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Is It Really Your Hormones? Estrogen, Metabolism & Midlife · The Integrative Clinician by BridgeWell

0:00
Welcome back to The Integrative Clinician.
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I'm Dr.
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Sheri Erwin, nurse practitioner, educator, and founder of BridgeWell Integrative Education.
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I want you to take a moment to picture a patient, someone that I think a lot of us have seen.
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She's 47.
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Over the last couple of years, she states that her periods have become unpredictable.
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She's gained weight.
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It's been difficult for her to lose weight, and that weight is in the middle section.
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She says, “I'm tired.
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I wake up at three in the morning.
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I feel foggy in the head.
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My libido has decreased.
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I'm more anxious than I usually am.
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I just don't feel like myself anymore, and I think it's related to my hormones.” And you know what?
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She's probably right.
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This is where I think we need to be careful not to overcorrect, because we spent years telling women that these symptoms were stress-related or just part of getting older, telling them to eat less and exercise more.
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We draw labs, they're normal, and they're sent out the door.
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Many of us working in integrative and functional medicine are seeing these patients because they're frustrated.
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They've been dismissed by primary care, and they feel like they're not getting answers.
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Now she's here, and she's looking for answers.
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She's looking for a conversation about perimenopause and menopause.
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And that's a good thing.
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We should recognize that menopause is a transition.
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We should understand hormone therapy.
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We should be comfortable talking about estrogen, progesterone, testosterone, vaginal and urinary symptoms, sexual health, bone health, cardiovascular risk, and what happens to a woman's physiology during this transition.
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But here's where integrative medicine asks us to go one step further.
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What if the question isn't, “Are hormones causing her symptoms?” What if the better question is, “What is happening around those hormones?” Because estrogen doesn't operate by itself.
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Neither does progesterone.
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Neither does testosterone.
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Those hormones are operating inside a woman who has a metabolic system, gastrointestinal system, liver, adipose tissue, skeletal muscle, immune system, nervous system, circadian rhythm, nutritional environment, stress response, and a lifetime of exposures.
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And all of those systems are communicating with one another.
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That is where this gets interesting.
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Today I want to look at a midlife hormone conversation through an integrative lens.
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Not hormones versus lifestyle.
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Not conventional medicine versus functional medicine.
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And definitely not whether hormone therapy is good or bad.
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I want to show you how I think about the physiology surrounding estrogen, because sometimes treating the hormone is exactly what the patient needs.
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Sometimes we need to address what is happening around the hormone.
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And very often, we need to do both.
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Let's start with the hormone story.
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Perimenopause is real.
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I know that sounds obvious, but it needs to be said because women have historically had their symptoms minimized.
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During the menopausal transition, ovarian hormone production becomes increasingly variable.
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Estrogen doesn't simply travel down a nice, predictable slope.
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It fluctuates.
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Progesterone exposure changes as ovulation becomes less predictable.
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Cycles may become shorter, longer, heavier, lighter, or increasingly irregular.
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Women can experience hot flashes, night sweats, sleep disturbances, mood changes, vaginal dryness, genitourinary symptoms, sexual changes, and many other symptoms during that transition.
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So when my 47-year-old patient tells me,“I think my hormones are changing,” I'm listening.
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I want to know: What happened to her menstrual cycle?
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I want to know: When did it change?
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I want to know: Did her symptoms emerge around the same time?
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I want to know: Is she experiencing vasomotor symptoms?
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I want to know: What happened to her sleep?
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I want to know: What's happening with bleeding?
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I want to know: What's happening with sexual function?
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I want to know: Any vaginal dryness?
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I want to know: Any pain?
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I want to know: Any urinary symptoms?
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I want to know: What changed first?
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I want to know: Because the timeline tells me something.
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I want to know: In women of typical age with a compatible menstrual and symptom history, we generally don't need to capture one serum estrogen level to prove perimenopause exists.
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I want to know: The history often tells us far more than one fluctuating hormone value ever could.
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I want to know: But here's the integrative piece.
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I want to know: Recognizing that she's perimenopausal isn't the end of the assessment.
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I want to know: It's actually the beginning.
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I want to know: She can be in perimenopause and also have a coexisting iron deficiency, insulin resistance, hypothyroidism, sleep apnea, significant gastrointestinal dysfunction, loss of a meaningful amount of muscle, or chronic underfueling.
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I want to know: Several things can be true at the same time and contribute to the symptoms she's feeling beyond just perimenopause.
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I want to know: This is one of the biggest shifts I want clinicians to make when they begin practicing integratively.
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I want to know: We're not necessarily looking for the one diagnosis that explains everything.
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We're asking: What are the major contributors to what this woman is experiencing?
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So here's your first pearl: Perimenopause can be a major part of the story without having to be the entire story.
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So here's your first pearl: So let's move on to the next part.
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So here's your first pearl: What physiology are these hormones actually operating inside of?
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So here's your first pearl: We want to go deeper into this.
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So here's your first pearl: Our patient says, “Ever since perimenopause, my body has changed.” Again, she may be right.
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So here's your first pearl: The menopausal transition intersects with changes in body composition and cardiometabolic physiology, including a tendency toward increasing central adiposity.
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So here's your first pearl: But I don't want to stop at, “That's menopause,” or, “That's perimenopause.” I want to understand her metabolic environment.
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So here's your first pearl: What is her insulin sensitivity doing?
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So here's your first pearl: What is happening with her glucose regulation?
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So here's your first pearl: Has her body composition changed?
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So here's your first pearl: How much muscle does she have?
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So here's your first pearl: Has she lost muscle over the last five years?
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So here's your first pearl: What is her blood pressure doing?
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So here's your first pearl: What are her lipid patterns?
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So here's your first pearl: What does her family history look like?
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So here's your first pearl: How is she sleeping?
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So here's your first pearl: What is she eating?
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So here's your first pearl: How much protein is she eating?
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So here's your first pearl: How much fiber is she consuming?
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So here's your first pearl: What does her movement look like on a daily basis?
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So here's your first pearl: Is she resistance training or not?
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So here's your first pearl: What's happening with alcohol?
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So here's your first pearl: Does she consume alcohol, and if so, how much and how frequently?
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So here's your first pearl: And something I think we need to talk more about: Is she actually eating enough?
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So here's your first pearl: There is an enormous amount of messaging aimed at women in midlife telling them they need to restrict more, eat less, fast longer, cut carbohydrates, exercise harder, and lose the belly fat.
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So here's your first pearl: Sometimes I meet a woman who is already exhausted, sleeping six hours a night, doing high-intensity exercise, skipping breakfast, eating very little during the day, drinking coffee to get through the afternoon, and wondering why her body feels like it's fighting her.
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So here's your first pearl: That doesn't mean fasting is bad.
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So here's your first pearl: It doesn't mean carbohydrate restriction is bad.
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So here's your first pearl: It means the intervention has to fit the patient.
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So here's your first pearl: That's integrative medicine.
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So here's your first pearl: We don't start with a protocol.
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So here's your first pearl: We start with the physiology.
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So here's your first pearl: Maybe she does have insulin resistance, and a particular nutritional strategy may make sense for her.
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So here's your first pearl: Maybe she isn't getting adequate protein.
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So here's your first pearl: Maybe preserving or rebuilding skeletal muscle needs to become one of our biggest priorities.
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So here's your first pearl: Maybe her sleep is significantly affecting appetite, glucose regulation, energy, and recovery.
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So here's your first pearl: Maybe alcohol is worsening her sleep and her vasomotor symptoms.
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So here's your first pearl: Maybe several of these are happening simultaneously.
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So here's your first pearl: And none of this means, “Fix your life, and then we'll talk about hormones.” That's not what I'm saying.
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So here's your first pearl: I don't believe in making women earn hormone therapy by demonstrating perfect lifestyle behavior.
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So here's your first pearl: If she is an appropriate candidate for perimenopausal or menopausal hormone therapy and she has symptoms that warrant treatment, that conversation can happen.
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So here's your first pearl: At the same time, I'm looking at her metabolic health.
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So here's your first pearl: Those aren't competing approaches.
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So here's your first pearl: They're complementary.
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So here's your second pearl: Don't ask only what her hormones are doing.
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So here's your second pearl: Ask what physiology those hormones are operating inside of.
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So here's your second pearl: Now let's move on to the next phase.
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So here's your second pearl: Estrogen doesn't disappear after it does its job.
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Let's get into this fascinating area: estrogen metabolism.
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Let's get into this fascinating area: When we talk about estrogen clinically, we tend to focus heavily on production and circulating levels.
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Let's get into this fascinating area: But hormones also have to be metabolized.
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Let's get into this fascinating area: Estrogens undergo metabolism in the liver.
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Let's get into this fascinating area: They can be converted into metabolites, undergo conjugation, move through the bile into the intestinal tract, and ultimately be eliminated.
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Let's get into this fascinating area: Some can also participate in enterohepatic circulation.
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Let's get into this fascinating area: So the liver and the gastrointestinal tract aren't separate from the hormone conversation.
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Let's get into this fascinating area: They're part of the physiology.
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Let's get into this fascinating area: This is where functional medicine has brought attention to something conventional
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hormone conversations haven't always emphasized: what happens to estrogen after it's produced or prescribed matters too.
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hormone conversations haven't always emphasized: Now, that doesn't mean I need to “detox estrogen” in every woman.
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hormone conversations haven't always emphasized: The liver is already metabolizing estrogen.
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hormone conversations haven't always emphasized: But I absolutely care about liver health.
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hormone conversations haven't always emphasized: I care about alcohol exposure.
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hormone conversations haven't always emphasized: I care about metabolic dysfunction and fatty liver risk.
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hormone conversations haven't always emphasized: I care about nutritional adequacy.
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hormone conversations haven't always emphasized: I care about bowel function and dietary fiber.
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hormone conversations haven't always emphasized: And I care about what we're learning about the interaction between the gut microbiome and estrogen metabolism.
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hormone conversations haven't always emphasized: Which brings us to the estrobolome.
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hormone conversations haven't always emphasized: The estrobolome is an emerging piece of the puzzle.
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hormone conversations haven't always emphasized: If you practice functional medicine, you've probably heard this term.
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hormone conversations haven't always emphasized: The estrobolome refers to a collection of microbial genes capable of influencing estrogen metabolism.
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hormone conversations haven't always emphasized: Certain gut microbes produce enzymes that can deconjugate estrogen metabolites in the intestine.
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hormone conversations haven't always emphasized: That creates the possibility that some estrogen may be reabsorbed rather than eliminated.
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hormone conversations haven't always emphasized: From a systems biology perspective, that's fascinating.
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hormone conversations haven't always emphasized: Think about what that means conceptually.
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hormone conversations haven't always emphasized: We have ovarian production, hepatic metabolism, conjugation, biliary excretion, microbial activity, potential deconjugation, and enterohepatic recirculation.
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hormone conversations haven't always emphasized: Suddenly the hormone system isn't just the ovaries.
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hormone conversations haven't always emphasized: It's an interconnected pathway involving multiple organ systems.
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hormone conversations haven't always emphasized: That is exactly the kind of physiology integrative medicine should help us see.
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hormone conversations haven't always emphasized: Now here's where evidence literacy matters.
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hormone conversations haven't always emphasized: The biological mechanism is plausible.
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hormone conversations haven't always emphasized: The human clinical evidence is still developing in this area.
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hormone conversations haven't always emphasized: We don't currently have a universally accepted stool-test target telling us, “This is the perfect estrobolome.” And we don't yet have evidence showing that manipulating a particular microbiome signature reliably treats the symptoms of perimenopause.
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hormone conversations haven't always emphasized: But “the science isn't finished” and “this doesn't matter” are not the same statement.
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hormone conversations haven't always emphasized: This is an emerging area.
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hormone conversations haven't always emphasized: So I pay attention to it.
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hormone conversations haven't always emphasized: I encourage you to pay attention to it.
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hormone conversations haven't always emphasized: Follow the research, understand the mechanism, and stay appropriately humble about what you can conclude clinically.
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hormone conversations haven't always emphasized: Meanwhile, there are things I can address today.
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hormone conversations haven't always emphasized: If my patient is significantly constipated, I'm going to address her constipation.
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hormone conversations haven't always emphasized: If she eats almost no fiber, I'm going to ask why.
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hormone conversations haven't always emphasized: If her diet has become incredibly restricted, I want to understand why.
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hormone conversations haven't always emphasized: If she has gastrointestinal symptoms, those symptoms deserve evaluation in their own right.
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hormone conversations haven't always emphasized: I don't have to promise that improving her bowel function is going to “detox her estrogen” to recognize that gastrointestinal health belongs in whole-person care.
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So here's your next pearl: Emerging physiology doesn't have to be ignored simply because it isn't ready to become a universal protocol.
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So here's your next pearl: It's something to learn from, understand, follow the evidence on, and watch as it evolves.
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So here's your next pearl: Now, what about DIM?
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So here's your next pearl: Because if you've spent five minutes in the functional hormone world, you've encountered DIM.
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So here's your next pearl: DIM is derived from compounds found in cruciferous vegetables.
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So here's your next pearl: And the reason functional medicine became interested in DIM isn't completely random.
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So here's your next pearl: There are human studies demonstrating that DIM supplementation can alter urinary estrogen metabolite patterns.
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So here's your next pearl: So there is a biological effect that's worth understanding.
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But here's the next layer of clinical reasoning: What am I trying to accomplish by changing the pathway?
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But here's the next layer of clinical reasoning: That's the question.
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But here's the next layer of clinical reasoning: “Do I believe in DIM?” isn't a useful clinical question.
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But here's the next layer of clinical reasoning: Why would I consider it in this particular patient?
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But here's the next layer of clinical reasoning: What estrogen-related concern am I trying to address?
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But here's the next layer of clinical reasoning: What evidence supports that use?
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But here's the next layer of clinical reasoning: What hormones or medications is she taking?
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But here's the next layer of clinical reasoning: What are the possible interactions?
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But here's the next layer of clinical reasoning: What outcome am I going to follow?
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But here's the next layer of clinical reasoning: And does changing an estrogen metabolite pattern necessarily translate into improvement in the clinical outcome I care about?
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But here's the next layer of clinical reasoning: We don't fully know that.
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But here's the next layer of clinical reasoning: That's an important distinction.
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But here's the next layer of clinical reasoning: A biomarker effect and a clinical outcome are not automatically the same thing.
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But here's the next layer of clinical reasoning: And there's another interesting question.
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But here's the next layer of clinical reasoning: Suppose I'm prescribing estradiol because I intentionally want this woman to have estrogen exposure.
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But here's the next layer of clinical reasoning: Then I add a supplement specifically because I want to modify estrogen metabolism.
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But here's the next layer of clinical reasoning: I need to understand what I'm trying to accomplish.
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But here's the next layer of clinical reasoning: That's not an argument against DIM.
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But here's the next layer of clinical reasoning: It's an argument for intentional prescribing and supplementation.
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But here's the next layer of clinical reasoning: Functional medicine should not mean,“You're over 40, so here's some DIM.” It should mean I understand enough physiology to know why I might use something, when I might not, and what I'm expecting it to do.
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So here's your next clinical pearl: A functional medicine tool becomes more useful when we can clearly articulate its indication.
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Specialty hormone testing: Ask a better question.
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Specialty hormone testing: I'm always talking about asking better questions because I think in conventional medicine, we start with a foundation set of questions.
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Specialty hormone testing: But here in integrative and functional medicine, we want to dive into questions that look at the whole person, not just the symptom.
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Specialty hormone testing: We're trying to understand what else could be related.
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Specialty hormone testing: So in this 47-year-old woman, she's had changes in her menstrual cycle.
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Specialty hormone testing: Is she having hot flashes, night sweats, or disrupted sleep?
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Specialty hormone testing: The answer is yes.
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Specialty hormone testing: Do I need a DUTCH test to diagnose perimenopause?
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Specialty hormone testing: No, I don't.
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Specialty hormone testing: But that's also not necessarily what a specialty hormone test is trying to do.
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Specialty hormone testing: I think sometimes we collapse two very different conversations together.
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One is: How do we diagnose the menopausal transition?
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The other is: Are there situations where additional hormone and metabolite information might help answer a more specific clinical question?
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The other is: Those are not identical questions.
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The other is: So instead of arguing, “DUTCH testing is useful,” or, “DUTCH testing is useless,” I want you to ask something more sophisticated: What am I trying to learn?
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The other is: If I order this test and receive pages of hormone and metabolite information, what am I going to do with it?
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The other is: Which findings would change the management I'm considering?
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The other is: Which findings are clinically validated?
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The other is: Which findings are interesting but still emerging?
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The other is: Am I prepared to distinguish between those categories?
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The other is: And that's a skill.
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The other is: Sometimes standard laboratory evaluation is enough.
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The other is: Sometimes no hormone testing is needed at all.
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The other is: Sometimes we're evaluating something other than typical perimenopause.
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The other is: Sometimes the age or presentation is atypical.
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The other is: Sometimes another endocrine condition is in the differential.
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The other is: Hashimoto's, for instance, or another thyroid condition may be part of that differential.
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The other is: Sometimes abnormal uterine bleeding changes the entire workup.
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The other is: And there may be situations in integrative practice where you're considering specialty testing to explore a specific question.
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The other is: If you do, know the question before you order the test.
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The other is: More data isn't automatically more clarity.
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The other is: But neither should we be afraid of data simply because it isn't part of routine conventional care.
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The other is: We should know how to evaluate it.
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So here's your next clinical pearl: Don't ask, “Should integrative clinicians order specialty tests?” Ask, “What clinical question am I trying to answer, and will this test help me answer that question?” Now let's put it all back together.
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So here's your next clinical pearl: Let's go back to our patient.
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So here's your next clinical pearl: She's 47.
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So here's your next clinical pearl: Her cycles have become unpredictable.
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So here's your next clinical pearl: She's having night sweats.
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So here's your next clinical pearl: She's waking up repeatedly.
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So here's your next clinical pearl: She's developed vaginal dryness.
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So here's your next clinical pearl: She's gained mid-abdominal fat.
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So here's your next clinical pearl: She's exhausted.
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So here's your next clinical pearl: And now we look a little deeper.
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So here's your next clinical pearl: Her periods have also become heavier, not just unpredictable.
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So here's your next clinical pearl: Her iron status deserves some attention.
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So here's your next clinical pearl: She snores.
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So here's your next clinical pearl: Maybe evaluation for sleep apnea belongs in our differential.
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So here's your next clinical pearl: She's lost muscle over the last several years.
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So here's your next clinical pearl: She stopped resistance training.
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So here's your next clinical pearl: She's chronically dieting because she's terrified of continuing to gain weight.
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So here's your next clinical pearl: She's getting very little fiber, and she's constipated.
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So here's your next clinical pearl: She drinks wine most evenings because it helps her relax, although she notices she wakes up more when she drinks alcohol.
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So here's your next clinical pearl: Her metabolic markers are beginning to shift.
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Now tell me: Is it hormones?
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Now tell me: Yes.
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Now tell me: I think her hormones are definitely part of the process.
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Now tell me: But look at how much more we understand now.
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Now tell me: This is where integrative medicine really shines, because I don't have to choose one explanation.
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Now tell me: I can say, “You're experiencing the menopausal transition.
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Now tell me: Let's talk about whether perimenopausal or menopausal hormone therapy is appropriate for you.
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Now tell me: And your sleep needs attention.
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Now tell me: I want to investigate this fatigue.
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Now tell me: Because your bleeding changed, I want to make sure we're evaluating that appropriately and looking at iron status when indicated.
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Now tell me: Let's look at what's happening metabolically.” Let's improve the quality and adequacy of her nutrition.
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Now tell me: Let's address the constipation.
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Now tell me: We also need to talk about alcohol and sleep.
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Now tell me: And I want to know which of these things matters most to her.
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Now tell me: That's not overcomplicating medicine.
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Now tell me: That's organizing it.
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Now tell me: We're taking a woman whose symptoms cross multiple systems and creating a coherent picture.
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Now tell me: And we're deciding what belongs first.
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Now tell me: It also has to be important to the patient for adherence to whatever we want to do, whether that's testing, treatment, or both.
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Now tell me: What integrative hormone care actually looks like I think this distinction matters.
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Now tell me: Integrative hormone care is not hormone therapy versus natural medicine.
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Now tell me: It isn't supplements versus prescriptions.
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Now tell me: It isn't DUTCH testing versus serum labs.
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Now tell me: It isn't lifestyle before medications.
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Now tell me: And it's not conventional medicine on one side and functional medicine on the other.
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Now tell me: It's choosing the right tool for the physiology in front of you.
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Now tell me: Sometimes that tool might be estradiol or progesterone.
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Now tell me: It might be treatment for genitourinary syndrome of menopause.
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Now tell me: Maybe it's resistance training, treating iron deficiency, evaluating for sleep apnea, addressing insulin resistance, improving nutritional adequacy, or treating gastrointestinal dysfunction.
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Now tell me: Sometimes it's exploring emerging pieces of physiology because the usual evaluation hasn't answered the clinical question.
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Now tell me: And sometimes several of those things come together.
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Now tell me: This is why I don't want integrative clinicians to become less curious.
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Now tell me: I want us to become more disciplined with our curiosity.
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Now tell me: There is extraordinary physiology being explored in functional and integrative
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medicine: the microbiome, hormone metabolites, nutrigenomics, inflammatory signaling, mitochondrial function, the gut-brain axis, the HPA axis, autonomic regulation, environmental exposures, and much more.
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medicine: Some of that science is mature.
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medicine: Some of it is emerging.
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medicine: Some of it is mechanistically fascinating but not yet ready to drive treatment.
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medicine: Our job isn't to reject emerging science.
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medicine: And our job isn't to turn every emerging mechanism into a protocol.
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medicine: Our job is to know the difference.
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medicine: That is evidence-informed integrative medicine.
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medicine: So here's your challenge.
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medicine: The next time a woman in midlife sits down and tells you, “I think it's my hormones,” start by believing that there may be something important in what she's telling you.
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medicine: Then get curious.
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medicine: Does this timeline fit the menopausal or perimenopausal transition?
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medicine: What symptoms are most consistent with changing ovarian hormones?
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medicine: What else is contributing?
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medicine: What is happening metabolically?
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medicine: What's happening with her sleep, muscle, nutrition, and gastrointestinal system?
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medicine: What medications and supplements is she taking?
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medicine: What about alcohol consumption and other exposures that matter?
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medicine: Are there other diagnoses I need to consider?
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medicine: What testing would actually help me answer these questions?
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medicine: And then ask the question I think matters the most: What does this particular woman need from me?
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medicine: Maybe she needs hormone therapy.
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medicine: Maybe she needs a deeper metabolic assessment.
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medicine: Maybe she needs both.
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medicine: Maybe the fatigue blamed on estrogen turns out to have another major contributor.
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medicine: Maybe it's her hormones, but maybe it's also her thyroid.
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medicine: Maybe it's her nutrition or hydration.
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medicine: Maybe improving her sleep changes everything.
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medicine: Maybe treating her vasomotor symptoms finally allows her to sleep well enough to work on everything else.
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medicine: That's the art of integrative medicine.
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medicine: One of the reasons I created The Integrative Clinician is because I don't think nurse practitioners need another person handing them a list of protocols.
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medicine: We need to understand how the pieces connect.
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medicine: That's what integrative medicine gave me as a clinician.
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medicine: It didn't make me abandon conventional medicine.
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medicine: It made my conventional foundation more useful because I began seeing physiology in a different way.
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medicine: I stopped looking at the gut as separate from the brain, metabolism as separate from hormones, sleep as separate from glucose regulation, hormones as separate from the liver and gastrointestinal physiology, and symptoms as isolated problems that each needed their own little checkbox.
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medicine: The patient sitting in front of you doesn't arrive divided into organ systems.
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medicine: We do that.
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medicine: Her physiology does not.
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medicine: And midlife hormone care is one of the best examples of why this matters.
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medicine: So yes, it really may be her hormones.
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medicine: But don't stop there.
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medicine: Ask what those hormones are interacting with.
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medicine: Ask what else has changed.
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medicine: Ask what other systems are contributing.
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medicine: Ask what you can address now.
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medicine: Stay curious about what you're learning and what is emerging.
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medicine: Use the best of conventional, functional, lifestyle, and integrative medicine to build a plan that makes sense for the woman sitting in front of you.
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medicine: Not just the protocol.
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medicine: The person in front of you.
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medicine: That kind of clinician is what BridgeWell creates.
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medicine: If you're a nurse practitioner who wants to go deeper into systems-based clinical reasoning and learn how to connect physiology across systems without abandoning your conventional foundation, that's exactly what we build inside BridgeWell Integrative Education, particularly in our Integrative Clinical Pathway.
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medicine: It takes you through the process step by step.
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medicine: So instead of collecting more disconnected information, you're learning how to organize it and use it clinically.
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medicine: If you want to learn more about this process, take a look at our website at bridgewelled.com.
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medicine: And if another NP came to mind while you were listening today, please share this episode with her.
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medicine: The emphasis here is that we need to look beyond just the hormones.
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medicine: There are many interconnected pieces, and there is so much emerging information in integrative medicine.
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medicine: I think we need more conversations about integrative medicine that aren't about choosing sides.
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medicine: They're about becoming better clinicians.
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So until next time, remember: The question isn't only, “Is it her hormones?” The better question is, “What is happening around those hormones, and how does it all connect together?” I'm Dr.
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So until next time, remember: Sheri Erwin.
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So until next time, remember: Thank you for spending part of your day with me.
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So until next time, remember: I'll see you next time on The Integrative Clinician.