RHR: What Mainstream Medicine Gets Wrong About Hormones with Dr. Sara Gottfried

RHR: What Mainstream Medicine Gets Wrong about Hormones with Dr. Sara Gottfried

by Chris Kresser

Last updated on

revolution health radio

What are the biggest mistakes in the mainstream treatment of hormone imbalances? Dr. Gottfried and I discuss these mistakes, post birth control syndrome, and what hormone treatment should look like.

Typically a woman will go in to see her doctor, and if she complains of any symptoms related to hormone balance, it seems to me that one of two things will happen. This is an oversimplification, but one is nothing. Nothing happens. There’s actually no investigation into hormone levels as a possible cause of her issues or anything that could affect hormone levels directly. Maybe two is that an antidepressant gets prescribed. Or three, if the practitioner is maybe a little bit more progressive than most, they might recommend hormone replacement, estrogen perhaps if the woman is in menopause or maybe estrogen and/or progesterone if she’s still menstruating. What’s wrong with that as a model?

In this episode, we cover:

3:30  Biggest mistakes in mainstream treatment model
9:23  Post birth control syndrome
22:43  What hormone treatment should look like
49:35  Three things most women with hormone problems would benefit from
55:35  Sara’s next book

Chris Kresser: I’m Chris Kresser and this is Revolution Health Radio.

Hey, everyone, it’s Chris Kresser. Welcome to another episode of Revolution Health Radio. I’m really excited to welcome Dr. Sara Gottfried as our guest today. She is the New York Times bestselling author of The Hormone Cure and The Hormone Reset Diet. After graduating from Harvard Medical School and MIT, Dr. Gottfried completed her residency at the University of California at San Francisco. She is a board-certified gynecologist who teaches natural hormone balancing in her novel online programs so that women can lose weight, detoxify, and slow down aging. Dr. Gottfried lives in Berkeley, California, with her husband and two daughters.

I met Sara a few years ago. I was on my book tour, actually, in Chicago, and I got a text from her. I think she was there also on one of her book tours, and we had dinner and hit it off and became fast friends. I have tremendous respect for Sara and her work. She’s one of the brightest practitioners that I know and just has a really holistic and informed perspective on functional medicine and nutrition and, of course, hormone balancing, which is an area that she has a lot of expertise in. In fact, if I have a question about hormones or hormone balance or anything to do with testing and diagnosis and treatment of hormone issues, I’m almost certainly going to ask Sara about it. There aren’t that many practitioners that I have that kind of respect for and collaborate with on a regular basis, and Sara is definitely one of them, so I’m really excited to do this episode. I’ve talked about hormones and hormone balancing to some extent in the past, but we haven’t really taken a deep dive, and I thought Sara would be the perfect person to do that with, so let’s jump in.

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OK, now back to the show.

Chris Kresser: Sara, I’m so happy we finally made this happen. I can’t believe we waited so long.

Sara Gottfried, MD: Hey, Chris. I’m so happy to be here.

Chris Kresser: Let’s kick things off by talking about the biggest mistakes that are made in the mainstream medicine model when it comes to addressing hormone imbalance. Typically a woman will go in to see her doctor, and if she complains of any symptoms related to hormone balance, it seems to me that one of two things will happen. This is an oversimplification, but one is nothing. Nothing happens. There’s actually no investigation into hormone levels as a possible cause of her issues or anything that could affect hormone levels directly. Maybe two is that an antidepressant gets prescribed. Or three, if the practitioner is maybe a little bit more progressive than most, they might recommend hormone replacement, estrogen perhaps if the woman is in menopause or maybe estrogen and/or progesterone if she’s still menstruating. What’s wrong with that as a model?

Sara Gottfried, MD: What’s wrong with this picture? Chris, you and I have met a lot of mainstream hormonal refuges over the years, and so I think there are many problems with the mainstream model. I’ll just rattle off a few of them, and we can drill deeper if you want.

Sara Gottfried

First, I would say, is there’s a lack of regard for root cause, especially if you’re seeing a primary care doctor who works by algorithm, by kind of rote algorithm. There’s this kneejerk quality to it. So if you’re 17 and you have acne, you end up with a prescription for a birth control pill, and there’s no careful assessment of the control system that could be leading to the high androgens or the food intolerances or the gut issues that could be at the root of the acne. And as you’ve described, if you’re 25 and you have painful periods, the pill, yet again, is considered the solution.

What I think is a problem here is that women are getting put on synthetic hormones or, in some cases, bioidentical hormones for almost any issue well into their 50s, 60s, and 70s, and there’s often a cost to it. There are long-term alterations to the control system for hormones, which I assume we’re going to get into today, and I just see this lack of regard for root cause, so that’s one.

A second mistake is the financial motive, and this one is really troubling. When you look at birth control pills and how they first started in the 1960s and maybe initially were thought to be an instrument of female empowerment, it’s now this gigantic moneymaker for Big Pharma. Just with the birth control pills that are on patent, it makes more than a billion dollars per year for pharmaceutical companies, and I have to say that I think the pill is the number-one endocrinopathy for women—which is totally caused by the prescriber—in the developed world.

Chris Kresser: An iatrogenic problem.

Sara Gottfried, MD: Iatrogenic, absolutely. And the same is true for hormone therapy, for hormone replacement therapy for older women. Premarin or conjugated equine estrogens synthesized from pregnant horses, that was the number-one prescription in the US for a long time. Even in 2002, when the Women’s Health Initiative was published, it was the number-four prescription in the US. We then had data from the Women’s Health Initiative about how it’s dangerous and provocative to the female body, leads to a greater risk of stroke and together with synthetic progestin increases a woman’s risk of heart disease and breast cancer.

And this then leads to a third mistake, which is a lack of rigorous evidence behind the mainstream approaches to hormone problems, and maybe even more insidious, the lack of awareness of the lack of evidence by folks in mainstream medicine. Premarin was prescribed for 57 years before we finally had a randomized trial to show that it was a problem, and this is a shameful part of our past in American medicine.

Chris Kresser: It’s bizarre, really. These chemicals, including drugs, are innocent until proven guilty. Obviously there’s a process for determining the safety of a drug before it’s introduced, but in cases of hormones, it seems like that process failed—early on, at least.

Sara Gottfried, MD: It certainly did. I think there’s another issue here, maybe a little more subtle than a mistake, but a sociocultural problem. This one is kind of creepy. I think there’s a patriarchal quality to how hormones are addressed. I’ll mention this just briefly so we can get to some solutions, but I was taught in my conventional training that you don’t need to check a woman’s hormones because they vary too much, with one exception—if she’s trying to get pregnant. And in that case, if she’s having trouble getting pregnant, then you check everything. You do a thyroid panel, you do a day-three estradiol, you look at her FSH and day-21 progesterone, her androgens, her cortisol, her cortisol metabolites. That’s a total double standard.

Chris Kresser: If she’s trying to procreate, we can get involved, but if not, forget about it.

Sara Gottfried, MD: If not, you’re on your own, or why don’t you take this nice birth control pill?

Chris Kresser: Yeah. Let’s talk a little bit more about that, what we might call post birth control syndrome, because you alluded to it a couple of times, that birth control is the number-one endocrinopathy and it causes a problem with our natural hormone regulation. I just had a patient last week that fits into this category, so it’s at the top of my mind, and I think it’s always helpful to use these kinds of examples so that folks who are listening know what we’re talking about and it’s not just theoretical.

This is a 23-year-old female, and from the beginning of her cycles, they were painful and difficult. She had skin issues and a lot of problems associated with that, and so, of course, not surprisingly, she was prescribed birth control and took it. Fast forward eight years later, she’s a patient in my office with numerous complaints. I tested her hormones, using both urine and blood, and found that her total estrogens were high with altered estrogen metabolism, so she was metabolizing estrogens down a proliferative pathway that can increase the risk of breast cancer. She had cortisol dysregulation, so inappropriate secretion of cortisol through the day and also high cortisol overall. Her androgens were high, so not only DHEA, but also etiocholanolone and androsterone and then testosterone and DHT. Her copper/zinc balance was totally out of whack, out-of-the-reference-range high copper and below-the-reference-range zinc. And then iron deficiency and a number of other problems. If you look at the scientific literature, pretty much everything that I just mentioned can be traced to birth control pills, but she was never told that this could be a problem.

Sara Gottfried, MD: Yeah, well, this is so troubling, and before we dive into this, is she now off the pill? Please tell me she’s off the pill!

Chris Kresser: Yeah, she went off of the pill, like, three or four months before seeing me. She knew that would be the recommendation and did it and then wanted to see where her hormones were after being off the pill for a few months. So, yes, she is off.

Sara Gottfried, MD: Yeah. Good. Well, I think this is a great example, unfortunately, of the endocrinopathy that can happen, as well as micronutrient deficiencies. I know you’ve talked about this with your listeners before, but just taking a step back, we know that the birth control pill makes the control system less flexible. The control system for hormone regulation, this feedback loop, which some people call the HPA, the hypothalamic-pituitary-adrenal axis—I like to think of it a little more broadly as the HPATG, the hypothalamic-pituitary-adrenal-thyroid-gonadal axis—that system becomes a lot less flexible when you go on the birth control pill. There are numerous micronutrient deficiencies, and what troubles me is that I doubt this woman ever got full informed consent.

Chris Kresser: No way.

Sara Gottfried, MD: No way, right?! This is kind of that mistake that we were just talking about, where I think so many prescribing health professionals aren’t aware of these potential risks.

Chris Kresser: Right.

Sara Gottfried, MD: They don’t know that 20 to 25 percent of women on the pill have vaginal dryness. That’s, like, the greatest irony ever, right?! Especially if you go on the pill because you want to have more sex! You have vaginal dryness, and you’re just like, “What’s going on?!” It can shrink the clitoris up to 20 percent. It just has a number of effects that may not be completely reversed when you go off the pill. That should be part of the informed consent.

There’s a study from Claudia Panzer where she looked at… you know, one thing that happens when you go on the birth control pill is that it raises this intermediary, sex hormone-binding globulin. I think of it as a sponge that kind of soaks up your androgens, and that’s one of the reasons why going on the pill can reduce your androgen levels and then reduce acne. But by the same token, when you stop the pill, up to a year later, women still have elevated sex hormone-binding globulin. There are these persistent changes to the matrix of the body that really disturb me.

Chris Kresser: Yeah. I’ve tested so many women now at various stages in that process, people who have just gotten off birth control maybe a month ago, people who have been off it for two years but were taking it for 15 years and still have abnormal hormones and either oligomenorrhea or dysmenorrhea or amenorrhea. They’re on different parts of the spectrum in terms of issues with the menstrual cycle, and maybe still, if they’re trying to conceive and that’s why they’ve come off the pill, they’re not able to because their hormone system is so dysregulated. That’s one of the saddest… “side effect” seems insufficient as a term for that, but that’s one of the most devastating potential effects of long-term use of the birth control pill.

Sara Gottfried, MD: Well, it’s a tragedy. I’ve seen a number of patients—I don’t know what the numerator and denominator are here because I just haven’t seen good data on it, but I’ve seen at least 10 people over my lifetime of taking care of patients who have ovarian insufficiency. Like, they just stop having their period. They’re in their 20s or 30s, and they have the hormones of a menopausal woman, and they want to make babies and they can’t. In fact, I think I sent you one of these women recently.

Chris Kresser: Yeah.

Sara Gottfried, MD: It’s just awful. It’s totally awful, and it’s very hard to reset the system. It’s not quite as flexible as we would like it to be.

Chris Kresser: No. With those patients, I’m definitely careful to set expectations up front because it is possible, and in most cases we’ve been successful, but it’s not something that’s going to happen overnight, and it requires really digging into all of the various mechanisms that can affect hormone function and to really reset and kickstart normal hormone production again.

So that’s the problem with the conventional medicine model—or one of the problems or some of the problems! Then there’s another world, which is this anti-aging medicine world, where the kind of prevailing idea is that… it’s kind of like the deficiency replacement model.

Sara Gottfried, MD: Yeah.

Chris Kresser: If the hormones are low, simple—just give hormones, whether that’s estrogen or progesterone or testosterone. That’s not even really necessarily the mainstream model. That more kind of fits in the kind of integrative, anti-aging medicine model. Let’s talk a little bit about the issues there.

Sara Gottfried, MD: Oh, yes. Well, I sometimes call this the topping-off model.

Chris Kresser: Right!

Sara Gottfried, MD: Where you’re taking the tank of all these different sex hormones and you’re topping them off. To me, this is a really unskillful way of working with the intelligence of the hormonal feedback system. It’s a sledgehammer instead of a nudge. And I find, after taking care of patients for the past 25 years, a nudge works a lot better! At least at the beginning and in the middle. This more anti-aging school of thought is almost like spray-and-pray.

Chris Kresser: Right.

Sara Gottfried, MD: Like, let’s top off every single hormone—pregnenolone, growth hormone, estrogen, progesterone. How about some testosterone? And, oh, a little DHEA, too. I think when you do that, it’s very hard to understand how you’re changing the feedback mechanisms, and there’s a total lack of regard for evidence, long-term safety, and other consequences. So I want to be careful not to get totally binary about how anti-aging is bad and functional medicine is the best approach, and I think the way to do that is to look at some of the evidence. So could we talk about Suzanne Somers?

Chris Kresser: Sure. Sounds fun! I don’t think I’ve ever talked about Suzanne Somers on my podcast, so it’ll be a first!

Sara Gottfried, MD: Good. Well, I think everyone can kind of visualize Three’s Company, or if you can’t visualize that, you’ve seen some of Suzanne’s blockbuster books. I’ve tracked her really carefully. I don’t know her personally, I don’t know kind of the backstory, but she started off in menopause with pretty hefty doses of what was then called hormone replacement therapy—estrogen, progesterone, and testosterone. And she took them to deal with what she famously called the Seven Dwarves of Menopause—Itchy, Bitchy, Sleepy, Sweaty, Bloaty, Forgetful, All Dried Up. I think those are the seven. That’s kind of cute, but lo and behold, within a few years, she was diagnosed with breast cancer. I don’t know if anyone was checking her estrogen metabolism, but it seems unlikely.

Chris Kresser: Yeah.

Sara Gottfried, MD: So she then left the care of the endocrinologist that she was seeing, and she started the Wiley Protocol, which is a series of different doses of estrogen and progesterone cream that you apply to your arms in order to mimic the hormone levels of a woman in her 20s.

When I first heard this concept, I was like, are you crazy?! Why would you want to take a 50 or 60 or 70-year-old woman and give her the hormones of someone in their 20s?! That makes no sense to me! But more important than that is there are no long-term randomized trials. The Wiley Protocol gives you this whopping dose of estrogen that’s about four-fold what the FDA has approved as a safe upper limit, and so it sets you up for estrogen dominance, for high estrogens relative to progesterone. And then, maybe not surprisingly, Suzanne Somers was then diagnosed with endometrial cancer. Endometrial cancer. Is that surprising? No. Is it preventable? Probably. Endometrial cancer usually is.

So what’s wrong with giving people these massive doses of estrogen and progesterone and testosterone in pellets, etc.? I think the biggest problem is there are no long-term randomized trials showing that it’s a good idea. And they’re often prescribed by people with limited training. Like, they did a weekend workshop and they’re actually emergency medicine physicians.

Chris Kresser: Right.

Sara Gottfried, MD: There’s kind of a blithe disregard of the skeptics. You know, just fill up the hormonal tank, and that will help you not get old before your time. I just think there’s a real danger here to the lack of robust data.

Chris Kresser: Yeah, when you look at it from an evolutionary perspective, which I often, of course, do in these situations, it doesn’t make a whole lot of sense, as you pointed out. It’s not like throughout most of human history women had the same hormone levels all the way throughout their lives, whether they were in premenopause or menopause, but then there was something about the modern lifestyle that dropped women’s hormone levels in menopause, and so giving hormones is like getting us back to a natural state. It’s a totally artificial construct, this idea that a menopausal woman’s hormones should be the same as they are prior to menopause. That’s just a notion that no one has ever really explained, at least that I’ve seen, how that makes sense or why that would even be a good idea.

Sara Gottfried, MD: Right, and I think there are many layers to it. I think some of it is valuing women as wombs and sort of saying, OK, let’s replace her back to what she was like in her prime, in her 20s.

You and I have talked also about, you know, when you look at a woman’s hormones, context is so important because often low estrogen, low progesterone, there may not be any symptoms associated with that. It may not be a bad thing. In fact, it may be associated with greater healthspan, and so what’s the innocent bystander versus a potentially pathological situation that we can address and improve quality of life and improve other outcomes that are important, like breast cancer, heart disease, so on.

Chris Kresser: Right, and as we’ve also discussed, even if the hormones are pathologically out of range, it doesn’t necessarily follow that addressing the hormones directly is the best way to remedy that, which leads us into the next topic, which is what is the best way to approach hormone issues from a functional medicine perspective.

Sara Gottfried, MD: Yes, well, I want to riff on this with you because I think we have different approaches. There’s a lot of similarity, but I think… what I’ve learned to do over the years is to start with root cause analysis. I’m going to kind of reveal myself here as an engineer! I feel like you get the best results when you approach hormone issues like a medical detective and you really work through a particular sequence of modules.

You and I have talked about this as kind of a root-and-branch approach. Do you want to say anything about that? I think that was your language, and I think that it’s so valuable here.

Chris Kresser: Sure. Anyone who’s been listening to this show for any length of time or following my blog will know this, but in functional medicine we try to address the underlying cause of illness rather than just suppressing symptoms. If you think of it as a tree, that would be looking at the roots of the problem. When you do that, it’s very often the case that the branches, which really kind of represent the manifestations of the underlying dysfunction, and if you think of a tree that branches out in a number of different directions, you can have many different manifestations—or symptoms, as we call them—of a fundamental cause that may seem like they’re unrelated if you’re only looking at the branches because one branch is going off in that direction, another branch is going off in the other direction, and they don’t really look related, but if you trace them back to the roots, you see that they’re related.

That’s one aspect of the root-branch model, but the other is—and I think this is the one we were talking about, Sara—is that although it’s true that the best approach to long-term healing is to address the underlying cause, it’s also true that sometimes symptoms can be so problematic and difficult to live with that you have to address the branch at the same time as the root just so that the patient can have the wherewithal to stick around and stay with the process long enough to deal with the root. For example, if a woman is having hot flashes multiple times every hour and is soaking the bed at night because of this and not sleeping at all, well, yeah, it’s all well and good to deal with the long-term underlying causes, but if that process if going to take months, you better do something right away to help her to sleep and stop sweating as much.

Sara Gottfried, MD: Yeah, that’s a great example. I think that often with hormonal symptoms, women especially are suffering, and they can’t take on some of the lifestyle redesign, the changes to the diet, and we want you to exercise this much and stop sitting so much. They can’t take it on when they’re exhausted and hot-flashing constantly, so I totally agree with that.

What I talked about in my first book, The Hormone Cure, is a really simple functional medicine approach, and we can talk about that. We can also get into some more details, but what I start with, which I think is probably self-evident, is with an initial assessment and really kind of understanding the symptoms, looking at all those branches, and also getting a sense of the relative weight that the patient places on them. That piece, I think, is especially important because it’s so different from person to person, and I can give you some examples of that in a moment. That’s the piece that I think is often missing in the mainstream medical appointment of whatever it is, 7.5 minutes.

Chris Kresser: Yeah.

Sara Gottfried, MD: I used to work at a health maintenance organization where I was expected to see 30 to 40 patients a day. You can’t sit for an hour and learn about every branch and every root in 7.5 minutes.

Chris Kresser: No.

Sara Gottfried, MD: Then I do confirmatory testing, and what I’ve found over time is that I can predict most hormone levels just by looking and talking to somebody. Occasionally I’ll be surprised, such as with cortisol. I think that’s sort of a less predictable hormonal character, but for the most part, you can sort of predict what’s happening hormonally and sort of what pattern somebody fits in. Then the approach that I talked about in The Hormone Cure is to start first with lifestyle redesign. You talk about this a lot—addressing the food, the movement, filling the micronutrient gaps. Most hormones take six weeks to reach a new steady state, so I’ll often start people on these targeted lifestyle protocols for six weeks, and then we measure progress, both symptoms and also laboratory tests.

Step two is herbal therapies. You have a long experience with Chinese medicine. I have been studying Ayurveda for a long time. I feel like this is the nudge that a lot of people need—with some exceptions.

Step three is bioidentical hormone therapy, but at the lowest dose and for the shortest duration, almost like small experiments, kind of these n-of-1 experiments, when the first two steps don’t yield results.

But going back to that woman who is miserable, having hot flashes every hour, often what I’ll do is we’ll start the lifestyle redesign. I know that the chance that herbal therapies are going to help her with having hot flashes once every hour is so slim—on the order of, like, 10 to 20 percent!—that it’s probably worthwhile to do some of the baseline testing and get her started on even a small dose of bioidentical hormone therapy, just to kind of get her through that initial period of time.

Chris Kresser: Yeah. Another analogy I like to use for this is a raft that helps you get from one side of the river to the other. It’s really useful, but once you get to that other side of the river, you generally don’t drag the raft around with you anymore. If we think of bioidentical hormone replacement as a raft, it can fulfill that kind of function.

Sara Gottfried, MD: For sure, and I think another helpful part, when you look at hormone issues from a functional perspective, is this mnemonic that I learned at IFM. I mean, it’s something I learned way before that, but they put it together in a way that I think is easy to remember. I don’t know if you’ve heard of this, Chris, before, but they use the mnemonic PTSD. Sort of an unfortunate mnemonic, but the P is production, synthesis, and secretion of that particular hormone. T is transport of conversion, distribution, interaction with other hormones—the crosstalk that happens with hormones. S is sensitivity to the hormone signal. Most people have heard of insulin resistance, and from you, they’ve heard about cortisol resistance, thyroid resistance. And then the D stands for detoxification, metabolism of the hormone, and then excretion of the hormone. I think that’s a helpful mnemonic to kind of think about some of those root causes that need to be addressed when you have hormone issues.

Chris Kresser: Yeah. As you say, my approach, I think it’s, of course, impossible to talk about hormone function without talking about all of the other body systems that affect hormones, the PTSD, every aspect of hormone production and metabolism. By that, I mean things like blood sugar regulation, other hormones like insulin and leptin sensitivity. Gut function, for sure, plays a big role. If there’s some kind of inflammatory gut condition, that’s going to affect hormone balance. Toxins, like heavy metal toxicity. I’ve been certainly spending a lot more time learning about biotoxins like mold and their potential effect. Then we have the liver. It’s part of the gastrointestinal system, but liver function, liver capacity and detox capacity, which obviously has a big impact on hormone balance and is something you have spent a lot of time addressing in your detox programs and in your books and your writing in general.

It’s kind of a good-news/bad-news thing, right? If a woman comes in and says, “I’ve got a hormone issue,” and you say, “No, you don’t. You have a gut, blood sugar, detox, heavy metal, potential mold toxin, gut-brain axis issue.” They’re like, “Whoa! Wait! What are you talking about?! I have a hormone issue!” Hormones are kind of the tip of the iceberg in that respect, but the good news is that the model for addressing hormones in the way that you and I are talking about is basically the model for addressing overall health. The goal is improving your health, and the hormones come along for the ride and naturally correct themselves when you restore homeostasis.

Sara Gottfried, MD: Totally. Yeah, I totally agree with that, and I think there’s kind of a cadence, sort of a right pace with uncovering, unraveling the reasons why someone has a hormone imbalance. And just as you described, when you have someone who’s sitting in front of you who’s a bit of a cortisol junkie—like I used to be—and they have high cortisol and you’re rattling off all these potential root causes, they want to go running from the room! They’re just like, “Aaaaa!” The good news is that when you have this integrated, functional approach, people feel better. Often it’s in that first six weeks or the first 12 weeks that people get better, and if they don’t, then you start looking for the zebras. You start doing the ERMI, the test for mold. You start looking at heavy metals, or in your case, you get referred people who are pretty complex, and so I think you frontload more of the testing.

Chris Kresser: Yeah.

Sara Gottfried, MD: But there’s a way to do it that is more kind of adjusted to the individual and how much they can take on.

Chris Kresser: Yeah, exactly. One of the things I know that you’ve gotten really interested in… Can I spill the beans here about the third book?

Sara Gottfried, MD: Yes!

Chris Kresser: Your next book that you’re working on is really focused on this. It’s the role of genetics in longevity and health in general and epigenetics, and so I’m curious where that research has led in terms of the hormone regulation specifically. Are there genes that you’re looking at that you think play a pretty big role in affecting predisposition to hormone imbalance? Or is it more of an epigenetic and an environmental, exposome-related influence? What’s the relative contribution of all of those things, in your mind?

Sara Gottfried, MD: That’s a great question, and I’m totally immersed in this data. It’s so much fun, and I feel like we’re at this tipping point with our understanding of genetics and what can be done, kind of the promise, the leverage of epigenetics, but the amount of data on the topic is increasing exponentially, so it’s a challenge to keep track of it.

But to answer your question… maybe I’ll start with your second question first. I’ve heard you talk because I think I’ve listened obsessively to every single podcast you’ve had, Chris!

Chris Kresser: Thank you!

Sara Gottfried, MD: My husband put me on a limit for how many I can listen to.

Chris Kresser: I’ll be speaking to him about that.

Sara Gottfried, MD: Please, talk to him. You’ve talked about this point that genes load the gun and epigenetics pulls the trigger, and I think that’s a really valuable way to look at it. I wish we had a good ratio that I could just rattle off when it comes to hormone balance. I think when we look at degenerative disease or kind of the disease of aging, we think the number is somewhere around 10 percent genetics, 90 percent exposure/exposome/epigenetics, and I don’t know if that same ratio applies to hormones. My instinct is probably that it’s more like 20/80 or 30/70, something like that.

I’ll talk about a couple of genes that have my curiosity right now. Frankly, there are about 50 of them, but maybe we can start with three!

Chris Kresser: Yeah.

Sara Gottfried, MD: I’ll open the kimono on myself first because it’s the genome that I know the best. The first one is CYP1B1. All these genes kind of sound like license plates.

Chris Kresser: Right!

Sara Gottfried, MD: They have ridiculous names and ridiculous abbreviations, but this is a SNP, a single-nucleotide polymorphism, and I am homozygous, which I think of as kind of a red light. I have the bad version of this gene. My genotype is CG, and that means I’m at an increased risk with my particular SNP for procarcinogenic activation of my estrogens.

Chris Kresser: Mm-hmm.

Sara Gottfried, MD: So if you look at my estrogen pathway—you talked about this a little bit with the patient that you described—if you look at how estrogen is used in my body, I make too much of 4-hydroxyestrone. Then, just to add insult to injury, I don’t methylate it to a safer estrogen. I don’t take that bad estrogen and then make it safer, which is 4-methoxyestrone. So I have to track my estrogen metabolism, especially now that I’m in perimenopause. It’s something that I learned about when I first started doing genotype testing related to hormone balance, and I started that in about 2006 with Genova. They have a couple of panels that I found to be worthwhile. So it just means that I have to be super-attentive to how much 4-hydroxyestrone I’m making, and then I need to sort of nudge my body along with how much I methylate that to make it safer.

Then, speaking of methylation, I’m a lousy methylator. If you just look at MTHFR, for me, I’m heterozygous for MTHFR, so I have about a 35 percent reduced MTHFR enzyme activity. That means I need to take certain supplements that kind of help me, and then I track about once a quarter my estrogen metabolism.

Chris Kresser: Mm-hmm.

Sara Gottfried, MD: Then a third one I’ll mention. This is maybe a little less complicated. I have two genes, GSTT1 and GSTM1, and these make me low in vitamin C. The interesting connection here is that vitamin C is a micronutrient that is really important for your progesterone levels, and so I have a tendency to not make enough progesterone. It’s kind of related to being crazy stress girl in my 30s because I was monomaniacally making cortisol. It’s kind of how I survived through my medical training, and my high cortisol would then block my progesterone receptors, and then my poor body could hardly make any progesterone because I didn’t have enough vitamin C.

Chris Kresser: Right.

Sara Gottfried, MD: We know that taking vitamin C can raise your progesterone level. So that’s just an example of three kind of sets of genes that I’ve been paying attention to.

Chris Kresser: It’s a really good example because everything that you mentioned is a combination of your genetic predisposition and then the particular lifestyle circumstances that you had.

Sara Gottfried, MD: Right.

Chris Kresser: It’s not like it’s set in stone that you have these genes and you’re for sure going to have low progesterone and you’re for sure going to have all of the issues that you mentioned, but if you combine that genetic predisposition with the modern lifestyle, that’s why you get these issues whereas somebody else gets different issues. I think it’s really important for people to understand that. We’re not talking about single-gene diseases here, where if you have a genetic mutation, you for sure are going to have a disease. We’re talking about patterns and probabilities.

Sara Gottfried, MD: That’s right. Yeah, that’s a really important point. Since we’ve been talking about birth control pills, can we talk a little bit about the genetics of the androgen receptor? That’s kind of a fun story.

Chris Kresser: Yeah, sure.

Sara Gottfried, MD: I feel like in the next 10 to 20 years we’re really going to change the way that we approach hormone balancing, and I hope that we get, at some point, to a place where you go see your clinician, you pull out a card from your wallet that has your genome on it, and we can say to that person, “You know what? A birth control pill is not a good idea for you because of these three SNPs.” In the meantime, it’s also kind of a spray-and-pray approach, especially when it comes to birth control pills. When I talk about birth control pills as being the number-one endocrinopathy, what I see is that women and men have differences in their androgen receptor.

I have a friend named Andrew Goldstein who’s a gynecologist back East, and he has a great analogy here. He talks about how some women have the Hummer version of the androgen receptor. When they go on the birth control pill and their tank of testosterone goes down because their sex hormone-binding globulin goes up and is like a sponge soaking up their free testosterone, they have all kinds of symptoms. They’re part of that 25 percent that has vaginal dryness, maybe decreased arousal, maybe even pain. And there are other people who have the Prius type of androgen receptor, and they can go for miles with a low tank of testosterone. They don’t notice symptoms. They sort of don’t know what all the fuss is about. If you’re one of those people with a Prius androgen receptor and you’re listening to us right now, you may be thinking, “Why are they talking endlessly about the birth control pill? I went on it and I had no problems.”

Chris Kresser: Yeah.

Sara Gottfried, MD: There are these different phenotypes that people have when it comes to hormone receptors, and it can really make a difference in how you respond, especially to synthetic hormones.

Chris Kresser: Yeah, and what’s really interesting, too—this is a subject for another podcast entirely—but with cortisol and the whole three-stage model of adrenal fatigue, which was never really based in any solid peer-reviewed evidence, one of the main things that that completely ignores is the role of cortisol receptors. Some of the more recent research suggests that a lot of the issues that we see with cortisol are not related to the overall production of cortisol being high or low—or even necessarily a disruption of the diurnal rhythm of cortisol—but instead with cortisol receptors on cells losing their sensitivity. Just like we can have insulin resistance and leptin resistance, we have cortisol resistance. And what you’re saying is some people may have relative resistance to testosterone or other androgens versus another person who has more sensitive receptors, and that is something that can make a huge difference but is really not being looked for at all by anyone in any approach.

Sara Gottfried, MD: That’s right. Yeah, I’m glad you raised this point about Hans Selye and the stages of adrenal dysregulation because I think that it was way oversimplified, and I think it’s confusing for a lot of people because they just think they need to crank up or down their cortisol levels when there’s this much more sophisticated biochemistry happening in the background.

Chris Kresser: Yeah.

Sara Gottfried, MD: I think we’re still pretty early in understanding hormone receptors and sensitivity. There’s some data, for instance, on the oxytocin receptor, and having a certain SNP for the oxytocin receptor makes you more likely to have autism. I just think it’s a very interesting topic. There are some genes like the short serotonin transporter gene that make you more likely to have cortisol resistance, and I feel like that’s the direction that we’re heading, where you kind of have a sense of, “Oh, I am a short serotonin transporter. I need to manage my cortisol 10 times better than my spouse,” for instance.

Chris Kresser: Right. Yeah, you can’t just look at someone else and say, “See? Look what they’re doing. I can do that, too!”

Sara Gottfried, MD: Right.

Chris Kresser: It doesn’t work that way. And of course, a lot of people figure this stuff out without even knowing their genome. If they’re paying attention and they observe their reactions to various stimuli and circumstances, they determine this stuff on their own.

Like for me, I’ve known for years that I’m relatively sensitive to caffeine compared to other people. I would just look at people who would order an espresso after dinner and just think, “What in the hell? What?! How is that even possible? If I did that, I would be awake the entire night, like, wide awake the entire night.” I just couldn’t even comprehend that that person was the same species as me because we’re so bizarrely different.

Then recently I had you take a look at my genes, and of course, there is a reason that I’m sensitive to caffeine like that—I’m a slow metabolizer of it.

Again, this is all fascinating, and I really do look forward to the time where we have that kind of information. And I want to remind people that you can learn a lot through observation and self-awareness until we come to that point in time where we have that level of knowledge and understanding.

Sara Gottfried, MD: Yeah, that’s such a good point. Fifty-one percent of people in the US are slow metabolizers of caffeine. You and I share that particular SNP. So chances are that at least half of you have this! And it’s not just clearing caffeine. It’s also clearing stress, and maybe it’s part of the reason why you and I have contemplative practices that we’ve developed along with our professional work.

Chris Kresser: Yeah. We’re getting off on a little tangent here—which is permitted on my podcast, even though people do frequently complain about it. That’s too bad! That’s just what happens!

Sara Gottfried, MD: You’re just trying to work with your genome.

Chris Kresser: Right! So you said 51 percent are slow metabolizers. That’s perhaps especially disturbing in light of the recent study, the caffeine study. Did you see that, about the effects of caffeine on circadian rhythm when it’s consumed in the afternoon or evening?

Sara Gottfried, MD: Hmm.

Chris Kresser: I’ll send it to you if you haven’t.

Sara Gottfried, MD: Yeah, send it to me.

Chris Kresser: In the intro, what they said—that blew me away. I mean, I guess I had some idea, but 90 percent of individuals consume caffeine in the afternoon, between 12 and 6 p.m., and 69 percent of people consume caffeine between the hours of 6 p.m. and 12 a.m.! I’m like, wait! We wonder why we have a sleep epidemic! This is crazy! Fifty-one percent are slow metabolizers of caffeine, but 69 percent are unable to metabolize that caffeine. And of course, this study found exactly what you would expect it to find, which is that, overall, consuming caffeine that late at night does adversely affect sleep, but the effects were varied.

Sara Gottfried, MD: Yes.

Chris Kresser: And they didn’t get into why they vary, but we know why they vary—because of the differences in caffeine metabolism that are genetically determined.

Sara Gottfried, MD: Exactly. If you look at the literature on caffeine, this one certainly makes sense and kind of adds to the story. Very few of the studies looking at caffeine have broken people into categories based on their SNPs, but when you do that, when you look at the people who are the slow metabolizers, they’re the ones who have the increased heart disease. They’re the ones who have to keep their caffeine less than 200 mg a day and certainly before 6 p.m. and, in my case, like, before 7 a.m.

Chris Kresser: Right!

Sara Gottfried, MD: I think that’s what we’re going to be seeing in the literature, is more of this, OK, let’s take this population-based model and now break people into categories according to their SNPs so that we can be a little smarter about how we approach this.

Chris Kresser: Right. OK, so we’re coming to an end here. I just want to kind of summarize and say again that the bad news is we can’t say here are three simple steps that every person can take to improve their hormone balance. I mean, we can get close to that, and I’m going to ask you that question, actually, in a second! But I think the overarching message here is that hormone balance is largely determined by many other aspects that affect our health, like our diet and our metabolism and our gut function and our liver detox capacity. So to really address hormones from a holistic or functional perspective, that’s what you have to be looking at.

Having said that, because I’m talking to the author of the bestselling The Hormone Cure, which has helped a lot of women recover their hormone balance, what are maybe three things that most women—no matter what the root cause of their hormone problem is—would benefit from in terms of helping to regulate hormones?

Sara Gottfried, MD: Well, I have to start with cortisol because I feel like… I mean, you’ve heard me joke before that cortisol is like the bad boyfriend.

Chris Kresser: Mm-hmm.

Sara Gottfried, MD: There’s a way that it needs to be wrangled. I think most of us don’t learn how to wrangle stress, and so we end up with this sort of chronic stress that’s very hard to clear in the body. I find that to be the root cause of hormone imbalance in, say, 98, 99 percent of the people that I work with.

Chris Kresser: Yeah. I would agree with.

Sara Gottfried, MD: The unfortunate part is when you start talking about stress management, people’s eyes glaze over, right? It’s like saying you need to stretch more.

Chris Kresser: They stop listening entirely.

Sara Gottfried, MD: “I’m on my iPhone now. Do you have anything else for me. I’m waiting for numbers two and three.”

Chris Kresser: Yeah.

Sara Gottfried, MD: To me, what is important is to develop what some people call the witness self, separating from the self-talk and sort of the mental chatter and the way that we get caught up in our modern lives, and finding a way to actively pause—by whatever means possible. I’m a yoga teacher. I had to become a yoga teacher just to wrangle my cortisol.

Chris Kresser: We teach what we need to learn, right?

Sara Gottfried, MD: Totally. And that’s not the solution for everybody. I have lots of people who will come to see me in my practice and they’ll say, “I just want to get this off my chest at the beginning. I’m not going to yoga. I hate yoga. It makes me want to shoot myself. Don’t tell me to go to yoga.” Those people do better with a guided visualization or a long vacation.

Chris Kresser: CBT or who knows.

Sara Gottfried, MD: CBT, vacation more often, surfing, saunas, hormesis, whatever.

Chris Kresser: Yeah.

Sara Gottfried, MD: That’s the first thing. The second thing is the microbiome, to pay attention to the microbiome. We haven’t talked about this yet—we have offline—but we are at this place, which I think is really fascinating, where you can think of the gut microbiota and their DNA as a separate endocrine organ. It’s controlling, modulating your estrogen levels, your testosterone levels. I wasn’t reading that article on caffeine and the circadian rhythm. Instead I was reading an article in Science today about the role of these subcultures within the microbiome and how they affect autoimmunity and lead to a greater predisposition, for instance, in women for autoimmune conditions.

Chris Kresser: And then we have the estrobolome, of course, right?

Sara Gottfried, MD: The estrobolome—what do you do to take care of that? Well, unfortunately it’s not as simple as many of us would like it to be. I remember I was reading a book a couple of years ago that was positioning certain microbes as, like, the Homer Simpson microbes that you need to get rid of and then others that you want to populate, kind of your ratio of Firmicutes to Bacteroides, and it’s not quite as simple as that. That ended up getting disproven… or at least called into question. But it’s something that we want to pay attention to, and so some simple solutions are things like fiber, resistant starch. Some people think taking a supplement like calcium D-glucarate can help you with getting rid of the bad estrogens in your body so that they don’t endlessly recycle in your enterohepatic system like bad karma.

Chris Kresser: I like that!

Sara Gottfried, MD: And then the third thing that I would say is humor. How’s that?

Chris Kresser: Yeah, perfect.

Sara Gottfried, MD: I think humor is essential to… Like, this topic of hormone imbalance, my husband, I’ve been with him a long time, and he’s a businessman. He’s just like, “Why did you specialize in hormone imbalance?!” It’s tough, it’s complex, and it brings up a lot of stuff. It’s not a walk in the park, and so I think humor is kind of a great way to manage it and to have as much fun as possible when you’re talking about the complex biochemistry and to sort of draw parallels and see patterns and have some fun with it.

Chris Kresser: That’s great, and I think those are three really powerful and far-reaching things that people can focus on because each of those things will not only affect hormone balance, but pretty much every other aspect of health.

The other thing I would like to recommend is go out and pick up a copy of The Hormone Cure. If this is something that you’re really serious about and you are suffering from hormone issues, it’s the best resource that I know of for helping you to figure this out, especially if you don’t have a skilled practitioner to work with. I have a copy of it sitting on my shelf, and so do, apparently, about 100,000 other people, I hear. You’re approaching a really fabulous milestone in the number of copies you’ve sold, so I want to congratulate you on that. That’s quite an accomplishment and well deserved because that’s 100,000 people that you’ve really helped with this message.

Sara Gottfried, MD: Thanks, Chris. I appreciate that. We can definitely make the world a better place if we reset these hormones.

Chris Kresser: I kind of spilled the beans a little bit earlier on what you’re working on or what you’re interested in now, but maybe you can tell us in your own words what this next book that you have cooking is about and what other things you’re working on or interested in.

Sara Gottfried, MD: Sure. My next book is about DNA and how to leverage epigenetics. This aging process, hormone imbalance, the challenges that we’re facing—many of them present these opportunities to change your epigenetic influence. It’s kind of a complicated topic. My agent says to me, “How do you get people to care about their DNA?” That feels like a really interesting challenge. How you really make this feel relevant and part of someone’s daily life and not, like, “OK, I’m only 40. Why should I care about having a longer healthspan when I’m 80 or 90 or 100?” But the truth is you have to address it now.

Chris Kresser: Yeah.

Sara Gottfried, MD: The problems in the gut, as you well know, the issues with accelerated aging, they start in middle age. They start 35 to 55, and so that’s what my next book is about. It’s super yummy, and of course, it has proven solutions from the wisdom traditions like Ayurveda and Chinese medicine and how to modulate your exposome with simple daily actions, like how you floss—which, by the way, no one does correctly, I’ve learned!

Chris Kresser: Right!

Sara Gottfried, MD: To taking a sauna. I am a total convert now to taking a sauna. It’s amazing how it turns on your longevity genes, your FOXO3. Super-exciting data just published in JAMA about it.

Chris Kresser: Yeah, we got an infrared sauna a while back, as you know, and I’ve spent a lot of time in there. It’s so great.

Sara Gottfried, MD: It’s totally great. And then a side project has been starting to wrap my head around mold and biotoxins. Oh, my gosh… that’s a big project.

Chris Kresser: Absolutely. I’m so glad we finally made this work. I’m surprised it took us so long, but better late than never. I’m really grateful to have you on the show. I think it’s going to help a lot of people, and I would love to have you back sometime.

Sara Gottfried, MD: Thank you, Chris. Such a pleasure to be here. Thanks, everybody.

Chris Kresser: That’s the end of this episode of Revolution Health Radio. If you appreciate the show and want to help me create a healthier and happier world, please head over to iTunes and leave us a review. They really do make a difference.

If you’d like to ask a question for me to answer on a future episode, you can do that at ChrisKresser.com/PodcastQuestion. You can also leave a suggestion for someone you’d like me to interview there.

If you’re on social media, you can follow me at Twitter.com/ChrisKresser or Facebook.com/ChrisKresserLAc. I post a lot of articles and research that I do throughout the week there that never makes it to the blog or podcast, so it’s a great way to stay abreast of the latest developments.

Thanks so much for listening. Talk to you next time.

44 Comments

Join the conversation

  1. Thank you!!!! This was jammed pack of great information and information that is hard to find anywhere else. I appreciate you talking about the long term negative effects of oral contraceptives. I see some of this in my own practice as a fertility education teacher. This information will benefit my clients as well. THANK YOU!!!!

  2. Hi Chris Kresser,
    I am dealing with infertility, low AMH, and decreased ovarian reserve. I am currently under the care of an excellent acupuncturist in Scottsdale, AZ and he gave me the handouts to the Healthy Baby Code in regards to nutrition. My question for you, is I am wondering what a sample day might look like for optimal nutrition (primal diet/paleo diet). Would you be willing to email me a sample pdf if you have one?

    Thanks,
    Carli

  3. Would someone post the reference link to the clitoral size reduction due to birth control pills?
    I’ve never heard that before!

  4. I thought it was quite an interesting discussion though obviously not everything was covered. I thought many of the comments above were too harsh; a podcast discussion can’t answer all questions. Gottfried’s point that hormones are no substitute for proper nutrition and lifestyle is hard to argue with IMHO. That being said, I was hoping PCOS might be discussed, not for myself (I’m a man) but for my daughter. The pill was the prescription for her PCOS. Was that the best prescription, and what are the long-term implications of being on the pill for PCOS? Anyone know if this is covered in the book?

  5. Loved the podcast. Sarah Gottfried said something about everyone flossing incorrectly. Where can we find information about flossing correctly?

    Thanks!

  6. Sara threw out a reference to the fact that most of us floss the wrong way. Any idea what exactly she’s talking about and/or a website reference?

  7. Hey, I know you mention CBT and stress management in this article.

    Basically I am a college student (male) who developed HPA issues while here unrelated to outside stress. However, the symptoms themselves such as anxiety/depression itself make me stressed in a vicious cycle. Before, I used to be a very high performing individual but then this hit and I lost my huge confidence that I used to have when it came to anything school related.

    I have tried all sorts of things like Clomid/HCG but these conventional things run into a wall. They work in the beginning before running into problems.

    I’m wondering if stress management or counseling is still used in cases like this where the hormonal symptoms are essentially the source of the stress but get aggravated mentally. Basically feeding into it by noticing the feeling down and then feeling anxious or down about feeling down itself. Like comparing myself 24/7 to what I used to be

    • Hi Rob —

      I just want to state that you’re not alone. Your story is very similar to mine — On top of this *other world* anxiety and depression that I had never before experienced, I began experiencing a lot of intestinal distress and panoply chronic infections during this time, too (these I continue to address).
      I just want you to know that you’re not doing this wrong — and any guilt you feel when comparing yourself to others need not be.

      I read some CBT books from Kabat-Zinn and all of the concepts were elucidating, but somehow I couldn’t get them to click — like I understood what was happening, but still couldn’t get out of it. And then there’s a lot of shame, knowing what’s going on, but not being able to fix it. I eventually found an affordable therapist to work through these things *with* me. I still struggle often, but I often feel able to ride the waves rather than be crushed by each one that rolls through. Every therapist is different — trust yourself in finding one that feels right for you. For me, it’s been a holistic approach. I went to this therapy for a while, am in the regular care of an integrative practitioner to address gut issues, and I’ve radically altered my lifestyle the best I know how. Healing can be a very slow path. I just hurt for you, knowing the spiral of feeling down about feeling down, trying to get back to your *old* self. I hope that you will make peace with yourself, and truly appreciate all that you are doing/reading to take care of yourself. Much love to you.

  8. I was given thyroid hormones and all other hormones at the same time as well as vit d3, b12, that I deficient…now I realize that all these bhrt and thyroid and supplements was not looking at the underlining cause of why at 48 everything went south at once, I had been thru a stressful event in the economy, wasn’t eating right, lost a lot of weight, and all they did was give me everything at once…..fast forward 8 years and I tried to go off of the hormones and my hair starting falling out in hand fulls and my dr just brushes me off , have vaginal dryness and she just said take more estradiol with the progesterone, had low testostere and low dhea and that was brushed off as well…..so now I feel like I have been a guinea pig…..looking for a another dr in the south ga usa area…..do you know a good one….

  9. Hi Sara and Chris, I am a practitioner in the UK and dealing with some patients with inflammatory bowel disease who also have hormone dysfunctions that are part of their whole health challenges. Even with considerable work re diet and good supplementation (with some insight into genetic SNPs and an organic acid test) we are still rather in the dark, in one patient in particular, re the right way to address her hormonal issues.
    Just to briefly fill you in on the problem, when we took her off the 3 month depot of contraceptive hormones her Crohn’s, which we had made great strides with, descended back to a terrible state, and the period she got went on for weeks, non stop. At last I begged her to go back on the Pill, progesterone only, which over the next couple of months did help and she is now doing well. But, neither she nor I want her under this synthetic hormone influence if we can put things right without them, so any advice from anyone would be of great interest.
    The conversation between Chris and Sara was interesting but not really too informative. Some clearer info on where real guidance can be found would be received with gratitude.
    Also, two specific questions about SNPs: what part might a deleted GSTT1 and a homozygous eNOS be playing in this patient’s reaction to loss of the injected three month long hormone mean (i.e. bleeding, unresponsive to styptics and worse IBD).
    Very interested in your input.
    Thanks
    Afifah

  10. I found this to be very interesting. The comments of many echoed what I was thinking, two younger people, one of them a man, discussing hormone use for older women. I am a 70 year old woman on bhrt and I hope to continue with it. I cycle progesterone and so have monthly bleeding. I follow the basic regimen of Dr. Diana Schwarzbein who advocates a sensible diet as well as bio-identicals. You shy away from discussing sex, with low estrogen there is pain, more yeast and urinary tract infections, a lot less pleasure. Then we are told to use a lot of lubricants to make it better. With sufficient estrogen, no infections, plenty of self-lubrication, maximum pleasure. I have been married to the same man for 44 years and I had no idea sex would be more thrilling at 70 than it was at 25! Also genetics, I have a genetic anomaly in my liver and am a fast metabolizer of estradiol. My Naturopath was always on me to lower my estrogen (prescribed by a hormone specialist) but after she tested my genes, she saw that what looked like a high dose of estrogen was not so much for me. We need to be taught to follow our instincts and how to determine when our hormones get too high. Then we need our prescriptions to be more flexible and easier to vary day to day. Metabolism changes and we can make small adjustments on our own.

    • Hear, hear, Laurie! You have nailed it. It seems that a lot of us older women (I’m 65) are left out of the discussion. I actually took some offense that it seemed “crazy” to give an older woman the hormones of a twenty-something. It might not be a good idea, but that had better be based on hard science, and not (which I suspect) based on a feeling that it’s somehow unseemly for an older woman to want to retain her sexuality and responsiveness. I say to the thirty-somethings who think we’re dinosaurs: just wait until you’re 65. You’ll see….

      Would you kindly tell me what the gene is that makes one a fast metabolizer of estradiol? Thanks.

  11. Would the book The Hormone Cure be a beneficial read for males? … Maybe for thyroid or low T? Or diabetes or losing weight?

  12. It would be great to know the exact SNP Dr. Sara mentioned. I looked up the genes she listed and got a very long list.

    Thank you!

  13. Hi everyone,

    Thanks for sharing your thoughts and experience. I want to clarify something that apparently was not clear in the interview. I do believe that there is a time and place for HRT in both menstruating and menopausal women, and I know that Dr. Gottfried feels the same way. What we were attempting (somewhat unsuccessfully, it seems) to communicate is that in most cases jumping right to HRT without first addressing the underlying factors that contribute to hormone imbalance is not an ideal approach.

    As Mims pointed out, the “ideal approach” may not always be possible or accessible, and there may be other factors which argue for earlier intervention with HRT. I accept and support this.

    But I’ve all too often seen practitioners that go straight to HRT without bothering to look at blood sugar, thyroid, gut, HPA axis, liver, and other systems that directly impact sex hormone production and metabolism. I think this is a mistake.

  14. Joining in again…

    I would like to suggest to Chris that he invite me or another experienced prescriber of menopausal bio-identical HRT on his show! There is a clearly a thread of interest in the topic and disappointment with a bit of how it was discussed with Dr. Sara.

    I join Chris in taking an evolutionary perspective to health matters (along with science, n of 1 experimentation, genetics, to name a few.) Here’s the thing: I’m 67 and evolution is long past caring about me, except perhaps as a grandmother.

    Selective advantage in evolution applies to conditions that affect the ability to reproduce and enhance the species, not the individual. Humans are fairly (totally?) unique in the ability of females to outlive their capacity to reproduce.

    For the sake of the species, I am happy to give up my fertility and to “serve the species” only by caring for others’ children.

    For myself, however, I think it is personally reasonable, and justified by science (there’s a lot, though none of it persisting for decades, obviously) to apply carefully selected bio-identical HRT, watching carefully to follow levels, evaluate and influence estrogen metabolism, and address any of the other issues a functional medicine evaluation would indicate.

    I’m speaking on this topic at the Physicians and Ancestral Health meeting in Scottsdale this month, so the research is fingertip ready… would love to have a chat with Chris, rather than a rant!

    Thank you so much,

    Deborah Gordon, MD

  15. Hello,
    I stopped taking the pill early 2015 and I have yet to get pregnant. Prior to that, in the fall of 2014 I had loop electrosurgical procedure to remove abnormal cells from my cervix. Add to this an infection in my stomach with h.pylori. Did all these things just ruined my chances to conceive? I am 28, 97 pounds, and currently taking supplements plus a probiotic. My standard blood labs came back “normal” for last physical exam. I feel like I am running out of time. Should I address my hormones first or my gut, or both? Thank you for your feedback!

  16. I am a medical researcher and alternative practitioner, I although Dr. Gottfried got a lot right , especially about the “spraying” of hormones at young women for contraception, I think there is a lot wrong here too.

    I agree with Karen, Donna, Rosie, Deborah, Barbara…
    this talk seems to toss the safe and sane use of bio-identical hormones based on Suzanne Somers promotion of an extreme protocol is missing the boat.

    The fact is, today women spend as much or more time of their lives without hormones, then with them. The average life expectancy for a woman in the western world is 80 plus. Looking at average menarche and menopause ages that gives approximately 40 years on either side of the divide. You better believe if all men had andropause of NO testosterone at age 45+, there would be a huge industry around providing it to them.

    200 years ago women lived to be 40. If we want to talk about a healthy, thriving old age for women, we need to look at a rational and evidence based approach to the use of bio-identical hormones, especially for women just entering menopause who already have bone loss and no family history of breast and uterine cancers. Many of them have 35+ more years on the planet.

    Yes, there is not a lot of science yet, because the boomers are the first generation to have access to bio-identical hormones managed well, from the onset of menopause forward. But menopausal women are happy to be those guinea pigs, because they feel so much better when taking BIH! We are all guinea pigs anyway with all the synthetic chemicals, cellphone/tablet/wifi radiation, vaccinations, environmental pollutants, GMO foods, etc.

    I also have spent hundreds of hours reading up on genetic mutations and the science behind them, as I am homozygous for the MTHFR 677TT mutation, which some people would say makes me 70% less effective at methylation reactions. However, these figures of kinetic efficiency reductions are determined in human cell lines (usually) in a lab setting.
    The fact is, the ability of a genetic mutation to effect an actual humans ability to make express enzymes and how that enzymes activity is altered, is in its infancy and a lot is not known. In fact, when the research will look at actual people in the real world with the same mutation, they often find the mutation seems to increase activity of the enzyme (like for SOD) or at least they do not see a lot of changes in downstream consequences.

    This article sums up well whatI have been thinking for a while now…..,
    http://www.medpagetoday.com/Cardiology/CardioBrief/55522

    The take home message is summed here well:
    “When we return genomic findings to patients, either in the context of clinical and research sequencing, we need to inform patients/participants as to how little we truly know about penetrance of mutations.” Penetrance, is a measure of how a mutation actually effects your phenotype (the visible manifestations of the mutation, like disease tendencies.)

    Back to my MTHFR 677TT…I have absolutely no evidence of harm: no infertility, depression, osteoporosis, elevated MCV, elevated serum MMA, etc. So, MTHFR, while potentially having detrimental effects for some folk (due to their unique epigenome, metabolome, etc. ), may be of little to no consequence to others.

    Meanwhile, there is little focus on the epigenetic regulation of genes…just because you have a normal MTHFR gene with no known mutations, you could still be hindering your ability to methylate thru excessive synthetic folic acid, excessive dark chocolate consumption, heavy metals. I also see clinicians ordered these specialty genetic labs (DDI, genova, etc) without informed consent. Not good.

    Oh, Donna, if you are still following this thread, if it where me, I would go back to your PCP and ask for bio-identical esTRIol (not estradiol) vaginal cream. It can be a lifesaver in these cases. It is not systemically absorbed, does not increase your risk of breast cancer, is easy to use and really helps atrophic vaginitis and increases quality of life.

    With respect to Chris and Dr. Gottfried, the whole functional medical approach would be great in a perfect world where everyone had the financial wherewithal to access it. But the fact is many, many women (And men) do not have the resources to go this route. We should not make them feel bad for not.

    Mims

    • I am heterozygous for both c677t, and a1298c. At 43 years old I almost died from heavy metal toxicity…It depends on the person and the circumstances of their life, as to the impact of the SNPs.

  17. Disappointing smugness from two young practitioners about following healthy practices and coping with hormone ‘lack’. Being peri-menopausal I was apparently well equipped to cope with the tidal wave of symptoms due to having rigorously ‘dialled in’ all the above mentioned factors.

    You two should readdress this topic when you’ve entered menopause/andropause and I suspect your attitudes to BHRT may have changed.

    I wholeheartedly agree with KAREN the very first poster to this thread. I second her eloquently written comments.

  18. I think some older women most definitely need BHRT to keep post-menopausal symptoms at bay and maintain cognitive functioning (and other types of functioning).

    If you’re living righteously your whole life from birth — and I mean righteously: breast-fed as an infant, perfect diet for your constitution, low-stress, toxin-free, perfect genes, etc., etc. — then chances are you’ll have a smoother transition into menopause (and, even then, there’s no guarantee that you will).

    But most people don’t live this way and by the time many women are 60, it’s hard, as a doctor, to give their body *everything* it needs and tweak *everything* just right in order to have the perfect post-menopausal experience. Multi-systemic damage has been done that is not always easy to repair at that stage of life.

    Enter BHRT. I think it’s a life-saver for many menopausal women. I’m not saying “go crazy with it.” I’m saying that wise supplementation can, literally, save a post-menopausal woman’s life, mind, relationships, etc.

    I think it’s easy for younger doctors to poo-poo BHRT, but just wait until they’re there themselves! For female doctors, wait until you hit menopause, and *then* see what you say about BHRT. For male doctors, wait until your wives and partners hit menopause, and *then* see what you think about BHRT! Younger people don’t have a clue, they really don’t.

    There are women who say they’ve “done everything right,” such as diet, exercise, stress control, self-care in general, and yet when they hit menopause it’s like they’re experiencing an internal earthquake. BHRT can help immensely in those cases, even long-term.

    I just don’t agree with everything that’s being said here. I think there’s a smugness about it and expectations about how people *should* be eating, living, and functioning that *most* people in this society will just never be able to meet.

    • Very interesting podcast and view point. I have to say I’m in agreement w. others here, that Dr. G might change her tune when it comes to her own change of life. I’m on small physiologic does of BHRT from a well informed functional medicine dr. and it has been nothing short of life changing! I get my levels checked regularly to make sure I’m not producing excessive bad Estrogens or I’m at least metabolizing them properly. I’m also a big believer in Iodine protocol and proper supplementing, clean diet, and exercise.
      In addition, I didn’t care for the dismissive commentary about Susanne Somers who has done a lot to expose people to better health and treatment of disease (specifically cancer). She doesn’t profess to be a doctor but interviews many of the great practitioners and gives them proper exposure to the public. Reducing her to a TV character she played in the 70s seems petty to me when she clearly has evolved and does a lot of good!

      • Yes, agreed, SS has done a lot of people a lot of good, and she doesn’t have to. She could just bask in her millions, but she keeps pursuing these health issues that the average person has no clue about. Like I said, there’s a real smugness here.

  19. Hi Chris, thanks for the great discussion about hormones and priorities in addressing imbalances.
    Regarding the treatment of women in menopause, though, I feel like a bit of a broken record in my disagreement with Dr. Sara. She is so great about so many things but really if you take everything you can learn from her:
    Get your life in order…
    check your genes and accommodate for them…
    check your hormone levels and hormone metabolism..and read the latest medical research…

    Take all those together and there is no reason a woman should be deprived of post-menopausal hormone replacement therapy for her lifetime. Suzanne Somers is not the model for wise hormone prescribing, though we can thank her for raising the subject!

    Hormones are part of Dale Bredesen’s (UCLA) cognitive improvement program and a routine, and I think scientifically validated, part of a healthy program I offer to all women, even if they are ten years past their hot flashes.

    We know so much more about prescribing hormones safely, there is no reason not to offer a woman the choice of her own experience with or without hormones.

    Evolution naturally favored the survival of young mothers only, but allowed men’s fertility and testosterone levels to persist into more advanced years.

    Women are going to live to 75-85 years of age: wise hormone replacement can make a huge difference in quality of life. Not for all, but should be available to all.

  20. Taking the birth control pill wrecked my late-teens, 20s and 30s. During this time I suffered depression, anxiety, panic attacks, exhaustion, weight gain, weepiness, confusion and hopelessness. This had a huge impact on my life at a time when I was supposed to on the steepest climb of my adult development.
    The pressure to take the pill, from medical practitioners, was very strong and at no time did anyone accept that the pill was creating these symptoms. They were very reluctant to look at alternatives and just kept trying me on different brands, and antidepressants were offered (of course). I know now that the pressure was due to national targets that doctors in the UK are financially pressured to stick to. The individual is never taken into account and at no point was I properly informed of the terrible side-effects of these medications. I don’t believe the leaflets inside the boxes of pills constitute ‘informed consent’.
    I stopped taking the pill in my mid-30s and things improved considerably, however I believe I am still suffering the after-effects, both in my physical health and my career and relationship development (I am approaching my mid-50s now). Medical hormonal treatment of women is a feminist issue. It is continuing to blight the potential of millions of women who are also not being treated seriously by our patriarchal medical profession. Yes, I am very angry.

  21. What kind of infrared sauna do you recommend? Far? And what brands are quality? I’m willing to spend a good chunk of money, and want to make sure I get one that is actually effective!

  22. I agree with Rosie.
    Additionally Dr Gottfried has a way of talking a lot but not really saying much. I have looked at her books and listened to her talk but I do not learn anything. It is a pity as the topics look really interesting but there is not substance. I was shocked to see that Chris goes to her for advice regarding hormones. I think that she is just a good promoter of herself.

  23. Glad to hear that vitamin C was mentioned. I definitely agree that we can over or under-complicate the adrenal fatigue reality.

    Truth be told, anyone that has a clue isn’t using actual cortisol (like it used to be) to supplement in a case of low levels, but addressing the issue with adaptogens is the safe and more long-term solution.

    We will never evolve to the modern, 24/7 world, so we have one option.

    Adapt.

  24. Well , after reading , still don’t know what to do . I’m 68, eat great & exercise, not overweight & have little to no belly fat ….thanks to Paleo. Problem is vaginal atrophy…sex has become way too painful with bleeding. Do I go back on bio identical hormones that I stopped because they where causing hot flashes at night? Can’t afford a functional medicine doctor !

    • Hi Donna, I experienced the same problems with vaginal dryness that ended my sex life. I have been using E3 suppositories ( Estriol 2mg) 2x a week and have no dryness issues. The creams never worked like these do. Good luck.

  25. I am disturbed by the lack of non-hormonal birth control out there for women. I just saw my Nurse Practitioner for a check up and was told there was no place I could get a new diaphragm in our area. They and cervical caps have been taken off the market in an attempt to force women on hormones (and the recurring monthly revenue to Big Pharma). I asked what non-hormonal options I had and she told me to look at Canada or other countries in order to obtain my replacement, or there is one non-hormonal IUD on the market (which too has its risks). I find this very troubling in light of the latest research discussed in this podcast. We seem to be losing healthy options and choices on a daily basis in the country with the “best” healthcare.

  26. Thank you for this great information!! With rheumatoid arthritis and post-menopausal hormone issues, I’m wondering how much hormones and autoimmune disease interact with each other. Can one be a possible causative factor or have an effect in some way for the other?

  27. Looking back, it seems my health issues have been prompted by periods of stress as well as hormones. When I married I began birth control pills, which gave me daily headaches. Off the pill. When I tried to get pregnant, I couldn’t so used fertility pills, having two children. Years later, after losing my favorite job; eyelids began drooping. Surgery later alleviated the problem. Thyroid medication which I began in 1978 wasn’t working; doctor, who didn’t say to not take calcium at the same time, began tweaking them as well as adding huge amounts of oral estrogen. I began spotting, growing lipomas and other cysts plus gaining 30 pounds. I stopped the estrogen. My job was extremely stressful as well. In 2007 I noticed loss of strength in the pelvic area. The weakness hit hard in late 2008 with a gradual weakening over the last seven years. I’ve had a second eyelid surgery as well as numerous blood tests for autoimmune diseases, with no diagnosis. Any suggestions?

  28. Thank you for this interview. Such a refreshing, encouraging and intelligent discussion, finally, to the complicated, maddening, and often brushed-over problems of the endocrine dance. As a former conventional healthcare provider literally “sick and tired” of trying to help clients, especially youth, with limited time and band-aid resources, it is great to see new options addressing the big picture, the whole person. Trite but true.
    I am personally looking forward to reading the book and finaly treating the roots and trunk of my own troubling branches.
    Thank you again

  29. I excitedly bought Gottfried’s book, The Hormone Reset Diet, hoping it would have some insights into my own hormone dysregulation. But it didn’t have any new information for me and I was disappointed in the misinformation in the book. I’m surprised to hear that Gottfried is such a big fan of Chris Kresser’s work. Her book is filled with myths that Kresser is famous for dispelling. She is a proponent of the acid/alkaline myth, she calls caffeine “battery acid” and her first chapter is all about the benefits of a vegetarian diet. Certainly, if someone is brand new to the idea of eating a healthy diet, then Gottfried’s recommendations of not eating sugar and avoiding factory farmed animal products will be helpful. Otherwise I didn’t glean any insightful information about hormones.

  30. I often find that women on BHRT after 6 to 9 months of intensive nutritional correction do not need it any longer. I wonder if Sara finds the same thing? I work very closely with a colleague of hers.

  31. You two are two of my favorite people to listen to. How inspiring!

    Anyhow, Dr. Gottfried, you need to include citations in your podcast shownotes. I have been searching everywhere for the term Estrobolome, including on Pubmed, and there’s literally one review article that uses this term (http://www.ncbi.nlm.nih.gov/pubmed/?term=estrobolome). This article is also a review on a hypothetical model and not a peer-review hypothesis-driven study. Perhaps you did search with other terms, and I really want to understand how you came to that conclusion. What were the studies? Were they done in humans or rodents? Was it correlation or causation? Please!

    I have the book and I love everything you guys do. I can’t wait for this 3rd book to come out. Perhaps I’ll order the SNP test through Genova too.

  32. With the huge popularity in IVF of older women, this is a generation that will come to realize the price for participating in assisted fertility. The risk were never explained to me and continue to be the dirty little secret they don’t talk about..
    You may give birth, but quite possibly you’ve ruined your health for life…
    Hopefully more attention and precautions will be made for this.
    Do you have any recommendations for these women?

  33. Lots of great info. THANK YOU both.

    So much resonates and is worthy of further contemplation. I’ll take some time to “digest” this info.

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