The Best Strategies for Balancing Hormones and Thyroid Health in Women

Foreign. We are talking today and digging into all things hormones. So hormones are such a huge piece of the puzzle when it comes to quality of life, but they also are heavily impacted by thyroid disorders. So I want to take you guys through this pre, menopausally, perimenopausally, postmenopausally. And the way that we'll do it is by going through each individual hormone one by one. So we will discuss reproductive hormones today. I will not actually discuss adrenals today. I want to save that for its whole own episode. I'll finish this off with some Q and as that you guys submitted via Instagram, so stay tuned. Let's begin first with testosterone. So very, very early on in thyroid dysfunction and in a woman's aging process, we start to lose testosterone production. Starting around age 25, 26, it initially starts to decrease. That escalates more rapidly when you have a thyroid condition. So symptoms of low testosterone really mimic one another all the way through the phases of a woman's life, from premenopausal Perry to post. So symptoms of low T certainly overlap some with thyroid conditions. But truthfully, we need to be addressing all of these issues, not just thyroid leaving low testosterone by the wayside or just fixing testosterone leaving thyroid by the wayside side. Right. We want to address everything together. So symptoms of low T are fatigue, low sex drive, poor physical stamina or endurance, like you're going to exercise classes, but you can never really build up your stamina or exercise recovery. Difficulty building muscle mass, difficulty maintaining muscle mass. And so these things again do overlap with thyroid, but they have an independent method of influence than just plain old thyroid conditions. So it is extremely rare for me to see people at modern thyroid clinic who are in their 30s, even with a long standing thyroid condition that have great testosterone. They usually don't. I think the first time I personally was treated for low testosterone was when I was 28, so right around the time that I had my thyroid crisis. So you can build up testosterone levels in a few different ways, obviously, foundationally. Always we want to fix your thyroid. Always we want to address your adrenals because part of your testosterone comes from your adrenal function, from your DHEA production that with a compromised adrenals you begin to lose. Another way to build up testosterone is to try to build muscle mass. Right. So our our skeletal muscle helps us produce more testosterone naturally. The tricky part about that is it's sort of this chicken or egg scenario, meaning when you don't have enough testosterone, it's really hard to produce an increase muscle mass to produce more testosterone. Whereas what we very commonly do at modern thyroid clinic, especially for people who are pretty physically active and willing to like, lift weights and do all the things once they feel better, we put them on some testosterone. We allow them to build up their muscle mass with weight training while they're on testosterone. And then a lot of them want to discontinue it and see if they can maintain that higher level of testosterone on their own, which often they can. We so and, and we're looking for that. I mean, in, in body scans, a great way to measure that. Obviously, monitoring testosterone levels, how we test and treat this hormone testosterone doesn't fluctuate greatly throughout your cycle. So we just have people check testosterone labs any day of their cycle. If they're premenopausal or peri, and then obviously anytime if they're postmenopausal, we do a bl. Our total testosterone optimal ranges for women would be about 35 to 65. That's where you should be walking around naturally with adequate levels of testosterone. If you're post, even pre menopausal or postmenopausal, the ranges for quote, optimal testosterone on many labs go down to like zero for women. So they're like, well, we don't want you to have too much, but we really don't care at all if you don't have any. So that's a problem. Like, testosterone really improves our quality of life, our vitality, our longevity, our ability to exercise effectively. So what a shame. They're very concerned about it for men, but not at all for women. So again, optimal ranges are 35 to 65. When we treat with testosterone, let's talk about multiple options. My preferred option is to do what's called a ready dissolvable tablet. I have my own right here. If you're watching the video and they are just, you open this, there's a little dissolvable tablet that you pop under your tongue. I literally took one 10 minutes ago. Let it dissolve in your oral mucosa as long as it can, and it absorbs through that oral mucosal lining. And the reason I like these, what's called RDT tablets, it gets in your system really quickly. It does not like a cream that has to build up over weeks and weeks. You can time it flexibly during the day. You don't have to do a cream twice a day. You don't have to worry about exposing your children to it. Right. So it's just sort of more convenient. The biggest one though, is an advantage over testosterone cream. So testosterone cream was the way that I used to do it for many, many years. The downside of cream, y', all is it does. It takes a long time to integrate into your system. But in addition to that, for women especially, usually you place testosterone cream, like, on your inner thighs. When you do that, you're going to grow more hair locally where you are placing your testosterone cream. Okay. And it's usually dark. It's usually a little bit black. And you know what? Most women don't want that. And it doesn't necessarily stop growing if you stop using testosterone cream, sometimes it sticks with you and you end up having to do laser hair removal, et cetera. So that's a bummer. And because of that, I switched to dissolvable tablets years ago. The one downside of dissolvable tablets compared to cream is I feel that they're easier to mess up. From a compounding perspective. I feel like there's a little more built in compounding errors in terms of dosing. It either leaves people a little high or a little low, and it's just harder to really hit the nail on the head. But pros versus cons, I still think it's worth it. When we treat people with dissolvable tablets, we always, always follow up with labs and, of course, discuss symptoms. So we check labs about three months after we start it, minimally after two. Specifically with testosterone ready dissolvable tablets, I have them skip the dose the morning before their labs, because what ends up happening is you get a false elevation while it circulates before it hits your liver and becomes available for your body. And we don't want to catch that number because that's not telling us how much you are actually able to use and is available. So I have them skip the morning of their labs. They can take it the night before, the day before, whatever. And again, I start by trying to attain physiologically optimal levels. Okay, what does that mean? That means where you should be naturally walking around without testosterone replacement. I do not in any way advocate for the overdose of women on testosterone. And an overdose, in my mind, is essentially most every experience with pellets. Sorry, ladies. I know many people love pellets, and I know, honestly, they can make you feel good. That doesn't mean that it's good for you. There's two very different things happening there. Generally, pellets are not dosed by the clinician. They're dosed by the makers of the pellet company. The clinician just inserts a little bit of data into the computer and the pellet company spits out what dose the patient needs. And usually that is ten times more than the patient needs. So to give you an example, women's physiologically normal range is 35 to 65. Men's optimal range is, you know, 800, 900, maybe, maybe up to a thousand younger years, really physically active. I have had women transfer to me over 800 of testosterone on pellets, another one over 1200, another one over 2000. 2000 is double A man's level. It's a really good way for you to start growing facial hair. And women can even grow. And I have had patients on pellets that transferred to me where this exact situation has happened. They can grow what is referred to as a micro penis where basically your clitoris enlarges more and more because of chronic exposure to elevation and testosterone. And that is a permanent thing that doesn't reverse if you take your pellets out or stop using them. And so, yeah, not really it for me. I would say on average most people that transfer to us with pellets are at a level between about 400 and 500, which again is kind of an average, above average dose for our level of testosterone for a middle aged man. Not really what I'm going for. So I am willing to increase women's testosterone above a physiologically normal level if they don't reach their symptomatic goals in a physiologically normal level. And I'll take them up to about 120, 130, but I'm not going up to 3, 4, 5, 600, certainly not going up to 2,000. So I think that wraps up the basics of testosterone. So we'll move on. Let's talk about the second additional hormone that I see drop very early on in women's lives, but especially with thyroid conditions. And that is progesterone. So progesterone, low progesterone I see in women in their 20s, 30s, 40s and beyond, of course, but very, very common. Okay, I want you guys to understand symptoms of low progesterone in premenopausal women. Women that are having periods. It's anxiety, irritability, agitation, insomnia worsened leading up to their period. That anxiety is building, building, building, irritability, building, building, building. They start their period and boom, they feel relief. They're like, wow, I've been so irritable. I don't know what was wrong with me this week. Gosh, I'm so sorry. I'm Fine, now. Yeah, no, that's low progesterone. They also can have shortened cycles, meaning Instead of every 28 days, it could be 25, 26, 24. And heavy periods. Progesterone is responsible for keeping our uterine lining intact. It's what helps us maintain pregnancy. So not only are women with low progesterone at an increased risk for early miscarriage in pregnancy, it's one of the most common causes of early miscarriage in pregnancy. It also can cause heavy periods and just shortened cycles because again, it's not keeping enough of your uterine lining intact. So some things to think about, perimenopause, same. Anxiety, irritability, agitation, insomnia. I would be shocked. I am shocked when I see women who don't have low progesterone in perimenopause. Like, it's just rare. I will tell you that fixing a woman's progesterone is one of the most life changing things I've ever seen in medicine. Did not know that 12 years ago, but it is. Because when you fix a woman's progesterone in the right way, they get relief immediately. Night one, they sleep better. Day three, four, five, they feel more calm, more Zen, more like themselves. I've literally been called a witch three times by three different patients for fixing their progesterone. They're like, I want to clarify, it's a good witch, but still you're some kind of a witch. And it's true. It's not true that I'm a witch, but it's true that the changes take effect so quickly that it is profoundly life altering. Post menopausally, women generally experience anxiety, irritability, insomnia that onset around this time of their menopause or late, and perimenopause, they're like, you know, I just kind of haven't really slept wells for the last four or five years. And they're like 55 years old. I'm like, well, that's probably your progesterone. And again, fixing that for women is in postmenopausal is incredibly, incredibly powerful. So how do we fix it? So my favorite thing to fix, low progesterone, is a bioidentical compounded form of progesterone orally in a sustained release method. Okay, I know that sounds so particular, but it needs to be particular. Would I recommend progesterone cream? No. In less than 0.001% of my patients. Why? Because progesterone cream takes a long time to integrate into your System build up levels and then it's just stable all day, every day. Oral sustained release progesterone that comes from a compounding pharmacy is literally made from yams or sweet potatoes. You take it before bed, you go to sleep. It hits most heavily while you are asleep, and then you wake up and it carries over the next day, okay? It lingers to allow that calm, zen, more like myself feeling, which is what we're going for, right? We don't want you feeling tired all day and having the same level. You need to sleep. Walking around during the day, that's not conducive for high quality of life. So the rhythm of sustained release bioidentical progesterone is great. I find people respond almost the opposite way on synthetic progesterone. They feel more anxious, they feel more irritable. Supplementing a woman with progesterone is not like putting them on birth control. Okay? We are not disrupting your cycle if you're premenopausal. We are complementing it. So literally, at modern thyroid clinic, we dose premenopausal women their progesterone according to your cycle. The first two weeks of your cycle, your progesterone should be lower, should be, you know, non dominant in that phase of your cycle, days one, when you start your period, until about day 13, 14, the second part of your cycle, we double it. We have you take two actual capsules before bed because that is the phase of your cycle where you need more progesterone. You're supposed to be preparing in case you're pregnant, preparing for your period, right? Protecting you from PMS and PMDD symptom, basically. So we double it then, and then it starts over on the first day of your period. So that's kind of how we do it. We test. I should have probably led with this, but premenopausally, we test women. This is going to get confusing. Bear with me. I'll explain it. At the midway point between ovulation and their next period. So if they have a 28 day cycle, ovulation falls on day 14. Their next period starts on day, it falls on about day 28. We have them go on day 21. If you have a shorter cycle, if it's like 26 days, maybe we have you go on day 20 or 19 if it's longer, if your cycle's 33, 34 days, maybe we have you go on day three, 23, 24, right? So we are trying to capture labs at that time because that is the peak of your progesterone okay, Your progesterone peaks in like 48 hours. It is up and it is down very volatilely, like very quickly in a small condensed period of time. So we want to capture that ideally so we can know what is your progesterone at its highest. That also creates predictability for estrogen levels, which we'll talk about next. You know, premenopausally. I like progesterone levels at peak to be between about 16 and 23. And non pregnant women post menopausally. When people are not producing their own progesterone, I find women feel well. We find women feel well with progesterone levels between about two and six. And again, our approach with hormones is what is the least amount of hormones you need to not have symptoms of lack of hormones or hormonal deficiency, and by, you know, protecting long term health outcomes, things that can help you, but not overexpressed hormones, that kind of thing. So those are our ranges. That's what we are looking for. We test women the morning after, you know, they take their progesterone, they don't need to skip it the day before, et cetera. And it is always a blood test. In perimenopause, it gets a little tricky. Often, you know, we rely heavily on symptoms because the predictability of periods becomes more challenging, which means the predictability of nailing down a peak of progesterone also becomes more challenging. So progesterone is really important for balancing out estrogen. It's also very neuroprotective as far as its hormones go. So it has a lot of, a lot of benefits for quality of life and even longevity. Shall we talk about estrogen next? I think so. Right. So estrogen's the one that really has been demonized in kind of mainstream medicine for a really long time. Meanwhile, functional and integrative medicine, people have really been advocating for the use of estrogen for years. Recently, the American Menopause Society came out and is now advocating for estrogen replacement therapy too. Though I do not agree with their methodology, what they advocate for, a lot of it. But I am happy that they are now at least advocating for this. Right. So what originally happened with estrogen is in the 90s there was a study that came out called the Women's Health Initiative, and it said basically that estrogen causes cancer. And so from then everyone has assumed that that study is good. And that is what we ran with in medicine for so darn long. Well, really quickly people began to analyze that study and be like this. Was not really effectively done. This doesn't seem like a valid study at all. And we probably need to take another look at this. So a lot of people already had discredited that study. Even the people that put on this study came out and were like, yeah, we were kind of wrong. However, all day, every day, clinicians, physicians of all kinds are still quoting that study as a reason to not use estrogen. In April of this year of 2024, honestly, one of the biggest studies I've ever seen in medicine came out and I think it was about, I should have pulled up this study before. I'll drop it in the show notes. I think it was over 10 million women, might have just been a million, but somewhere between a million and 10 million women over 20 years on estrogen replacement. That's a big study, y'. All. And it looked at long term health outcomes associated with estrogen replacement versus people who are not on estrogen replacement. And guess what they found? They found the women that participated in estrogen replacement had less of a risk for breast cancer, ovarian cancer, less of a risk for cardiovascular events, which is the thing that kills most. All of us. Improved risk factors for brain health, meaning they were less at risk for, for brain health issues as they age, less obviously at risk for osteoporosis, osteopenia, and really blew the previous study of the Women's Health Initiative out of the water. And so if your clinician is still telling you, oh no, you can't do estrogen, estrogen so bad they are not keeping up with giant, enormous advances in medical literature, and you need to find a new clinician, we'll stop, period. Because this is not an ignorable study that we're talking about. It's a study that absolutely will change medicine permanently, forever. So I'm a big, big advocate for estrogen replacement in women. Not only can it help you metabolically from an inflammatory perspective, research shows metabolism decreases with menopause, thyroid function decreases with menopause, inflammation increases, weight increases, you know, and then osteoporosis, osteopenia, cardiovascular risk, all these other things trickle in as well. So I always advocate for supplementing women with estrogen if they have any symptoms of low estrogen. Symptoms of low estrogen are hot flashes and vaginal dryness. Okay? Also some hair, skin changes, some weight usually retained around the midsection, and it can be incredibly powerful for these things. I, again, in this regard, I don't over medicate women on estrogen. I don't need you to have as much As a pregnant lady. Right. I just want you to have enough that's protective for your long term health outcomes and mitigates your symptoms. And what we find is a level between about 35, 75 ish for most women is enough. And so that's what we stick with. If they need a little more, that's fine. That's still all very conservative. So testing. So part of what I disagree with with the American menopause society is they advocate for not testing levels to adjust them. I think that is insane. So we test three months later after we start women on estrogen and look for levels and also correlate those levels with symptoms. Right. And again we're looking for about 35 to 75 and postmenopausally. Right. That's stable. It's, it's not fluctuating. I was going to add something else. Oh the kind of estrogen we use. So I generally stick with biased transdermal cream that you can put on your inner thighs. That kind of thing builds up slowly over time but creates a lot of stability. Or what I've been doing lately too is a vaginal trochee. Troche is a little like waxy tablet that you can insert vaginally at night. Not messy, isn't going to cross expose a partner during intercourse, et cetera. And it gives you systemic support. But it also gives a little extra support for vaginal lining, which can atrophy as estrogen drops, which can cause bladder prolapse, all kinds of things internally. It can cause painful intercourse. Right. I didn't mention that earlier. Painful intercourse is a huge problem with women with low estrogen. And it is traumatic, y'. All. Like women become, they have PTSD associated with sex. And it is so sad. And it's honestly really hard to reverse. So the sooner that you're able to intervene with something like that, the better. And you need to because otherwise you become terrified of sexual activity. So the vaginal trochee really allows for proliferation and just absorption of estrogen vaginally to thicken up that lining, to create a lot of lubrication for intercourse, et cetera. Which is, it's amazing. People don't mind doing it. It's not messy. It's honestly great. Both of these forms are bioidentical. Both of them are also from compounding pharmacies. Compounds in general usually cost about 120 bucks every three months. So kind of like a $40 copay. But you pay in 90 day increments because it's always cheaper that way to do so the one thing I don't, I don't love is oral estrogen. So I should add that oral estrogen causes a lot of issues downstream with changes in the way that your other hormones are metabolized by increasing your sex hormone binding globulin. And it's circulating freely in your system and very high levels. But before it is available, it's just, I don't like it, I don't view it as really safe. And I think it causes issues downstream with other hormones, thyroid, et cetera. So don't recommend that form. But to each his own. Talk with your doctor. The flip side of this conversation with estrogen from low estrogen is estrogen dominance. And this is usually in pre or perimenopausal women. It's where they have too much estrogen. And these symptoms very, very much mimic low progesterone. Okay, so again, it's anxiety, irritability, agitation, insomnia, worsen leading up to your period, heavy, crampy, moody periods, migraines leading up to your period, specifically with this breast tenderness around ovulation, cramping around ovulation, around day 14, spotting around ovulation. So those are sort of estrogen symptoms. A lot of those symptoms overlap with low progesterone because it's a lot of it is about the ratio of the two. We use DIM and calcium D glucarate to reduce estrogen dominance in our patients by upregulating the metabolism and transportation of estrogen to be excreted out. And it works very, very well. It's honestly pretty life changing and you don't want to walk around with a lot of excess estrogen anyway. It's, again, it can increase risk for blood clots, et cetera, which I don't think is an issue in women. Postmenopausal supplementing with reasonable amounts of estrogen. Right. The goal is you don't need a ton, you just need enough. So it's important to think about. I view estrogen replacement as extremely safe. Do I think it could be used irresponsibly? Sure. But I view it as very, very safe when it's done in a responsible, safe way, in the way that we do it at modern thyroid clinic. So many, many times I get questions about do we do hormone replacement at modern thyroid clinic? We absolutely do for all categories. Um, I wanted to scroll through just a little bit of Instagram questions about this topic and make sure I covered all of your questions. How to recognize perimenopause while on birth control. Um, I would say a lot of it is can be symptoms. But again, your birth control can put you into perimenopause like a lot of birth controls put people into a pseudo postmenopausal state. When it comes to estradiol, your progesterone, those numbers read as zero, which again, over time can lead to health issues. So it's very, very important that you listen to your body and you work with someone who helps to overcome those issues. And I think I covered all the hormone questions in the context of this talk. So if you've enjoyed this, if you enjoy our podcast, y', all please, please, please leave a review, write a review, give us a rating. Share this episode with a friend who might be struggling with hormonal dysfunction. It really, truly helps us. Stay tuned on my Instagram to give me feedback on what you want me to talk about next. I always want to provide information that is valuable and insightful to you, and I love to hear what that might be. So stay well and always remember, there is no reason to still have thyroid symptoms.