The Gutsy Gynecologist: Does Hormone Replacement Therapy Help or Hurt? with Dr. Tabatha Barber

Today I have Dr. Tabitha Barber, otherwise known as the gutsy gynecologist, who I met through social media. And I'm so excited to have her on midlife conversations today, because I want to dive into. I have so many questions, but specifically about hormones, like synthetic versus bioidentical, and this whole preconceived idea that they are unhealthy for us or they're somehow cheating. So I want to dive into that today. So thank you so much for being here.

Oh, my gosh, I'm so excited to have this conversation. It's super important. And I will tell you, like, until I went through it myself, I didn't have strong feelings about it, but I sure do now.

Yeah. Well, let's back up and talk about this. First of all, how did you become the gutsy gynecologist and how did this become a focus?

Wow. So my story is a little bit different. I am not your typical doctor. I was a high school dropout. I got pregnant in 11th grade. And through that whole process, things were done to me. Nothing was explained. It was a total nightmare. And I came out of that like this woman on a mission to really change how health care was delivered to women. I didn't have a voice or a choice. And so, you know, I went through all the painstaking efforts of getting my ged, going to college, going through medical school, residency, all this stuff. And fast forward, I'm in practice, I'm supposedly having this dream life, and I was miserable. I was so sleep deprived and exhausted, and my gut was a wreck, and I had no memory. I could not remember the patient I delivered the day before. It was so sad. And so I went on this healing journey and I found this whole world of health and wellness that I didn't know existed as a doctor. Because what I don't think a lot of people realize is that doctors, we are so burnt out and overwhelmed and exhausted that we're in survival mode just like you are. We're not healthy. It's like becoming a doctor was the most unhealthiest thing I've ever done in my life.

And so we don't so many times. My gosh, about. Because the hours and the studying or the. The debt that people take on, all of that.

Exactly. And so I never watched TV or read books or magazines outside of, like, the two journals that I was required to read. And so I really didn't know about health and wellness. Everything was focused on disease and being sick and managing disease. And so obviously, once I found this world of Functional medicine and wellness and anti aging. You can't go back. You know, your eyes are open, you just see life differently. So I started to try to try and see my patients this way, but it doesn't work in the conventional model because I had 15 minutes, you know, and I wanted to ask, like, how's your marriage? How are you sleeping? What the heck are you eating? And I just couldn't do any of that, so I eventually had to leave. But it's been life changing to see the transformations of actually getting women back to a healthy state and helping them thrive. And, and so much of this has to do with hormones. And what I've come to realize is as a gynecologist, I was inadequate at taking care of women during menopause and that middle transition, I just, I didn't have the tools. And I think it's interesting that you.

Just said that because I find that with most traditional doctors, not all, but most of them, they become diagnosticians versus like, like, what is the problem and what's the pharmaceutical remedy like? It's just that versus this whole holistic, like, let's look at everything and what's going on. For example, I can't tell you how many times I've had a doctor when you met, when I've mentioned menopause or perimenopause. They just want to put you on birth control pills. Like that's the only answer. Like, let's go on birth control pills where. And this is so common, I hear this versus like really looking at this holistic approach that you're talking about.

You hit the nail on the head. So women are really surprised to realize that gynecologists are not hormone experts. They are in fact surgeons. I spent four years learning how to do a hysterectomy four different ways, delivering babies that C sections. I did not study the intricacies of the endocrine system and how your hormones fluctuate and change over time. And that was something I had to go on and learn as a functional medicine provider and an anti aging provider. Like I didn't learn that as a gynecologist. And yet we look to our gynecologist for those answers. And that's why so many women are, you know, being misled and misguided because the gynecologists actually don't understand menopause and they don't have the answers you're looking for.

So let's talk about first, I'd love to know. First of all, I want to get in the mindset of why does a traditional gynecologist go automatically to synthetic birth control pills? Like, I want to hear, what's the process in that thought? Like, why do they think that's a good idea?

Yes. So I will tell you, the training of a gynecologist is pretty basic when it comes to hormones. And birth control pills are kind of our tool of the trade. We use it to, we say we regulate your hormones, but in fact, we are not regulating your hormones. We're shutting down your own hormone production. We normally have a communication between the hormones of your brain and the hormones of your ovaries and your thyroid and your adrenals, and they're all talking to each other. But the birth control pill shuts down that conversation between your brain and your ovaries, and you no longer make your own hormones. So you take these synthetic hormones and we say it helps with acne, with periods, with moods, when in fact we're just giving you synthetic hormones. And then if you try to come off of those, a lot of women don't go back to making the hormones that they were supposed to make. And so now we're seeing a huge influx of fertility issues and pcos and premature menopause. And it's because we have override. Oh, we've broken down that system. So the hormones are no longer being produced. And so that was a tool in my toolbox as a conventional gynecologist, because when I went through training, and this is how it is for all doctors, we get drug rep lunches two or three times a week. The drug reps come in, they feed us lunch and they teach us lunch and learn. Yes, lunch and learn. They teach us how to, how to treat whatever symptom with their drug of choice of the day. And that was pretty much the extent of my learning of how to manage hormones. It's not recommended that we test hormone levels. There is a very large range that was created a gazillion years ago. And it's really to identify tumors of the adrenal glands or the ovaries, or flat out menopause, not producing any hormones. There's no optimal levels for having balanced hormones for the different stages of women's lives for the different days of the month. The only thing that we've really studied and come to understand are some basic fertility lab results. But when it comes to being balanced and optimized, especially in menopause, we just. Conventional medicine has failed. So we have to look to functional medicine and anti aging medicine. And they have actually done the studies Those lab levels are there. And so if you go to your conventional gynecologist and they say, oh, there's no point in testing hormones. We don't know what that means. Or they tell you you look fine because you're in that range of like three to 300, you know, that crazy huge range. Those are lies. That is just not the truth. We have figured out how to test, how to optimize. You're just asking the wrong person.

Okay, So I want to dive into this. And I. And I have. So to me, if you already are in active menopause, testing is. Is easy because you can see exactly what's lacking, what you need to tweak. What about perimenopause? Because, like, for instance, my own example is I started ovulating while I was menstruating. Like, it was like, it got crazy. Like, I'd have a period every two, so my hormone levels were all over the place. So how does one test? And should they be testing during the perimenopausal stage? And is there a right time to do that?

Yeah, so perimenopause is a little bit tricky. It's kind of a roller coaster ride. And the most important part for women to understand is that perimenopause has really gotten worse over the past couple decades for a few reasons. Like, when I went through medical school, I was taught that perimenopause was like a year two before you stopped having periods. You might have a couple hot flashes and mood swings, but you stop having your period and then you're good. And really, that was the extent of it. And now we're seeing women struggling with period issues and mood swings and all of these perimenopausal type symptoms 5, 10, 15 years before they stop having periods. And what it really is, our hormone imbalances, we have jacked up our estrogen levels and tanked our progesterone levels from the lives that we lead. So there's a couple big things. Drinking too much alcohol, that diverts our liver's ability to metabolize our estrogen. And so it feeds into this estrogen dominance picture, which can cause heavy periods and breast tenderness and irritability. Our crazy, stressful lives that our grandmas never led. Like, you know, being a Boss entrepreneur at 50, like, you're doing all these amazing things that comes with a lot of cortisol production, a lot of stress production, and that will drop your progesterone level. And so then we see this picture of too high of estrogen, too low of progesterone. And it goes on for a long time. And those are the patterns that cause this roller coaster of symptoms. And so it's not easy to just intervene with a pill, you know, to. To fix you, because really, it's driven by our lifestyle choices that we make every day. I know, like, this is your jam. Like, you have to move your body, you have to manage your stress, you have to eat clean and get those toxins out of your cosmetics and all these other things, because literally they're driving hormone imbalances. And so if you could get a hold of all of those pieces of the puzzle that are shifting things, it's going to be a lot easier to manage this perimenopausal roller coaster. And what I see most often is women first need progesterone because progesterone is made after we ovulate each month. And if we don't ovulate, which happens just with aging, we run out of eggs over time, especially after 40, or if we live a stressful life, we don't make enough progesterone so that we're in this estrogen dominant state. And. And then we start to have drops in our estrogen, and so we'll have a spike, and then we'll have a drop, and we'll have a spike, and we'll have a drop. And so getting at least your progesterone level back up helps those heights and drops not feel so crazy when it comes to estrogen. So progesterone can be really helpful going into that roller coaster transition.

So I have a question about progesterone. Two things. So, one, it's interesting that you said progesterone should typically be first, because I find a lot of people are prescribed testosterone first. And then I've heard the story over and over again. This happened to me where that was converting to estradiol, so it was creating a bigger problem. So I have a question about that. Like, why did doctors go to testosterone first? And then my other question is on progesterone, because I've heard about the importance of cycling it, but how do you cycle it if your period's all over the place?

Yeah, that's a great question. So depending on what age you are and what your goals are, some women don't even cycle the progesterone. Some women take it every night. And it's just enough to keep that estrogen in check. If you really want to cycle it, what you can do is a lower dose the first half of your cycle, say 12 to 14 days. A higher dose. The second half or, or none. The first half higher. The second half. Part of it is how are you sleeping? How is your anxiety? Because progesterone is our natural antianxiety hormone. It keeps us calm, it helps us sleep and keeps us balanced. So if your adrenals are so out of whack that you're not sleeping at night and you really need that progesterone every night, we'll talk about doing it every day. If it's really. I just need to get this period back on track to keep this estrogen in check and then we'll cycle it and really get that balanced out. And you need a provider who understands where, where and how to do that.

I personally take it every night and I, and I love what it's done.

So do I. And it's been a game changer. Right.

Like you said, it's amazing. So, okay, talk to me about the testosterone thing because that I'll say with me, that was the first bioidentical that I did, a low level testosterone and I couldn't believe that it created. It was, I didn't understand this. Now I do. It was converting to estradiol and I've heard countless people tell me that same thing. So what's that thought process there on why doctors are typically starting with testosterone?

Well, it's definitely a fad that's going on right now. It's, it's in favor to like really support testosterone levels in women to keep you from gaining excess weight, keep your muscle mass strong and lean. Testosterone helps with brain function and drive, just like getting you out of bed and feeling motivated to do something. But you're absolutely correct that it can be aromatized into an estrogen, especially if you have more fat cells. And so you have to be careful doing testosterone replacement because I see all kinds of results on women. And mind you, like, I've seen thousands of women, I check their labs, I do this all of the time. And I have seen women who religiously will do high dose of testosterone cream and their numbers won't budge. And I've seen women do small amounts of testosterone cream and drive their numbers up into the hundreds. So literally we're all so unique in how we.

I'm that sexist and metabolized like a tiny amount. My doctor was shocked. She's like, I, this is like crazy. I have to be, I can't take it every day. It has to be a very sporadic thing throughout the week and very small dose.

Yeah. And people who have Gilbert syndrome, maybe you have that where they don't glucuronidate their bilirubin in their liver. That shows up as like elevated bilirubin their entire life. There's no other real reason. It's not really symptomatic issue. People don't get concerned. But I see it a lot of times where women cannot metabolize their testosterone because it uses that same glucuronidation pathway as the Gilbert's does with the bilirubin. And so I would caution, like if you know you have that, just do the testosterone slowly and make sure you actually need it. Because there are, there is this trend of practitioners who want to really get your levels up there to like back when you were 20 or 25. I don't necessarily think that we need that to have the benefits of anti aging and slowing the disease process and feeling like ourselves. I don't think we need to have those high levels of. But that is a trend. Right now there's a community of practitioners who, they want your numbers like way up there. And so it sounds like that might be what you're seeing. And I just, I see women struggle with that. They get acne around their chin, they get hair on their chin, they get hair loss on their head from too much testosterone. You don't want all of that?

No. Okay, so talk to me about when you should test. I have so many questions for you, but I'm going to start. I don't, I want to make sure I'm not skipping these. So when should you test? Because I know if you're on a regular cycle, you're still on a 28 day cycle. A lot of doctors will recommend, hey, on day 21 is when you should test so we can get consistent levels. But what if you're all over the place or like, and I'm talking perimenopause right now, like you're getting your period every 10 days or you're skipping two months. Like how do you know when to test and to actually get a read on what you should be trying to.

So if you're having a regular cycle 26 to 30 some days, that's typically telling us that you're still ovulating. It might not be consistently every month, but you're probably ovulating. You're probably making enough progesterone to keep that lining intact in the uterus. Because this is what happens. Estrogen grows the lining in the uterus, progesterone keeps it stable until they both drop and then that Lining sheds, and that's what you bleed for a period. So if you don't have enough progesterone to stabilize that lining for that two weeks after ovulation, you get this breakthrough bleeding, all this spotting, this early period, period in three weeks instead of four, that's a good sign that you don't have enough progesterone to manage what estrogen grew. So if you are having like no periods, light periods, you're probably not even growing, aligning because you don't have enough estrogen. And so that's where it takes the practitioner understanding what's happening at the physiologic level. Like, how is this affecting the lining? And then we accordingly, like, decide this is what's going on with your hormones. So if it's a regular, it's a sporadic, I guarantee your progesterone is going to be low. We don't have to try and check your levels. Days 19 to 22, where progesterone peaks because it's not going to peak.

Got it.

And does that make sense?

Yeah. That timing. Now, what if it's the opposite? Like, what if you're getting a period every 10 days, every, like, what's happening there? Because that's another thing that happens in perimenopause.

So it could be two things. It could be too much estrogen growing that lining and no progesterone to keep it stable, or it could actually be that your estrogen has dropped and now the lining is so thin that the arteries are just continuing to be exposed and bleed. So that lining in the uterus has so much blood supply, like thousands of little tiny arteries, and if you don't have enough lining, it's too thin. Those arteries are just exposed and they bleed and they bleed and they bleed. And that looks like a lot of bright red bleeding. It'll go on. Like, someone will say, oh, my God, I've been bleeding for three weeks.

Wow.

That's often an indication that your estrogen dropped and you're no longer growing that lining.

Okay.

But we don't like to guess, we like to test. And so get those levels. If you need, get an ultrasound, it can actually measure the thickness of the lining. Because if you have a thin lining and low estrogen. Yeah, you probably need estrogen replacement. If you have a thick lining and your estrogen levels are high or normal, you need progesterone.

Okay. I'm about to ask you about just the different myths around safety of stuff, but I want to ask just. I'm think as you're speaking about this, what happened to me. And maybe this is common, maybe this is not common with mine. I would skip a few months, like no, no cycle. And then I would have the two months in a row I'd ovulate, like double ovulate. So I would have like every. Is it, what is that when you're, Is it your ovaries given its last hoorah? Like what's happening when that's happening?

Exactly. So that communication that I was talking about between your brain and ovaries as it's no longer functioning like a well oiled machine, as your ovary stops producing the right amount of estrogen, your brain starts yelling at your ovaries, make more estrogen. And that looks like an, an FSH level that's getting higher and higher. It's louder and louder because it's yelling at your ovaries. And so your ovaries will be like, oh my God, okay. And it'll shut, shoot out some estrogen, but not enough to sustain it. And so the brain is continuing to yell the ovaries like squeezing that last little bit of juice out of the rag, you know, and giving you all it has. Like literally. That's a perfect analogy of what happens until it just finally is like, I'm done. Yes, I can't do this anymore.

That's what I innately was thinking. If that's fine. Yeah, I was like, because why it was like skipped a few months. Then I'm like, okay, now it's having a party. Like what's. I'm like, it's like telling me it's my body saying like let's go, let's, let's, let's get as much as we can out. Okay, let's talk about, I want to talk about the safety because it's so interesting to me. Like I'm on bioidentical hormones. I think they are life changing for me for so many reasons. The biggest problem I was having was hot flashes. Like that was driving me crazy. And I was having three, four or five an hour. Like it was in the middle of the night the whole thing. So. And I tried all the supplements. What really worked for me was adding the bio that really balancing the bioidentical and very low doses. It didn't take a lot of to make a difference for me. But when I tell people that or when someone asks, it's almost like they go to this, oh, that's dangerous, that causes cancer or you know, that's cheating. Like what is that that people think that because this is not our mother's hormones. This is not the synthetic stuff that was 30 years ago. This is different.

Yeah. This is so important. I really want women to know that they have a choice in how they are transitioning into the second half of their life. Because we are living almost half as long as we, you know, are in our reproductive state, in this menopausal state. So in the year 1900, the average lifespan for a woman was 49. We died. We didn't have to go through living in a menopausal state. Now, average age is 83. So you have at least 30 good years. Let's hope where you have to live without your hormones. And I'm sorry, but your hormones really define who you are. Ask anyone who's gone through menopause. And this was so shockingly clear to me the day that I just laid on the couch and wouldn't talk to my husband. I wanted to give up my business, my friends, my husband. I didn't want to be married. Like, he disgusted me. And I. He goes, what is wrong with you? It took me four days to figure it out, and I'm the expert, but I finally went, oh, my God, I think I need estrogen. And holy cow, did I. As soon as I put a patch on, and like you said, it was a low dose. It was like 0.0375, which is almost the lowest. I had a little spark of who I was. I put on two patches, and within two days, I. I was off the couch apologizing to my husband, going, I need to, like, clean up this mess. I just, like, ignored my business for how many days, and, like, I had to get back to who I was. And it was because I was lacking my hormone. That really defines who we are. And, you know, we see it in our skin changes in our fat distribution and so many things, but when we can't even function, we can't sleep, and we don't feel like ourselves. Like, I'm sorry, but I believe I have the right to take some hormones and to feel like myself again. And we have to just understand that we are not shifting into menopause the way our great grandmothers did. We're not sitting on the porch and knitting. We are out there pumping iron, running businesses, having families, taking kids everywhere. Like, we have shit to do. Yeah, we need to be able to do it. So you absolutely have the right. And the biggest thing is to do it safely, like you said. So there's a not so safe way to take hormones, and then there's a safe way. And so you need to find a provider who understands how to test and give you the appropriate replacement levels to be in a, in a range that prevents aging, prevents disease processes from begetting, but doesn't like, jack you up to a 20 year old. Because I promise you, as soon as you go into a hormone a menopausal state with low estrogen and progesterone and testosterone, aging sets in. Oh yeah, bone loss, sense in, cardiovascular disease sets in. Dementia sets in. Women are twice as likely to suffer from dementia at decades younger than men because of this estrogen issue alone. As soon as you go through menopause, your risk of heart attack and heart disease like doubles. It's crazy because we have estrogen receptors in our entire body. So all the little arteries that are pumping our blood, they have estrogen receptors that keep them elastic and mobile so that they can squeeze and pump our blood. So as soon as your estrogen drops, your blood pressure goes up because those arteries are stiff and they can't pump the blood as easily. Your cholesterol numbers change, your insulin resistance starts to develop because the cells are no longer sensitive to insulin without that estrogen protecting them. There's so many benefits. And when all before 2002, when this stupid study came out that we can talk about, it was standard for women to go on hormone replacement therapy. When I was in my first year of medical school, the cardiology class, the respiratory class, we do all these systems, they talked about the benefits of estrogen. And then 2002, this crazy study came out. The media just blasted it everywhere. Estrogen causes breast cancer. Estrogen causes blood clot and stroke. Stroke. And it took almost 20 years for the researchers of that study to come forward with their tail between their legs and say we were biased. We leaked those results early because we wanted them to show a certain result. And those results were actually not correct.

Wow. So meanwhile this damage has been done.

Meanwhile the damage has been done. The doctors all freaked out. I'm going to get sued. I got to take everybody off my hormones. Millions of women were miserable and are still suffering and wanting to go back on them when there was so many issues with that study, Honey, it was like the average age woman was 63. More than half were obese and smokers and already had cardiovascular disease. There wasn't actually an increase in breast cancer in the estrogen group. It was the estrogen and progestin group. So synthetic progestins, which I don't recommend. That was the arm of the study that saw One extra case per, like, a thousand. It was the tiniest little increment. It wasn't even statistically significant. So here we are, cleaning this mess up for the past two decades, and what we've really learned is that if you use bioidenticals, you don't have the same risk of blood clot and stroke as you did with those synthetic hormones in that study. You get all of the benefits that the hundreds of studies before that study and since that study have shown, they continue to show this benefit of heart, bones, brain, skin, vagina, bladder, all of it. So you need to use bioidenticals. And even if you use synthetic, the risk is only there for women who are more than seven to 10 years out. And it's really about blood clot and stroke. It's not cancer.

Interesting. Talk to me about the difference between synthetic and bioidentical.

Oh, I love this. Okay, so this is a bunch of semantics, because it's all in the wording. It's very confusing. Synthetic technically means that the chemical is made in a lab and bottled up as a pill or a patch or whatever. Bioidentical, the way we use the term, means that it's chemically the same as the chemical your body makes. But bioidentical hormones are usually synthetic because they're made in a lab. So just to confuse everybody a little bit more, but in the general, I would say space, usually synthetic means conjugated equine estrogen from horse urine or synthetic progestins, whereas bioidentical is referring to estradiol and progesterone. So that's really what most people mean when they use those words, even though they're not accurate representation.

So wait, now I just learned something. So wait, so this is horse earned. Did I hear you correctly?

The synthetic estrogen? Yes, that was in the trial that showed the risk of blood clots.

Got it.

They make it from horse here. And they take the pregnant horses, they take that hormone, and they give it to us.

And what's the bioidentical made from?

That is made from plants. That's made from yams. And yams.

Okay. And yams do all the hormones. I've always. I'm so curious, like, how is that even a thing? Like, how do make hormones?

So the yams don't make the hormones. They're still made in the lab, but chemically, the structure, the molecular structure is the same estradiol that our body makes. Got it. So does that make sense?

I think so. I think I'm catching On so, but, so just eating yams is not going to change your level. This is actually, they're using it as basically the, the, the thing to change to, to change.

Yeah, you can get supplements and things. They're called phytoestrogens. We see it in. Well, we've tried to really show that there's benefit of it and the studies have been mixed. So I think for a small percentage of women using that plant based phytoestrogen supplementation can be of benefit. But for the majority of women, they require the actual prescription estradiol and progesterone.

Now if someone has cancer in their family or they've had it themselves, does that change you recommending hormones?

So we need to have a conversation really. The genetic component of say breast cancer is very small. It's like 1 to 2%. And so it really is your lifestyle that drives cancer. And there's really awesome testing you can do. It's called Dutch testing, it's dried urine testing. ZRT is another company. They'll do with saliva, but with urine you can see how your hormones are being metabolized. And so you can see is your estrogen going down a bad pathway called 4 hydroxy estrone. This pathway causes something called a quinone reaction. It damages our cells, it damages the DNA and that's what can cause cells to go rogue and grow as cancer. If you put that 4 hydroxy estrone in with a lot of cortisol and stress, a lot of inflammation from a poor gut and poor gut health, it's like the perfect storm for those cells to go rogue and turn into cancerous cells. So it's never one thing, it's never overnight. It's a long process. And I'm more concerned honestly about giving women birth control pills for 20 or 30 years straight. That is where we should put some of our focus. Because those are synthetic hormones, those are synthetic progestins that was associated and implicated in that study in 2002. But we don't use common sense. We say, oh you are fine, you can take that for 30 years. But God, as soon as you hit 50, you better come off those. Those are dangerous.

Right?

Like that's insanity. What did you do for 30 years to your body?

And that's what's so interesting. I think about my age group. So I, I'm, I'm 51 and in my age group, so many of us, because we didn't know and we weren't in this field or whatever we were on, I was, I was on birth control Pills from the time I was like 16 years old to regulate my period for 20 years, like literally 20 years, and then came off those had my daughter. And it's just funny that now I'm doing bioidentical and people automatically go to, that's bad. But it wasn't bad to be on synthetic birth.

That's what I'm talking about. That's insanity to me. Like, there's no common sense. And I promise that will never get studied because, you know, we all want that freedom to control our fertility. Heck, that's how I got through medical school, right? I didn't have a second baby. But I want you to know what you're signing up for. You are potentially signing up for, for something that is driving hormone dysregulation and cancer and leaky gut and hormone, mineral, vitamin imbalances, all of that. So use it for birth control. And when you don't need it anymore, get off of it and be informed.

Because I wouldn't even be on it personally with what I know. I wouldn't take it now for birth control. But that's what I did. Because that's. We didn't know any better, right?

We didn't know any better. And I really want women to understand what they're signing up for because there are safer options. Options, yes.

Okay, so this is so. Okay, another little kind of one off question. But how important is it to do something like taking DIM or something when you are taking estrogen to make sure it's processed right? Is that important? And then why would you not do like a DHEA instead of testosterone if that helps produce it?

Those are great questions. So DIM actually goes back to this estrogen metabolism that I was talking about that you can see on a Dutch test. So it will show you the three different pathways that your estrogen can potentially go down. And DIM will help that estrogen go to the liver to be metabolized, meaning be deactivated. Your body's done using it. It needs to get a garbage tag put on it and sent to the urine or stool for removal. But if our liver is busy doing other things like metabolizing estrogen or all the garbage food that we're eating all the time, all these carbohydrates, it won't metabolize our estrogen. So DIM helps push it to the liver to be metabolized. But DIM can also lower your overall levels of estrogen. So you do have to be careful during this roller coaster transition, because I've seen women who have this estrogen Dominance picture, their levels are really high. As soon as they start the dim, they crash. And their estrogen.

That's when my hot flashes started, by the way. Before I was taking estrogen, when I was, when the testosterone was converting to estradiol, I was taking dim for that. And that's when the hot flashes started. Yes, but now I take dim with the estrogen.

Yeah. And some people really need to do that long term because depending on your genetics, you might not be a great metabolizer or maybe you don't get enough B vitamins in your diet and you don't methylate. Well, there's a lot of different factors. And so dim actually works. It's a big deal. So you shouldn't just like take it willy nilly. If you do, it's like an experiment, like you realized, like you really can shift just by this, taking this supplement. But in general, it's helpful to help your liver metabolize it. That four hydroxy pathway I was talking about that we don't like too much of, that can damage the cells and the DNA. You want to block that pathway. Not only do you want to divert it away from that pathway with dim, but you want to block that pathway from doing this reaction. And that is with antioxidants. Glutathione is our major antioxidant. We make it in our body. It goes around, it cleans house, it gets rid of all those broken cells and broken DNA so they can't transform into cancer. But if you don't eat brightly colored vegetables and fruits and make enough antioxidants, you can't block that pathway. So some women will take glutathione, they'll get glutathione shots, and that can really make a difference.

Yeah. Which is another. This is a whole other topic, but this is why, as someone who with a nutrition background and with a book called Aging in Reverse, I am not a fan of carnivore or strict keto. Because you're taking out all those fruits and vegetables.

Yes. Women need those brightly colored vegetables. Yes.

Okay, so talk about two other supplements. I want to ask about dhea, because I know that helps increase testosterone and then also maca, which helps regulate hormones. I wanted to hear your opinion on those.

So maca is fabulous. I rarely hear of anyone not tolerating it well or not benefiting from it. I think most women do great with it.

Can you take it with synthetic hormones? I mean, I'm sorry, with bioidentical hormones. Can you take MACA with it?

You can you can. A lot of women who don't do hormones will, will do MACA and here's the kicker. So our adrenal glands, I like to call them your backup ovaries because they make DHEA our anti aging hormone. And as you mentioned, that gets converted into testosterone and estrogen. And so as soon as our ovaries stop making the hormones we need, our body says, hey, adrenal glands, it's time to kick in and support us and get us through. And so you need to make that DHEA so it can convert into your sex hormones. But if your adrenals are tanked when you go into menopause, you're screwed. Like, that's the women who really suffer is because their DHEA levels are low, their cortisols are low or too high because you need DHEA for that conversion. And so I recommend everybody get their DHEA s level checked. And you want that in triple digits. Like, I see women regularly who are like 20, 40, 60, and it's miserable. You don't want to get out of bed, you don't want to function, you have no drive. It's a struggle to get through the day. If you take a little bit of DHEA and bring those levels up like 150, 200, you're going to be functioning again. It's incredible. It's fabulous. And like you said, you might not need testosterone supplementation because some of it gets converted. So that's why testing is so important to actually just look at all of these levels because we are all individual and there is no one size fits all.

Okay, another question here. This is another common one that I hear from midlife women all the time. And I'm wondering if this is a cortisol related to cortisol. 3am Wake up and 3pm Crash.

Yes. Oh my gosh.

So, and why 3? Why is it 3am and 3pm why isn't it 2 and 2?

We have little clocks in our bodies and we have one main clock in our brain. And these are called our circadian rhythms. And they go along with the sun and the moon and the tides and all the other energy in the universe. So it's really beyond our control. Yet we try to control it, right? We try to go to bed at 1am and get up at 4am or do all this crazy stuff. And when our adrenal glands aren't producing cortisol in the correct 24 hour pattern that they're supposed to, it looks like crazy town. So what happens? This is really common. So women are like really kicking butt in life and doing amazing things. Having the family, having the career. They get into their 40s and they're just like, go, go, go, non stop dusting until dawn. And so they produce cortisol all day long. When really you're supposed to just have this beautiful cortisol awakening response in the morning. It looks like a little spike, your natural cup of coffee and then it kind of comes down the rest of the day. But not us, us Women in our 40s, we just leave that cortisol up, up, up all day long and then we finally get to a point after three to five years where it comes crashing down and we just don't make that cortisol anymore. And some women even point where they flatline and they don't have that cortisol awakening response in the morning. That's a sign that you've lost your resiliency. You no longer can respond to stress appropriately. At a physiological level, like mentally, emotionally, you might be able to handle it, but that doesn't mean your physiology is handling it. And that's where women don't understand. So if you're going into this transition flatlined, like your adrenals are no longer responding, there's just no way you're going to even make it through menopause smoothly. You're going to end up losing your job or losing your spouse or, you know, being estranged from your kid. Like these are life changing events from these hormone imbalances. But what you're talking about, that's usually like the second stage of this dysfunction, like the cortisol pattern is a little bit flipped, where all of a sudden you're making cortisol at night instead of in the morning, and then it's low in the morning and high at night. And so it's about working with those circadian rhythms, getting up with the sun, getting the sun to your retinas, stimulating that cortisol awakening response, exercising earlier in the day. So you're not stimulating cortisol at night, getting away from the blue lights in the evening, doing meditation and yoga and things to really calm that cortisol production and get that pattern back where it belongs. And that will improve a ton. But there is one other piece to that 3am Wake up. And that's blood sugar. I see this a ton. Especially in the past three years with, we're just drinking every night, two cocktails, two or three glasses of wine. As soon as we're done metabolizing that alcohol, our blood sugar drops and we wake up. We, we're sweating, we're miserable, we're jittery, we can't fall back asleep. And that's a blood sugar dysregulation. You pair that with some hormone imbalance, it feels terrible. So that's another piece you got to.

Get in check for the afternoon piece. If someone is dialing this in and figuring this out, but they're having that 3pm crash, because that's a very common thing that usually can bounce back up, what do you advise they do during that 3pm time? Should they be trying to rest right then? Should they be adding that caffeine to stimulate what's, what's the good and the bad to do at that time?

So definitely don't do the caffeine because for a lot of us, that will keep us up the rest of the night. You want to support your adrenal glands. A lot of us at that point need some adrenal adaptogens which help support our adrenals to make the cortisol that we need, like ashwagandha and rhodiola and things like that, or glandulars, if you're flatlined. But you want, as soon as you're feeling that you want to get outside, you want to get fresh air, you want to get sunlight, you want to get physical movement, not cardio. I don't want you to try and go out and run because that's going to tank your adrenals worse. But I want you to physically get your blood and lymphatic system pumping and move the toxins out of your body, get the oxygen and stimulate your adrenal glands to wake up. Yeah.

I got to tell you that I. I have forever, my whole life I've had like the little like three o' clock crash. And what I learned, and it only lasts for about an hour, but what I learned personally, and it's kind of aligned with what you're saying, is the stimulants were not working. So if I did that, it just made me feel worse. Forcing myself to focus wasn't working. And also forcing myself to rest right then wasn't working. But doing exactly what you just said, I started planning my walk during that time most days. And even if I don't feel like going, it's. It's like within 15 minutes, I feel like a new person.

Yeah. Isn't it amazing? And it matters what you ate for lunch. So if you had a carb heavy lunch, you're definitely going to be out for the next couple hours. And this is a huge thing, like I really am a proponent of intermittent fasting and low lower carb lifestyle for menopause. Those carbs.

But, but, but, and I think you are aligned with this car. We're looking at different types of carbs because vegetables and fruits are one thing.

Yes.

But you're talking the starchy carbs.

I don't want you eating out of boxes and bags. I don't want you eating fast food. I don't want you eating subway sandwiches and all these big fat breads and things. Like, literally, you cannot eat bags of ramen and stuff like you did in your 20s. You cannot eat like that in menopause.

No. And I'm a huge fan. Like, you have intermittent fasting or just even longer gaps between meals. I think so many women our age, we were trained in our 20s and 30s. I know you remember this, that you have to eat every two hours or you're going to eat your muscle. And it was the opposite of intermittent fasting. And all we're doing is secreting insulin all day long now.

Exactly. So we have to stop feeding our mouths all day long. Like I personally do, 16, 8 or 18, 6. And then I'll have dinner to dinner every week or two. And that is where the magic lies. Like, that's how I keep the weight off. That's how I keep my brain functioning. I get everything done that I want. You know, people are always like, how do you write books and have supplement lines and do these programs and see patients? Because I don't eat garbage and I.

Don'T eat all the time. I'm with you. It's, it's. And you know, it's. Before I even really dove into intermittent fasting, I didn't realize that's what I was doing. I had like naturally gravitated towards these longer gaps and but it is funny how we did learn in the 80s and 90s, you know, we were told to eat every two hours and it's just the worst thing that we could be doing with this. Yeah.

And not to eat any fat.

Oh, yeah.

Oh my gosh, it's terrible.

Yeah. I remember eating bags of fat free gummy bears when I was 20, thinking, oh, but they're fat free. The pasta. Fat free pasta, you know.

Oh my God.

Oh, it's so funny. Well, this was so helpful. I, I, gosh, I might have to have you again eventually because this is, I have so many more questions. But this is great. Where, first of all, how can someone work with you? Where should they find you? Where can they learn more and where's the best place to follow on social.

So yes, come work with my team. Dr. Tabitha.com. it's D, R, T A B A T, H, A, no eyes, all A's. If we do like these comprehensive programs, if you need to look at your gut and food sensitivities and adrenals and all of this because you know you've been like running on empty here for a while and you're hot mess like we got you. We do it all. We look at all the pieces and it's, it's so transformative. Or if you have been doing amazing but now your hormones are tanked and you just need some bioidentical replacement or thyroid hormone like we got you. That's what we do. And so I would love for anybody that needs that support to reach out. I'm licensed in over half the country so I can see women all over and then follow me at the gutsy gynecologist and listen to the gutsy gynecologist.

Show Natalie Jill on and her videos are great. You'll love following her on social media. That's how I found her.

Yes.

Thank you so much. This was fantastic.

Love it. I'll be happy to come back.