On this episode of the Less Stressed Life, we're diving into our September focus on perimenopause with Jennifer Gularson, who is back to break down the different hormone replacement therapy (HRT) options available during perimenopause and menopause.

We talk about estrogen patches, progesterone, testosterone, creams, gels, and pellets, including how they work, why one option may be a better fit than another, and what to consider when starting HRT. Jennifer also explains hormone testing, why she often introduces hormones one at a time, and how treatment may change as you move through the menopause transition.

Check out Jennifer's other episode, #453 Low libido, testosterone, estrogen and HRT - https://www.buzzsprout.com/775589/episodes/19164554

KEY TAKEAWAYS:
🧬 The different forms of estrogen, progesterone & testosterone
🩹 How estrogen patches, gels & oral options compare
🌙 Immediate vs. sustained-release progesterone
🌸 When HRT may be considered during perimenopause
🧪 Testing and adjusting hormones over time
⚖️ Pros & cons of hormone pellets
💗 Why vaginal estrogen may still be helpful with HRT

ABOUT GUEST:
Jennifer Gularson, PA-C, IFMCP is a board-certified Physician Assistant and functional medicine practitioner specializing in perimenopause, menopause, hormone therapy, and women’s midlife health. With over 20 years of clinical experience, she focuses on personalized, science-based care to support longevity, metabolic health, and overall wellness for women navigating hormonal changes.

WHERE TO FIND GUEST:
Website: https://www.yourbestlifewithjennifer.com/
Instagram: https://www.instagram.com/jennifergularson/

SPONSOR:
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🤝 You don’t have to figure it out alone
❤️ Do your best and leave the rest

WHERE TO FIND CHRISTA:
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TRANSCRIPT:

[00:00:00] Jennifer Gularson, PA-C, IFMCP: it could be the hormones, but are you giving your body a chance to actually use the hormones the way that you're supposed to? So are you pooping every day? Are you detoxifying? Are you moving yourself? Are you sweating? Are you trying to get rid of toxins?

[00:00:12] Jennifer Gularson, PA-C, IFMCP: What's your diet like? Are you overburdening your system so then therefore that messes up your hormones?

[00:00:19] Christa Biegler, RD: I'm your host, Christa Biegler, and I'm going to guess we have at least one thing in common, that we're both in pursuit of a less stressed life. On this show, I'll be interviewing experts and sharing clinical pearls from my years of practice to support high-performing, health-savvy women in pursuit of abundance and a less stressed life.

[00:00:49] Christa Biegler, RD: One of my beliefs is that we always have options for getting the results we want, so let's see what's out there together.

[00:01:07] Christa Biegler, RD: Today on the Less Stressed Life I have back Jennifer Gularson, a leading expert in women's midlife health, functional medicine, longevity, and natural aesthetic enhancement. She practices at the Osteopathic Center for Healing, delivering concierge-level care to patients, and specializing in helping women navigate perimenopause, menopause, and complex chronic health concerns.

[00:01:28] Christa Biegler, RD: She's a board-certified physician assistant and graduate of the University of Virginia and University of Maryland Baltimore, where she... And she brings more than 20 years of experience along with advanced training in bioidentical hormone replacement therapy, peptide therapy, metabolic optimization, regenerative medicine, aesthetic medicine, and evidence-based longevity therapeutics.

[00:01:46] Christa Biegler, RD: She was here not too long ago. I don't know the exact date and time and episode number, but she came on to talk about a very, a not often talked about but a really needed topic. We talked a lot about libido, but we wanted to have her back to talk about the bigger hormone replacement and transition between perimenopause, menopause, et cetera.

[00:02:05] Christa Biegler, RD: So welcome back, Jennifer.

[00:02:07] Jennifer Gularson, PA-C, IFMCP: Thank you so much. It's so fun to be back.

[00:02:09] Christa Biegler, RD: Yeah, it is fun to be back, and you're in a new setting. You're in your office. Yes. So why don't we just start... I love starting with a story, and a lot of times there's a personal story, but when we were just talking before we hit record, you said you had a new patient in just right before this or this afternoon, and I wanted to hear...

[00:02:26] Christa Biegler, RD: I just think stories are fun. And so will you tell us a little bit about this patient who came in and why she came in today?

[00:02:33] Jennifer Gularson, PA-C, IFMCP: Yeah it's a very common story that I hear mid-40s, late-40s, and then into early 50s, where they just aren't getting answers to all of their questions.

[00:02:44] Jennifer Gularson, PA-C, IFMCP: And this specific patient was on a, a birth control pill, and was not feeling great, and went to her GYN and said, "Maybe HRT?" And she said, "No, you don't need it." And so she was just a little frustrated. So then she went in. She's dealing with a lot of chronic fatigue, a lot of depression, anxiety not sleeping, joint stiffness.

[00:03:08] Jennifer Gularson, PA-C, IFMCP: No hot flashes or night sweats, but went to see her... She had a new psychiatrist, 'cause she said maybe it's I gotta change out my m- medication." She was on an SSRI and Wellbutrin. And thankfully, her therapist sent her to a new psychiatrist, and that psychiatrist is well-versed in women's midlife, and was said, "I'm listening to what you're saying.

[00:03:29] Jennifer Gularson, PA-C, IFMCP: I really don't wanna change your medicines. I really do think you need to have some hormone testing." So that's when she went back to her GYN, and the GYN said, "Nope, you don't get that." And then she found her way to me.

[00:03:39] Christa Biegler, RD: Yeah. It's a meandering tale sometimes. So- Yeah ... I wanna talk about some of those symptoms that she was describing, because we have some sort of stereotypical classical symptoms, including hot flashes, but you were describing some that may or may not be.

[00:03:56] Christa Biegler, RD: I feel when we're talking about hormones, so often people come in and say, "I think this is my hormones," and my thought around that is true, and hormones also rely on all your other systems working well as well. So I wanna talk about- Yeah ... what's happening in the body as we start to transition into peri- First of all, we should really stop and talk about this woman being on birth control, right?

[00:04:16] Christa Biegler, RD: In mid-40s. It's seems a bit ridiculous, doesn't it? It's like, what's the point? She

[00:04:20] Jennifer Gularson, PA-C, IFMCP: was actually 51. Okay. Yeah, she was 51. So yes. And-

[00:04:24] Christa Biegler, RD: I wonder why she was put on birth control in the first place ...

[00:04:27] Jennifer Gularson, PA-C, IFMCP: especially since she had to go to extreme lengths fertility treatments, and had to use donor eggs in order to conceive her two children in her 40s.

[00:04:36] Christa Biegler, RD: Yeah. I'm, like, trying to come up... I know that being put on birth control is like a band-aid answer for a lot of things, but it's sometimes it's hard to fathom why would somebody be putting you on that at this-

[00:04:48] Jennifer Gularson, PA-C, IFMCP: Okay. So I will take you through their thought process, and they're not entirely wrong,

[00:04:52] Jennifer Gularson, PA-C, IFMCP: And this was through a GYN, but also primary care can get lumped into this. We weren't taught any of this. Some of this is not our fault. You have to definitely do a lot of digging and a lot of treating, and I've been doing it for so long that it's just "Oh, does, everybody doesn't know this?"

[00:05:07] Jennifer Gularson, PA-C, IFMCP: But no, you don't know this. So- If you go through what's happening in perimenopause, there's huge fluctuations in what your brain is asking for and what your ovaries are able or unable to produce. There's a big disconnect between those two things. In our 20s and 30s, it's like clockwork.

[00:05:26] Jennifer Gularson, PA-C, IFMCP: Your brain asks, your ovary delivers. At some point, that starts to poop out. So now you got your brain really screaming for estrogen, and your ovaries may be able to do it, and then sometimes they over-deliver, so then you get estrogen dominance. Sometimes they under-deliver, and you get symptomatic. So what the thinking is with a birth control is like, let's just shut the whole thing down.

[00:05:49] Jennifer Gularson, PA-C, IFMCP: Let's satisfy your brain, shut the ovaries, and give you a steady state of these synthetic medications. That way they're not symptomatic. But in the perimenopause situation or timeframe, other things happen. So I have a lot of women who are on birth control pills, and they're va- vaginal dryness.

[00:06:09] Jennifer Gularson, PA-C, IFMCP: Their libido tanks. And they do have some joint stiffness or achiness just because there's not enough. I understand why it happens. G- GYNs and family practice are very comfortable prescribing hormone-related things as it pertains to stopping a pregnancy, and they just I feel comfortable writing this prescription. I don't feel comfortable writing hormone replacement, which is actually 10 times less than... The amounts of estrogen are 10 times less, and they're bio-identical. They're actually less dangerous. But that's where the training and the knowledge and the just being comfortable, being like, I'm not hurting anybody.

[00:06:43] Jennifer Gularson, PA-C, IFMCP: I'm actually doing them a favor," their bones, their brain, everything. Yeah. So I know why, that's sorta why it happens.

[00:06:50] Christa Biegler, RD: Yeah. And I think about there are consequences to being on birth control, right? It impacts- Yes ... the gut microbiome, B vitamins- Yes ... tank, et cetera. And so and then there's often some things that happen to your mood quite a lot as well.

[00:07:04] Christa Biegler, RD: So it's a challenge because it's like what... was being on this medication for a long time actually- Not a nail in the coffin, but was it contributing to the overall

[00:07:16] Jennifer Gularson, PA-C, IFMCP: symptomology? Yes, and in her case I say yes because she had a child. She went on for a year and a half, had the heavy periods.

[00:07:24] Jennifer Gularson, PA-C, IFMCP: There's perimenopause symptoms because, when you do fertility treatments, technically a lot of times you'll go into p- menopause a little bit earlier just because you've had such hyperstimulation. And she just seemed she was one of those. And then also her mom went into menopause in her early 40s, so she was had a history of, family history of early menopause.

[00:07:45] Jennifer Gularson, PA-C, IFMCP: Her sister, who is six years younger, is having worse symptoms than she is. It's a constellation of symptoms often mistaken for other things, the GI symptoms for, gut related issues. The stiffness in the joints and things are often you're seeing a orthopedist and maybe getting joint injections, which is horrible on another level.

[00:08:08] Jennifer Gularson, PA-C, IFMCP: Psych stuff, not sleeping, put on Trazodone. Um, symptoms that just rear their head or get worse, and traditional things aren't working so then you get put on, see a psychiatrist or somebody who's putting you on ADD meds, plus your Zoloft, and then your libido tanks, and it can be really hard navigating this time.

[00:08:28] Jennifer Gularson, PA-C, IFMCP: And then add on top of that, like we talked about in the last episode, all the stuff that we're dealing with in midlife with your kids and career and all that stress, and then not sleeping, and then maybe, going out and having a drink with your girlfriends because you're stressed out.

[00:08:43] Jennifer Gularson, PA-C, IFMCP: It just compounds itself. . It's a hard time.

[00:08:47] Christa Biegler, RD: Yeah. Yeah. But there's so much to unpack here. Yeah, I'm sorry. So what I want to underline... No, it's great. I'm making notes. One thing I wanted to highlight from what you said already was, I think it's a really useful connection because I don't always think that we realize that our brain is in charge of so much.

[00:09:02] Christa Biegler, RD: And so I like when you said the brain is asking for something, and the ovaries may or may not be able to produce them. And especially early 30s or before perimenopause, my goal with clients is always to get all of their systems operating at optimal level, but to be producing your own hormones as long as possible.

[00:09:21] Christa Biegler, RD: When that starts to decline your ovaries start to say, "I'm not gonna produce these hormones," and the adrenals take on an extra brunt, et cetera. And you've been talking through some symptoms, but I think one of the challenges that we are looking at with perimenopause is, and this is how my brain is processing it so far.

[00:09:39] Christa Biegler, RD: I guess I want you to take us through what starts to happen in perimenopause because as I've been- somewhat trying to understand this in my own brain a little bit. It seems if your systems or something in your body was not optimal before This transition, this hormonal transition will really accentuate this.

[00:09:57] Christa Biegler, RD: It will really exacerbate this overall because it's like you have some of these symptom- we, some of the symptoms that we see talked about a little bit more in the online influencer perimenopause space is histamine stuff going up. I actually did an interview last week on ADHD symptoms going up.

[00:10:12] Christa Biegler, RD: You were just talking about gut and joint things, et cetera, you were just saying also if you go to have a drink, it like then further taxes the systems. And it seems to me that if things were getting by before and they weren't really operating really well, then this time is g- really going to amplify that.

[00:10:29] Christa Biegler, RD: But I'd love for you to tell me if that's wrong, and talk t- us through what's happening in perimenopause. I think Lara Briden, it might be her, it might be someone else, calls this the second puberty, right? Yes. Because it's actually, we're actually seeing kind of some increases of things, and you were just describing that with that thought process of why you would put someone on birth control overall.

[00:10:47] Christa Biegler, RD: So walk us through what's happening in perimenopause. Correct me if I'm wrong on my thought process of course as well, but let's talk about kind of the beginning and when this starts in this age and some of these symptoms that you're... Like, what people are coming in and just, and complaining of. Even though you've been talking about it, I think so often people are trying to often discern once they hit a certain age, is this perimenopause or is this something else?

[00:11:10] Jennifer Gularson, PA-C, IFMCP: Yes, I think it gets blamed for a lot and then not blamed for enough. Maybe that's what it is.

[00:11:14] Christa Biegler, RD: Yeah.

[00:11:15] Jennifer Gularson, PA-C, IFMCP: So yes, when you're born, you have all the eggs that you're ever gonna have in your ovaries, and by the time you reach puberty it's diminished by half or I actually just wrote down specifically in ages and how many you have left, but let's say by the time you're 35 or so, you're down to like 10% of the eggs that you used to have.

[00:11:36] Jennifer Gularson, PA-C, IFMCP: And it was interesting, and of course that makes sense, you only have 300 to 500 ovulations in your lifetime, so only three to 500 eggs actually come to fruition, but you're buil- you're born with over a million of them. Wow. So by your mid 30s, you're down eggs, and then by your late 30s you're really down, and early 40s.

[00:11:56] Jennifer Gularson, PA-C, IFMCP: And as the egg population decreases, the quality of the eggs decrease also. And those eggs are, they create, obviously the egg, but what's left over creates the progesterone for you to hold onto that egg should it get fertilized. So one of the first things we see is a decrease in progesterone.

[00:12:15] Jennifer Gularson, PA-C, IFMCP: When you have a decrease in progesterone, women can feel like their cycles are shorter. They can feel like their cycles are heavier because you're, now you have a disproportion of estrogen to progesterone. And so you'll have heavier cycles, clots. And then also their PMS symptoms might happen that week right before the period where the progesterone is slowly declining.

[00:12:36] Jennifer Gularson, PA-C, IFMCP: If it was only halfway up there to begin with, and now you've had a decline, you're gonna be more symptomatic. So you have overall lowering of some of the hormones. And then every once in a while, you just don't even produce an egg, so you have no ovulation. So then it signals to the brain, "Hey, we didn't have an ovulation last week.

[00:12:56] Jennifer Gularson, PA-C, IFMCP: We gotta ask louder." So now your follicle-stimulating hormone goes even higher, your estrogen level can get even higher, and it's trying to make that egg appear, and sometimes it does, and then you'll have a normal cycle, and then it just ebbs and flows. So that's what's happening, this chaos, the zone of chaos, the hormone chaos.

[00:13:14] Jennifer Gularson, PA-C, IFMCP: One month it might be good. You might have six months where you have nothing, and then you're experiencing some of the symptoms. So when those things happen, if you don't have all the things the baseline things in play, just like you were saying, your journey could be worse.

[00:13:31] Jennifer Gularson, PA-C, IFMCP: Everybody's gonna have their own journey, but if you are not eating well, if you are not sleeping, if you're burning the candle on both ends, or if you're working your butt off, if you're not exercising, if you're exercising too much, if you're not eating protein, if you're eating too much fats and inflammatory diet, and you have a predisposition to not be able to handle things well 'cause your genes are just a little off, then that sets you up for a worse perimenopause.

[00:13:55] Jennifer Gularson, PA-C, IFMCP: So- Unfortunately, in the midst of all these thir- when you're in your 30s and 40s, getting all your routines down is really important so that you establish good habits in the midst of being all these busy and, so it's just, it's... Like I said, my heart goes out to all of...

[00:14:12] Jennifer Gularson, PA-C, IFMCP: i've been through it, and I'm, now I'm 53, but it's a hard time, and you feel so overwhelmed. And I was on a girls' trip, and the entire time we were talking about which kind of magnesium, and how much protein, and how can... And do we do creatine, and which kind? And I feel so overwhelmed.

[00:14:28] Jennifer Gularson, PA-C, IFMCP: And to how many more supplements? And now I heard about vitamin D3, and how do I check it?" So everybody's overwhelmed, and they're trying to do everything perfectly. And you just lose sight of "Where do I start?" And that's where, the coaches are really good and helpful in getting everything, sleep hygiene down, exercise down- so that you can go through this. Everybody's gonna have a little bit of a rough spot, but it makes it so much easier if you're cleaned up with your foundation is clean.

[00:14:56] Christa Biegler, RD: Yeah. And we can always go back and clean up those foundations- Oh, yeah ... because a lot of what you're describing are the skills that we get to gain.

[00:15:06] Christa Biegler, RD: Yeah. And just because we gain a skill one time doesn't mean we only get to use it once, because sometimes life just happens, and we get out of balance, and What's nice is that the basics are very important. And so if you have been adhering to do all of these basics, you're really emphasizing that before going.

[00:15:22] Christa Biegler, RD: And I think one of the struggles I see with doing those girls trips with friends is people go about this different ways. And so some people go straight to hormones, and some people go to supporting all the other systems first. And so it's been interesting to watch that all play out and to see what happens on the other side because for me-

[00:15:45] Christa Biegler, RD: From my vantage point, hormones are life-changing, and they may not always be the first line of therapy or defense, right? They're not something you wanna stack onto a shaky foundation necessarily. Otherwise, the foundation's still gonna be shaky underneath, and you might be frustrated, and I think that's kinda the challenge.

[00:15:57] Christa Biegler, RD: I wanna use your client's story from earlier today, though, of how easy this is to happen and how this is really probably the majority of the population. Your client said, her sister's symptoms were worse than hers, and I think that we're experiencing maybe the first generation where women are starting to become more taking kind of ownership and charge of their health.

[00:16:17] Christa Biegler, RD: Because in the past, it was very quiet suffering. I think most women going through this, they would say their parents didn't talked about this at all, and there was not the education that we have now. And so we're going through a wave of education and self-awareness, et cetera. And at the same time, when we compare ourselves to others, and I use this example every once in a while, any of my clients that are nurses, I always have to go and scoop them up because they have this little self-doubt "Maybe my stuff isn't that bad," 'cause they're working with emergencies every day, right?

[00:16:50] Christa Biegler, RD: Or, like- Yeah ... things literally falling apart. And so when they compare what's going on with them, which doesn't feel good, to what the crazy awful things that they are sometimes dealing with. It was just the fourth of July, so I'm thinking about... my brain's going to the worst possible things that they're dealing with.

[00:17:04] Christa Biegler, RD: Like the firecrackers? They're like

[00:17:05] Christa Biegler, RD: Yeah. "I was just taking care of someone whose hand was blown off. Maybe my issues aren't that bad." And it's like, hey, we cannot be comparing ourselves to that. But I just think that with your patient, it's like she was probably... it took her going to three or four different people minimum before she got lucky enough to end up in your office, right?

[00:17:21] Christa Biegler, RD: And very often people aren't that lucky to find someone who really knows much about this, and that's that's kind of the challenge. That's what we're trying to do always on this show is- Yeah ... help people understand what they don't know. Yeah. Okay, so basics are important, and you were just talking about where we start.

[00:17:35] Christa Biegler, RD: And I think I have such... You've done such a beautiful job kind of walking us through this journey so far, and so I think the question maybe is either where do you start or we can even keep going down this perimenopause journey. 'Cause it's... When you describe it like that I just love it for the brain.

[00:17:52] Christa Biegler, RD: So we've got this decline of progesterone, but sometimes estrogen is still It's not being checked. It's not being checked. And so if you're not detoxing your estrogen very well, then those symptoms may go up. You might have have your more intense PMS, et cetera. And so I guess the question is, when you're first doing assessment, if someone comes in and they're more of the perimenopause stage, let's continue on that kind of chronological order.

[00:18:17] Christa Biegler, RD: How are you assessing for is this perimenopause related or not? Where would I maybe start? And then this is... I'm sorry, it's such a loaded question. And then maybe there are some things, we've talked about this a little bit. There's things that are not perimenopause, and they really should be looked at as well.

[00:18:34] Christa Biegler, RD: Maybe let's start with that one. It's like, hey, if people are coming in with this, and this, really we should be working on some other things and not, I don't know if it's like a condition to be treated as much as like a, "I'm supporting my systems," but maybe I'm wrong.

[00:18:46] Christa Biegler, RD: So walk us through if someone comes in and they're more in that perimenopause camp or the step before that, if they're dealing with symptoms, they're like, "Is this my hormones?" But it's really not, and it's a red flag. I think let's cover that one first.

[00:18:58] Jennifer Gularson, PA-C, IFMCP: Yeah this patient also is a good example 'cause her ferritin is really low.

[00:19:02] Jennifer Gularson, PA-C, IFMCP: And her gut isn't really healthy. So for, for 30 to 45-year-olds, it's yes, it could be the hormones, but are you giving your body a chance to actually use the hormones the way that you're supposed to? So are you pooping every day? Are you detoxifying? Are you moving yourself? Are you sweating? Are you trying to get rid of toxins?

[00:19:22] Jennifer Gularson, PA-C, IFMCP: What's your diet like? Are you overburdening your system so then therefore that messes up your hormones? And definitely checking a thyroid looking at stress and the adrenals, and then your hormones. That's a three-legged stool that if one of the legs is shorter, things start flying around.

[00:19:39] Jennifer Gularson, PA-C, IFMCP: So spec- specifically for her she actually has low folate and low B12, so those things can affect her her gut, her energy, as well as her mental stuff. Vitamin D was i'd probably wanna increase that, so that's something. Her gut, she wasn't pooping. She is on a GLP-1 so it's are you eating enough and eating the right nutrients?

[00:20:02] Jennifer Gularson, PA-C, IFMCP: Are you nutrient dense? Which she has two smaller children, and she admits, "I take care of my kids first, and I take care of myself second, and I don't eat as well." And so all of those things play a role. And do I work on those things first? Yes. Do I do it maybe in concert with maybe a little bit of progesterone second half of the cycle?

[00:20:24] Jennifer Gularson, PA-C, IFMCP: Or, really mapping out symptoms, that's very helpful for me, like doing a symptom tracker and... but yes the iron storages for the... and the vitamin storage, nutrient testing, gut testing, all of that sort of plays a role. Sometimes there- Super efficient with everything, and they're just experiencing the decline in hormones.

[00:20:44] Jennifer Gularson, PA-C, IFMCP: But certainly the thyroid issues and habits I really concentrate on first, and it may be in conjunction with starting some hormones to help them along.

[00:20:55] Christa Biegler, RD: Yeah. I think that's such a grounded way to answer that. You talked about assessing adrenal status, thyroid status, I think gut status. Is that what you said?

[00:21:04] Christa Biegler, RD: And one of the challenges is that depending on the provider that someone goes to see, I don't think that conventionally our tools for assessing gut status and adrenal status are very adequate. In fact, I would say that even assessing thyroid status is not really adequate, but it's more normal.

[00:21:22] Christa Biegler, RD: It's more commonplace. If you go into your provider, they're not gonna look at you funny if you ask them to assess your thyroid, whereas if you ask them to assess your adrenals or gut, they would say... They might say "I have no idea what to..." It's just not part of... It's not standard of care really.

[00:21:35] Christa Biegler, RD: No. It's always fun to talk to someone who can really be integrative, right? They've had a foot in both sides. I appreciate that 'cause we need to have, we need to have both angles. So you can speak to it from both sides and say, I guess I'll ask you this. I have my ways I look at adrenal.

[00:21:50] Christa Biegler, RD: I honestly think symptoms tell us so darn much in general. But I also think that doing... I think it's maybe helpful to tell someone that just doing a single blood test for cortisol in the morning isn't a very healthy picture or a very useful picture. If anything, if there's any blood test to me that might give us more indication might be DHEA because your adrenals are making DHEA.

[00:22:12] Christa Biegler, RD: And so if you're not, if your DHEA is low, there's a pretty good chance that your adrenals aren't making that happen. And as far as gut status we just don't look at the gut that way. I know that you practice functionally, so I would say, i'll just ask you... i'm trying to clarify for the listener is okay, you're telling us to look at these three prongs.

[00:22:29] Christa Biegler, RD: I one million percent agree with you. And if people don't necessarily have access to a provider who really knows how to assess these things, what might your advice be to that person? It's a tough

question,

[00:22:41] Christa Biegler, RD: sorry. Ooh, what is the answer-

[00:22:43] Jennifer Gularson, PA-C, IFMCP: Yeah ... to

[00:22:44] Christa Biegler, RD: me as symptoms?

[00:22:46] Jennifer Gularson, PA-C, IFMCP: So I think it's not unusual or it's not unheard of for patients to come in and say, "In addition to the T4 and the T- TSH that you're going to test, can you please test a free T3?"

[00:22:57] Jennifer Gularson, PA-C, IFMCP: And so they'll get pushback sometimes. And then also an iodine and selenium. The- all these are lab tests that I can test through LabCorp and Quest that insurance usually pays for, especially if you're feeling fatigued. I agree, a morning cortisol test it tells you if something's really bad.

[00:23:16] Jennifer Gularson, PA-C, IFMCP: If it's really high or really bad, it's telling us something, but then we'll just do more testing. Through LabCorp testing, you can get salivary cortisol testing, and I just give them a kit and have them test four times throughout the day, and that will give me some information. However, for 160 bucks, the Genova Adrenocortex, the salivary testing gives you a nice picture where you should be and where you are so that- If I have a patient who really needs convincing that their cortisol is high or low, or we don't know if they're, it's super low, I will do that test.

[00:23:51] Jennifer Gularson, PA-C, IFMCP: If not, I'm like, "Okay, you're waking up at 3:00 in the morning, and you're sweating, and your cycles are normal, okay, and you're super stressed out. Let's just assume you have high cortisol and treat it as such, and do all these things to help. And here are the supplements, here's the support."

[00:24:07] Jennifer Gularson, PA-C, IFMCP: DHEA's perfect. You're having these symptoms and your DHEA is 400 you're stressed. We need to bring that down. And as far as the gut test, there's a couple that you can do through LabCorp, but not a ton. I like to see the beta-glucuronidase level for patients, especially if they're having estrogen dominance symptoms.

[00:24:27] Jennifer Gularson, PA-C, IFMCP: So that's, for those of you who don't know, it's an enzyme that actually stays in your gut, and it takes your conjugated estrogen that you're ready to remove, and it recirculates it back into the system, which you do not want to do. So bringing that down, but then looking at inflammation. Sometimes you need to show people

[00:24:44] Jennifer Gularson, PA-C, IFMCP: if I show you need to take the B vitamin, then you will take the B vitamin. Sometimes it's not based on the symptoms. So those are the big three tests that I do. A full thyroid panel, including iodine and selenium, and then your and vitamin D, of course, B vitamins, folate, B12.

[00:25:02] Jennifer Gularson, PA-C, IFMCP: You can do a cortisol. It doesn't tell you much. I like the salivary cortisol testing. You can do that through LabCorp. The salivary testing is such a pain in the butt. It... You have to really think about oranges and and lemons and limes, and then- Like spitting on a

[00:25:15] Christa Biegler, RD: tampon.

[00:25:16] Jennifer Gularson, PA-C, IFMCP: Yeah, okay. So true.

[00:25:19] Jennifer Gularson, PA-C, IFMCP: Ah. And then the gut test. And usually I only, I do the gut test once. And then I also do Dutch testing and actually, Genova just came out with a really cool test that does micronutrient testing organic acid testing, and estrogen breakdown. Nice. And it's pretty reasonably priced, and I understand that this is all a lot of out-of-pocket cost but that's actually a really good test too, to do.

[00:25:47] Christa Biegler, RD: Yeah, for a long time, Dutch was the only one that had estrogen metabolism, which can be helpful at any age, because if you're not detoxing estrogen well, it can go down a cancerous pathway, even if you're overall low because you're not producing as much. And so I think it can be, might be useful at different times.

[00:26:03] Christa Biegler, RD: I'm not saying pro or con, but there are some new competitors, right? Yeah. So there was a different competitor before Genova that I had some clients looking at as well. The thing to take away from this little section is that- If the energy is low or you're exhausted, or this may even present as achiness, to be honest, because low vitamin D can cause some achiness.

[00:26:24] Christa Biegler, RD: Really any of having like low thyroid, that could cause total aching. That's very possible. But anyway if energy is low, slapping a sex hormone on top of it may not account for everything. Or if you're losing your hair, right? If your adrenals, your thyroid, or your gut status are off, and the low ferritin is gonna cause major fatigue and hair loss.

[00:26:46] Christa Biegler, RD: The thyroid could cause major fatigue and hair loss and dry skin and slow motility and cause more gut symptoms, et cetera. The adrenals are I think of as almost like a, not a regulator, but it's like you gotta make that system happy before everything else can often be happy very often.

[00:27:01] Christa Biegler, RD: That's my takeaway from that section, and so it's really looking at those other pieces as well. Let's talk about when someone comes... So we're talking a little bit about when it's not hormones. You did a beautiful level-headed job of maybe I'm gonna help them with lots of things and then also give them progesterone second half of the cycle.

[00:27:21] Christa Biegler, RD: Some people like checking serum, So we were just talking about Dutch tests, and that will te-test your adrenals, give you a little bit of a picture of detoxification of estrogen test sex hormones, look at the metabolism just in general. But you can also do serum testing for hormones For progesterone, estrogen, testosterone.

[00:27:41] Christa Biegler, RD: And some people are really staunch about checking that during certain parts of the cycle. Other people would say there's a few different times you can check it during the cycle. Is that automatically something that you do for everyone who walks in the door, is check those few tests? And do you have them check it?

[00:27:57] Christa Biegler, RD: And I bring this up because when you say Dutch test, sometimes it sounds nice to do a test but actually executing the test can take more than two months sometimes, or three months. Yeah. And like the last time I did a Dutch test, I left all... I peed on all the strips and then I left them out for too long.

[00:28:13] Christa Biegler, RD: And then I put them in the envelope, and they were like, "Hey it says you took this test two weeks ago." And I was like, "Yeah, probably. It took me that long to mail it." They're like, "It's no good anymore."

[00:28:21] Jennifer Gularson, PA-C, IFMCP: Yes.

[00:28:21] Christa Biegler, RD: We first had to do a new one. And it was like, oh, okay, let me time my cycle again to take it. And I only tell you that it's an amazing test and an incredible company, but so often as humans, we love- It's a lot of work

[00:28:32] Christa Biegler, RD: to test. We love to test, but then we don't really know what that looks like on the other side, and it's oh, I'd actually like to feel better sooner than three months from now. So just looking at what your options are. So I guess the question is, yes, do you test those sex hormones, and then do you test them at certain times of the month or any time of the month, depending on where the woman is in her- Yes

[00:28:51] Christa Biegler, RD: perimenopause or menopause journey?

[00:28:52] Jennifer Gularson, PA-C, IFMCP: So I try to be pretty, I understand that, again, that it's a lot of out-of-pocket cost. So I do use a lot of, and I if you will, grew up testing blood. So I do test blood. If the patient is cycling, then I try to get day 19 to 21, knowing that it's sometimes hard 'cause there's a weekend or whatever.

[00:29:12] Jennifer Gularson, PA-C, IFMCP: But then oftentimes I'll say, if you can't get that exactly, just keep track of your cycle really so I can know. So either day two or three of the cycle, so if first day of the your cycle is the day you start bleeding, day two or three can tell you some things, like how hard is your FSH, like, rising really quickly.

[00:29:30] Jennifer Gularson, PA-C, IFMCP: It's more so for PCOS, but day 19 is gonna tell me if you ovulated or not. How critical is that? Most, this is where all the controversy comes in, and I think as we get, we're just... This is the infancy of hormone replacement. Even though I feel like I've been doing it forever, this is where all the questions are.

[00:29:52] Jennifer Gularson, PA-C, IFMCP: I just read an article somebody wrote who I respect in the industry. She's like, "We need to have serum estrogen at 100 for your post-menopausal women." What happens with my women, a lot of my women, is if I get it that high, then they're bleeding. So how high that they're, you're protecting your brain or you're actually building bone, they say serum 100.

[00:30:10] Jennifer Gularson, PA-C, IFMCP: And I like try to keep it at around 50 because I don't wanna proliferate the u- endometrium. And then you have the... it goes on and on. It transfers over to post-menopausal women who are supposed to have no endometrial stripe or very small. Now they're on hormones, so is there a new standard that needs to be taken into consideration?

[00:30:29] Jennifer Gularson, PA-C, IFMCP: Yes, this woman's on hormones, and so do we expect her endometrial stripe to be a little bit at 69, not what a 69 with no hormones? I feel like that's a whole big thing. The whole mammogram issue with fibrocystic breasts or you have dense breasts. Yeah, you're gonna have dense breasts for longer because you're on hormones.

[00:30:47] Jennifer Gularson, PA-C, IFMCP: So does that need to change? Does that... in the industry. So I think there's a lot of things that need, that are going to evolve now that- if I'm guessing by any standard that there's no estrogen patches out there available, that there are way more women on the estrogen, so therefore there's a, crisis, basically.

[00:31:05] Jennifer Gularson, PA-C, IFMCP: I went to three different places today for my own patch. So there's a shortage of them. So getting back to testing, I test my post-menopausal women probably twice a year, and especially if they're on testosterone. I think that is a very reliable serum test, free and total testosterone. I like that for if I'm doing replacement.

[00:31:23] Jennifer Gularson, PA-C, IFMCP: The estradiol, it helps me. I see what their FSH is. I try to keep it below 50, around 50, and then a total estrogen estradiol around 50. Those numbers seem to say I'm protecting their bone, I'm protecting their brain, I'm protecting their heart. And then if they have other symptoms, I'll tweak it based on symptoms.

[00:31:43] Jennifer Gularson, PA-C, IFMCP: So you have a whole camp of people that say, " You just need to treat based on symptoms." You have people in the middle like me that I do when I can't figure it out or if I'm, after doing it for so long, it can be clinical judgment, and also talking to your patient and making a decision together, shared decision-making.

[00:31:59] Jennifer Gularson, PA-C, IFMCP: And then there's people in camp that you have to test every single time. It just gets expensive.

[00:32:04] Jennifer Gularson, PA-C, IFMCP: So there's the controversy in-

[00:32:06] Christa Biegler, RD: Yeah ... in the group. There's a lot of controversy. I'll touch on something that we've talked about on the podcast before, but I'm, I wanna make sure that this episode serves people whether they've heard every episode or zero episodes.

[00:32:17] Christa Biegler, RD: You were just talking about protecting bone, brain, and heart, and this is the consequence of our decline of estrogen, right? That our body starts to decline along with our hormones declining. That's just I think that's the nicest way to say it. Our body's like, "All right, I'm declining now."

[00:32:33] Christa Biegler, RD: done. And there's a major increased risk of cardiovascular events, neurodegeneration, including Alzheimer's, et cetera, and bone health without 20 years after the onset of menopause. I think that's how I'm saying it, but correct me. Anything more you wanna say to that?

[00:32:48] Christa Biegler, RD: It's, to me, one of the biggest arguments of understanding hormone replacement therapy and who it's right and who it's not for, but what do you think about this?

[00:32:56] Jennifer Gularson, PA-C, IFMCP: Yes. So estrogen declining has a lot of problems, and your body depends on it. Every cell in your body has an estrogen receptor from your hair all the way down to your toenails and everywhere in between including your heart and your brain and your eyes and all the places that you have people complain ailments, ear, ringing and all of ear itching, all of that stuff, your skin.

[00:33:17] Jennifer Gularson, PA-C, IFMCP: I will go back to my patient today. She's such a great example. She asked her OBGYN, "Is there a problem with me going, as in perimenopause, going on hormone replacement?" And the women, the answer from the OBGYN was, "When you do hormone replacement in perimenopause, you're increasing the estrogen so much that it just puts you at risk for other things."

[00:33:46] Jennifer Gularson, PA-C, IFMCP: And it's very opposite of my philosophy is that in perimenopause, I'm trying to provide you a safety net so that you don't bottom out. It does nothing to increase. If anything, you're increasing the estrogen, your FSH will come down, and then it, your brain won't be so active. So if anybody walks away with anything it's totally safe to do in perimenopause.

[00:34:08] Jennifer Gularson, PA-C, IFMCP: In fact, you lose more bone in the first two years during those declines. So in perimenopause you can lose more bone that you're not aware of because of the decline. And we don't test you traditionally until you're 65. That's way too long to wait and see where you were. I tend to test earlier, and I feel like that's where the trends are, testing earlier, because you have the protective effects, especially for the cardiovascular risk and cholesterol and yeah, anti-inflammatory properties.

[00:34:38] Christa Biegler, RD: I'll come back to cholesterol because I think that's something that can be alarming for women to see their cholesterol start to rise when they're like, "I don't understand why-" Didn't change- "... it's all right." We didn't change anything, right? But the decline of estrogen allows for cholesterol to increase.

[00:34:52] Christa Biegler, RD: Why is that what's happening exactly?

[00:34:54] Jennifer Gularson, PA-C, IFMCP: So the building block to all hormones is cholesterol, so that's where there's a danger for having too low a cholesterol. I think cardiologists would probably argue me up and down but you see it in the older patients where they're on statins for so long, and is that contributing to dementia?

[00:35:10] Jennifer Gularson, PA-C, IFMCP: Don't know. But all I know is that the building block of all the hormones is cholesterol. So if you're at the bottom of the barrel, if your estrogen, progesterone, testosterone is low, your body is going... It's miraculous. It's going to throw out more cholesterol and then hope that you can turn it into all the hormones that you need.

[00:35:29] Jennifer Gularson, PA-C, IFMCP: receptors become dysfunctional without the estrogen and stuff, so it is multifactorial. I just make it easier for my patients to understand that's what's happening.

[00:35:39] Christa Biegler, RD: About bone loss or bone degradation in the first couple of years in menopause, is that correct, in menopause?

[00:35:45] Christa Biegler, RD: Is weightbearing exercise- I think about my brain is wanting to do this thing where it like buckets things into structural approaches and nutritional or chemical approaches, which would be like estrogen and and other approaches. And so my brain wanted to go straight to in weight-bearing exercise, aren't we preserving bone health or do you need a little bit of both?

[00:36:05] Christa Biegler, RD: I guess like you can't outdo... we may not really know, but I'm wondering, can you use weight-bearing exercise as one modality instead of going on estrogen right away? And it's probably who knows? Or maybe you need both.

[00:36:18] Jennifer Gularson, PA-C, IFMCP: I have seen like lifelong yogis who do weight-bearing exercise all the time and are doing tons of yoga, walking and they come in and they're like, "I've tried it and I'm still osteoporosis, and I don't want to go on the medicine, so this is..."

[00:36:32] Jennifer Gularson, PA-C, IFMCP: The estrogen is- the next best thing. So it is an FDA-approved reason to be on hormones is osteoporosis. And so the lack of estrogen lets the bone break down faster. And I, like the three-pronged approach of progesterone and testosterone building bone, estrogen keeping bone not from breaking down.

[00:36:53] Jennifer Gularson, PA-C, IFMCP: So those three things plus your nutrition, your vitamin K, your weight-bearing exercises, all of those things. The other thing that I think we need to do a better job of is looking at bone flexibility versus just the DEXA scan and how strong the outer bone is because you want it strong on the outside, which is what the medicines do, but you also need things to be spongy on the inside and strong on the inside, but not so strong it gets brittle.

[00:37:18] Jennifer Gularson, PA-C, IFMCP: So there are some tests in Europe they do a lot of tests that test how spongy or how flexible your bone is. It's not just about how hard it is.

[00:37:29] Christa Biegler, RD: I have never had anyone talk about that before, so that's pretty fun.

[00:37:33] Jennifer Gularson, PA-C, IFMCP: It's called a trabecular score. And then some DEXA scans have that trabecular score.

[00:37:38] Jennifer Gularson, PA-C, IFMCP: In my area we have one at one facility that will do it. But there's also something called ecoLite, which I would love to bring to my facility, where it's a sonogram, and it will give you body composition but also, yeah, flexibility. So you need both of those things.

[00:37:55] Christa Biegler, RD: Cool.

[00:37:55] Jennifer Gularson, PA-C, IFMCP: Of course I'm gonna be more biased that, I don't think estrogen fixes everything, but estrogen is involved in most things, so Yeah

[00:38:02] Jennifer Gularson, PA-C, IFMCP: it can help in addition to having good habits.

[00:38:05] Christa Biegler, RD: Yeah. Okay, let's walk through if someone comes in and they say, "I'm interested in HRT." So I've asked you spotted questions around this about assessment, so if they're coming in and they're wondering if they should go on HRT, how would you maybe look at it?

[00:38:20] Christa Biegler, RD: And then I think there's sort of layers of education and discernment and discernment is probably done by the clinician who's treating you. You were talking about patches, but hormones come in different forms. They come in pellets and they come in patches and they come in creams, et cetera.

[00:38:34] Christa Biegler, RD: When you're answering this if you'll just account for a little bit of that. If someone's coming in and saying, "I think maybe I need hormone replacement therapy," how do you help them decide if it's for them? And I think we can look at it like this. It's how does it look like out there in the world, and then how do you maybe do it from your experience?

[00:38:52] Christa Biegler, RD: Does that make sense? 'Cause so often, and what I'm really saying is people come in and they're on 200 milligrams of Prometrium, and then sometimes they do better on this bio-identical progesterone cream. But they wouldn't even know that it's like there's multiple versions of doing, quote-unquote, the same thing, right?

[00:39:10] Christa Biegler, RD: And so that's what I'm getting at here is what's it look like for you if someone comes in and says, "I think I'm interested in this thing"? How do you wanna assess, and then what are their options in the world and what do you, have you chosen to do?

[00:39:21] Christa Biegler, RD: I do not know about you, but I feel the change of season is upon us. And for many people, it's back to school or back to work, or for me, it's back to focus. And I wanted to share a few tools that I'm using that might make this transition a little easier for you as well. Now, first of all, if you've got a kiddo that gets stressed or anxious about school or sports and/or you just don't like taking supplements by mouth, have you tried this Mag Relief lotion from Jigsaw?

[00:39:48] Christa Biegler, RD: A lot of topical magnesium sprays burn, but this lotion has zero smell, zero burn, and it contains organic oils and my favorite kind of topical magnesium, which is OptiMSM. You can just put some on. Usually, it's gonna be legs and feet, but you can put it wherever you want on your body. Put some on after exercise, before bed to help with sleep and stress.

[00:40:08] Christa Biegler, RD: Another type of magnesium that I am adding to my rotation is these Brain Boost from Jigsaw. It's mag threonate, which means that it's the type of magnesium that crosses your blood-brain barrier to help with focus. And in studies, beyond focus, it also helps with deeper sleep, which then helps improve daytime alertness and reduce grouchiness.

[00:40:30] Christa Biegler, RD: So if you have not tried the Brain Boost mag threonate from Jigsaw, it might be helpful for getting back into the swing of things. That's what I'm gonna go ahead and try. And then finally, I am still drinking this very licious Electrolyte Supreme with a splash of sparkling mineral water on repeat. It's kinda like one of those sparkly energy drinks, but better for you because it's a combo of a multivitamin, vitamin B, minerals, and electrolytes without a vitamin flavor at all.

[00:41:02] Christa Biegler, RD: So in September, Jigsaw is giving Less Stressed Life listeners a special increased discount of 15% off any order as many times as you want with the code LESSSTRESS15. That's for the entire month of September. You can take 15% off with the code LESSSTRESS15, and they're sending out a free stainless water bottle to anyone with a new electrolyte subscription.

[00:41:23] Christa Biegler, RD: So if you miss the 15% off code in September, no problem. You can always get 10% off any order anytime with LESSSTRESSED10 as the code. As always, thank you so much for supporting this podcast and using our codes at https://www.jigsawhealth.com/.

[00:41:41] Jennifer Gularson, PA-C, IFMCP: Okay, so I'll start with estrogen and it's all available.

[00:41:44] Jennifer Gularson, PA-C, IFMCP: Because estrogen's usually the big- the scariest one for people 'cause they've heard all the myths about the breast cancer, and the blood clots, and heart disease. And, now that the black box warning has come off, I think a lot of women are more educated. So estradiol or E2... So there's three different estrogens.

[00:42:03] Jennifer Gularson, PA-C, IFMCP: E1 is estrone, E2 is estradiol, E3 is estriol. So E1 we don't replace. E2, estradiol, is exactly what your body is making. And that commercially available, is available in a patch, which is the most common. And I like it because it gives you a sort of a steady state of application of estradiol throughout the day.

[00:42:25] Jennifer Gularson, PA-C, IFMCP: It comes in five different doses and it's nuanced what you pick for... I pick different for different reasons, but sometimes you pick one and it's too much, sometimes you pick one and it's not enough. You have the patches. They either come in twice a week or they come once a week.

[00:42:41] Jennifer Gularson, PA-C, IFMCP: I typically like the twice a week only because the once a week sometimes can fall off. And I could go on a soapbox here, but they only give you four patches, so if you miss one patch, like that's a whole week, and you can't get your prescription refilled because it's a monthly prescription. So like the patch situation- All the behind the scenes that- Yeah

[00:42:58] Jennifer Gularson, PA-C, IFMCP: people don't think about. They should have one extra patch for Pete's sake, just in case. So for me, the once a week are a little bit bigger. They look ugly 'cause they look like big Band-Aids. And sometimes for me the adhesive makes you get itchy and I react to the once a week.

[00:43:12] Jennifer Gularson, PA-C, IFMCP: So the twice a week is great. And on the top of the lid of the box, it tells you when to change your patch. So those are the patch the patch options. You also have cream, or gel I should say, and they come in little gel packs in a couple different dosing, and that is applied every day.

[00:43:31] Jennifer Gularson, PA-C, IFMCP: So some women don't like it because that's something you have to do every single day and then you have oral formulations, so the estradiol comes in a .5 and a 1 milligram tablet. I tend to shy away from that unless, patients can't tolerate other things and this is controversial, too, but the estradiol was never...

[00:43:50] Jennifer Gularson, PA-C, IFMCP: You have to go through a first-pass metabolism when you take anything orally, meaning it has to be detoxified through the liver. So there is a slightly increased risk of blood clot when you do that. But when you're talking about estradiol, it's less than a birth control pill, which is also less than when you're pregnant.

[00:44:07] Jennifer Gularson, PA-C, IFMCP: So there's different levels of risk for it. But if you've ever had a blood clot or whatever you definitely cannot take an oral estrogen, but you can take transdermal through your skin. So patches are okay and the gel is okay. So that's estradiol. And now I mentioned that E3, estriol. So estriol I use a lot vaginally 'cause it's great, but there is no commercially available estriol.

[00:44:32] Jennifer Gularson, PA-C, IFMCP: We're seeing a lot of this on if you're on Instagram, it'll spam you about For Your Face. So there's a bunch of companies out there with estriol 'cause it's a weaker estrogen, so it's great for tissue, skin on your face, your vulva. And you can also do it at a dose where you're systemically absorbed in something called Bi-Est, two estrogens.

[00:44:53] Jennifer Gularson, PA-C, IFMCP: This is a compounded product. You do not pick this up at your local pharmacy. This is a specialty product. And for some people, I do that, especially if they have a lot of autoimmune diseases or if they have a lot of inflammation because estriol is very calming to that. But that's a whole nother little bucket of things.

[00:45:10] Jennifer Gularson, PA-C, IFMCP: And then you can also do pellets. Estrogen is available, estradiol is available as a pellet. It's inserted underneath the skin. it kind of looks like a small grain of rice. And it tends to be give delivery over the course of about three to four months So that's estrogen.

[00:45:29] Jennifer Gularson, PA-C, IFMCP: Now progesterone. They're not to be confused with progestin, which is what's in birth control pills. So progesterone is commercially available in a pill which uses peanut oil as the carrier, which is hilarious, but we'll just gloss over that. It comes in 100 milligram or 200 milligrams, so if you don't fit within that 100 or 200 or 300 or 400 milligram, you have to get something compounded.

[00:45:54] Jennifer Gularson, PA-C, IFMCP: It is immediate release, meaning it dumps in the progesterone all at once. I personally take a, a sustained release progesterone 'cause I just like having it throughout the day, plus I think for me it helps with anxiety, it helps with irritability, and then don't ask my kids that though.

[00:46:12] Jennifer Gularson, PA-C, IFMCP: And then it also helps with just a sustained release for me just helps everything stay even and I stay asleep. For some people I even have some people take an immediate release, like I say CVS brand or whatever, the commercially available, and a sustained release to help them do both things, fall asleep and stay asleep.

[00:46:30] Jennifer Gularson, PA-C, IFMCP: So any combination of this is usable. So the compounded, you can compound it any way you want. So for a perimenopause person, I might say, "Hey, 50 milligrams, take one to three to four. Just figure out." You can take 50 milligrams first part of your cycle. You can take 100 mid-cycle, 200 right before your period, and then if you're having a period, stop and then recycle it again.

[00:46:53] Jennifer Gularson, PA-C, IFMCP: I try to teach my patients to listen to their body, to really tune into your symptoms so that you can self-regulate what you're doing. There is the advantage to taking an oral progesterone is that it goes through your liver, it's metabolized, and you get the effect of the calming effect of the GABA.

[00:47:09] Jennifer Gularson, PA-C, IFMCP: So it's metabo- broken down into something that increases GABA, which for most people, I would say 80% of people, it's very awesome. For they can't tolerate it. They get more anxious, and they can't sleep. For those people, you can use the commercially available progesterone vaginally, so you can just stick it in...

[00:47:29] Jennifer Gularson, PA-C, IFMCP: or rectally. Both of those will, the reason why you're taking progesterone in most cases is to protect your uterus so that you don't get endometrial cancer and then the last option would be, like, a compounded cream for progesterone. Again, you don't get the brain effect, like the sleepiness but for people who cannot tolerate then that's great And then testosterone.

[00:47:52] Jennifer Gularson, PA-C, IFMCP: So testosterone, again, no FDA-approved forms of testosterone for women but that doesn't mean that we don't have tons of data that it's great. And then we also have years and 30 years of safety data looking at trans men and them taking 10 times the amount that I give women now, and they don't die.

[00:48:11] Jennifer Gularson, PA-C, IFMCP: They don't have heart attacks. They don't have breast cancer. So we have data, especially in trans men, for 30 years, and then we have tons of data now for women on that five milligram dose, which has become the norm that people have said, yeah around five milligrams. So that is a compounded prescription that is a cream.

[00:48:33] Jennifer Gularson, PA-C, IFMCP: You can also do weekly injections and then the pellets. No progesterone pellets, just estrogen and testosterone That was a

[00:48:42] Christa Biegler, RD: really good summary. So when people are coming in initially, sometimes they're just being put on progesterone, sometimes you're putting them on a combo, 'cause I think there's combo creams of progesterone estrogen?

[00:48:53] Christa Biegler, RD: Is that correct?

[00:48:54] Jennifer Gularson, PA-C, IFMCP: Creams, yeah, you can compound your creams to anything. A lot of my colleagues will do estrogen and testosterone together. Yeah. I think that's what I was thinking. I like everything separate because if you wanna increase one and don't wanna increase the other one, I'm just, I just like to do one thing at a time.

[00:49:08] Christa Biegler, RD: Yeah. So what I hear is people come in, they may or may... How often do you actually put someone on all three? Like, how common is that? Isn't it typically one or two, and then you change things? And how long do you wait before you change things typically?

[00:49:22] Jennifer Gularson, PA-C, IFMCP: Yeah. It all depends on where they're coming from and where they are in the cycle.

[00:49:25] Jennifer Gularson, PA-C, IFMCP: If you are an educated woman who's been tested out the wazoo, has all their tests and all their data, and you haven't had a period in two years and your testosterone's in the toilet, I already know you don't have estrogen or progesterone, I can put you right on everything. And then I test after you're on it to see how you're doing.

[00:49:42] Jennifer Gularson, PA-C, IFMCP: If you're in perimenopause, it may be a combination. Like this woman today, I said, "Here, I want you to stop your birth control, go on this progesterone for a month. Play with it, 100 milligrams, 200 milligrams. See how you feel." I gave her the patches. I said, "When you're ready, message me and we'll say, ' starting the patch now,' and see how you're doing."

[00:50:03] Jennifer Gularson, PA-C, IFMCP: But I said, "In two weeks, if you're off your pill and you're on the progesterone and you start having hot flashes, not sleeping, and it looks like it's an estrogen thing, then you can pop the patch on." I usually s- try and start one thing at a time, especially in perimenopause. And then- Makes sense

[00:50:18] Jennifer Gularson, PA-C, IFMCP: for her, she already had testosterone and it was low, and I'm like, "Plus or minus testosterone," but she's very analytical. She's like, "I wanna do one thing at a time." I'm like, "Okay, do a month of progesterone, add the estrogen, and then y- a month later you can add the testosterone." So I try

[00:50:32] Jennifer Gularson, PA-C, IFMCP: advocate for them to tell me how you feel and then we can go from there.

[00:50:36] Christa Biegler, RD: Couple things about this. Sometimes you see people going on estrogen, and then their provider has them on DIM to detox out the estrogen. I used to think this felt kinda weird, right?

[00:50:47] Christa Biegler, RD: It's add it and then detox it. But there's so many benefits to estrogen, and then you also need to detox it well. So what do you think... I think just generally you need to optimize detoxification as a whole would probably be my thought process around that. But what do you think about these two things going together, people going on estrogen and then being put on DIM in general?

[00:51:07] Christa Biegler, RD: It's just I used to see it all the time, and now I don't see it so much anymore.

[00:51:11] Jennifer Gularson, PA-C, IFMCP: It's interesting because why are teenagers not on DIM then? 'Cause their estro- I

[00:51:18] Christa Biegler, RD: think that could be dangerous.

[00:51:19] Jennifer Gularson, PA-C, IFMCP: Their estrogen is way high. So anyway, my thoughts on DIM, if I do a estrogen metabolite test and they have trouble processing and getting it into the O2 bucket they make too much four then I probably would put them on it but you have to be careful because if they are crappy methylators, now you're pushing it all into that two bucket and it's gonna- Yeah

[00:51:40] Jennifer Gularson, PA-C, IFMCP: spill over. And so you have to make sure they're not only do you... If you put them on DIM, they need to be pooping.

[00:51:46] Christa Biegler, RD: Yeah. She's saying is it's going down the 4OH pathway, the cancerous- Yeah ... pathway versus the healthy metabolism 2OH pathway. Yeah I feel like there's a limit to how much DIM 'cause you also don't wanna be overdoing that, and then you wanna consider everything else at the same time.

[00:52:02] Christa Biegler, RD: If it's in a formula... It's a very effective if you would need it, but if it's in a formulation, I only want 100 or 200 max is my thought process around that.

[00:52:11] Jennifer Gularson, PA-C, IFMCP: The other thing is in PCOS, I think DIM could be much better because you're already at a, your elevated estrogen state, like you're high estrogen, and if you have crappy metabolism, that's where I think it's more helpful and maybe in the perimenopause.

[00:52:26] Jennifer Gularson, PA-C, IFMCP: But we're... If you're talking about levels of 50 are not that high. A serum level estrogen of 50 is not that high. You're at 300 during ovulation or preludial. So it's all relative to how much, and it actually can pull estrogen out. It helps... if you're already low estrogen and now you're using DIM to pull that out of circulation, I don't know.

[00:52:50] Jennifer Gularson, PA-C, IFMCP: It's... You're right, it did... I don't see it as much. There are some clinics out there that do pellets that they just put everybody on it, but I also think that's a system where it's like we'll just charge them for it. I don't know. They put it on as part of a protocol, and it's not as individualized as it should be.

[00:53:07] Christa Biegler, RD: Yeah. I haven't really ever heard anything positive about pellets. And this kind of... And it's not something you can really adjust, like you said. It's once it's in, you're stuck with it. And so I feel like the follow-up testing can be interesting overall, and I'm curious when you're doing follow-up testing,

[00:53:23] Christa Biegler, RD: Are you trying to find the sweet spot so it looks maybe more like before perimenopause or something? Because my understanding is people go on pellets and then they're testing, like the numbers are all over. It's crazy numbers, right? And then that causes... Anytime people get labs back before they've seen their provider and anything is off, it is like A recipe for alarm typically, right?

[00:53:45] Christa Biegler, RD: Yes. No matter what, it's oh it would make sense that it's really high 'cause you're on this thing, right? So I'm curious how you approach testing after you go on HRT, what you're looking... are you looking for the normal ranges before perimenopause or if you're looking at different...

[00:54:00] Christa Biegler, RD: is there some different reference range that you're following?

[00:54:03] Jennifer Gularson, PA-C, IFMCP: Yes. I had this conversation today with somebody. So one thing I'll just briefly touch on pellets really quickly. They can be very good for the right people. I'd say for a majority of people, they're not. But I do everything, and I spent years doing pellets.

[00:54:18] Jennifer Gularson, PA-C, IFMCP: That's mostly what we did when we first started. But that was, years and years ago. And for the right person it can be very good But I'm also very conservative and I do testing if you test at the peak, about two months af- or a month and a half after you give your pellets, you can get the peak, and then I'll test them at their trough and see where they are right before to see if I'm being super physiologic.

[00:54:41] Jennifer Gularson, PA-C, IFMCP: But for some people, the other modalities just aren't working, so it's just one more tool in the toolkit. I can't... Unless they come in saying, "This is what I want," I typically don't start with it. For men, yes, a lot more men will do it just because maybe they can- Yeah, makes sense. So as far as testing goes I usually will start patients, if I'm doing testosterone, I will test them after three months, make an adjustment, test them another three months, and then if they're stable, then it's every six months.

[00:55:08] Jennifer Gularson, PA-C, IFMCP: And what am I looking for? For estrogen, so are different because their labs are gonna be all over the place. Very much go on symptoms 'cause I'm also doing very, more lower, a lower dose of things. Yeah. Post-menopausal I'm looking again for that FSH to come down a little bit, under 50, and then their estradiol around 50 or 60.

[00:55:31] Jennifer Gularson, PA-C, IFMCP: They're not bleeding, their boobs don't hurt, they're sleeping okay. Their testosterone between 50 and 100, with a free around three or four. And of course looking at pregnenolone also, not a lot of people look at that, and DHEA, and making sure those are all stable also. Yeah. And the progesterone I'm doing if they're taking 100, and serum test, serum progesterone isn't a great test but if there's like, if it's zero, then I probably would go up, and of course if they're having a little bit of bleeding, then yes, up.

[00:56:04] Jennifer Gularson, PA-C, IFMCP: Up to two, three, 400. That's usually my max. I know people go up to six, 800, but- Yeah. We're all different. Yeah.

[00:56:14] Christa Biegler, RD: We covered so much, and I really appreciate it- Yeah ... because I feel if someone's really questioning... I think this kind of needs to become a little bit of a prerequisite to aging for ourselves because as people are discerning, we have a lot to discern.

[00:56:26] Christa Biegler, RD: Not in this- Yeah ... I don't mean in an overwhelming way. We have a lot of opportunity. We have this option to take ownership and autonomy of our health and support our body to work as optimally as it can, and then we have the opportunity to add in hormones once, at any point, right? Before or after we optimize the rest of our body to preserve our health as long as possible.

[00:56:49] Christa Biegler, RD: We have that opportunity. It's accessible to us. I think the challenge that we face is finding someone who will walk that journey with us and is able as well, because when I went to Dutch Fest, the original Dutch Fest years ago. It was pre-2020. That's all I know. That's how we mark life, right?

[00:57:05] Christa Biegler, RD: Be- Yeah. It was before or after. It was some time before because has it... I don't know if it happened again. I can't remember if they did it. And what I learned at that time was, like, it was a little bit of a Wild West. People are trying and seeing a little bit overall, right? And so there is... I think that there's no exception.

[00:57:21] Christa Biegler, RD: I don't see another alternative than like learning our own body and understanding ourselves. But hopefully an episode like this really gives people a well... Which is why I wanted to have you back to talk about this your wealth of knowledge around it, and to p- find someone who has w- walked so closely with clients to know what has worked and not worked over this...

[00:57:40] Christa Biegler, RD: really whether, I don't know if you wanna use this word, but because hormone replacement therapy hasn't been around for I don't know, much more than a couple of decades, a few decades, I'm not sure we could consider you a pioneer in this space- Yeah ... whether, I don't know if you like that or not.

[00:57:55] Christa Biegler, RD: But it's like you're well-versed-

[00:57:56] Jennifer Gularson, PA-C, IFMCP: Sure ...

[00:57:56] Christa Biegler, RD: you're well-versed in the history of hormone replacement therapy. So we talked about, how you might look at things differently in a perimenopausal woman because her hormones are fluctuating quite a bit depending on what her ovaries are able to respond to her brain, which is why- all the other things going on in her life is... It's almost like a, it's an, in our late 30s which is typically the onset of perimenopause, it's an opportunity to get those basics and those foundations in place. Those will only be- Absolutely ... available moving forward, right? We can really...

[00:58:23] Christa Biegler, RD: It's like, it's almost like a, to me in my head, it's a game. It's oh, how many symptoms could I avoid or improve by supporting basics or doing these free things or doing the simple things first, right? Because then I can always add on hormones as needed, when needed later. One last thing, I there's no real exit strategy related to going on hormone replacement therapy, right? It's just when you are ready because if you go off of, you're gonna potentially have those symptoms return, correct?

[00:58:51] Jennifer Gularson, PA-C, IFMCP: Yeah, so we used to say so now the standard thinking is within 10 years of you losing your period, we wanna start you and then not over 60, but that's not a hard and fast rule.

[00:59:04] Jennifer Gularson, PA-C, IFMCP: I start a lot of people later. But now I would say even, start in perimenopause, start when you having symptoms. A lot of people will notice that they just can't make the gains at the gym or they're doing exactly the same thing, everything's dialed in, it's just not as good, and then they add a little testosterone or estrogen and things get better.

[00:59:21] Jennifer Gularson, PA-C, IFMCP: And then we used to say, "Oh, you'd be on for five years and then stop. 10 years and stop. 50..." Now it's you do it till you die. It's going to prolong your life, hopefully, and give you better quality of life. And if it doesn't prolong your life, it will give you better quality of life until the end.

[00:59:36] Jennifer Gularson, PA-C, IFMCP: I did forget one part of the estrogen. I'd be remiss if I didn't talk about a very important part is the vaginal estrogen. So for women who are taking systemic estrogen, whether it's a patch, whether it's a pill, if you decide that's for you, if it's the creams, whatever, you still can do vaginal estrogen.

[00:59:53] Jennifer Gularson, PA-C, IFMCP: It's such a low dose, it does not contribute to the overall estrogen that's circulating in your body. It is basically skincare for your vagina and your vulva, and it keeps it healthy. It decreases UTIs. It decreases you waking up sneezing and peeing, your pelvic floor, pain during sex, increases libido because it doesn't hurt.

[01:00:14] Jennifer Gularson, PA-C, IFMCP: So I just wanted to put a ring thing in there that you can take, do a patch, and you can have vaginal estrogen. Absolutely, and it is encouraged

[01:00:23] Christa Biegler, RD: Awesome. We have covered a lot, and so is there anything you wanna leave people with? And then where can people find you online?

[01:00:31] Jennifer Gularson, PA-C, IFMCP: So the one thing I would say is if you're not getting your answers, please find another provider.

[01:00:35] Jennifer Gularson, PA-C, IFMCP: And I offer advocacy, too, if you wanna have a conversation on how to talk to your provider, how to find a provider I offer consultations on that. So please don't take no for an answer, like she didn't. She was told no, but she said, "That doesn't sound right to me." If it doesn't sit well with you, like I just saw something in our 20s and 30s we were thinking and judging, but in our 30s, 40s, 50s, we're more having our intuitiveness is coming out.

[01:01:00] Jennifer Gularson, PA-C, IFMCP: Listen to your body, pay attention, write your symptoms down, know what you're doing, and advocate for yourself. I think, women my age are now asking for hormones and stuff, but the 30s and 40s are saying "Perimenopause sucks, too, so we need more information." So just be good to yourself.

[01:01:17] Jennifer Gularson, PA-C, IFMCP: It's not in your head. You can ask questions, and you can find somebody that's gonna listen to you. And then my website is https://www.yourbestlifewithjennifer.com/. I'm jennifergularson on Instagram and Facebook and I see patients in person here in the DMV DC metro area. I'm in Maryland,

[01:01:34] Christa Biegler, RD: perfect. Thanks so much for coming back today.

[01:01:36] Jennifer Gularson, PA-C, IFMCP: Thank you.