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In the last episode, we met Justine. As a reminder, here are a few details about her case. The Case:  

 The Investigation 

If you didn’t hear the first part of this story, please go back and give  episode 153 a listen. In that episode, I spoke about Justine’s case with Emily Sadri, an expert in Hormone Replacement Therapy (HRT) and achieving hormonal harmony. Emily is a good friend to the show having previously shared her insights in episodes  141 on Semaglutide (like Ozempic) and Weight Loss and  107 on Birth Control Use with Thyroid Issues.

In the last episode, we talked about the many misconceptions around hormones during perimenopause and menopause. Now, let’s pick up where we left off in the last episode by looking at the timing for hormone support and the physiological restoration protocol (PR protocol). When to Start Hormonal Support 

A question many women ponder is when to start supporting their hormones, especially as they transition into menopause. Emily noted that the dosage and timing of hormone support depend on whether a woman is still having a menstrual cycle regularly or if is their cycle has become irregular, for example, every 3-6 months. For instance, women who are still cycling (i.e., ovulating) might only need a minimal dosage of estrogen (1-2 milligrams) transdermally daily, while others might require more substantial support. The key is to start with a little bump up and track and monitor for changes. The Importance of Monitoring Hormones 

One alarming revelation was the number of physicians who prescribe hormone replacement therapy without regular testing. Traditional doctors are often focused on resolving a singular symptom. So, if the dosage reduces, say hot flashes, then the doctor considers the problem solved. But, solving one symptom is not equal to being in optimal health. Emily and I both believe in the value of consistent monitoring. After all, our bodies are ever-changing, and what worked two years ago might not be effective today. Estrogen and Progesterone: Misunderstood Roles 

A common misconception is that only progesterone affects sleep. However, Emily pointed out that estrogen plays a vital role in our circadian rhythms and sleep cycles. In fact, estrogen is a precursor to serotonin, which in turn is essential for producing melatonin, our sleep hormone. It's crucial to maintain a balance between estrogen and progesterone for optimal health. All the more reason to be monitoring hormone levels once treating them, because the individual may misinterpret or miss the symptoms of a hormone imbalance. And, off-balance hormones can work against each other. Physiological Restoration: Embracing the Natural Rhythm 

Physiological restoration is all about mimicking the body's natural hormonal rhythms. This method called the Physiological Restoration Protocol (PR protocol), can be especially beneficial for women in perimenopause or those transitioning into menopause. This method requires the woman to adjust their daily dosage according to where they are in their cycle but it is not as complicated as it sounds since there are generally just two topical treatments to manage. There is an app that helps make it quite easy. The key is understanding that our bodies are all changing and treatment needs to flow with those changes. It’s a spectrum - we’re not robots, explains Emily. It's all about understanding and supporting the body's innate processes.

Utilizing tools like the Dutch test can offer profound insights into hormonal health. For those navigating perimenopause, the cycle mapping feature can be especially enlightening, painting a picture of your hormone fluctuations throughout the month. However, Emily says that the simple Dutch can be misleading, so you want to also look at the organic acids section to get the full picture. Starting Hormonal Support Later in Life 

If you're approaching your 50s or have already transitioned into menopause, hormonal support may still be a consideration for you, says Emily.  While earlier intervention can often provide smoother results, starting hormonal therapy within a decade of your last period can still be advantageous. Estrogen Metabolism: It's Not Just About Detox 

There’s been a lot of talk among functional medicine practitioners about having patients detox when starting an estrogen protocol. This might include supplements like  DIM or  Calcium D-Glucarate. However, it's crucial to first understand an individual's estrogen metabolism before diving into detoxification. Emily likes to make sure that patients have proper methyl donation and  magnesium levels. She may also look at  glutathione but more for those in perimenopause (and takes caution with anyone in full menopause, being sure to monitor symptoms). Supplemental support can be important, but every woman is unique, and what works for one might not be effective for another.

Supplements that Emily considers for perimenopausal and menopause on HRT include:

In addition to the previously mentioned supplements for peri and menopause:

Mystery Solved - Getting Answers from Hidden Hormone Imbalances
Taking in everything that Emily shared, it was time to solve Justine’s hormone health mystery. She was thrilled to hear that there was an explanation for everything that she was experiencing. For so long, she thought she was crazy! She didn’t realize that even small changes in her estrogen can cause such significant symptoms. If you’re going through something similar, please know that you are not alone and you’re not crazy either.
Justine's symptoms led us to explore her hormone levels in detail. We decided to conduct a Dutch test, but not just any run-of-the-mill one-day snapshot. Instead, we opted for a cycle mapping test through Dutch. This involved collecting urine samples daily throughout her menstrual cycle, creating a comprehensive picture of her hormone fluctuations. It was like doing a pregnancy test each day, but with a special card that captured vital data.
What's unique about cycle mapping is that it doesn't just show us hormone levels on one specific day; it reveals the entire hormonal pattern throughout the cycle. We tracked estrogen and progesterone, observing when they surged, dipped, and in between. Additionally, we cross-referenced this data with serum tests, which analyzed her blood for total estrogen and estrogen on specific days (day 12 and day 21) and progesterone on day 21.
The results were illuminating. Justine's estrogen levels were relatively good on day 12, right before ovulation, indicating that her initial hormonal signals were functioning correctly. However, the concern arose when we saw that her estrogen levels didn't rise as expected around day 21. They did increase slightly but lacked the robust curve we typically observe. Interestingly, her progesterone levels were within an acceptable range, albeit a bit on the lower side.
This data highlighted a deficiency in estrogen as the primary issue. To address this, we collaborated with Justine's healthcare provider to prescribe a microdose of estrogen, administered throughout her entire menstrual cycle. This approach aimed not only to boost estrogen levels but also to stimulate estrogen receptors, ultimately supporting the production of progesterone.
Typically, when women experience hormonal changes, especially in perimenopause, they're often offered progesterone without comprehensive testing. However, as Justine's case demonstrated, simply supplementing with progesterone isn't a one-size-fits-all solution. Testing is crucial to understand precisely what each woman's body needs.
 Factoring in Thyroid Function to Hormone Replacement Therapy (HRT)
Understanding that hormones and thyroid function are intricately linked, we decided to delve deeper. We conducted a full thyroid panel, which revealed that Justine had suboptimal T3 levels. She wasn't efficiently converting T4 to T3, placing her in the category of a "low T3 thyroid type."
Her T3 levels weren't low enough to warrant T3 medication, but we recognized the importance of enhancing her conversion process. To achieve this, we focused on optimizing her gut and liver health and ensuring she had the necessary minerals, particularly zinc, which is pivotal in hormone conversion.
In parallel, we made dietary changes by introducing anti-inflammatory foods. We also examined her personal care and cleaning products for harmful chemicals, shifting toward natural alternatives. Finally, we addressed her hormone metabolism by supporting methylation using Methylated B Complex and  Calcium D-Glucarate.
One standout addition to our approach was BrocoProtect, a sulforaphane supplement. Unlike some alternatives that lower estrogen levels, BrocoProtect helps direct estrogen toward the favorable two-hydroxy pathway while minimizing the less desirable four-hydroxy pathway, which can lead to free radical damage and DNA issues.
Happy Ending - Hormone Balance Restored, Symptoms Mitigated
The results were promising and swift. By Justine's next menstrual cycle, she noticed positive changes. Her energy levels improved, stress diminished, and she even observed a reduction in abdominal fat. This initial transformation gave her motivation and a clear plan for the road ahead.
Hormone support can indeed yield rapid results, and our journey with Justine serves as a testament to the power of personalized care. We continue to monitor her levels, making necessary adjustments to maintain optimal hormone balance.
Eliminating Health Mysteries
For Justine, we were able to find that missing piece of the health puzzle and help her regain her health. Could this be the missing clue for you or someone in your life? If this episode resonated with you, please share it.
Links:
Resources mentioned
Thanks again to my guest Emily Sadri.  You can connect with her on Instagram or check out her website.
Suggested Products

 Related Podcast Episodes: 

153 A Novel Approach to Supporting Hormones in Perimenopause and Menopause 111 What Is Your Thyroid Type? (and How to Manage It)  141 The Honest Truth about Semaglutide for Weight Loss and Thyroid Health  107 Demystifying Prolonged Use of Birth Control Pills + Thyroid Connection  129 How to Lose that ‘Menopot’ and Sail Through Menopause

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