Episode 54: Perimenopause Isn’t a Diagnosis, It’s a Midlife Shift with Dr. Theresa Pugh

In this episode, Dr. Theresa Pugh and I talk about what’s actually happening in perimenopause, especially the information that isn’t explained clearly. If you're in your 30s or 40s  or you work with women in this age range, this podcast episode is for you.

Dr. Theresa Pugh is a board-certified family practitioner with over 20 years of experience in family medicine. She received her MD degree from the  Medical College of Virginia at Virginia Commonwealth University and completed residency at Carilion Health Systems where she was able to train with the sports medicine department at Virginia Tech. 

A lifelong horsewoman, she continues to ride and compete in hunter/jumpers and became trained in equine assisted learning in the Epona method. She is a facilitator for an Austin-based non-profit called Horselink who provides sanctuary for retired competition horses while providing equine programs for people who have experienced trauma. Dr. Pugh became interested in integrative medicine after being diagnosed with Sjogren's Syndrome. 

Through her own healing journey, she gained valuable insight and experience into utilizing different healing modalities to balance mind, body and spirit. She is currently in private practice at Resilient Health in Austin and enjoys helping others with autoimmune conditions as well as practicing precision,  personalized healthcare using advanced testing and medical genomics. 

We cover:

• Why perimenopause starts earlier than most people realize
• The difference between estrogen dominance and low progesterone in perimenopause and how they can show up together
• What’s really happening when you wake up at 3am or feel ragey
• How symptoms like constipation, hip pain, frozen shoulder, and anxiety can all be hormone-related
• Why labs don't always tell the full story
• What to know about DIM, methylated B vitamins, and hormone detox
• How fascia, nervous system dysregulation, and stress play into it
• Why some people don’t tolerate progesterone and what to do about it
• We also talk about why so many women are told they’re “too young” to be in perimenopause and how to track symptoms so you can advocate for yourself or your patients. This is the conversation I wish more providers were having. It’s time we stop writing off women’s symptoms and start looking at the full picture.

Timestamps:

00:00 Introduction and Welcome

00:26 Understanding Perimenopause Symptoms

02:18 Hormonal Changes and Their Effects

03:37 Estrogen Dominance vs. Perimenopause

05:58 Progesterone and Its Impact

08:04 Detox and Lifestyle Adjustments

13:41 Emotional and Physical Changes

16:50 Hormone Replacement Therapy

29:25 Stress and Hormonal Balance

34:45 The Importance of Connection and Laughter

37:18 Small Changes for Big Impact

37:58 The Importance of Sleep

38:37 Infertility and IVF Stress

42:07 Understanding Menopause and Perimenopause

45:02 Managing Hormonal Fluctuations

50:32 Tracking Symptoms and Seeking Help

57:25 The Role of Vitamins and Supplements

01:07:54 Validating Perimenopause Experiences

01:12:06 Conclusion and Final Thoughts

You can learn more about her and the practice she works at, Resilient Health below:

https://resilienthealthaustin.com/

If you are a health or movement professional and want to stay in touch with future episodes, webinars, courses, events and more. Subscribe to my email list here

I’ll see you in a week!

Transcript

0:00

Hello everyone and welcome back to TMI talk with Dr. Mary. I'm your host, Dr. Mary. I'm excited about this episode. We're talking about how perimenopause is not a diagnosis, it is a midlife shift and all the things that come with that. And if you follow my social media in the past or recently, you know that I am in my early phases of perimenopause at the age of 39. And many times I've been told I'm too young and. It just can be incredibly dismissive. And so I wanted Dr. Theresa Pew to come on with me to talk about what's actually happening in perimenopause, especially with all of the information, and it can be really confusing to understand what's what I. So if you're in your thirties and or forties or even fifties and you work or you work with women in this age, this podcast episode is for you. So a little bit about Dr. Theresa Pugh. She is a board certified family practitioner with over 20 years of experience in family medicine. She received her medical degree from the Medical College of Virginia at VCU, which is the Virginia Commonwealth University and has completed residency. C at Carle on health systems where she was able to train with sports medicine department at Virginia Tech, A lifelong horse woman. She continues to ride and compete in hunter and jumpers and has become trained in equine assistant learning in the Epon method. She is a facilitator for an Austin-based nonprofit called Horse Length that provides a sanctuary for retired competitive horses that provide equine programs for people who have experienced trauma. Dr. Pew has become interested in integrative medicine after she was diagnosed with Sjogren's. Through her own healing journey, she has gained valuable insight into understanding and utilizing different healing modalities to help balance the body, mind, and spirit. She's currently in private practice at Resilient Health in Austin, Texas, and she enjoys helping others with autoimmune condition. Conditions such as practicing precision, personalized healthcare, and using advanced testing and medical genomics. So what we're gonna go over in this episode will be, we're gonna cover why perimenopause starts earlier than most people think. Like I was mentioning earlier, the difference between estrogen dominance and low progesterone and perimenopause, and how they can show up together what's really happening when you wake up at 3:00 AM and feel ragey. I love that one just because it's what I'm feeling sometimes how symptoms like constipation, hip pain, frozen shoulder, and all anxiety can be related to perimenopause and the hormone changes. Why labs don't always tell the full story. What to know about dim M-T-H-F-R, methylated B vitamins and hormone detox. How fascia nervous system dysregulation and stress can play into perimenopause. Why some people don't tolerate progesterone and what to do about it. We also talk about why many people are told they're too young to be in perimenopause, and that it's important to track your symptoms so you can advocate for yourself or tell this to your patients as well. Because we know in our current healthcare system, time is limited with practitioners unless they're out of network. That. They can get more time, but the reality is there's still a lot of people that are unable to do that. And so we talk about tracking your symptoms to fully understand or be able to articulate with faster results to your client's practitioner, or for you as well if you're going through this. So without further ado, we will jump into this episode. Welcome back to TMI talk with Dr. Mary where we dive into non-traditional forms of health that were once labeled as taboo or dismissed as Woo. I'm your host, Dr. Mary. I'm an orthopedic and pelvic floor physical therapist who helps health. Movement and rehab professionals integrate whole body healing by blending the nervous system into traditional biomechanics to maximize patient outcomes. I use a non-traditional approach that has helped thousands of people address the deeper roots of health that often get overlooked in conventional western training. And now we are gonna be starting our next episode. welcome to the show, Dr. Pugh. I'm excited that you're here. Thank you so much for having me. Yes. We're gonna dive into all things perimenopause, and you've already taught me so much just with you and I being friends outside of this and just your advice that you've given. Even just when we went to dinner a few weeks ago, I was like, oh my gosh. Just so mind blowing the stuff that you know. So thank you for coming on. Absolutely. Well, let's just go ahead and jump in. Yeah. So what, how can somebody know when they're in perimenopause? It can actually be difficult to know early on because some of the symptoms can overlap with a lot of different things. Um, particularly my patients with thyroid disorders. Some of those symptoms are very similar and so it can be hard to tease out at first exactly what's happening. But I think if you start to notice particularly any kind of cyclical changes, so if you start having headaches that seem to happen in a cluster for a couple of days each month, uh, if you start to have mood swings that happen for a couple days and then all of a sudden you feel like yourself again, something like that would kind of clue a person in that it might be a hormonal issue. Yeah. Well, what are you seeing? Like for me, I, I started realizing it was like the end of my luteal phase. So those last like as my estrogen. And progesterone were declining in the luteal phase. Mm-hmm. That was when I was seeing a lot of my symptoms. When do you see, is that for most people or like is there a common theme like maybe the spike of estrogen during ovulation? When do you tip, when, what are like the common times that people notice it? Those would be the two. So right mid cycle, maybe day, you know, 10 to 14. 12 to 14. When the estrogen is spiking up at ovulation, you can see more of the estrogen. Uh, really strong estrogen symptoms. So breast tenderness and swelling. Weepiness, I always tell patients like, if you start crying at at t commercials, your estrogen is probably a little high. Are there sad at t commercials? No, they're not sad. So if you're just like, oh, oh, you know, kind of crying at something that you normally wouldn't, that might be a clue that your estrogen's a little high. That's. Thing ever. You're probably an at t convertibles. Yeah. You really shouldn't be. Okay. And then you, and then you kind of come back into your body for a bit, and then, you know, then the progesterone's coming in for the luteal phase, so your progesterone comes up. People might feel a little more stable when that comes in, but then as both hormones are diving right before your period, so that week, right before your period, for some people it's just two days, three days. But for some people it's longer. It might be seven days depending on that ratio of the progesterone and estrogen. Um, but when those hormones start to drop, that's, that's probably when most people notice the most symptoms. And it's, it's the most dramatic. Yeah. That was when I started noticing, I'm like, why am I in a rage? Mm-hmm. Why do I just hate everything? Mm-hmm. I'm, I don't understand. I'm doing all this. Inner work and mindset work and slowing down. I mean, that's when I knew, I was like, okay, I had been waking up and meditating. I was walking in the morning getting sunshine, eating, eating super, like, you know, whole Foods going to bed early. And I was like, this is not, something is off. Yeah. And you can almost gaslight yourself. Yeah, yeah, yeah. I mean, estrogen keeps us from eating our young, so just think about that. So when you want to just like, ah, you know, go after everyone for no reason, that's a clue that your estrogen is dropping. Yeah. Uhhuh. Yeah. Yeah. Well then how, I think the part that I have questions on is how much of that though, how do you determine between estrogen dominance and perimenopause? So perimenopause, one of the first things that happens is your progesterone levels start to drop. Yeah. That's the first thing that starts to happen. So it actually throws you into an estrogen dominant type state. I see. Okay. Yeah. So as the ovaries start to kind of wind down, your ovulation is not as good. Your eggs are not as healthy. You may not be ovulating all the time. So when you don't ovulate, you're not gonna make the corpus lium, which is what the, the follicle turns into after you ovulate. The corpus luteum is what produces the, the progesterone. So particularly during months, you don't ovulate, your progesterone levels will be terrible, but just in general, you start to not produce as much progesterone. So then your estrogen levels, relatively speaking, are gonna be higher than they would've been when you were younger. I think when people think about estrogen dominance, they think like estrogen is actually more than the progesterone. So can you explain like what that. Is for people so they can understand. It's, it's pretty complex. So it's, we did a whole episode on it too. You wanna listen but just, yeah. Maybe more of explaining how like progesterone is more than estrogen. Yes. So in the luteal phase, so in the follicular phase, we'll, we'll back up. So during your period, both of those hormones are pretty low. Then during the follicular phase, progesterone stays low. So those first really, if we, if we go on the classic 28 day cycle for the first two weeks, your progesterone stays low while the estrogen starts to rise. Then estrogen spikes up and peaks at ovulation. It's gonna dip down after ovulation, and then it's gonna come back up and have another little sort of rollercoaster hill. During that time, so right after ovulation, that's when the progesterone is coming in. But the progesterone really is kind of higher, relatively speaking, than the estrogen at that point. So when, so if, you know, if we've got progesterone, now I'm using my hands, which you can't see on the audio only podcast, but if you've got it, progesterone higher than if you've got progesterone, higher than estrogen. But then all of a sudden in perimenopause, your progesterone comes down. Now you're sort of left, relatively speaking with more estrogen. But really the, you know, we, we kind of put it simply like that, but it's, it's a bit like a symphony where everything's playing. It's all making lovely sounds, but sometimes an instrument will come in a little stronger and you'll hear it a little more. Then it'll fade back and another instrument will come in. So the endocrine system, that's how I imagine it in my head, is we've got all of these hormones in tiny, tiny amounts too. It's amazing how these tiny amounts of chemical messengers have such big effects on our body. But really on a minute to minute, hour by hour, day-to-day basis, there's all this fluctuation and ebb and flow of all these things. So when we're talking about these levels, you know, we're talking about them very generally, but you have to keep in mind that when you do say blood testing, we're getting a one second in time picture of what's happening there. So I use a lot of the patient's symptoms to kind of tell me about the picture. I do use serum levels as well, but I like to have my patients track their symptoms over a couple of months with their periods, you know, kind of marking on a calendar when their periods are seeing when these symptoms happen, because then I can say, oh, okay. The these things are happening when your estrogen is dropping. These are happening when it's going up, and we can get a little bit better picture of it. Then when you look at the blood levels, you can say, okay, with this progesterone estrogen question, is this somebody who has normal estrogen and their progesterone is just coming down like it does in perimenopause? Or do we have somebody whose progesterone maybe is still okay, but they're estrogen dominant? So maybe they're not in perimenopause yet. Maybe they're just estrogen dominant. Or do we have both? Do we, you know, do we have someone who's coming in estrogen dominant and their progesterone starts to drop and now they've got a big gap here between. You know, those hormone levels and, and you need to kind of address both those things so then we might support their progesterone as well as supporting some estrogen detox, you know, maybe supporting their liver or something like that so that they can normalize those estrogen levels. No, I love that you brought up the detox part'cause I feel like this isn't talked about as much. Mm-hmm. In the perimenopause and menopause movement, people are talking about, oh, hormones, hormones, hormones. But we're not talking about how they break down in us excreting them. Mm-hmm. Another piece too is fascia. So if our fascia's restricted, our lymphatic system that flows through, it can't move as freely. And then if our estrogen and is, and progesterone declining it, it like limits that resiliency mm-hmm. In that too. And so. It's just another, from my stand, from like a PT perspective. Mm-hmm. You know, I'm talking to people about their fascia and understanding like hydration and movement. Even if it doesn't feel like it's much just even just walking 10 minutes a day. Even if you're like, I didn't wanna do anything today. It's like, just move 10 minutes. Mm-hmm.'cause it's helping pump that lymph through the body and help the body detox. But I think kinda what you're saying about the liver detox, that is a whole nother level of, oh my gosh, this is insane. And so explain to me. Okay, so when we were at dinner, I was telling you, um, so I actually went down. So I started at a hundred milligrams of progesterone. Couldn't tell. It was too sed sedative. Mm-hmm. So, because. There's nothing lower than that that can be prescribed. I had to have it compounded. Mm-hmm. So I went to 50 and that's been the sweet spot. Mm-hmm. Like I have felt good. I'm sleeping through the night. Like the biggest symptom for me was sleep. Yeah. Um, and so what was it that you were saying about. Being careful about the way progesterone breaks down too. Weren't you saying something along that, uh, I don't remember what, what the conversation was at dinner. That's okay. But sometimes early in the perimenopause, uh, timeline, women sometimes don't tolerate that full dose of progesterone that we typically use, which is a hundred milligrams and it's a gel cap, so we can't like, break a piece off of it. We couldn't. Yeah, yeah, yeah. So sometimes what you'll see is, yes, it's too sedating. Uh, occasionally I have women that, you know, will retain fluid or get headaches with it. Progesterone is pretty early in the, um, steroidogenesis pathway. So the pathway of how we make all of our hormones, so they all start with cholesterol. We make a parent hormone called OL alone, and then progesterone kind of follows right after that. And there's some. Other things going on. So then progesterone can feed some testosterone and also feed estrogen, but it also makes cortisol. Um, and I think you've covered that in some other podcasts, and that's a whole nother, maybe separate conversation about stress effects here. But, um, so. Early in the, in the process of perimenopause, if you're still making some progesterone and you, then you get another big slug of progesterone that's maybe more than your body needs. It might shunt into these other places. So it might go down into make more cortisol or make more testosterone. And then a person's having acne. Oh wow. Yeah. Oh, that's okay. That's what you were saying then. Yeah. So yeah, so sometimes we just need to give a little bit. So I'll do some low dose compound or maybe a little bit of topical progesterone, like a 20 milligram cream or something like that. Uh, because. Yeah, progesterone helps us sleep. It's calming. You know, some women, their first symptom is they just start having anxiety, heart palpitations, or they can't fall asleep. They wake up at 3:00 AM when your adrenals turn on and your cortisol starts to pop up. So those are some of the first sort of subtle symptoms for some people. Yeah. I had no idea. I was like, why do I keep waking up middle of the night to pee? Yeah. I never did that. Yeah. And then I was, then I went through my PT mind. I'm like, oh, am I not? I need to retrain my bladder, but I'm like, nothing's changed. Yeah. There's not like I'm eating. Any things that irritate my bladder before bed. And then finally I was just like, I can't, I'm so tired. And so it's just, I'm thankful that I found it pretty quickly, like how it, how it worked for me. And who knows. It will probably, it will adjust the time. But what about the people?'cause I've had patients that can't tolerate progesterone at all. They almost have like these adverse effects where they're just like extremely anxious. They just don't feel good. Is that because they're probably given too much and it's breaking down into these other pathways? Yeah. And then again, if they really are sort of in, in adrenal stress mode, so if sympathetic nervous system is in overdrive, their body's in fight or flight mode and it's going danger, danger, danger, uh, we need to make cortisol, it'll be. It's kind of going great. We have progesterone, let's make more cortisol from that. And so then I might approach it from a totally different place. I might go, okay, first, then we need to work on that piece. So where, what's the source of that stress? Let's get you doing some breath work, some meditation. Do you need to outsource that and go get acupuncture and let someone else help you with it? You know, do you need some body work? You know, just whatever it will take to kind of get the nervous system calming down. We might do some adrenal calming type herbs or supplements, uh, any number of ways. It doesn't matter really how you approach that. It's gonna be whatever works for that person. And then you can sometimes come back later. And just use a much lower dose of the progesterone. Oh, that makes so much more sense. And then you kind of ease them into it. Yeah. And most people can end up tapering up on the progesterone and tolerating it just fine. Wow. Yeah. But initially they may not, they may just not need that much. They may just need to be not taking away their progesterone by making cortisol. I see. Well, and the other thing that I've seen in this phase of life is like, as the hormones are changing, people have less tolerance to bullshit. Yes. Literally. Like it is. No. Yeah. And so I, I also feel like during this phase of life, there's a lot of questioning, like relationships, like there's a lot of divorces, there's a lot of like changing of friendships. Mm-hmm. And like switching jobs, because I think the capacity is so much lower for anything that doesn't feel like aligned for that person. Yeah. That then it's like what I've seen, and I've seen it in my friends and clients and even. I am not married now, but it's like just not saying all marriages are gonna just fall apart during perimenopause, but I'm saying like maybe the stuff that we were putting up with for a long time that wasn't working for us, it just like kind of rears its head and it's right there. So you're talking estrogen there because estrogen makes us kind of pee. People pleasers. Right? It makes you really tolerate, how would you raise a toddler otherwise, right? Like, I don't know. I don't have a toddler. You have to have estrogen. Yeah. To have to have that love and compassion and that I'm gonna care for this and I'm gonna, no matter if it throws up on me or throws a temper tantrum or keeps me up all night, I still love it so much. And so that estrogen just gives you all of that love and people pleasing all that. So then when you start on this estrogen rollercoaster of perimenopause, and you get these times where your estrogen is really low, now what do we have more testosterone. Right? So we get ragey, oh my gosh. Then we get to feel like what it's like to be a man. Wow. That, I mean, I always thought it was. To actually hear you validate it.'cause that was a theory of mine, of being like, oh, it must be that their estrogen is decreasing. Mm-hmm. So they have less tolerance for bs. Mm-hmm. But the other piece too, I think, is that because the hormones are so in this flux stage, that the nervous system is like hyper reactive. Mm-hmm. Mm-hmm. And there's less tolerance even for. Any people policing or things like that.'cause they just don't have it in them. Yeah. And then that's when I see their bodies kind of developing. Like hip pain is a big one. I see. Or um, pelvic pain in any capacity, like low back pain or constipation are some big ones. And I know that estrogen decreased. Estrogen cause constipation too. Yeah. So estrogen is moisturizing. Okay. Yeah. So when you start to get declining estrogen levels, and this is a big one that I think isn't talked about enough, but again, some women, their, one of their first symptoms is constipation. Well constipation or some kind of joint problem. Mm-hmm. So frozen shoulder, um, hip, yeah. Hip stiffness, plantar fasciitis, lateral epicondylitis, tennis elbow. If you have someone, especially PTs out there, if you have someone that's coming to you and they're like, I have never had a shoulder problem in my entire life. I didn't have an injury. I don't play a shoulder dependent sport. And all of a sudden I can't sleep'cause I can't lay on that side, I can't, I can't raise my arm. And if they're in their forties, early fifties, you know, you could really help that person by saying, Hey, you know this, this can happen because of declining estrogen levels. You know, if you're a candidate, that might be a great way to approach this, is to get on some hormone replacement therapy, get your estrogen levels at least so they're not bottoming out.'cause the way I think about it is, again, estrogen is moisturizing. It makes everything stretchy. So when that level comes down, if you think about a joint capsule, it basically shrink wraps. Mm-hmm. Right? Yeah. So think about that frozen shoulder just goes and tightens up and. There you go. You can't raise your shoulder anymore and you can put, you can help someone so much. Now, the natural course of it, if you don't do anything, I have found, and I think a lot of people see this, is that frozen shoulder usually starts on one side and goes to lasts for a year. Yeah. Goes to the other side, lasts for a year, and then for some reason the body can adjust to those lower estrogen levels and it lets up, but you're, you're talking two years of horrific pain, no sleep, uh, not able to put a bra on, not able to put certain shirts on it's misery. You know, it's so you can really shorten up that course, uh, by Yeah. Getting some estrogen in your system. That makes, I mean, I just think back to earlier in my career before, first of all, we weren't. Really even talking about menopause, at least publicly until like the last year or so, or maybe even a little bit more. But thinking about all of the women that I have treated that in that phase of life, experiencing severe shoulder pain. Mm-hmm. And this was not like something you learned? No. Yeah. And it, it just, I think there's also a piece of perimenopause that like really makes me angry is that like it's 2025 and, and, and we still don't understand it. I think there's a piece of me that's grieving this like sadness of. Okay, so we're, we're just supposed to just have babies and like, then it declines, right? And then that's it. And it's like, so even biologically, I think there's a little bit of grief of like, my body's not the same anymore. Mm-hmm. What's going on? And then people are inundated with all this information. Mm-hmm. And one of the things that I, I told people I was speaking at an event, um, a few weeks ago. I was like, listen, you all are gonna hear a lot of information over the next few weeks at this event. It's important that you sit with it. Do some breath work and realize like what resonates with you. Mm-hmm. Because there's so many pathways that there's so many people talking about this and, but the one thing that we're not taught is discernment. So like how to determine who to listen to. Yeah. And like what to here, because it can be, it, it, yeah, it's a lot of information, but also people present in different ways and that makes it hard. I think, you know, if someone comes in with very classic, oh gosh, now I'm having hot flashes and night sweats, and I, I can't sleep. It's like, okay, they're, they're in perimenopause, great. But if you come in and you say, my shoulder hurts and I can't raise my arm. And then I also, you know, I've been crying that, uh, you know, uh, your practitioner may not think right away, oh, this could be perimenopause unless they've been there. Totally. And they, and they kind of put those pieces together. So if, yeah, I think it's, it's difficult because it's not. A very straightforward progression. Mm-hmm. For each person the picture looks different. So yeah. So that's why I tell people if they're in it or listening, I'm like, just when you find the information, just see what resonates with you.'cause there is a piece of like, oh that, you know, when you can sit and your nervous system's a bit calm or like doing some breath work, which can be hard to do if you're dysregulated because of all this, but you know,'cause you can go like, oh this person's selling these supplements so I need to do that. Or everybody's taking this supplement. But it's like there's so much I don't respond to Chase very well. Yeah. And that's a big supplement a lot of people are talking about. I'm like, I break out on it. Mm-hmm. My skin gets worse. Mm-hmm. I become angry. So Yeah. It's interesting'cause yeah, Vitex or Chase Tree Berry often raises progesterone and you didn't do well with, with it. I Progesterone well did so. Yeah. Makes sense. But I did do well with. The, like broken down progesterone. Mm-hmm. Yeah. So the um, compounded version. Yeah. So it's so interesting. Yeah. Knowing, like being on the side of this, of, of learning it while I'm going through it.'cause the researchers are just constantly evolving. Like daily. Yeah. And there's, and and I think that's important that you realize that there's not the same tr there's not a protocol, there is not an algorithm. And I think people who don't understand the process want this algorithm of how do you treat perimenopause? And it's not like that. You have to individualize it. You have to do, I like to think that I do personalized medicine. Like I talk to the patient, I see what their specific symptoms are, what is their, you know, what are their other underlying health issues. And you've gotta personalize that because what works for one person will not work for another person. Oh yeah. And there are so many factors involved with that, but we're also starting to see, it's all the way down into your DNA. Yeah, the genomics of your hormone production, hormonal metabolism, hormonal clearance, and detox through the liver of estrogen pathways. That's all different for different people. So it's not going to be this cookie cutter type of treatment for every person. So if you find, you know, if you're, if you're seeing someone who says, well, everyone needs this, or Everyone needs that. I have heard that Yes. And heard some podcasts that were saying a hundred percent for ev, vaginal, estrogen for everybody. And it doesn't. Okay. Well, maybe that, but, but not everybody, like, I just think that it just depends. Right? Yeah. Like, you know, yeah. There's some people that can't tolerate it and then people will say, well, it's the additives in it. Mm-hmm. And I'm like, well, I've had people where we've compounded it Yeah. And they've tried everything and it just doesn't work for their body. That's true. Yeah. True. You know, but that is a theme I hear a lot of, uh, it's safe for everybody and it doesn't go in the bloodstream. I'm like, but it's still in your body. Mm-hmm. You know? Mm-hmm. So I, I have a, that, those types of things Yeah. Frustrate me a little bit. Me too. You know?'cause I'm like, if you, you're still, it's still in your body, right? So it still might be minute, but you're still getting estrogen in your body. Right. Right. So to say that it doesn't cross that. Yeah, that's, I have, I have, what do you think? Well, it was speaking specifically for that the, the vaginal estrogen that we use is a very extremely low dose. Yeah. Uh, but that's not to say there aren't people who don't have problems with it. There are people, I've had patients that were so sensitive to that small amount that it did, you know, cause them some issues. There are, if you get the, uh, you know, typical non-compounded type that's produced by a pharmaceutical company, there are parabens and other things in it. Those, they, they react more so, yeah. Yeah, yeah. Uh, but no, there, uh, there are some people, so that's Estrodiol, which is the typical estrogen that our body is used to. And there are people that just don't tolerate that for whatever reason. We don't know why their receptors don't like it in the vaginal area, but they might like estriol, which is a weaker form of estrogen. So, yeah, e even with that, which you know, is kind of one of those universal things that. Most perimenopausal women will benefit from some vaginal estrogen to, to keep that tissue Yeah. You know, healthy and moisturized and reduce the risk for urinary tract infections and pain with intercourse. Yes. And all of those benefits. Sometimes you still have to individualize that treatment. That's what, yeah. But that's what I'm saying. Yeah. Especially with systemic treatment though with, with systemic estrogen, you, you really, you know, will see some people can tolerate patches really well, other people don't. Someone might, their body might like the gel better. Somebody might not be able to absorb it very well in one spot versus another, a different form. So it, it really makes a difference to individualize that for people. Totally. And from a pelvic floor standpoint, I've seen vaginal estrogen work. Yeah. Wonders for people. Yeah, absolutely. But then I've had people be like, I don't want to keep putting this stuff in my vagina. Mm-hmm. You know? And so there's just, I'll also recommend if they don't wanna use vaginal estrogen, have you heard of reverie? Mm-hmm. So reverie, the hyaluronic acid. Mm-hmm. Yep. I've seen that work really well.'cause it kind of plumps up the tissue a bit. Mm-hmm. Very similar to estrogen.'cause even though like there's still people that are fearful of using estrogen. Yeah. Um, and, and so we wanna like, support them. Don't be scared of vaginal estrogen, but I mean the, the, what was the study that scared everybody? It was the Women's health Initiative. Yeah. So that's decades of people believing something. And so it's, yes. It's, it's getting people to realize, oh, that was actually a lot of misinformation. Well, yeah. The biggest thing is the Women's Health Initiative used conjugated equine estrogens, which are estrogens from pregnant horses. That is not the type of estrogen that the human body makes, that type of estrogen bonds to a different estrogen receptor than what estradiol binds to. So estradiol in any form is what we consider a bioidentical form. It doesn't have to be compounded. There are patches that are made by pharmaceutical companies. There's gels, there's all different forms. So that's one myth I wanted dispel is some people think that bioidentical means that it's compounded. That's not what it means. It's about the type of estrogen. So estradiol is the bioidentical form of estrogen ES three. So it doesn't have to be,'cause I know that there was debate. I've heard people say like, if it's compounded, then it's not regulated. And then there's, it's not say I, I've just heard so many different things, but that's more about, you know, the, the compound forms are gonna be made by a compounding pharmacy. Mm-hmm. So you have a human who is going in and making each batch of it. And so there is a little risk of error with that. Right. So you have to trust the pharmacy. You have to trust the pharmacy. That's important. That's, that's not talked about is like Yeah. Looking up to see, looking, yeah, yeah, yeah. The reputation of the pharmacy. Yes. Has the, does this phar, you can actually, at least in Texas, you can go on the Texas Pharmacy Board, you can look and see if there have been complaints about a pharmacy. Oh, good to know. Yep. And so, uh, there are pharmacies that I am not comfortable using, um, because I've had some issues with them and there are ones that I trust. And so, uh, the experience of your compounding pharmacist makes a difference the more they've done. Um, probably, you know, but it's, it's still a chance for human error. I mean, even a person who's experienced, who's done a lot. You know? Yeah. If, if you're having a bad day, there's a risk for error. Yeah. So, you know, that's one thing about the non-compounded forms. If it's produced in a factory, you gotta think they've got their, you know, system set up and it's gonna be made the same each time. Now you can have differences between different brands. So if you take, say, an estrogen, an estradiol patch, a 0.05 patch, there are, I don't know how many companies make that, but there's a lot of different companies that make that. And you will also see sometimes when you go to the pharmacy, they give it to you from company A, and then maybe the next time you pick it up, they might have gotten a better deal from company B, and now they've switched you from this companies to this company. Well, maybe there's a different adhesive, or the patch is a different size or. Any a number of factors that could have changed your absorption of that estradiol. So that's something that if someone's stable and doing well and then all of a sudden seems like they're off, I kind of, I always say like, did your, did you switch? Yeah. Did your medication look different? Did it change? And that's true for pills, for patches, for anything. Yeah.'cause that happens too. So there's a lot of places, there's a lot of nuance. Oh my God. I mean, I knew there's nuance, but just to know, even just like these little details. Mm-hmm. It's so important for people to know and even practitioners or anybody in the health and wellness field. Mm-hmm. To know, hey, if,'cause people might be like, oh, well it didn't work for me. Well what didn't work? What did you use? Right. What you know. Yeah. Did you try a different brand? Right. You know, was your system like there's so much in that. Yeah. And during perimenopause, if something didn't work for you two years ago. That doesn't mean it's not gonna work now because your system is very different two years later than it was when you were younger. Guarantee you, that's good to to remember. Yeah. I was just like, you're right though, that is not talked about very much with, you know, all the little places it can go wrong. Well, I think it's important for like practitioners and consumers to know. Mm-hmm. Because, you know, I'm figuring this out too. And you know, just to know that it break can break down in these different pathways. And you know, one of the things that we talked about with estrogen dominance is like, well, why is progesterone low in the first place? And if you're chronically in fight or flight, the body produces cortisol. Mm-hmm. Is it instead of, or it's. It prioritizes it more, right? Uh, well, it's, if you think about sort of water flowing down, you know, in a river and then sort of diverting into different parts of a stream, it's like sometimes it'll go a little more to the right. Sometimes it'll go a little more to the left. So it's, you're not gonna shut one of those off completely. You're just might divert more resources towards one pathway over another. So when the body is in fight or flight mode. So I, I like to tell my patients, like, let's think about how the body survived thousands of years, right? The primitive systems are all about survivals. So if they're, if you leave your cave and there's a tiger in the grass. Okay. We need to be able to fight, flee, or freeze, right? So we need cortisol to spike up. We need adrenaline if we need to run, like we need to have these systems on ready to go at that moment. The last thing your body needs to use resources for is your reproductive system. Yep. Because that is not the time to bring a baby into the world is when there's a tiger right there. So the trouble is those systems in our body have not evolved to realize that your text message is dinging you. Or the breaking news that happens every five minutes is not a tiger snapping a twig. It responds the same way. So we're getting hit by these little. Tiger attacks essentially all day long from the minute you wake up and you look at your phone to the minute you put it on the charger at night, we're just getting hit with it all the time. Every time somebody cuts you off in traffic or, I mean, if you think about all the little things that give you a tiny, you know, internal jump every day, that's a lot. Well, I think so. Of course our body's gonna be shunting these resources towards our survival hormones, and so I really encourage my patients that you have to stop, you have to have time during the day. That you are sending a signal to your body that we are not being stalked by a tiger. And that doesn't mean that you're sitting there playing a game on your phone because those notifications are still coming in. You're putting it away, you're going outside, you're getting away from anything that could be interrupting you. You're just lying and breathing. I, I don't care what people do, but I'm like, you've gotta stop at some point. Mm-hmm. You know, take a break even if it's for a couple minutes. Well, totally. And one of the things that I'll get,'cause we treat with a lot of people in a lot of chronic pain and have, have done a lot of like the generic kind of PT stuff and I'm like, we need to be looking at the nervous system. Right. But then, but I think people get stuck'cause it's like they can do that, but they don't understand why they're in that mode in the first place. Yeah. So I'll even, I mean, I have them go to therapy if they're ready to do that. Mm-hmm. But also starting to question why are you running around with your head cut off? Like, what are these, like, let's go deeper. Mm-hmm. And just notice, just notice like sometimes I'll give journal prompts. I'm not. Telling them what to do. I'm just like, just start thinking like, why? And you know, why is it that we need to fill the kids' schedules back to back to back to back every weekend? Where did we learn that from? Yeah. Who showed us that that was normal? And then we have to challenge those beliefs because we can't stay in that. I mean, that was my life for 33 years is just, that's because what I saw my mom do, and then my mom did what her mom did and then, you know, and it's like mm-hmm. It's this pass down thing. And I feel like we're all kind of getting to this breaking point of like, we just can't do it anymore. Yeah. It's too much. We're not meant to see people like so many breaking news stories on social media. Mm-hmm. People fighting on these, all these different things. There's so much more in love and kindness in the world than we see on social media and on tv, and we're more isolated than ever. Mm-hmm. Right. We're, we're. We're just, we heal in community. Mm-hmm. Like safe, healthy community. Mm-hmm. Not just community. Just to have it. And so I like challenge people to really start like, what are some hobbies you'd like to go and you've always wanted to do. Yeah. Because your body's gonna force you to do it. Either you do it now or you crash later. Mm-hmm. Like there's no choice. Yeah. Absolutely. We get sick. I mean, I got cancer. It's like, I'm not saying everyone's gonna get cancer. I'm just saying like, we have to, there has to be a point where we have to Yeah. Slow down and start questioning why we're constantly triggered by things. Right. Right. I mean, I'll even notice it too, is if I wake up and the first thing I grab is my phone, it's like blue light text. Oh my God, I have to catch up with all this stuff. Mm-hmm. So I'm already like putting my body Yeah. In that state immediately. Yeah. And even before bed, that's like some of the easiest things that people can do. Mm-hmm. Turn your phone into airplane mode. Mm-hmm. To reduce EMF. Mm-hmm. Put it away from your bed. Put it in the kitchen. Put it in the kitchen, read. Mm-hmm. To music, read an actual book, music something for 30 minutes to an hour at least. Mm-hmm. Mm-hmm. And see how you feel. Absolutely. Yep. And same thing in the morning, slow. Like,'cause the, those two things have changed my life. Yeah. Yeah. Like just changed. I wanna hit on your point about connection. Yeah. Being so important because I think that this has gotten so much worse post COVID a thousand percent, right? I mean, we lost a lot of being in community, being in connection. I think there's still that little bit of reflex of like, Ooh, danger when I see get too close to a person or in a crowded place. And that puts us right back in that fight or flight, sympathetic nervous system mode. And what we need to do is have times where we're really. Cultivating that connection. And when you make eye contact with a person, that increases your production of oxytocin. Oxytocin is the love hormone. It, it, it, you get it. Just even from looking at a dog as well, like animal, we can have it with animals. So oxytocin makes us wanna connect. It makes us have love, it gets for women, it gets the breast ready to redu to, uh, release breast milk. So that's why when a lactating mother sees a baby and looks them in the eye, they can actually express breast milk. Yeah. So oxytocin, it's a short acting hormone, but if you think about it, oxytocin is gonna put us back into a healthy reproductive state because it, it's gonna get the body ready for that connection. So if you're someone who's trying to get pregnant and you're in stress mode all the time. Your body's not gonna wanna get pregnant. So we've gotta have these times where we come back into this healthy connection, increasing the oxytocin, relaxing, making it a safe environment to, to have a baby. And, and you'll have much more success that way. Well, I think that adding to that, like laughter, yes. Laughter releases dopamine, serotonin, oxytocin. And I wanna say the, the fourth one is nore, I'm not mm-hmm. Endorphins probably. Yeah. It would be. Anyways, the point of that is that even just with those three, serotonin, oxytocin, and dopamine. Yeah. And you laugh, you know, you hear the saying, laughter is medicine. It truly is. I mean, it truly freaking is. Yeah. We have little, like, we have a little pharmacy in our brain. Yes. And if we can hack it, we don't have to hack it. We have to work with the body. Yeah. Even like the first few minutes of like getting up, like going outside and like letting your eyes like the sun, like. Y you, you see sunlight with your eyes.'cause the other piece I think is we're staying inside all the time. Yeah, yeah. Like just today I didn't get my full walk in and I'm like, oh.'cause I was rushing a little bit this morning and I was like, okay. But I was actually okay'cause I didn't have any coffee, which I was like, okay, I can't be rushing and have coffee'cause then I'm gonna be even more dysregulated. So I was like, okay, well I'm gonna choose to not have that today. Yeah. And I'm gonna go for a walk this evening. Mm-hmm. But still, there's that piece of these little details that we're not, we're wondering why we're constantly depressed and anxious and yes, there's a lot going on. But if even just these minute changes Yeah. Can make. Yeah.'cause if you're having trouble sleeping in perimenopause Yeah. Getting up, having that light early in the morning to wake the body up and then having that quiet time at night can really help you reset. And it seems trivial and not important, but it really, it's, it's, I'm here to say, really important. Say it is life changing. Mm-hmm. And the days that I don't do it. Yeah. I am dysregulated the whole day. Yep, yep. Because it sets the, and, and this sets the tone. Sleep is so, oh my gosh. Mm-hmm. It is so important for everything. Absolutely. But that also wasn't taught years ago, you know, it was like this hustle, hustle, hustle. Mm-hmm. And now we're starting to realize, especially with HRV stuff coming out to measure our stress, which is on, most people are tracking on their iPhones, and they have no idea they're tracking it. Exactly. I love showing my patients, I'll be like, Hey, you've been tracking this for like three years, you know, what happened this day? Or that, you know, and of course it's a glimpse of it. Mm-hmm. But still. Mm-hmm. But I think that there's, yeah, there was, there's a lot there about that. And, and then it, and then my heart goes to the people dealing with infertility. Mm-hmm. Because they're not taught this stuff. They're No. And usually they're shoved right into IVF, which you're pumping yourself with all these hormones. Well, not only that too, what I see is also just the, the process of it. All the appointments, all the blood draws, all the needles, all the, that is not a. A nurturing environment to have your body in. And it gets very stressful and yeah, I, I, I think it's a hard place to put your body in while also telling it to, to try and hold a pregnancy. So I think that that's really important and I really encourage my patients during that time to, I, I send them quite often to acupuncture, um, because I'm like, you've gotta be counteracting some of this really stressful stuff, um, if you wanna hold onto that pregnancy. But yes, but even knowing the hormonal disruption is pretty huge. And I think for some patients certainly can have long lasting lifelong effects and sometimes throw them into perimenopause maybe earlier than they would have. It's hard to know if that's true, but, well, I mean, people were saying it's all safe. I'm like, yeah, but let's see. Long term. And I'm not saying like I did IVF, like I did IVF'cause I'm a genetic carrier for a terminal illness. And so I didn't end up conceiving,'cause I. It just didn't end up working out and I got divorced, so, but I know what it's like to go through that process. It is incredibly stressful. Yeah. And I remember just injecting myself being like, everyone keeps saying this is safe, but like for me it was the only way to have for me to have kids in the way that I wanted to.'cause I didn't wanna take a risk of that being a 25% chance Yeah. Of that versus people are kind of pushed into it really soon. Mm-hmm. Without like having people kind of walk through them. Mm-hmm. And this isn't blaming the people going through IVF by any means. It's, it's you's more of, they don't have the re they're not. Given like the full, the full picture spectrum. And if they get that full spectrum and they choose to do IVF, by all means. But I, I really think it's super important that patients and people going through this understand what's happening in the body. And even the tests, they'll be like, we don't know why, but if you're, if somebody's working like a hundred hours a week and they're chronically, they're not sleeping mm-hmm. And they're, you know, dealing with sick parents or something like that. Mm-hmm. And it's like eating processed foods. Eating processed foods, like let's work on that first. Right. You know, and there's, there's a, there's a lot in there, especially add-on if you're in a male dominated field. Mm-hmm. And you're in a high stress job. Like there's just live in a high cost of living area and you've just gotta work, work, work to even survive there. But these are the things about health that we're not talking about. Yeah. Yeah. I mean, supplements can't replace that. A healthy meal can't replace that. Mm-hmm. You know, and I've just been a strong advocate for it after I got sick.'cause I was like, oh, I did all those things. Right. Yeah. And then I got sick. Right. So what, what else is there? Yeah. Yeah. So it's so interesting. And so, um, yeah. Are there any other common themes that you see? I mean, I know that you and I were just chatting a little bit before too about how I see a lot of people get gaslit if they're starting to have symptoms in their thirties. Mm-hmm. Mm-hmm. And we know that it's starting sooner. Mm-hmm. And especially with people that have history of maybe endometriosis, which most people don't even know if they have endometriosis. Mm-hmm. They have the symptoms. So I think that's underdiagnosed. Well, and, and maybe we should even like start at square one and tell people. Menopause. The definition of menopause is that you've gone a full year without a period. Mm-hmm. And that's not someone who say had a hysterectomy or a IUD or something where that's causing them to not have a period. But if you've naturally not had a period for a year, there's nothing magical about a year, but it's just at a year, if you've gone that long, then statistically you're probably done. Um, now I've had women that ovulated 14 months out and we've restarted the clock again. But I do see people don't really understand this concept of like, well, what is menopause? So menopause is when you've hit that time where you've gone a full year without a period, then you are menopausal. You are menopausal then the rest of your life. And people go, oh my God, I had these symptoms the rest of my life. No, no, that's not what's happening. That's just simply that your ov ovarian function has essentially shut off at that point. So perimenopause is the time before menopause. Mm-hmm. That can start. 10 years before you get to that point where you're not having periods anymore. So these little hormonal fluctuations can start to happen, you know, really early. And, and the range for going into menopause, for most people it's gonna be about ages 45 to 55. Now you're gonna have women that go later. You're gonna have women that have premature menopause and go earlier. But if you think, okay, well 45 is sort of the start of that and this can perimenopause can start 10 years before that, 35 is reasonable that some women may start to have some changes at that time. Totally. Yeah. Even with their medical history, like I was talking to another friend, I went through chemo, she's like, I'm pretty sure I'm in early perimenopause. Mm-hmm. I was like, probably mm-hmm. You know, we were told that it wouldn't affect it, but I'm like, come on, your body's in like extreme distress. Right, right. For as long as you were on chemo. Right. But there's so many factors to that and I think it, it makes total sense. Mm-hmm. And then even with endometriosis, especially if we have it around the ovaries, how that can reduce. Yes, the scar, the ovarian function from the scarring mm-hmm. And things like that. Yep. And so. You know, you add on all of these things. Yeah. And it can make sense when you start looking at it from that overall perspective. But I love that you clarified like, Hey, this is actually what mm-hmm. Menopause is. And it was cool though, is when I've talked to people that. Our, like, post menopause. We're like, oh, it's great over here. Yeah. That's pair, that's what I tell my patients is like, you, you're scared of menopause, but actually what you should be scared of is pairing perimenopause and not having help. If you've got somebody that can help you out and get you through it, it's gonna be fine. There will be some little bit of bumps in the road, but perimenopause, here's my analogy, is a little bit like a blindfolded roller coaster. It might be in the dark, you know? So like you're on this roller coaster, you don't know whether you're going up, down, left. Right. You might be making a loop and going upside down. It's hard to know. You don't know what's ahead of you, but, oh my God. Um, yeah. So, but it's not gonna last forever. Yeah. Like, so it, it's when, so we, we kind of touched on the, the beginning stages when the progesterone starts to drop. So the important thing to know also is your progesterone levels are starting to go down and the estrogen is really, uh, that's the thing that's, that's. Causing a lot of the issues because what's happening is the body is trying to have a fire sale on these last remaining eggs. It's like, let's spit these out and see if we can get one more, you know, baby out here, fire sale. So, yeah, so, so what's happening is, is the ovaries are kind of sluggish. The body's going go, go, go, go, go. And stimulating all of this estrogen. So instead of your estrogen just going up like a nice normal peak at ovulation, it's, you're now getting hyperstimulation very similar to what happens in fertility treatments. That's a hyperstimulation. You're trying to really get the ovaries going. So you get this huge surge of your estrogen goes way, way up higher than you're, you're used to. And then what? It's gotta crash, right? It's gotta come down. So it's a bigger cliff to fall off of, right? So these big swings in estrogen are really what cause a lot of the problems and a lot of the fluctuating symptoms that whiplash us back and forth in perimenopause. So, you know, one of my approach, well, I mean we, we could go into approaches and I said I personalize it, but if we know that somebody's having big estrogen swings, uh, and if their overall estrogen levels are starting to come down, you know, when they've getting gotten into perimenopause for a little bit, we might give them a little bit of estrogen just so they're not bottoming out so much. Oh, I see. It's kinda like blood sugar a little bit. Yeah. Like you don't wanna like just have a bunch of blood sugar and then spike and crash. You wanna add protein with it a little bit. Yes. So it's like a little bit of estrogen. Yeah, that makes sense. You've got a little safety net there that you're not totally, they're they're not bottoming out. Right. Because that would make, that makes total sense.'cause I think we think of so much of menopause perimenopause as, oh, not enough estrogen, but it's having that spike and it's, it's when, right. So sometimes I've had some patients that their main symptom was horrific migraines a few days before their period. So they're starting to get these estrogen swings that are bigger. Bigger crash right before their period as it's coming down. There's a really easy solution there, and I've done it in the office where I've given them an estrogen patch to put on. They put the patch on, they leave it on for three, four days. They get a little bit of estrogen coming in, so they're not going so far down into the basement. You can literally see someone's headache melt away within 45 minutes in the office by just giving them a little bit of estrogen so they may not need it all the time. Right. That's what I, so this is where you, you gotta know it's nuanced. You gotta know the process. Yeah. It's nuanced. And so they don't need estrogen at ovulation. That's not gonna go well. They've got plenty at that point this, or they're early in the process, but they're bottoming out right before their period. So just a little safety net there. Take away those migraines. I mean, now you've given that woman back two, three days of their life that they were in misery before, so, yeah. Yeah. I know, like for me, like, I like the idea that even just having the progesterone, do people ever go on progesterone the whole time, or is it always. The second half of the LT or the, you'll see different approaches there. Okay. Um, so sometimes early we will just do it in the luteal phase. So you might take it for two weeks during the luteal phase and then stop for two weeks as you get further into perimenopause. And those levels are dropping more. If, if someone's comes back and they go, I, I cannot sleep during my follicular phase, you know, so every time I stop it, I feel worse. I'm not sleeping, I'm feeling more anxious. I will go ahead and just do it every evening. Um, and then because later you're gonna start to get more irregular ovulation and skipping ovulation and having irregular periods, then you don't know when to take it. You know? I was gonna say, at what point do you, because I'm like, okay, mine stuff's predictable now, but Yeah. So then it's just impossible, you know?'cause if you start having like intermittent bleeding, you're like, do I take it now? Do I stop it? I dunno what to do. That gets stressful. Then you just take it every day. Because even though it like. Is there, there's still like a lower dose of progesterone all the time. Is that correct? Do you mean, so like when we think of progesterone, we, we mean, okay. It spikes of luteal phase today, four, roughly 14 to 28. What about, you know, one to days, one to 20 to 14? Do you mean the natural progesterone production? Yes, correct. It's very little. Okay. But it's still there. I'm sure there's still some, yeah, yeah, yeah, yeah. But it is not like the L teal phase. Okay. Yeah. It's a big shift. That's what I was thinking. No, I loved, I love knowing that.'cause it's, it can be so empowering for people to listen because people don't even know where to go for how, like you, I think you're, you're booked, right? Yeah, yeah, yeah. So you're booked and there's other people that are, that I know in Austin that are doing this and they're booked, you know, six mm-hmm. To 12 months out. And so I'm hoping, my hope is in this podcast that. Whether people are practitioners or they're, you know, people wanting to learn for themselves, that then now they can start understanding their body and asking and almost,'cause I've seen other primary cares be like. Well, what do you want? You know?'cause they're not educating mm-hmm. Themselves on it. And so there has, there's almost like this, okay. At least they can advocate mm-hmm. And start being like, Hey, what do you think about this or that. Mm-hmm. Because there's not a lot of people that are helping even OBGYNs. Yeah. Yeah. I mean, I think one thing that patients can do that is helpful, and, and I have my patients do this, but I I, I think a lot of doctors don't necessarily do this, but, um, start jotting your symptoms down because you think you know what's happening and you, two days later, you've forgotten what was happening. So I like to, I actually have a, a little, uh, tracker that I give people. It's a grid with all the symptoms and then they kind of score the symptoms each day. But you can even do it, I think it's helpful to have it on a calendar where you can see the whole month and when your period happens, and then you can see like, oh, that was the couple days before that I was having a headache or. I had a mood swing or something like that. If you can take a specific thing to your doctor and say, this is my symptom, and this is when it's happening. If they know a little bit, at least it will guide them more. Yes. They can help you with that symptom, right? Yeah, you could. You're giving them some information because like I said, early on, you know it, we don't always know. Is it just that your progesterone is low? Is it, do you have too much estrogen? Is, is there a little bit of both? You know, it's kind of figuring that out early on. Once you get further in, it's, it's actually a little more easy because then it's like, well, everybody needs the progesterone probably, and then at some point you add the estrogen in and then you just kind of titrate according to symptoms. But I think having those specific symptoms that you want addressed is, is helpful and saying like, it's happening when my. Estrogen is dropping or I'm having this symptom at ovulation. Is that something you can help me with? Yeah.'cause then they can kind of distill it and it's good for any healthcare people or wellness people listening is tell this to your clients. Right. Or, or, you know, if you are going through this yourself, then we can help guide that. I even use like the app and, and I don't know, it's like the iPhone app or whatever, that you could track your cycle and then you can input, um, yeah. Some of them just make like a list though. Like, and I, they don't, the visual of it is not easy to see like, oh, that, especially if you have symptoms of ovulation. Yeah. It's hard to see that.'cause that's why I kind of like having like a month big one month on a one page to, to be able to see, ah, that's, that's two weeks before your period, that's ovulation. That's when your estrogen is high. Mm-hmm. So at that point, you know, maybe we need to work on your estrogen levels, so, yeah. Yeah. Yeah. That's so cool. It's so good to know. And, um, I've learned so much. Just, oh, and then the other piece, what were you, uh, what about dim? Mm-hmm. So dim, uh, we didn't talk about estrogen. So when we talk about estrogen, we're typically talking about estrodiol, right? That's the, the kind of normal estrogen. But there are actually a lot of different forms of estrogen. Uh, so one of the first estrogens that's made is called estro. And then most of the estro, when you're not pregnant, most of the estro gets converted into estradiol. When you're pregnant, you actually switch to making the estro gets converted more into estriol, which is a weaker estrogen. Um, so there, that's a difference between pregnant and non-pregnant, but any of the estrogen that's sort of left over and not being utilized has to be cleared from the body. There are enzymes in the liver that do that. And there are some genetics behind this as to which of those enzymes might work better or work less for certain people. There are kind of two main pathways here. One is called the two hydroxy pathway that makes more anti-inflammatory type of metabolites. The other pathway is called a four hydroxy pathway or four hydroxy metabolites, and those are more in pro-inflammatory. Those are gonna be the estrogens that are more likely to stimulate, say, the cells that turn into endometriosis may increase the risk for breast cancer. All the things that we think, ugh, the bad stuff we think of Bad estrogen. Bad estrogen, because I think it does get a bad rep. Yeah. Yes. And the chemicals that are in plastics stimulate that enzyme that produces more of the four hydroxy pathway. Mm. So please. Limit your use of plastic. Do not heat your food in plastic as much as you can avoid, you know, drinking. Don't leave pl, we're in Texas. Don't leave a case of plastic water bottles in your car and drink the water from that. I think that's horrible. I think a lot of these plastic chemicals are really affecting our estrogen metabolites. So back to your thing about dim, what DIM does is it encourages that estro to be co to convert more into those two hydroxy metabolites, the less inflammatory metabolites. Oh. So it's gonna pull it away from that four hydroxy pathway. Wow. Yeah. Oh my gosh. Yeah. This is so, so dim is very protective. Um, if I have someone who has, say a, a family history of estrogen, you know, receptor positive breast cancers, prostate cancers, and men actually, uh, we see sometimes are stimulated by some of those, um, estrogen metabolites. So we think it's just testosterone. It's not, it can just, it can be estrogen as well. Wow. There's some good studies on DIM and prostate cancer and lowering PSA in men. So, uh, DIM can be very, very protective for those hormonally driven cancers. But if you've got a woman who's having really low estrogen, she may not feel well on dim. Right. I see. Yeah, because it's trying to excrete. Okay. You're you're encouraging more sort like the excreting of it. Yeah. Yeah. It wouldn't excrete the, the first kind would the hydro, what'd you say? It was the, so dim encourages you to take any SS estrogen you have, it encourages it to go down the two hydroxy pathway, make two hydroxy metabolites that get cleared through the liver. So, so you're kind of sucking it out there. So if, would it amplify the per, like the detoxing through the liver. Mm-hmm. So people that are on estrogen or that have low estrogen, it's gonna make them feel worse. Right. Versus that's somebody like me, it like. I started taking dim after we talked because I was like, oh, I need to help excrete this extra estrogen. I just didn't know that we were talking about where, like, we didn't go into details, but like that, that, those two pathways. Yeah, yeah, yeah. Are there, is there a specific dosage that is often recommended or what is the typical dosage is? Obviously it depends on the person, but what I mean,'cause there's so many different types of dim, most, uh, most of them are a hundred milligrams. Uh, and then depending on, again, I kind of personalize it depending on, you know, how much I, how much support I think someone needs. Most of the time we do either one or two capsules a day. Oh, okay. Yeah. Yeah. Cool. Now, I, I said that like some people don't tolerate dim, most people do benefit from dim, so I use DIM a lot, but I know there are certain situations where people may not, you know, tolerate it very well. Are there other types of like. Other types of minerals or vitamins that assist during this time, like to help with, I know that, um, during my luteal phase, things anxiety we found helpful or like B complex and B12 vitamins. Mm-hmm. Are there common ones that you've have seen helpful? Uh, there's a ton. There's a ton. So yeah. Vitamin D with K, vitamin D. Yeah. Your, your methylation. A B12, methylated B12 methylated folate. So supporting that methylation pathway of detox is important. Um, what, what, can you explain what that means though? Because I'm like methylated? Explain to me what that means. Yeah, so there are different, uh, essentially there are different detox pathways in the body. One of them is methylation, where the body will chemically attach a methyl group onto something. Think of it like a handle that the body can go, oh, lemme grab onto that and take it out to the trash bin. Right? So we, uh, that's the methylation detox pathway. There are a lot of vitamins that. Assist in pro, assist in that pathway, and B12 and folate are two of the big ones. So when you take in a folate, say you eat some leafy greens that contain folate, you're bringing in just natural folate. It has to go through a series of chemical reactions to get turned into something called methylfolate. Um, methylfolate is like the active version. That's what the cells actually use to run these other pathways. So there's the methylation detox pathway, but there's also the process of methylating these vitamins to activate them. So there, and there's a lot of geno genetics behind this as well. Is, is that like M-T-A-H-F-R? Yeah. So M-T-H-F-R is the, the last enzymatic step in that pathway of methylating folate. Over 50% of people have at least some issue with M-T-H-F-R, so it's very, very common. There are a lot of other genes and a lot of other enzymes that are involved in that pathway. My practice utilizes medical genomics and we actually look at those genes to see which forms or which types, you know, you might need more support in. Um, but that's one that a lot of people have heard of, but it's really just a tiny, tiny piece of that picture. Uh, but either way, everyone can take methylated folate. Everyone can take, I will say there are a couple of exceptions here, or people may not feel well with high doses of these, but uh, if you take in, uh, non methylated folate and then you can't convert it into methylated folate, it's not gonna work that well. So it can kind of accumulate and then you may not feel well from that. So. Okay. Yeah.'cause I take the methylated it'd B12. Yeah. Yeah. I see. Yeah. And is it also just kind of easier to do that, like easier on the body if you're taking a supplement that's not methylated versus, right, so you're essentially allowing it to skip a bunch of biochemical steps and it's like, oh, this is already the methylated form. This is a lot easier for me to use. Are there a bunch of, is every vi, this might sound silly, but it is every vitamin, should you get that in the methylated form? Is that a thing? Not all of them are methylated, are methylated, but there are activated, so, uh, not all of them do this, but there are other pathways like B six, the, the activated form is called PARADOXAL five phosphate or P five P, uh, riboflavin, or B two is riboflavin five phosphate. So it's got an extra phosphate group onto it. So yeah, there is sort of this activation of, of the vitamins. I, I don't know all of them, but no, I don't expect you to, I just, because I've seen that. And then the other one I've seen too, like vitamin D. So vitamin D is good and vitamin D is, you know, kind of a special one.'cause it's actually a hormone. Yeah, essentially. So, and we can, we can absorb, you know, through the skin and it can get converted in the skin from sunlight and then it, it ha so it's a little bit of a different, a different beast. But vitamin D works with methyl B12 and methylfolate to run a lot of detox pathways, but also neurotransmitters. So to balance our dopamine, norepinephrine, it all relies on, on those vitamins. So if you, that is a, that is very low hanging fruit too for people. Like if you, you should have your vitamin D level checked. Um, if you're tired, check a B12 level. And here's a pet peeve of mine. The labs have ridiculous ranges for B12. They're so. Absolutely ridiculous. So what, and, and vitamin D too, right? Uh, that was, let's say I'm normal at 30. Yeah. But I'm exhausted. Yeah. I, the B12 one is really worse. Ridiculous. Okay. So what labs do is they'll take, I don't know how many samples they use, but let's say they take a hundred samples and they go, okay, 95% of people fall between this range and this range. Yeah. Well, who's getting their blood drawn? Like, people who don't feel well. Yeah. And mostly older people, most teenagers are not getting their blood drawn, right? Yeah. As we get older, it's harder to absorb B12. We don't pull it into the body. There's a hormone in the stomach called intrinsic factor that we need to pull it in. Most of us make less intrinsic factors as we get older. So older people have lower B12 levels, that's not necessarily a good thing. Yeah. So these ranges on B12 for a lot of these labs go anywhere from like either 250 or 300 to 1100. That's a ridiculously wide range. My, it's like a, what, what is that called? It's um. The standard deviation or something. Yeah. So it'll be 95% fall, you know, and if you look at a bell curve, right, the biggest chunk of that bell curve is gonna fall between this number and this number I was talking to. But most people with levels of B12 below 400 are experiencing some kind of symptom. They might be tired, they might be having headaches, cognitive dysfunction, memory issues, uh, nerve tingling. All kinds of things can happen with low B12. So B12 is one that I have. A lot of patients come to me with chronic fatigue and they bring me their labs from their previous, whoever they were seeing, and they go, well, I had my B12 checked and it was normal. And I go, well, it was 300. That's terrible. Yeah. We get them up to 800. 900, a thousand. They feel so much better. It's so simple. Well, the other piece too, I think that's interesting, even about like vitamin D is we've been so scared of the sun'cause of skin cancer, right? Yes. That's huge. But it's like we can't absorb the sun if we have sunscreen on. Right, right. So even just depending on the melanin in your skin mm-hmm. Like just getting out in the sun. Like I've been starting to walk my dog in shorts in a tank top. Mm-hmm. Every morning just to like get 15 minutes of no sunscreen. Mm-hmm. Just sun on my legs. Mm-hmm. On my shoulder. Like the most things that I can expose my skin to, but we're. It's so, no. And most people in Texas, everyone's surprised about this. Most people in Texas are vitamin D deficient, probably because it's hot. And June, July, August, September, it is so hot. You are not gonna be out at noon. And when you go out, when it's actually cool enough to walk, you know it's, it's nighttime, it's 8:00 AM or 10:00 PM and there's either no sun, or the sun is at such an angle, those rays don't hit your skin. They kind of glance off of it so they don't actually penetrate in. Same thing in the winter, like it's nice here in the winter, you can be out in the sun, but the sun, the angle of the sun is lower, so you're getting less hours where it actually will penetrate the skin and give you that vitamin D. So, oh my gosh, I didn't even think about I, yeah, the angle of the sun matters, so. I just wanna live in your brain. I'm like, how do you, you're so freaking smart. It's just so many years of No, but you, but your analogies too. You're like, it's like this. It's like this handle and then it's taking it over here. And I just, I think that really resonates with people when you can explain stuff that way.'cause the hormone pathways can get so overwhelming. But I've been like following you this whole time.'cause I would've, but it's really complex. But yeah. But also I've been stu trying to study it myself mm-hmm. And be like, I don't understand how is this and this and this. And you know, even just knowing that, you know, cholesterol's the start of the hormone cascade. Mm-hmm. You know, I, I think back to like the nineties with the low fat stuff. Oh yeah. And people going through menopause, then perimenopause. Oh my gosh. Yeah. They're going through perimenopause. Yeah. On a non-fat diet. Mm-hmm. Mm-hmm. And we know all doing hours of aerobics and hours of aerobics, chewing up everything that they're taking in, not able to produce their hormones. I mean, I just have so much empathy. For those people. Yeah. You know, it's just, it's, it's crazy. And even when I talked to my mom, she's like, I don't remember perimenopause. I go, I do, I remember we would do through perimenopause. I think we all do. I mean, she's like 72 now. But I remember my first reaction to menopause. She was like, I don't know why I'm screaming. I, and then she start crying and I was like, is she okay? Yeah. Yeah. But I don't even think, yeah, they, they weren't talking about it back then with her. I'm sure she would've. Oh, goodness. No. Mm-hmm. But, and sadly, medical schools aren't teaching it. Most of them aren't. I don't think. I mean, I, I've been out for decades now, but I wasn't taught, taught. I think there's gonna be a big push because people are just, and, but I have a, a, a resident working with me now who's only a couple years out of school, and she was really taught very, very little to nothing about this. So, yeah, the thing that is wild to me, I had to learn it afterwards. Well, even OB GYNs. Yeah. People are like, oh, I'll just go to my ob. I'm like. Uh, depends on when they trained and how, depends on when they trained and where they trained and how good that that program was at doing it. And it's like you have to have a mentor that really was good. Like that's, it's, it's kind of interesting, like who you mentored with, like who taught you when you were in training makes a difference as to what you learned. There's just, there's enough stuff coming out. We need to be talking about it learning because if we're working with, if we're working with anybody from the ages of 35 to 55, yeah. Yeah. It. We need to Yeah. Be aware. Yeah. I mean, because people, and there's s they're suffering. Yeah. Yeah. I will say too, that there's a little bit of an art to it too, like of for sure, you know, kind of figuring out what's gonna work for people. Um, but you know, there's some, you know what I told the person that's working with me right now who, who really wasn't taught much. I was like, here's some basics. Like, just, just start, you know, you can at least get somebody started and then if they're not responding the way that you think they should, you know, you can have'em, see somebody who has more experience, but the, the vast majority of people, if you, if you kind of know the process, you can at least get'em some things to get'em a little bit of help and, and get'em feeling better. So, totally. Yeah. I mean, there's more and more resources out to, even if you just validate what they're going through, just validate that, please. Stop telling people that they're too early to be in perimenopause. Right, right. Because I was told that a few times and I was like, please just stop. I, I just, I I don't want to hear that. Yeah. I know. I've tried all of the things I did. I'm a huge advocate for holistic healing, but I'm also like, there's medications that we need. Absolutely. I'm the same way I use. A very integrative approach. I write prescriptions. I love to not write prescriptions, but I wanna do what the person feels is best for them. Yeah. And it's gonna be very different for different people. Mm-hmm. And it takes, I am lucky to have the luxury in my practice, to have time to talk with people. Yeah. I've been in a practice where you saw 25 or 30 people a day exhaust, you had exhaust 10 minutes to do all of the stuff. Look at their blood pressure, you know, look at their lab work, you know, do the exam, refill the prescriptions, like do all the stuff that you're totally out of time. You don't have time to sit and have this nuanced discussion about their symptoms when they're happening. All of that. And, and that's, you know, unfortunately a huge fault in our medical system. And I really feel bad for people that. Don't have time to sit and talk with their, you know, provider about what's going on. Um, but that's why I said if you can track and come in with some very specific, I think the more data points Yeah. I'm like data, data, data, data, data, exactly. Right. You track your periods, track your symptoms, come in with very specific things, this is what's happening. Then you've really helped them hone in on what they need to do to help you. But, but then also too, just like say somebody does have that practitioner, that's 15 minute appointment, you know, like you said, like go in with that. And then if, if somebody's listening is that practitioner that has 15 minute appointments, then you tell that patient to do this. So then when they come back, right, you've got another 15 minutes. Right? Yeah. So at least they're going away with more frequent something validating them. Mm-hmm. Hey, this is real. And if you can't help. There's somebody else. And that doesn't mean we're bad practitioners. No. It just means that we're putting our ego to the side Yep. To say, Hey, I actually think somebody else can help you with this. Mm-hmm. This is probably what it is. And then they get to go with that information. Even knowing, I was just talking to somebody the other day, they were saying like, oh, my practitioner mentioned I might be in perimenopause. And it started to make sense and they didn't know where to go after that. Mm-hmm. But at least they got that information. Yes. And you're like, oh, I'm not Just so they're validated outta control. Totally. Like my brain is not outta control. There's actually something chemical happening here. We had another patient who's about the same age as me. She's super sweet. Um, uh, she walked in the other day, she was working with Arista, and I was like. Hey, how you doing? I'm like, I'm great. I'm a progesterone. She's like, what? I thought I was crazy. We're the same age and you're on it. Oh my gosh, I feel so validated. I'm like, yeah. Yeah. And even when I posted it, I posted it on my Instagram story and I was like, you know, welcome to perimenopause. And it was just message after message after message. Oh my God, thank you for saying that. I'm not crazy.'cause I think it's the younger people that are like, am I crazy? Mm-hmm. It's the people in their thirties mm-hmm. That I'm noticing. They're like, am I crazy? Yeah. I'm, I'm, I'm in my thirties. And I'm like, no, you're not. You're really not. Yeah. And those were the messages that were coming through was, thank you for sharing that. Mm-hmm. I've been validated. It's not telling people to share stuff on social media. Maybe it's just we are openly talking about it with our friends. Absolutely. Or somebody that you trust. Um, I just did it so. Openly because I'm in this profession. Mm-hmm. And I know I've done enough work where I could share my stuff and I'm okay with criticism if somebody wants to say something. So I feel more comfortable sharing it that way. But not everybody does. But the more we can kind of normalize it. Mm-hmm. Especially, I think in that 30 to 35 to 40 range, you know, I think it's, it's tough'cause they struggle. Mm-hmm. They really do. Yeah. And I'm one of those people. Yeah. And I, I feel for people. Mm-hmm. Absolutely. But. Yeah. Yeah. Well, this was such a lovely discussion. Yeah. There's so much more. You could, we could probably talk for hours, but I know we totally could. We'll have some other topics to talk about. So thank you so much. This was incredible. Good luck to everybody out there and your blindfolded, hormonal rollercoaster you're gonna, but now they have more information with your incredible brain. I'm like, oh my gosh. I need to just shadow you forever. Um, and so you're not taking on new clients now, but I could still say, so you're at Resilient Health. Mm-hmm. And so there's other practitioners that, and, uh, physicians that work with you that can practice similarly. Yeah. We are all, we are actually looking for a new physician because we are all quite busy right now. Yeah. But yeah, we do because it makes sense why you are. So maybe they'll have an opening with another physician. Mm-hmm. But if you are a physician listening, I would definitely check out their practice. Please. Because they, it's a great place to work. Yes. Yes. So, all right. Well, thank you. Thank you so much for having me. Thank you so much for listening to my podcast. It would be a huge help if you could subscribe and rate the podcast. It helps us reach more people and make a bigger impact. I would also love it if you could join my email list, which is LinkedIn, the caption for podcast updates, upcoming offers and events. You can also find me on TikTok, YouTube and Instagram at Dr. Mary pt. Thanks again.