Katie: [00:00:00] Hi everyone. Welcome. My name is Katie. I am part of the team at Paloma Health, and we are hosting this event tonight with our cohost Mary Shomon who I will introduce in just a moment. For those of you who are new, maybe you heard about this event through one of the speakers,  Paloma H,ealth is the first online medical practice focused exclusively on hypothyroidism.

And we provide end-to-end care for hypothyroidism, which means that we've got at home thyroid blood test kits, virtual consultations with thyroid doctors and nutritionists and a daily vitamin and supplement. This is our fifth installment of our Speaker Series. This is a monthly event where we do a deep dive on a specific topic related to hypothyroidism or Hashimoto's.

Each event is about 60 minutes and it will be recorded. So you can revisit this again late. if you miss information or can't stay for the whole thing. Tonight's topic is about perimenopause and menopause and how to navigate that time in life with hypothyroidism and our speakers are awesome.

We've got Dr. Anna Barbieri of Electra Health and Jill Chmielewski, who is a registered nurse. And both of them have a lot of experience and expertise in menopause and perimenopause and the space. Mary will introduce them more in a second, but first, let me introduce you to Mary Shomon. We are so excited to have her as a co-host to this event. Mary is a Paloma Health advisor.

She's a hormonal and thyroid patient health advocate. And she's also a New York Times bestselling author. She's actually written a book on menopause. So Mary I'll let you tell everyone a bit more about who you are and what you do. And then we can go from there.

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Mary: [00:01:49] Thank you, Katie. I have been a patient advocate for, I think almost a quarter century now in the thyroid space. And as Katie mentioned, one of my books was on menopause and thyroid. And I remember when I proposed the book to my publishers. I said, I want to write a book about menopause and thyroid disease. And they said, oh my gosh, who's going to want to walk around with a book that's titled menopause and thyroid, they're going to want to hide the cover someplace.

But I felt like it was a very important issue because at that time I was just going into peri-menopause and boy, was I surprised. I needed to buckle up and get ready for the ride. So I am so excited today that we have Dr. Anna Barbieri and Jill Chmielewski, who are here to share with us about perimenopause, menopause, and how it intersects with hypothyroidism, because there's a lot of crossover and there's a lot of confusion.

And both of these incredible experts are going to help us sort out all of these complications and maybe help us get rid of some of those hot flashes in the meantime. So let me give you a little background on both of them before we launch into their presentations. Dr. Anna is a specialist in hormonal health and the menopausal transition.Jill ChmielewskiJill ChmielewskiJill Chmielewski

She's a founding physician at Electra Health, which is a next gen healthcare platform for the tens of millions of women currently in menopause. And those who are soon to be navigating perimenopause and menopause. Dr. Barbieri obtained her medical degree from SUNY Syracuse and completed her residency in obstetrics and gynecology at Mount Sinai medical center, where she currently serves as an assistant clinical professor.

So she's got lots and lots of initials after her name and lots of qualifications to talk to us today. And Jill is a certified integrative nutrition health coach, a certified applied functional medicine practitioner, women's health educator, registered nurse, and in her spare time, she's a mom of four.

She is helping midlife women like all of us break free from the mainstream way of thinking where disease and decline are accepted as an inevitable part of aging and embrace the notion that it's absolutely possible to feel well through midlife and beyond. If you take care of yourself the right way, that's the key.

Everybody, she created the peri to menopause roadmap to help us get the confusion out of this transition from peri-menopause to menopause. I know that you're all excited to hear from both Dr. Barbieri and, Jill.  Dr. Anna, are you going to be our first presenter tonight?

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Dr. Anna Barbieri: [00:04:47] Sure happy to do it. So thank you so much, first of all, for that lovely introduction. And I'm very excited to be here with all of you, and to share this spotlight with, my colleague, Jill, and I think, you will see how we in medicine are really starting to finally, after all these years, approach perimenopause and menopause from a slightly different perspective than just treating it like an illness that needs to be medicated.

So we really want to give you some good information, answer whatever questions you may have, and really leave you feeling inspired to take on the menopause in a more positive way. To add a few more words to my bio and explain to you a little bit why I'm particularly interested in this topic.

I'll give you a little bit of a couple of minutes overview, and then I thought I would take a little bit of time, just a couple of minutes to go over a few slides with some really important points that we need to understand about hormonal health during this time of our lives. So I'm on the board certified obstetrician gynecologist.

I have delivered over 2000 babies in my life, but I don't do that anymore. A couple of years ago, I decided to really refocus my practice on gynecology specifically, and within that, on hormonal health. So I've always been interested in hormonal health and the sort of, kind of mental puzzle of how our hormones function together and how they could affect

so many facets of our lives. And I wanted to marry that somehow with my interest in what's called integrative medicine. And that is an approach to health and medicine through different interventions and different approaches. So not just a prescription pad, not just surgery. But really to learn how to incorporate things like nutrition, botanicals, supplements, mind, body, methods to really help us thrive and get well, if we need to get well.

And I really try to focus my practice, now specifically on hormonal health, yes, other aspects of gynecology as well, but really looking particularly at this perimenopausal and menopausal transition through this lens of integrative medicine from a personal aspect. I'm in my late forties. And boy, was I surprised to discover that I was going through perimenopause a few years ago because

really, we were trained in medical school to look at menopause, the kind of typical symptom profile of hot flashes and night sweats. And in the meantime I had, none of that, all I had was just simply an impending sense of anxiety and self doubt. That was really very physical in nature

and I did not even realize at the time, but that's what it was. I thought I was too stressed doing too many things and it wasn't until I was able to look at my own hormones or rule out thyroid dysfunction. We'll talk about that a little bit later and really try to take a deeper dive into my understanding of this issue, but this whole world opened up.

So I really decided to spend a lot of time on that really study it. And really have started to take care of so many women, that are going through this transition and who needs just a little bit of sometimes information and guidance and yes, sometimes medications, but really it starts with a knowledge of what to expect.

How to get through this transition, how to thrive through it and how to stay healthy. So I do a lot of menopause care and I'm really proud to serve as Electra's founding physician, to really bring this type of healthcare into more women now. And, Katie, if we could have my first slide up, that would be great.

So I wanted to really make a couple of points here before we go through the questions. And I'm sure many of you will be familiar with this information. If not, great. If yes, hopefully it will be a nice quick review. So perimenopause and menopause, this transition is really associated with the three major female hormones: estrogen, progesterone, and testosterone.

And yes, we all have testosteron. That's an important sex hormone for us also, but these hormones do not function in a vacuum. All hormones function together. They're really different members of the same orchestra and hormones really needs to function together in a group for us to feel optimally.

Thyroid hormone, which is, I think, what brings everyone, all of us here, is really like this conductor. And I actually love that. The conductor in this orchestra is this gorgeous woman right in the center there, but the thyroid is the conductor. Thyroid hormone basically tells all the cells in the body how efficiently to function.

And the thyroid hormone needs to lead the other ones in their function, estrogen, progesterone, testosterone, their function as part of that whole system. And  when some of them are out of balance, the whole orchestra may be. So hormones are never really just an isolated point. They don't function on their own.

We need to take a look at them more holistically, especially through the transition of perimenopause and menopause where, those three major female hormones can fluctuate very much. So we're going to talk a little bit later tonight about those three hormones, how they relate to thyroid hormones and also how they relate to adrenal hormones and cortisol, especially.

if I could have the next slide, Katie, that would be great. What happens to those three main hormones as we started going through perimenopause and menopause? As you can see from the age of roughly our mid twenties, testosterone tends to very gently slope down but that transition is pretty smooth.

I would say, when you look at estrogen and progesterone, they tend to stay relatively even. Of course they change with every cycle. They go up and down. Estrogen goes up as we start our period and then it peaks and then it has another peak after ovulation, then it drops.

Before the next period, progesterone starts to go up after ovulation, stays elevated for about 10 to 14 days, then drops. And it's really the drop of estrogen and progesterone, but gives us a period and that sort of nice wavy change keeps them going on throughout premenopause of course, as long as our other hormones are normal.

When we head--typically our early forties, this can happen earlier-- we enter peri-menopause, as you can see here, estrogen starts to go down, but pretty gently, then it goes through this very crazy transition when it's up and down and up and down and can change every cycle and be different in every cycle.

But progesterone actually drops and it drops earlier. Then estrogen and this pattern, this is what we typically see in perimenopause. So early perimenopause, those first couple of years of change, usually we see shorter cycles. Sometimes heavier bleeding, worse PMS, more thyroid dysfunction here. And this tends to be related, not so much to very low estrogen, but actually to a real drop in progesterone and this imbalance between these two hormones, sleep disturbance,

anxiety, can be a very common part o, this time here. And this is exactly what I felt at that time. And as we get closer to actually menopause, when we stop having our periods, this later part of peri-menopause is then characterized by this very swift drop in estrogen. And that's when we start to

skip cycles. have hot flashes, have night sweats  v, aginal dryness can start. And those are really due to estrogen levels, really dropping down until we reach menopause. When all of these hormones are actually now have reached stable levels again, but they are much lower compared to before. Katie, if I could have the next slide, please.

So what happens  during this menopausal transition? How does this big hormonal change affect us? It affects pretty much every single organ system and every single part of our bodies. We know this because we can have lots of different symptoms of it. And this is my last slide promise. Katie, if I could have the next one.

These are some really, super, common symptoms. And as you read through this list, knowing that you know quite a bit about thyroid health already, you can actually compare the symptoms on the left, which is typical. Peri-menopause granted, not everyone feels all of these. Some women are very lucky and feel it hardly any of them.

And then some of us will feel most of them. But if you look at them compared to the symptoms on the right, they are really less sane. So that's really my last point here, though. Symptoms of perimenopause and menopause and the symptoms of thyroid dysfunction, especially hypothyroidism can really mimic each other.

And that's where knowledge and expectation, good medical care, appropriate testing, and then appropriate intervention, both in terms of how we adjust our lives, but also how we can be treated, whether it is with supplements, herbs or medications really come into play because this can be a very confusing time.

These two, conditions, both a hormonal change in terms of peri-menopause and thyroid conditions very often mimic each other. So it can be a very confusing time and hopefully we can clarify some of this for you in the next 45 minutes.

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Mary: [00:15:29] Thank you so much. Thank you, Dr. Anna, that was a really fascinating overview.

And I really hope people looked at that side-by-side list of the symptoms of perimenopause and hypothyroidism and realized how they really are the same. And in some cases it may be one or maybe the other, or it could be both. So we're going to hopefully dive into some more information about that, but let's go on right now to Jill who's going to share some of her thoughts with us before we go into our Q and A. Jill, take it away.

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Jill Chmielewski: [00:16:07] Sure. Yeah. Thank you. Thanks so much, Anna. That was great. That was such a great overview. so my name is Jill Chmielewski, as you guys know, and I'm a registered nurse and currently I work as a women's health coach and educator specializing in helping women optimize their health and hormones.

I've been a nurse for about 27 years. So I've been around the block a few times in healthcare, spent a lot of time in women's health and I've been having hormone discussions with patients for a really long time. Going back to my very first job, which was a neonatal ICU nurse, I was having conversations with women who had issues with infertility because a lot of patients at that time had

kids in the NICU that were twins and triplets, and it was the result of infertility issues. And being in the healthcare space for as long as I have been, in reproductive endocrinology and in the NICU and in other areas of women's health, it's been largely hormonally focused. On a personal note, I have had hormonal issues dating back to my teenage years. And I'm sure a lot of you can relate. Irregular periods, I was diagnosed with PCOS or polycystic ovaries in my twenties. I ultimately went through infertility treatment. I was super fortunate because I have four kids. They're all teenagers, one in college and three in high school now, but I went through a lot with hormone issues and then like Dr. Barbieri, same thing. I'm in my late forties. I'm actually 49. I'll be 50 next year. And I'm on the very tail end of perimenopause. So I'm once again in that place of hormonal imbalance and it's normal, and it's exactly what I would expect at this time in my life  l, ike many of you here, but it's difficult.

It's really difficult to start going through a lot of those hormonal issues especially like many of you, I'm sure you're going through it alongside your kids who are in puberty. Hormonal issues can be a really, they can be a drag. They can be really difficult to go through.

So I think tonight will be great for us to talk through all of that. I also want to mention that, I too suffer from hypothyroidism, so I have the perimenopause stuff going on and I was diagnosed about six or seven years ago with hypothyroidism. Although I would say, I, if I look back, I probably would suspect that I had thyroid issues going back into my twenties.

So I've had a lot of experience personally and professionally with hormone issues. As a health coach, I primarily work with women in their forties, their fifties, and beyond. When I first started, about five years ago, I worked with men and women. And over time, I've had such a love affair with hormones.

I love the hormone education. And so I started to really, I think, draw in and attract patients that were going through a lot of those changes in their forties and fifties. So the bulk of the work I do with patients now is helping them with their health issues. But hormonal issues are a big part of why women today are not feeling well.

And I just want to mention too, and I think this is a really important point about hormones. And I think Anna touched on this earlier when it comes to hormones, education is a big part of the picture. And if you think about the hormonal education you got, yeah. Most of our hormone education was when we were back in junior high and it was just in a health class or something at school.

And it was mostly about our periods and how they relate to pregnancy. And that was sort of it. So I think, after that, women may seek out information about hormones. When they're suffering from irregular periods, or they're thinking about planning a family or having issues getting pregnant, or now when they hit the perimenopausal years.

But I think by and large, most women are in the dark about what their hormones do in their body beyond just reproductive function. And I can tell you, in my work with, as a health coach, most of my patients have no idea the benefits that hormones confer in their body, head to toe, from brain function to blood vessel function to protecting against cardiovascular disease, what they do for our skin, what they do really head to toe.

So I'm super excited about tonight because we'll be talking about that. And it's so important that as women head into the perimenopausal years, that they understand that hormones have been doing a whole lot more than just periods and pregnancy for the last 35 years. You can understand that why, when you hit this period in life, you feel the way you do. You don't feel like your old, vibrant self. So I'm excited about this discussion.

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Mary: [00:20:49] Great. Thank you, jill, that was a really interesting overview of your own experience and like many women, who are struggling with various hormonal issues, it's not always just one condition. You have PCOS, hypothyroidism hormonal issues now heading into perimenopause. So your situation is pretty common for a lot of women.

Why don't we go ahead and move on to some questions for Dr. Anna and Jill. And I want to start, Dr. Anna, I'd to ask you first and then have Jill also provide her thoughts on this. What do you feel for you is the biggest myth about perimenopause and menopause that is making the situation more difficult for women?

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Dr. Anna Barbieri: [00:21:38] I know when I was going into my peri-menopause and I'm already post-menopausal at this point at 58. But, I remember thinking somehow it was going to be  like an episode of the golden girls, like I'd have about two weeks of hot flashes, my periods would stop, and menopause was over. I didn't realize peri-menopause was going to go on for quite a long time. And that menopause was actually the point when I started to have the relief from all of it.

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Mary: [00:22:05] Why don't you tell us what some of the myths are that you're hearing or what you think the worst or most difficult myth is that women are probably struggling with that might help them to understand a little bit more about what's going on?

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Dr. Anna Barbieri: [00:22:18] Sure. So I think for me the biggest myth is that it's all bad. We tend to view menopause as this sort of natural and inevitable just sea of badness out there. We equate it with all these terrible symptoms that we can have equated with getting older or less attractive, more tired, sicker, invisible, really serious stuff.

But in reality, like we can make it into a time of some empowerment, of thriving, not just surviving this time and really feel, wiser, And more liberated from some of the issues we were facing before. So I think for me, both as a woman, as someone of this age, and as a professional in this space, I think just picturing menopause as this negative thing that we either have to just treat like an illness.

Or we should just give up and several of these things because there's nothing else to do and we can really change it anyway. that's really it. So I'm here with this campaign of making this transition at more positive one.

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Mary: [00:23:39] Jill, what do you think is the biggest myth that, is making it difficult for women?

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Jill Chmielewski: [00:23:44] Yeah, I totally agree with Anna. I feel like that's a really pervasive belief that it's just going to be this terrible time and we're going downhill from here. The other thing that comes up a lot for me with clients is that it's just about the end of the period, as opposed to all of the other things.

So it's the period is ending. And that's it, but that really, I think, is tied to that harm on education where we've really been taught that our hormones are for having babies and periods, as opposed to, hey, there's all of these things that have been happening in our body thanks to our hormones.

And like Anna was saying, feeling anxious or different experiences that we have, we don't really think about them as being related to perimenopause and hormonal decline because we don't realize that our hormones have been helping us with sleep. And yeah, giving us energy and helping us to think a certain way or helping us with our moods.

Yeah, I think there's a lot of myths, but those are definitely two that I see quite often. Very common for women, both to feel like it is some sort of great tragedy to have to overcome or treat like a disease.

The thing that's always surprised me is puberty is not a disease. Why is menopause a disease? They're both transitions, hormonal change. But periods for women, but we don't treat puberty as if it's some sort of illness that needs to be medicated. In many cases, I think we need to take some of the same approaches we go into the peri-menopause. Jill, I'm wondering if you can give us a little bit of insight into the difference between perimenopause and menopause and the timing issue, because a lot of women don't realize they think menopause is the whole period of hot flashes and wacky menstrual periods and things, and they don't always understand that there actually are different phases of this with different characteristics and the timing of all of it. So if you can explain that a little bit for us.

Yeah, sure. that's great because I think we actually, we've just referred to all of it as menopause and I think we've gotten a little smarter in the last few years, so we're really defining it a little bit differently.

Menopause itself is really just the absence of a menstrual period for a year. That really is what we would consider menopause. The average age for menopause is 51. So that just really means that about half of us are going to go through menopause before age 51. And about half of us after age 51, if a woman goes through menopause before age 40, typically she's considered to be early menopause or you may have heard the term premature menopause.

But perimenopause itself is really the time leading up to menopause and it can last five years. It can last 10 years. It can last longer than that. It's not this short transition period of just the one or two months. Prior to menopause, which I think is what a lot of women have expected it to be.

But it's different for everyone. I think nobody goes through the exact same way as Anna was talking about earlier. We really, our hormones really peak in our twenties, mid to late twenties. So when you think about it in a way, as we hit our thirties, we start to see things, start to go down a little bit.

Typically that's why I tell women, don't just wing it. When you go through perimenopause, you really want to get on top of it and know what's about to come. But I would say most women and I can't say all, but a good portion of women will start to have what we call anovulatory cycles or cycles without ovulation between, around age 35, maybe late thirties. And that may be the thing that sort of kicks off peri-menopause. We only make progesterone when we ovulate--really robust amounts. So it makes sense that progesterone, like Anna was talking about when she showed the graph earlier, we start to see that steady decline in our maybe mid to late thirties, early forties. It just depends on the woman.

But when we'll see progesterone starts to go down and at the same time, while projesterone is declining, that's when we start to see estrogen go down a little, but then it's in this erratic, what we call like estrogen chaos. So it's all over the place.

And then typically I would say. For the most part for most women in the one to two years before menopause itself, you'll see estrogen starts to finally start making its downward descent. So that's the difference between the two in a nutshell. The only other thing I want to mention is before menopause, our ovaries have been largely for producing our sex hormones. And as we start to transition, our adrenal glands, which are these tiny little glands that sit on the top of our kidneys, they start to take over some of the sex hormone production, and they're responsible for also producing our stress hormones.

So that's why sometimes in this midlife phase, women are caught between taking care of kids and having a career and taking care of aging parents and they're stressed. And the hormonal production is shifting from ovaries to adrenal glands, which are already very busy making stress hormones. So that's when women start to feel can feel pretty lousy during this transition.

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Mary: [00:28:47] Wonderful overview of the timing and the perimenopause and menopause and how they are different in some ways. And, I'm wondering, Dr. Anna, if you can tell us a little bit, let's get into some of the issues related to thyroid, particularly.

So when we're going through perimenopause and menopause, we know now that the estrogen is fluctuating and heading in a lowered state, progesterone is dropping. What is this doing to the thyroid? And what kind of an impact is it having on the thyroid? Is it causing hypothyroidism or worsening hypothyroidism? What's it doing to our thyroid gland?

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Dr. Anna Barbieri: [00:29:29] Sure. As we mentioned before, hormones do not function in a vacuum. They are functions are very much interrelated. We know that the thyroid gland has estrogen receptors, and that estrogen can bind to those receptors, changing the function of, the thyroid.

We also know that estrogen affects another protein it's called thyroid binding globulin. So this protein binds up thyroid hormone. So the more of this protein that we have, the less free active thyroid hormone that we have, and our body sense that as relative hypothyroidism. So in a way, the more estrogen we have and the less progesterone we have, which happens quite a lot, especially in those early perimenopause years, right? Estrogen up and down, progesterone really dropping. We actually see this relative abundance of estrogen increase in that thyroid binding globulin, and then, maybe a relative decrease in fact, thyroid function with higher TSH levels.

And then there's the direct effect on receptors. As well, progesterone can also affect, our thyroid and that lower progesterone levels are also associated with lower thyroid hormone levels. And in fact, when women with pretty borderline or mild. Hypothyroidism are treated with progesterone, their thyroid function improves.

And this is one of the reason I think, Jill, does this work with her patients a lot learning how we can really optimize our bodies for hormonal balance. What can we do during this phase to maximize our progesterone function? How do we detoxify from excess hormones? How do we metabolize our hormones better?

So these are thyroid and sex hormones are very interrelated as our adrenal hormones and cortisol in particular, the more cortisol we make, because the more stressed we are, the less progesterone we make. and that. Lower progesterone then will impact that imbalance with estrogen, which will therefore impact fibroid help.

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Mary: [00:31:55] Okay. so we have a woman, Dr. Anna, we've got a woman in her mid to late forties, and she's got a symptom profile, fatigue, weight gain, brain fog. She's depressed. She's anxious. She's not sleeping. Her periods are irregular. How can you tell if she's in perimenopause or hypothyroid or both? What are you going to do to make that differentiation?

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Dr. Anna Barbieri: [00:32:22] So that is a great question because I think I see her about seven times a day. So it has to be, there are certain things that are quite standard that we can do. But, and this is another really important point that I want to make hormonal healthcare needs to be very individualized. We really need to take a look at the particular person in front of us.

So we, it starts with a symptom profile. How long has this been going on? What are what's going on with skin, with hair, with weight? Has this been a problem since someone's late twenties or is it just now? What, Have there been other changes? Major stressors in the last several months, other medications, other supplements that were added.

So really it all starts with taking a really good look at the person front of us and their history and their lifestyle what's going on in their life. And then of course, there's the diagnostic aspect because often it is still really confusing and for a 45 year old with that symptom profile. She may have polycystic ovarian syndrome.

She may have hypothyroidism. She may be in peri-menopause. I still might not know. So that's when we come to diagnostics. So usually with that, with that, patient, I will certainly start with some lab work, a thyroid profile. We can do hormonal profile, including, estrogen levels, FSH levels, aMH levels. I do like to take a look at, especially with weight gain, with insulin resistance, testing and diabetes testing, and also take a look at, certain nutrient profiles that are very important for hormonal health, especially vitamin B levels, vitamin D levels and magnesium levels. There are other ways of testing, including saliva and urine testing that are little bit more, I would say, comprehensive, but I think starting out with a, just a good regular, blood test that we can do right in the office is going to be the go-to test in the beginning.

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Mary: [00:34:41] Great. That's a fantastic overview of what a comprehensive evaluation with an integrative physician should involve. If you go in with that symptom profile of that combination of perimenopausal on the hypothyroidism symptoms, but you need somebody that's going to be able to make that differential diagnosis for you.

Now, Dr. Anna was raising an issue about testing. And so when it comes to the thyroid tests, we know that blood tests like the  Paloma at-home test kit or the blood test that you get from your doctor are considered very accurate. But when it comes to testing the sex hormones, Dr. Anna was talking about other tests that can be done.

And Jill, I know that you are a fan, as I am, of the Dutch test. So I'm wondering if you can tell us a little bit about the Dutch test. And why you prefer it over the blood test or saliva or as an additional add on or more comprehensive picture, for sex hormones? So tell us a little bit about the Dutch test.

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Jill Chmielewski: [00:35:47] Yeah, and I do like blood testing, I think, especially from an economics perspective, financially insurance covers it. It can give you a really nice snapshot into your general overall hormone picture. The Dutch test is a dried urine test that uses, if you've never done one before, I know, you know about it too Mary.  been trained on that test. So I know a lot about that test. Different practitioners will use different type of urine testing. But I love just even their reporting system, I really liked. But it essentially checks 35 different hormones, including all three estrogens. So estrone, estradiol, estriol it checks, progesterone.

It's metabolites, testosterone, DHT, a melatonin, and some other key markers as well, to give us a picture just a much more, like Anna was saying a little more of a comprehensive picture into hormone function. One of the things that I really love about it is that it contains information about hormone metabolites and a lot of women have never even heard this term before, but the way that, a couple of things that I think that are really important to understand about hormone metabolites are number one, our hormones have a biological effect on our body, so they will confer.

They will make something happen in our body. Estrogen will make the uterine lining grow. That's one of the things that it can do, but estrogen metabolites are really how estrogen is. Broken down in the body. And once it's broken down, those metabolites also have a biological effect on the body. So it's really important to take a look at those metabolites as well.

And they can help us to really understand, different metabolites are associated or have a correlation with certain things. So we can get a bigger picture in terms of, maybe why someone might have fibroids. Or maybe why for talking about estrogen, there is some research to suggest that there's a link between metabolites and the risk for a woman developing breast cancer or other diseases.

So getting a picture of the hormones, not just estrogen, but testosterone as well, we can see it's metabolites. And that can be really helpful for a woman, especially in the perimenopausal years when it comes to testosterone and women say, all of a sudden they have maybe some acne, maybe they have hair growing somewhere they don't want it growing. Maybe their hair is thinning. We can see the way that testosterone is actually being broken down in the body as well. And we can actually do something about it. So if estrogen is going down a pathway, we don't love, or testosterone is leaning towards a path that we don't love or it's imbalanced.

There are certain lifestyle and food and supplements that we can use to shift those pathways and help a woman to feel better in her body. So I love the Dutch test for that reason. It's a little bit more of an investment for patients, but I think it gives them a lot of information and it can be nice for comparison sake.

And I find that patients and clients really like to get that information about their body. I'm not opposed to saliva testing. It's a little bit different. I think it can be a little bit more cumbersome to use. Saliva hormone levels tend to be a little bit lower. So sometimes you're not going to get quite the same picture that you'll get in a Dutch test, which collects urine four times throughout a 24 hour period.

So you get a really comprehensive picture about the full days, like a 24 hour day worth of hormones.

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Mary: [00:39:16] We have a question from one of the viewers who wants to know if the Dutch test is ever covered by insurance and how much does it typically cost?

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Jill Chmielewski: [00:39:26] My understanding is if you, if your physician orders that it's typically quite a bit cheaper than if you were to just log on, because patients can order a Dutch test on their own.

Although I wouldn't recommend it just because it's a very comprehensive report that most patients won't know what to do with. I think if you were to do the Dutch complete, which is the one that I was referring to earlier, I might be wrong, I want to say it's maybe $299 or $399. I might be speaking out of that might not be quite right.

But going through your physician is going to knock off probably at least a hundred dollars. Anna, do you know? Because I  think youo have used the Dutch test as well.

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Dr. Anna Barbieri: [00:40:03] Oh yeah. I definitely use the Dutch test and I use it as well. Especially for cases that tend to be more confusing. And I really, I like the Dutch test a lot too, for all the reasons that you've mentioned also. But the Dutch test also offers, cortisol tests as part of it.

And that is the salivary portion of it. Because what I like to do is not, it's not just to fix someone's irregular period by giving them birth control pills. Sure. That will work. That will mask whatever is going on. But I think the point here is to really understand what's going on at the basic level, get to that root cause and then go at that.

So I do use the Dutch test. So it does cost about $300 to $350, depending on the panel that one uses. I am not aware of it being much cheaper if it's used through a physician or physician's office cause we do have the kits that come with my name on it but it tends to be similar, except for, the use of, diagnostic codes on it does allow the patient to then submit it to their insurance company for out of network reimbursement.

So some of my patients are finding that they are getting quite a bit of money back, for spending it.

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Mary: [00:41:26] Okay. I think we have so many wonderful questions coming in from viewers. So I think we're going to go ahead and go to the viewer Q and A portion of our presentation tonight. And Katie has been checking in with all of the viewers and putting together a list of the questions. But I think I'm going to, I'm going to go ahead and start out with one of the questions before we jump to Katie's because I've seen several come through. And one of the questions is, a lot of folks seem to be asking about hair loss, whether hair loss is related to the thyroid or their peri-menopause or both, and what to do. It's like help, where is my hair? T hey're really, worrying about hair loss because I know this is an issue that a lot of women are going through in their forties and their fifties, and they're trying to sort out what it's what's causing it.

Dr. Anna, do you have any thoughts about hair?

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Dr. Anna Barbieri: [00:42:29] Yes, hair loss is complicated. Like we all know, and hair loss may be related to thyroid. It may be related to menopause. It may be related to both. Or it may be related to other. So there is a laundry list of things that can contribute to hair loss, genetic factors, high testosterone levels, and how that testosterone gets converted to certain other more active types of testosterone that will then make us lose our hair.

This is another thing that the Dutch test actually can tell us about, being sensitive to gluten, for example, gluten sensitivity intolerance, celiac disease can be related to that. Anemia, thyroid dysfunction, stress, whether it is stress that we experience and let's remember major stress will lead, if it leads to hair loss, it's going to do so in about four to six months. So it's important to find out if something happened as this is a way our hormonal system and particularly our adrenal system reacts to it. Stress in terms of us putting products on our hair. This is the time, right? When we all start to do more things with our hair as our hair colors change.

So all of that. It's important to really look at all of those reasons and then try to rectify them. But hair, your hair loss is a very common issue. Yeah.

And we definitely

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Mary: [00:44:03] want to look at those hormonal issues and the nutritional issues. And, Jill, did you have any additional thoughts to add on the hair loss issue?

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Jill Chmielewski: [00:44:12] Yeah, I think from everything that Anna said I do, it's so complicated and I often, I have so many patients that ask me, what do I do? Because we love our hair and we don't, of course we don't want it to go anywhere. So it's a really stressful thing to happen in a woman's body. Stress is probably like Anna had said, I think that is probably the number one reason. I see that. And you go back, like you said, it happens later. So it's like looking back at the stress because of the hair follicles cycle, you go back a few months and you go, oh, that's what was happening. And now you see this sort of, this hair loss happening.

The other thing I would just mention, and it goes a little bit hand-in-hand with stress, but also with nutrients is, we, sometimes if we're eating in a rush, we are stressed out. We don't produce as much stomach acid as we normally would because we're all in our minivans driving kids. And we're not, we need to eat slowly.

We need to be less stressed so that our digestive system can not just eat the food, swallow the food, but actually break the food down, get those important proteins broken down into amino acids, which help hair and everything else. Get those minerals on board, get the vitamins on board, take care of our gut health, because a lot of that absorption is happening in our guts.

And a lot of what we're putting in our bodies these days in terms of just, processed food and all kinds because of other things in the way we live or we're running and rushing racing, we're not doing our bodies justice. So we're not absorbing nutrients and our hair is one of the places that we're going to see it because we need nutrients to get up to our scalp. So I would say, look at the food and lifestyle is well.

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Mary: [00:45:52] Okay. Dr. Anna, we know that when we're in peri-menopause and ultimately in menopause that we are seeing less estrogen and in some cases are feeling some of the symptoms and side effects of not having as much estrogen, but are there natural things that we can do to help relieve some of those symptoms that don't involve taking prescription estrogen?

And I guess part two of that question is if we do have to go to estrogen replacement, what are the safest forms of estrogen? Because we hear concerns about some forms of estrogen being safer than others. and of course we have the big studies that show that said, oh, estrogen is dangerous.

And a lot of women became afraid of using estrogen, but what can we do naturally to help deal with estrogen decline? And if we do have to take estrogen, what are the safest forms?

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Dr. Anna Barbieri: [00:46:53] So I'm smiling Mary, because this has like my most favorite topic in the world. And I could probably go on for three hours on this it's so please stop me because I also like to explain a lot.

But to really boil it down to my two-minute answer is yes, yes, and yes. There are a number of natural things that we can take, or do to help with estrogen production. So I'll just focus on increasing estrogen. There is lots of other things that go into peri-menopausal where you're trying to balance things.

This is just about increasing estrogen from a natural perspective. Yes. Eating. Everything starts with nutrition, whole foods, colorful foods, enough healthy fats in our diet because actually fat is the, and cholesterol, is actually the backbone of hormonal production. So really taking stock of our nutrition super important.

Decreasing stress. In fact, things like adequate sleep and meditation help with estrogen levels in the brain and our brain responds better as if it were exposed to more estrogen. We don't really understand quite why that is probably through the relationship with, cortisol, but really nutrition, stress reduction, super important.

There is of course, herbs and supplements. There is a number of them. I will mention things like soy extract and soy isoflavones. These are categorized as phyto estrogens, meaning estrogenic, plant compounds. They are not as powerful and immediate as taking estrogen, but they can be helpful. Black cohosh as on the other one.

And there were some other ones that actually can help with estrogenic or other symptoms of low estrogen, but won't act like estrogen. For example, one of them would be, something like Swedish flower pollen, it's called reli Zen. It's actually safe to even, for even women with, hormonally dependent breast cancer to use.

So there's a number of things there. Of course, hormone therapy is there also. We know that the big study from 20 years ago it was called women's health initiative. That was the study that literally overnight reversed the trend of HR to your hormone replacement therapy prescriptions. Lots of women became super afraid of it.

Lots of doctors became super afraid of it, stopped prescribing overnight. It's been almost 20 years and amazingly, there are still people that actually apply the conclusions of that study to today's practice, even though many of its conclusions have been really disproven over time. So for most healthy women, especially women around the age of menopause hormone therapy will actually provide them with more benefit.

So then harm. And that goes for both short-term symptom relief, as well as for long-term health benefits. But of course, like everything, it may carry some risk. So the decision to really start hormone therapy needs to be very individualized and we need to know we need it. It needs to be done with a well-educated patient, and a practitioner who really knows what they are doing in this space. There is a lots and lots of different types of hormones. I think the science is pretty clear now, that hormones that are identical to the form that our body produces are likely safest. So when I write for hormone replacement therapy for my patients, it is typically going to be with transdermal, which means cream, patch, gel, estrogen, that is bioidentical. Meaning the form of it is exactly the same as what our body makes. And usually with oral progesterone and that's called micronized progesterone. And there's just so many, again, I am, I think into minute 10 of this explanation, I could go on and on because there's just so many different combinations and

doses and forms. But really, I think that summarizes it. So please tell me to stop.

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Mary: [00:51:36] Actually  I wanna raise a question with Jill. Based on what you said, because Raven, one of our viewers, had a question about soy and the thyroid and, Jill, as a certified nutrition coach, I'm sure you get this question a lot too, because we know that some soy foods can actually help with menopausal symptoms, but we also know that soy can sometimes interfere with the thyroid function.

So what is your guidance, for your clients on using soy to help with perimenopausal or menopausal symptoms?

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Jill Chmielewski: [00:52:15] When soy comes up in conversation, I think like anything, it's so individualized. So I think each person has to be looked at individually if somebody is going to use.

So I always recommend using a non-GMO, so non-genetically modified, I think in the United States, like 97% of our soy is genetically modified, which is not the kind of soy we want to use. We see like in Japan they use not genetically modified soy. And a lot of the women say that they don't suffer the same kinds of symptoms and peri-menopause.

The hot flashes and a lot of different things, but what they're using a very different type of soy, everything here is so processed. So I think if you're going to consider soy typically fermented, not genetically modified is what you'll look for. From a dosing standpoint, again, I'm not a nutritionist so I don't counsel on-- I'm an integrative nutrition health coach--but in terms of actual nutrition, I am with my scope of practice, being a nurse I'm limited in what I can say in terms of exactly the type of soy or foods or supplements that a person can use. So just general education. I don't know if Anna, you have anything to add, or if you have a position on that at all with patients.

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Dr. Anna Barbieri: [00:53:28] I do. With soy and hypothyroidism, especially with Hashimoto's, which is an autoimmune condition, some people's immune systems will react to soy. So for example, when I recommend a really solid anti-inflammatory diet, I will ask patients my patients to avoid soy at least for a while, and really to test, kind of how they do with soy later on, as we start adding things back in.

And I totally agree with you, Jill, that soy really should be either consumed as from a really non-GMO organic source or preferably  as tempe. There are also soy supplements that will decrease that risk of autoimmunity or sparking your immune system and soy that will already circumvent the issue of soy metabolism.

So we know that women in Southeast Asia have less of these typical would we consider typical perimenopausal symptoms and maybe it's the soy. They eat, but maybe it's also because they have a different level of certain enzymes that break that soil down into metabolites, which then will act like estrogen.

So there are supplements on the market that are already in that sort of your next sort of step form, but we'll avoid the whole soy, issue.

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Mary: [00:54:59] We have still with, there are so many other, wonderful questions, but we're not going to be able to get to all of them as is often the case because people are so fascinated by both of you, Dr. Anna and Jill, and all of your incredibly wonderful information here. I know we, I think we are probably going to have another speaker series on menopause and perimenopause, Katie, because this is definitely a hot topic for our viewers and people really want to know, what's going on and what's happening in this really important and incredibly powerful time of our lives.

And I'd like to thank both of you, Dr. Anna and Jill, for all of this incredible information, and for sharing your wisdom with all of us about this perimenopause, menopause, and thyroid connection. And I'm going to go ahead and turn it over to Katie to finish us up here, but I want to thank you all for sharing all this great information and thanks to everyone for all the great questions, because there were just some really amazing questions.

And I wish we could've gotten to every single one of them, but hopefully we'll schedule everyone again and you can come back and we'll get more of those questions answered. Katie, I'll turn it over to you now.

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Katie: [00:56:19] Thank you, Mary. And thank you so much to Jill and Anna, thank you for your expertise and sharing your time with us.

I know I learned a lot and we're all so thankful for you being here with us. And thank you to each of you who have joined us as attendees tonight. We hope this was valuable to you. And as mentioned, it's recorded and we will send out a replay in the next day or two, and we will be sure to include our speakers contact information, websites, and social in there so that you're able to continue to ask them questions through their channels because we know we weren't able to get to everyone's questions tonight and we do our best.

Our next event, we're excited, is coming up on Sunday, October 18th. And the topic is, how to get your energy back with hypothyroidism, which we know is a big topic.

We will make sure that you get the invitation to that event and we hope you will join us again. Live. On Sunday, October 18th. So thank you all for being here on a Monday night and we really appreciate your time. We're so thankful to our speakers and we'll see you soon.

Have a good night.

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Mary: [00:57:18] Thank you.

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Dr. Anna Barbieri: [00:57:19] Good night.

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Jill Chmielewski: [00:57:20] Good night.