High Insulin, Severe PMS, Fibroids & Postpartum Anxiety: Your Hormone AMA

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0:42Gemini and Chrome is here for it. Ready to make anything online make sense? There's no place like Chrome. Check responses set up required. Compatibility and availability varies 18+. Today we're doing a little something different. We're going to do Ask Me Anything. And it's going to be a little bit spicy because we're getting into the stuff that gets brushed off way too often. Like, hey, your labs are normal, even though you don't feel normal or you're having severe PMS with endometriosis. We're going to talk about postpartum anxiety, progesterone with fibroids, and why your digestion can get a lot worse in your luteal phase.

1:15And as always, we're not going to do vague wellness stuff. We're going to do actual things. I'm going to guide you on the red flags, practical next steps. and why I decided to do this Ask Me Anything is because I announced my new book that is coming out, which is ADHD and Women. I made a huge mistake not putting it behind me in the episode. That's a fail. It's like having ADHD and then promoting a book on ADHD. That's fun. So I announced the book. It is available for pre-order now. The response has been amazing. I will tell you, I'm like always insecure because I'll write a book and I'm like, I think this is good.

1:49I think this is gonna help people. and then when I have to like go and share it with everybody I'm like oh what if they hate it what if they don't like it what if it doesn't do what I intended it to do but the response has been really positive and I'm like okay instead of like letting your brain lie and make up stories in your own mind about reality let's just like focus on like the positive so with that said welcome to the Dr. Brighton show I'm your host Dr. Jolene Brighton and today's AMA we're going to be getting into all things hormones as usual. But if you can take a minute, like, comment, subscribe, share this with a bestie, I would appreciate it because it helps the podcast so, so much.

2:27But let's not hold it up and let's jump into our first question. Why aren't doctors interested in elevated fasting insulin if hemoglobin A1c, that's a marker of what your blood sugar's been over the last three months, fasting glucose, lipids, those are all normal. Can this elevated fasting insulin be causing background weight loss resistance despite being in a calorie deficit doing 10 ,000 steps a day and strength training three days a week. So firstly, yes, elevated fasting insulin can matter even when your glucose and your A1C look completely normal. So hyperinsulinemia, that's what we call high insulin, it often reflects the body needing to produce more insulin to keep your blood sugar normal, which can be an early sign of insulin resistance.

3:12What is happening is the pancreas is releasing more and more insulin to overcome the reduced insulin responsiveness that's happening at the cellular level. Now, why don't many doctors focus on this? Most conventional screening guidelines are built around diagnosing diabetes or prediabetes, so they are prioritizing your fasting glucose, which is not the best marker, or your A1c, and sometimes they'll even do an oral glucose tolerance test. Now, the standard of care is focused on evidence-based diabetes diagnosis and management. I'm not arguing against that. But in it, fasting insulin is not typically used as a routine diagnostic marker in primary care.

3:52And so what I need you to understand is that your doctor may not be ignoring you because they don't care. It's because they're practicing inside a system that waits until your glucose becomes abnormal, and then they give you a medication for it. So So metabolically speaking, though, insulin is often elevated before glucose rises. And that means your body may already be working harder behind the scenes to keep your blood sugar looking normal, cute, on paper, right? So when it comes to functional naturopathic medicine, we look at a fasting insulin because if your fasting insulin is elevated, then that tells us what's coming down the pipeline.

4:28I don't got to wait for you to be diabetic or pre-diabetic for me to intervene and say, we got to do something different. Now to the weight loss component of this question, insulin is not like a magic fat storage villain. But if it's chronically elevated, that can make fat loss feel harder for some people because it reflects reduced metabolic flexibility. It also reflects impaired glucose handling. You may have higher hunger signals in some cases as well. I know you said you're in a calorie deficit. So when we see insulin resistance, we're not just looking at insulin resistance. We also want to be looking at other factors like is poor sleep, inflammation, stress.

5:09Do you have polycystic ovarian syndrome? Are you in perimenopause? Are you under-recovering? So we start to look at all of the variables that can play a role here because insulin resistance is not usually riding solo. And if you have elevated insulin, it's not usually the only thing that's going on. But what I will say is that if you are in perimenopause, you may be experiencing a decline in estrogen that's leading to an increase in visceral adiposity, and that is causing the issues with insulin to rise. I have a whole episode on it that I will link to. But in terms of practical next steps, I would definitely discuss with your clinician the fasting insulin trend.

5:50Is it trending up? How does it relate to the fasting glucose, A1C, but also what is your waist hip circumference? I think that's a really important measurement as well because that can be showing us that visceral adiposity is sneaking up. If you go to drbrighton.com slash plan, you can get an anti-inflammatory meal plan, exercise, sleep guide on how to address perimenopause, weight gain. But other labs to talk to your doctor about, CRP, C-reactive protein, marker of inflammation, full thyroid panel, maybe checking in, do you have sleep apnea? Like that could be a possibility. What's going on with your cortisol?

6:32And if you're really concerned about it, you can also do an oral glucose tolerance test, although the insurance won't likely cover it and they won't likely want to do that if your A1C has been normal and we're not seeing any abnormal fasting glucose signs. Let's get into our next question, which is, what is your opinion on antidepressants used periodically, two weeks per month? So I'd assume that's the luteal phase to alleviate severe endo-related PMS symptoms. So the first question is, is it PMS or is it PMDD? Because intermittent or luteal phase SSRI use can be an option for PMS. However, when we see the SSRIs are often necessary is when it's premenstrual dysphoric disorder.

7:22That is PMDD. And with PMDD, we believe there is GABA receptor dysfunction. There is heightened hormone sensitivity, commonly seen in those with ADHD and autism. So we see physical symptoms, but we see a lot of mood symptoms. And when we have severe luteal phase mood symptoms, SSRIs are typically used only in the luteal phase, which is opposed to major depressive disorder when they're used throughout the whole cycle. In PMDD, it's roughly only about like 30 % of people respond to SSRIs. The increase in serotonin does actually help them. So if it helps you, great. If it doesn't, we need to look at other options.

8:02Now, the endometriosis nuance in this is that endometriosis can amplify luteal phase symptoms. So endometriosis has pain, inflammation. There can be sleep disruption. There's heightened prostaglandins. There's nervous system sensitization. That can all worsen mood symptoms. And we don't have studies right now to show there's a high crossover between PMDD and endometriosis. but anybody who listens to women, treats women, and actually listens to them, knows that there is a high crossover happening between endometriosis and PMDD. And what I believe is happening there is because endometriosis is the systemic inflammatory condition, it is disrupting neurotransmitter function in the brain.

8:43We also see that those lesions start to ramp up in the luteal phase, especially if they don't have adequate progesterone to actually oppose the estrogen. And so as those lesions ramp up, they are producing more cytokines. Those are chemical messengers of the immune system. They are inflammatory. They are producing prostaglandins. That's menstrual flu, period poops, having really bad period cramps. They also can release histamine. Histamine can also affect our mood. For some people, it makes them feel anxious. For other people, histamine can make them feel really fatigued, like their brain is slowing down, even depressed.

9:23And so there can be a lot of things that endometriosis is doing to contribute to mental health symptoms. And maybe in the short term, you're using an SSRI. I mean, maybe it tends to be the thing that works for you long term, but I would want to look at what else is going on and how endometriosis could be contributing to your moods. I would also want to understand, is this PMS or is this PMDD? Because with PMS, we often need progesterone. Progesterone is often an answer in PMS and maybe also estrogen metabolism, helping support your estrogen detox pathways, making sure you get the right metabolites.

9:56In PMDD, it's not the level of the hormones. It's how your brain's actually responding to your hormones. And so sometimes, yeah, progesterone does help. Sometimes in perimenopause, estrogen and progesterone do help. Sometimes it's an SSRI. Sometimes it's doing many, many things. And when you add endometriosis into the mix of all of this, that starts to complicate the picture. And that means you can't be just treated as a reproductive condition and a mental health condition. You have a full body condition that's happening. And I just want to say, because people can be really judgmental about SSRIs.

10:32Like, you know, if you're living in your body and you're living with this inflammatory disease, you've got hormone fluctuations, you've got a nervous system that's dysregulated and an SSRI is saving your life because that's what's important for people to understand. SSRIs can be absolutely life-saving in PMDD. And when you consider the high rate of self-harm with endometriosis and the high rate of self-harm with PMDD, and you put those two conditions together within a medical system that tends to gaslight you, dismiss you, and give you just like the overall runaround while your whole life clock is like ticking down, just waiting for you to get some freaking help.

11:06Sud, as a woman with endometriosis, took 29 years to get diagnosed. Like sometimes these medications are absolutely life-saving and you should never feel guilty for using anything that we have in our medicine toolkit to make sure that you can live your best life. Our next question is, can you take progesterone with fibroids? And in some cases, progesterone does help fibroids, but the answer here is maybe and it depends because this is very individualized. fibroids are hormone responsive and both estrogen and progesterone can cause fibroids to grow. They can be involved in this biology, which by the way, there is some data that roughly around 80 % of those with endometriosis have co-occurring fibroids.

11:55So if you have fibroids, you might also have something else going on and then you may also need progesterone for that. So that's very real reality is that in managing endometriosis with concomitant fibroids, we may need progesterone or progestin therapy. Now, just because you have fibroids and progesterone could stimulate some people's fibroids doesn't mean that every person with fibroids has to avoid progesterone. It does mean the dose, the route, the symptoms, the bleeding pattern, the fibroid size, the location, your reasons for taking it, that all has to be part of the discussion as well. And there's also several ways to treat fibroids.

12:33Some of them do include using hormone therapy. There's also surgery that depends on the size of the fibroids. And then there is a new therapy, which is HIFU, high intensity focused ultrasound that can also be used. And so it's all about the size, what your goals are, your fertility goals matter in this as well. And in some cases, progestin-containing options like a progestin IUD, those might be considered for abnormal uterine bleeding that is related to fibroids. But the evidence varies on this as well and how people respond varies. So, I mean, I feel like this is an unsatisfying answer because progesterone is not automatically forbidden in fibroids, but I don't want to make a blatant statement that progesterone is always safe or progesterone always grows fibroids because the truth is actually a lot messier than that, which is why we've got to see how it works for the individual and how you respond to it.

13:36Now, in some instances with submucosal fibroids that distort the uterine cavity and are more likely to cause heavy bleeding, progestins and progesterones may help with that bleeding. If you have large fibroids that are causing bulk symptoms, there's a lot of pressure, that's probably not going to improve with progesterone. Now, let's say someone is using progesterone because they need help sleeping in perimenopause. They are on estrogen therapy. They need endometrial protection. That is very different. That has benefits compared to the risk. So here's what I would say. If you have fibroids and you're starting progesterone, I would get baseline imaging.

14:16I would track symptoms and I would plan to reassess whether that's bleeding, pain, pressure, or just repeat imaging to assess fibroid growth. I would plan on doing that. Hormones should not be handed out like party favors without no follow-up, but they also shouldn't be kept from people who could really benefit from them. So when it comes to fibroids, the most important thing is that we know what we're working with. We know the best course of action for the treatment, and we understand the limitations of progesterone, the benefits of progesterone, we do the risk-benefit analysis. And then once you're given hormones, we continue to track that.

14:53And if you're, you know, on estrogen therapy and your fibroids are growing, but you're also on progesterone therapy, that might be a discussion of like, do we need to remove these fibroids? Do we need to do something different? Nobody ever wants to have surgery, but at the same time, when we consider like, you know, the risk of osteoporosis or other conditions that come along with not having optimal estrogen, progesterone, you know, it's all about the risk versus benefit analysis. So not an automatic, no, you can't have progesterone. It depends. And also let's track it. Our next question is about postpartum and stay tuned.

15:32If you're not postpartum, you're nowhere near postpartum because I'm going to have more questions to answer. And, you know, you always have the option to like skip ahead. Don't tell my producer, but you can always just skip ahead to the next question that serves you. But let's answer this question about postpartum. One thing I hear from women all the time is that they're struggling with symptoms like hot flashes, sleep disruptions, and brain fog, but aren't sure where to turn to for help. Menopause is inevitable, but suffering through it isn't. That's why I want to tell you about Alloy. Alloy is a digital health platform that connects you with a menopause specialized doctor who can create a personalized treatment plan tailored to your needs, all from the comfort of your home.

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17:13And most of those people maintain skin that's still more clear at one year with monthly dosing.

17:39reactions can occur that can be severe. Eye problems can occur. Tell your doctor if you have new or worsening eye problems. You should not receive a live vaccine when treated with Epglyss. Before starting Epglyss, tell your doctor if you have a parasitic infection. Ask your doctor about Epglyss and visit epglyss.lily.com or call 1-800-LILY-RX or 1-800-545-5979. So the question is, how do you naturally recover from postpartum depression and anxiety? And this is really common for women to experience. And what I will first say is that, yes, I'm a doctor. I'm not your doctor. You may need to meet with your doctor.

18:14And natural support can be powerful. But sometimes, depending on how severe it is, you may actually need a medication. And if you do, that is not because something is wrong with you. It is not because you're not grateful enough for being a mom. Too many moms try to white knuckle it. And so let me just say that like if you need therapy that is a medication, it's not natural, there's nothing wrong with you and it doesn't mean you have to be on that medication for life. Now in terms of things to help naturally, so we know that progesterone gets metabolized to allopregnenolone. Allopregnenolone is a neurosteroid metabolite.

18:51What does that mean? It's a whole lot of like doctor speak to say. It is going to affect your brain in your GABA system. And so with that, we give birth, we lose our placenta, we lose progesterone, and we can feel really anxious because of how the GABA system is reacting. If you are a neurodivergent individual, you have a neurodevelopmental condition, you may be even more sensitive to the hormone changes that happen in postpartum. One thing that we can leverage and utilize is oral micronized progesterone. Not progestin, not the mini pill, not a birth control pill they tell you is progesterone.

19:28That's not progesterone. And that progestin never ever will ever be allopregnenolone. The body is just like, I see you, I see you grabbing onto my receptors, and I ain't going to do nothing with that. You're not going to allopregnenolone. So what I will do is after milk is established, if somebody is choosing to breastfeed, I will bring in oral micronized progesterone. Usually 100 milligrams does really well. It might be more like 200 milligrams. I have other colleagues who start it right away and they don't see it interrupting milk. I know breastfeeding is hard enough, so I don't do anything that could potentially make your life harder with breastfeeding.

20:05That is one strategy for helping with anxiety. Now, I am also a fan of things like magnesium, magnesium glycinate to help with sleep. You getting support around sleep so you can actually sleep. It's one of the best things for your mental health. You getting outside, getting sunlight, moving your body. And I've also had two kids. So I know how hard it is to do all of these things. And when it comes to sleep, if you can even just protect four to five hours of sleep, just getting a stretch of four to five hours uninterrupted, that can be a complete game changer. And that usually requires your partner to step in, family to step in, or hiring a night nurse.

20:43And it may even require you to pump or even have a formula conversation, which I know can come with like a lot of shame and feeling like, why can't I just do all of this? This is like how we evolved and like my ancestors could do this. Like I've heard all of this before. I've also said all of this stuff to myself before. But like the most important thing is not just healthy baby, okay? It's healthy mom. And the research shows us happy, healthy mom makes for happy, healthy baby. And I think in medicine, the focus is always like, you're pregnant, we're all about the baby. You have the baby, which a lot of times treats you like you're just a body in the way of the baby.

21:24And depending on your age, that your body is trying to harm the baby. I had my baby at 40. And it very much was that vibe. And then once baby's born, all attention is on baby and nothing is on you. And that is just a backward system. It's a both situation. We need attention on both. Now, other things that matter is your nutrition. Absolutely making sure that you're getting adequate protein, carbohydrates, getting enough fat, super important for your brain, especially omega-3 fatty acids. If you lost a lot of blood, like a lot of us do in labor, iron repletion. If you don't have enough iron, you can experience anxiety from that.

21:59So it's always iron bisglycinate with having vitamin C with it as well. And then if you can eat organ meats, that's certainly going to help. I wrote a whole book called Healing Your Body Naturally After Childbirth, and I talk about before liver supplements were even a thing, I wrote this book and talking about how great organ meats are at helping bring up your iron level. Nutrient deficiencies can be a cause of mental health symptoms. If you don't have enough B12, if you don't have enough vitamin D, all of these things can affect your mental health. Okay, and then we need to talk about the biggest elephant in the room, which is why in hell are we not testing women's thyroid after they give birth?

22:40So CBC, complete blood count with a ferritin storage form of iron, a thyroid panel, TSH, free T4, free T3, thyroglobulin and TPO antibodies, vitamin D, B12, possibly inflammatory markers, depending on your history. These are things that I would be looking at six to 12 weeks postpartum. It just depends on your symptoms. because I don't want to like send you to do one extra thing. So I might be like, we can wait until like three to four months postpartum before doing this blood draw. But four to six months postpartum is typically when postpartum thyroiditis comes up. That's healing your body naturally after childbirth.

23:19My first book, I wrote about this in that book. And that was my experience as well. Anxiety and depression, very classic symptoms. This is also the same time that postpartum depression and anxiety tend to come on. So what we see is that you can be anxious at first. This is the classic progression. You're very anxious because you're having more of like what would look like Graves, hyperthyroidism symptoms. And you're the super mom and you can get all the things done and you don't need that much sleep. And then you flip into I'm depressed, I'm lethargic, I'm gaining weight again. Maybe your milk supply is declining.

23:53Milk supply declining can be one of the first signs of postpartum thyroiditis. Postpartum thyroiditis is an autoimmune condition of the thyroid. It's thought to be transient because it can go into remission around a year postpartum, but it often comes back. So that's not really something that's transient. That's something that went into remission. What comes back around 12 months postpartum? Usually a period, usually cycling. And women are, you know, historically based on all this data, having babies younger than what we are now. And so now we're in a big gray zone of like, how common is this?

24:27because over 35, it's much more common to get Hashimoto's, which is a form of autoimmune disease, which is essentially what postpartum thyroiditis is. But the postpartum thyroiditis isn't thought to be a persistent and permanent thing until you have the next baby and it happens again. And then you get older and then, oh, yeah, you have Hashimoto's. So if you ever have autoantibodies and symptoms, you have an autoimmune disease and it's just a matter of what's going to trigger it to rear its head again. So with all of this in mind, we need to do lab testing. If that TSH is above 2.5, if we're seeing low T4, low T3, we want to think about using thyroid medication.

25:06Oftentimes, I will say that many psychiatrists know this. Many psychiatrists will actually say, you're a new mom. Let's test your thyroid. Okay, let's give you thyroid hormone if that's the problem. What we see is that many OB-GYNs, and this is the slippery slope of PCPs and OB-GYNs stepping in for mental health providers is that they'll give SSRIs, SNRIs. They're like, why are you treatment resistant? Basically, we know treatment resistant is usually a sign of thyroid disease in mental health across the board. And so, you know, I always ask the question, why start with an SSRI when we could just start with a really cheap and easy blood test and then treat appropriately and treat the root cause?

25:46So while people will often say, well, using thyroid medication is not natural. It is hormone replacement therapy and it's a hormone you can't live without. You absolutely cannot live without it. So if you need that, great. You may also need selenium and iodine. And that's why I formulated my prenatal plus the way I did because I read the research. I went through postpartum thyroiditis. I have a Hashimoto's. And I'm like, there is a sweet spot of a balance of selenium and iodine that actually is protective for this, that is protective of mom's thyroid and gives baby what they need. And so if you're wanting to do natural things, definitely selenium and iodine can help.