Your Gut Microbiome Changes in Perimenopause – Here's What to Do About It

Welcome to the medical destructor, a place where well-versed humans can ask the hard questions and get evidence-based answers you won't find anywhere else. Our community is always informed, empowered, and science-backed. Every guest on the show must be clinically trained, MDs, NPs, PAs, and researchers who want more and expand beyond their conventional education. I'm Dr. E the NP with a PhD and I help smart, well-versed humans go for medically-gaslit to medically empowered. Today's guest checks all the boxes that matter, classically trained, board-certified, and then brave enough to cross the aisle when the data and the patients didn't line up. Dr. Christine Marin is a DO, a family medicine physician who now practices functional medicine after her own run-in with recurrent pregnancy loss. We're going straight into the gut hormone connection, why pariamenedopause or rexier GI, and what to do that actually works. If you're looking for science-backed strategies that go beyond standard protocols, you're in the right place. Let's dive in. Dr. Christine Marin, I'm very excited to have you here. I said it all together. Thanks for having me. Of course. Of course. Okay. So, in case you didn't know, this is called a medical disruptor and the criteria to -- Oh, I knew. I knew. Okay, amazing. The criteria to be on the show is that you're a classically trained MD, DO, and PPA. And then you kind of went over to the dark side, the bright side. And that's an important delineator, I think, of this podcast. So before we get into our really cool topic, something in hormones that we have not discussed yet, ladies and gentlemen, before we get into that, I want to hear a little bit about your journey and what made you transition over? Yeah. Well, first of all, I love that you have that delineation because we both know what it's like to be in clinical practice and like how much you learn on the dark side before you move to the light side. I was sort of always into the light side, maybe a little bit too much, really. So now I feel like I have this really balanced perspective, but, you know, I had my own kind of health journey as most of us did. I went to medical school, really interested in alternative medicine, actually. So I'm a doctor of osteopathic medicine, a DO. And I chose that route because I really wanted something that would be more integrative and honor that side of me. I went to college in Boulder. I had hormonal issues when I was younger, actually was like misdiagnosed with PCOS or maybe it wasn't a misdiagnosis. I don't know all the things, you know, now, whatever. And I was really into acupuncture and healthy living and nutrition and holistic all the things. So anyhow, I went to a DO school. I did my training in family medicine. So I'm board certified by the American board of family medicine. That experience was really tricky for me to go through that residency because I was like, felt like I was doling out medications. And I'm like, I know I wouldn't take them either. I, like, it's interesting. So even as you're prescribing, you're like, oh, I don't want to prescribe it. I mean, I just felt like, man, like I hear you. You're telling me you feel bad and like this medication doesn't make you feel better. I mean, it was all very traditional, like hypertension, diabetes, care, right? And there's some guidelines to follow. And it was great experience. And it just did not align with what I believed in my heart to be right. And I'm not saying I don't prescribe medication, like don't get me wrong. I see, I see both sides of it, but it's very risk benefit. And it just, you know, it didn't feel good for me. It didn't feel like something I would do. And of course, on the other side of it, it's like patients do need to take a lot of ownership of their health and own their nutrition and their lifestyle and all that kind of stuff. So, you know, I was kind of between a rock and a hard place in that, in that aspect. But the reason I pursued functional medicine was because I had recurrent pregnancy loss. And I knew something was wrong with my body. I mean, I had symptoms simultaneously, specifically gut symptoms. And I knew something was up with my health. I just didn't know what it was. And that started my journey. And professionally and personally things collided. I knew exactly when I started studying functional medicine for my own health, that this was going to be the thing I had to do for, or wanted to do for patients. I also found myself referring all of my patients to functional medicine doctors. You've got to become one of those eventually. So yeah, I pursued that path for my own purpose and for my patients. And yeah, I mean, I initially I worked with Amy Myers, like we back in the day, the autoimmune solution. And so we worked with a lot of patients who had autoimmune disease. And they opened my own practice after that. And it's just, it's been a really awesome path. And I love what I do. Amazing. So you actually, you had your own practice first in conventional medicine or you worked for someone else? No, I, no, I joined Amy's functional medicine practice in when you first came out. Prior to that. No, I mean, I should have a residency. No, after I was in the nursing. See, I did urgent care for my husband was a military doctor. So while we were still in San Antonio, I did urgent care. Two years. So like really high volume of patients, which was good. Actually, I preferred that to family medicine. I knew I could not work in a traditional family medicine setting. Interesting. I had to come to terms with it because I still work in family medicine. And I had to come to terms with it. It's interesting. There's a few points that you started to interesting. One, with urgent care and ER, there is less of an, I think there's less of an ethical dilemma because they're urgent or emergent. And so like we have to fix the bone. We need to fix the pneumonia. There's less of this like, ooh, could I do it differently? With family, there is. There is that. I agree with you. But I do still practice. And what I've come to appreciate also is that there are different patients who need different skill sets. And I'm, you know, in some patients are probably not going to make for whatever reason the lifestyle change. And so then it's really important to support them in that way. But I had to come to that. Yeah, no, I think you're totally right. And I think that's really well put. Like there's different patients who need different skill sets. And to any primary care doctors or family medicine doctors listening, like thank you. Yes. What you do because it's damn hard. Yeah, it's not easy work. And it's really important to have somebody guiding the ship. Yes. It's an interesting place to be in. It's sometimes frustrating because sometimes you like you really don't have to be this sick. Yeah. But sometimes are easier said than done, depending on, you know, what people are dealing with in their lives. But coming back to you, this is great. So it was a personal and I would say most of my disruptors are either they got sick or someone in their life got sick. In my case, it was my wife. So you had recurrent pregnancy loss. Can you give us the fast forward of what was ultimately the reason? Oh, my gosh, there's so many reasons, right? This is where I'm like, it's like a bond. And fire, right? You got to take out all the logs and yeah, there's a lot of stuff going on, but Hashimoto's okay. It is them hormone imbalance, low progesterone, mold exposure, SIBO, massive Candida, fungal overgrowth in my God. I think that's most of it. Oh, is that all? Okay. You know, and I'm glad that it was a list, right? Because I think we want to get our audience away from it's this one thing. I have a mold and if I just fix mold and why am I not better? Because it's rare. It's not just that. It's like if you're reacting to mold, it's like why? Let's go down the journey system and how's your nervous system? And oh, by the way, the last like three years of my life have been really dedicated to like nervous system work and embodiment and getting out of stress and survival mode. So there's that too, right? Stress, the underlying issue as well. So yeah, it's just, it's not a quick fix. It's a whole lifestyle evolution. Yes. And stress is a big part of it. The more I speak to clinicians who have been doing this for a long time, the more they eventually realize that they have to start with the stress. But evolution of the provider, right? So, so you know, ultimately the talk that we're going to talk about is the gut hormone connection, which is fascinating. We have not discussed that yet. We, I think our audience is well versed. Hopefully this is not the first time you're listening. If this is like quick recap, if your parent mental pals will talk somebody quick about getting HRT, social, get a fast. But we've already, there's plenty of episodes for you to watch that. Tell us, what does that even mean? What are you talking about? Yeah, they're so connected. I mean, especially in parrymenopause, you know, it's not just about your hormones. It's this midlife. All these things are changing and it's all connected. Just like I said with me, it's like, it wasn't just thyroid. It wasn't just hormones. It wasn't just gut. They're all connected and they all influence each other. And guess what? So does your mindset and your stress levels. And the way that your body is conditioned to process stress and get through it. So we should talk more about that and how high achieving women push through and tend to kind of disembodied and disconnect from their bodies. But you know, it's all connected and your gut influences your thyroid levels. It influences your sex hormone levels and your sex hormones influence your gut and your gut microbiome in a really big way. And that's obviously really relevant in parrymenopause. But be really specific, right? Because you don't mean like so a parrymenopause, I mean, a menopause, but you know, listen, you're just not making the hormones. So you're talking about a different type of. Yeah. So let's talk about like how do hormones in parrymenopause influence the gut microbiome? Tell us. And then about how the gut microbiome influences like how you metabolize hormones and even your cancer risk if you're on hormones, which by the way, they don't cause breast cancer, we've already covered that. Listen to the first 10 seconds of the podcast. No, but. Okay. Thank you for saying it again. I can't say it enough time. So just to say it again, I'm very pro HR team in the right patients. So gut microbiome. Brown is really important for a lot of different things. - Okay, quick break. If this episode is hitting home, just ask yourself this. Are you gaslighting yourself without even realizing it? I've made a free guide called self, gaslighting habits to watch for. So if you're constantly second-guessing yourself in the exam room, this is your starting point. Check out the link in the description. Now let's get back to it. - The more we know, the more we don't know when it comes to the gut microbiome and it says metabolism and thyroid health and sex hormones and all that kind of stuff. So research is showing, especially in the last five to 10 years, research is emerging that is showing how the paramanopausal woman or midlife woman has a change in her gut microbiome and the diversity of the gut microbiome declines, starts to decline around age 40, which corresponds with hormonal changes. If we look at the male versus the female gut microbiome, their sexual dimorphism, which means that the female and the gut microbiome are different. They're just a different composition. Females tend to have more diversity in their gut microbiome than males until age 40 when it starts to decline. And so we see that plateau and decline along with hormones. And lots of other things females do, like take birth control pills and have a lot of stress and drink alcohol, like that influences gut microbiome in a negative way as well. But diversity when we talk about gut microbiomes are really important concept. When we have less diversity, we're more likely to have things like gut dysbiosis or overgrowth of fungal organisms, CFO or Candida as people call it, maybe even parasites or something like this, right, clustering overgrowth, age, pylori, all these different gut infections, gut infections, as you know, influence intestinal permeability. And that sets us up for a lot with inflammation and autoimmune disease, all that kind of stuff. And so what we're seeing is that as our hormones decline are gut microbiome actually changes. And so the menopausal woman who's not on hormones will have a different gut microbiome composition than someone else. There are three really key aspects that I always like to point out here with this change. And one of them is that we see more histamine. So how many paramedic pausal women have itchy skin or they have allergies or maybe they have headaches and brain fog because histamine, well, there is probably also hormonal in some ways, but often histamine is a big player. And so we see that women in paramedic paus have more histamine, which coincides with this gut microbiome change. We can get more into it. The other big one is hydrogen sulfide. So hydrogen sulfide is toxic to the enterocytes when it's in a high amount. And that's a certain type of overgrowth we don't want. Hydrogen sulfide is a bad thing. But it corresponds like we see more of it in paramedic pausal, also can cause metabolic issues like weight gain. And the third one is intestinal permeability. Guest influences that. Estridial, which is amazing that actually estrogen influences your intestinal permeability and the tight junctions. Like, I think that's super cool. So question here. And I think the answer is, you know, this seems like a question of chicken egg, right? So-- Yeah, 40s. So is it because my hormone starts to go down, therefore my gut is not doing well? Or is it my gut is not doing well? Therefore my hormones are starting going down. Probably a little bit at both. But I would say more, the hormonal change influences the gut microbiome and then the gut microbiome influences the way that we sort of balance out the hormones. So I don't know. I mean, there's other reasons why your gut microbiome might be messed up, like birth control pills and alcohol and antibiotics and pestas. I'm just mean specifically the death between men and women and gut microbiome. I mean, I think it's both, really. Wow, fascinating. So you're saying, if I just want to say it back to you, that if you're someone who never really had stomach issues and now in your 40s, you're developing the stomach issue, it is because of this slow and steady decline of hormones. Or the fluctuations rather of hormones. Yeah, it's probably, it's playing a big role. It's like, I say hormones help us increase our resilience and the decline of hormones. Right, we have a decline in resilience. Or if you look at that back in analogy, it's like, when we take hormones, it helps us start bail in the water. And there's multiple reasons for that when we talk about gut, but hormone replacement therapy can improve our gut microbiome. There's pretty limited research on there. But there is out, upcoming, well, there's emerging research and there's one paper I'm aware of showing that probably HRT influences the gut microbiome in a positive way. But also we know that estradiol influences intestinal permeability. And that's for sure. And we also know that women who have IBS tend to have a exacerbation in symptoms around paramedicase as do women with IBD. So inflammatory bowel disease, crowns, all sorts of colitis, a lot of those patients experience a worsening of their symptoms around paramedicase. Yes, I think that's a really good point. I think that a lot of women will tell you that they have GI issues around their period. And you're like, well, how? What's the connection? I mean, yes. Yeah. And the estradiol is a big influence. But progesterone and testosterone influence it too. Like we know in pregnancy, right? We've got a lot of progesterone on board. A lot of women experience constipation in pregnancy because progesterone helps to relax the smooth muscle. So obviously plays an important role at GI transit in the way that our smooth muscle works and coordinates. And testosterone also plays a big role with gut microbiome. We just don't understand it as well as we do with estrogen. This is fascinating information. So it says so much about like, you know, why in our 40s, is like things that we could eat before we can't eat anymore. Yeah. And that's amazing. And the idea that estrogen pays apart in leaky gut is pretty revolutionary, right? I mean, right? Because we know so many things, you know, around the antibiotics, I had a bad virus, I had a concussion, like we kind of have a list of things of like ever since that moment I had leaky gut. But some women, too, are probably like, I don't know what happened. And everything was fine. And then it's not. And so you didn't have to have this moment, this fall off the cliff moment. It's just the fact that your hormones are declining that you suddenly have this leaky gut, which then, once you have this leaky gut, now all of a sudden you develop the Hashimoto's or all of the sudden you develop the autoimmunity because of everything that falls from that. That's really fascinating. Isn't it? I mean, when I came upon that I was like, hold up. Can we hold the phone? And I say this all the time when I lecture but I'm like, do people get this? Do you understand? This is really important. It's very significant. That's a big deal. Yeah, it's a really big deal because sometimes when I, you know, some patients are still hesitant about HRT because they are still believing the kind of the old rhetoric. And so I say to them, and then now I'm going to add this to my list, I say to them, listen, this is because they're like, oh, I don't have hot flashes. I'm fine. I'm like, man, this is not about your hot flashes, right? This is about your brain, this is about your heart, just about your bones. But now I could say this is about your gut. Also about your gut. If you want your belly better. I'm like, my arm. It's a big deal. A super-indulatory. A lot of people need to be in tight junctions. Like, I want to be able to eat all the things. I want to be able to eat all things. I want to be on a super restrictive diet. Yeah, that's really interesting because, you know, I found myself now having, that I'm able to tolerate more things that I did 10 years ago. And I thought, well, I know, but now I can add more to it. It's because I've done so much work. I've done the elimination of 5,000 years ago and then the reenactulation. And I've gotten to a place right now where I could tolerate much more than I used to. But I never considered that I'm also on HRT. Totally. And that's a factor. OK, so here's the other thing. I'm always-- How many period better puzzle women are struggling with symptoms? And what's the first thing they're offered if they go to their doctor? Probably birth control pills. Like that's a frequent situation. But I think it's the only thing they have for me. I mean, yes, it provides contraception. And there's comfortable. So the thing they prescribe forever so they're comfortable with it. But it actually can do the opposite with your gut, right? It can hurt the gut microbiome. It doesn't help. Because it's too much or why? No, because the synthetic hormones-- Oh, OK. --got microbiome in the same way, because it's not like the bioidentical estradiol. And-- Plus, it's in it-- like I forget my ignorance. But isn't it also-- it is a higher dose necessary. So now we also have to detoxify from it. It doesn't ever have to work. I think it's more like it's this dose that shuts our ovaries down. Like it's high enough dose to shut down our natural fluctuations and our natural production of estradiol. So then we don't have it. And estradiol is a really good thing, you know? There's this misconception around a lot of people who think about estrogen dominance. And we can talk more about that when we'll transition to talking about how the gut metabolizes hormones. Because that's another big, important piece of the puzzle. But estradiol is so good for us. It's really good for our immune system and our intestinal permeability. And so if we shut that off and we're just replacing it with this synthetic fake estrogen, that's not what our body uses. And it's a good moment to just-- for those who are listening to know that we say the term-- estrogen, but there are three. There are three. Estrogen is in the hormone, actually. It's estradiol and estradiol. So estradiol is like the one we take in bioidentical hormone replacement therapy or women who take biest, which I don't really prescribe biest, but 10 years ago or whatever, that's what people could get in terms of taking something that is bioidentical. So estradiol is a low potency hormone that is good for the genitoyourine attract. It's good for your skin, but it doesn't do a ton in terms of like systemically increasing our levels. And then estrone isn't when we're going after that comes from fat tissues more inflammatory. Right. OK, so that's really good. So when we're talking about estrogen-- oh, I thought estrogen was bad or I thought estrogen dominant. Like we really have to talk about the type of estrogen and what we mean. What are that? So first tell us-- oh my god, if some places don't want to go. Let's talk about estrogen dominant. - Let's talk about two bad estrogen. 'Cause I always think this is really critical, so people don't get it. - Tell me. - Zenoestrogens and phytoestrogens. So zenoestrogens come from chemicals, like plastics and things that mimic estrogen. It's kind of like birth control pills. I put those in that category. Like end-incrindestrupting chemicals. Those are zenoestrogens. And then phytoestrogens are plant-based estrogen. So, I mean, soy is not the demon. Like some people do find soy. I don't eat a lot of soy personally. There's different things behind that. But soy will provide phytoestrogens. Phytoestrogens are really good for us. So, really looking at fat and being like, we have fat dominance or fat's bad. Like, yeah, too much of a good thing can be a bad thing, but like, there's trans fat and then there's polyunsaturated fats and like, they're all different. We can't just lump estrogen in that same category. - Yeah, okay, I love that. So now tell us what we mean. We hear it's term estrogen dominance. Estrogen dominance. What does it mean? And why is it so bad? - So it really is about balance. It's just estrogen and progesterone are very good in-yang. And we need enough progesterone to offset estrogen or to balance it out. So if we don't have enough progesterone, we've got a lot of estrogen. Women can get symptoms from that. It's called hyperestrogenism or estrogen dominance. But really it's like progesterone deficiency. - Yes, thank you. - Right? Like, so- - What are the symptoms of estrogen dominance? - The same as progesterone deficiency. They might have like, PMS, tender breasts, really heavy painful periods. Like, they're for something with like, crazy ass periods and she's like bleeding through everything. And yeah, what we're gonna say, sleep? - Can't sleep. - Can't sleep. - Yeah. - Irritability. Anxiety is a big one. - Yeah. And so it's interesting. So estrogen dominance is really a world of progesterone deficiency and that's important because it's, you don't have to wait for menopause to start getting treatment. You can start your progesterone and paramanopause. - Totally. - Totally, sometimes even estrogen. So, okay, so we have this estrogen dominance space which you try to get out of, but it's not just progesterone deficiency, right? Because there's a nutrition component to it. - Yeah, and with estrogen, just like everywhere else in the body, flow is so important. So like a good example of flow has to do with like, your urinary bladder. Like if you're not drinking a lot of water and you tend to get a UTI, like what do you do? During a ton of water, get the flow going. You're gonna flush it out, gall bladder, same thing. If you don't have flow, what happens? You get gallstones. It's not good. Same thing in your brain actually. If you don't have good flow, it's like neurodegenerative diseases. So flow is a really important concept. You want it in? - Nice concept. - Get it out. And so with estrogen metabolism, it's really important that we are metabolizing it well. And this is where the gut comes in in a big, important way. So let's just kinda, I guess let's, like just talk about estrogen metabolism because there's three big phases. Phase one is through the liver. We rely on these CYP enzymes and we metabolize estrogen in a certain way. There's a favorable way down this two hydroxy pathway and there's a less favorable way down this four hydroxy pathway. So it has to do with liver health. That's a really critical component here. And then phase two happens through CMT methylation. So this is where some nutrients are really important. Things like B vitamins and magnesium can help with that. This is where sometimes we get into talking about nutrigenomics and how do we support CMT methylation? And this is when we talk about SNPs. So those of you who are familiar with MTHFR, maybe you've also heard of COMT, but they're just genetic reasons why you may need more support with methylation and you might need more of certain nutrients. So that's phase two. Phase three is eliminating it through your gut and that's pooping it out. And so for women who are really constipated, we don't have good flow. You feel like poop out the estrogen. It's really important to have a bowel movement every day and to have good at gut health. So in the bigger picture though, this is where the microbiome plays a really critical role. So the gut microbiome has this subset of bacteria that's called the astrobloom. So the astrobloom is the subset of the gut bacteria that's responsible for regulating estrogen. - I'm gonna say this back, correct me if I'm wrong, okay? - Okay. - For our TV audience. Okay. So we said a lot of things here and we said first, we said, you know, we don't want to have too much estrogen on board, but is it really too much? Like part one of the conversation was like, is it too much estrogen on board or is it the ratio of progesterone declining? So that's part one and that's where we like, go get some progesterone, go get some progesterone because that will kind of help that ratio. But then there's this other part where you might just have too much on board for various reasons and you might have too much on board because you are not getting rid of it. And getting rid of it, go ahead. - And because paramanopause, you have these some women have these big peaks of estrogen. - Yes, yes, absolutely. So there's this part one of, it's just not the ratios right, getting more progesterone, but part two is you have these peaks, but you have to be able to get rid of it. You have to be able to offload it. And that's true also if you're taking HRT, if you're taking estrogen. And so what you describe is one, two and three, one and two is happening kind of, whether you're liking it or not, like it's happening. And then three is the one that you could see whether you're going to the toilet bowl or not, right? So for one and two, it happens, part of it happens in a liver. And part of it happens in this subset of your microbiome called the estrobalone. And a lot of things need to happen in there. A lot of nutrients, this is what the nutrients you were talking about. So when we're talking about the B vitamins or we're talking about liver health, whether it's milk, this, whatever supplements we're talking about, we're talking about converting that estrogen to ultimately get into your toilet bowl. - Yeah. - And then the last part of it is making sure you actually poop. So I just want to talk about that because there's this ratio piece with the projection on, and then there's this piece that's like, we also have to break down what we have. We can't have it just like getting stored and not broken down. So this is why, and I love that idea of flow, this is that second piece of that of the balance. So now take us to sex home-embeining goblin because a lot of people will see that in their blood work, especially a post-menopausal woman. And they don't understand what that means. What does it mean, a-h-b-g is high? What does that mean? - So I'm gonna backtrack a little bit 'cause my shbg analogy is really more for clinicians. It can also be for women who really understand. - Okay. - So let's not do a conclusion. But tell us in general what that means and why do I care? And is there anything I can do about it as a non-clinician? - So your body makes sex home-embeining goblin as a way to protect you. And the time I see at the highest is when women are in birth control pills or on exogenous estrogen, but not necessarily transdermal estradiol. Typically I don't see that transdermal estradiol increases it. But when you have a high shbg, it binds stuff up. So it also coincides often with like a high thyroid binding goblin, so binding lovins are protein. So they bind stuff up. So you're free hormones, whether that's free thyroid hormone or free testosterone are not gonna be as bioavailable that they're all bound up. And they're more likely to be all bound up when you're on birth control pills. So that's why birth control pills influence thyroid in a negative way. It's also why birth control pills decrease libido because they decrease free testosterone. So the shbg is part of your body's, it's a compensatory mechanism your body has to try to protect you. So like in the case of birth control pills, your body is like, "Oh, I see all this exogenous estrogen. I'm gonna bind it up to protect you." But there's like a bystander in that protection. Is that like, okay, well, now your libido's kind of in the tank and your thyroid might decline as well. So shbg is there to protect you and there's some consequences. So then where I was getting with that analogy is beta-glugoronidase. So really when we go back into talking about like liver and COMT methylation, so phase one and phase two of estrogen metabolism, then we get into phase three and we talk about microbiome and the astrobalm. So the astrobalm secreates beta-glugoronidase. And beta-glugoronidase will bind up or free your hormone or your estrogen so you can either excrete it and your poop or hang on to more of it. And so it's this really like exquisite mechanism that we have to maintain hormone balance. The problem is it's broken when we have dysbiosis. So that built in balance that our body has, this really intelligence balance, like our bodies are so freaking smart. And when we break some things like, you know, the machine doesn't work as well. So beta-glugoronidase, in a state of dysbiosis will hold on to more estrogen and estrogen-dominant states and increase risks of high estrogen issues, maybe endometriosis or uterine cancer. So this is the part where it can dictate to some degree like your gut can dictate to some degree your risk for uterine cancer when you're on hormones. So this is researched by Lorette Chambers, I think her last name's Chambers. So she's a gynecology oncology doctor. So she's doing some of that research. But yeah, it's really interesting to look at how does the microbiome influence your risk for uterine cancer? So I'm just here to say, I think it does. - That's a really good point. And so just once again, just kind of making a little more basic beta-glugoronidase is something that we could test for. And I love what you said about calcium. - Good, great. - It's a good great. Because a lot of times clinician will see, oh, there's a lot of beta-glugoronidase. glucuronides too much on board. So you take this calcium, why am I struggling with this world today? - Calcium de glucuronides. - Thank you. It's not happening for me today. It's not happening at all. Calcium de glucurides to help kind of balance that because oh my god, there's a problem with detoxifying. But you're saying, okay, yeah, that's going to work, but you're saying, but why did this happen? And if you can fix the microbiome, we will notice the beta glucuronides going down on its own. Which is interesting, right? And that's once again the evolution of the provider because you know, at first you learn this thing, then you want to fix this thing so you fix it with a supplement. But then eventually you're like, but let's take a step back and see how we could fix that. I love that. That's not happening. - And on our body, it's like innate intelligence. And why is this happening? - Yeah. - Then the other side of it, like in a paramedic pausal woman with estrogen or menopausal women's estrogen deficiencies, it would be in our best interest to like have some more beta glucuronides and hang on to those hormones. So it's like, it might be an appropriate response to be high or to be low in certain cases, just like SHBG. It's like it's there. It's trying to protect you in muting. And the machines broken because the dysbiosis. - Yeah. The problem is also that that's really just super focused on hormones and sometimes you have other things on board. The beta glucuronides is responding to and you're trying to detoxify from old or so that sometimes it's hard because we're only talking about hormones, which is a problem also. But we're staying here right now. And I think this might be a little bit advanced. So let's pull back a little bit. Tell us about sex hormone binding, globulent and the postmenopausal woman because you're describing in the paramedic pausal woman, but the postmenopausal woman, it's different. - So as I test SHBG and all my patients, it's a simple test you can get on blood work. So if a woman who's in menopause has a high SHBG, we have to wonder why? Why do you have a high SHBG? I mean, there's other reasons that that can happen. And then how do we support your hormones, your thyroid health, your testosterone levels when it's high? We know that a woman with a high SHBG is probably not going to respond as well to testosterone therapy because her testosterone, her total testosterone might be high, but she's not going to make or have as much free testosterone available to her. So that woman just tends to not do as well. So then we can look at the gut and maybe it's about the gut dysbiosis piece. I mean, in a menopausal woman, it's not, she's not a birth control pill. That is hands down the most complex, like every woman on birth control pills will have a high SHBG. - Yeah. I think also stress is a huge component of elevated SHBG. At least there's been a lot of studies around that as well. And so are you saying that the woman that's not on birth control, in which case does nothing she could do, should really focus on strategies to reduce her hormone binding glibuline. So that she can have more of her hormones? - Let's take a look at why. Are you saying that that is like a strategy that you have? Maybe. I think really it's like my main concern isn't so much her SHBG. It's like understanding how that influences her hormones. And as we do all the other things, we do, it's going to get better because it always does. Like it always comes into balance. So I think it's an important piece of the puzzle, but it's not like the one thing I go after necessary. - Okay. - Really I'm going after if there's a gut microbiome imbalance. - So you see the paramanopausal woman. Tell us like your things, what are the things that you're doing? The paramanopausal, she's not sleeping, she has brain fog, she's irritable, she's fighting everybody in her life. Where are you going? Are you going gut first? I kind of do it all at the same time. So I have a three-pillar approach. So one is like root cause. So often that's a gut health issue, but it sometimes could be like a toxic exposure, like too many heavy metals or mold exposure. Also, there's nutrient depletions all the time, right? So the first pillar is like let's replace nutrients that are depleted. Maybe she has low vitamin D or B12 or whatever. We're not going to fix her anxiety if she has deficient B12. And look at gut dysbiosis. Are there underlying gut infections or something going on? At the same time, I'm looking at her hormone levels and doing whatever we need to do to balance those hormones. So estrogen, progesterone, testosterone, thyroid, whatever it is, like you know, kind of do I like to test hormones? So I usually do serum testing day three to five and then you'll face I'll do as well. I do Dutch testing. So you're in testing, but I don't rely on it because it's just a one day and time kind of situation. I like to get multiple labs and see is this one of these women who's got like high estradiol, low estradiol, high estradiol, you know, back and forth. Or is it one of those women has like low estradiol overall? Because I see both types in perimenopause and the low estradiol overall woman, like she sometimes gets forgotten about because a lot of times a perimenopause we're looking for that woman who's like got these peaks and valleys peaks and valleys. But yeah, most of the time I do serum testing. Do you change your HRT based on those two types? Yeah, I mean the type who has low estradiol overall probably can give her estrogen. And the one that has peaks and lows, you probably want to keep her digestion focus more on progesterone. And then maybe I'll give her estrogen to put a little bit of gas in the tank. Yeah, but maybe not. It depends. And she's the one to where I might focus on more nutritional support and liver support. So maybe she's going to have dim maybe, right? Like it's the target. No, but something to help with like estrogen metabolism. And we're going to focus on gut health and liver health and all that kind of stuff anyways. But making sure she's got good phase one, phase two, phase three, metabolism for that hormone for estrogen is going to be really critical in her and then making sure we balance it out with progesterone. But that that type with the peaks and valleys, that's where I definitely start with progesterone in her. So I guess I'm just wondering, right, there's there's a world of like it's progesterone and or estrogen. How important is the testing? Like isn't the symptoms so much more because we know we're going there. We know we're given the medication. So can we just treat on to like how important is it to like come day three five and then come day others? Yeah, I mean, we could just treat on symptoms and this is a good distinction to make. So could we treat on symptoms? Sure. Yeah, especially if she's got like symptoms like a hot flashlight, that's easy. Are you sleeping? Are you sleeping? Yeah, whatever it is. But we also know that having estrogen in a certain range is going to help with bone health. Yeah, which is a big deal. So I don't really want to treat your estrogen and have your estradiol level be 30. I want to get it more like 75, you know, so checking those labs for me is important and also just demonstrates like what's actually going on with her hormones before you can start it and then after we start it, are we getting into therapy to grain or not? The other thing is like I've had a few patients where just certain preparations just didn't work like I had an interesting one. I gel, Divi gel. So she's on an estradiol gel and her level just would not go up and so we ended up transitioning her to the patch, which is usually I may go to anyways, but she had some concerns about the adhesive. So we didn't start that and now her levels are good, but it's like I would never have had that data if we weren't testing. Also, I've seen this happen with the vaginal ring. So I'll prescribe a femurring sometimes. So that the one that delivers systemic levels of estradiol and this woman came back and her levels were still really low and I was like, what is going on? And it turned out that the ring had fallen out and it wasn't there in the first place. So like, oh, it's just a good data to have. It's easy to get. So I'm asking because a lot of times, women, GYNs won't test or they only test for FSH. Great, thanks. So and I advocate, I'm like, it really doesn't matter. You're in your 40s to 50s. You need HRT. Like, I don't really care. And there's really kind of like one to two options. So it's interesting to that you have, but you are bringing interesting points with this data. I guess what I'm trying to say is I don't need women to try to prove that their impairment, opause, menopause, you're at this age, you're symptomatic. Let's go. I love your piece about the data because it gives you more nuance, but it's not necessarily a mandatory hurdle to overcome. If you put me somewhere and you were like, you may not test, there are tests available. I would still start HRT. Yes, love that. I treat them symptoms, but I have tests available. They're low risk. They're not super expensive. Women are able and willing to go get them. Yes. If a woman was like, I cannot get lab stone, I would be like, okay, you know, it's not a requirement. Yeah, love that. Now in the postmanopause, women, do you still test or want to reach levels? Yeah, no idea, because I want to make sure that we're getting her dose in that good adequate range, like 60 to 100 or so for extra dial. And for projection, you know, like we can look at progesterone and you know how some women will metabolize progesterone differently. It's just there's going to be different absorption in estrogen and progesterone. That's why like we can't just give a standard dose to every single woman. Not every woman needs the same thing. It gets complicated. If it were that easy, then great. But there's a lot of complicated factors, including how do we metabolize and excrete these medicine, right? So we want to make sure she has enough progesterone. So like the minimum by guidelines for progesterone would be 100 nightly or 200 half the month, milligrams. And at the same time, progesterone's really important for offsetting the risk of endometrial hyperplasia, which is thickening of the lining of the uterus that can lead to the risk for endometrial cancer. And yeah, that's a big deal. I mean, I don't want on any of my patients to get into me. cancer when they're on HRTs. So that's why we give you progesterone, but let's make sure you have enough. What's the range that you go for? Because you mentioned the range for estrogen. What's the range you're looking for? I have to turn for progesterone. I mean, sometimes it's higher and I'm okay with that as long as there's no big side effects that they have. Yeah. Whatever. And I tolerate it well. And then I'll, you know, I'm sure you agree that you talk so much about the uterus, but the women without uterus still need progesterone. Yes. Yes. death run still protects your bone, your brain, your breast, and your uterus. And, you know, there's this handful of women who don't tolerate it very well too. Most women do also want progesterone, but tell me more about the women who don't tolerate. What does that look like? It can cause a paradoxical effect almost like when, you know, when some people take Benadryl and they're like, oh my god, it's like, I can't sleep. I'm super wired. Sort of similar. Like, they take progesterone. They don't sleep well. Sometimes there was like moodiness. I've had some patients have acne and really bad breast internness and things like that. Usually that kind of stuff goes away. Yeah. But yeah, I mean, some, some women do not tolerate progesterone that well, although sometimes it's because they don't have enough ester dial. And so it can be consequences. That's interesting. Yeah. You also brought up a good point, which is like when you said these symptoms go away, I think there is a little bit of a learning curve for the patient when they're starting on hormones. It's not like tomorrow you feel great. Sometimes you feel a little bit worse. Yeah. And that's important because I think some women give up rather easily. And I think it's important to let people let women know like first few months might be bumpy. And figuring out especially if you're in the bleeding stage. And you're like, you're like, what's going I cannot function? Right? So, you know, getting it, sometimes giving it like six months before you get it right. So it's a bit of a journey. It doesn't happen overnight. And I think some people give up. So it's important to let people know it takes time. And sometimes you gain weight a little bit at first before you start seeing the benefits of getting weight and control. And yeah, I do think social, I'm love social media. And I love how much it's taught women about this. But I think there is this feeling that it's instantaneous. Yeah. Yeah. Quick fixes are just really. Yeah. Yeah. So what else do you want to tell our shared audience? Yeah. Perhaps I did not ask. You know, let's go back to the stress piece because I think that's really important. And now I'm going to have the SHBG and high stress on my radar. Because that's really not like one of the things I put on my radar a lot. But I think what happens in so many women is we get to a point of like stress and survival mode. And a lot of times this is something that's conditioned in early childhood. We're taught to be independent, to take care of ourselves, to be the boss babe. Women tend to really disconnect from their bodies. And it's a good coping mechanism when we need it to dissociate. You know, we have that coping mechanism for a reason. It's not like something to feel bad about. But so many women get into this pattern of dissociation. And my perspective on this is like if we're dissociated from our bodies chronically, we're disconnected from our bodies and our symptoms, how are we going to have good hormone health? Hmm. Playing our body to prioritize stress and survival, not reproduction and pleasure. So women, so many women in this stage of life, it can also be a really important time to remodel our lives. So it's in better alignment with who we are, who we want to be, and to get grounded again. And to get connected again in our bodies to support our digestion. Like how are we going to have good digestive health? We don't like live in our body. And for eating so fast, just to get to the next thing. Yeah. Just like the next thing, move on, go. So I think we as women can be a really beautiful transformation in paramedics and in midlife where women start to prioritize themselves again after motherhood. Yeah. That's what we're not mothers. It doesn't even mean we are mothers. But like it's this phase of our lives where women go through like the maiden, the mother, and the queen. And I am really into that. I love that. And there is also like this concept of like it is slow down to speed up. Yeah. Because you know, I don't want to put it out there like, oh, slow down and you can retire. And then you're just going to sit there and chew your food 100 times a second. Like that's great. It's important. But we are, I'm a agree, and I know that's not what you mean. I just want to double down on it. It's just this idea at in this age, because we are at the height of our career. And we have a long, it's very different than a generation ago. We have a long way to go and many, many things to conquer. You will burn out if you stay at the pace that you did. And so really reconnecting to your bodies is so important in taking time and listening to stress levels so that you can keep killing it. It's a hard one to take. It's like slow down to speed up. Yeah. It's a really, it's a great way to say it. Yeah. I mean magnetize, right? You get more done when you work. I mean, it's like the concept of not working as hard, not pushing through like, yes. I mean, women just like push like, it's matter to matter. It's like hard and I also think it makes us at this age, the potential to be better leaders to our younger counterparts. I at least that's my experience. Like as I slow down and take a look at what I need and I'm able to look at to my younger female counterparts, be like, where are we? Are we good? Like, what do we need? Which makes us stronger leaders. That many of our male counterparts are still in the 10x, 5x, like mode. God bless them. You're going to have a different type of team. Yeah. You have a different type of team. And a team that is based on feminine energy is unstoppable. Yeah. I mean, it's mixed, right? Like between the feminine and masculine and I'm not like a band and a band and you're your masculine, like push and success, like great embrace it. And bring in more of your feminine energy and balance going, right? It's like back to you and Yang and balance. It's like bring her into the picture because she's the one with all the intuition and all the magic. Yeah, it's bring her into the picture. I love that so much. That beautiful feminine energy. Damn, she's so good. And it is so much yummier to live in, like embodied in our feminine essence and power. And like good push hard, be a badass. Absolutely. Sacrifice yourself. Yeah. Back to the part you said about like being better examples to our colleagues. Yeah. And also to our daughters. Like girls, right? I'm like, yeah, I had this whole discussion with them. I was like, you do not need to scoot over and accommodate anybody. You take up your space. I guess she's seven. So I wasn't ready for she's seven. I have this conversation by 20 year old. The side was the girl with the line. Yeah. We'll see how that turns out. That's an experiment. I don't really know, but oh, that's so much. Dr. Maran, how do people work with you? Yeah, go to my website, drcristinemarin.com and you go from there. I'm on Instagram. That's like my primary kind of place. I'm on Facebook too. I have not joined the TikTok thing because I don't want to. Okay. And you are, you know, living, embodying, you know, in your own body. That doesn't speak to you. I think about the things I want more now. Like that's another piece of it actually is like, how do we get in touch with what we want? Huh, female desire. And like, we didn't know. We really taught us that for the most part. Yeah. Yes. I find it a lot when I'm talking to consult, I'm going off script here. We're talking to consultants. I'm like, very clear in what I want. And it's very counterintuitive to the pathway to success. You know, you have to do this and this and this. I'm like, not doing any of that. We're going to go this way with an inner knowing that we're still going to be successful with actually more integrity. And I and I see that a lot in that there's not people aren't used to seeing that type of growth in a non linear pattern. Does that make sense? Yeah. It makes sense in the aspect of not, like, people are not used to hearing that from a woman. Yeah. Yeah. Yeah. Yeah. Yeah. Like, we didn't know this is how it works. No, that's not works for you. This is not how it works for us. And it's a there's a yeah. Like, people have to adopt that. And it's, you know, it's a little changed like culture that they're used to maybe. Yeah. And we're here for it. We're going to make out for your daughter and my daughter. We're we're making a better path. Although, I don't think they need us. They're pretty awesome. Yeah. Anyway, Dr. Mariner, of course, we're going to put all your links everywhere. I don't see patients anymore. So I love if my pot, if when people listen to podcasts, they connect with you and they come to you. Yeah. It makes me so happy because we just need more instructors in the world. And so people like that. X is Colorado and Michigan. Those are where those are the places I'm licensed. We say it again. Where? Wow. That's different. Yeah. Long story. I mean, I did residency in Texas. My husband's military doctor. He did fellowship in Detroit. We moved to Michigan. And my practice kind of followed me this whole time. And then we're back in Colorado, which is where I was born and raised. Love it. Texas, Colorado, Michigan. Women, if you're there, call Dr. Mariner. Yeah. Thank you for being here. Thanks so much for having me. Well, that's another episode of the medical destructor. And this is what medical destruction looks like, not blaming, but exposing the limits of the training and pushing the conversation forward. You're part of a community that doesn't exist anywhere else, a safe space for people who want real scientific information, but also want to ask questions without being made to feel crazy. Our community is informed, empowered, and signs back. Ready to go deeper? DrFratLamandre.com has my book, PDFs, newsletter, and a link for consults. Until then, keep asking questions, keep asking for more and keep disrupting.