptation, the body has to adapt to, like, you are start off cold and you get more warm.

Or if you make a big dietary change, like all of a sudden you pull sugar from your diet or you aren't getting the sleep that you need or you're taking on more what is it the, so much of like June, like you've got graduations and end of school and camps and vacation like.

June is a stressful month, so so is December. So it's all of those things. So it's I go lifestyle first, which is you've gotta be eating well, you've gotta be getting enough protein, you've gotta be getting a minimum of seven hours of sleep. You've gotta be drinking water, you've gotta watch your caffeine intake.

You absolutely. You have to watch your alcohol intake. There are supplements and other things that can help with that. You know, I think of them kind of like the other tools that we're having in our toolbox. For other things like GLP ones, they're not magic. They're a tool in the toolbox to help you make and adhere to the lifestyle changes.

But without the lifestyle stuff, nothing's gonna stick long term. So it's helping I also tell people to Marie Kondo their calendar. Like, look at stuff and decide does this bring you love and joy? And is this something you have to do? And a lot of times there's things on that list that you don't have to do anymore.

You you took 'em on because you were the right person at the time, but you've outgrown the position or the positions out, or it's just not in your need cycle anymore. So figuring out a filter that you can use to really. Look at life. I have a personal filter and a work filter, and I ask myself if I'm gonna take on a new commitment, if it's work related, does it fit into these goals of what I'm taking on?

And if it's personal, does it fit into these goals I'm taking on? Because I tend to say yes to everything, which is why I've been a phase three, not once, but twice. It's a matter of having things before you get there so that you can logically go through them. Because my answer is I don't want to be where I was once upon a time.

Yeah. So I've had to make changes. 

Those are the really hard things. Hard implementing those behavioral changes. So hard. So hard. And, you know, I think we all have the best of intentions. But , it is difficult. It's hard to say no. Right. Especially when you're in that sandwich generation and your parents are needing some help and your kids are starting to.

Need more help in, you know, that growing up kind of way. It is a difficult time. So then, you know, with the cortisol, is that always behavioral? 

Usually, yeah. In Western and again that, you know, I'm pretty much dealing functional stuff because if I really think somebody has Cushings or Addison's, which are the Western, you know, and when you talk to a Western doc, like when I, when it appears in my problem list, people are like, oh, I don't know why this is here.

And I'm like. Because you don't know what I'm talking about, right? Because Western, we don't discuss this in Western. You're either really high or really low, and this midsection is not discussed. Not acknowledged, not anything. So I. The, there's no support in Western medicine around it because there are no Western treatments there.

There are for phase three. There is, but it's controversial. You can do a low dose steroid treatment, which I've had to do because I had tried absolutely everything else and couldn't pull myself up under the supervision of somebody who wasn't me. 'Cause I don't manage my own care. But it's.

There the whole con, it's this whole concept. I have the same problem with iron. I'll give Iron is a perfect example of this. Iron disproportionately hits women and we're told because most of the labs say that nine and 10 are normal, up to date says 50 is normal. And so we tell women who are in the at, at 15, who feel like they're having brain fog and that they are, having restless legs that they're fine, they're not fine. The lab says they're fine, but they're not like the, we know that 50 is where we need to be. Most women are, haven't seen 50 since premenstrual and especially if they've had children. And so our practice has gotten a lot more aggressive about checking during pregnancy making and checking postpartum.

I write IV iron like it's going outta style. And people are a lot better. And your mid 40 patient, if she's been having heavy periods, often will have a low ferritin and they feel like trash. I had one patient come in and she was like, she was in phenomenal shape and she was like, dude, I'm getting winded doing my hiking.

And normally people had been telling her, you're 46, like that's normal. Like you, you're gonna get winded when you go hiking. And she was like, I just. And I said, you know, let's, talk about you. And she told me, periods are heavy. I'm like, let's check your iron. Iron was nine. Got her some IV iron and she was like, it's not me.

It was like not having enough iron to deliver oxygen to my lungs. No wonder I was winded. And that's also a big source of brain fog because I have a lot of people who don't wanna tell me how bad their brain fog is because they've got a family history of Alzheimer's. And they're afraid that I'm gonna tell them that they have Alzheimer's.

The other thing is when. When patients are having a lot of urinary symptoms with negative cultures. The other thing that Western hadn't really dealt with that we started looking at about four or five years ago was urea plasm which was for the longest time considered just a normal bacteria. I cannot tell you how many women are positive for urea plasm, where everything else is negative for bladder symptoms, especially in their younger years.

And we treat them and it gets better. That also holds true for vaginal discharge. Yeah. Like if I, I had a patient who was having so much discharge, she was wearing a tampon a day minimum, and she was positive for urea plasm. Once we cleared it, she was like, wait, is this how other women live? And I was like, yeah, 



we end up screening a lot for urea Plasm too.

And

I agree.



It does show up and it is the answer.

Not infrequently. More than I ever would've dreamed. 

It's right up there. But these are three examples of if you had asked, and if you still ask, if you still ask people, should you treat that iron? That's nine. The majority of people will say no.

And if you ask, like when patients

come to you and say, Hey, my doctor wouldn't scream me for ear plasmas. And you're like, yeah, I know. Like

it's these things that we learn and we get better with, but we. Tell people that they're not there because we don't under, because we didn't learn it.

Yeah, yeah. 

Yeah. I mean, there's only so much that we know. Yeah. So, but then if you're having some of these issues and you've seen your PCP and your PCP has reassured you that you're fine, but you don't feel fine, I mean, who do you see? You can't see everybody. 

A lot of my patients come to me from, you know, they're seeing naturopaths like, you know, naturopathic practitioners, their foundational knowledge is in prevention.

They're foundationally looking at that. Acupuncturists also looking at that. They may not check the labs, but I. I've consistently done acupuncture at least twice a month for 20 years. Like it is, it's one of my foundational therapies. But it's also, there are more and more doctors that are doing functional and integrative medicine, like the ifm.org has a search feature where you can find people who are functional medicine certified.

I do say all of this with caution, like, because functional medicine is coming up, I'm watching more and more clinics. Especially where hormones are concerned spring up that are charging cash. I'm watching a lot of cash clinics. Yeah. And it's a, especially if your pellet, it's a very lucrative, it's a very lucrative business who don't have the training like they have done a little bit.

There's a lot of yeah, they're, I'm watching a lot of that and they have the best of intentions, but. If you are like hormones, I always tell people you're not good at hormones until you fall flat on your face Many times, and I have fallen on my face many times, and I've trained under about five different schools of thought on hormones, like I haven't just looked at it with one lens.

I've looked at it with five and the things that I have found, like for instance, in that 44-year-old, what I find more often than not is either her ovaries are completely normal, like FSH is 8.7, and her estradiol level is 55, or I'll find her FSH is 4.6 and her estradiol is 120 on a day, one, two, or three.

And that is, they're starting to have some ovarian dysfunction and. It, I, the, what I'm seeing in the perimenopausal journey is not a low estrogen to start or even midway through. I'm seeing high estrogens and I'm seeing high estrogens right up until the end and when we're talking about early intervention.

In hormone treatment, we're not talking about giving a, that 44-year-old who's still cycling, whose periods are heavier who feels off estrogen. The first hormone they need is progesterone. That's the first hormone that starts to fall off. And then what they need is you need to look at the lifestyle.

You gotta, you've gotta tee up everything. What's their blood sugar doing? Do they have a thyroid problem? Like usually I find. Many things. It's usually their vitamin D is low, especially in Oregon. Their iron is usually needs some help. Sometimes their B12 needs help. Their four point cortisol's off. Sometimes I'll pick up early Hashimoto's or active Hashimoto's.

I definitely pick up a lot of blood sugar stuff. And if that patient is like, look, I'm not sleeping especially in the second half of my cycle. Or, you know, so I will, first thing I often will give is some progesterone, either cyclically second half of the cycle, I. Or if they're really trashed all month long.

But most of them don't need estrogen. They need things to reduce their estrogen. And I have having watched hormones for much longer than it was cool to look and talk about hormones. I'm finding that those women are high and the high estrogen patients are my most miserable. I do not have a group of patients who's more miserable than my patients whose estrogens are going high.

They're more emotional. They they're more irritable. They feel like like I I tell 'em, I'm like, does it feel like you're wearing a hair shirt? You know, the torture from the, me medieval times and. There are supplements and like part of it is we have to be thinking about what our environment's doing.

We have um, we have endocrine disruptors, we have you know, there's all these, you know, what is it when you have, I always tell people one of the simplest things is filtered water. Even something as simple as a Brita filter, because when they filter, when they clean the water for water treatment, they don't filter out the hormones and you excrete hormones in fecal matter.

It goes through wastewater treatment plants, but they don't necessarily filter out. Hormones in the water, drinking, filtered water, having regular bowel function. Like a lot of folks, I'm like, let's get you on magnesium so that at least you're pooping every day. Make sure you're getting your fiber, getting your protein.

But it's figuring out okay. And sometimes it's out of a loop ovulation, like you're ovulating twice in a month or twice back to back. But when your estrogens are. And a lot of those folks are getting headaches too, like the estrogen withdrawal headaches, because what goes up must come down.

And if your estrogen level is, you know, 150 at the first part of your cycle, it's gonna be, 3 50, 400 mid cycle. And then when it heads down, back to that one 20. You can have hot flashes, you can have like mood changes. You can have menstrual flooding, but giving more estrogen isn't the solution there.

And so it's figuring out what that four, where that 44 year olds on the spectrum, 'cause that 44-year-old could have an FSH of. 60 and her estrogen can still be holding, but that patient is needs that those, the ovaries are playing a much bigger role. Yeah. 

But when we in that patient, are you still just checking hormones on day 1, 2, 3, or do you check them at other points in the cycle too?

No I'm checking just. 

Yeah, I am checking and I'm not checking a progesterone level because there's not a whole lot of data outside of proving ovulation with progesterone. 

Okay. 

And a lot of the data that where people are getting numbers like, I need to be at this number, I. Is based on oral estrogen replacement data.

And oral, how oral hits the system is very different than how transdermal hits the system. And so it, it's really important. And so there are other people like, you know, there's a dried hormone test out there, there are salivary tests. I find that in the perimenopausal years, serum day one, two, and three gives me my.

Best option. Those other ones are because most of them are gotten in the second half of the cycle. So if there was an early ovulation, if there was a double ovulation, if there was no ovulation, it's gonna read differently than what we, what I'm used to looking at from a fertility data, which we have lots of data, so I tend to lean toward where we have numbers.

Yeah. In menopause, that's a different ballpark because in menopause those folks have got a little more data than we do because we weren't really looking at nor numbers in transdermal hormones. 

So I'm gonna switch to menopause in just a second, but I do, I just have a question. So, do you ever use birth control pills?

In this 

timeframe I have, I have people who are on them. That is not typically my first line. Most, most patients who come to me who are not on birth control pills are usually not on birth control pills by choice. They didn't love how they felt. They because most people who've gotten to their forties have tried multiple types of contraception and they know what they like.

And so I don't love, but that is the Western treatment. The Western is birth control pills. Because Western doesn't have any other tools in the toolbox. Birth control pills are actually higher hormone than hormone replacement therapy. One of my partners and I do a lot of hormones and she was like, it's so interesting when she's got somebody who's on birth control pills who wants to be switched to hormone replacement therapy so they don't miss out.

And I've seen those folks too. Birth control is actually higher hormones than hormone replacement therapy. By a large margin. So if I've got somebody who's on birth control, I don't take them off to get them onto HRT based on an age. Average age of menopause is 51. I'm, I usually leave them on.

If they don't have any risk factors, I leave them on because I know that they're going to be more content where they are. Then where I switch them to, especially if they're in that transition when I switch them, because it's like pulling away consistency and they don't love it. But no, I, that's not tend to be where I go, if I need to stop somebody who's hemorrhaging, there's I have used it, but it's not, it hasn't been my go-to for quite, quite some time.

Okay. Like I would probably say over a decade. 

Switching to menopause, if you have someone who's 54, they're having hot flashes, weight gain, poor sleep, haven't had their period in, you know, 11 months, maybe a full year. Menopausal or getting close, what are you testing in that person?

Or you just treating them because you know it's menopause. 

I do exactly the same I did in the 44-year-old, and it's 'cause I've been burned a couple of times. I had this absolutely beautiful woman in my office who had not had her period in six months, was having all the symptoms that you're talking about.

I checked her labs. She had diabetes that had not been diagnosed or managed, and her estrogen level was 300. Okay? So this is not a patient who I needed to give hormones to yet. Yes. Your patient is probably more likely because again, if you've made it 11 months, you're usually like, yeah. I usually will tell people like, we're gonna check this just in case I'm wrong.

Because I've had the body laugh at me before. Especially with, because if your estrogen level is. 300 consistently, your body's not gonna necessarily menstruate because it's not, if the, if it doesn't drop part of the menstruation, fuel is the drop in estrogen. Estrogen has to drop. If it's not, then the body, you know, acts like it's in a pregnant like state.

And it's a little bit different. So. What I always tell people is I, yeah, I'll check all the same stuff, because in that case, like there's usually cortisols going on and vitamin D is often off and iron's off, like the same situation is going off. I just know that I, that patient is more likely gonna need estrogen and so I usually have plans made around that.

Okay. 'cause I don't need them to wait to see me back to start it. So I usually say, get your hormones, you're gonna get a message from me. If they're low, we're gonna start this. If they're not, we're gonna do this. And then we're gonna retest in three months. Because what I'm finding is the final push, like a, as in, in somebody who tracks these folks, I, if I see somebody who last December, her FSH was, you know, 26.8, but her estradiol was 200 or 300.

I know that we are, we're moving toward the final stages. 

Yeah. 

And that's why it's so important to get an FSH and an estradiol, because I wanna know how hard are the ovaries working? So if I've got a patient whose estradiol level is 400 and her FSH is 4.6, that's somebody who. Yes, we know we have some dysfunction there, but that's not the same picture as somebody whose FSH is 36 and that number.

Okay. It's just, it tells me they're further down the spectrum and I need to watch both of 'em. 'cause neither one of 'em feels great, but one of 'em may fall off the cliff and the one who's. FSH was in the thirties with that high estrogen. Once that estrogen switches, the ovaries don't have the reserve of the one who's got the 4.6.

And I've had those people literally spin on a dime like they are high, high, high. And then I. I usually will leave labs for them to test because they'll tell me something went completely haywire and we'll check and they've spun. They now FSH is 80 and their estradiol is 18. It's, that's why I always check both and it's really hard when I've got somebody who's just got one because they were checked by an outside provider.

I, I don't know where they are. Yeah. I wanna know, so I still test all the stuff because that patient still usually has all of the other stuff and you wanna know where her blood sugar is like that. If you look at our society right now, one in three has, is going to have diabetes. Like I can pick up the pres, the pre-diabetics, and we can modify diet and lifestyle and not ever deal with the diabetes diagnosis.

Great. That's fantastic. 

Yeah. Well, and in terms of present prevention, that is so very important for your overall health. So I just wanna take two more minutes of your time. Who are you giving testosterone to? 

I actually, so testosterone, if you look at the Americ, the radio the who is it? The American Endocrine Society.

What they say with testosterone is perimenopausal women with a positive HSDD screener. So hypersexual. Dysphoric disorder. Those are, and there's a screener for it, and there's four questions on it. And if those folks have that they're appropriate to give testosterone to for libido. And then in menopause, what they've argued is that, yes, testosterone can be used in menopausal therapy.

But I, how I tend to look at it is looking at the patient in front of me. So the first question I ask is, how old are they? If they are perimenopausal, I'm looking at their hypersexual disorder screener, and it's usually positive. And so I will and we'll talk about that. Testosterone is not a magic cure.

What I tell everyone when I'm giving folks testosterone is I don't have a single patient. Testosterone is naturally elevated due to polycystic ovarian syndrome. Who isn't begging me to lower it. I don't have one. I have zero patients who have elevated testosterone with PCOS, who aren't wanting me to lower it.

Now granted, most of their, the number that's high is their free testosterone, so I definitely see a correlation with the. Acne, the hair growth with free testosterone. So I check both. So if you've got a perimenopausal woman sitting in front of you with a positive screener, we talk about that.

This is one therapy. I'm also looking at all the rest of the stuff because as we talked about, I. Cortisol comes off in front of testosterone. So if I don't, if I've got a cortisol problem, it's gonna downregulate how the hormones behind it work as well. So those are folks I'll give testosterone to. And we watch it.

I'm not a fan of pellets. It brings, um, testosterone levels really high. Yeah. In those perimenopausal women, women, um, like really high. Um, and I'm, I, you also have to watch the dose. It is an anabolic steroid. There is a reason I have to use my control drug license on those prescriptions, and I don't think people recognize this is a controlled substance.

It has abuse potential because it can juice you. So in menopause, what I'm looking at is if a patient does not have ovaries, the data's really clear on that. That's the one group of patients where they've shown giving testosterone therapy. Does clinically study, prove and improve sexual function like that is, but we're not taking out as many ovaries as we once were.

So that group of people, I have a very low threshold. I have that conversation early and I leave it on the table. The other group that I will start on is if, again, low libido in menopause, but also the really athletic women. The women who are used to. They've got a lean muscle mass. They've really noticed, and again, the data's not like the data says sexual function, but I will look at those women like when they're really, they're like, I'm losing my edge.

Like I'm fatiguing way sooner. My muscle, like all of the things I will give them. Are the ones that I noticed. The biggest bang for my buck is. Libido. And then those patients that are that lean muscle mass, very fit and really noticing and like not so much their energy, it's their muscles.

Their muscles are just not, they're fatiguing faster. They've lost. They're losing some strength. I don't like it's currently on Dr. TikTok is basically everything that ails you and you just give testosterone for Yeah, and it's, you have to watch it. Like, I have people who are getting acne and abnormal hair growth or losing their hair.

Male pot pattern, baldness. Yeah. Like it is, 

I don't think people realize how it really impacts you, right? Yes. And how much in your body it impacts you. So I just wanna thank you for spending this time with me today. You have such a unique skillset and such a different way of looking at things. And you know, I think we're at a point in time where so many women are being told by social media that they're being gaslit.

There are doctors ignoring them. There are some deficits in our education in Western medicine. I mean, I think that's definitely true, but you're just such a great example of someone who has coalesced all of this information and can really help people. So thank you for that. Oh, definitely. And I 

I think what.

We're failing to tell women is that we can make change. You know, it's that whole concept that we need. Again, external, external, external. Like, yes, there is no doubt that I have patients who need hormones and need other things, but it's really that we have the power to look at our lives and say, all right.

What do we wanna keep? What do we wanna get rid of? Where do we need help? And I think those are important to check in regularly on, you know, that was the whole point of New Year's resolutions. But I think we need to think about them like every six months, like, you know, do a finance check-in and a wellness personal life check-in.

And that's what. Folks that are living that financial independence life whereby, so it's really encouraging patients to check in with themselves and figure out what they need. Yeah, 

I mean, I really agree with that and I think that's so empowering. And I think the other side is, you know, you did such a great job of emphasizing all of the behavioral things that we need to change.

And the answer isn't just a pill, right? It's not estrogen for everybody. It's not testosterone. There isn't a magic bullet. I mean, sometimes there is a bullet that will help a lot, but you know, there's all this hard work that we have to do too to get to where we wanna be. And that's the piece that I think a lot of people forget about.

And I think it's hard because, you know, as we age, like it is hard. Am I as quick as I was in my twenties? No. Am I way more wise? Like I always joke I don't wanna go back to my twenties with my 20-year-old brain because that brain. Oh my God, that brain needed some work, but it's, we need to embrace where we are and I am, I'm in a great relationship.

I have a great family. I didn't have my kids and my husband in my twenties. Like I've earned so many positive things and I think we'd lose sight of sometimes the, all the positives because we're also dealing with, yeah, I don't sleep like I used to and I can't drink like I used to and I can't eat like I used to.

But. There are a lot of things that I can do that I couldn't use to. 

Yeah, that's a good point too. Right. We need to stop focusing on all the things we can't do and we wish we still could do. Although the, you know, waking up in the morning and being sore is legit. And is an interesting surprise, right?

Like, how did this happen and what did I do? So, all right. I just wanna thank you so much. Definitely 

have a good day.

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