Whole Person Care for Perimenopause Symptoms

Kalea Wattles, ND, IFMCP:
Perimenopause is a critical time in a woman's life and sets the stage for health and wellness in the later years. During perimenopause, the production of estrogen and progesterone begins to decrease overall. But daily hormone levels are less predictable, with major hormone fluctuations potentially leading to symptoms. Within this complex hormone environment, understanding an individual patient's complete health story is a vital step for wellness and balance.

Carrie Levine, CNM, IFMCP
There's no aspect that isn't touched by this change. And so really, setting up for it optimally means looking at sort of our lifestyle and our current health habits and the current state of our health and addressing it sooner as opposed to later. Some things, many things are likely to snowball even in a more accelerated way during perimenopause and menopause because of the often anti-inflammatory benefit of estrogen. So if you already have some joint and muscle pain and you’re perimenopausal, you might pay attention to it now because chances are reasonable that it's going to be worse as you move through the process.

Kalea Wattles
On this episode of Pathways to Well-Being, we welcome women's health expert Carrie Levine to discuss whole-person care for perimenopause and personalized approaches for assessing and treating dysfunctional hormone patterns. Welcome to the show, Carrie.

Carrie Levine
Thanks for having me, Kalea.

Kalea Wattles
Well, I've been following your teachings on functional medicine for women for a long time, and we know that these hormonally mediated conditions can be somewhat challenging to address because they touch on so many other body systems. There are so many complexities here around the female reproductive system. I wanted to start today's episode by talking about your practice of functional medicine for women's health and 
hear from you, what is it do you think about the functional medicine model and approach to hormonal conditions that sets this type of model apart from anything else someone has probably ever experienced?

Carrie Levine
I don't know how you take care of women without functional medicine. It's like, I don't know how you can take care of a human for that matter without looking at the whole person and all of the variables that affect their health and wellness. And to me, it's like I can't really make sense of someone's symptoms if I don't understand the context of her life. I need to know, what is her stress like, what is her sleep like, what is her movement like, what is her nutrition like, what are her relationships like? Because we know, functional medicine practitioners know, that those aspects have a profound effect on our physiology, and that effect is really just amplified during perimenopause and menopause. It's like just all of that on steroids.

Kalea Wattles
Yes, I think that makes good sense. And one thing I really appreciate about your approach to menopause and perimenopause is that you're honoring that it's not just a change in someone's reproductive function, but there's all these implications in terms of their risk for chronic disease and even their quality of life and their lived experience. And menopause, we see it's regarded as this significant biological change, and the focus is often just addressing the symptoms once they've already occurred rather than taking this proactive approach during perimenopause. Will you talk to us about what a healthy or an ideal perimenopausal timeframe might look like so that we know what we can expect or how we can support women during this phase?

Carrie Levine
You know, I think we can anticipate the change in physiology and the sort of ripple effect that that has on every aspect of our life. There's something about the ovarian hormone production starting to slow down that triggers not only the physical symptoms but also the psychospiritual symptoms as well. That whole, quote, unquote, midlife crisis, which doesn't have to be a crisis if it's managed well, right? It becomes a crisis when it goes off the rails because people don't know what's happening, the why and what to do about it. So anticipating that ovarian hormone production is going to slow down, anticipating that our ideal exercise is going to change from what it was when we were in our 20s, what optimal nutrition is, is going to change from what it was in our 20s because our metabolism is gonna change. Our resilience, our ability to rebound from stress changes because of the HPATG axis. Like there's no aspect that isn't touched by this change. And so really setting up for it optimally means looking at sort of our lifestyle and our current health habits and the current state of our health and addressing it sooner as opposed to later. 

Some things, many things are likely to snowball even in a more accelerated way during perimenopause and menopause because of the often anti-inflammatory benefit of estrogen. So if you already have some joint and muscle pain and you’re perimenopausal, you might pay attention to it now because chances are reasonable that it's going to be worse as you move through the process. That kind of thing. You know, if there are weight issues, if there are cholesterol issues, if there are hormone imbalances, addressing them sooner as opposed to later, not waiting until things feel desperate would be ideal.

Kalea Wattles
Yeah, so when you're working with women, let's say they're coming into the clinic, they are having all of these perimenopausal symptoms, and they say, "I wanna be really proactive during this time so that I enter my next chapter gracefully." Are there some themes that are coming up? You mentioned maybe increased inflammation, maybe some metabolic factors we wanna consider, but what are the types of themes that you're seeing over and over and over in your perimenopausal patients?

Carrie Levine
One of the biggest ones is work and really wanting to make a change with work or being burnt out from the work that was done. And for women whose work is primarily in the home, there's a real change in capacity for caring for others. You know, I will never forget one of the first perimenopausal women I spoke to when she was like, "I don't wanna cook Christmas dinner. Like, I don't wanna do it. What I want to do is sit in my window seat, read my book, and order out Chinese food." You know, and women don't know that that change is not unique necessarily to them. It's unique to each of us in our experience of it, but that sort of less inclination to caretake at a super high level, it changes. So that honestly is a lot of what comes up. 

You know, I'm thinking about a woman I saw last week who was a first-grade teacher and has a special needs kid and is in her late 40s, and she's like, "I cannot." And I echoed that, "No, you cannot. You don't have the physiologic resiliency that you had when you were 40." Now we can bolster you, there's all kinds of things, like if you want to, we can bolster you with a variety of different modalities, but she doesn't want to. She's like, "I just need a paycheck, and I need to rest and get my strength back." 

So there's a lot of that. Like, I don't know who I am, I don't know what I want, I don't know what makes me happy. Those are huge. Fatigue is huge, again, because of the stress-hormone connection. I would say joint pain and muscle pain are also huge because of the fluctuating hormone levels and the loss of some anti-inflammatory benefit from them. And then that, of course, can extend to gastrointestinal symptoms, skin eruptions, you know, on and on and on it goes. Of course, the sort of conventional medical things, right? Cholesterol, insulin, glucose, insulin resistance, blood pressure, all of those things. There's a lot to work with.

Kalea Wattles
A lot of juicy information to cover here. And in IFM's Hormone module, we talk about how the perimenopausal timeframe often overlaps with other big life changes. Like maybe kids are going to college or parents are aging, and you maybe become a caretaker. And so there's all of these other variables. And when I'm listening to you talk about the approach, certainly there's the medical management, you know, side to things, like you said, measuring the cholesterol and the insulin and all of those pieces. But also you talked about how you gave your patient permission to just rest a little bit. And so it almost sounds like maybe even more pressing is almost a coaching aspect to figure out what can you offload and how can you create time for the rest, and so it's both, right?

Carrie Levine
Oh, 100%. And I mean, I think that's what I love about functional medicine, right? It’s the center of the matrix, that mind, body, spirit or whatever the exact language is, because I've always considered that in taking care of people. And there's sort of like justification and confidence in knowing that those are the aspects that drive our physiology. I send so many women to career counselors because they're like, "I know I cannot do what I've been doing for the last 20 years for the next 20, but I have no idea what else I might do." And I'm like, of course you have no idea. How could you possibly have an idea? You're working a full-time job, you're still raising children, you are taking care of elders. Where in that equation is there bandwidth to consider yourself and who you might like to evolve into? You know, it's like telling a new mom, you know, that, you know, what's best for her family is that which makes her happy. How is she supposed to know? 

I should speak first person, right? When I had my kids, I was delivering babies, and I was on call 50% of the time. And then I moved to Women to Women and started learning functional medicine and read a book called Perfect Madness: Motherhood in the Age of Anxiety by Judith Warner, who sort of scoured the data, and what the data showed was what kids need is for moms to be happy. It doesn't matter if they're home full-time or they work full-time, the mom just needs to be happy. And I remember feeling enraged because I was like, how am I supposed to figure that out? How am I supposed to figure it out? And so midlife women are really in a very similar situation, right? 

Many people refer to midlife as a labor and a birth and a birth of ourselves as opposed to children if we chose to have them. And it is turbulent. It is mentally, physically, and emotionally turbulent, and all of those variables are unstable.

Kalea Wattles
Wow, yep. Can relate so much to everything you're saying. It brings me to my next question. You know, sometimes patients will come into me, and they'll say, "I can't tell if I'm perimenopausal or I'm just stressed out. Just my life is kind of…" So there's all of these disruptors and so many variables, and I wanted to get your take of, I'm sure people say similar things to you, and how do you respond to that?

Carrie Levine
Well, it's true. It's hard to know, right? We know that stress is gonna change ovarian hormone function. So when someone's hormones become unbalanced, you know, is it because there's essentially a hormone imbalance or because the stress level is really high? And how many of us have seen women who've been menopausal or postmenopausal, right, if we're really sticking to the term, the definitions, right? Post-menopause being everything that happens after menopause, the day that is the year after the last period, right? So how many of us have taken care of women who we thought were postmenopausal and then they re-menstruate because there is a decrease in stress in their life or a major life change or whatever? And so I do think that there can be a sort of stress-induced menopause that can be reverted with addressing both adrenal and hormone health.

Kalea Wattles
And as we're thinking about these hormone patterns, I think as a clinician, something I find so challenging about perimenopause is that there's all these hormone fluctuations, but that's not pathological, that is expected. That is the normal balance of things, but it's hard. It's hard to manage because they're fluctuating so much. Will you just maybe walk us through kind of what that perimenopausal hormone change looks like in a normal situation?

Carrie Levine
Right, so in early perimenopause, the thinking is that there is high estrogen relative to low progesterone. And people will talk about that term estrogen dominance, which I think is so tricky and often misunderstood because generally that high estrogen or that estrogen dominance is thought to be that way really because the progesterone is relatively low, and that progesterone is relatively low, as I'm sure you know, because we ovulate irregularly and our progesterone is secreted by the vesicle that's left after ovulation. So if we're not ovulating regularly, then we're not gonna have, quote, unquote, normal progesterone levels, and that estrogen is going to be high relative to it. And so you'll see the high estrogen symptoms and the low progesterone symptoms, right? Like the PMS on steroids, the mid-cycle to menses, hot flashes, night sweats, insomnia, irritability, the feeling like one is manic, the food cravings, the fatigue, the inability to recover from a workout, the low sex drive, the bloating, et cetera, et cetera, et cetera. Deep into perimenopause, all of the things that happen leading up to that year without a period, it is thought that both the estrogen and the progesterone are low at that point. And so then you might have more hot flashes, more night sweats. People will use language like, "I get out of bed, and I feel like I'm 90, I feel like I'm my grandmother." There's some joint stiffness, typically, for many, not typically, but for many. What else? Well, that's a little bit of what might be seen.

Kalea Wattles
Yeah, and can we kind of bring this, loop this back together with our discussion about stress? Because sometimes I find that when I'm trying to tease apart the hormonal pattern, that the cortisol piece can also contribute to things like the night sweats and can contribute to things like weight gain. And so will you talk to us a little bit about your evaluation during perimenopause? Do you look at hormones? Or they're changing too much? Do you do salivary cortisol? What's your typical approach? I know obviously we're gonna customize for every person, but if you have some kind of foundational assessment you'd be willing to share.

Carrie Levine
I mean, a fair amount can be discerned through conversation, as you know, right? A good history, you can get a pretty good sense of what's going on. I generally will recommend a DUTCH Test, the dried urine test for comprehensive hormones. I don't know if that's legit to say, but there it is. It can edit it out if it's not okay. But what I love is that it's so comprehensive in terms of giving me the array of hormones. And it gives me the cortisol and the DHEA. 

And so I have the whole picture right there, you know, and I will talk with women like, you know, if the cortisol is looking super duper low and we're having a conversation about hormone balance, you know, I always will say, you can lead with the adrenals, and we can start there and see, is that good enough? You know, we sort of make a 90-day plan, and at the end of 90 days, reevaluate, same, better, worse, good, good enough, not good enough, you know? And if we are good enough, then great, we nailed it. And if you're not good enough, then let's peel the onion another layer and layer in another intervention. Some women, as you know, want everything all at once, which, you know, I am all about honoring women and how they wanna take care of themselves. If they want it all, I will give it all. I think that that can make it really difficult to figure out how much of this is adrenal and how much of this is like ovarian hormone related. But sometimes women don't care. They just need to feel better, which is all fine and good.

Kalea Wattles
That's precision and personalized medicine, where we take into account patient preference as well. So I think that's really approachable. And I want to also now start to bring in the inflammation piece, because you mentioned in the beginning how as our hormones are shifting, sometimes we have less, I'll say, less inhibition of inflammation all of a sudden. And so let's think about someone who maybe when they were premenopausal had something like PCOS or endometriosis, some kind of condition that already was characterized by chronic systemic inflammation. How do we transition patients with this type of history into menopause where we might see inflammation get even worse?

Carrie Levine
For me, it means involving the gut, the gut as being an organ of inflammation. And so in my history taking, I am sort of scouring, you know, I will ask specifically if it hasn't come up, I will ask specifically, do you have joint pain? Do you have muscle pain? I always ask, how is your digestion, meaning, are you pooping every day? Are they soft and formed? Do you trend loose? Do you trend constipated? Do you have any skin eruptions? Do you have rosacea? Have you been diagnosed with psoriasis, eczema? Any of those kinds of things, cause as you know, people new to functional medicine don't necessarily put the pieces together in their head the way that we do. Why it might be really helpful for us to know what their stool is like, even though we're talking about hormone balance, right? And so there's that sort of piece of education. 

And so, and then for me, I am always super curious about doing stool testing and finding out the beta glucuronidase, you know, levels. Because to me, that's the intersection of the gut-hormone balance, right? If that beta glucuronidase is elevated, then I'm thinking that there is hormone that is not being detoxed optimally and adding to the load. And that absolutely, positively has to be addressed. But in the same way that it can be complicated to tease apart what's hormones and what's adrenals, it can be complicated to tease apart how much inflammation is gut-related and how much is adrenal, right? 

And like I talk to people, I'm a fan of the pie analogy, you know, like it's probably a little bit of a lot of things, and I don't really know, is the gut piece 5%, 50%, 75%? I don't know. But this is the beauty of systems biology, where you're not thinking that just addressing one system is going to get people well cause it so often doesn't. You've gotta address all of the influencing systems to get people to the point of wellness that they want.

Kalea Wattles
I love this pie mental model.

Carrie Levine
Don't you think?

Kalea Wattles
Well, and also, it's such a nice visual, and it also gives you as the clinician the opportunity to say, "I actually don't know how much, like how big the slice of this pie is, but it doesn't really matter because ultimately we're gonna address all the systems or the whole pie, so it's okay.”

Carrie Levine
Totally, totally. How could we know? You know, which is just like, I tell people, I'm like, I have no idea what's gonna happen when DHEA hits your bloodstream. It might get sucked up and used up as DHEA, and you might feel like you can get through a day of work without feeling like you have to nap or it's gonna shuttle down and turn into testosterone and you're gonna have acne and chin hair, like, how could we possibly know? There's no way to know because there are too many variables. You know, what did they eat? Did they move? How many hours of daylight are in the day? Do they live in Seattle? You know, like what's all of the things that are going to influence what happens when something hits our bloodstream? There is no way to know, in my opinion. And so there is art and there is mystery, and there has to be a relationship so that there's dialogue. "Hey Carrie, I tried this, and this is what I experienced. Does that make sense? What do you think?"

Kalea Wattles
Yeah, thank you for calling out DHEA. I think it is a great injustice that our DHEA falls off so quickly once we're, you know, past 25, 30, and it's really dropping. And that's something I see in my patient population. I presume that you have a lot of low DHEA in your clinic as well.

Carrie Levine
Yeah.

Kalea Wattles
This is an area where, because we can get DHEA over the counter, you know, it's like some people will take these big doses. I tend to start pretty low and increase slowly. Will you just recap, because this is such a hot topic in the longevity field, what's your strategy for repleting DHEA?

Carrie Levine
I mean, I'm always talking about the lifestyle piece, right? So like, how significant is rest and restoration? Is that something that is incorporated into people's lifestyle, which isn't gonna change the natural declination of DHEA over a lifetime, but are we doing what we can to optimize what we have? I always start there. And then I generally prescribe it in sublingual drops. It's just the way I was trained. It's a hormone. Best if you can give it sublingually, bypass the gut and the liver, you know, eliminate that whole detoxification with it. And then in my population, I find that women like control, by the way, in case you didn't know. And it's really good when women can control the dose of their own medication. They like that, and I like it too. It's empowering, right? It's like I'm having a cozy day, I'm reading a book, I don't really feel like I need very much, but maybe I need a little. I have a big day or a big presentation or a big race. I think my stress level is gonna be super high. I'm gonna really bolster myself with a higher dose, and letting women find, this is again, precision, right? Precision, personalization, which is just like, I don't know, is she gonna feel good with four drops in the morning and two drops in the afternoon or five drops twice a day? Or is it five drops in the morning and one in the afternoon or she's gonna forget her midday dose altogether because she's busy and that's okay? So I like the titration, I like the personalization, and I like giving women the power and the control over their dosing.

Kalea Wattles
Just imagining myself as the patient and my doctor is telling me, here's this intervention that I think is gonna be really helpful. Let me teach you how to dose it yourself and how to bring in some intuition to the whole thing. And just how cared and nurtured I would feel if I had that ability. So I just wanted to honor that and call that out. We've talked about a lot of things that can support women through this transition. You know, looking at hormones, looking at inflammation, looking at the gut, looking at the liver. Do you find that sometimes when you're working on supporting all of these body systems that your patients don't actually end up needing hormone replacement therapy or maybe they need less hormones or maybe you extend the time before they need hormone?

Carrie Levine
I love this question because as you know, hormone therapy is so hot right now. It is experiencing quite a resurgence with the redacting of the Women's Health Initiative findings and the finding that hormone therapy increases the risk of breast cancer, which has been redacted, just to be very clear for listeners so that they get it right. And so women are calling and they're like, "I want it. I want it." 

And I'm grateful for the way that I was trained around hormone therapy because the way I practice still feels aligned with what's happening in the world, which is one woman at a time, a risk-benefit analysis for each individual woman, that the benefits may outweigh the risks no matter what they are, whether it's a personal cancer history or a personal history of blood clotting, that we can do a lot to ensure people's safety and wellness, which is one of the reasons I love comprehensive hormone testing, that absolutely positively includes the 2, the 4, and the 16-hydroxyestrone. That's actually the thing I care most about. That's the thing that compels me to ask women to invest in that kind of testing because I wanna know, how is she detoxing estrogen? And is she doing it in a way that is increasing her risk for disease or protecting her? Because there's stuff we can do, right? There's stuff we can do to influence how our body detoxes estrogen. 

So I'm all about meeting women where they are. And it was super helpful for me to go to AIC and hear Stacy Sims' presentation on menopause and exercise and be reminded that exercise does everything that estrogen does plus. It might not be as awesome at treating vaginal dryness, but that's easier, right? And that's actually really targeted. Like if that's all a woman's coming for, then you can just give her estrogen for her vagina. You don't have to give it to her systemically. But if you're concerned about your brain, you're concerned about your bones, you're concerned about your heart, you're concerned about your body composition, you're concerned about your cognition, these are the reasons women want hormone therapy, right? Except that they think that it's gonna be a magic bullet to weight loss, many do. But if those are the benefits, if those are the concerns, and those are the potential benefits of estrogen, exercise hits all of them. So it was really good in the fury of hormone therapy to be reminded how therapeutic our lifestyle can be and to share that teaching with women so that they can choose from a place of knowing. That has been really helpful and compelling.

Kalea Wattles
Well, with our functional approach being really centered around those modifiable lifestyle factors, we've got the exercise piece and then exercise's counterpart, nutrition, we have to go there because when you were talking about the way that we metabolize estrogen, that either puts us at a higher or lower risk for things like breast cancer, I imagine that your treatment plans include some nutritional recommendations to help to modify those pathways. So will you talk us through some of, you know, as you're creating treatment plans, I'm sure that there's nutritional recommendations that come up again and again as you look at hormone patterns. Tell us some of your go-to nutritional recommendations.

Carrie Levine
30 grams of protein, three times a day-ish. More if you're training harder and lifting super heavy. Vegetables, mostly cruciferous, right? Because of that sulforaphane and because of that promotion of the more protective estrogen metabolites, not to mention the fiber, which fuels the short-chain fatty acids, which fuels the beneficial bacteria, which helps decrease the inflammation and helps maintain a healthy gut microbiome. Healthy fats, right? So coconut, salmon, avocado, olive oil for all of the reasons, for a mitochondrial function, for cognition, for all of those things. And that really is like the short version. 

You know, there's so much controversy around fasting. I understand all of the different angles around it. I really tend to land with the individual on that one. If she feels good and she feels like she's fueled for her day and had the energy that she wants to do what she wants, then great. For the women who were fasting and who were hungry or cranky or whatnot, no. You know, I definitely tend to be, encourage more of a three meal a day kind of approach. But not everybody feels well with that, which is okay, right? Like, it's okay if we know how with the things that make us feel good, it's okay for us to do them. Yeah. So I personalize the fasting. 

It's really about encouraging much more protein than has been previously thought needed. I am always talking with all patients, no matter their age, about vegetable consumption, the good, healthy fats. I think that, well, it's not just a thought, it's there in the data, right? That in general in midlife, women become more insulin-resistant because of the decline in estrogen. And that makes us more susceptible to insulin resistance. And so our capacity for carbohydrates is different. You know, I cannot eat a pint of Ben & Jerry's the way I did in my 20s and still feel the same for all kinds of reasons, carbohydrates being part of it. And also to soften that ‘carbs are evil’ kind of mentality with the complex carbs. We were talking about this earlier, right, in terms of our individual responses to what we eat. And I sort of discovered by way of a stool test that I did for myself actually that I needed more complex carbs than I was having for a good gut microbiome. And I knew that I felt better eating more of them too. But I was not allowing myself, I was doing what women do, which is give my power away to an external authority about what's supposed to be good for me, except that it wasn't great for me. And the monitoring really showed me that complex carbohydrates, even simple carbs ingested within the context of a meal when there is adequate fat and protein, doesn't influence blood sugar the way standalone simple carbs do. It's different, and it's different for each of us.

Kalea Wattles
Yeah, a theme that I'm hearing throughout this conversation is a level of body awareness is gonna be so helpful for us to get to the root of any of these things. Because like you said, from an expert perspective, there are a million things that we can do based on, you know, what life stage we're in perimenopause, there's a million things we're gonna find on the internet. But having that feedback of awareness of how we react to things is going to be the difference maker in what we keep and what we know is not serving us.

Carrie Levine
Right, and that's, I mean, part of what has happened in women's health is that women historically have given our power away to someone else about what's good for us. And what's unfortunate about that is that largely focuses around weight because of our society and because of socialization. And then the pendulum swung in certain populations where it was all intuition all the time, right? And it turns out that is not always accurate either. We all know a woman who's walked around with a grapefruit-size ovarian cyst and not known that it was growing in her body, you know? And whenever I hear a woman say, "I know my body," my heart sinks just a little because I believe that to be true, and… And I think there's so much to be gained by having guidance, and by not dismissing science that has considered women. We should totally dismiss the research that didn't look at women at all cause that doesn't relate to us, right? But there is research that was done with women that can speak to our experience and can provide some helpful guidance combined with what we know to be true about ourselves. I don't think it's ideal to be either/or. I think it's ideal to combine both, but it's hard. It's hard for women to be that body aware, to be that dialed in, to find a practitioner who's willing to consider all of it, who will take the time, who will educate about options, all the things.

Kalea Wattles
I think you're really underscoring the importance of this functional medicine approach that is very patient-centered, that is going to blend the medical management aspect with the patient's experience and their intuition. And you mentioned earlier that there's this resurgence and an interest in hormones because we're learning more, we're more aware, we're more in tune with our body. And so I'm wondering if you're finding that there are more perimenopausal women who are, you know, still menstruating, who are reaching out to you and saying, "I'm interested in trying hormone therapy because I've learned that this might help me in my menopausal transition, and I just wanna be proactive and start now." Is that coming up for you?

Carrie Levine
Oh, 100%, yeah. Or they're putting together the dots of family history and wanting to be preventive or proactive about that.

Kalea Wattles
And so in that scenario, are you saying let's start with, you know, the cortisol and the inflammation and some of our standard evaluation first and see how much traction we get, or is it okay to kind of say, oh, right, let's try some hormones?

Carrie Levine
It depends on the woman, right? I mean, always for me, you know, I have plenty of women who walk through the door and say, “I'm depressed, I want an antidepressant.” And I have women who walk through the door and say, “I'm depressed, I don't want an antidepressant." You know, I have women who walk through the door and say, "I want hormones." And I have women who walk through the door and say, "I don't want hormones, but I gotta deal with some of this stuff." So for me, it's really about meeting women where they are and what their preferences are. I will definitely say to a woman, if she says, "You know, I'm afraid of hormones, or I don't wanna consider hormones,” or whatever, I will get into the research a little bit with her because I want to dispel fear. If there's unfounded fear about that as a tool in the toolbox, I want to dispel it so that she knows like, here's this giant continuum of things that are available to me to help me feel my best. And I don't wanna vilify something that doesn't need to be vilified when used appropriately, right? 

And so I will sometimes say that, and I will on occasion say to a woman, "I think you're a great candidate for hormone therapy. Is it something that you wanna give a try?" You know, I don't know. Sometimes people don't respond the way I think they're gonna respond. It surprises me still to this day, but every now and again, I will prescribe progesterone in particular, thinking it's going to be super duper helpful, and it has the absolute opposite effect, and that's okay. You know, that's what I tell women, like, most of the time, people do really well. Every now and again, I have someone who has a response that I did not expect, and I do not write that off, you know? I'm like, okay, it didn't work for you. Let's see, what else do we have in our bag of tricks that can support you?

Kalea Wattles
Something that brings me such pride in the functional medicine model is I know with 100% confidence that you're never saying, "Here's your hormone replacement," and send them on their way. It's the HRT plus all of the lifestyle factors plus the tour around the functional medicine matrix. So it's always a both/and scenario, and the hormones never come at the expense of doing the foundational work. And I think that is the key differentiating factor. Like it's functional medicine's time to shine in that scenario because there are so many tools available.

Carrie Levine
Totally. And I will also say that for the women who comes and is absolutely not functioning, I might say to her, let's get you functioning first, right? Here's your life ring. Let's not pretend like this is the only answer, but let's at least get your head above the water, right? Because you know how hard it is when you're not functioning to get moving or deal with food prep or take a complicated gut healing supplement regimen. Like some women, they can't do those parts. So I certainly at times will lead with hormone therapy, but that's just the life ring to make sure their head stays above water and gives them a break from the suffering so that she can then gather herself and we can, and then figure out, okay, what's the next reasonable baby step that feels realistic for you to take? Maybe it's a 10-minute walk after dinner. Like, can we just get you out the door for a few minutes a day? There is a lot of coaching, a lot, yeah.

Kalea Wattles
Well, that feels very comprehensive, very approachable.

Carrie Levine
I mean, you have to, right? I mean, it doesn't make any sense to tell someone what they should do if they have no idea how to go about doing it, and if they're gonna feel like a failure because they're not gonna do what the doctor, quote, unquote, prescribed. Like, what use is that?

Kalea Wattles
Yeah, yep. We have discussed so many strategies for supporting women through their perimenopausal or menopausal transition. And I would love, as we're coming to a close of today's episode, for you to give some advice for maybe other primary care docs who might be listening or those, if there's patients listening and they're going to their primary care doc and they are wanting to have this conversation, what are some questions that PCPs should ask during their consultation to kind of get to the root of some of these contributors to this transition that might be overlooked or that might not be highlighted as regularly outside of the functional medicine world?

Carrie Levine
What does work look like for you? Do you like your work? How many hours a week are you working? Are you partnered? What's your partnership look like? Do you feel supported? Are you sleeping at night? Are you moving your body? What have you eaten in the last 24 hours? Are there any foods you eliminate because you know they make you feel lousy? That's where I would start.

Kalea Wattles
Yeah, I mean, you're really touching on those lifestyle factors, and maybe no one has ever asked those questions before. That is a real possibility.

Carrie Levine
I have women weep daily because no one has asked them, you know, are you sleeping? Are you having sex? Does it hurt? Can you orgasm? Can you run and not pee? You know, like...it's incredible, really, what women don't get asked, you know? And I will say on the other end of the continuum there is, I have this subpopulation of women in my practice who are in their 80s, 70s and 80s, and they have walked through the door independent of each other and been like, "Will you put your hands on me? Will you do a physical? Because I can't get my doctor to touch me." Because, you know, the Medicare physical is a bunch of check boxes, you know? And these women want a breast exam. They want a pelvic exam. They want their, you know, uterus and urinary function evaluated. Like, they want that, and they can't get that in the conventional model, let alone the women who come and say, you know, "I know I've been on hormone therapy for 10, 20, 30, 40 years. I'm gonna die of something. I can't get a doctor to refill my prescriptions. I want my hormones. I know what's at risk." 

So there is an interesting invisibility, I guess, maybe for older women that they're experiencing. And I have midlife women talking to me about that, about how invisible they feel and how nobody will talk to them about their hormones. How many women come in and say, "Nobody is talking about hormones." I'm like, really? I don't know what you're looking at on Instagram, because my algorithm is like, everybody is talking about hormones. But women still come to the clinic and say, "Nobody is talking about, how come people aren't, I can't believe they don't talk about this. Why aren't women talking about this? Nobody is talking about this." Really? Cause I'm talking about it all day, and I have been for quite a while now. So it's interesting what is women's experience out there in the conventional model.

Kalea Wattles
Well, this is a great opportunity for me to thank you for continuing to talk about it and to shine a light on this topic and to make it visible, to make it accessible and approachable. It's just been always a pleasure to chat with you and to hear your insights. And as there's, like you said, this resurgence of interest in hormones, all the interest in longevity, this work will become more and more visible and important. And I am so grateful to spend time. Thank you for everything you've shared today.

Carrie Levine
Thank you. It's always fun.

Kalea Wattles
See you next time, everyone. 

Kalea Wattles
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