Episode 13: Mastering Menopause Through Nutrition, Hormones and Self Advocacy with Esther Blum

Evelyne: Yes. So Esther, I interviewed you on my own podcast to elevate your energy back in 2014. I can’t believe it’s been that long.

Esther Blum: Oh my God.

Evelyne: That was really fun.

Esther Blum: Oh my God.

Evelyne: By 2030, there will be 1.2 billion women going through menopause. Yet many, if not most, will be experiencing a combination of symptoms that disrupt their quality of life, including hot flashes, insomnia, brain fog, vaginal dryness, low libido, weight gain, and fatigue. What’s worse, our conventional medical system is not offering women the support and treatment options necessary to feel better. And this is where you as an integrative and functional medicine practitioner come in. Esther Blum is an integrative dietician, and for the past 27 years, she has helped thousands of women master menopause through nutrition, hormones and self-advocacy. She’s the bestselling author of See Ya Later, Ovulator!, her newest book. Great title, Esther.

Esther Blum: Thank you.

Evelyne: Cavewomen Don’t Get Fat and Eat, Drink, and be Gorgeous. She’s known as Gwyneth Paltrow’s menopause mentor and was voted best nutritionist by Manhattan Magazine. She has appeared on the Today Show, ABC and Good Day New York. What a bio. Esther, you are so passionate about helping women during peri and post menopause. Has that changed over the years as you’ve now entered perimenopause?

Esther Blum: Yeah, I get this question a lot and when I went into functional medicine, I was a hospital dietician for the first five years of my career, and during that time I got trained in functional medicine and once you know, you know. And I was like, I got to get the hell out of here. But I always had a side hustle, private practice, and who were the first women that came in to see me? They either were autoimmune or struggling with autoimmune conditions or menopausal mamas. So even in my twenties, I had to start treating them then when I really was very green out of the gate.

But I’ve started with diet and lifestyle and supplements, and then as my knowledge of testing grew, then yes, of course, it’s constantly evolving. The research is constantly evolving. When I first went into functional medicine, that’s when that stupid Women’s Health Initiative study was published. And I remember calling my mom and be like, “You cannot be on hormones anymore.” And she was on the synthetic cocktail and took her off and we were all terrified and we learned as we went.

And since then, of course, for those of you don’t know, the Women’s Health Initiative study was putting post-menopausal women who were 10 years out of menopause who already had an increased risk for cardiovascular disease and hyperlipidemia, and they were put on synthetic estrogen derived from the urine of pregnant horses, which really is not physiologically compatible with a woman’s body. And they also were not given any opposing progesterone or testosterone or DHEA. So it was a very poorly designed study, and the data was so poorly interpreted. The risk of increase in clots and heart disease and stroke was so so so so minimal, it was not statistically significant, and that’s what the media held onto and ran with it.

And all of a sudden, women who were enjoying better quality of life with some degree of hormone replenishment just had the rug pulled out from under them. So since then, the guidelines have been updated that hormones are safe. It’s very rare or unusual to be associated with risk of clots like a birth control pill has a way larger association with clots or excess alcohol intake than menopausal hormone replacement therapy. So we’ve really come a long way in our knowledge of wisdom.

Evelyne: I also learned, and I don’t know why I didn’t realize this before, but that hormone replacement therapy is actually such a small fraction of what you would get in a birth control pill, which is very interesting.

Esther Blum: Yes. It’s a fifth of the dose of birth control pill, and yet we cannot get testosterone even FDA approved for women, which again, it’s a microdose, number one. Number two, testosterone is the predominant hormone in a woman’s body until menopause. Okay, so tell me how this makes any sense of what is out there. It doesn’t.

Evelyne: I want to talk about those hormones in more detail, especially testosterone, but can you give a general overview of what’s happening with our key hormones like DHEA, progesterone, estrogen and testosterone both in perimenopause and in post menopause?

Esther Blum: Yeah. So perimenopause is really when you start to see those shifts where women come into my practice and say, wow, the first half of my period is Jekyll and the second half is Hyde, and I don’t know what’s happening. I’m getting a real uptick in anxiety and insomnia, and I get these wicked crime seed periods now that I feel like I can’t leave my house. So what’s happening under those circumstances is that progesterone starts to decline and think about it, right? Not only are ovaries starting to wind down the party because mother nature doesn’t want us carrying babies too late in life or by midlife. She wants to wind that party down and we also naturally have more stress. We may have aging parents, we may have young children at home, and you just take one of those circumstances or then pair both together and your progesterone is really going to tank. Your hormones are driven from the top down, so what’s going on in your mind and in your heart will absolutely take your hormones. Your body is going to stop ovulating with a decline in progesterone because again, under extreme stress, no woman should be pregnant. This is what mother nature is saying, don’t get pregnant, don’t ovulate right now. You can’t handle it.

So progesterone starts to decline. And during that time, again, there is a real uptick in mental health changes. You can have cardiovascular changes, you can have rapid heartbeat or develop some arrhythmias. You could also notice that you’re not sleeping through the night, you’re kind of having a hard time falling asleep and then having a hard time staying asleep. You’re kind of awake from three, four in the morning on and your anxiety is really, really worsening and/or depression. So all of those can happen in the early stages of perimenopause.

As perimenopause picks up speed and really, and a woman’s period in perimenopause could easily be 10 years, by the way. And this is why a lot of doctors miss the menopausal symptoms because they’re like, well, you’re 42, you’re not menopause. Yes, but your body is preparing to go into menopause. I could tell you mine started in my mid-forties, but nobody figured it out. It wasn’t until after I went on hormones and saw my symptoms resolve and I was like, duh, I’ve been in perimenopause this whole time, even though periods were completely regular and on time. You can still have crappy hormones when that is the case. So as perimenopause continues, your ovaries are really starting to put on that finale of fireworks displays of eking out as much estrogen as it can, so your estrogen levels can spike. You can get surges with levels three to four times higher than your baseline.

So you pair that with declining progesterone and you can get meno rage is what I call it, real extreme irritability, just outbursts of rage. You can feel weight gain, breast tenderness, irritability as I mentioned. Also like moodiness or depression. And you can also get very, very heavy periods with blood clots because there’s no estrogen to keep progesterone in check and balance it out. And hormones, I liken hormones to a symphony. They’re not solo artists, right? So when imagine a symphony without a conductor or when there’s two violin players missing, of course it’s not going to be the same. It’s the same with your monthly cycles. They’re going to get off kilter and then you can also have eventually a decline in testosterone and DHEA and estrogen. I don’t see that all the time. I look at lab tests on every single person I see in practice, and not everyone has low testosterone. Not everyone has low estrogen, but most people have low progesterone. And so early intervention is key.

And the other piece I see is a real poor HPA axis. The hypothalamic pituitary adrenal axis is not in great shape. So I see very low cortisol curves if at all a curve. Sometimes it’s a flat line, it’s really suboptimal, and we want to remember that once the ovaries are finished producing estrogen and progesterone or they’re only eking out very tiny, tiny amounts, the adrenals pick up. They take over that production of hormones. So if you have someone who’s going in very stressed, very depleted, or someone with history of a lot of trauma or someone who is fighting chronic illness, let’s say mold or Lyme or autoimmune conditions or infections like gut infections, you’ve really got to support the adrenals and give them a boost until that person perhaps decides to go introducing hormones in or is a candidate. You do need to support the adrenals and hormones eventually can really help restore cortisol curve, but not alone. You really do need the adrenal support as well.

Evelyne: Yeah. You’ve given me so many directions we can go and I want to talk more about the HPA axis. I want to talk about introduction of hormones, gut health, obviously. Let’s back it up a little bit and talk about the lab testing that you like to do. I know that you do this with all of your clients, so tell us what are the most common labs that you use and what are the key pieces that you’re looking for on those labs?

Esther Blum: Yes, and if you’re missing, if you’re driving or you’re walking, listening to this, don’t worry, this is all in my book, See Ya Later, Ovulator! So no worries if you just want to absorb, let wash over you.

So first test, I do three tests. The first is blood, and I am looking at really your risk of cardiovascular disease, which can dramatically increase in the absence or a decline of hormones. So I’m looking at your insulin, your fasting blood sugars, your A1C, I am looking at your inflammatory markers, your C-reactive protein, your homocysteine, your lipoprotein level A. I am looking at a comprehensive thyroid test panel including T3, T4, reverse T3. I’m checking for your thyroid antibodies. I’m checking your TSH. I’m also looking at, of course, your triglycerides. I do look at cholesterol. Cholesterol alone isn’t a risk factor, but if you’re pairing it with someone who’s got insulin resistance and high blood pressure and particle size of your cholesterol is an issue, then yes, then it can be absolutely a risk factor. And then of course, I’ll check vitamin D, magnesium, zinc, your folate, your B12. That’s my starting point with blood work.

And a lot of doctors will say, well, this isn’t covered under insurance. You can absolutely appeal that with insurance, or a good doctor will say, you do need these tests because remember, in this country, Homer Simpson is the baseline for a “normal lapse”, right? That’s our prototype at this point because obesity is so rampant. So you tell your doctor, I’m here to optimize myself and really save the healthcare system a lot more money and not be on drugs, not be prescribed drugs.

Then I do two other tests. One is the DUTCH test. I do a DUTCH complete, that’s a dried urine test for comprehensive hormones. This collects urinary metabolites. You give five urine samples over the course of about 15 hours. You start late afternoon, evening, overnight, and then to an early morning sample upon a rising and two hours after. And what that does is because doctors will say, or our patients will say, I collect my blood work for my hormones. Blood work is not as reliable source as saliva and urinary metabolites because they’re not looking at how your hormones pass through your liver, how you’re methylating them, how you’re detoxing them, and phase one and phase two detox in the liver. And you’re also not looking at cortisol curve. You can take an ACTH challenge to look at your cortisol levels, but that’s only going to tell you what happened at eight in the morning between eight and 12. A DUTCH test looks at a really comprehensive cortisol curve and you want to see what’s happening overnight. So that’s why I really like that.

And it also, the complete test adds on organic acid. So that gives me, again, a real great window into your glutathione status, your B12, your folate, and also your dopamine and serotonin and melatonin. So it’s a really comprehensive test. I really love it.

And the other test is a GI map, and this enables me to see how well you’re detoxing your hormones in the gut. It’s going to look at your beta glucuronidase, but then it’s also going to tell me about the integrity of your microbiome. So do you have a leaky gut? Is gluten an issue? Are you carrying a lot of pathogens or dysbiosis or methanogens? Are you digesting and absorbing your food? Do you have enough HCL or pancreatic enzymes? Do you have H pylori? So it’s a really nice indicator as to what’s happening, and these tests are dismissed regularly by the medical establishment. But doctors, it’s interesting because before they dismiss, they should see how they’re solving their patient’s problems, putting them on Prilosec and never getting to the root cause of why they’re having heartburn to begin with. Never getting the root cause of healing that knowing that people on Prilosec are going to destroy their bones and their nutrient absorption.

So I like to look at the root of the root. I like to look under the hood. I like to get really good results for people. I get them feeling better and give them the opportunity to get off their proton pump inhibitors.

Evelyne: And when you’re looking at all of these tests in conjunction, many of the symptoms of perimenopause and post menopause can also be contributed to other conditions. So are you going to start them on hormones? Are you going to start with the gut? Are you going to start with adrenal support? Where are you looking to prioritize?

Esther Blum: I prioritize gut and adrenal support because I have women who’ve come to me with hot flashes and when we fix the inflammation in their gut, the hot flashes resolve without me even really working on methylation or even connecting them to a doctor who’s going to introduce hormones. So I always start with the gut, and I also add adrenal support because oftentimes I have to first replenish and replete very minimal to low levels, really depleted levels of beneficial bacteria. I have to spend three, four months just getting those up, and then I can do a good kill off phase where I’ll kill off H pylori, I’ll kill off the dysbiosis and then replenish hydrochloric acid. So it creates kind of this fire while this very hostile environment for overgrowth to happen again.

During that time, if someone’s depleted and their cortisol curve’s very low and then you put them on a kill off phase, they’re going to be so exhausted and tired. So I support the adrenals whenever needed, only if needed. If someone’s got strong adrenals, I don’t, but most people do need some adrenal support so their body can heal itself and use the extra bandwidth it takes to eradicate these pesky bugs that are really inflammatory and have biofilms and all of that.

Evelyne: Do you find that most of the reports that you look at, do you have a flat cortisol curve or is it like an inverted curve and then depending on what you see, what are the research backed supplements that you introduce or lifestyle strategies or both?

Esther Blum: Everyone’s cortisol curve is really different. I can say in menopause, I do notice a much less robust cortisol curve. What I notice the most is that 3:00 PM crash, which also gives me a window into your thyroid function too. Your thyroid function may be suboptimal in those circumstances, which is another great reason to support adrenal function, by the way. Because you’ll inadvertently help support your thyroid as well.

So first and foremost, lifestyle. You can never out supplement your lifestyle. A lot of people have a poor cortisol curve or it’s spiking at night, and I’m like, “What are you doing at bedtime?” Well, they’re on the iPad. It’s a little threesome, right? They’re in bed with the husband and the iPad, or maybe the phone is there too, and it’s like the screens are detrimental. I’m like, “Please delete your social media apps and doom scrolling from your phone. Just only do it on your computer during the day. Put your phone in sleep mode at night.” I’ve gotten really religious about my sleep hygiene because when I get naughty and when I’m sitting there scrolling, I don’t sleep that night. But a lot of people too, you’re not producing melatonin under those circumstances and no one wants to read about the news and there’s so much depressing, overwhelming things that we can ingest and then trying going to sleep, that doesn’t work. So first and foremost, the screens, X a day on the screens.

Then of course, meditation, getting those alpha waves going and people say, I can’t meditate or I don’t need it, that’s too woo woo. I’m like, “Dude, all meditation is is bringing attention back to your breath.” Or my favorite thing to do is imagine how big I want to go in my life, the pie in the sky dreams. I make sure I work on those every morning and every night because that is a really big foundation for my success and creativity.

And then of course, I like to have people have protein by day and carbs at night, and I like people to have at least 40 grams of carbs with dinner, with protein, and of course with fibrous veggies. But with dinner, because that slight uptick you’re going to get in blood glucose, and I’m talking like sweet potatoes, beans, lentils, lower glycemic carbs or white potatoes that be cooked and cooled or white rice, which is a bit higher glycemic, but when you have those higher carb intake at night, that bump in insulin is going to tamp down the cortisol response. So that helps too because I get a lot of women coming to me who’ve been on keto or super low carb and they’re terrified of carbs. They think it’s going to make them fat, but yet they’re not sleeping all night. I’m like, that’s going to make you way more fat than having some carbs with your dinner. So we have people have carbs at dinner and they’re so happy because who doesn’t love carbs? Hello? And who doesn’t love sleeping? Hello? So that’s really helpful.

Supplement wise, what do I do? First of all, magnesium, because that’s a great methylator. I love mag glycinate for anxiety or if you’re really constipated, magnesium citrate is great. I do love adrenal support. Holy basil ashwagandha number one. Ashwagandha is so, so, so great for adrenal support. I believe I mentioned holy basil, I’m not sure. Rhodiola.

Evelyne: You did. Yeah.

Esther Blum: Also, valerian, kava, passion flower, just the calming nourishing herbs that you can even steeping three bags of chamomile tea or a good sleepy time tea is like a natural Xanax, and if you’re waking up in the middle of the night, topical magnesium in the insides of your elbows or behind your knees is another really, really great way to just fall asleep, fall back to sleep if you find your mind is racing. But I’m always like, don’t rely only on pills and supplements. Do the deep breathing if you wake up in the middle of the night. If you can break that cycle and remind yourself, this is not actually the time. I always say, Esther, no one solved the world’s problems at three o’clock in the morning, go to sleep. You’ll deal with this at 6:00 AM but right now it’s your time to sleep, and then I’ll come back out. So it’s remembering all those things for sure.

But yeah, I do love some good nighttime supplements. I love trace minerals too on iodine kelp. Even having a little bit of honey with sea salt before bed can also really help. Or having some golden milk with some turmeric in there and some black pepper. That can also be great for sleep too.

Evelyne: I want to go back to what you said about carbs. I know that you’re a big fan of protein as well, and I just would love for you to expand more on some of the eating guidelines that you give to your clients and also with carbs. Are you looking for say, their carb tolerance? I think I’ve heard you talk about using CGMs or continuous glucose monitors with people.

Esther Blum: Yes, absolutely. So one of the biggest meno myths I think is that women can’t have carbs, and we actually really work on increasing women’s carbs and because carbs do upregulate T4 to T3, which is the active form of thyroid hormones. So it’s not no carbs, it’s smart carbs. So on average, if are you’re finding fat loss resistant and you’ve got that extra bra fat in the back by your scapula and you have the meno pot, then yes, you probably have some degree of insulin resistance and you can wear a continuous glucose monitor, even two weeks of wearing one, you’re going to find out really quickly what it’s like overnight with your sleep, how you’re breaking down your foods, how exercise affects your sugar.

One of the greatest ways, and I see this clinically in my practice, because we have people wearing glucose monitors and tracking. Walking 10 minutes after a meal dramatically improves your blood sugar. Like the studies will say 17% improvement. I will tell you I eat a big breakfast and then I go walk my dog. My sugar goes up to 110 and by the end of that walk it’s down to 78. So it’s dramatic. It really makes a difference. So that’s important.

But yes, so for the average woman, a hundred grams of carbs is a nice way to optimize your blood sugar control paired with protein that is higher. So if your carb’s around 110, your protein, you can aim for 120, 130. The best way to calculate out your protein is to aim for one gram per pound of your ideal body weight. So if you’re five three, your ideal body weight’s like 115, 120. If you go higher than that, that’s fine, but aim for a minimum of 115 to 120. The average person, its simple terms, needs four to six ounces of protein at breakfast, lunch, and dinner.

And the research has shown that to create an anabolic effect of your food, you have to have protein distributed evenly throughout the day, and the minimum threshold is about 30 grams, 40 grams, 50 grams, but at least 30 grams. In other words, if a woman is eating two ounces of protein for breakfast, or I often see one ounce of protein for breakfast, right? People have one egg on a piece of toast. I’m like, I could floss my teeth with that for a snack. That’s not protein. So you want to have four ounces of protein. I’m like, get a protein shake with two scoops of protein or have two eggs and two and three slices of turkey or have a cup and a half of cottage cheese.

A, you’re going to crush your cravings in a day. You won’t have cravings when you have this much protein because your blood sugar is going to be so stable. B, appetite control. A high protein meal sustains your blood sugar for four to six hours after you eat it. So if you find that you are snacking between meals, you’re not eating enough protein because when you eat enough protein, you have satiety for hours and hours after. So optimizing, and most people are having, the ratios are flipped where they’re having 150 grams of carbs, 200 grams of carbs, and they’re having like a hundred grams of protein. When women flip the switch, that’s when fat loss occurs.

So other women can have, if you’re more metabolically active, if you are leaner, you have more muscle mass, you are strength training, then you can go higher with carbs overall, or you can just go higher with carbs on the days you’re training. My weightlifting days, for example, I’m at 150 grams of carbs. Pardon me, my non weightlifting days, I’m about 150 grams of carbs. My weightlifting days, I can go up to 200 grams of carbs because just before lifting, I’ll have 40 to 60 grams of carbs.

So that’s the other thing women need to understand is we actually need to fuel our workouts and fuel our metabolisms. We’re not losing weight. I see far more weight loss resistance from undereating than I do from overeating. Most women are eating 1200 calories a day, which is basically your baseline just for breathing and sleeping. Your body does need more, and if you gain weight eating more, then you need to get more active. Then you’re probably sitting all day and need to eat more.

Evelyne: Great reminders about the carbs and protein. I want to talk about gut health a little bit before we dive into the hormones and hormone replacement. Can you tell us more about the estrobolome and the role of calcium D glucarate?

Esther Blum: So your estrobolome is a subset of your microbiome that the sole job of the estrobolome of the bacteria are to metabolize, detox estrogen in the gut. So if you have an elevated beta glucuronidase, it will probably track. It’s either inevitably going to track with you having inflammation, some dysbiosis, some leaky gut, or just very poor estrogen detox. Often women with high beta glucuronidase also have very poor phase one and phase two detox in the liver on the DUTCH test.

So the way to treat it is really simple and straightforward, and most women are so relieved when you get rid of that meno bloat, when you get them pooping every day, when you get them just not feeling distended and having reflux is A, you want to kill off any overgrowth that may be interfering with your digestion. For example, H pylori shuts off the production of hydrochloric acid. It does this very intentionally because it can’t thrive in an acidic environment thrives. It needs an alkaline environment to grow and proliferate. So you want to remove any bacterial overgrowth, be it H pylori or dysbiosis. And then you want to also clean up that leaky gut. And so we often will clean up gluten. A lot of people with a leaky gut often are not tolerating gluten and or dairy and some of the other food sensitivities that we commonly see. We get rid of the offending bacteria. We heal up and seal up that beautiful gut wall and repopulate with good bacteria and then eventually digestive enzymes with hydrochloric acid.

And also from a dietary perspective, eating fiber, getting in a couple tablespoons of ground flax seed, making a flax pudding or just adding fiber supplements to a smoothie or some water, and of course eating cruciferous vegetables. All of these are sponges that really help support estrogen detox. And then BroccoProtect is one of my go-tos for also supporting that gorgeous phase one, phase two detox in the liver so the gut can be eliminated through the gut eventually. So all of those are good go-tos.

With calcium d-glucarate and DIM, I look at where the wheels are coming off the bus. Not everyone meets those nutrients to detox estrogen. It really depends on if it’s a sulfation issue versus a glucuronidation issue. So I’m very specific how I use calcium d-glucarate. I use it less frequently than sulforaphane and/or DIM, believe it or not, but it really depends on the person. Sometimes if there’s an elevated beta glucuronidase, sometimes it indicates that person’s indicated for calcium d-glucarate. Sometimes people get DIM and calcium d-glucarate. It really depends. And if a woman is having estrogen deficiency symptoms and she’s having vaginal dryness, DIM would not be the way to go because you will worsen her symptoms in those circumstances.

Evelyne: I want to go back to what you said about the cruciferous veggies and flax seeds, for example, just to make it really practical for practitioners to be able to share tips with their patients and clients. How many servings a week, for example?

Esther Blum: Oh, ideally every day and I remember when I did my functional medicine training, there was this wave of fear around cruciferous vegetables that everyone was going to destroy their thyroid if they ate too much broccoli and cauliflower. And I was like, you’d have to eat wheelbarrows of that to really have the effect. That’s why I supplement in addition, because often it’s hard for people to get it. You could say it as a practitioner, you could say, eat the cruciferous vegetables, eat the artichokes and the kale and the broccoli and the cauliflower and the radishes and all of those wonderful veggies. But the reality is what does compliance look like? What happens when there’s a mom who’s driving her kids to soccer practice at night and then going to see or take care of her ailing parents on the weekend? Is she sitting home making ginormous servings of steamed broccoli? She may not be. She may not be eating them more than a few times a week.

I always say keep it frozen. Buy frozen broccoli. Often, frozen veggies are picked and frozen versus ones on the grocery shelves, which are picked, warehoused for maybe a month, then shipped, then sitting on the stores of the aisles of the grocery store and then brought home where they’re cooked a week later, so they may not have the same nutrient profile. And so I’m like, if you are on the fly and you don’t have time to make all of these things, then keep them frozen and at the ready for when you can.

And I also love soups. Throwing and just steaming a whole pot of veggies and pureeing them in a soup with some olive oil, a little salt, throwing them in a Vitamix. I love mashed cauliflower. It makes like a great bechamel sauce, believe it or not, where instead of all the butter and flour and cream, you’re just steaming broccoli with chicken broth, I steam like a head of, or pardon me, cauliflower with a head of chicken broth, and then I’ll throw it in the Vitamix with a quarter cup of olive oil and a teaspoon of salt. And that, I coat it as a sauce for other veggies. So it’s just such an easy way to get. It’s delicious.

Evelyne: Sounds really good. I’ll have to try that.

Esther Blum: Yeah, it’s good.

Evelyne: Let’s talk about hormone replacement therapy. So what is your take, I think this is one of the most common questions, on the appropriate timing of starting bioidentical or hormone replacement therapy in general?

Esther Blum: The minute you are having symptoms, you should get your hormones checked. The minute you think that your body’s off, it’s off. There is no woman who comes to me whose symptoms don’t track with things being off. Most women are truly intuitive about their bodies. We know, excuse me, when the wind blows sideways, we know when our cycles are off and you’re like, wow, I was extra irritable that cycle. Wow, my sleep really stung. Wow, I am getting just really heavy periods or my periods are getting irregular. Start to get checked. Or they’re coming closer together, not farther apart, which is like the worst case scenario. We don’t want that. So get your levels checked.

Often what I see the most, I tend to see women more late perimenopause/menopause, but some women do come to me wanting to optimize and say, help me go into this like armed and dangerously curved. So I’m like, okay, got you. So progesterone, even cycling progesterone the last two weeks of your cycle is unbelievably safe and people are terrified of hormones. Let me tell you, hormones are FDA approved. You can get a ball of progesterone for under $4 a month. So imagine instead of taking all these sleep pills and antidepressants and anti-anxiety medications, you may not have a true mental health issue. You may just have a cost-effective remedy within arm’s reach at your local pharmacy and you can take it the last two weeks of your cycle. It’s incredibly safe. It’s incredibly gentle. A starting dose is usually about a hundred milligrams. But yeah, so progesterone is really, it’s a fantastic way to start bringing in hormones. If you’re a candidate, again, oral DHEA is another great supplement to start.

And then you do need to keep testing as your symptoms change and as your periods change. You can recheck your hormones every couple months, every six months to just see where you’re at and you’ll know when it’s time to start bringing in testosterone and bringing in estrogen. And you may feel, some women don’t have a symptoms, but most of us feel more tired. We feel more brain foggy, more forgetful, cognitive changes, mood changes, sleep changes, hot flashes, vaginal dryness, changes in libido. All of those are really key.

The other thing I really would be remiss if I didn’t mention is vaginal estrogen. The Framingham nurses study looked at women using vaginal estrogen for 18 years. There was zero increase in serum levels of estrogen. Again, it’s a microdose. It stays localized in the vaginal canal. I do have cancer survivors in my practice who are using vaginal estrogen as per their oncologist because it’s quality of life issue. It’s very, very safe, and you also want to use it on the clitoris and urethra to prevent atrophy and UTIs. So that’s huge because that’s another very big sign of menopause are UTIs. So we want to make sure that when you’re older and God forbid you’re dehydrated, you’re in a nursing home, you’re in diapers, you can offset the risk of all of that and pelvic floor prolapse and vaginal bladder prolapse, you offset all that risk. And you can also give hormones like DHEA or testosterone vaginally. DHEA works if you don’t want estrogen. That will also maintain the structure and integrity of the vaginal walls and testosterone in there can help improve libido.

Evelyne: Yeah. I have a question. Since you’re a dietician, which of these hormones are you recommending, and I know we have people listening all across the spectrum of prescribing abilities. What are you recommending versus what you are referring out to a doctor who can prescribe hormones from all of these?

Esther Blum: Yes. So to be clear, I have zero prescription privileges. So I will go through the testing. I will prescribe diet and I will prescribe supplements and lifestyle. And I have a strength coach on my team who she customizes workouts, she does meditation. We have a lot of support. And then I will connect my own private patient/clients to a functional medicine provider who will prescribe hormones. And I’ll usually liaise with the doctor. I will send them the test results and the supplements and diet so everyone’s on the same page. And fortunately, most people, most of the practitioners who are providing. That can be a nurse practitioner, it could be a naturopath, an MD are usually beautifully collaborative. And I love to advocate for people I’m treating. So it’s really collaborative. But yes, I have zero prescription privileges. I can only say, it seems like you need, please go to. I’m very careful how I word things because I would never want to practice outside of my scope.

Evelyne: Absolutely. And so with your patients, say for something like vaginal estrogen, is that something that also has to be prescribed?

Esther Blum: Yes. These are all, they are considered medications. And the interesting thing too is testosterone is not FDA approved for women. Even though anytime a doctor feels that it would be of benefit, it can be prescribed no problem. But you’ll notice, some of you listening may get asked by your own patients, what do you think of Winona or what do you think of any of those companies that have monthly subscriptions and you can get hormones delivered to your mailbox from an online provider? Bear in mind, those and I do my due diligence, they don’t seem to prescribe testosterone at all, and I cannot guarantee vaginal estrogen either. It seems like it’s progesterone and estrogen and that’s it. So just know it’s not as complete of a picture. And a lot of doctors initially don’t prescribe vaginal estrogen. They say, well, let’s get it in you systemically and see.

I will say I have a lot of women who are on systemic estrogen and still totally symptomatic. One of my patients last week said to me, “I can’t even wear leggings. I’m in so much pain.” And I advocate for her. And the doctor just changed her estrogen from a sublingual to a Biest cream. I said, “That’s lovely. Please put her on vaginal estrogen. It’s so benign. It’s something you can use the rest of your life.” Follow the work of Kelly Caspersen or Rachel Rubin who are both physicians advocating for vaginal estrogen. It’s so, so safe and gentle.

Evelyne: And are you then the one who does the hormone retesting or does that all go to the prescribing physician who you’re working with?

Esther Blum: Yeah, we kind of tag team. It depends. A lot of times when I send someone to a physician for hormones, they’re going to do the retesting, but I do have patients that say, please redo my DUTCH. I want to see where I’m at. I want to see how I’m metabolizing and we do because the benefit of the DUTCH is you can really see the symptoms of like, oh, the pathways are off. Again, there is insufficient glutathione to really help push estrogen down the right pathways so someone can still be having a lot of breast tenderness or irritability or not getting resolution with puffiness and weight gain. So again, we really have to… Or sulforaphane, we really have to get it moving down the right pathways. B complex of course is another. B supreme is one of my favorites. It really is. So I really like a B complex that has a higher ratio of B1 to B6 because you’re really going to support sleep as well while as you’re supporting detox pathways. And there is not menopausal women out there that does not crave and need a good night’s sleep.

Evelyne: Absolutely. I have more questions on the timing of hormones. So you said start it as soon as you have symptoms, but what if someone hasn’t started or they’ve already been in perimenopause for years or on the other side, maybe they’re already post-menopausal for years. Is there still a benefit at that point? What does the research say about this?

Esther Blum: You’re going to see far more benefits with early intervention, especially when it comes to bone density and cardiovascular risk prevention and preserving gray matter in the brain. However, you can still, I get in my inbox DMs all the time. I’ve been menopausal for 10 years. Is it too late for me? I wish I had this information sooner. So in that case, and I made a reel about this on my Instagram feed, but you really do want to make sure that you are determining cardiovascular risk. You can get an ultrasound of the uterus, just want to make sure that all systems are go before you start and you can still see benefits. Absolutely. It’s never too late. And especially my goodness, again, even going back to vaginal estrogen, you’re going to get relief no matter when you start that.

Evelyne: Yeah. Thank you for sharing that. And I know that in your book you have a lot of research listed as well in the back, which can be very helpful if people want to dive deeper.

Esther Blum: Yeah, there’s about a hundred studies back there and many physicians generously share those. Some of those with me and then others I just found just reading and doing research because every time I get questions, if I don’t know the answer, I’m like, “Let me go read the research.” And so it’s there. And that’s the crazy thing is hormones are FDA approved. There is solid research to support, and yet it’s still not being taught enough in medical schools. About 50 to 60% of medical schools have menopause education on the curriculum, but it’s minimum at best. And I say, how do you have a practice full of women coming to you and you dismiss or pat them on the back or put them on the pill or the IUD and you don’t have better solutions for them?

And especially the worst is when I hear the doctors themselves are suffering and have said, literally said things to my patients like, “Well, I just take Benadryl shots at night.” What kind of life is that?

Evelyne: Oh boy.

Esther Blum: There is a better life. Yeah, there is a better life. So it doesn’t have to be that way. And I think that’s why I wrote the book really is to teach women how to advocate in the doctor’s office and also to teach that the change is going to begin with us. We can sit and wait until the curriculum changes or we can just leapfrog over it and just say, I’m going to ask for it. I’m going to say, I’ve done the research, I know the benefits. I’m happy to show you the studies. Give them my book, of course, if you like and say, let me try it for three months. Let me try it. What’s the downside? The downside is I feel better, and you don’t have to hear me crabbing in your office every couple months with no solutions. That’s option one.

Option two is you call the closest compounding pharmacy in your state that you can find, and you speak to the pharmacist and you say, what doctors are running hormone prescriptions through your pharmacy? You’re going to get a nice list of at least a couple of doctors that you can check out who are functional prescribers who work with hormones and are hormone literate. Or you can go to ifm.org, that’s the Institute for Functional Medicine .org and do your due diligence, go to those doctor’s websites, see if they prescribe bioidentical hormones and are hormone literate. What you don’t want when you go for hormones are pellets.

Evelyne: Oh, yes, I wanted to ask about that. Why do you not like pellets?

Esther Blum: Pellets will jack your hormones up to three to four times of what the baseline should be. Remember, in menopause, you don’t need the hormones of a 20-year-old. You also don’t need the libido of a 20-year-old. Some people may enjoy it. For a lot of people, it’s seriously uncomfortable, no joke.

And the other problem is a lot of women get very ragey. They gain weight, they lose hair on their heads and start growing it from their chin. So there’s absolutely no ability to control the release of those hormones once they are inserted subcutaneously, and then you’re stuck for four to six months and you have zero control over that. You just have to wait. Versus a bioidentical, the delivery system, especially if it’s topical, if you’re using a Biest cream or a progesterone cream or a patch or a testosterone cream, you can titrate those doses the next day or the next application or a troche. Hormones will come in troches, which are dissolvable lozenges. The benefit to that is they bypass the liver. Same with transdermal delivery, bypass the liver. So if you’re a poor methylator, it’s easier for your body to absorb, but they’re safe, they’re gentle.

And pellets are… It’s like going from driving a Kia to a Maserati. Your body doesn’t need that level of increase in hormones, especially imagine you’ve been out of the cycling business for two years and all of a sudden you’re on this massive high dose of hormones. It’s a complete shock to the system.

Evelyne: Interesting. Thank you for sharing that. I want to go back to some of the things that you shared that patients can do, and I think for practitioners listening, I think it’s so beneficial to think about if you want to work with more per postmenopausal women to seek out providers who can prescribe and establish relationships with them so they can handle that hormone prescription part. You can handle the lifestyle and the diet and supplements and all those other parts.

This also leads me to something that I’ve been thinking about, especially recently, and I just had this conversation yesterday in a doctor’s office. How can the average person afford this? Especially if, and actually, I want to back up for a second. I didn’t even ask you. When somebody starts hormones, do you just stay on them forever? Do you take them for a period of time and then when symptoms get better, do you cycle off and switch to supplements? What is your take on that?

Esther Blum: Yes. So right now, the North American Menopause Society position paper says you could stay on it as long as 10 years safely. However, I have women in my practice who are in their seventies who have been on it for 20 years, and they say anytime they go off, the hot flashes return, the vaginal dryness returns, the wrinkles come on faster than they can even blink. So it’s a quality of life issue more than anything else. There are lots of doctors that believe in it long-term. I personally plan to stay on it the rest of my life, but there isn’t enough research out there yet to say one way or the other, but the benefits really do seem to outweigh the risks for sure.

Evelyne: Thank you for sharing that. Yeah. Hopefully we’ll get more longitudinal studies in due time. So going back to the accessibility, not everyone has access to functional medicine physicians, and even if they’re seeing another type of practitioner to then do the hormone testing and the hormone replacement, obviously we know that something needs to change systemically, especially if people are limited to their insurance system and their doctor won’t give it to them or doesn’t know about it or doesn’t feel that it’s safe. I was just wondering what your thoughts are on that.

Esther Blum: Yes. So a shameless self-promotion, I am going to be creating an essential guide to hormones that I’m going to make available for $27, which I believe is very affordable, and it’s going to list all the hormones you can ask for. All the ingredients in the FDA approved products and make it really simple for you to say to your doctor, these are all FDA approved. Please pick one from each category of what… Right now testosterone is not FDA approved. That you do have to get from a compounding pharmacy.

But to answer your question, the reality is, as much as I’m painting a very perfect picture of an ideal scenario of a woman get treated through menopause, there are plenty of women who go on hormones without any testing at all. And I know this because some of them are my best friends. People who follow me on Instagram will write to me and say, A lot of doctors just will say, the ones who are more hormone literate or understand will just say, Hey, yeah, you’re in menopause. You’re getting your period once or twice a year, basically. You’re so late in the game. Let’s just put you on estrogen and progesterone and see how you do. And they’re not really testing. They’re not necessarily following up, or they’ll get a blood test, and those women do fine too.

So there’s more than one way to skid a cat, right? There’s the perfect way, and then there’s the reality barbie, right? So it’s okay. It doesn’t have to be perfect. And down the line, I would say testosterone, vaginal estrogen, those are all important things to add in and consider for sure. Not all women have symptoms of vaginal dryness and atrophy, but if you do and you’re on the patch and not seeing results, add it in for sure.

So yes, I mean, the reality is I would much rather see, it’s kind of like the pastured meat versus non-organic supermarket meat. At the end of the day, if you’re getting protein in, that’s my main concern. It’s the same for hormones, right? Don’t let perfect be the enemy of done, right? Eat your cruciferous vegetables, eat your fiber, get your greens, really minimize or cut out alcohol, minimize caffeine, hydrate yourself, strength train, eat protein by day, carbs by night, manage your stress, do a little deep breathing before bed and then bring in hormones. And it’s really that simple. We tend to overcomplicate things. Yes, my testing is like couture, but Off The Rack, we buy our clothes at Marshalls and we buy our clothes at Zach’s, right? You can have both scenarios and still work at all income levels because we do need to make this accessible for women at all income levels. Every woman deserves exquisite menopause care. Every woman deserves access to hormones if that’s what she wants for her body.

So it can be as simple as saying to your doctor, even if your doctor’s not hormone literate, saying, please, let me try this for three months. I’ve done the research. Let me try it. I’ll sign an NDA, I won’t sue you. I will take personal responsibility if I don’t feel well on this. Right? But we’ve got to do it. We’ve got to do it. Got to start somewhere.

Evelyne: You brought up alcohol and caffeine, which I definitely wanted to touch on. So before we wrap up, why are they so much more problematic during this stage of life?

Esther Blum: Yeah. Well, so about 32% of women develop non-alcoholic fatty liver disease with the decline in estrogen, believe it or not. So already, you’re making it much harder for your liver to detox alcohol and caffeine as well. We also have been living on this planet longer. We’ve had exposures to pesticides, chemicals, toxins, air, mold, whatever’s flying around, and your liver’s tired. And then stress also helps your liver take a beating.

So we really want to lighten the load that the liver has to do. You may find you don’t tolerate caffeine nearly as well. I think of my twenties when I could drink a Diet Coke and go to sleep or coffee and go to sleep. Now, you give me coffee even in the morning, I’m not sleeping for three days. It is no joke.

Evelyne: Whoa.

Esther Blum: I am exaggerating a slight amount, but not much. So the caffeine clearance, it slows down. And same with alcohol metabolism. And here’s the other rub with alcohol. Your liver is going to detox class one toxins first, right? Alcohol is a toxin. Alcohol’s way more toxic, by the way, than a small amount of bioidentical hormones you put in your body. So you have a drink and your liver says, yeah, you hold on there, hormones. I got to get this alcohol out first. So your hormone detox is put on hold four to six hours while your liver’s trying to clean out the alcohol. So that can leave you in a more estrogen dominant state than if you’re not drinking.

Now, I’m not going to say I never have a drink because I do. I still enjoy martinis. I’m just very judicious about how much and how often. It doesn’t occur to me. That’s how I knew that I had been doing really good work on myself when I was going through stressful things or I lost both parents. Alcohol was the last thing that I turned to. I turned to meditation. I turned to therapy. I turned to walks in nature. Baths, all the things we know we’re supposed to do, snuggling with my dog. You have to really take time to be introspective and handle your stress and your grief or your trauma because the answers are not at the bottom of a vodka bottle. As much as I wish they were, they’re not.

And the pandemic really skyrocketed drinking, especially for women. And there’s all this messaging for moms like, oh, it’s one o’clock and your kids are so awful that you have to drink. I’m like, wow, that is sad. And yes, kids, all of us have stress with kids. But again, you’ve really got to reframe that paradigm too, because it just makes you sleep worse and be far more irritable and bloated. And it’s impossible to heal your gut when you’re drinking all the time and detox your hormones well.

Evelyne: Absolutely. And thankfully now it is more acceptable to be in that sober curious movement and to stop drinking for your health. So we’ve made some progress there.

Esther Blum: For your mental health too. I find it just so depressing. The times when I drink are usually on vacation when I’m happy. I cannot drink when I’m sad or depressed. It’s like, why are you going to worsen that situation?

Evelyne: Absolutely.

Esther Blum: It’s not doing you any favors. But some nice herbs are really great. You can absolutely have herbs, all those beautiful adrenal herbs we talked about, or some kava or holy basil, that’s a great way to mellow out.

Evelyne: Yeah, definitely. Esther, there’s some questions that we ask every guest on our podcast. And the first one is, what are your top supplements that you take for yourself every day?

Esther Blum: Well, I do take BroccoProtect. I do take B Supreme Magnesium Glycinate, my Trace Minerals, my Vitamin D. I have a whole container of supplements. But I would say those are my top few. And I’m doing some good gut cleanup now, so taking lots of probiotics too.

Evelyne: And what are your top health practices? I know you talked about meditation. What are some of the ones that keep you balanced?

Esther Blum: Yeah, so I meditate for five minutes in the morning, and I do this on my walk with my dog and at night. So I listen to at Gabby Bernstein, five minutes in the morning and then Davidji on Inside Timer. It’s Ji is his last name. It’s a deep healing meditation. That’s like 18 minutes at night. I walk for an hour every morning, almost every morning. If it’s super pouring rain, I don’t. But snow, ice, cold heat, I am out with my dog in nature. I strength train twice a week and do Pilates once a week. I love to go to the gym with my son. It is such good bonding. We have so much fun. And he’s really strong, so he really pushes me. And then I also talk a lot on the phone to my friends. That is like my medicine. I go on dates with my husband once or twice a week.

And I am really working on travel. I just booked a couple of trips the last quarter of the year because to me, just getting out of my own head is really important. And it spurs creativity. It sparks joy and just absolutely relaxes me. I can’t even tell you the joy I get, the natural high I get. And then music is also my savior. Absolutely music.

Evelyne: Yeah, definitely. And then the final question is what is something you’ve changed your mind about through all of your years in practice?

Esther Blum: Oh, the absolute arrogance I had that nutrition could fix everything. When I went into functional medicine, I was like, well, and I would just blame people’s illness on the fact that they weren’t eating a healthy diet.

That was so ridiculous because the reality is the traumas we face and the work we do on ourselves matters more… That the mind is your greatest multivitamin and saying no is your greatest multivitamin. I was watching the documentary Heal, that Heal documentary. I think it’s on Netflix. And they went through all the modalities of medicine. I believe there’s 10 or 11 main healing modalities. And the top two was the mind. That’s where Joe Dispenza talked about. Healing his fractured vertebrae and was told he was never walk again. And he started meditating seconds at a time, minutes at a time, hours at a time. And of course, he walks and is fully functional. So it’s really doing the deep work. Very few people are doing the deep work they need to heal intergenerational trauma or personal trauma, and if we don’t, we are just repeating the cycle again and again. And we will stay sick. People develop autoimmune conditions and chronic illness because they’re not handling personal grief, processing, personal feelings, relationships with parents or loved ones. So that to me is greater than any diet and any supplement you can take is the inner work.

Evelyne: Yeah. Thank you for sharing that, and thank you so much, Esther. This has really been a pleasure. I really appreciate your time and your expertise, and where can people find more about you?

Esther Blum: Yeah, so I have a gift for everyone. You can download my Happy Hormone Cocktail for free. Please go to estherblum.com/cocktail. Of course, we have to have cocktails here and then Instagram. I’m @GorgeousEsther.

Evelyne: Awesome. Thank you for tuning into Conversations for Health today. Check out the show notes for resources from this episode. We also have the full transcript of every show on our website, podcast.designsforhealth.com. Please share this podcast with your colleagues, follow, rate, leave a review wherever you listen. And thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence-based, cutting edge research and practical tips.