The 3 Tests You Should Do Before Considering BHRT

Real quick, before we dive into this episode, I have a little sleep secret I want to tell you about. Look, sleep is crucial for your fitness, but it's crucial for just plain old everyday life and function. And I find I sleep great unless I have a migraine. And I've had more than my fair share since perimenopause all the way through postmenopause. My secret weapon was Blue Sky CBD sleep gels. Each gel contains 25mg of CBD and 25mg CBN for deep restorative sleep. Something about it helps to reduce inflammation, which I believe for me was key in helping me get to sleep. But the biggest thing is so many of the over-the-counter solutions, whether for sleep or migraines, can ruin gut health, and liver health. Neither one of those did I want to be problematic for me. So this option is recommended by healthcare providers worldwide and backed by thousands of happy customers, many of whom come from our Flipping 50 community. There is zero THC, so it's non-habit-forming. It's made by a trusted family-owned company that we all can feel good about. Third-party tested for purity and potency. And if you're interested, you too can try a sample for just $6. But even better, you can get 30% off forever with discount code FLIPPING50. That's FLIPPING50. Just go to flipping50.com/blueskycbd. We'll put that link in the show notes and you'll find it everywhere on Flipping 50 at My Favorites. What are you waiting for? Good night. If you are considering bioidentical hormone replacement, this is for you. And look, even if you're already on bioidentical hormone replacement or have thought, no, no, no, not for me, I think you'll get something out of this interview because the way we break down the relationship between cortisol, adrenals, and thyroid and the ovaries gives this podcast really a spin in what's not a new conversation here in the Flipping 50 Show about bioidentical hormone replacement. But it's really about you. It's about any woman in the midlife journey. Let's jump in. I'm Debra Atkinson, and you're listening to Flipping 50. I started this podcast over a decade ago to answer questions about fitness and menopause and beyond. Before you know to ask them. The goal: to help accelerate your results with the science and the practical application of proven protocols while living your best life. There's no more powerful health influencer in the world than a midlife woman. It's not just you, but it's the 3 generations that you influence. My unique 40-year career, including being a university senior lecturer in kinesiology an industry subject matter expert and international speaker, to founder of the first and the only exclusively made-for-menopause-and-beyond fitness membership in the world. Every week, I interview experts behind the science of optimal hormone-balancing fitness and longevity and share answers to our community's questions so you can have the vitality and the energy you want, need, and deserve. If you are considering bioidentical hormone replacement, this is for you. And even if you're currently on bioidentical hormone replacement, you'll learn or confirm something here. The discussion about bioidentical hormone replacement is not a new one here at Flipping 50, and yet my guest dropped some nuances about it, and I know you'll appreciate it. I was scribbling madly, and we've got some show notes for those of you who might be listening while walking, working out, or driving, and you know they'll be here when you want them. If you've got daughters or daughter-in-laws, in my case, there's something here for you too on that front. If you've wondered why cholesterol goes up for many women, or for you, during midlife, or why autoimmune numbers seem to increase in midlife, there's a reason, and our guest Explains it. My guest is Dr. Shilpa Suyana. She's an MD who's triple board certified in internal obesity medicine and functional medicine. She's recognized by her peers by receiving the Most Humanistic Intern and Resident Award in all 3 years of her internal medicine residency and celebrated her patients by being presented at the Best Doctors Women's Choice Award. She treats women in perimenopause and menopause, optimizing their hormones, energy, and weight, especially if they've been previously told that their labs are normal. Dr. Shilpa Sayana, thank you so much for joining me.

Thank you so much for having me. I'm excited to be here.

Well, everybody just heard your bio too, and I want to make sure that we don't just step over this because it's kind of a big deal. Triple board certified is like, okay, tell us first of all how that comes about. You, you say, I'm not just good with the base, base, you know, MD, I need more. Where did that come from? Or did you know while you were going to medical school, this is what I want to do, but then other areas opened up to you? How does that happen?

Yeah, it happens because you keep searching because what you're using isn't working. So I started off as a conventional internal medicine doctor, actually, before my— and after internal medicine, I did this whole long fellowship of global medicine, did that for about 5 years and taught other doctors how to treat rare diseases and infections. And then at that time, I was in my 30s. I had a baby, I had aging parents, I had like so many hats and all this juggling that I was doing with many of many people, you know, and many of my patients. And I coincidentally happened to find like a mass in my neck. And I was like, this is so strange because we don't have an explanation in conventional medicine why I would have this. But during that like 10-day wait for the biopsy results, it was like the first time I really was on the other side of medicine. And even though I felt deeply empathetic to my patients, but at that time I was like, wow, this system could be so much better. And because I would ask doctors like, why do I have this? And they would be like, why are you asking why? It just is what it is. And so going through that, thank God it was benign, but that really opened my eyes to what's more in medicine. And then I went on to— because a lot of my patients were coming to see me were women who were gaining weight or feeling tired. And so I went on to get my obesity medicine boards, which was all about like just giving medications, you know, overweight, give them medications, and that wasn't satisfying enough. And then I discovered functional medicine. Functional medicine was similar to medicine because there's a protocol, like in conventional medicine, as to how you go through things. There's a system which I could resonate with. But what was so awesome was that it was about the whole person. Like, you're listening to the person in front of you, their whole story. And I went from seeing people— my initial intake was like 20 to 30 minutes to 2 hours. And that's like so amazing. And and just like how I want to practice, 'cause I can be fully present, hear someone, and then look for the clues as to what may be going on with their symptoms currently. So, triple board certified happened coincidentally, but it was because what I was doing was just not enough.

I love that. Such a great explanation. But there's something else that you said that I want to unpack a little bit more. So even though you, we kind of just brushed over, it was benign, huge sigh of relief, I'm sure. But that also has to impact you for the rest of your life. That waiting for the answer to that question. How has that changed you? I mean, did it make you reevaluate your own habits, your thoughts, your—

Yeah, and when I asked my conventional doctors, I remember it was the first, I was in a big practice, I asked like one of our like senior doctors, like, what could this be? He's like, oh, it's kind of concerning, 'Probably could be like stomach cancer.' And that's just how he said it. And I was like, 'Wow, he just said it that way.' And then he's like, 'I'm gonna go see my next patient.' And I was like, 'Wow, that was just really callous and poor bedside manner. I will never do that to someone,' when we didn't even know what it could be. It was like this benign tumor. But what it really awakened in me is why. No family history of this, nothing that was obvious in conventional medicine that could explain it. But what I suspected was is severe amounts of high stress. Like I was about to be promoted to the global head in this organization. Had a little baby, just too many things. And we're not meant to do so many things. So probably my cortisol was through the roof and didn't even have the insight to know that. Because if you have high stress or high cortisol, in essence, that's a pro-inflammatory state. Your body is saying, no, please stop, listen. And I wasn't listening. I was like, oh, I'm going to keep going.

This is such a great question. And this is a little serendipitous. And I'm going to take a quick pivot here, quick, if we can, because I just had this question. We talk sometimes to women about exercise. Well, actually, frankly, we talk all the time here about that. But we also— and I'm an endurance lover, so this is really a hard thing for me to share with somebody because it's a hard reality for me to face on my own. You know, given to my own devices, if I had the time, I'd love to take off right now and go for a 4-hour bike ride. I just would. And I know that I would be trashed by the end of the day. And it used to take multiple rides to do that. But now it's probably going to do it right away. And someone asked the other day, well, isn't there a way to do that but yet come back and maybe do box breathing and fix it? And I just was like, for a minute I sat and I thought, oh, she wants it bad. She just wants that bad. But we still, you know, my interpretation of that would have been essentially that we've done some damage there and we've also spent time and energy where it doesn't serve us, and then it robbed us of the time spent where we could have done some proactive things. But I'd love to get your response to that and not interject my own answer. What would you have said to that?

You know, I think so many of my patients either do not exercise at all, and which is like so tragic because I think during that time of my own benign mass journey, I was hardly doing any movement. Like, this whole emphasis on just moving and building muscle losing muscle is, is aging. It just wasn't there. But I have a lot of women who, like, want to just keep— exercising is how they manage stress, exercising is how they burn off that cortisol, and then hit perimenopause, menopause, and they don't have hormones, and their ligaments are nice and stiff, and they injure themselves. And once that happens, they, they completely fall apart because that hard exercise and hitting it hard was the way they managed their hormones. And so trying to find other ways of managing is important, but I think checking your values, like where is your cortisol, is it in a good space, where are the— where's the snapshot of your hormones, how is your testosterone, can you afford to do that, and is that appropriate for you at this time?

So, so good. Such good questions. And I think maybe what we really hit on right there is, in the way that you so eloquently asked, is the asking And the importance of allowing each of us to, to answer, because I think we're more receptive even though we may not like the answer. We tend to know it. And yeah, it just hits differently when we get there on our own versus, you know, somebody being told that is so different.

Yeah, exactly. I think when you're in the frame— we've heard this quote before— when you're in the frame, it's really hard to see what's happening. But yeah, and women are very intuitive creatures, like they know. It's about having that space to be like, oh yeah, maybe this isn't healthy for me.

Yeah. So along that lines, you know, most of our listeners are over 45. For you outliers who are younger in here, we're thrilled that you are because your journey is going to be even better. And those of you— we've got some upwards of 77, 78 still joining our group because they feel fantastic, and we anticipate we're gonna, we're gonna age right along with them. But What else— what are natural ways that a woman can help her own hormones? And, and if we say that it may be beneficial, if you want to say, okay, specifically helping cortisol or insulin or, or estrogen or testosterone, what are ways that we can help ourselves even if we put aside the hormone therapy for a moment?

Yeah, absolutely. And I have a lot of women in that in that category. Almost 50% of our patients come to us because they don't want hormones. Either they're terrified of them or they have a family member with breast cancer or just really want the natural approach. And a lot of times I liken the hormonal pathways to a family, a family, a family generation. So think of your adrenal glands, which produces cortisol and your DHEA, as the wise grandmother. And then think of the thyroid as a supporting mom, and then think of the ovaries as a sensitive grandchild. And the ovaries are very directly impacted by generational stress. So if your adrenals have gone through a ton of stress and trauma and pain, then it's going to impact your thyroid and it's going to impact your ovaries. And you might go into menopause really dramatically and not go into it gracefully with an easy process. So yeah, if you do have young listeners, people as young as 35 to 45 listening, check your hormones. See where they are, see how you can protect grandma so menopause doesn't happen so rapidly. But so knowing these numbers are important, and it's very frustrating to me when I hear patients saying, you know, I beg my doctor for these hormones like cortisol, thyroid, and nobody's even checking them. So find a person who you can partner with and check these numbers. And then if your cortisol is not optimal, that's another big distinction between conventional medicine and functional medicine is conventional medicine normal. If you're within the normal range, you're normal. But functional medicine is, are you optimal with your labs? Is your cortisol optimal? Is your thyroid optimal? Just some number examples is if your TSH, which is your thyroid hormone, which is, um, you know, it should be conventionally less than 4 for you to be not diagnosed with thyroid disease. But if it's 3.8, you know, your conventional primary care might be like, you don't have any thyroid issues. But a functional provider will be like, it's not optimal. Let's improve that with things such as working on grandma. How can we help your cortisol by giving you things like ashwagandha, giving you things like cordyceps, having you do more fun things, hanging out with your girlfriends? How can we help your adrenals so that your thyroid gets better? And for your thyroid, could we give you more selenium, more iodine? How could we improve that without jumping to prescriptions? Because once we do that, you're stuck on thyroid hormone forever. When your body is taking a hormone, it stops making its own, be it thyroid, be it hormone replacement. So it's important to first see, and we give all our patients first lifestyle hacks. What can you do in terms of exercise, sleep, fun, joy, diet, nutrition that could help this axis first? And once they've exhausted that, and as we're working them with herbs, then we even think of medications. But the first thing is what natural solutions are for your adrenals, adaptogens like cordyceps, rhodiola, your thyroid, selenium, iodine, zinc, things like ground-up thyroid, actual organic thyroid gland from animals. All of that can kind of help feed the thyroid before you even get to the necessity for anything to support your sex hormones. But it's—

well, yeah, I love that. And I want to ask, for those of us in the back who may already be on some thyroid medication, do you see instances where adrenals and maybe cortisol improves, and that even someone on medication either is able to reduce medication or able to come off.

Absolutely. And I see this the most in my women who are thinking of getting pregnant and their thyroid is like suboptimal. So I do suggest for that case, get on some thyroid meds with the promise of getting off it afterward, because during pregnancy it's difficult to keep your thyroid optimal if you already are slightly off. But other than that, I really think you can at least safely reduce the dose and potentially get off if you can really improve your adrenals. And what's draining your adrenals? Like, what's affecting grandma? Chronic stress, chronic anxiety, and chronic inflammation. And so we do work with women on how you're managing stress and processing the anxious world. But really, it's inflammation is where we really spend a lot of our time.

I love that. And I also— it's so interesting to me. This is meta meta. I feel like because we're talking grandma, we're talking you know, master, and we're talking grandchildren. But also, I think you're talking literally— we are talking to many women who either have, you know, young women, adult children who are now beginning to go through the birthing stage. I've got my hand up, and one of the things that I want to gift my— this first time I've had a girl. In fact, I had to ask her for hair advice. She knows more than I do. So But one of the things I want to gift her is like a bone density test, you know. Now let's find out where your peak is, because 20 years from now it'll be so great. Do you recommend that? And hormone panel too?

Absolutely. I would say the younger women I'm seeing in the generation between 25 and 35 are much more empowered. Like, they want to know. I'm like, symptoms? No, I just want to know. I was like, that's awesome. That's where we want to be. And we, you know, we just do it. So for those people, for those kind of patients, we do a lab consult. Let's just do a snapshot and see where you are. What can you optimize now? So things— so you're just aware. So, and another big part of just testing is this whole concept of testing for toxins. Yeah, hormones directly. And that's something you can do something about in your 30s, 40s, you know, before waiting till your bones are kind of demineralizing and you're putting a lot of toxins in your bloodstream, and then it's harder.

Yeah, you know, it's— and again, serendipity. So I've got a little thread going on this morning with the family members just about what causes cancer, and you know, so-and-so is dealing with something. And I'm like, well, you know, lots of toxins before we knew what they were and that we were drinking, breathing, and putting them on our bodies. That's a big part of it. But I also want to ask other things. So testing toxins, potentially testing hormones, but also is there a nuance I think that listeners may need to know about, about it's not just going in for a regular panel. There's beyond that. What do you recommend we all take a look at, right? Whether we are considering bioidentical hormone replacement or we just want a snapshot.

Yeah.

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Absolutely. And I'm happy to, like, send this so you could add it to your notes in terms of what we check in our longevity hormonal panel. But these are numbers you can ask your doctor for directly. You can go to Quest directly and get them. But we— what do you think of the— we run to the hormonal panel, which is the AM cortisol before 10 AM, your DHEAS, which is a hormone that makes cortisol, your thyroid. As a conventional internist, we just check a TSH and maybe a free T4, but there are 3 other tests worth checking, which are your 2 autoimmune thyroid numbers, the Hashimoto's numbers, and a reverse T3. So those are important things to check. And on the sex hormone side, estrogen, progesterone, testosterone. And I think some things people commonly forget to check is total testosterone and free testosterone. And with that, you should check something called sex hormone binding globulin. And on your order, it'll be SHBG. But basically, that protein binds all your testosterone. So I have a lot of women who come to me who are like, look, my testosterone is kind of on the high end, is really good, but I don't feel like I'm strong, or I'm— I feel like I have good libido, or I feel like I am confident. Like, why am I like this? But my testosterone levels are really good. But when we look deeper, we see that the free testosterone is really low, and that's because that sex hormone binding globulin has bound it up. And common things that increase that sex hormone binding globulin is being on birth control, so for younger women, or having nutrient deficiencies or inflammation either from the gut or toxins. So look deeper as to why. So that's the hormonal part. And then on the longevity part, which I think is super important, that goes along with hormones, is you must make sure you have some autoimmune markers and ANA and ESR. So ANA is an autoimmune antibody and ESR is an inflammation rate for autoimmune, because as people go from perimenopause to menopause to postmenopause, we see autoimmune just skyrocket 3 times.

Wow.

So it's important to know what's happening with the autoimmune levels and then inflammation. We check an HSCRP and we do check things, not only iron but ferritin. And so many women have low ferritin. And I'm in LA. We have a lot of people who are vegan and vegetarian. Maybe they aren't eating enough iron, but if they have a lot of toxins, their iron reserve will be low. And the last thing I think is probably helpful to check, which we check in almost all our patients, is some genetics, because, you know, regular conventional medicine is very linear. We just— very reactive. But functional medicine is more triangular. It's genetics. Things you're exposed to, and then stress response. And the genetic side is important to know. Do you have genes that don't detoxify naturally? Do you have genetics that don't make good antioxidants? Do you have genetics that don't make collagen very well, so you're very prone to injury? So those are some of the things we check, as well as do you have genetics that could make blood clots very easily? And now we might be giving you things that increase estrogen and you might be at risk. So genetics, this longevity panel that includes inflammation and nutrients, which are vitamin D and B12 in everyone, and hormones. I think it's important to check that. I would say if you go to a good lab and your insurance covers some of it, it shouldn't be more than $300. Or if, you know, insurance is not going to cover it, it's actually cheaper and it's like $250. So you can get a lot of data and just have to think about what's optimal and understanding those labs. But it's So important to know that and be empowered to partner with your doctor and advocate for yourself. Like, why is this so low? You know, please explain.

So interesting. Yeah, and that was a great list, so I appreciate that so much. We'll put that in the show notes for everybody. I want to talk to this idea. I know you started and you said a lot of women come into the office and they don't want to do hormone replacement. I'm also wondering if not, not as a persuasive argument, but if some of that is not like lack of education— we were never given all the facts, we were given part of it, or maybe, maybe heard the part that made us fear— fearful. And so we kind of shut off and said, no, no, not for me. Um, is, is a part of it once we're open now to conversation a little bit?

Depends on where you— which generation you're in. Like, if you're in your 50s, 60s, you're scared of it because remember at that time it happened abruptly. Like, we were like, get off hormones, it's scary. And that's what happened. But if you're in your 40s, 30s, you're ready for hormones. You're welcoming it just because of the movement. I mean, I'm grateful that we're living in a time where there's so much awareness. But if you're a little older, there's a lot of subconscious fear that we put there over decades. So when— and this is about education and how we do hormones is we don't— and if you have— find a conventional doctor who might give you hormones, they might give you estrogen and progesterone right away without checking levels. Yeah, we check levels on everyone because I had—

that's crazy to me.

Oh yeah, no, that's conventional medicine.

That's like shooting, shooting in the dark.

Yeah, I mean, that's honestly— if you find a doctor who's willing to prescribe your hormones, yay. But the likelihood that they're going to check your hormones is super low. And in their defense, they're not taught optimal numbers. Like, I learned all my perimenopause, menopause knowledge post-medical school, post-residency. We're just not taught that. We are very reactive, like, are you dying? Do you have cancer? Do you have a stroke? You have diabetes? And that's what insurance covers, and that's how we respond. We're not talking about, are you living your best life? Are you, are you gaining muscle? How is your brain fog? And how is your memory? Those are not kind of conventional medical questions, but it's important to ask.

And so good. So I'm chomping at the bit here just for listeners to inject that this is very much like fitness as well, right? A basic fitness certification, even a 4-year degree— and I have been on the, the committees and behind the teaching of both— there is no mention of the word menopause. There's no mention of the word hormone-centric fitness or exercise, or a difference, you know, whatever phase you might be in outside of— I will say outside of prenatal and postnatal, you know, that, that's been longstanding. But, you know, menopause, perimenopause, postmenopause, the difference, the nothing, nothing. So it just—

yeah, I know. And it's so important to recognize that we're coming to a different time where we're talking about this more. And we feel for like our daughters and our granddaughters that this will be a different time. So what can we do for now? Because we have so many women who are in their 50s, 60s, and that's not the way it should end. I mean, a couple months ago I had a patient come to me because she was 87. And she was on testosterone and she was like, my gynecologist retired and my primary care won't give it to me. And yeah, and she looked amazing. And I was like, wow, you're so fit. You could like put all our 50-year-olds to shame. And I was like, here it is. You know, we're going to check your body and make sure you're tolerating it. What are your levels and how is your liver processing it? But, you know, here's 6 months supply. Go and keep doing you.

That's amazing. Okay, so talk to me, backing up to this. Is, you know, in looking— number one, shooting blanks is not a good idea. Like, just, here you go, here's a, here's a generic number and amount of estrogen, progesterone, go have it, tell us how you feel later. We're not going to do that. But also, I think you have maybe a unique approach to how you start someone on hormone therapy. Talk to me about starting estrogen versus progesterone versus both together, and what makes you decide what's right.

So after we do like a longevity hormone panel, the next thing we do is we do a gut test. I know all of us is like, I don't have any gut symptoms, like I just want hormones. Yes, but we do a gut test to really see how is your gut processing these hormones. You know, if we ever have to think about medication, is your liver ready for tomorrow's prescription? So we do a gut test with everyone. And surprisingly, people who say they absolutely have no gut symptoms have a lot of inflammation. Because they just— the body has gotten used to it. And so we work on inflammation first and then we do natural hormone kind of supplements that could help. And then if people are just like, I'm ready for hormones, we go to that. And so we're looking at numbers. Like just yesterday I had a patient who was like, I'm here for estrogen. I saw a couple of weeks ago and we brought her numbers in. And so estrogen levels were great. She was only 49. And she wasn't— her FSH, which is how you know, are you in perimenopause and menopause, wasn't very high. So she was still in perimenopause. And estrogen was perfect, her progesterone was perfect, but what was so low was her testosterone. It was like super low. It was almost like somebody who was 20 years older, and she was only 49. And because we do deep testing, we found out also that her gasoline levels were very high. And just like, how do I have high gasoline levels? She lives in LA, and she does live next to a highway. And we do know—

so you're not kidding— gasoline levels, which is like gasoline byproducts.

And why that's important to know is Gasoline or MTB in rats— we don't do these studies in humans because there's again no business model— but in rats, if you have high MTB, it lowers your testosterone levels. So, for her, we just need to kind of reduce her MTB burden, and her testosterone should increase. But it's— and so, but for her, we gave a little bit of testosterone so she could start feeling like herself again while we worked on the root cause. And so, for a lot of women, we just start with what's the lowest Is it testosterone? Or if you're not sleeping, let's try some progesterone. And the last hormone we kind of add is estrogen if needed. And it's about like, what can your body tolerate and where are you now and what do you need?

Amazing. This is amazing. I mean, literally hearing you walk through this step by step, you know, I don't know that anyone's described it quite this way, you know, in terms of you know, what do we want to look at first and then next to be sure that you're ready for it. And, and in part, I want to come back to like us, so you and I, listener, because sometimes I think we can be a part of the problem, you know, with conventional medicine. You know, we've, we've gone in— I know I'm guilty of it, you know, just give me a prescription, I need to be better because I have to be at X, Y, and Z make me better now.

Right.

We've demanded things that potentially have in the long run not been the ideal for us.

And yeah, I love the way you're so sequentially and thoroughly going through to kind of, I like, you know, have kindness for you and your listeners in terms of you've suffered for a while and you're like, I need help now. And that's where it's like meeting you where you're at and saying, you know, in the long term, we also have to work on X, Y, and Z. And when you explain it like that, people are like, 'Okay, now give me what I want now, and I'll give you what you need as well.' So good.

Talk anything else about testosterone. So you kind of talked about like there's a reason why it's low or something is in the way. I have never heard of that, by the way, before. So kudos to you for opening my eyes. Are there any negative side effects to testosterone, just for listeners because I think, I think there still is that stigma or stereotype that, that testosterone is maybe not needed by women as much, or isn't there a risk that, you know, I will get acne or get big?

No, absolutely. And we're not trying to make women men. And in nature's perspective, we've kind of done our part. Like, you know, we, we all want to look like you, like you're nice and fit and muscular. That's what we want to be. But if you just leave it up, left it up to nature and chronic stress, we wouldn't get there. And so testosterone is a super important hormone that helps with muscle strengthening, brain, brain fog, the ability to have confidence and reduce your lean body fat. So it's so important to improve those testosterone numbers. But side effects of taking testosterone, there's a couple of things when I think of testosterone, the first thing I think of is I want to ask, talking to women, is do you have a history of polycystic ovarian syndrome? I guess a young child where you may have had a lot of acne or facial hair. So I already know that this kind of person may be very sensitive to giving them testosterone. So I should start with the lowest dose. And then giving somebody testosterone, you want to make sure your gut's in a good place. They don't have a very high sex hormone binding globulin so they can actually feel the testosterone. And then when you do take the testosterone, it's, you know, it's unfortunate right now there's no oral testosterone, it's just a cream. And so it's about educating women to use it regularly. But that's the one thing when women start feeling the benefits of testosterone, they're very, very consistent. And the side effects can be— I tell my patients sometimes you could feel a little bit more aggressive, but we're not trying to make your hormones super therapeutic.. But another common side effect is hair loss, hair loss right here. And so how you can overcome that, which is something doctors don't think about often, is about splitting the dose in half. So it's all about reducing the peak level of testosterone so the testosterone is not becoming DHT. So you have high levels of DHT, you can have hair loss. So if you can split the level of testosterone and do half in the morning and half at night, there's no peak testosterone, so the hair loss side effect is much lower. And it's important to check, like, every 3 months, checking your hormones. Where is your DHT if you're on testosterone? So you know the numbers and are not flying blind.

That is great. Is that true too for women who are postmenopausal? Do they need to test that frequently as well?

They do if they're super therapeutic, because sometimes women come to me and the doses are just super high, and I'm like, you really need this much? Like, where is it all going? And so if your levels are super high, you can make high DHT, and it's important to know 'Cause I know women over 40, every single strand is so important.

Yes, this is so true. I have two questions where, or a phenomenon similar in two different things that we see inevitably. So we've started being far more thorough. When I have a private client, it's even more so. But even among our group students that come in, we try to take that information, to educate them more so if they're working with somebody like you, so they can be sure— make your doctor aware of this. This is something that actually may limit your progress with what you're doing because you need this. But we see two things. One, a lot more autoimmune disease, so a lot more Hashimoto's, maybe more flares in things that they had been dormant before, but also an increase of cholesterol. I mean, that one is almost across the board. And, and for everyone else, I would say this is a third, so not two, but insulin resistance, belly fat. I mean, that is whether a woman gains weight or not, she almost always has a redistribution to the belly where she never had it before, potentially. But can you, can you lean into the autoimmune, the cholesterol, and, and potentially if you have any any little tidbit to offer about the insulin resistance?

So the autoimmune is super common. And a lot of times I said, patient recently who came in, she's like, I'm here because I can't go for my annual physical and everything's always been beautiful and I'm super active and eat well. But this is the first time my doctor said I needed Lipitor, a statin for my cholesterol, and metformin for my blood sugar because I'm slightly pre-diabetic and my cholesterol suddenly high. She's like, this can't be happening to me. Like, nothing's changed. Changed. And she was in menopause, and so we talked about that piece. But the part about autoimmune, um, the part with autoimmune just tripling around the perimenopause-menopause state is due to a lack of estrogen, because estrogen really helps with immune modulation. So if your estrogen is not there, then it impacts that autoimmune. And then the second piece with autoimmune is I think a lot of women have had some autoimmune stuff going on but haven't and when they do check, it's a surprise. And I think that also has to do a lot with just chronic cortisol. So when your cortisol is chronically high because of life events, just, just all your busyness, that is in essence a pro-inflammatory state. So what are you doing for self-care in your 30s, 40s, and 50s? How can you really double down on that, especially in your 60s? So your body is like, things are okay, I'm not being chased by the tiger, I can breathe, and I won't be in this pro-inflammatory state. So I think you can do so much. And most of our autoimmune diseases, we try to get into remission and maybe not fully gone, but really dramatically reduced by just working on the gut and hormones and toxic burden. With regard to cholesterol, a lot of times as you're entering your 40s, your bones get a little demineralized and you are— you do have an increase of toxic burden. I think your liver is just busy now dealing with all these toxins, so it can't make good cholesterol. And so with that in the backdrop of not having enough hormones, you just kind of see these cholesterol numbers rise. And with regard to insulin, once your cortisol is rising, it's going to— you're going to need that blood sugar to keep running from the tiger. And if you have this chronically high blood sugar spikes, you're going to naturally increase your insulin. So with insulin, it can be due to stress and inflammation. The question is what's driving your insulin? And the one thing I just wanted to share is that I only found out this, this, this statistic like 6 months ago, but women in the United States have the highest suicide rate between 45 and 55.

Oh my gosh.

And it's really disheartening because this is finally where you're free. But it's also a time where your kids are going to college, your parents are aging. You may have reached a peak in your career and trying to figure out, is this it? You may be going through a divorce and it's a lonely time and you're going through all these hormones and you kind of feel like, are you crazy? So I think it's so important for us to be really educating and empowering women in this decade to be like, it's not you, it's your body, and we got you.

So back to the cortisol, does that, does that tend to kind of that initial shock of the body kind of adjusting to things, does that stabilize by itself, and/or are there things that naturally we can do to help that stabilize?

So the biggest thing with the cortisol, sometimes women come and the cortisol looks okay, but so important to look at DHEAS, and that's the hormone that makes cortisol. And sometimes they're like, I don't have that much fatigue, but I've gained all this weight and I have insulin resistance. And you look at the cortisol, it looks pretty good, but the DHEA is so low, and it just tells us that this human has aged so much more quickly than she should have. Either because of chronic stress, chronic anxiety, or chronic inflammation. And giving people a little bit of DHEA or reducing inflammation so your DHEA can improve naturally can really help kind of stabilize your cortisol.

So good. Such great information.

Thank you.

You are going to have a lot of people wanting to come and learn a little bit more. Where can they find you?

Yes, you could find me on our website. It's SianaMedical.com. And I'll also include the discovery call link in here if you want to talk and they want to see if we, if we're a right match, if they want to do a lab consult or come in and see us. And we do have free webinars monthly, so if anybody wants to join, you know, I'm just happy to share. And especially with this special decade that we need to like all step up and support women.

Yeah, yeah, so love that. Okay everybody, so we've got the links in the show notes for the website, also Instagram and YouTube, ways that you can get a little bit more education. We'll have the details on that longevity panel in the show notes for you too. Thank you so much, Dr. Shilpa. Thank you.

It's such a pleasure.

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