Why Perimenopause Hormone Therapy Can Make Symptoms Worse: Gut, Liver, Thyroid, and Toxin Factors | Pamela Langenderfer

19:18Pamela Langenderfer:So when you get into like Idaho, Oregon, Washington, you're hard pressed to find a house that doesn't have mold.

19:24Dr. Brighten:Yeah. And people always say, well, my house is new. It doesn't matter. Even some of the new houses can have quite a bit of mold. and you don't always see it. And so that's why it's so tricky. One of the things I've learned over the years though is that our medicine should work. I mean, it does work. So if it doesn't work, then you have to kind of step back and go, do you have mercury fillings? Do you have breast implants? And that is a huge, huge one that I have seen make a big difference why people can't get well. And then you start to look at the heavy metals, the molds, things like that. something is affecting the body and making it not work.

20:04Dr. Brighten:But some of those mycotoxins, and I agree with you, mold is like a whole other beast. But then I'm like, okay, I'm going to learn about it, but I don't want to be an expert necessarily. But it makes a difference in someone's hormones because some of those mold strains are actually estrogenic. And so if someone has a really high amount of that in their body, it does have to be dealt with because you won't be able to fix their hormones until you decrease that level.

20:29Pamela Langenderfer:Yeah. So when you're, I want to keep going in the lab testing, but when you're coming across mold, yet somebody is like, you know, they very much need to start progesterone, estrogen, maybe even testosterone therapy. What is your approach when you're dealing with both things simultaneously?

20:46Dr. Brighten:I spend at least four to six weeks actually taking them through a detox. So I often won't give the hormone right away unless the person is really, really miserable. And the reason for that is because their chances of having a negative reaction are so high. And then it's kind of a mess. And now you're stopping, starting. So when we take people through a structured detox in the beginning, so we spend about four to six weeks doing that, and then we introduce the hormones, it goes so much smoother. And people tolerate them better. They have a much better response to them.

21:22Pamela Langenderfer:And when you're addressing the mold, I assume you're also looking at the environment. So reducing environmental exposure. What do you recommend for people listening to reduce environmental exposure to mold or even know if they have mold in their environment?

21:35Dr. Brighten:Well, first of all, if you want to know you have mold, you have to do some sort of testing. And dust testing tends to be more accurate because if you just test in the air, I mean, it could be behind a wall and you could not pick it up. So you do have to have some sort of testing to see if it's even in your house. But even for the environmental toxins, it's really just reducing your exposure. So for myself, for example, I was home at my parents' farm this summer, and it was wheat harvest season, and my dad had 80 acres of wheat planted around the house, and everybody's harvesting. And so just by being around that and breathing it all in, all of my gluten markers were through the roof.

22:15Dr. Brighten:And then I measured my toxin levels when I got back, and my BPA levels were super high. because I didn't want to drink out of the well. So I was drinking out of plastic water bottles for like a couple weeks straight. And so that was really kind of shocking to see how high it went just by having that exposure. So whatever you can do to reduce your exposure, choosing better hair products, beauty products. And, you know, we all can't be perfect. I mean, we all have those favorite things that we know are toxic. So you just choose your toxicity and you just try to reduce how much of it you're going to have.

22:52Pamela Langenderfer:I think that's the most important part, though, is having the informed consent, like actually having the information as a consumer so you can choose. So we talked about the mold. You said you take people through a detox. What does that look like for people listening? Because this might be totally new to hear that like, oh, you've got to move mold out because often people are told you have a liver and you have kidneys and you have a gut. They're going to detox for you. I always laugh because I'm like, and how well do your kidneys work if you don't put in water? We have to have inputs that come in.

23:22Pamela Langenderfer:If you're not eating amino acids and you're a carbitarian, then good luck detoxing through your liver because they require all of these inputs.

23:32Dr. Brighten:Yeah, and I'm glad that you said that because that is one thing people don't understand, that importance of protein. If you don't have enough of it, you can't detox because you need those amino acids for your liver to work. And so one of the things we focus on is we take people through a pretty structured elimination diet. And part of the reason for that is because, you know, sometimes you say the word detox and there's like crazy detox things out there. People do these intense things. They're in the bathroom all the time. I think there are some crazy detoxes out there and then people do them too intense, too fast.

24:04Dr. Brighten:They feel awful. Like it stirs the pot and you kind of open Pandora's box if you don't do it right. So we do take people through an elimination diet and I tell them this isn't forever. You know, sometimes I think it's so easy to get dogmatic and all these different like diets and nutrition and do this and do that. At the end of the day, how do you feel? I mean, I'm not very motivated to avoid something if I don't feel a difference from it. And that's really what we take people through an elimination diet for is to get them familiar with their body. and if we do it in a very slow structured way oftentimes 50 percent of their symptoms go away so i'm like man i would have gave you all these supplements you really don't need and it's just because you were eating something that was causing so much inflammation so by doing that and we support them with different supplements that support the the liver and the kidneys and then making sure they're getting enough fiber because that fiber part like you you don't know until you know, and I'm a big proponent of food tracking, macro tracking, because if you've never done that, you have no idea what 35, 40 grams of protein looks like.

25:12Dr. Brighten:You have no idea what it means to have 25 to 30 grams of fiber in a day. And people really need that visual. But that fiber part is so critical because if you're going to go stir up the pot, you need something to absorb it and catch it So that way you can get it out. So that's really what we focus on in those first six weeks for people. And they do feel a whole lot better just by lowering that toxic burden on their system.

25:39Pamela Langenderfer:Yeah. And I think it's so important for women listening to understand that as we age and we lose our estrogen, our microbiome diversity declines. And it's one of the contributing factors for which there are several to our body weight distribution changing where our body fat actually is. And research has shown that when people are intaking more fiber, they have less of a propensity to store the highly inflammatory, metabolically active visceral fat. So when we're talking about fiber, what do you recommend the goal should be that women are trying to achieve daily with their fiber intake?

26:15Dr. Brighten:A minimum of 25 grams that they can do more, but not everybody's digestion can handle that. And so it's kind of the same thing. It's another good sign or a red flag if you're trying to get more fiber in and you feel worse. Well, you got a gut problem going on. So we have to take that slow with people so that way that they can make sure that when they put the fiber in, they're able to handle it. They're not actually getting more bloated, more constipated from it, because that unfortunately is sometimes a byproduct of adding more fiber in. And so that just is a signal you actually have probably some sort of SIBO or other type of bacteria overgrowth going on in there.

26:54Dr. Brighten:But the fiber really can change the microbiome. And as you talk about the microbiome, you know, there are different probiotic strains that tend to be more lower in histamine. And histamine can be a big trigger for hormone problems and increase estrogen and cause more estrogen dominance. And so by making sure you have more of like the bifidostrains and some of these other bacteria in there, you can actually help to manage some of those histamine levels for people that sometimes even cause depression in women. Or rage.

27:28Pamela Langenderfer:Yeah. Yes. Or that too. Yeah. And it's something so everyone listening, I'll link to an episode that I did about the menstrual flu or the period flu that talks a lot about the estrogen histamine connection and how that can make us feel so awful before our period. But I have always said like, everyone's like do a low histamine diet. And I'm like, that is not the answer. Can it help short term? Yes. But the answer is in the gut. So can you speak a little bit more about because if you're starting someone on estrogen therapy, whether it be topical or oral, it really doesn't matter if estrogen is coming in and you've already got a histamine issue, that can be related to what's going on with the gut.

28:13Pamela Langenderfer:So how do you approach someone in that instance?

28:15Dr. Brighten:So sometimes it's a genetic problem. So if somebody has their genetics, you can see they might not have an or be susceptible to not having enough of the DAO enzyme. So you could put the DAO enzyme to help with that. But I found doing low histamine probiotics probably be the most helpful because that is really what helps to degrade histamine in the gut. And this was something, you know, I always feel like I make all the mistakes on myself first. And so that's how I help everybody else.

28:45Pamela Langenderfer:Yeah, I just want to like echo that because I feel like so often when I have practitioners on the podcast with myself, like all of us have our own journey. And then And people are like, oh, but you're going to be able to help so many more people. But I think you get to like our age and then you're like, but I'm done. I've learned the lessons. Leave me alone.

29:04Dr. Brighten:Like, I don't want to learn anymore. Don't have to go through it again at all on there. Yes. Yes. And that's kind of what I had learned, you know, on myself is because, well, you know, go back like 10 years ago where everything was eat more fermented food, heal the gut, bone broth. And so I'm trying to heal my gut and I have really bad eczema. And so that's what I've spent 30 years now trying to keep in remission. And sometimes I have flares and it gets triggered. But I was eating all of this fermented food and I looked worse and worse and I could not figure it out at first. And then I learned, oh my gosh, it's a histamine issue.

29:40Dr. Brighten:And all that histamine was actually what was triggering my symptoms to be even worse. So then I also didn't understand lactobacillus acidophilus, which is in like every probiotic is actually a high histamine strain. So when I changed my approach, started using more low histamine strains, there's different lactobacillus and bifidose that are considered low histamine. It made a huge difference in my skin, but then also on my gut and my hormones. And so that's where I feel like if we have those right things in there. And then you do have to be careful sometimes with the histamine food. I mean, as you know, those low histamine diets are very difficult because I don't have time to be cooking every meal from scratch every single day.

30:24Dr. Brighten:And you're not supposed to have a lot of leftovers and all of that. But it comes down to that management. If you know that there's an issue going on and you're trying to have kombucha every single day, well, you probably can't have kombucha every single day because it's not helping you.

30:38Pamela Langenderfer:I literally tell my patients anytime we have to do elimination diet or maybe we need to do low FODMAP diet or you know any kind of specialty diet and I tell them straight up I hate these diets more than anything like I hate it as a foodie so my goal is to get you off of this as soon as possible like we use it and that's what I want people to undertake away from this conversation is that when you talk about using a therapeutic diet like doing an elimination diet that has an end date on it. It expires. So in the vein of giving people health, we were talking about, so we did gut testing, there's the environmental toxin testing, mycotoxin testing.

31:15Pamela Langenderfer:What are you looking for specific in hormone testing that maybe influences or changes how you prescribe hormones?

31:22Dr. Brighten:So I do a lot of urine testing, specifically the Dutch testing, because for me, it's really important to see how someone's metabolizing the estrogen. So if they're detoxing it down one of those bad pathways, they're usually going to have a more negative reaction to the hormones. So that's what I'm looking for more than anything in the urine testing. And then with blood testing, I'm just trying to get an idea of where their levels are. And I feel like what happens with the blood testing, people get very focused on a number. And then I see practitioners going, oh, I need to make sure estradiol levels are here or testosterone levels are here.

32:02Dr. Brighten:Meanwhile, the patient is bleeding and they're having breast tenderness. And so I've learned that the hard way many times is that you have to, it's a balance because you want the person to have symptomatic relief. relief. And yes, I understand it's important to have these levels optimal so that way you can have some protection on your bone and the brain and the heart. But if I just do that, I will see bleeding start to happen. And so now I got to refer to a gynecologist. We have to go through the whole process of making sure we have vaginal ultrasound. Possibly endometrial biopsy.

32:36Pamela Langenderfer:Yep. All of that. Which barbarically the U.S. doesn't totally give you great pain management for. So So we definitely want to try to avoid, you know, the worst case scenarios in these things. So what you're talking about is that we know in the research, they say like we want to target in the blood serum estradiol around 80 to 100. That's what's going to be protective of the brain, the heart, the bones. You should also be getting DEXA scans because I don't believe that in the future that we're going to that anyone's going to say, oh, it's just about the serum estradiol. So I do think you have to still track these things.

33:10Pamela Langenderfer:However, I'll echo what you say. Some people, you get them to 60. That's where they feel great. They feel awesome. Their dex is looking great. Like you are sending them to their cardio workups. Like you're getting all the data back and everything looks great.

33:25Dr. Brighten:Eczema is unpredictable, but you can flare less with Epglyss, a once monthly treatment for moderate to severe eczema. After an initial four month or longer dosing phase, about four in 10 people taking Epglyss achieved itch relief and glare or almost-clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing.

34:07Dr. Brighten: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 EBCLIS. Before starting EBCLIS, tell your doctor if you have a parasitic infection.

34:18Pamela Langenderfer:Ask your doctor about EBCLIS

34:19Dr. Brighten:and visit EBCLIS.lily.com or call 1-800-LILY-RX or 1-800-545-5979.

34:25Pamela Langenderfer:And what you're speaking to is treating the individual. What we are at is a precipice of conventional medicine of the run of the mill OB-GYN who was never actually trained in perimenopause, menopause, or hormone therapy. coming into the space now and then trying to create the cookie cutter model, right? So they're trying to shift it into like, how can we effectively treat as many women as possible with the best evidence base? That is going to do well for probably 60 to 80 % of people. But there is always going to be the 20 to 40 % where that cookie cutter model is not working for them. And that's where we have to get creative and we have to explore.

35:03Pamela Langenderfer:You mentioned estrogen metabolites. It is not just about serum estradiol. So can you break down these metabolites, what you're looking for, and what you think every listener should know?

35:12Dr. Brighten:We're looking at the 4-OH and the 16-OH pathways. So specifically, if those pathways are high, in a very simplistic way, you can think about them as they're bad estrogens, and specifically that 4-OH. So if you see those levels high, then you want to intervene with different supplements, nutrition-wise, making sure that you're having foods that have a lot of the cruciferous vegetables in them, going back to the fiber, doing things like ground flax seeds. All of those things will make a big difference in how you metabolize those hormones.

35:48Pamela Langenderfer:And while I will say I would never allow the cost that prohibits people from getting lab testing to prohibit them from getting hormones, I will echo what you say that if we test ahead of time and I see that your 16 OH estrogen pathway is upregulated, I know when I give you estrogen, you're likely going to have rest tenderness. You're going to be that person that has that side effect. And as you talked about genetics previously, if you are someone with a COMT mutation, so you have a genetic variation in that, you may not be processing your estrogen correctly. So now you may be the person who feels more irritable with estrogen.

36:29Pamela Langenderfer:Your brain is feeling more foggy with estrogen. You're having more of those PMS-like symptoms and you're like, but I'm not even menstruating. What's going on? It's because of your unique pathways and how you're actually running your estrogen. And in some cases, these are really easy to shift. So can you give us like the top five things that you would say? Like if you're not doing this today, start because it's going to help you manage your estrogen so much more effectively.

36:56Dr. Brighten:Magnesium is a big one because that'll help that COMT gene. Doing broccoli sprouts, and there's many supplements now that have broccoli extract in there. And ground flax seeds. And I know there's controversy about that where, you know, I was always taught ground flax seeds are really important for breast cancer protection. And then I've seen other people out there saying, know they're going to cause breast cancer, but I have just seen - Let me break it. Can I break it down? Yeah, break it down. Yeah, yeah.

37:24Pamela Langenderfer:Okay, here's the thing. Flax seeds, the whole flax seeds have lignans in it, and that is what's protective. When they have done the research on flax and said, this is problematic, especially a lot of the research has come out of prostate cancer, it's flax oil. So it's when you highly process the flax seeds, so it becomes a processed food rather than the whole food and you separate it from the lignans that things become problematic. And we know that it's highly unstable. It has to be kept in the fridge, but come on. Like it could be in a cargo ship. It could be like on a truck being shipped. So now you're consuming a highly oxidized oil.

38:03And so the big question in the research is like what is happening

38:06Pamela Langenderfer:with the oil here and what the research has actually shown. If it's the whole flaxseed and you're grinding it up yourself or you're buying ground flaxseed, you get the lignans and those are actually protective. So I've had this conversation like a hundred times because people are always like, oh, isn't flax going to cause breast cancer? And I'm like, literally in an environment that is filled with like BPA and parabens and like all of these environmental toxins that we know, like glyphosate, I mean, that are associated with cancers. The last thing we need to be worrying about is a whole food. Like that is the last thing.

38:39Pamela Langenderfer:So anyhow, you go back off. You said magnesium, you said flax seeds.

38:43Dr. Brighten:Broccoli. We talked about broccoli. And then, of course, from there, we have diandolmethane, which is the DIM, which is used quite a bit as well to help those pathways. And then you can focus on some of the methylation things like methyl B12, methylfolate. So I think it's really approaching it from this big picture. methionine is sometimes helpful too but when you get a lot of those pathways working and most the time focusing on someone's diet does do 50 of the work and that's just even putting more vegetables in because I mean how many people aren't getting enough I mean I'm guilty of that you know too we're sometimes like gosh did I even have any vegetables today just by doing some of those simple changes with that really is enough to help to to shift that and then the other thing I encourage people to do because you had brought up before, you know, sometimes the cost of some of these labs and and I get it, you know, for people, sometimes the cost can be a little bit of a barrier.

39:38Dr. Brighten:But on the flip side of that is that our health care system is a mess right now. And I always view things as I investing in my health and in my future. And I we talk a lot about, you know, not just the lifespan, but the health span.

39:53Pamela Langenderfer:So I want to go back into more about the hormone placement therapy, menopause hormone therapy. When you are looking at prescribing this for someone, how do you typically start things? Like, are you starting with progesterone first?

40:08Dr. Brighten:Are you starting with estrogen first? When do you consider testosterone? It really just depends. Depends where the person's at and where their lab values are at. So if I have someone that's still having periods, I tend to not start with estrogen. I usually will start with progesterone and testosterone for them. And then if I have someone that has not been having periods, then I'll start to introduce estrogen. And one thing I will say, you know, there's all kinds of delivery methods. There's patches and creams and pellets and injections. I do them all for people because it just depends on the person and what works for them.

40:43Dr. Brighten:And so I have some people that they hate the cream. They hate doing any type of compounded creams because there's sometimes so much cream and they're lathering up in it every day. And then sometimes they'll do a patch and then they're exercising a lot and they sweat the patch off. So you really have to keep in mind when it comes to hormone replacement therapy, there is not one way that is the best. But what we do know is the best is that estrogen needs to be topical. You really shouldn't do oral. And there are people that will disagree with me on that. But I always do topical estrogen. If you have a uterus, you have to have oral progesterone.

41:21Dr. Brighten:You can't just do progesterone cream or a troche. But sometimes I feel like the capsules aren't enough. And I will combine it with creams and trochees because it has to do with how the person is absorbing. And everyone's skin is so different too. And then the same thing with testosterone. I'll start people typically on a cream, but sometimes I do a pellet because they feel better. They like more of the convenience of it. So it just really depends on what works best for that patient. So I'm not married to one specific thing as long as I know we're doing it safely and the person's getting results.

41:59Pamela Langenderfer:And I want people also just to make the connection of what you said earlier about the necessity of lab testing is because when we start you on a topical, we know not everybody absorbs that the same. And so we have to make sure we're hitting the mark. And sometimes you're getting just enough that you're like, I'm feeling better. But when we do the testing and we realize like we need to change routes or we need to go higher dose, we need to switch it up, whatever it may be. And we actually get you into more of a therapeutic window. That's when people are like, oh no, now, now I'm actually feeling a lot better.

42:34Pamela Langenderfer:Let's talk about the controversy between using topical estrogen and oral estrogen.

42:40Dr. Brighten:Oral estrogen is the thing that's the most problem with increasing risk, you know, blood clots. And then when you look at some of the literature, though, the increased risk of that is really not as high. But I think the thing is, is that you don't always know if somebody has a blood clotting disorder. So topical estrogen can be used if somebody had factor V ligand, which is a blood clotting disorder, that's a genetic issue. And so because I don't always know somebody's history or their genetics, or I do feel like because of COVID, I mean, I do see a lot more problems than what I used to before, that I'm always more comfortable just sticking with the topical delivery of that.

43:23Dr. Brighten:And so that's why I and that's partly what the guidelines say with topical estrogen with that versus the oral, though I do know some practitioners that do use oral estradiol.

43:34Pamela Langenderfer:Let's talk about the nuance around testosterone.

43:37Dr. Brighten:Well, I would say testosterone is probably one of the biggest controversies for women out there, too, because you have, you know, the reference range. And so if you're in the range, then you're fine and you don't need it. Well, everybody is in the range, but yet people have a lot of symptoms. So the top things that I see for women that need testosterone, it's usually low libido, low energy, low muscle tone, and they just don't have like that get up and go anymore. And they're exhausted. And I will say that when you get testosterone in, it really does make a difference for those women.

44:13Pamela Langenderfer:We've got the labs. We've got the symptoms. How do you counsel patients on this? What should women know?

44:19Dr. Brighten:So when it comes to testosterone, same thing, depends on what you're doing in the delivery method. So if you're doing a cream versus a pellet, the labs can look quite different. And the labs will go much higher on somebody that has a pellet. So again, you have to pull back and look at the big picture. And oftentimes, somebody is going to be double or triple out of range with a pellet. And some people are symptomatic and some are not. They feel a whole lot better. So when it comes to testosterone therapy, I always tell people, I always tell them, I'm going to tell you all the bad stuff first because this is what we're going to look for.

44:52Dr. Brighten:Are you having hair loss? Are you having hair growth? Are you getting a lot of acne? Are you getting clitoral enlargement? Is your voice changing? Like those are the things that we don't want to have happen. So when I work with people on testosterone, I mean, they're checking in with me about every three months. So we're either just doing a follow-up or checking labs. And then I'm looking at that big picture for them. So you can't just go off of what the lab values are. Because for menopausal women, the reference range, I think it's like 7 to 40. Well, you can come in at 7 and you're told that you're normal and this person does not feel normal.

45:31Dr. Brighten:And then once you get the testosterone levels in, you might see the levels go up to like 100 or even 150 on a blood test if somebody is doing a pellet. But if the person feels good and they're not having a lot of symptoms, that might actually be okay for them. But then you might have somebody where their levels are at like 60 or 70 and they're getting male pattern baldness and they're having hair loss. And that has a lot to do with how they're metabolizing that testosterone. And so for them, those levels might be too high. So the same thing, you can't just focus on a number. You really have to look at the person's symptoms and you have to communicate with the practitioner and the practitioner has to listen.

46:10Dr. Brighten:because I do think that there can be problems with pellets. Yes, I think people can get overdosed. And a lot of that is because the person gets focused on the lab number. And so they just give the person more and more and more. Meanwhile, this person is telling you of all these symptoms that they're having. So that's why I spend a lot of time talking with somebody. We make the decision together. Okay, you know, it sounds to me like maybe we should go down on your dose. So you have to really listen to the patient. and the patient and you have to be in a partnership together.

46:43Pamela Langenderfer:I definitely agree. What is going into your testosterone panel?

46:48Dr. Brighten:On a blood test, a total testosterone and a free testosterone. So those are the two big things. And you can add a DHT on there as well. And then sex hormone binding globulin. So those would be some of the big things on blood. When it comes to urine testing, though, and you're looking at a Dutch test, that's where you can see what you're doing with those androgens. So if you're converting them down a more potent pathway, that's when people start to have more of the issues with acne and you would see some of the PCOS symptoms happen as well. So I, again, like to do the combo of both. But when I'm screening for testosterone, I often look at blood testing because that's more of the standard when you're looking at that.

47:29Dr. Brighten:But also, if I'm seeing the person have a lot of symptoms, then I'll start to look at some of those urine metabolites or the DHT marker.

47:38Pamela Langenderfer:And what other tests are you tracking when it comes to prescribing testosterone to make sure that they're not having any adverse effects to that?

47:46Dr. Brighten:Well, testing is mainly with the urine and the blood testing. And then a lot of it is we have them fill out a symptom questionnaire every time that they come in. And so I'm looking at that symptom questionnaire, what some of the symptoms are, because that's where I feel like you're going to see the most in terms of tracking other things. I kind of go back to that big picture is if you're not if your microbiome is not healthy, your gut's not healthy, the liver is not healthy. It will make a difference in how your body is metabolizing that testosterone. So we try to optimize everything and look at the big picture.

48:18Pamela Langenderfer:Why are so many menopause providers missing the thyroid picture?

48:22Dr. Brighten:I feel like the thyroid is one of the other things. When do you see it go wonky? It's usually right after someone has a baby and then right when they go into menopause. And so that's a part of just my hormone screening panel is I always check everybody for thyroid issues and do a thorough test, meaning we're checking the TSH, the free T3, the free T4, thyroid antibodies. I look at a reverse T3. I look at ferritin levels. So I get a big picture on what's happening there. But the thyroid really is like the canary in the coal mine. It's kind of the thing that I feel like goes out of balance first when somebody's really stressed and run down.

49:00Pamela Langenderfer:What should women know if they do have hypothyroidism, they're currently managed on a medication, and then they're starting estrogen therapy?

49:07Dr. Brighten:I think the big thing is if you're on thyroid medication and starting estrogen therapy, looking at your labs, making sure that you're converting enough to the active form. And sometimes, I mean, if you're estrogen dominant, that actually starts to impact your thyroid and how your thyroid functions because it can affect some of those receptor sites. So making sure everything is balanced and that you're doing some type of monitoring of it.

49:33Pamela Langenderfer:I see so often people are like, I've been on the same medication for years. They start estrogen therapy and now we have to make an adjustment because estrogen can change binding proteins. Estrogen can change how you utilize your thyroid hormone. And I think that is also a missing piece in the puzzle when women say, I start hormone therapy and I actually feel worse. If women listening to this right now did one thing Monday morning to start to optimize their hormones, what would you challenge them to do? I think the biggest challenge would be making sure you're eating protein at each meal and making sure you're getting vegetables at each meal and making sure you have fiber in there as well.

50:11Dr. Brighten:If you could just focus on the diet part of it, it will make a big difference. It's not going to cure everything, but it really gives you a better framework to start with.

50:21Pamela Langenderfer:Well, this has been a fantastic conversation. Thank you so much for sitting down with me. Thank you for having me.

50:25Dr. Brighten:It's been great to catch up with you.

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