Recently I interviewed Dr. Stephanie Gray, and we chatted about sex hormones. If you would prefer to listen the interview you can access it by Clicking Here [1].
I am very excited to interview Dr. Stephanie Gray, who is a functional medicine provider. She helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them. She is arguably one of the Midwest’s most credentialed female health care providers, combining many certifications and trainings. I’ll include all these certifications and credentials in the show notes. Specifically, she helps women in midlife who feel their bodies have betrayed them step back into their bodies by restoring optimal hormone levels so they can regain their sleep, figure, mood, and feel amazing once again. She is known for keeping hormone replacement therapy sexy, safe, and effective.
Dr. Stephanie is also the Amazon best-selling author of her book Your Longevity Blueprint; host of Your Longevity Blueprint podcast; and co-founder of Your Longevity Blueprint Nutraceuticals with her husband Eric. They enjoy spending time outside with their son William. They founded the Integrative Health and Hormone Clinic in Hiawatha, Iowa. Thank you so much for joining us, Dr. Stephanie.
Dr. Stephanie Gray:
Good morning. Thanks for having me on. Excited to be here!
Dr. Eric:
What I’d like you to do is give a little bit of your backstory. How did you become interested in learning more about functional medicine and doing what you do today?
Dr. Stephanie:
Sure. I think everyone in our field has our own personal health crisis, which I can get to. I also feel pretty blessed that I was raised in the Midwest in Iowa in a healthy family. We always had home-cooked meals. We were always engaged in physical activity, went to the chiropractor. Our parents were self-employed, so they wanted to keep us healthy because we didn’t always have great insurance. High deductible plan, even back then. We were taking vitamins. My parents were growing wheatgrass juice on the countertop. They weren’t hippies, but they were ahead of their time.
I feel very blessed that I was raised in a family that valued health. A lot of our neighbors had great insurance. Any time they were sick, their parents took them to the doctor, and they were given antibiotics. Back then, I almost envied they had great health insurance, so they could go to the doctor. I now appreciate the fact that my parents were helping to prevent me from ever needing to go to the doctor. I was raised with that mentality.
Secondly, I had my own personal health crisis which fueled my passion for functional medicine. I was already in functional medicine when this happened. One day, sitting at my desk, after seeing patients in the morning, my heart took off to the races. I had what was called medical tachycardia, very fast heart rate. You probably deal with this with hyperthyroidism. I did not have that. I was very stressed out. I had a very fast heart rate. In that moment, I tried to push the button on my phone to intercom my husband, who is our office manager. I was so disoriented, dizzy, lightheaded. I didn’t know what was happening. I thought I was having a stroke. I walked down the hallway of my clinic. I was very pale.
Long story short, my nurse found me. Went to the emergency room. I was sent to cardiology, who referred me to Mayo Clinic. They told me I could take a medication to control my heart rate. I already knew, practicing functional medicine, taking a medication wasn’t going to tell me why this was happening to me. That was only a Band-Aid approach. That wouldn’t really get to the root cause of the problem.
There are times and places for medication. Maybe I should have taken a medication at some point because my heart rate was so fast. But I knew in that moment that I had tools with functional medicine. My husband said, “It’s time. You will have to apply these principles that for years you have been teaching your patients to yourself.” That’s when I created the Longevity Blueprint because I really had to regain my health.
I was already in functional medicine when my health crisis started, but functional medicine helped me regain my health.
The other piece of my personal story was I was also struggling with infertility, which makes sense. My body was in a stress state, with a fast heart rate. I wasn’t in the place where I could grow a human. My body unfortunately had very low progesterone. We can talk about hormone levels. The stress I was under in that time of my life was robbing me of progesterone, which is needed to achieve and maintain a pregnancy. I had a lot going on. Thankfully, I had some tools that really helped me rebuild my health.
Dr. Eric:
With the tachycardia, you were able to avoid medication, which I assume was a beta blocker. Was that what they recommended?
Dr. Stephanie:
Yep. It was really sad. I feel like I had a very thorough workup. Having a high deductible, you pay $7,000-10,000 to get this huge workup to rule out big, bad things, which I didn’t have. They said I had atrial tachycardia. Where it was happening, they couldn’t offer me an ablation. Medication was what they had recommended. I just didn’t feel like that was what I needed.
In hindsight, it wasn’t. I really needed to change my lifestyle. I will say gluten was a huge trigger for me. Pretty much any time I have cross contamination with gluten—I finally figured this out— but I would have very fast heart rate after certain meals. I tested myself for Celiac, and I remember when my nurse brought me the results, she just handed them over to me. I looked at them and thought, Oh crap. I’m one of those people. I have to go gluten-free. This was a decade ago. I had been preaching the importance of removing inflammatory foods to my patients. I was already 80% gluten-free, but I needed to be 100% gluten-free, which I have been for the past decade. That was a huge game-changer for me.
I also had SIBO (small intestinal bacterial overgrowth). I had so much gas, bloating, and pressure. Sounds silly, but I would have palpitations and fast heart rate until I could burp and alleviate some of that pressure and air. That wasn’t something that conventional medicine was putting the pieces together. I had to figure that out myself. I was low on magnesium, low on progesterone, super stressed out. Once I got my minerals up, my hormones balanced. Stress is a lifelong thing. I still have some stress in my life. Once I set some healthy boundaries, all of those things together really helped to calm my body down. I didn’t need to take medication.
Dr. Eric:
Stress for most people is a work in progress. Being a functional medicine practitioner myself, we are both aware of the impact of stress. It’s something that obviously never goes away. It’s always something you have to work on. I’m with you on that.
I talk a lot about functional medicine. I don’t know if any of my guests actually have spoken about what functional medicine is. Can you briefly, for those who are not familiar with functional medicine, differentiate between functional medicine and conventional medicine?
Dr. Stephanie:
You bet. I like to use the analogy I share in my book to explain this, which is the fire department versus the carpenter approach. Think of conventional medicine as being the fire department. That’s what I sought out. I went to the emergency room. The fireman has two tools, an ax and a hose, which I consider medications and surgery. For me at least, they weren’t offering surgery. For some other ailments, they would. Conventional medicine is great for acute care in that regard. Their tools are drugs and surgery.
When we think of chronic disease management, and me trying to get to the root cause of my problem, I needed a carpenter or contractor, who tries to rebuild the body. That’s where functional medicine comes in. Think of functional medicine as being that carpenter. They will ask how and why an illness occurs. They will try to discover the root cause, the dysfunction in the body, so you can fix it and prevent future fires, so you don’t need the fire department.
I would say that I do think from an acute care standpoint, if you get hit by a car, if you have a heart attack, we do need conventional medicine. We do need the fire department. I think the fire department isn’t great when it comes to chronic conditions and preventing those.
Dr. Eric:
Thanks for the explanation. This relates to the house blueprint concept as well that you talk about in your book?
Dr. Stephanie:
Yeah. We are so immersed in functional medicine. I don’t want to speak for you, but we just assume people know what we do. It is actually rather complex. When I was going through my health crisis, my husband said, “You need to make a blueprint, an outline as far as all we offer to help patients. They may just come to our clinic for fixing a gut issue or optimizing hormones, but we offer so much more.” I thought, okay, what’s a relatable analogy for patients to learn functional medicine? I created this Longevity Blueprint. I’ll try to describe that.
I’m comparing your home and how you maintain it to your body. Most of us know: mow the lawn, keep hair out of the drains so they don’t get clogged, change your furnace filters. There are innate things we do to maintain our home, so our home lasts a long time. We don’t always know what to do for our body and specifically each organ system in the body.
Throughout the book, I am comparing one aspect of the home to an organ system in the body. For instance, chapter one, which is probably most important, I talk about gut health. I am comparing the foundation of our home—you have a strong foundation upon which to build your house—to the gastrointestinal system in the body. We have to have a strong gastrointestinal system upon which to build great, long-lasting health.
That is just one example. Within each chapter, I am going through all of the available, complex functional medicine testing options for each organ system. I really talk about your human fingerprints being a detailed, unique marker of human identity, as are your test results. Your test results will differ from your neighbor’s. Those test results help your functional medicine provider personalize a plan to rebuild your health.
I can keep going if you want me to explain some of the other parallels I am drawing with the house and the organ systems if you want.
Dr. Eric:
Sure. Let’s go for it.
Dr. Stephanie:
I didn’t mention this yet, but something else that really helped me reduce stress was getting chiropractic adjustments. I don’t know what your thoughts are on chiropractic care, but I wanted to include it in the book. I would feel so tight and stressed. I would have a fast heart rate. Then I would get adjusted, and everything would lessen. I wanted to include the importance of maintaining the framework of the home, aka the spine, our musculoskeletal system in the body. That’s chapter two.
Chapter three is all about the electrical work in the home. I am comparing that to genetics in the body. Some lights, you want turned on. Some lights, you want turned off. There are certain genes we want expressed and other genes we don’t.
Chapter four is all about having the correct keys to unlock certain doorways in the home. This is a stretch, but I was comparing that to having the proper nutrients in the body, repleting nutritional deficiencies. You want that correct key to fit that lock to open the doorway or to bind to a receptor. You want to have the certain cofactors for enzymatic reactions in the body.
Chapter five, I am comparing the importance of tackling the laundry. We have a constant influx of dirty clothes needing washing and drying and folding and putting away. That is an ongoing problem, at least in my house. I am comparing that to the detoxification systems in the body, your liver, gallbladder, and bladder working appropriately so you can eliminate toxins.
Chapter six is my favorite. Maybe we can spend some time here. I am comparing the heating system and cooling system in the home to the endocrine system in the body, optimizing your hormones.
In chapter seven, I am comparing the plumbing system in the home, because you want clog-free plumbing, to the cardiovascular system.
Chapter eight, I am comparing the importance of having good roof integrity, aka treating and strengthening the immune system. You don’t want to have chronic infections. You want to make sure you have that protective barrier, your immune system in the home or the roof in the house.
Chapter nine, I am encouraging patients to find a contractor, aka a functional medicine provider, to help them work through all of this because again, it is complex. It’s not easy. You do need to run some advanced tests and be able to interpret those results as well.
Dr. Eric:
Those are some pretty neat analogies. Thank you for sharing. I definitely want to get more into the hormones. Before doing that, as far as my thoughts on chiropractic, being that my background is a chiropractor-
Dr. Stephanie:
I didn’t know that!
Dr. Eric:
Definitely in favor of regular chiropractic adjustments. I am a little bit overdue, I’ll admit, for my wellness adjustment. I do try to go in regularly. I don’t really practice chiropractic like I did years ago. It’s more functional medicine, focusing on helping people with thyroid/autoimmune thyroid conditions. Still, I definitely recommend chiropractic. Can’t say enough about chiropractic.
Let’s talk about hormones and where they fit into this analogy. I really want to dive a little bit deeper into the hormones.
Dr. Stephanie:
Here I am discussing how important the heating and cooling system is in your home, comparing that to the function of your thyroid, your ovaries or testes, adrenals, all of those organs that help produce hormones. You don’t want to have cold intolerance, your fingers and toes to be cold. You don’t want to have hot flashes or night sweats either. You want to have a favorable body temperature.
In this chapter, I am discussing ways for patients who are younger to produce hormones naturally. We can certainly go there. But I also talk about ways to replace hormones. I do have a heavy natural hormone replacement therapy practice. I’ve had lots of patients who’ve had hysterectomies who need replacement.
Here, I am dispelling a lot of myths: Hormones aren’t safe; they cause cancer; women don’t need testosterone. We can dive into as much as you would like.
Lastly, I also discuss the importance of optimizing estrogen metabolism. That’s what my doctor focused on, looking at urine hormone, metabolism testing to help reduce risk for estrogen-related cancers.
Dr. Eric:
We’ll talk more about the estrogen metabolism. It sounds like you recommend hormone replacement to a lot of women, especially if they have a hysterectomy, but maybe younger women, not as much. Is that correct?
Dr. Stephanie:
It really depends. Back to my story. Sadly, I was in my 20s when I first started checking my hormones and was struggling with infertility. I had my son at 35, a little later in the game, but it took me years. I was on progesterone. I had to take progesterone injections through my pregnancy because my levels were so low.
Not that everybody is as low as me, but I see a lot of high performers. They are just driven individuals, entrepreneurs, busy bodies, Type A, have higher stress. Unfortunately, when they are not supporting their bodies with nutrition and detoxification, they can end up with lower sex hormone levels earlier in life.
Progesterone is the first hormone I do start replacing. Many times, I have to replace that for women in their 20s. It’s not just a hormone I wait until someone is 50 to replace. If they are having PMS, heavy periods, anxiety, premenstrual headaches, infertility, they may need progesterone much earlier in life. That’s really determined based on a combination of symptoms and testing to confirm that they are low.
Dr. Eric:
That was my next question: How does someone know if they have a hormone imbalance? You don’t just randomly recommend bioidentical hormones. You do test your patients.
Dr. Stephanie:
No, no. I love testing. I don’t know about you, but I love it because I have seen so many patients, even menopausal patients, go see their gynecologist. They are put on estrogen without having any hormone tests run when they never needed estrogen in the first place. They come to me. I test their levels. They are sky high. Maybe they needed progesterone or testosterone, not estrogen. That is a big pet peeve of mine, when providers are willy nilly prescribing hormones without comprehensive testing.
There are various ways to test hormones: saliva, blood, and urine. There is blood spot testing as well; I don’t do a ton of that. Depending on the age of the patient, their cyclical status, the symptoms they have, that helps me determine what is the best means of testing their hormones.
Sometimes, for younger women, I will do a month-long saliva hormone test, where they will spit into a tube every couple days for the full month, so we can gauge-If they are having a symptom like a headache with ovulation day 14, or maybe day 26, they are having a headache, we can correlate symptoms with labs when we can see both together. I do like the month-long saliva hormone test for those sorts of patients.
For patients who aren’t cycling, we really don’t need to do a full month-long test because their levels are pretty stable. For perimenopausal patients who maybe are cycling every 2-3 months, or menopausal patients, I’ll just do blood testing on them.
You can still do blood testing on cycling women, but you need to test them a week after ovulation. That is when progesterone will peak. If patients don’t want to do saliva testing, I’ll try to have them target that window to do the blood testing.
For post-menopausal women, I just test them any day. It doesn’t matter.
We will test estrogen, progesterone, testosterone, sometimes DHEA, prednisone. A full thyroid panel, which I’m sure you talk about a lot on here. Many times, we will test cortisol as well. I can do that in saliva, or we can do cortisol in urine testing.
That leads me to the next form of testing we can run on patients, which is the Dutch test, dried urine comprehensive hormone test. We also just test one day, but that specific day, we can run cortisol multiple times throughout the day. Cortisol is supposed to be high in the morning, so patients are full of energy. It is supposed to gently reduce throughout the day, being lowest at night so they can sleep. We can see their Circadian rhythm, which many times is disrupted in the perimenopausal stage. We can also see their hormone levels. Plus we can see hormone metabolites. We can see how they are eliminating estrogen, which is really important, especially if I am going to be prescribing them estrogen.
I think your question was how does someone know if they have hormone imbalances? A) We test them. B) I have them fill out a symptom questionnaire. Many patients who have low estrogen have vaginal dryness, hot flashes, night sweats, urinary incontinence, memory fog. If they have low progesterone, they may have PMS, anxiety, heavy cycles, poor sleep. If they have low testosterone, which I am seeing a lot of that these days, they may have poor mood, motivation, drive, libido, energy, muscle mass. Many patients can have poor mineral bone density with any of the hormones being low.
We combine symptoms with labs to determine what is the best course of action for this patient. Do we want to try to boost hormones naturally and use supplements and herbs? Are they at a point where they are not producing anything? Maybe they have had a hysterectomy, so they just need hormone replacement therapy. If so, we can go there as well.
Dr. Eric:
A few questions. When looking at cortisol, it sounds like you lean more toward the Dutch test for looking at adrenals when compared to saliva testing?
Dr. Stephanie:
I do both. Let’s say I want to test their sex hormones. If we are going to do a Dutch test, to be clear, you can do it with or without the cortisol. It’s an extra $100 to do it with cortisol. For many people, it’s convenient to add that portion on. If we are not running sex hormones, let’s say they come to me, and we are focusing more on thyroid or gut health or other things, and we are not doing urine hormone testing, I will do saliva cortisol testing. It depends on what I am running for that patient to decide the best combination of tests. How do we make it the most cost-effective for the patient, too?
Dr. Eric:
I take a similar approach. When I dealt with Graves’, I did saliva testing, back in 2008. I wasn’t familiar with the Dutch test. I don’t know it existed back then.
Dr. Stephanie:
I don’t think it did, not through that company.
Dr. Eric:
I did saliva testing for adrenals. These days, similar to you, if I am just going to focus on adrenals, usually I will have someone do a saliva test. If we are doing the hormones, looking at the hormone metabolites, I usually recommend the Dutch test. We’re similar there.
Another question I had: In the past, I would do the cycling hormone test through saliva. Then the Dutch test also offers-
Dr. Stephanie:
They have it, too.
Dr. Eric:
I don’t know why I got away from doing the saliva test. Now, if I recommend a cycling hormone panel, it’s more the Dutch test than the saliva test. I don’t know if you use that.
Dr. Stephanie:
I failed to mention that. There are so many testing options these days. Yeah, I offer that to patients, too. It’s based on patient preference. Some people just don’t want to dip their urine. Some people think it’s easy and convenient to do the urine dipped test. Others like doing the saliva test.
It comes down to cost, too. The saliva test for some people ends up being cheaper if their insurance- We won’t go off on a big tangent. Do it through Genova, and they might get some insurance coverage. Precision is urine. I try to explain all the options to patients. Both can be accurate and very clinically useful.
Dr. Eric:
I’m glad you mentioned the blood test because some people, even if they are cycling, it might be cost-prohibitive for them to do. They would do the blood test one week after ovulation, correct?
Dr. Stephanie:
Yep, which is easy in a 28-day cycle. I have patients go to the lab on days 19, 20, or 21. If their cycle is 35 days or 21 days, then it becomes a little more difficult to determine when the best testing window is for that patient. I always ask if they have any ovulation symptoms, kind of twitching, cramping. Some patients get headaches with ovulation. Cervical mucus changes. If they are having any of that, I make sure we do labs after symptoms suggestive of ovulation. We don’t want to test before.
If someone is having a short cycle, 21 days, we may need to test them very early based on that. They may be ovulating day seven or 10. That becomes trickier. That’s where you need a functional medicine provider to help you know when to test in those situations.
Dr. Eric:
When testing in the blood, can I ask what you test for? Is it just estradiol, estrone, and estriol?
Dr. Stephanie:
Good question. Another one of my pet peeves is providers not looking at estrone. We know in the post-menopausal phase, estrone is way more predominant than estradiol. Many times, estradiol will look normal, but estrone could be very high. I have seen a lot of patients get mistreated with their provider thinking, “You have low estrogen levels. Let’s give you estrogen,” when they really weren’t low. Their estrone was high, but that was never detected. I think I learned that the hard way a long time ago.
I do test estrone in men and women. And estradiol, pretty much every single time I am doing blood work. If I am giving men and women testosterone, I also want to make sure that’s not aromatizing or converting over to their estrogens. Some patients convert over to estradiol. Some we see it in estrone. I think it’s important to test both.
Dr. Eric:
Do you ever test for total estrogens?
Dr. Stephanie:
I don’t. If I don’t order it, it comes back like that sometimes. They give me total estrogens. Maybe we should have this discussion another time, but I don’t know clinically how to use that. I do want to know what portion of that is estradiol versus estrone. You can give me your opinion on that, too.
Dr. Eric:
Good point. When I test for sex hormones in the blood, I’ll commonly test for estradiol and total estrogens. If it’s high, like if estradiol is looking okay, and total estrogens are high, I guess it could be either estriol or estrone. A lot of times, I’ll assume it’s the estrone. I guess you don’t know unless you test for estrone.
Dr. Stephanie:
I would say you’re still doing what’s better. You’re testing for all of the estrogens versus just estradiol. That’s when I think providers miss things, when they are just testing that portion. I guess it’s a good thing to test for total estrogens. We just don’t know the breakdown in that.
Dr. Eric:
Do you look at FSH, LH in everybody? Or just post-menopause?
Dr. Stephanie:
In younger women and men, yes. Totally depends on why they are coming to see me, if it’s fertility-related or not.
Post-menopausally in women, I really like testing FSH. That is telling us how unhappy the brain is with circulating estrogen. Sometimes, I like to explain to patients that when their FSH is very high, like over 100, their body is screaming for estrogen. They need it; they want it. That’s another confirming marker that we need to do something to boost estrogen or give them estrogen replacement. I do test those often. I will say I don’t test them in every single situation though.
Dr. Eric:
Why are hormones important to the aging process? How do they help with longevity?
Dr. Stephanie:
I have already mentioned today symptoms that hormones can help with: hot flashes, PMS, low libido, etc. At the end of the day, hormones are extremely important from an aging standpoint. Even if you’re listening and have zero symptoms, you feel great, hormones will still help you preserve your memory, bone health, heart health. When we think of the top leading causes of death—heart disease, which can be the silent killer—hormones will really help reduce chances of having cardiovascular events. When we think of estrogen helping with vaginal dryness, it helps with the elasticity of the tissues, and not just in that region. It helps with cardiovascular elasticity, to prevent stiffness and narrowing. You even have estrogen receptors in your eyes, all over your body.
As you age, not to get wrinkles and to look good and feel good, I really do think estrogen, progesterone, testosterone, thyroid, and cortisol all are extremely important. I can keep expanding, but hopefully the heart, bones, and brain, everyone should want to keep their memory as they age, hopefully those benefits were strongly conveyed there.
Dr. Eric:
Can you talk a little bit about synthetic versus natural hormones? There is definitely a difference. I assume most of the time you are recommending bioidentical hormones.
Dr. Stephanie:
Absolutely. In my book, I actually put in picture diagrams of the molecular structures of synthetic testosterone versus natural and synthetic progestins versus progesterone. When you think of synthetic hormones, they have to be tweaked in a lab. They are man-made because they are a profitable drug.
A little different than a hormone that is more bioidentical to what your body is making. Those are usually plant-based. Those are also slightly tweaked in the lab, so they are turning a yam basically into a hormone structure that is biologically identical to what your body is already making, meaning taking natural progesterone should fit like a key fitting in a keyhole. That progesterone should fit into your progesterone receptor exactly.
Synthetic progestins have a totally different molecular structure. They are going to bind partially but not fully as well as natural progesterone would into your hormone receptor. Synthetics are harder for the body to detoxify. They come with greater risks. They were what’s used in the Women Health Initiative study that scared away everybody from using hormones.
The #1 most prescribed drug last year was Prozac. All these women were left with many symptoms that hormones could have helped. Rather than find safer options of the hormones, we just started prescribing antidepressants to these poor ladies. I do think that hormones can be used safely and appropriately. We just need to absolutely be looking at labs, symptoms, using only bioidentical hormones, and given in the safest strata of administration as possible for that patient.
Dr. Eric:
Do you use any natural agents, like chaste tree or maca root, to help with progesterone?
Dr. Stephanie:
Yeah. Maybe I’ll expand on what I think you’re asking, if I use natural agents before we get to hormone replacement therapy to boost hormones. I personally took a blend of ProgestoMend from Douglas Labs, a blend of progesterone-boosting herbs, for my health years ago before I actually went on progesterone.
I actually want to go back and also say before I even get to those things for the younger population, I also talk to them about three things. The first is reducing stress. Stress is your body’s biggest hormone hijacker. There is no pill, potion, or powder that is going to replace lifestyle changes. Even for me, I had to say no to some things. I had to back off. I had to get into yoga and deep breathing. One of the best things you can do to optimize hormones is reduce stress.
The second thing would be to detoxify the body. I used to go to Bath & Body Works and get all these toxic lip glosses and lotions. I had all these chemical hair straighteners. I was essentially self-inflicting myself with all these endocrine-disrupting chemicals that were creating more of an estrogen dominance that led to endometriosis and some infertility. I wish I would have known back then to avoid fragrances and these parabens. I didn’t know, but you can only move forward. You can’t go back. I would encourage listeners to work to eliminate environmental toxins and do a liver cleanse, something like that, to help as well.
The third thing would be to work to fix nutritional deficiencies. Magnesium for instance, everybody needs. It’s important for thyroid hormone production and sex hormone production. It was certainly something I was really low in. That is just one example of a supplement, a nutrient that can help to boost hormones. There are several others.
For many of my patients, I am running nutritional analyses to see what vitamins, minerals, amino acids, antioxidants, Omegas they need. Let’s saturate the body with the nutrition they need first, and then retest hormone levels.
If still, after reducing stress, detoxing the body, fixing nutritional deficiencies, they are still not where we need them to be, then I will pull out the herbs. Yes, I’ll use herbs to boost estrogen, progesterone, testosterone if we need to, or lower testosterone. For patients with PCOS, sometimes we need to lower the androgens. I do use herbs after I get through those first three steps.
Dr. Eric:
Typically, what do you use to lower androgens? Saw palmetto?
Dr. Stephanie:
Saw palmetto is excellent. It specifically will block testosterone’s conversion to DHT. It’s a 5-alpha reductase inhibitor or blocker. We have a different combination of those herbs. Men will use them as well. Pumpkin pygeum horsetail, stinging nettles, saw palmetto. Those are the ones off the top of my head. We have a blend and various products that we’ll use for patients when needed.
Dr. Eric:
With testing for nutrients such as magnesium, you mentioned Omegas, I don’t know what testing you use, but I know you mentioned earlier Genova. Do you use the NutrEval, or do you use some other test? Blood testing?
Dr. Stephanie:
I am privy to Genova’s tests because I think, “I’ll use Great Plains for OAT testing.” We use probably 50 different lab accounts at our clinic. I am privy to Genova because I am privy to how they present their results. They are color coordinated with high needs and low needs. It’s very patient and user friendly. I do like that test. That also looks at nutrient needs. It will also give me a glimpse into gut health because it has some bacteria and yeast markers on there. It has oxalates and toxin markers and a basic heavy metal screening. It’s a really comprehensive glance at one’s health. That can help direct us to know which path we need next to go down. Do we need to focus on gut health? Do we need to focus on detoxification? I think it’s a great test. Everybody should have that test run.
Dr. Eric:
Depending on the answers that the test gives, you mentioned gut health. Do you ever run a comprehensive stool panel? Maybe look at beta-glucuronidase or other markers of dysbiosis?
Dr. Stephanie:
Yep. Many of my patients, which you are probably running as well, are doing food sensitivity testing. Back to chapter one of my book. In that chapter, I discuss literally what you just said. A stool test, a food sensitivity test, maybe SIBO testing. A lot of these patients will have gut infections. An infection is a stress on the body. Stress will rob you of hormones, not just psychological stress, but stress from things like infections. I absolutely run stool tests. I usually start with food testing. Let’s face it, most patients have GI issues as well. If the food testing and changing the diet improves symptoms, we may not need to dig deeper. Sometimes, we do. The stool test is usually the next step there for sure.
Dr. Eric:
Just a quick question with food sensitivity testing. Do you use IGG or MRT?
Dr. Stephanie:
I like IGG. I’m privy to that. I feel like there are different opinions. I think everyone finds what’s clinically most useful for them. I think it varies per lab because some labs’ tests are more repeatable. I do like IGG testing. IGA and IGE, sometimes, too.
Dr. Eric:
Getting back to the hormones. I don’t think you mentioned as far as type of hormones. Do you recommend for example progesterone cream or pellets?
Dr. Stephanie:
We offer everything here. When I started practice, I started with what I felt was the safest: the topicals, the transdermal application. I do think for patients who are very sensitive and have mild symptoms, topicals are great. A couple years into practice, I found out a lot of these patients are having dermal fatigue, where they get receptor resistance. They are applying the cream to the same place over and over, and they quit working. I needed to learn other ways to replace hormones.
I used sublingual dosing, so I do prescribe a lot of compounded sublingual hormones. Like putting B12 under the tongue, we do compound hormones under the tongue. I do prescribe oral progesterone because we can compound a sustained release version to release throughout the night, keeping patients asleep. Sublingual can’t be compounded as a sustained release version. That needs to be in the delayed release capsule. I do prescribe oral progesterone.
We do a lot of pellet procedures. Progesterone has not been invented in that pellet form yet, so the pellets are more for estrogen and testosterone. Estradiol and testosterone for men. Women will need estrogen as well.
I found throughout the last decade+ of practice that a lot of patients who are very symptomatic, or let’s say, they come to me and are not symptomatic but need to build bones. Hormone pellets are the quickest, best way to do that. Using topical hormones can help a little bit. Oral hormones can help a little bit more. I know there are patches as well.
I don’t remember off the top of my head, but I want to say oral and patch replacement therapy helps 1-3% as far as improving bone mineral density. Pellets can help up to 8%. Pellets in the literature really outperform any other form of hormone replacement therapy, which is really cool. I have seen patients come in with osteoporosis and a couple years later have normal bone density, which is amazing. There is no drug out there that is helping to build bones like natural hormone replacement therapy can. That is exciting for me as a clinician but super exciting for patients as well. They get to go back to their other doctor and say, “Look at this. My bones are improving.” Really exciting.
Not everyone is a candidate for pellets. Those patients who are sensitive to everything, no way am I putting a pellet in them. You can’t take the pellets out once they are in. There are patients who are good fits for the pellet. We just have to strategize with the patient what hormones they are going to take, what form, and what dose. Personalize that approach for them.
Dr. Eric:
Earlier, you mentioned an example of someone having a hysterectomy, and you will recommend hormone replacement. Is that every woman? Or is it just if they have a complete hysterectomy?
Dr. Stephanie:
That was one extreme example, which unfortunately I see a lot. I have a lot of patients in their 30s and 40s who have had hysterectomies because they had heavy bleeding or fibroids. I will also point out sadly, knowing they have had these surgeries, yes, we can replace hormones and help them, but having the surgery never got to the root cause of the problem as far as why they had the heavy bleeding in the first place. Removing the uterus doesn’t get to the root cause of the problem. We still have more work to do with those patients. Tangent there.
I have patients who haven’t had hysterectomies who need hormone replacement therapy. Maybe they had a very stressful decade of their life from mid-20s to mid-30s, and they are burned out. I see men and women with extremely low testosterone. I still replace individuals who haven’t had surgeries like hysterectomy. That was just one sad, common example that I also see.
Dr. Eric:
I’m sure there are some people listening to this who are completely anti-hormone. “I don’t want to take any type of hormone. I just want to do things naturally.” I keep an open mind. If stress and adrenals is the big problem and depleting the hormones, of course, I want to do things to help improve their stress handling skills. You spoke about doing this, too. In the meantime, the person might need to be on progesterone. Maybe not depending on the situation.
For those who have concerns about hormones, there are some who just maybe don’t want to take it. There are others who are concerned about it will maybe cause cancer, especially if you recommend estrogen. Can you talk about that? Maybe alleviate any fears people have about that.
Dr. Stephanie:
Common question I heavily discuss in the book. Hormones don’t cause cancer. If hormones cause cancer, we would have a bunch of 20-year-olds with cancer because they are the ones with high levels of sex hormones, right? We would see patients going through puberty, high hormone levels, getting cancer, and 90-year-olds not getting cancer. That’s not the case. The opposite is true. We don’t see cancers usually in young individuals with high hormone levels; we see it in the elderly with lower hormone levels. I do want to dispel that myth.
Some people need to be more careful with hormone use. If they have significant family history of breast cancer, I am going to be very cautious giving that patient estrogen. That also comes back down to you doing the year-end hormone metabolism testing. If I can assure we have these three major estrogen metabolism pathways working in your favor, and we optimize them, that will increase my confidence with the safety of me prescribing that hormone. In conventional medicine, none of this is done. That totally baffles me. In those cases, I will be more cautious with the use of estrogen, but it doesn’t mean it’s contraindicated. Hormones don’t cause cancer.
I will say hormones can feed an existing cancer. If someone had an estrogen receptor positive breast cancer, I am absolutely not going to give them estrogen. If a man had active aggressive prostate cancer, I am not going to give him testosterone. But hormones don’t cause cancer.
I will say the increased risks that were shown in the Women’s Health Initiative study although that was a very poorly designed study we could talk about. In that study, they were using synthetic, oral, horse urine, basically. The estrogens that were used there were from horse urine, and they were given orally. We think a lot of the risks with estrogen come down to that estrogen being synthetic and taken by mouth. When the hormone is taken by mouth, it has to be metabolized through the gut and liver, and that is where increased clotting can increase the risk of cancer. It’s not the hormone itself, but if we are metabolizing it improperly, bad things can happen like fibroids, cysts, and heavy bleeding.
Dr. Eric:
Let’s talk more about estrogen metabolism. What are some of the things you do to help support estrogen metabolism?
Dr. Stephanie:
Sure. The only way to assess metabolism or detoxification or elimination is in the urine. Genova used to offer this test, which was available back in 2008, but it can’t offer it because they use helium as one of their analytes for androgen. There is a helium shortage. Precision Analyticals is a main lab that offers urine testing for estrogen right now.
Bottom line is in that test, we can look at three pathways. One is the 2-16 ratio, looking at how high your 2s are—this might be over the heads of listeners—as compared to the 16s. If that ratio is unfavorable, there are things we can do like increase consumption of cruciferous vegetables or take a supplement called DIM. DIM is like eight pounds of vegetables a day without the gas. That will improve the 2-16 ratio to reduce breast cancer risk or even just risk of fibroids and cysts.
The next pathway we can look at is methylation. Many times, if I see poor estrogen methylation, I assume they are a poor methylator in general. It’s a phase two detox pathway. If methylation is poor, usually the easiest thing we can recommend to improve that is methylated B vitamins. Not everybody responds well or tolerates them, so sometimes we have to use other strategies. Methylated B vitamins can help there.
Lastly, the most dangerous marker on a urine hormone metabolism test is called 4-hydroxy estrone. If oxidized, that can lead to DNA damage and then cancer. How do we prevent that? We give antioxidants. This is what my doctorate was on, these pathways. Back then, the major antioxidants in the literature that could help that were n-acetyl cysteine and resveratrol. I think n-acetyl cysteine is great for a lot of things in general. A lot of patients take it for immune purposes these days. It boosts glutathione, which is the most powerful antioxidant in the body. I do think glutathione itself is very helpful for protecting you against that elevated 4-hydroxy estrone. There hasn’t been a lot of studies on it, but the ones that exist are more for n-acetyl cysteine because that’s what boosts glutathione.
There are things we can do if we find unfavorable estrogen metabolites to optimize them, to improve them, which is hopefully very encouraging to the listeners.
Dr. Eric:
Thanks for sharing that. Is there anything else that I should have asked you that I didn’t ask you? Anything else you want to expand on?
Dr. Stephanie:
I don’t think so. I will just say don’t fear hormones. Hormones can help you age well. A lot of patients have been burned, maybe because they saw a provider who didn’t quite know what they were doing. If you were going to have brain surgery, you’d want to go to a brain surgeon. If you want to optimize your hormones, go to a hormone specialist. See someone who really knows what they’re doing, so you don’t get burned. What they are giving you is really safe and effective.
Dr. Eric:
One more question that came to mind is how frequently do you retest? If someone is on progesterone or whatever hormone, when is the first follow-up? How frequently? Is it every month, every few months?
Dr. Stephanie:
Variable. I’ll say on average, for a new patient, they come in and see me. We will test hormones after the first visit. We will bring them back to go over those hormones. We will initiate some form of hormone replacement therapy.
Let’s say they know they want hormone pellets. They will get peak pellet labs done six weeks after their first pellet insertion. We will see what range they are in six weeks after the procedure. They will come back again. We will go over those labs. For many patients, if they are smooth sailing, if their labs are good, we have achieved symptom relief, we only test their hormones once a year. Once we know we are smooth.
For sublingual and topical, it’s a little different. I measure those primarily doing the Dutch test. I will get them hopefully smooth sailing within the first 2-3 months. We may have to tweak the doses a bit. Once the Dutch test comes back favorable, if levels are optimal, then I will test them once a year.
Not everybody is just smooth sailing out of the gate. For some of these patients, if we have to tweak their dosages, I am not going to wait a year to retest. We will retest at another three months. Once we’re smooth sailing, then I will test them once annually.
For some patients who have higher risk of breast cancer, they may want to do the Dutch test twice a year. It’s fine, it’s their money. I will test them as often as they want.
For blood testing, if I am just putting someone on progesterone, I may test their level two or three times in the first six months to make sure their dose is appropriate. Again, once they are smooth sailing, it’s usually once a year.
Dr. Eric:
Awesome, thanks. Where can people learn more about you, Dr. Stephanie?
Dr. Stephanie:
I have a couple different websites. YourLongevityBlueprint.com has my book, our podcast, and all of our supplements. There is a free tip sheet on the homepage reviewing some of what we talked about today: three tips to boost your hormones naturally, breaking down reducing stress, fixing nutritional deficiencies, and detoxifying your body.
My clinic website is IHHClinic.com for Integrative Health and Hormone Clinic in Iowa.
You can also find me on Instagram, StephanieGrayDNP, and Facebook. I also have a free e-book, YourLongevityBlueprint.com/Creating-Resilience. That is a step-by-step guide on what stress is and how to minimize its impact on your body and hormones.
Dr. Eric:
Check out Dr. Stephanie’s book, podcast, and other resources. Thank you so much for sharing your knowledge. It was a pleasure chatting with you. That was a lot of valuable information, especially with regards to hormones and touching upon some other great information. Look forward to being on your podcast as well. This was amazing, so thank you so much, Dr. Stephanie.
Dr. Stephanie:
You bet. Love talking about hormones.