I am delighted to have my good friend and fan-favorite, Dr. Tabatha Barber, joining me again to share her wisdom on the podcast!
Dr. Tabatha is a triple board-certified OB/GYN specializing in menopause and functional medicine. She has a wonderful podcast called The Gutsy Gynecologist Show and is often referred to affectionately as the Gutsy Gynecologist. Dr. Tabatha was with me in two previous podcast episodes, 206 and 212 and both are in the top twenty downloaded podcasts in the last 18 months!
Many women suffer unnecessarily when going through perimenopause and menopause. Dr. Tabatha and I have an AMA (Ask Me Anything) episode today. We discuss weight gain related to perimenopause and menopause, issues with estrogen replacement therapy, how libido can be impacted by many different factors, how to address a partial hysterectomy and HRT, and bioidenticals versus synthetic hormones. We also get into lab work, skin reactions relative to perimenopause and menopause, emotional eating, leptin resistance, and many other topics.
I’m grateful for all the great questions and have no doubt this episode with Dr. Tabatha will be another fan-favorite!
IN THIS EPISODE YOU WILL LEARN:
Why do too much estrogen and too little estrogen both cause weight gain?
How fragrances and plastic contribute to the imbalance between estrogen and progesterone.
How changing to organic tampons and pads, or using a Diva cup, can be a game-changer for women.
Should women who have had a partial hysterectomy and are on HRT still check progesterone and testosterone levels and fast like a post-menopausal female?
Dr. Tabatha shares her thoughts on plain estradiol versus Biest and Triest.
Dr. Tabatha offers her recommendations for a healthy 48-year-old female with zero libido.
What can a 17-year-old with high testosterone do to get her testosterone level within the normal range?
Is there a biological or mindset issue at play if you never feel full and always want to eat, irrespective of how healthy or satisfying the foods you eat are?
The benefits of fasting.
What can we do to support our pelvic joints?
How do our hormones affect our skin?
“Joint pain is probably the most common menopausal symptom- and the most denied and ignored.”
- Dr. Tabatha Barber
Connect with Cynthia Thurlow
Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Dr. Tabatha Barber
Transcript:
Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
Today, I'm joined by my fan favorite and good friend, Dr. Tabatha Barber. She is a triple board-certified OB-GYN specializing in perimenopause, menopause, and functional medicine. She is often affectionately referred to as The Gutsy Gynecologist, and she has a wonderful podcast called The Gutsy Gynecologist Show. You can catch her on two previous podcast episodes 206 and 212, both of which rank in the top 20 downloaded podcasts in the past 18 months. I am so glad to have her back.
Today, we did an AMA style which is an Ask Me Anything. We spoke at length about weight gain related to perimenopause and menopause as well as the issues with estrogen replacement therapy and how in a low estradiol state, as well as in an estrogen-dominant state, weight loss resistance can be problematic, as well as xenoestrogens, the role of libido and how this can be impacted by many different reasons, how to address a partial hysterectomy and HRT bioidenticals versus synthetic hormones, skin reactions relative to menopause and perimenopause including histamine released mass cell degranulation and high estrogen, the impact of emotional eating and leptin resistance, as well as many other topics. Thank you so much for these great questions. I know this will be another fan favorite episode with Dr. Tabatha.
It's such an honor to reconnect with you, and to be able to share your wisdom and to serve as a resource. I know that the last time we connected, you were licensed in over 30 states. I'm sure you probably are licensed in even more now. What's the number now?
Dr. Tabatha Barber: [giggles] I'm not even exactly sure.
Cynthia Thurlow: [laughs]
Dr. Tabatha Barber: I did give up a couple that I haven't seen women in, I think, let me tell you, Maine in Iowa. But I am hoping to pick up California here in the next couple of weeks.
Cynthia Thurlow: Oh, I hope so.
Dr. Tabatha Barber: I'm bringing on a provider who's licensed in California, who has studied functional medicine in hormones. So, I'm really excited because women are just begging for help. They're searching, like you said, and their conventional doctors are not helping them at all. So, I'm really excited that I'm going to be opening up to California giving women the chance to feel good again.
Cynthia Thurlow: Yeah. It's interesting to me because I run a group program and obviously, I'm licensed in one state. So, when there are people who need or ready for hormone replacement therapy or just need someone in person, California has been a big void, unless people are in the LA, Orange County area. It's been really challenging to refer people out. And that, for me, has been a source of pain point for myself, but also my patients. So, I'm grateful that you'll have that connection to California. So, let's start with what I refer to affectionately as the big elephant in the room. This is a question from Michelle. She said, "I'm exploring the idea of hormone replacement therapy to help with menopause symptoms of hot flashes and weight gain. I've heard estrogen replacement helps with weight gain and that it causes weight gain," which is true.
Dr. Tabatha Barber: Oh, my gosh, that's a great question. They're both true.
[laughter]
Dr. Tabatha Barber: Too much estrogen causes weight gain, too little estrogen causes weight gain. So, that's why women are so confused. I, myself, I was very confused about that when I was just practicing standard OB-GYN, because we're trained to think that the weight gain happens only from menopause from that drop in estrogen. But now we understand that estrogen dominance, you do gain weight, because estrogen is a growth hormone. It is telling your body to get ready to carry a pregnancy. So, it puts the fat around your hips, it puts the fat around your waist. It's a growth hormone. It makes your breasts bigger. So, too much or too little is not good. You want to figure out that sweet spot.
Cynthia Thurlow: Yeah. I think for a lot of individuals, I hear women saying things like, "I'm fearful to take hormones because I don't want to gain more weight."
Dr. Tabatha Barber: Right.
Cynthia Thurlow: I do know that there was this study that came out in late 2022 and we can certainly link it, and it speaks specifically to this rise in follicular stimulating hormone. So, FSH, which is a routine lab and the drop in estrogen. So, drop in estradiol, predominant form of estrogen heading into the end of our cycling years, that in and of itself along with these changes in skeletal muscle are oftentimes what drive the challenges with weight loss resistance. So, you can be low in estrogen in your body, but also be estrogen dominant given the fact that we're just exposed to estrogen-mimicking chemicals, all these plastics. I always say this toxin bucket that we're exposed to throughout our lifetime can be hugely problematic in perimenopause and into menopause. I think that can sometimes be a shock. I think people are like, "Well, I'm doing all the right things. How could I possibly be estrogen dominant?" Has it been your clinical experience as well that it's the exposure to these estrogen-mimicking chemicals that can offset that receptor and actually make the weight loss resistance piece? It can be another contributor, but can actually exacerbate it.
Dr. Tabatha Barber: Yeah. So, I would say there're a couple of things. Those xenoestrogens is what we usually refer to them as, because they're binding to estrogen receptors and sending a warped signal that is similar to estrogen, grow, grow, grow. Women are getting exposed to these in their scented candles, in their fragrances that they're wearing and burning in their houses. And so much of it is coming from the plastics in our food. We're heating our food in plastic like never before. Or, when you get takeout, it's always in plastic. So, that hot food is causing all of that plastic chemical to seep into your food and then you're ingesting it or you're drinking it. And so, that really is contributing to this imbalance of estrogen and progesterone, where estrogen is dominating. Naturally our progesterone levels start to decline because we aren't ovulating consistently every month. We're running out of eggs essentially. And so, then you get more imbalanced because of that.
So, you get this combination and it ends up as a perfect storm of just feeling irritable, gaining weight, having headaches, more PMS symptoms, breast tenderness, the whole work. So, it's not a fun time, but it's definitely something that you can tackle and minimize. Clean up your environment, clean up your diet, get all of those plastics, those fragrances, those chemicals out of your life as much as you can, and that's going to have a huge impact. I'll tell you, just going organic with tampons, pads, or a DivaCup, that can be a game changer for women. All of a sudden, their periods aren't as painful and heavy because they're not getting all that toxic burden that they're absorbing right through their vagina. Our vagina is like a sponge. It's very absorbent. It will soak up whatever's in there. And so, if you have cheap tampons full of chemicals it's really toxic to your body. So, those are just a few quick ways that you can turn things around for sure.
Cynthia Thurlow: Well, how many of us thought nothing of buying the Tampax brand tampons our entire lifetime? Only in the last, I think there are a lot of startups, younger women who are speaking up and speaking out against the kind of conventional chemicals that we're exposed to. And to your point, the vagina is a very vascular environment. It's much like our mucosa in our mouths, very, very vascular. There's a lot of medications that we prescribe to be taken right along the buccal mucosa. And so, if you're listening, you're still getting a menstrual cycle, know that there are other options. You are worth the additional $4 or $5 to have products that are going to better. I have a lot of girlfriends that love the DivaCups. It requires a little bit of trial and error, obviously.
Dr. Tabatha Barber: Right.
Cynthia Thurlow: Probably, don't want to try that on a day you're traveling, [Tabatha laughs] but I think that can be a really nice option, and probably, a bit more environmentally friendly than tampons and pads as well.
Dr. Tabatha Barber: Yeah, exactly. I do want to mention that topic of FSH, that study that you alluded to, we are now understanding that maybe we don't want to do hormone replacement just enough to minimize our symptoms. Maybe we do want to bring that FSH level down because that does have an impact on weight. We're not only seeing it in the research, but clinically, I'm seeing it, my colleagues are seeing it. If you are on estrogen replacement therapy, you want to get that FSH level down a little bit, and that will help with your weight.
Cynthia Thurlow: Okay. So, this is going to be one of the questions that will come from you saying that. I was always taught that an FSH greater than 40, you're very close, if not knocking on menopause's door. I've read some research recently that's suggesting that threshold is even lower, like 25, but I have many menopausal women, when I'm looking at their labs, their FSH is 90, 100, 80. And so, what you're suggesting is having a discussion to help optimize. So, we'll use that FSH, not as a throwaway lab in menopause, but as a way to determine that we're providing more hormonal therapy, more hormonal support to get that lowered.
Dr. Tabatha Barber: Right. I'm not talking down to 20 or 30, but maybe 40, maybe 50 or 60 if you're up in the 100s. It is a dynamic level, just like the other hormones, because it's a brain hormone, it's responding, it's getting that feedback mechanism from the hormones you're taking or making, and it's responding by making more or less of itself. And so, it does fluctuate. It's not a one and done. It's not a light switch. It's a dimmer. It slides up and down. It doesn't turn on and off. And so, it is worth looking at that in a little bit more context than we have in the past. Conventionally, we're like, "Yep, we check it. It's high. You're in menopause. You're done." What we've come to realize is, it's not a light switch. Once it's high, it stays high. I've seen premature ovarian failure reverse. I've seen FSH of 180 go down to 20. It's incredible what our bodies are capable of when we really support the systems and get them functioning again.
Cynthia Thurlow: That's really helpful. Even listeners, I learned so much from Dr. Tabatha myself. Even as a clinician, I'm like, "Okay, FSH is a dimmer. It is not an on off light switch." So, let's pivot and talk about a common question that we receive. Women who've had early partial hysterectomies wondering where in the world they are, because they're no longer getting a menstrual cycle. This woman in particular, Paula was saying, "I'm 44. I still have my ovaries. I am on HRT," Bravo to your GYN for taking care of you, "and it's working well. Should I still check progesterone and testosterone levels? Should I fast like I'm a post-menopausal female." I think there's a lot of ambiguity about how to manage the post partial hysterectomy female in terms of how do they take care of themselves, should we be monitoring other hormone levels? What are your thoughts on this particular type of patient in generalities?
Dr. Tabatha Barber: Well, there are a few certain things they have to think about. Conventional gynecologists still believe that they only need to give estrogen to a hysterectomy patient, because the belief is that progesterone is only in your body to protect your uterus from unopposed estrogen. It is not well recognized in the conventional space that progesterone has benefits for your entire body. I just want to quickly mention. It's because we use so many synthetic progestins as conventional OB-GYNs that we don't understand the benefits of progesterone other than the uterus. And so, it just gets disregarded. So, I have a feeling, even though she says she's on HRT, I have a feeling she's only on estrogen replacement therapy. So, that can be part of her issue right there is, again, you are imbalanced. You're out of balance. You need some progesterone.
I would say progesterone is our calming natural antianxiety hormone. It helps us sleep. It keeps estrogen in check because you don't only have estrogen receptors in your uterus. You have them through your entire body, in your brain, in your skin, in your bones, in your heart, your cardiovascular system. And so, it is imperative to keep the estrogen and progesterone together, because that's what feels good, that's what feels right for our bodies. And so, we can get women who've had hysterectomies, who are on estrogen replacement therapy, who still struggle with their weight and their sleep and their moods and all these other things, because they don't have a complete hormone replacement therapy.
Then there's the argument of what about testosterone? Because testosterone is made in our ovaries and a little bit in our adrenal glands. And so, luckily, we make a little more testosterone from our adrenal glands. So, sometimes, women don't have that drop, but sometimes they do. It depends on how healthy your adrenal glands are going into menopause. I like to say adrenal glands are the backup ovaries. As soon as the ovaries fail, we're looking to the adrenal glands, "Hey, help us out. Give us testosterone and estrogen." And so, if you go into menopause with adrenal dysfunction, it's going to be a rough ride. So, it is important to get those levels checked, because I've seen women who think they're on the right hormone replacement therapy, but no one's ever checked their testosterone. They have like zero testosterone. They can't lose weight. They can't build muscle in the gym. Their brain struggles to function. We tend to think of testosterone only as sex drive and affecting our libido, but it's like overall drive for life. It affects our ability and our desire to want to get up in the morning and even function. So, that's a really key piece.
The other part of it is our adrenal hormone, DHEA. So, DHEA is our antiaging, keep us young and healthy hormone. It keeps cortisol, our stress hormone in check, kind of how progesterone keeps estrogen in check. We need DHEA. So, if you go into menopause with adrenal dysfunction and you're not making DHEA, you're really going to struggle because you need those balancing antiaging, keep you young and healthy hormones. So, I think getting that complete picture is really what's needed to understand what's going on in your body. What we're doing is we're just picking and choosing a lab here or there and we're not getting the full picture. So, we're getting a confused picture. We're guessing. That's literally how I was trained was you just go by symptoms. You base it clinically and you just guess. You give them the lowest dose and then you wait for their symptoms to go away and then you increase it if you absolutely need to. But there's no testing, it's all guessing, and we really need to get away from that mentality of practicing.
Cynthia Thurlow: I think it's so important to understand that there's differing opinions, but also understanding that it's more than just, are you having a lot of symptoms? For anyone that doesn't know this, there's a great book. I talk about The XX Brain, in particular, because it talks about progesterone and testosterone and estrogen receptors we have in our brains and understanding that we also have estrogen. All of these sex hormones have receptors diffusely throughout the body. It's not just in our reproductive organs as you appropriately stated. Fun fact, I'm taking a course through a forum right now and the physician was saying that, "25% of women actually maintain healthy testosterone levels in menopause." So, not every woman listening that's at that stage of life per se might need supplementation or might need medication. I am not one of them. I am one of those people that my testosterone levels have just continued to decline and that's more the norm than not.
Very good point about the fact that there are synthetic progestins, there are synthetic estrogens. What we want to have is bioidentical. We want progesterone, we want estradiol. There's Bi-Est and Tri-Est, we got a lot of questions about this. What are your thoughts and feelings? Obviously, you're not speaking to any one person. We're having general discussions. We're not giving medical advice. But what are your thoughts about plain estradiol versus Bi-Est and Tri-Est, which are these combinations of different types of estrogens?
Dr. Tabatha Barber: That's a great question. So, what we've been trained is that you want to give a combination of estradiol and estriol. When we first started understanding that we have three main estrogens, estradiol, estriol, and estrone, we were giving all three in the alternative space. I'm not even talking conventional. We just don't do this in conventional. [Cynthia laughs] But in alternative space, we would give Tri-Est. That was common back in 1980s and 1990s I would say. And then we realized, "Oh, estrone, hmm, maybe we don't want so much of that. We're seeing that it might be damaging to the DNA in the cells and maybe it's contributing to the cancer risk. Maybe that's the piece of that." And so, then Bi-Est got popular. We just did estradiol and estriol. And estriol is a much weaker form of estradiol. And so, it was felt to be safer because it's weaker. It's not going to stimulate cancer. So, that was really popular for a while.
Now more research is coming out and showing that estriol might actually be blocking the benefits of estradiol in menopausal women. We might be doing them a disservice by giving them this estriol, because in fact, our body makes estriol from estradiol and estrone. So, we don't necessarily need to give it. There's still a lot of gray area. I will tell you that doctors, and nurse practitioners, and PAs, we tend to practice how we trained. So, if you trained 40 years ago, you're probably practicing the same as you did until you retire. And that's just the truth for the majority of practitioners in the country.
It's not very many of us that are constantly learning and attempting to change how we practice and treat patients because it's scary, it's uncomfortable. You don't know what the outcome is going to be. But I will tell you that it is starting to trend more toward just estradiol for postmenopausal women for systemic therapy. When you're talking about vaginal health, it does appear that estriol is beneficial and really helpful for that skin tissue. So, I go back and forth. I typically use estradiol for anything systemic. Like, if we are trying to get rid of menopausal symptoms, protect the bones, protect the brain, any of that kind of stuff, I'm using estradiol. I will use estriol, if someone has had breast cancer and they're super nervous and they want to be conservative and they just want vaginal or bladder support. I would use estradiol vaginally or estriol. There's always a question of like, "Well, what kind of form should I use?" Every woman wants to know that before they come to see me, "What do you prescribe?"
Cynthia Thurlow: [laughs]
Dr. Tabatha Barber: I try to explain to women, "It's dependent on the individual. It's awesome that we have all of these options available." The patches, the cream, the sprays, the gels, the ring inserts, the troches, because not everybody absorbs things the same as the next person and not everybody tolerates it. Some people are allergic to glue adhesive and can't use patches. Like, there're hundred reasons why you need a different form. In general, the conventional space believes that anything going in the vagina doesn't really affect you beyond your vagina. So, [giggles] just know that. It's not really true. That stuff is absorbed.
I have women say someone's had breast cancer and their oncologist is okay with vaginal estradiol. They get a little bit of a systemic benefit from that, but their conventional doctor doesn't acknowledge it. So, it's okay. It's kind of a gray area. It's confusing, but I will say, you don't always need crazy high levels of systemic hormones. Sometimes, some vaginal estrogen is enough to really make you feel better. So, it's dependent on your age, your medical situation, your risk factors, all of that. So, don't assume pellets are for everyone or patches are for everyone. You want to go to a provider who understands the benefits of the different modalities and knows which one is right for you.
Cynthia Thurlow: I think that's really key is bio individuality. This one size fits all philosophy, particularly, when it pertains to perimenopause and menopause does not work. So, you want to make sure you're working with a provider that is able to fine tune and tailor things to your own unique needs. Much to your point, there are people out there-- I'm sure you probably have some people that don't absorb as much estrogen through their skin or maybe as much as testosterone and understanding that there needs to be this kind of a platter or array of options to fine tune what works best.
Now, while we're talking about testosterone and estrogen, let's talk about libido. Jessica said, "I have zero libido. I'm 48. Yet, I eat healthy, sleep and exercise." This is common. "What supplements or medication can I try?" So, I think we're going to go back to testing, because we don't want to guess. But when you're working with a perimenopausal woman or even a menopausal woman who says to you, "I have zero libido," like, "I may mentally have a desire to have sex, but there's no physical connection. I'm struggling with loss of orgasms. It's harder for me to have sex, because I have lubrication issues." There are so many pieces of the puzzle that go along with this. But let's assume that this question is coming from someone who is in a monogamous relationship and just wants to improve upon what her options are in terms of figuring this all out.
Dr. Tabatha Barber: We always jump to testosterone, but I will tell you from personal experience, I've had endless number of women tell me their libido improved just with estrogen getting back on board. I think that we don't understand fully how our libido works, but I do think it's a combination of our hormones. It's not just testosterone. Sometimes, getting that estrogen level is enough for women and they're like, "Oh, my gosh, I'm so good." I literally see every scenario. I see women who get on estrogen, progesterone, and testosterone. They don't tolerate the testosterone because they tend to metabolize it down the more androgenic pathway. They get the cystic acne on their chin or they get some hair thinning or something. They just don't like how it's working in them. And so, they go off of it, yet their libido improves on the estrogen and progesterone.
Some women, they need a lot of testosterone. Some women are on estrogen and progesterone and they feel good and have a better libido when their testosterone is at the upper limits of normal, whereas other women can't tolerate that at all. Another piece of it is, what's your sex hormone binding globulin doing? Because that is a carrier protein that these hormones bind to, either if you're bound up to this carrier protein, then it's not really available to do its job. So, a lot of people will have elevated sex hormone binding globulin, but also have high hormone levels. We're afraid to give them hormones, but they need it, because their hormones are not available. So, it really is a more complicated picture than we're making it sound.
In general, I would say, there're a couple of things. Get your levels tested. It's so easy to test a total and free testosterone. It's a simple blood draw. It's covered by insurance. Get your DHEAS level done. See what those three look like. Some labs will also give you, like, a bioavailable testosterone, which is a third way to test it. That's saying, it's not attached to that carrier protein. It's available for use right now. [Cynthia laughs] So, you'd be surprised, if you get your level done, it's probably like 0.1 or 0.2. It's like spitting in the wind. There's nothing there. People get confused because a lot of conventional doctors will only test a total testosterone, and they'll be told, you're normal because it's "in the normal range." So, you're missing the piece of do you have any free available or is it all bound up?
I would love to just mention this caveat that the lab ranges on our labs are for disease. They're telling you, "Yes, you have an organ and it's functioning, it's making hormones, or you have a tumor that's making hormones." It's very extreme. You're either in ovarian failure or you have a tumor. There's no optimal range on these labs. So, you really cannot go by those references. So, just a caveat there. I would say it's really common for younger women to have a desire. They see someone they're interested, they feel like, "Yes, let's connect. I have a libido." And then you act on it or not. Whereas once you get more toward menopause, I recommend doing the act to create the libido, to create the feeling, because it's not necessarily just there anymore. Our biology is our biology. If we're no longer reproducing, that piece isn't there to stimulate the need to procreate. We forget that we're just these procreating animals. But that's the truth. That's our biology.
So, what I recommend is women get into the acts and that creates the desire to want to keep doing it. So, that means, like, spending some time looking in your partner's eyes, getting intimate, having those conversations, massaging each other, smelling him or enjoying the pieces that you enjoy, like, their skin or their touch or their voice, and really honing in on that, and that will start to create desire. Then you will notice, you will want to engage in it more because it feels good. That's how we work as people. So, that's what I usually recommend. So, get tested, figure it out. You can try supplements. I say they work probably 30% or 40% of the time, but usually, you need either DHEA, which can be gotten as a supplement or you need testosterone replacement.
Cynthia Thurlow: I think it's really important to just mention that don't automatically think that you have to jump to medication that there is this lifestyle piece. I think a lot of people, I mean, I'm certainly at a stage of life where I have teenagers. They're no longer as intensive, helping them get fed and dressed and bathed. But the parenting becomes just as intense just in different ways and it allows partners and hopefully that they're reconnecting, because they have a little bit more time by themselves together than they did when their kids are younger. Now we're talking about testosterone. There are also questions about individuals that have high testosterone. So, Angie said, "My daughter just had blood work come back and her testosterone is high. She's young." So, this is a 17-year-old. "What are some solutions to get it within normal range?"
Again, this is not medical advice. I believe it was 75 is what she says here. I know that as an example, PCOS is the number one endocrine disorder in the world. I think a lot of people underestimate how prevalent it is. And so, I know PCOS or polycystic ovarian syndrome, and I have a great podcast with Dr. Felice Gersh on this that we can link up is pretty common. But when you're dealing with adolescents, young women, when they come in with suboptimal levels of testosterone, what are you thinking of beyond PCOS, or is that the only thing you're thinking about?
Dr. Tabatha Barber: No, I'm very much thinking about their diet and their lifestyle. Teenagers and women in their 20s, they're busy. They're doing a lot of stuff. There're a lot of stressors on them that they don't necessarily know how to navigate very well yet, because they haven't had those life experiences. So, it can feel super overwhelming. Just being in high school, taking AP classes, doing a couple sports, trying to keep up with your friends and go out on the weekends, that can be enough to cause hormone disruption right there. Your hormones are already struggling to be balanced, because this HPO axis is so new. Your brain and your ovaries talking back and forth. It's a new conversation. They don't know what they're saying to each other yet. It takes a few years to really learn that communication. Just like you have trouble talking to your teenager, your ovaries have trouble talking to the brain.
So, if you go and you add in too much cortisol or stress hormone, that mucks things up and throws things off. And then you go add gut issues, because you're living on a diet of high fructose corn syrup, gluten, and dairy, which is all super inflammatory, that is really going to drive these imbalances. You're right, we're seeing metabolic issues in younger and younger people, and that causes all these hormone imbalances. So, first and foremost, I'm glad she got her level checked. That's impressive in and of itself because we're often overlooking that. I would like to know what her DHEAS level is as well, her sulfated DHEA and her free testosterone. Then try to get her estrogen and progesterone levels according to the cycle.
Typically, we want to measure them on cycles day 10 and 21. If you're having a regular cycle, just to see what your peak levels are, what they are at their highest. A lot of times, if you're going into some metabolic dysfunction, your estrogen-progesterone are going to be off. But the other piece that doesn't get checked is the blood sugar and insulin. So, that is key. You might have to really advocate for her to get those done, because most insurance companies only pay for that after you have diabetes. But I want to know what is her average blood sugar over the past three months? Is that A1c down around 5 where we want it? Is her fasting insulin down around 5 where it's healthy? I want both of those below 5 for a 20-year-old. She should be probably 4.5, 4. Those are really good indicators of what's going on.
So, just know that sleep affects all of this, our diet, our stress levels. And so, teenagers are the perfect storm for this PCOS setup situation. But I'm glad that you did that with Felice Gersh, because she's amazing with PCOS. And this stuff is reversible. That is what people need to really know, like, have hope, because you can turn all of this around. This is not a disease that you're just going to struggle with the rest of your life. You can stop all of this.
Cynthia Thurlow: Yeah, I think it's really important for people to know how much that lifestyle piece really plays into these hormonal imbalances. As someone who was a thin, phenotype PCOS person that never had abnormal labs, it wasn't until I tried to get pregnant that we realized I had this progesterone deficiency and we went down that rabbit hole. So, I think there's this common misnomer that everyone with PCOS is obese. That's actually not the case. And so, that's why I remind people that if you've got some of these symptoms, you don't necessarily have to have classic symptoms on an ultrasound in terms of having cysts on your ovary. It could be this insulin resistance, inflammation, high normal or supratherapeutic is what I'm trying to say, testosterone levels, all these things along with that fasting insulin, etc., can really be keys that this might be something worth pursuing and addressing proactively instead of waiting until I was in my 30s wondering why I wasn't ovulating.
Interesting question. We're going to pivot a little bit and we're going to talk about feelings of satiety. So, Jill sends, "Is there a biological issue or mindset issue if you never feel full and always want to eat regardless of healthy or satisfying the foods you are eating? Now, I've come to find that there's a lot of different reasons that motivate patients to eat. It is not just intrinsic hunger, but when you're working with women and they're asking you, "Is there something changing in my body? Like, is it this change in estrogen that's driving the lack of hunger?" What are some of the things that could be contributing when you hear a patient address this and say that they don't feel satiated irrespective of how healthy the food is that they're eating? It's not just that they're eating a standard American diet. This is even happening with healthy food.
Dr. Tabatha Barber: Yeah, I don't hear that a lot. I think I hear a lot that I eat because I'm bored, or because it's time, or because I'm going out and I want to enjoy with my friends or my family. I would say we have to look at leptin levels. Sometimes, you can get some leptin resistance happening. So, it is becoming more common to check a hemoglobin A1c or an insulin, but not yet leptin. We can start to have some resistance the same way that we have insulin resistance. So, I like to think about resistance as you have all your cells that need to take the blood sugar out of your blood and store it or use it to make energy, you need to do something. But if your cells are inflamed and those hormones can't bind and send their signal thing those processes can't happen. And so, you have to make more of the hormone to send the same signal. So, insulin has to start yelling, "Please take up the sugar. Please take up the sugar." So, you have to make more and more and more to yell louder.
That's the same thing with FSH and menopause. It has to yell louder, so that levels increase. That same process can happen with leptin. And so, that's one of the biggest reasons. I love fasting. I really do women see that it resets things and it makes their hormones sensitive again. They don't have to be stuck in this resistance pattern of, "We're not hearing you. We're not hearing you." It's like a reset. If you calm your gut down, a lot of bad stuff will die off and the hormones will reset. A lot of women will realize, "Oh, I was just getting mixed signals or messages, or I was getting confused messages." I think one of the most confusing messages we get is carb cravings. I believe most of that is coming from the chemicals, from the bacteria and the yeast in our gut. That's not us wanting it. It's not our brains wanting it. It's what's living in our gut. They want those sugars, those carbohydrates. Yet, we make ourselves feel bad for having these cravings when really we just need to kill these guys off. They got to go and part of it is starving them out with fasting. Or, sometimes you have to use some herbicidal stuff like oil of oregano and thyme or mastic gum and different things for bacteria.
So, I love stool testing. I just think that's where it's at because wellness begins in the gut, disease begins in the gut. if you're not addressing that piece of it, you're going to be confused about what your body's trying to tell you. So, I would ask her to really do some journaling and some food diary and figure out like, "Is this simply food related? Are you getting enough healthy fats to feel satiated enough protein?" I think what I hear commonly is they think they're getting enough and then when they actually log it, they put it in an app or they write it down. They're surprised, "Oh, I'm not eating enough. I skipped yesterday and today, and I only ate two bites of this." We really have a warped idea of what we are intaking. So, I think it's really multifactorial. I think we put too much blame on ourselves. We have to look at the gut microbiome and see how this is playing into all this. Then what are our hormones doing? Are they functioning well or do you have some resistance going on? So, there's a lot of pieces to this puzzle. Then you have the whole emotional eating thing on top of it, right? That's a whole another subject.
Cynthia Thurlow: Yeah. No, that's such a thoughtful response. It's interesting that one study that I referred to earlier about the high FSH and low estrogen and the protein needs, they actually talk in that study about the fact that if women aren't hitting those protein metrics, so at least 100 grams of protein a day. For anyone that's listening, that's thinking, "I'm nowhere near that close," that's okay. You can work towards it. But understanding our protein needs actually increase as we get older, and so we're trying to maintain muscle, we're trying to build a little bit of muscle. Understanding that if we don't eat the protein, guess what? Our body is going to go looking for it. What does it usually look for? Carbs and fat, which when they come together, they don't typically come together in nature naturally, so that we're usually ending up eating foods that are hyperpalatable, easy to overeat.
Just so, I just want to reinforce that piece, like, if you do nothing else when you're tracking food is track your protein just so you have some awareness about how much you're actually consuming, because I find for me, if I hit those protein metrics, I'm full. There's no eating. Eight ounces of steak will fill me up. I'm not looking for more food. I am totally satiated. But if I eat three ounces of protein like you do at a lot of restaurants, you get protein on a salad, don't be ashamed or embarrassed. Ask for more. I was in Chicago with a mutual friend of ours a few months ago. Every time we went to this one restaurant, I was like, "Can I have a side of shrimp? Can I have a side of chicken in?" Because the protein portions were so small, I knew that would then lend itself to me craving other foods that weren't per se necessarily the healthiest, because I was traveling. So, thank you for that.
In terms of looking at pain, so middle-aged women that are dealing with pain, sometimes cyclical. So, this is a question for Melody. She mentions that, "She is cyclical around day 21, sacroiliac joint dysfunction after two kids." She said, "After giving birth twice, I've had a wonky joint that "periodically goes out" for a few days and gives me a lot of pain. After tracking my pain for a while, I noticed that it often coincides with my cycle and is at its worst around day 21." Remember, Dr. Tabatha talked about the magic day 21, which I know is when progesterone surges. "I'm wondering if you think this indicates that my hormones are out of balance or is this something to be expected hormonally and is better dealt with mechanically through physical therapy? Thank you."
Dr. Tabatha Barber: Oh, my gosh, great question. If nobody takes anything else away from today, [Cynthia laughs] I hope they take away knowing that our joints are affected by our hormones. Joint pain is probably the most common menopausal symptom and most denied, just ignored. Literally, our hormones affect our joints because it affects the collagen, and the muscles, and everything going on associated with your joints. Progesterone is a relaxing hormone. As I mentioned, progesterone levels are really high in pregnancy because you need to relax your pelvis. You need to accommodate room for an entire human being to grow inside of your body. So, you do get lax joints. We, sometimes, see that after pregnancy it continues to happen. There're a few key things. You got to strengthen those muscles that support your joints.
This was like my major issue. I've had a bad left knee my whole life, and I would go to the doctor and they would say, "You need to strengthen your quads." I just thought that was crazy and a bunch of crap at 15. I was like, "That doesn't make any sense." And then I go to DO school, and I learn how the musculoskeletal nervous system works and realize that everything going on around the joints is what's important. What's supporting the joints, the fascia, the blood flow coming into it, all of that stuff is what supports and keeps your joints healthy. So, you have to have strong muscles. You got to hit the protein like you mentioned. You have to do weight training and resistance training. But when it comes to the pelvis, that can be a really complicated picture.