Addressing hormonal imbalances is one of the most important actions a women can take towards well-being. I have also found this to be one of the most effective treatments in the functional medicine arsenal. Today we discuss hormones with gynecologist Dr. Anna Cabeca.
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Women’s Health & Hormones with Dr. Anna Cabeca
Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am here today with Dr. Anna Cabeca. And we’re going to be talking about female health issues and mainly about female hormones. So super excited to have this conversation. Anna, welcome to the show.
Dr. Anna Cabeca: Thank you. It’s great to be here.
DrMR: It’s good to have you here. And Anna, before we get started, I just wanted to share a personal story that happened earlier in the day which I’m hoping people will get a little bit of a kick out of. And I’m sorry for boring you with this story. But hopefully, you might get a kick out of it too.
DrMR: I was in line at Pete’s Coffee, getting an espresso, as I’m sure the audience knows I’m struggling to do less of. But it’s a slow wean off process for me. And there was some confusion in the line. And the person ahead of me, I think they felt bad like they had cut me. And I clearly knew that they hadn’t. It was fine. It wasn’t really a big deal.
But apparently, this person paid for my coffee also. They gave the barista some extra money and said, “Whatever he has, I’ll cover it.” And so I went over. And I said, “Geez, thanks, man. I really appreciate that,” and shook the guy’s hand, only to realize when the person responded it wasn’t actually a man. It was a woman.
And it put me in a really weird position when you say, “Hey, thanks, man” to a woman. So anyway, kind of a weird situation. But hopefully, she didn’t take any offense to it.
Anyway, let’s talk more about female hormones. And Anna, can you give people a little bit of background because I know this is something that is squarely within your box, of course. Tell people a little bit about your clinical experience with hormones.
DrAC: Yeah, no. Absolutely. So I am a board-certified and Emory University trained obstetrician and gynecologist. And I have been practicing in hormonal management in women’s health for over 20 years.
Over my scope of practice, over the years of practice, I started doing functional medicine and bioidentical hormone therapy because I really understood at some point after client after client that the prescription drugs and the surgical solutions that are often the first things we use in our toolbox weren’t long lasting solutions, nor did it fix the underlying reason to the problem.
So I started digging in deeper into getting the root cause medicine, as they do in functional medicine. And bioidentical hormones became a really big part of that in balancing women’s hormones naturally.
And so that’s where my clinical expertise evolved, especially in the area of sexual health for women as well as for men. There is no prescription that will address the problem. So it became really important to understand the many factors that relate into obtaining optimal health.
DrMR: I completely agree. And the female hormone piece I don’t think always gets the attention it deserves in functional medicine and is clearly something that we have not talked a lot about on the podcast. But in my clinical practice, it’s definitely something that can be a pretty powerful factor when addressed for women.
And there are a few things that come to mind as some of the more prevalent symptoms that are associated with having a female hormone imbalance, namely things like fatigue, depression, low sex drive, poor memory, moodiness, of course hot flashes, dry hair, skin, and nails. And then also sometimes—and I see this more so in women who are still cycling—their digestive issues will wax and wane with their cycle. And they tend to have, in my opinion, this bidirectional relationship.
But Anna, what does a woman typically look like who has imbalances in her female hormones? What does this look like for people listening trying to identify with this?
DrAC: Yeah, no. Actually, it’s quite interesting evolution. And I hear what you’re saying. And just a really quick note to tie hormonal balance into our gut health and our digestive health, there’s a huge correlation because our hormones are also metabolized in our gut by our microbiome. And it’s essential.
So PMS symptoms, peri-menopausal symptoms are a big factor of an imbalanced or digestive tract issues. We always say we have to heal the gut first. So detox and gut health become the first line in balancing hormones. There’s no way around it.
Symptoms of Hormonal Imbalance
So typically, we’re going to start seeing hormonal changes in women around the age of the 30s. And typically right now in the U.S., one to four of us, if not more, are already in the menopausal/peri-menopausal age range. So it’s really key for us to get our hormones in balance and our mood stable. It can make a big difference in a happier, more peaceful world.
So our hormones start to change around age 35, in our mid-30s, really starting to see that even a little bit earlier. But we’ll start to see some shift in our mid-30s. So our patients will come in. Clients come in. And they’re complaining regularly of mood swings, irritability, PMS symptoms.
And so the standard of care model, as their doctor, because these PMS symptoms, we have to quickly treat them. So we recognize in standard-of-care medicine is that they have immediately a Prozac insufficiency or deficiency. So we’ve got to give them Prozac or an SSI or Celexa or what’s new on the shelf. So we’re treating the symptoms there.
And then what happens is they come back in. Their cycles continue to be irregular. Maybe they’re having break through bleeding, forming ovarian cysts, continued PMS symptoms. So we say, “Okay, well, let’s just shut down the uterus.” And then what happens is they’re prescribed a pack of birth control pills. “Okay. This is your answer.”
Well, then the client continues to come back in, maybe more break through bleeding. It’s not really helping with menstrual cramping or pain, fibroids, ovarian cysts, etc. So the next line of treatment in our standard of care is to perform an endometrial ablation or a hysterectomy. And since you’re over age 35, while we’re there, why don’t we just take out your ovaries? And you won’t have to worry about that.
So this is what our clients are seeing regularly. And this has been going on for decades now.
And then what happens? The patient comes back in. Well, as a gynecologist, I’ve already taken out their uterus, maybe have removed their ovaries. And my first line therapy for the psychiatric symptoms hasn’t worked. So here’s a referral to the psychiatrist and the divorce attorney because I understand the relationship problems that can arise.
DrAC: And off you go. So recognizing that very early on, I started looking at using bioidentical hormones, using functional medicine principles, detoxing, healing the gut. And lo and behold, from operating two to three times a week, I went to referring out one to two surgeries a year. And that makes a huge difference when we get to these underlying symptoms.
But what is really important for women to understand is that, especially when it comes to gynecologic issues: irregular bleeding, uterine fibroids, ovarian cysts, etc., are a result of hormone imbalance, are a result of a dysbiosis, are a result of inflammation. So we have to address those whether or not we have a uterus.
And I think that’s where we have to shift the paradigm of gynecologic care in women’s health.
DrMR: Completely agreed. And as you’re saying that, there are a few things that I am reflecting on in my own mind which is—maybe to paint this very broadly, I look at interventions in my mind as highly successful and then moderately or mildly successful. And I admittedly bring my own bias to this like anybody else will. I always try to remain open minded.
But I definitely put diet and lifestyle changes, of course, into the highly effective box, as I do all the gut work that I do. And I also put hormones in there too. It’s another area, hormone support. There’s a number of them. And we’re working our way toward some specifics in terms of recommendations. But highly effective.
And I compare and contrast this with things that, again, I’m not an expert in, but just have not seemed to produce the same amount of result. And these, in my mind, are things more like mold exposure or heavy metal detox. I certainly think there’s a time and a place.
But when I reflect on my clinical experience with these things, it seems that the hormones and the gut work and the dietary and lifestyle changes seem to more consistently be effective for patients whereas some of these other interventions tend to, I think, have a higher success rate.
So it’s not to say that one is better or worse than the other, but I just want to offer that for the clinicians listening or for the patient trying to figure out how to organize their healthcare options and interventions.
But to get me off my soapbox here, let’s talk more about some of the hormonal changes that we see in both menopausal and in cycling women. So for the women listening, they can start to understand what’s happening internally that might underlie some of the symptomatic manifestations that we’ve been talking about.
DrAC: Yeah, absolutely. So what happens is that come our mid-30s, women know, we go through a natural cyclical change on a monthly basis. With the first day we start bleeding, we call that cycle day one. And all our hormone levels are low, specifically estrogen, progesterone, testosterone. Those will cycle throughout the month.
Ovulation occurs somewhere between day 12 and 14. And then that enters us into the luteal phase. So progesterone levels increase. Estrogen level, testosterone level increases. And this is where, as women, we’re creating this lush endometrium that’s getting ready for your pregnancy. And then if pregnancy doesn’t occur, the endometrium sloughs. And hence, you start bleeding again, cycle day one.
So that’s the anywhere between 22 to 38 day cycle. Typically, we say 28 days. But that’s because the pill packs are 28 days. A woman’s natural cycle just depends on what her monthly pattern is. We have a daily circadian rhythm, a monthly rhythm.
And so each of us will have just a slightly different one. So it’s important to understand that 28 is just maybe an average. But it’s definitely not set in stone that that’s the normal rhythm.
And then over time in our 30s, progesterone starts to decline. And that leads us into this estrogen-dominant phase which is what I described in that symptom—the client coming in and complaining of the PMS, the irregular cycles. And that is typically because of estrogen dominance and that being a result of progesterone insufficiency because we have a decreased fertility response during that time. So we’re not producing as much progesterone.
Plus there are many now, in our society and in our environment, estrogen mimickers or endocrine disruptors that can affect our body, can mimic estrogen in our hormone receptors and cause this added imbalance of hormones.
And so what we see during this time very typically of estrogen dominance and progesterone insufficiency, we’re seeing the irregular cycles, the break through bleeding, the heavier than normal cycles.
And you add in inflammatory, for whatever reason—from a gut dysbiosis, from digestive issues, from food sensitivities, from immune responses—and we’re adding in an inflammatory component. And here we’ve not added in hormone imbalance and inflammation. And that’s going to just take us down a rocky road of diseases and diagnosis. And ICD-9 codes for our practitioners.
So during this time, we’re naturally going to see that decline. But where I have found most intervention to be very useful is the first step is to, number one, assess with lab work. Do comprehensive lab work. Number two, detoxify and do a modified elimination diet and detoxification program.
Number three, address the digestive health issues. Improve probiotics. The microbiome is so crucially important to our hormonal balance. And often, number four, but maybe I have instituted it as part of my number one is bioidentical progesterone cream. And I use a formula that I created with progesterone and pregnenolone, two of the mother hormones.
So for our listeners, this hormone progesterone is a hormone of pro-gestation. That’s how it became names. It’s a hormone of fertility, of maintaining a healthy pregnancy. And it’s part of our normal ovarian hormone production. It’s a very normal part of ovarian hormone production.
But now, as we get older, the number of follicles that we produce decrease. It’s just a function of age, the natural aging process. But our adrenals produce progesterone. We produce progesterone from cholesterol. And it’s a really important hormone to help our brain, our bones, and our breasts. Those are the three B’s that are so important for women and men and why progesterone really becomes important as well as some adrenal hormones and androgens in women as well to help offset the imbalance and the estrogen dominance.
The Right Balance of Hormones
DrMR: And there’s a doctor named Janet Lang who used to do some lecturing on various aspects of hormonal health. And I like the way that she used to term it. She used to say that estrogen causes cells to grow and progesterone causes cells to grow up or to mature or to differentiate. And you need, on a cellular level, the right balance of these two to have healthy cellular function. Of course, the cells comprise the tissues. And tissues comprise the organs. And the organs and tissues make up your entire body. So these things really do come all the way back to, I guess we could say most fundamentally, cellular health. And so you’re really getting to a very deep level of causality if you can get the hormones balanced out.
Now, there’s something I wanted to get your thoughts on because we talk a lot—and when I say “we,” I use that term broadly. I think in this healthcare space, we hear the term estrogen dominance a lot. But I think it might be helpful to try to paint some shades to this. And I’m curious to get your thoughts on this, whether you agree, whether you disagree, whether you would modify it.
But a way for people to take stock of themselves and try to identify what box they might fit in, because, at least in my opinion, it’s not always that there is an estrogen dominance. There can sometimes be a frank estrogen deficiency. And I’ve had a few women come in who clearly fit the mold of being estrogen deficient. But they read so much on the internet about how prominent estrogen dominance is. And they were getting in their own way, so to speak.
So for women that are very thin, you have a higher probability that there might be estrogen deficiency because one of the things that helps maintain estrogen production as we age is fat cells. So for women that are very petite and thin, they are more at risk for being estrogen deficient, more so my opinion.
And in regards to progesterone, what I’ve seen is the more stressed out someone is—a woman is, in this case of course—the more likely that they may be progesterone deficient.
It doesn’t really speak to the issue of detoxification. But those are just some ways that I partially try to partition people out. It’s not 100% rule. But that’s a guiding lens through which I look at this. But Anna, what do you think about that?
DrAC: Yeah, absolutely. You can have both estrogen deficiency and symptoms of estrogen dominance at the same time based on the ratio of estrogen to progesterone. So we can see that.
So if we think about common symptoms of estrogen dominance, that includes painful periods, irregular periods, heavy menstrual cycle, decreased sex drive, headaches, fatigue, short term memory loss, lack of concentration. Very commonly, we see mood swings, irritability, depression, and hot flashes. All of that is part of estrogen dominance.
And with that also we can see water retention, weight gain, sleep changes, thinning of the scalp hair. And even in the instances of estrogen dominance, we can see a very estrogen deficient symptom of vaginal dryness because it’s about what’s happening at the receptor site.
And there’s got to be a better term and description that we could use that would really tie this into our whole hypothalamic-pituitary-adrenal-gonadal axis a lot better than what we’re doing because the terms certainly don’t represent a good visual of what’s really happening at the cellular level.
But we’ll see this. We’ll see estrogen dominance and bone loss. We’ll see estrogen dominance and PMS. We’ll see this in clients when you even do lab work testing. And they’re estrogen levels are still low. But guaranteed, their progesterone levels are even lower. So there’s a ratio imbalance.
But also, we have toxicity and damage as well as nutrient insufficiency to the receptor site. So we’re not seeing the balanced function of our hormones the way we should see them. And so we see infertility. We see these irregular symptoms and this confusion over what the labs mean and what the terminology means.
So I agree. There’s a better way. Estrogen dominance doesn’t necessarily represent the lab results—
DrAC: Or the free-circulating hormonal results in that picture. We have to look at it in a better way. So yeah, I would tell our listeners don’t get caught up on the terminology.
DrMR: Right. Okay, good. Good.
Thyroid-Female Hormone Connection
DrMR: Something else that I think is similar to being overly generalized, I guess, is thyroid where oftentimes people think they’re hypothyroid when their thyroid function is actually fine, but there’s something thwarting thyroid hormone metabolism kind of similar to some of these estrogen things where it may not be that they’re truly deficient, but there may be a problem at the receptor site.
But with thyroid, as a transition part here, there’s also the connection between female hormones and thyroid. And it’s another thing that I’ve seen women come in, complaining about symptoms that they think are being driven by hypothyroid. And it’s actually when we get their female hormones balanced out that all the “hypothyroid-like symptoms” go away.
So can you talk a little bit about the thyroid-to-female-hormone connection?
DrAC: Yeah, no. Absolutely. Especially during these instances of the estrogen dominance, the imbalance. And our circulating levels of estrogen and progesterone, not to mention our androgens, our stress hormones, DHEA, what’s happening there as well as progesterone.
But what we’ll see is an increase in TSH (thyroid stimulating hormone) absolutely. And at the same time, as a result of that too, we’re going to see a spike in cholesterol. And whether the cholesterol is spiked to make more thyroid hormone, make more estrogen and testosterone and DHEA or whatever the reason is, we’ll see an elevated cholesterol with an elevated TSH with this instance of progesterone deficiency or estrogen dominance, as we’ve termed it.
So there’s a definite correlation there, and getting our hormones balanced is really key to that. So healthy levels of hormones.
But it starts with cleaning up the receptor site. So detoxing, that becomes really big, and then using bioidentical hormone therapy. And I use that quite frequently. And I think that’s a really important aspect.
But also note that many women who are coming to us have been on long term birth control pills, anti-inflammatory medications, antibiotics, etc., that create mineral insufficiencies plus the dietary problems that we have. And we need specific minerals like iodine, zinc, magnesium, and vitamin B6 to have healthy receptor sites.
And that’s a really important understatement because we’ll prescribe something and not realize that can create a mineral or vitamin insufficiency that can affect our hormone production, especially when it comes to iodine which is so important for thyroid function. It’s also important for the estrogen receptors.
So no big surprise, but if we have deficiency because of competing molecules like fluoride, bromide which are competing with iodine, we’ll have an iodine insufficiency. We’ll have estrogen issues as well as thyroid issues at the same time.
DrMR: So one quick thought and then a follow-up question. Something that I always thought was interesting regarding how the female hormones can impact thyroid function—and this is kind of a loose connection, but I always thought it was interesting—is that certain fertility clinics, and you would know the details behind this far better than I would, but I know certain fertility clinics will have a woman use their basal body temperature chart to help know when they’ve ovulated.
And as I understand that, it’s because progesterone can potentiate thyroid hormone. And it might be that when estrogen is dropping, I believe it impacts thyroid hormone binding globulin or what have you.
But there’s clearly this connection between the female hormones and body temperature. And again, body temperature sometimes being a thing that people think are denoting a thyroid problem. But in this case, it might just be the delicate dance between the female hormones and the thyroid hormones. Anything you’d want to add on that?
DrAC: No, I think it’s a beautiful way to tie it in together, because one of the things I have my clients do at the first five days of the cycle is to look at their basal body temperature. If you’re not cycling, if you’re menopausal, just at any time, look at five days of your body temperature monthly before you get out of bed, so your resting basal body temperature.
And I think that, over time, especially if it’s low to begin with, we want to work on building that up through thyroid nutrition, because thyroid nutrition, important nutrients to support the thyroid and detoxing, and avoiding foods and gluten and things like that that can interfere with thyroid function. So importantly, to just see that easy way to see, is your basal body temperature improving?
But yeah, definitely with ovulation, we get an increase—and that’s one of the ways we can tell with body temperature measurements, looking at ovulation through a spike in our body temperature at the time of ovulation.
DrMR: Sure. Sure.
And you make another interesting comment that I wanted to touch on, which is iodine. And we’ve talked at pretty great length about iodine in past podcast episodes. And there are a few important things that I think are important to mention there. And Anna, if you have any disagreement, please, this is definitely not anything that I don’t enjoy having healthy discourse about.
But in my opinion, which is based on a pretty exhaustive review of the literature, high dose iodine is problematic for people that have thyroid autoimmunity. It has been pretty incontrovertibly shown in the research literature. However, a normal dietary intake of iodine doesn’t seem to be a problem.
Also, I think the best research for the clinical use of iodine is with things like fibrocystic breast disease and probably comes back to something that you said earlier where iodine does have an impact on estrogen receptor sites. And so I certainly think the appropriate level of iodine for female hormones is a really important aspect of this.
But what else would you comment on iodine? And are you having people use milligram doses? Are you doing a lower dose? What does this look like in your practice?
DrAC: Yeah, no. This is an excellent point because I’ve run the gamut with that. I think the first thing before we even consider iodine replacement is to know someone’s thyroid antibodies—antithyroglobulin antibodies and TPO antibodies (thyroid peroxidase antibodies). So it’s important that we know the antibodies before we even discuss replacing iodine outside of diet.
But dietary iodine replacement can go a long way, sushi seaweed.
DrAC: That can really go a long way. And the first thing I always tell my clients is that thyroid supporting foods—oyster, sushi seaweed, and Brazil nuts, two a day.
So with that said, definitely I have, especially in fibrocystic breast and ovarian cysts, used iodine, maybe 6.5 mg or 6 mg dosages at peak. Now, I have gone up higher in certain clients that I followed to get better results in a short term.
But in general in my program, the 150 mcg should be sufficient if we’re getting it in a dietary way. If there are any thyroid antibodies, we certainly don’t want to go above that. But I have used low dose iodine replacement in clients that we were treating for significant issues like ovarian cysts and fibrocystic breast with amazing results.
DrMR: Yeah, it can be quite a remarkable nutrient for some of those female-hormone-related imbalances. So I’m really glad you actually brought up the point of iodine.
Diet, Lifestyle and Detox Considerations
And with that, let’s talk a little bit more about—I know you mentioned detox. But before we jump to detox, are there any important dietary and lifestyle pieces outside of some of the basics that I’m sure people are familiar with—getting an adequate amount of exercise, getting enough sleep, managing your stress, eating generally non processed, maybe a paleo-ish type of diet—are there any caveats or particularly important points regarding diet or lifestyle for women to be aware of?
DrAC: Yeah, absolutely. I run some online programs including a program called Magic Menopause for those of us who are in menopause or peri-menopause. And I have clients from their mid-30s to their 70s who have joined me in that program. And what I blog about and write about, what I discovered is that once we hit this menopausal state, our bodies become super efficient—super efficient at using every single energy molecule in our body possible.
So what I recognized is that quickly, part of detox was getting alkaline. And we talk about that a lot in functional medicine. Alkaline-rich foods will help our bodies support phase 1 and phase 2 detoxification. And then we noted the research on ketogenic diet. Well, in my clinical experience, I found that if we try—and myself particular try a very low carbohydrate diet, I go what I’ve coined “keto-crazy.” It throws off my neurotransmitters.
DrAC: This cannot be good for women. This must only be for male athletes with 8% body fat because it just does not work for women. Well, when I put the ketogenic concepts in with an alkaline concept and I checked, and actually created, urine test strips to measure pH and ketones only. When I get clients into that keto-alkaline state—wow! It’s energy, enlightenment, fat loss, clarity.
It’s almost like unclogging those receptor sites, to put it into a functional kind of geeky term. But if you get what that means, it’s like your body becomes really efficient. And there’s a high level of clarity and energy that comes into place with this.
So the keto-alkaline concept—ketogenic with checking to make sure you stay alkaline because we know paleo and ketogenic diets can turn us more acidic. They are higher acidic-based foods. And as functional docs, we want 80% alkaline and 20% acidic in balance for the most part, especially when we’re keeping detox pathways open.
It’s really important, especially as our hormones are fluctuating in the peri-menopause and menopause—and they’re going crazy and our disease profiles can increase—, that we really keep a continuous level of detoxification up and reset that natural balance.
But with that said, Michael, 25% of health and a healthy lifestyle and even becoming keto-alkaline is—25% of it is what we eat. Really more of it is the lifestyle. How are we sleeping? Are we having regular bowel movements? Are we getting outside? And those other issues really create this keto-alkaline concept.
And we can test that. Patients can test that at home. People can test that at home easily for pennies. And that makes a huge difference.
When we marry those two concepts, that helps women. That helps men. We know that’s very empowering for brain health. But I think that alkalinity piece, getting both alkaline and in ketosis is huge for health.
DrMR: Now, achieving that keto-alkaline state, can that be achieved somewhat simply just by making sure someone has adequate vegetable intake? Because I’m assuming that’s probably one of the main threads of this where if people go keto, they don’t eat enough vegetables. That puts them into an overly acid state.
So would it be fair to say that if someone was just being mindful to make sure that they’re having generous amounts of vegetable intake, they’re going to be much more likely to be alkaline?
DrMR: Or do you have to be more precise than that?
DrAC: Well, I found out in my clients and in myself as well sometimes what we think we’re doing as healthy—we’re eating enough vegetables—isn’t enough for what our body is dealing with at this moment—the stress we’re dealing with, the environment we’re dealing with. It may not be enough.
So if we’re not testing, we’re just guessing. So by testing and knowing that at least if you wake up alkaline, is what I tell my clients—try to get your pH at least 7 in your urine when you wake up. And that’s a very good thing to do.
And what I found is, in my 300 women who went through my Magic Menopause program, at the start over 95% of them were not alkaline. They were acidic. And many of them have already been to functional docs, have been through programs and thought they were eating enough fruits and vegetables. Well, lo and behold, it wasn’t enough for what we’re dealing with. So making those shifts and actually being able to test it is really important.
Now, guys do this a lot easier. Guys get alkaline quicker. And they get into ketosis quicker. It’s just not fair. But it is reality.
DrMR: Now, what about detox? Are there some key points regarding detox that you found to be helpful?
DrAC: I think that the thing that comes to mind very loudly for me is that the regular bowel movements are so important. I think especially with the hormonal issues, constipation creates a huge amount of hormone imbalance. And so an important part of what comes in must go out healthfully. Part of that is healthy, regular bowel movements. And that’s daily bowel movements and to really get clients’ GI tracts healed.
Again in my medical practice—now, I retired my medical practice a couple years ago now. But in my medical practice, what I would do and what I do with my online clients is I recommend baseline labs.
The big part is modified elimination diet. So we’re really eating no white, no wheat, no sweet, very little red meat. And if you can pick it, peel it, fish it, hunt it, milk it, grow, then for the most part you can eat it.
Just kind of emphasizing those concepts and bringing in intermittent fasting, trying to get up to 15 hours between dinner and breakfast so that your body can rest and restore. So that’s an important missing piece of detoxification that I think we really have to work harder at based on our late night eating society.
DrAC: So we really have to work hard on eating an earlier dinner.
DrMR: And I’m glad you make the point about the bowel movements because it speaks to what I’ve seen in a very high number of female patients which is when their gut gets healthier a lot of the female hormone imbalance symptoms go away. And sometimes, we have to do more, of course. And we’re working our way to some of those “more” in a second here. But it’s amazing to me how many women, just we see things like hot flashes, insomnia, depression, breast tenderness get better as their gut health improves—
DrMR: Because it definitely has a strong connection, yeah.
I want to go to hormones, bioidenticals, in a second. But before we go there, what about some herbal remedies? There’s black cohosh, also known as cimicifuga. There’s dong quai. There’s vitex, also known as chaste tree. Are you using much of herbals? And what would you offer people in terms of what you think the more effective herbals are?
DrAC: Yeah, one thing that I’ve always like for hormone balancing and PMS symptoms is vitex, the chaste tree berry. And that has been very, very useful. 100 mg per day typically is what I start with.
But another thing that I use is maca. I use maca in pretty much everyone. And the formula I use is Mighty Maca, a superfood combination with over 30 ingredients.
And maca is an adrenal adaptogen, because many of us are dealing with adrenal issues and adrenal hypofunction, adrenal hyperfunction. So supporting the adrenal glands becomes really important. And no surprise, maca is a very alkalinizing root. So add that in with a combination of greens and antioxidants, it’s a really good blend.
I also like GLA oil, so gamma linoleic acid. So from black c0urrant or evening primrose, there are a lot of good protective effects for that, for our breasts and in general for hormonal balance. So that’s another component.
And then magnesium is huge. I’ll use a lot of magnesium in clients, and check a red blood cell magnesium and often prescribe or recommend additional magnesium supplementation, pretty much universally.
DrMR: One thing that I just wanted to chime in on herbs—and I like the maca angle. I think that’s very, very insightful. And I agree with you regarding chaste tree. I think that’s very helpful.
And just for the people listening, the clinical studies on many of these compounds like black cohosh and chaste tree, they’re there. We’ve got some very good randomized control trials using these. And I thought about including and scrounging some of those together to include in the notes. And I did not have a chance. So I apologize for that.
But those studies are out there. I reviewed most of the available data probably five or six years ago when I was really putting together what I use in the office for our herbal female hormone balancing protocols. And there is definitely good evidence.
But one thing that’s important to mention is regarding wild yam. When I was doing this fact checking a few years ago and reviewing the literature, I had been told in different functional medicine education classes or seminars or training courses, what have you, that wild yam is a way of obtaining progesterone naturally. What black cohosh is to estrogen, being an herbal estrogen modulator, wild yam was supposed to be for progesterone.
But when I read the research studies, everything regarding wild yam suggests that it was modulating estrogen. And so I said to myself, “What am I missing here?” So I did some digging. I made some calls.
And I ended up speaking with a doctor who owns a company that essentially does bioidentical compounding. And he informed me that wild yam has to be bacterially fermented to produce bioidentical progesterone. But wild yam in and of itself is actually an estrogen modulator.
The only reason I bring this up is, if a woman is trying to help increase her progesterone levels and doing it with wild yam, which you will see at a health food store—you’ll see natural progesterone balance on the label. And the ingredient might be predominantly wild yam. You’re not really going to get a progesterone enhancing effect from that. You will be able to modulate estrogen which can help with the estrogen/progesterone balance.
But I just want to chime in that it’s important to understand that unless it has been bacterially fermented, which it will say on the label, wild yam is more of an estrogen modulator. So my two cents on that.
But let’s transition over to bioidenticals because, Anna, I know you have a lot of experience with it. Why don’t we start by telling people a little bit about bioidenticals? And then we can transition over to some of the controversies that sometimes accompany the use of hormones.
DrAC: Yeah, no. Absolutely. And I agree with you. I don’t recommend wild yam or yam-based, honestly, hormone creams. So when I’m recommending progesterone, it’s a USP progesterone and USP pregnenolone, so I know exactly how much.
DrMR: For people who aren’t familiar with that, explain to people what that stands for and what it actually means.
DrAC: So it’s just a pharmaceutical grade bioidentical progesterone, very standardized, very specific, absolutely bioidentical. Not a synthetic in any way. So I think that’s really key to understand that we have exact measurement, especially when we’re looking at creams and very similar to when we’re prescribing compounds. We want to know, for example, there’s 20 mg of progesterone per mL.
Now, we want that standardized throughout the entire formula. And we want to know that that’s a bioidentical progesterone. So when we’re using our classification like USP progesterone or USP pregnenolone, we know that that is exactly pharmaceutical grade, certified bioidentical.
DrMR: Exactly. So if you’re using some of these things, guys, check what you’re using to make sure is has the USP. And I believe that’s just short for United States Pharmacopeia or something along those lines.
DrMR: Okay. So it’s just the U.S. pharmacy stamp essentially. So you know that it has been regulated.
DrAC: Yeah, it’s better than—
DrMR: Yeah. Yep. Okay, so bioidenticals.
DrAC: So yeah, where do we start? Some of the things that I use—because often working with clients across the country, if I haven’t seen them, we can’t prescribe. So I become very good with what we can do over the counter.
And again, when we work through therapeutic lifestyle changes, we’re going to get probably over 90% of the cure right there when the client has control and power through the therapeutic lifestyle changes, 25% of which is through diet and exercise, maybe 35% with exercise added in there. But the rest is the other things we talk about, the head-to-toe approach that we incorporate.
And a small part of that is when we add on bioidentical hormones. A good proportion is 90% therapeutic lifestyle changes and then within this maybe adding additional bioidentical hormones. So progesterone and pregnenolone over the counter dosages that we can get in a cream.
But again, very important, understanding the ways we take it. Oral progesterone or any other mode of delivery in any other strength above 20 mg is prescription only. So you have to work very closely with your physician in these formulas.
So we typically start at a low dose transdermal cream with 20 mg of progesterone or 10 mg of pregnenolone or just start with progesterone, one hormone at a time. And use that in the luteal phase of the cycle from after ovulation till day 28 of your cycle and/or to the first day of bleeding. But typically, you’ll stop a day or two—use it for two weeks, and have your cycle. That’s typically when we’ll use it.
But it really will depend on the client. But especially if we’re trying to gain fertility, we don’t want to start progesterone before ovulation. We want to till ovulation and then start progesterone.
And then menopause, typically we’ll say day one through 25 of each month or Monday through Friday, take the weekend off, something so that clients have a regular rhythm with the progesterone but yet taking one or two days off periodically.
Now, with using progesterone, again, in any type of bioidentical hormone, we want to start low, go slow. And that’s really important because we can get excess. It’s a hormone.
So we have to be very conscientious of, okay, well, what’s happening if I’m getting excess progesterone? And that could stimulate sugar cravings. It can stimulate weight gain. And none of us want that. So a little bit does go a long way.
I use progesterone at night for clients. The reason to use it at night is to help them get a better night’s sleep. Also, oral progesterone—excellent for sleep at night. And that can be a lifesaver for women—peri-menopause, postpartum, and definitely in menopause as well.
So very safely and with bioidentical progesterones—there is a tremendous amount of safety data on it—again, in low doses, in the right hands, in clients that are having and embracing our functional medicine lifestyle approaches, then we can get really excellent results.
So that’s one of the first hormones that I’ll start innovating in clients who are showing hormone imbalance symptoms. And it’s very rare that a patient cannot take or start with low dose progesterone therapy.
So that’s very rare because we’re using a bioidentical hormone that our body produces anyway. But when we do see an imbalance, it’s typically because they’re pushing cortisol pedal to the floor. And then we shunting to cortisol. And that can be disruptive. So we’re just watching for the symptoms of that and what’s happening.
So the second hormone that I love to recommend is DHEA. And now I use a DHEA cream for the vulva because women have complaints of any issues of incontinence, a decreased sex drive, decreased orgasm, decreased libido that we can experience as we get older. So adding a little androgen, specifically to the vulva, urethra, vaginal tissue, can be very restorative.
Typically, when a woman is complaining of vaginal dryness when they go into their primary care doctor, they’ll be given a prescription for estrogen vaginal cream or estrogen vaginal tablets. And I really want to make this point because so many women are suffering and have been for decades because either they’re not getting treatment because “estrogens are bad for you” (not true necessarily). And estrogen vaginally only works on the mucosa.
But when we use either prescribing testosterone or DHEA vaginally or using a topical DHEA cream like Julva, we’ll get an increase in improvement in the collagen, improvement in the muscle. So that restores healthy vaginal tissue, lubrication, function, and sensitivity as well as decreasing symptoms of incontinence. So this is hugely beneficial for women.
And I’m going off track. But the concepts of incontinence, and the rows and rows of incontinence pads when I go into the grocery store, and the clients who have had slings and mesh erosions and are really struggling and have never had vaginal androgen therapy—it’s devastating.
And I will tell you as a surgeon who did six slings in one day, there are a lot of incontinence procedures. When I started using vaginal androgen therapy, the patients would no longer have incontinence symptoms. So ethically, I couldn’t operate.
DrAC: And then I would just see how this occurs. And now that really led me to my latest solution for women which is my Julva cream which has some plant stem cells in it to help with regenerating tissue and then has some natural DHEA. So it’s for topical use for the vulva to just help restore this area in women, a very common complaint that we see and suffer with and often never even talk about.
So I really want to open up this conversation for women to have because we don’t have to live with these symptoms. And prolapse surgeries, incontinence surgeries, vulvoplasties, and vaginal rejuvenation procedures all can have devastating consequences. So if we can use an ounce of prevention with some benign intervention, that makes a huge difference.
And that leads me to just emphasize again the tie in to gastrointestinal health. As the vagina is a reflection of that, we need a healthy microbiome, healthy bacteria, and healthy probiotic intake whether we’re taking it orally or using occasionally vaginally to help also keep the vaginal tissue really healthy. So in women’s health, this is really, really an important area.
DrMR: Yeah, well said. And it’s something I’ve heard quite a number of nice things about—the vaginally administered DHEA. I’ve been hearing good things through the grapevine about that. So I’m glad to hear you bring that up.
And you also use a term, “benign,” which is a nice transition to one of the criticisms or one of the concerns that’s associated with hormone use which is could it cause something like heart disease or cancer or other negative side effects? These are hormones. Aren’t they dangerous?
And a lot of this has to do with the finer points of, are these hormones synthetic hormones? Are these hormones bioidentical hormones? And I will link to a review I did on a paper written by Kent Holtorf—
DrMR: Who’s a fairly prominent anti-aging guy. He wrote a nice review paper on this issue. So I reviewed that paper awhile back. I’ll put a link to that.
Myths and Misconceptions
But let’s talk a little bit more about this issue, in case anyone is new to this conversation, help us understand why the bioidenticals should not be lumped into some of the negative early press that was had on the half of synthetic hormones.
DrAC: Oh, yeah. And this is really been such a disservice to women, and it’s really unfortunate. But what we’ve seen over time, the evolution of hormone replacement for women, is quite interesting from a historical perspective. In the early 40s, 50s, we discovered the Premarin from pregnant mares’ urine. The estrogen that was going to help, the purple pill that was going to help women balance their hormones and be happy or more content wives.
But lo and behold, so giving oral Premarin, what was noted was an increase in endometrial cancer. So the researchers said, “So apparently, the estrogen is causing a thickening of the endometrium which creates an imbalance. And here we need to create something that is able to be used to prevent endometrial cancer. So here let’s create progestin.”
So the first on the market was Provera. And that’s a synthetic. But it was termed a progesterone. But now, if we’re using the words progestin, it’s because Provera (progestins) are very different from bioidentical progesterone. Chemically, they are not the same molecule. Physically and physiologically, they have a different cardiovascular panel and side effect including inflammatory, including just cardiovascular increasing lipid profiles and negative cardiovascular profile as well.
So we put that on. Okay, they didn’t get endometrial cancer. But now, they were getting more heart disease as opposed to estrogen was supposed to protect against heart disease. So all this came out with the HERS trial in the late 1990s.
And so, well, Wyeth-Ayerst then invested in looking at, now, the Women’s Health Initiative studies and said, “Okay, well, we’ve seen some benefits here with bone health. Estrogen in and of itself doesn’t seem to increase the risk of breast cancer. So let’s do the study.”
And lo and behold, the estrogen arm alone…And this was oral estrogen. Again, a very hard time recommending oral estrogen to any women over age 50. I prefer transdermal is we’re going to use it in a bioidentical estrogen.
But in the estrogen alone arm, lo and behold, things seemed okay for the most part. But add in the synthetic progestin onto that component, and we had an increase in breast cancer, an increase in cardiovascular disease. And we did not get the memory benefits that we hoped for. We did get bone benefits as a significant finding. So here was looking at progestins again.
So women were told—2002, I think was the first announcement. “Okay. Stop your hormones.” And this led to—really, it’s been over a decade of continued misinformation about this.
But Dr. Fournier from France did an initial study. In 2005, it was published—somewhere between 2005 and 2008, looking at 50,000 women on bioidentical progesterone. And lo and behold, no increased risk of breast cancer or negative cardiovascular effects with bioidentical progesterone.
However, in women who were on pregnane and norpregnane, a synthetic progestin derivatives of progesterone—not progesterone—had increasing risks of breast cancer.
So there is a huge a difference. And unfortunately, the progestins and progesterones—the terminology in our medical literature, in the lay press, in the news media, etc., has been interchanged. And so it gets confusing. We’re comparing apples to oranges when we’re looking at progestins and progesterone. And that’s with even oral progesterone.
So we feel like there’s a very good safety profile with that. And then again, now we look at those two hormones and say, “Okay, the mode of delivery, how you’re receiving it, also how your body is eliminating it, detoxifying it; those are important things to consider when we’re replacing hormone therapy.”
And then the next thing is testosterone. In 1999 when I graduated Emory OB-GYN and came into my private practice as a National Health Service Corps Scholar in southeast Georgia, one of my first clients to come in to see me, Michael, was a 63-year-old CEO of a biotech firm that waited months to see the new female doctor from Emory into our small little rural location.
And she’s like, “Doc, I’ve had ductal carcinoma in situ of the breast. I was diagnosed many years ago at Emory. I’m not on hormone therapy. I have vaginal dryness. I have no sex drive. I’m a woman of the 60s, and I’d rather die than live like this. What can you do for me?” This is my first week in practice.
I’m like, “Shoot.” Okay. She’s 6 feet tall. And she’s thin and silver haired and looking me straight in the eyes. And I’m like, “Okay. Let me look in my doctor’s bag.” So I look. And I look. And I look. And I’m like, “I’ve got to go back to the research.”
So that’s when I started using androgen therapy in women because I looked at—first of all, vaginal estrogen does not increase breast cancer morbidity or mortality. So I started really liking vaginal hormone therapy way back then. And looking at the research on vaginal estrogen actually decreased morbidity and mortality in women who had had a history of breast cancer. So yay!
And then looking at testosterone therapy, is there any increased risk of breast cancer in women who are on replacement doses of testosterone therapy? And I could not find anything. And then also DHEA.
So I started using androgen hormones in this client. And I saw her over the decades. And she just had an amazing increase in bone density, still lobbying on Capitol Hill. The last time I saw her, she was on crutches because she was skiing the black slopes in Colorado at age 73.
DrMR: God bless her. Jeez.
DrAC: Yeah, so it doesn’t matter how old we are. We can make a tremendous difference. But we really need to understand. So part of my mission has been in creating safe options for women who are suffering, who are left to bite the bullet, so to speak, who are left to just grin and bear it, who are left to endure it or power through it because we’re strong enough. And this is a normal part of life. And so we’re going to be the seven dwarfs of menopause, if you ever saw that cartoon.
DrMR: It’s funny that you mention that—
DrMR: Because I have that photo. And I was planning on including that in our show notes. So yeah, if you’re listening to this, pop over to the website and check out the image. There’s a Seven Dwarfs of Menopause cartoon, which is pretty hilarious.
DrAC: Yeah, so it’s like we’re supposed to be all of that and still be joyful—
DrAC: Kind, confident, and sexy. So that’s where the so much misinformation has evolved. And women, we’re tough. We are tough. And when we have that concept, “Well, then I’ve just got to power through.”
Well, let me tell for the women listening and the men who love them, that we do not have to suffer one day more. There are natural alternatives that can really change your life, improve your health, improve your relationships and zest for life.
We are not living in the Amazon jungle. We are not living in the hills of Indonesia. We are living in a beautiful, amazing place with tons of chemicals and hormone disruptors and endocrine disruptors. And so we have to defend ourselves against it with whatever nutritional science can help us do.
So this sense of “I’ve just got to grin and bear it” doesn’t make sense at all. And with that note, I would tell clients, “If you have pain every time you have sex, why the heck would you want to have sex?” Whether it’s from vaginal dryness, discharge after you have sex, or urinary infection afterwards, why the heck would you want to have sex?
So we have to look at this whole thing and be able to restore our health, restore our anatomy, restore the tissues in as natural a fashion as we can.
Episode Wrap Up
DrMR: I think that’s incredibly well said and a nice comment to bring us into a close. But before we do close, is there anything else that’s important to mention that you want to bring up?
DrAC: Oh, wow! Gosh! Where do we start? I would just like to refer clients to my freebie page. And on my website–
DrMR: Yes, please. Please do.
DrAC: Thank you. At DrAnnaCabeca.com/freebie. And there are a few free webinars that I offer that, especially in my “Help, Doctor. My Sex Drive Has No Pulse” one that I will give information into really restoring our “feminine sexy” and helping from the many layers that can cause us to lose desire. And I think that’s really important and so understated. And we leave that aspect off our checklist altogether. It doesn’t even make it on our checklist sometimes. And I think it’s really important.
And I would encourage clients to look at my website on Julva, the DHEA vulva cream that I created with Alpine plant stem cells because we’re just getting amazing results. And clients are doing really well with that as a solution to something they’ve been struggling with for a long time. So I’m excited about sharing that with your audience. Thank you.
DrMR: Absolutely. No, this has been a great conversation. And I think, as I know you agree with, that this not always an area of care that women get the help that they should in. But it can definitely make a pretty strong impact. So definitely, thank you for taking the time to have this discussion and for everything that you’re going over at your website.
And I guess until we speak again, keep fighting the good fight. And we’ll hopefully talk to you again soon.
DrAC: Thank you so much. Thank you for having me.
DrMR: Thank you, Anna.
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