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

Dr. Pamela Langenderfer: [00:00:00] The gut plays a big role with how we metabolize hormones and get them out along with the liver. But if you simply just start detoxing the liver and you don't give it any type of exit to get out, the person is gonna be worse. 

Dr. Brighten: What are some signs that women need to address their liver health? 

Dr. Pamela Langenderfer: A lot of PMS, irritability, breast tenderness.

We're told it's normal, but that's not normal. 

Narrator: Dr. Dr. Pamela Langenderfer is a powerhouse in perimenopause and menopause care. 

Narrator 2: Blending functional medicine, hormones, and acupuncture to help women get their energy back. 

Narrator: And actually feel like themselves again. 

Dr. Brighten: If women listening to this right now did one thing Monday morning to start to optimize their hormones, what would you challenge them to do?

Dr. Pamela Langenderfer: The biggest challenge would be ... 

Dr. Brighten: What is the biggest mistake prescribers are making when they prescribe women hormones? 

Dr. Pamela Langenderfer: The biggest mistake is, is that people think that they can simply give a prescription. And being able to write a prescription for hormones is really only one piece of [00:01:00] the puzzle. And if you simply give a prescription and you're not working on the person's foundation and addressing their gut health and their liver, they're not gonna utilize those hormones very well.

Dr. Brighten: Okay. So we gotta break that down because in this new age where people are finally acknowledging that like hormone therapy is important for women, something that we've been prescribing for well over a decade, I think you've probably been prescribing around 20 years. 

Dr. Pamela Langenderfer: Mm-hmm. 

Dr. Brighten: Nobody's really talking about the gut.

No one's really talking about the liver. And in fact, people who are stepping into this r- arena and prescribing have no training- Yeah. ... in this whatsoever, right? They, the training they have is, uh, only if there's gut symptoms, do I refer to a gastroenterologist? So why does the gut and liver matter so much when it comes to using hormone replacement therapy?

Dr. Pamela Langenderfer: The gut matters a lot. I mean, as you know, and I think what makes us a little bit different is that in naturopathic medicine, we're taught to treat the whole picture. We're always taught taught to look at that underlying cause. And I can't tell you how many [00:02:00] times that you have somebody come in and I think about one particular patient that came in and she had a hysterectomy and she needed hormones because she was miserable, having really severe hot flashes.

And part of the reason she had her hysterectomy is because she had endometriosis. Mm-hmm. So when I put her on hormone therapy, I get this phone call saying, "I feel like I'm gonna have a period, but there's nothing there." And part of the thing that happened with that is that if you simply do hormone therapy and you're not addressing the gut and the liver, then the person doesn't metabolize the hormones very well.

And the gut plays a big role with how we metabolize hormones and get them out along with the liver. But if you simply just start detoxing the liver and you're stirring up the pot and you don't give it any type of exit to get out- 

Dr. Brighten: mm-hmm. ... 

Dr. Pamela Langenderfer: the person is gonna be worse. And then they're gonna have this experience with hormones that they're bad, they don't work for me.

[00:03:00] And that's not what I see. If you address all the other issues, people tolerate them better. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And often, if I give somebody hormones and they don't tolerate them, that's the number one red flag that there's some other problem going on. And as you know, the more constipated somebody is, well, they're gonna keep recirculating all that estrogen into the system and then depending on what other issues they have going on, you're gonna see symptoms become worse.

Dr. Brighten: Mm-hmm. You know, it's interesting because I have actually seen gynecologologists online refute the idea that bowel movements, that gut health have anything to do with our hormones. However, it is well documented in the scientific literature. They've even done isotope tagging. So they've actually put radioactive isotopes on estrogen and have tracked that and have found that there is a recirculation of estrogen.

And some studies point towards recirculation of estrogen potentially being problematic in the development of [00:04:00] certain cancers. Mm-hmm. You mentioned endometriosis. If you are reactivating your estrogen and putting that back into circulation, that is going to be problematic for endometriosis. We know that estrogen can fuel that endometriosis fiber, fire.

And in addition to that, endo can be resistant to progesterone. And so there's a lot of nuance in that conversation. For women listening right now, and they're like, "Okay, I'm considering hormone therapy. How can I identify that I have liver or gut issues that need to be addressed?" 

Dr. Pamela Langenderfer: I think one of the big things with the gut is if you're constipated- mm-hmm.

because if things aren't coming out, well, they got nowhere to go. Mm-hmm. So if you're not having a bowel movement every day, which so many people think, "Oh, I have a bowel movement every couple days," that's normal because it's maybe always been normal for them. But even though that might be their norm, that's definitely not optimal health.

So first of all, if you're not able to have a regular bowel movement, that's [00:05:00] one of the big problems. And then if there's any type of irritable bowel syndrome, so if they're having a lot of bloating, um, digestive issues, that would be another big red flag that the gut might be part of the issue there. And so those are probably the most obvious, but sometimes you can have gut issues, but you don't have gut symptoms.

Mm-hmm. And I think those can be the ones that are a little bit harder to identify. 

Dr. Brighten: Yeah. And I think it's really important for women listening to understand that the new onset of constipation and changes in digestion can signal many things, some which being very scary, like ovarian cancer, others being things like development of Parkinson's disease.

And so a doctor telling you, "Mm, it's fine if you don't go every single day, but you are now starting to develop constipation can be the early warning signs of something chronic and maybe more serious developing." I wanna go to the liver picture because you're also a Chinese medicine practitioner. Mm-hmm.

What are some signs that women need to address their liver health? 

Dr. Pamela Langenderfer: So in [00:06:00] Chinese medicine, the big signs that there's a liver issue is a lot of PMS, irritability, um, breast tenderness, and actually even depression. 

Narrator: Mm-hmm. 

Dr. Pamela Langenderfer: And so I always think about this person, they just feel like, uh, like they're kind of stuck and things are stagnant and they, um, can easily get tipped over, you know, just from like any little thing sets them off.

And especially in Chinese medicine, when somebody gets breast cancer, that actually has a lot to do with the liver meridian. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: So that, those are some of the things that you start to look for in pattern recognition, um, with the Chinese medicine piece of it. But a lot of, um, times, again, we're told it's normal because a lot of people have those symptoms and it's pretty common to have breast tenderness or PMS symptoms, but that's not necessarily normal.

And because it's so common, a lot of people don't think of that as an early sign that something's wrong and that they're maybe not detoxing their [00:07:00] hormones properly. 

Dr. Brighten: Because 90% or more of women have experienced PMS at some point in their life, that therefore makes it just a normal experience of being a woman.

However, we do see that this has increased over time. More women are reporting these things, and I think there's a big environmental component to that. Mm-hmm. Can you speak about what are practitioners missing when it comes to managing perimenopause and menopause from that environmental medicine perspective?

Dr. Pamela Langenderfer: So this is something that I see quite a bit. And I often now start testing patients to see, do you have mycotoxins, heavy metals, environmental chemicals? But it really has a lot to do with the person's burden. And so I have, um, a handful of patients where they're people I've worked with for a long time and, you know, sometimes you have people and you're like, "Gosh, dang it.

Why is nothing working?" And, you know, every time you try to give them something, they react to it and they don't, um, respond well to it. Well, once they started digging [00:08:00] into their toxin load, that's where I could really see where the problem was. Mm-hmm. So one of my patients, um, that I've worked with for a while, we measured her toxic burden, and she had almost 40 markers that were high, and half of them, like, in the red, which means, like, they're really, really high.

There's a pretty high burden. And so my approach from her had to be a little bit different, because when you take people like that, and then you start doing all this liver detox, and you start pushing, pushing, pushing the liver, they will get worse. Mm-hmm. And they will not get better. So with this particular patient, I couldn't do any of that.

So I had really had to change my strategy with her, where we had to slowly get those toxins out over time, and people really have to understand that if you're carrying that high toxic burden, it's gonna take six months to a year. You will, you will not get that out quickly. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And by simply focusing on that, she was able to lose 22 pounds w- with, we didn't [00:09:00] really do anything different except pull these toxins out.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And a lot of these toxins are xenoestrogens. I mean, they mimic estrogen in the body. They're a huge trigger for, um, women for any type of hormonal issues, um, any, you know, hormonal imbalance, even that PMS. And you can see it in our kids where we're having girls that are eight and nine years old having periods.

We're seeing men. I mean, I have, you know, men come in that are 30 and they have testosterone levels that are only 250. So they're, they're like a 70-year-old man. And that is not something I used to see. You know, I've been in practice now for 24 years- mm-hmm. ... and you never used to really see that happen before.

And unfortunately, it's becoming more of the norm. So really focusing on those toxins and really understanding where somebody's burden is will really change how you approach them, especially if you're trying to give them hormones. 

Dr. Brighten: Mm-hmm. Dr. [00:10:00] Elisa Song also noted that we are now seeing them for the first time in history a delay in puberty in boys.

Mm-hmm. So girls are hitting it sooner, boys are hitting it later, and the biggest reason that we're looking at is xenoestrogens in the environment, so how they're actually modulating our hormones. Everything you're speaking to, I'm gonna actually link to several reproductive endocrinologists I've had on the podcast because there's this, like, you know, little dogmatic story going around that, like, if you hear someone's utoxins, roll your eyes because that's not real.

Those people perpetuating that are directly doing harm. Mm-hmm. They're directly doing harm, and I will stand and die on that hill. Reproductive endocrinologists have been sounding the alarm for decades now about environmental toxins, xenoestrogens, and what they're doing to our reproductive health. But for whatever reason, in medicine, you'll have, like, the dermatologist over here that says, "Mm, we have to have parabens, we have to have xenoestrogens available in our skincare products, and they're fine.

[00:11:00] It's not that much, you know, uh, the studies are done on this individual product, this individual product's fine." And then you have the reproductive endocrinologist over here saying, "No, there's actually been studies showing higher level BPA related to infertility and miscarriages." So let's actually, like, parse that out as I'm talking about this.

When you are saying toxins, so this individual you were just talking about, what are we talking about specifically? So people understand that because they do think that well-meaning individuals have thrown around the word toxins a lot- mm-hmm. ... or chemicals, and because they're imprecise in their language, it's kind of discredited this whole idea and made people m- skeptical of it.

Mm-hmm. And I appreciate skeptics, but I would like to give them the information to help them understand, what do you mean when you say toxins? 

Dr. Pamela Langenderfer: So when I say toxins, I'm talking about some of the things that I see pop up on some of the environmental toxin panels or, um, heavy metal panels. So one particular one that I think about is atrazine.

Mm. And atrazine is, uh, [00:12:00] there's a ton of research on that. Like 20 years ago, I think they did on frogs showing that when they expose male frogs to that, they become more feminine. And part of the reason, I always feel like that's kind of how I got more into this medicine is because I grew up on a farm in Michigan in the Midwest there, and my dad farms wheat, corn, soybeans, and there's tons of chemicals everywhere, glyphosate, you know, the atrazine, and one of the things by the time I was 21, I mean, my hormones were a hot mess, and that's kind of what drove me to start to look into, there's gotta be another way.

Like something, you know, has gotta be triggering me to be worse and to start to have all these hormonal imbalances. So atrazine is unfortunately a common one that I do see pop up in these panels, and that is such a strong xenoestrogen that it is a big contributing factor to men's testosterone levels declining.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And so if you can reduce those things out of [00:13:00] somebody's body and then, you know, as you know, everybody's genetics are different. So if you're genetically prone to not detox very well, which that's me, I'm a poor detoxifier, when I get exposed to those chemicals, they're gonna build up in my system more, and it's harder for me to get rid of those.

And so it's really taking, you know, this, but spend my whole entire career trying to figure this out, mainly for myself to see, like, why, why do I feel the way I do? How come I can't, you know, go and be in a room where somebody just painted and now I'm sick? Mm-hmm. Like, why does any little things seem to tip me over?

And a lot of that has to do with the fact that I can't clear these chemicals. And that's typically what I see in patients, especially the really sensitive ones. 

Dr. Brighten: Mm-hmm. Let's go through, if a woman's coming to you, let's say she's in perimenopause, she's having night sweats, hot flashes, she's not sleeping, she's irritable, she's raging, we all know, right?

We've all [00:14:00] been there when our husband breathes too loud. Like the audacity. It's a breathe right in our space. So she's having all these clear symptoms of low progesterone, of maybe unchallenged estrogen, estrogen fluctuating. Where do you start with a patient like that? 

Dr. Pamela Langenderfer: So if I have somebody that has a lot of symptoms, I am a big advocate for testing- mm-hmm.

because I, I have been on both sides of the fence there where in the first part of my career, maybe not doing as much of our functional medicine testing and, um, now doing a lot more of that. And part of that is because in the beginning, a lot of patients didn't wanna have to pay for testing. 

Dr. Brighten: Yeah. 

Dr. Pamela Langenderfer: But testing really does help.

And it, it does give you a roadmap because once I started to have a roadmap, then I can see where I really needed to intervene because some people, they do need progesterone, um, but some people, the progesterone is fine. It's just that that estrogen is so, so high. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And so it really comes down to helping them to break that down and to get that out of their, their body.[00:15:00] 

So I always like to do, I do a combination of urine testing, blood testing, and I like to get a big picture of everything, and then that gives me some direction on where to go. 

Dr. Brighten: And at what point do you consider doing gut testing with somebody? 

Dr. Pamela Langenderfer: I will do it right away, and oftentimes, um, what I do now is I will start with all of the testing in the beginning, because if I just have it right out of the gate, it does make everything go faster where- 

Dr. Brighten: So much faster, I agree.

Dr. Pamela Langenderfer: so much faster. Yeah. Otherwise you do a test, you wait a few months, you do another one. 

Dr. Brighten: Yeah. 

Dr. Pamela Langenderfer: So if people just ... And, you know, and I get it, it's an investment to do these tests, but if you do them right from the start, you at least have some idea because sometimes the gut maybe really isn't that bad- mm-hmm.

and you would've wasted all of this time treating something that's really not the problem. 

Dr. Brighten: Yeah. So with doing all of this testing, what kinds of things are you looking for that's going to guide your treatment? 

Dr. Pamela Langenderfer: So gut testing, um, you will see if somebody has a elevated [00:16:00] beglu- beta glucuronidase, which shows us they might have some excess estrogen in the gut.

Um- 

Dr. Brighten: Can you explain what that is for people who might not know? 

Dr. Pamela Langenderfer: So if you have excess beta glucuronidase, basically your body isn't, uh, detoxing your estrogen very well, and it's going into the guts and then it gets reabsorbed. And so it starts to contribute to that estrogen dominant symptom. And so utilizing different things like calciumD glucrate can make a big difference in helping to clear that estrogen out.

Um, then I'll look at their toxin load and even some of the mycotoxins, I always feel like I was trying to, you know, resist learning a lot about mold, and then you just kind of have to. 

Dr. Brighten: It's like, I will say that mold, mold is something that's not my specialty will always refer for mold because I feel like it is, it is just its own beast- Yes.

all in itself. But we do see there is a lot of mycotoxin exposure. Yeah. And it's very interesting because even within the same family, you'll see that one person is so sick and maybe four people are [00:17:00] fine. Yeah. Or, you know, a couple of people are like, "Something is off, one person's really sick," and then there's that individual that's like, "Everything is fine."

And so you just never know until you actually test. And I'll preface this for everybody, that you live in Idaho. 

Dr. Pamela Langenderfer: Mm-hmm. 

Dr. Brighten: Um, so when you get into, like, Idaho, Oregon, Washington, you're hard pressed to find a house that doesn't have mold. 

Dr. Pamela Langenderfer: Yeah. And people always say, "Well, my house is new." It, it doesn't matter.

Yeah. Even some of the new houses can have quite a bit of mold, and it, you don't always see it. And so that's why it's so tricky. Uh, one of the things I've learned over the years though is that, you know, our, our medicine should work. I mean, it does work. So if it doesn't work, then you have to kind of step back and go, "Do you have mercury fillings?

Do you have breast implants?" And that is a huge, huge one that I have seen make a big difference why people can't get well. Mm-hmm. And then you start to look at the heavy metals, the molds, you know, things like that. Something is affecting the body and making it [00:18:00] not work. Um, but some of those mycotoxins, and I, I agree with you, mold is like a whole other beast.

Um, but then I'm like, "Okay, I'm gonna learn about it, but I don't wanna be an expert necessarily, but it makes a difference in someone's hormones because some of those mold strains are actually estrogenic." 

Narrator: Mm-hmm. 

Dr. Pamela Langenderfer: And so if someone has a really high amount of that in their body, it, it does have to be dealt with because you won't be able to fix their hormones until you decrease that level.

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

Dr. Pamela Langenderfer: I spend at least, uh, four to six weeks actually taking them through a detox.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: So I often won't give the hormone right away unless the person is really, really miserable. And the reason for that is because their chances of having a negative reaction are so high. 

Dr. Brighten: Yeah. 

Dr. Pamela Langenderfer: And then it's, [00:19:00] you know, it's, it's kind of a mess. And now you're like stopping, starting. So when we take people through a structured detox in the beginning, so we spend about, you know, four to six weeks doing that, and then we introduce the hormones, it goes so much smoother.

Mm-hmm. And people tolerate them better, they have a much better response to them. 

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

Dr. Pamela Langenderfer: Um, well, first of all, if you wanna know you have mold, you have to do some sort of testing and dust testing tends to be more accurate because if you just test in the air, uh, y- you mean it could be behind a wall and you could not pick it up. So you do have to have some sort of testing to see if it's even in your house.

But even for the environmental toxins, it's really just reducing your exposure. So for myself, for example, I was home at my parents' farm this summer and, uh, it, it [00:20:00] was wheat harvest season and my dad had 80 acres of wheat planted around the house and everybody's harvesting. And so just by being around that and breathing it all in, I, all of my gluten markers were through the roof and then I measured my toxin levels when I got back and my BPA levels were super high- 

Dr. Brighten: mm-hmm.

Dr. Pamela Langenderfer: because I didn't want to drink out of the well, so I was drinking out of plastic water bottles- Yeah. ... for like couple weeks straight. And so that was really kind of shocking to see how high it went- mm-hmm. ... just by having that exposure. So whatever you can do to reduce your exposure, choosing better hair products, beauty products, and, you know, we, we all can't be perfect.

I mean, we all have those favorite things that we know are toxic. So you just choose your toxicity and you just try to reduce what, what, how much of it you're gonna have. 

Dr. Brighten: I think that's the most important part though is having the informed consent. Mm-hmm. Like actually having the information as a consumer so you can choose.

So we talked about the mold. You said you [00:21:00] take people through a detox. What does that look like for people listening? 'Cause this might be totally new to hear that like, "Oh, you've gotta move mold out. " Because often people are told, "You have a liver and you have kidneys and you have a gut. Like they're gonna detox for you.

Mm. I always laugh because I'm like, "And how well do your kidneys work if you don't put in water?" Like we have to have inputs that come in. If you're not eating amino acids and you're a carbatarian, then- Yeah. ... good luck detoxing through your liver because they require all of these inputs. 

Dr. Pamela Langenderfer: Yeah. And I'm glad that you said that because that is one thing people don't understand that importance of protein.

If you, if you don't have enough of it, you can't detox because you need those amino acids for your liver to work. And so one of the things we focus on is we take people through a pretty structured elimination diet. Mm-hmm. And part of the reason for that is because, you know, sometimes you say the word detox and there's like crazy detox things out there.

Yeah. People do these intense things, they're in the bathroom all the time. But I think there are some crazy detoxes out there and then people do them too intense, [00:22:00] too fast, they feel awful. Like it, it's, it stirs the pot and you kind of open Pandora's box if you don't do it right. So we do, um, take people through an elimination diet and I tell them, "This isn't forever."

You know, sometimes I think it's so easy to get dogmatic and all these different like diets and nutrition and do this and do that. At the end of the day, how do you feel? I mean, I'm not very motivated to avoid something if I don't feel a difference from it. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And that's really what we take people through an elimination diet for, for is to get them familiar with their body.

And if we do it in a very slow, structured way, oftentimes 50% of their symptoms go away. So I'm like, "Man, I would've gave you all these supplements you really don't need." Mm-hmm. And it's just because you were eating something that was causing so much inflammation. So by doing that, and we support them with different supplements that support the, the liver and the kidneys, and then making sure they're getting enough fiber, because that fiber part, like you, you don't know until you know, and I'm a big [00:23:00] proponent of food tracking, macro tracking, because if you've never done that, you have no idea what 35, 40 grams of protein looks like.

Mm-hmm. You have no idea what it means to have 25 to 30 grams of fiber in a day, and people really need that visual, but that fiber part is so critical because if you're gonna go stir up the pot, you need something to absorb it and catch it so that way you can get it out. So that's really what we focus on in those first six weeks for people.

Mm-hmm. And they do feel a whole lot better just by lowering that toxic burden on their system. 

Dr. Brighten: Yeah. And I think it's so important for women listening to understand that as we age and we lose our estrogen, our microbiome diversity declines. Mm-hmm. And s- it's one of the contributing factors for which there are several to our body weight, uh, distribution changing where our body fat actually is.

And research has shown that when people are intaking more fiber, they have less of a propensity to [00:24:00] store the highly inflammatory, metabolically active, visceral fat. So when we're talking about fiber, what do you recommend the goal should be that women are trying to achieve daily with their fiber intake?

Dr. Pamela Langenderfer: A minimum of 25 grams if they can do more, but not everybody's digestion can handle that. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And so it's kind of the same thing. It's another good sign or a red flag if you're trying to get more fiber in and you feel worse, well, you, you got a gut problem going on. So we have to, um, take that slow with people so that way that they can ma- make sure that when they put the fiber in, they're able to handle it, they're not actually getting more bloated, more constipated from it because that unfortunately is sometimes a byproduct of adding more fiber in.

Dr. Brighten: Yeah. 

Dr. Pamela Langenderfer: And so that just is a signal you actually have probably some sort of SIBO or other type of bacteria overgrowth going on in there. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: Um, but the fiber really can change the microbiome. And as you talk about the microbiome, you know, there are different, um, probiotic strains that tend to be [00:25:00] more lower in histamine and histamine can be a big trigger for hormone problems and increase estrogen and cause more estrogen dominance.

And so by making sure you have more of like the bifido strains and some of these other bacteria in there, you can actually help to manage some of those histamine levels for people, um, that sometimes even cause depression in women. 

Dr. Brighten: Or rage. 

Dr. Pamela Langenderfer: Yeah. Yes. Or that too. 

Dr. Brighten: Yeah. And it's something so, uh, everyone listening, I'll link to an episode that I did about the menstrual flu or the period flu that talks a lot about the estrogen histamine connection and how, you know, that can make us feel so awful before our period.

But I have always said like, you know, you, everyone's like, do a low histamine diet. And I'm like, "That is not the answer." Yeah. "Can it help short-term?" Yes, but the answer is in the gut. So can you speak a little bit more about, because if you're starting someone on estrogen [00:26:00] therapy, whether it be topical or oral, it really doesn't matter.

If estrogen is coming in and you've already got a histamine issue- mm-hmm. ... that can be related to what's going on with the gut. So how do you approach someone in that instance? 

Dr. Pamela Langenderfer: So sometimes, um, it's a genetic problem. So if somebody has their genetics, you can see they might not have an, um, or be susceptible to not having enough of the DAO enzyme.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: So you could put the DAO enzyme to help with that. But I've found doing low histamine probiotics probably be the most helpful- 

Dr. Brighten: mm-hmm. ... 

Dr. Pamela Langenderfer: because that is really what helps to degrade histamine in the gut. And this was something, you know, I always feel like I make all the mistakes on myself first. And so then that's how I help everybody else because then I figure out- 

Dr. Brighten: I feel like

Yeah, I just wanna, like, echo that because I feel like, uh, so often when I have practitioners on the podcast with myself, like, all of us have our own journey- mm-hmm. ... and then people are like, "Oh, but you're gonna be able to help so many more people. " Right. Yeah. But I think you get to, like, our age and then you're like, "But I'm done."

Right. "I've learned the lessons. [00:27:00] Leave me alone." Yeah. Like, I don't wanna learn anymore. 

Dr. Pamela Langenderfer: Don't have to go through it again- Yeah. ... at all on there. Yes. Yes. And that's, um, kind of what I had learned, you know, on, on myself is because, well, you know, go back, like, 10 years ago where everything was eat more fermented food, heal the gut, um, bone broth.

And so I'm trying to heal my gut- mm-hmm. ... and I have really bad eczema. And so that's what I've spent 30 years now trying to keep in remission and sometimes I have flares and it gets triggered. But I was eating all of this fermented food and I looked worse and worse and I could not figure it out at first.

Mm-hmm. And then I learned, oh my gosh, it's a histamine issue. And, um, all that histamine was actually what was triggering my symptoms to be even worse. So then I also didn't understand lactobacillus acidophilus, which is in, like, every probiotic is actually a high histamine strain. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: So when I changed my approach, started using more, um, low histamine strains, there's different lactobacillus and by, by fiddos that are considered low histamine, [00:28:00] um, it made a huge difference in my skin, but then also on my gut and my hormones.

Mm-hmm. And so that's where I feel like if we have those right things in there, and then you do have to be careful sometimes with the histamine food. It's not ... I mean, as you know, those low histamine diets are very difficult because I don't have time to be cooking every meal from scratch every single day- mm-hmm.

and you're not supposed to have a lot of leftovers and all of that, but it, it comes down to that management. If you know that there's an issue going on and you're trying to have kombucha every single day, well, you probably can't have kombucha every single day- Yeah. ... because it's not helping you. 

Dr. Brighten: I literally tell my patients anytime we have to do elimination diet or maybe we need to do a low FODMAP diet or, you know, any kind of specialty diet.

And I tell them straight up, "I hate these diets more than anything." Like, I hate it as a foodie. Mm-hmm. So my goal is to get you off of this as soon as possible. Mm-hmm. Like we use it, and that's what I want people to undertake away from this conversation is that when you talk about using a therapeutic diet, like doing an elimination diet, that has [00:29:00] an end date on it.

Yes. It expires. So in the, the vein of giving people health, we were talking about, so we did gut testing, there's the environmental toxin testing, mycotoxin testing. What are you looking for specific in hormone testing that maybe influences or changes how you prescribe hormones? 

Dr. Pamela Langenderfer: So I do a lot of urine testing, specifically the Dutch testing, because for me, it's really important to see how someone's metabolizing the estrogen.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: So if they're detoxing it down one of those bad pathways, they're usually gonna have a more negative reaction to the hormones. Yeah. So that's what I'm looking for more than anything in the urine testing. And then with blood testing, I'm just kind of trying to get a idea of where their levels are.

And so I feel like what happens with the blood testing, people, um, get very focused on a number. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And then I see practitioners going, "Oh, I need to make sure estradiol levels are here or testosterone levels are here." [00:30:00] Meanwhile, Well, the patient is bleeding and they're having breast tenderness. And so I've learned that the hard way many times is that you have to, it, it's a, a balance because you want the person to have symptomatic relief.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And yes, I understand it's important to have these levels optimal so that way you can have some protection on your bone and the brain and the heart. But if I just do that, um, I will see bleeding start to happen. And so now I gotta refer to a gynecologist. We have to go through the whole process of making sure we have a vaginal ultrasound 

Dr. Brighten: and- Possibly endometrial biopsy.

Dr. Pamela Langenderfer: Yep. 

Dr. Brighten: All of that. Which barbarically in the US doesn't totally give you great pain management for, so- No. Yeah. We definitely want to try to avoid, you know, uh, the worst case scenarios and these things. So what you're talking about is that we know in the research, they say like, we wanna target in the blood serum estradiol around 80 to 100.

Mm-hmm. That's what's gonna be protective of the brain, the heart, the bones. You should also be getting DEXA scans because I don't believe that in the [00:31:00] future that we're gonna, that anyone's gonna say, "Oh, it's just about the serum estradiol." Right. So I do think you have to still track these things. However, I'll echo what you say.

Some people, you get them to 60, that's where they feel great. Mm-hmm. They feel awesome. Their DEXA is looking great. Like you are sending them to your other cardio workups. Like you're, you're getting all the data back and everything looks great. And what you're speaking to is treating the individual.

Mm-hmm. What we're at is a precipice of conventional medicine of the, the run-the-mill OB- GYN who is never actually trained in perimenopause, menopause, or hormone therapy, coming into this space now and then trying to create the cookie cutter model, right? Mm-hmm. So they're, they're trying to shift it into like, how can we effectively treat as many women as possible with the best evidence-based?

That is gonna do well for probably 60 to 80% of people. Mm-hmm. But there is always gonna be the 20 to 40% where that cookie cutter model is not working for them- mm-hmm. ... and that's where we have to get creative and we have to explore. [00:32:00] You mentioned estrogen metabolites. It is not just about serum estradiol.

So can you break down these metabolites, what you're looking for and what you think every listener should know? 

Dr. Pamela Langenderfer: We're looking at the 40H and the 160H pathways. So specifically, if those pathways are high, um, in a very simplistic way, you can think about them as they're bad estrogens and specifically that 40H.

So if you see those levels high, then you wanna intervene with different supplements, um, nutrition-wise, making sure that you're having foods that have a lot of the cruciferous vegetables in them, m- going back to the fiber, doing things like ground flax seeds, all of those things will make a big difference in how you metabolize those hormones.

Dr. Brighten: And while I will say, I would never allow the cost that prohibits people from getting lab testing to prohibit them from getting hormones, I will echo what you say that if we test ahead of time and I see that your [00:33:00] 160H estrogen pathway is upregulated, I know when I give you estrogen, you're likely gonna have breast tenderness.

Mm-hmm. Like you're gonna be that person that has that side effect. And as you talked about genetics previously, if you are someone with a COMT mutation, so you have a genetic variation in that, you may not be processing your estrogen correctly. So now you may be the person who feels more irritable with estrogen.

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

Dr. Pamela Langenderfer: Magnesium is big one because that'll help that COMT gene doing broccoli sprouts and there's many supplements now that [00:34:00] have, um, broccoli, uh, extract in there and ground flaxseeds. And I know there's controversy about that where, you know, I was always taught ground flax seeds are really important for breast cancer protection.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And then I've seen other people out there saying, "No, they're gonna cause breast cancer." But I, I have just seen- 

Dr. Brighten: Let me break it. Can I break it 

Dr. Pamela Langenderfer: down? Yeah, break 

Dr. Brighten: it down. Yeah. Yeah, yeah. Okay. Here's the thing. Flaxseeds, the whole flaxseeds have lignans in it, and that is what's protective. When they have done the research on flax and said, "This is problematic," especially a lot of the research has come out of prostate cancer, it's flax oil.

Mm. So it's when you highly process the flaxseed, so it becomes a processed food rather than the whole food, and you separate it from the lignans that things become problematic. And we know that it's highly unstable, it has to be kept in the fridge, but come on, a sh- like it, it could be in a cargo ship, it could be, like, on a truck- Yeah.

being shipped. So now you're consuming a highly oxidized oil. And so [00:35:00] the big question in the research is, like, what is happening with the oil here and what the research has actually shown. If it's the whole flaxseed and you're grinding it up yourself, or you're buying ground flaxseed, you get the lignans and those are actually protective.

So I've had this conversation, like, 100 times, so- Yeah. ... because people are always like, "Oh, isn't flax gonna cause breast cancer?" Yeah. And I'm like, literally in an environment that is filled with, like, BPA and parabens and, like, all of these environmental toxins that we know, like glyphosate, I mean, that are associated with cancers, the last thing we need to be worrying about is a whole food.

Yeah. Like, that is the last thing. So anyhow, you go back off- Yeah. ... said magnesium, you said flaxseeds. 

Dr. Pamela Langenderfer: Uh, broccoli, we talked about broccoli. Um, and then of course from there, we have diandyl methane, uh, which is the DIM, which is used quite a bit as well to help those pathways. And then you can, uh, focus on some of the methylation things like methyl B12, methyl folate.

So I think it's really approaching it from this big picture. Um, [00:36:00] methionine is sometimes helpful too- mm-hmm. ... but when you get a lot of those pathways working, and most of the time, focusing on someone's diet does do 50% of the work- Yeah. ... and that's just even putting more vegetables in, because I mean, how many people aren't getting enough?

I mean, I'm guilty of that, you know, too, where sometimes I'm like, "Gosh, did I even have any vegetables today?" Just by doing some of those simple changes with that really is enough to help to, to shift that. Mm-hmm. And then the other thing I encourage people to do, because you had brought up before, you know, sometimes the cost of some of these labs, and, and I get it, um, you know, for people, sometimes the cost can be a little bit of a barrier, but on the flip side of that is that our healthcare system is a mess right now, and I always view things as I'm investing in my health and in my future.

Dr. Brighten: Yeah. 

Dr. Pamela Langenderfer: And I, we talk a lot about, you know, not just the lifespan, but the health span. 

Dr. Brighten: So I wanna go back into more about the, uh, hormone replacement therapy, menopause hormone therapy. When you are looking at prescribing this [00:37:00] for someone, how do you typically start things? Like, are you starting with progesterone first?

Are you starting with estrogen first? When do you consider testosterone? 

Dr. Pamela Langenderfer: It really just depends. Depends where the person's at and where their lab values are at. So if I have someone that's still having periods, I tend to not start with estrogen. Mm-hmm. I usually will start with progesterone and testosterone for them.

And then if I have someone that has not been having periods, then I'll start to introduce estrogen. And one thing I will say, you know, there's all kinds of delivery methods. There's patches and creams and pellets and, and, and injections. And I do them all for people, um, because it just depends on the person and- mm-hmm.

and what works for them. And so I have some people that they, they hate the cream. They hate doing any type of compounded creams because there's sometimes so much cream- Yeah. ... and they're lathering up in it, you know, every day. And then sometimes I'll do a patch and then they're exercising a lot and they sweat the patch off.

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: So you really, um, have to keep in mind when it comes to [00:38:00] hormone replacement therapy, there is not one way that is the best, but what we do know is the best is that estrogen needs to be topical. You really shouldn't do oral, and there are people that will disagree with me, you know, on that. Um, but I always do topical estrogen.

If you have a uterus, you have to have oral progesterone. You can't just do progesterone cream, um, or a troche, but sometimes I feel like the, the capsules aren't enough, and I will combine it with, um, creams and troches because it has to do with how the person is absorbing. 

Dr. Brighten: Yeah. 

Dr. Pamela Langenderfer: And everyone's skin is so different too.

And then the same thing with, um, testosterone. I'll start people typically on a cream, but sometimes I do a pellet because they feel better, um, they like more of the convenience of it. So it just really depends on what works best for that patient. So I'm not married to one specific thing as long as I know we're, we're doing it safely and the person's getting results.

Dr. Brighten: Mm-hmm. And, uh, I want people also just to make the [00:39:00] connection of what you said earlier about the necessity of lab testing is because when we start you on a topical, we know not everybody absorbs that the same. Mm-hmm. And so we have to make sure we're hitting the mark. And sometimes you're getting just enough that you're like, "I'm feeling better."

But when we do the testing and we realize, like, we need to change routes or we need to go higher dose, we need to, you know, switch it up, whatever it may be, and we actually get you into more of a therapeutic window, that's when people are like, "Oh no, now, now I'm actually feeling a lot better." Let's talk about the controversy between using topical estrogen and oral estrogen.

Dr. Pamela Langenderfer: Oral estrogen is the thing that's the most problem with increasing risk, you know, um, blood clots. And then when you look at some of the literature though, the increased risk of that is really not as high, but I think the thing is, is that you don't always know if somebody has a blood clotting disorder.

Narrator 2: Mm-hmm. 

Dr. Pamela Langenderfer: So topical estrogen can be used if somebody had [00:40:00] factor five ligand, which is a blood clotting disorder that's a genetic issue. And so because I don't always know somebody's history or their genetics or I do feel like because of COVID, I mean, I do see a lot more problems than what I used to before- 

Dr. Brighten: mm-hmm.

Dr. Pamela Langenderfer: that I'm always more comfortable just sticking with the topical delivery of that. And so that's why I, and that's partly what the guidelines say with, um, topical estrogen, uh, with that versus the oral, though I do know some practitioners that do use oral estradiol. 

Dr. Brighten: Let's talk about the nuance around testosterone.

Dr. Pamela Langenderfer: Well, I would say testosterone is probably one of the biggest controversies for women out there too- mm-hmm. ... because you have, you know, the reference range, and so if you're in the range, then you're fine and you don't need it. Well, everybody is in the range, but yet people have a lot of symptoms. So the top things that I see for women that need testosterone, it's usually low libido, low energy, um, low muscle tone, and they just don't [00:41:00] have like that get up and go anymore.

Mm-hmm. And, and they're, they're exhausted. And I will say that when you get, um, testosterone in, it really does make a difference for those women. 

Dr. Brighten: We've got the labs, we've got the symptoms, how do you counsel patients on this? What should women know? 

Dr. Pamela Langenderfer: So when it comes to testosterone, um, same thing, depends on what you're doing in the delivery method.

So if you're doing a cream versus a pellet, the labs can look quite different. 

Dr. Brighten: Mm-hmm. 

Dr. Pamela Langenderfer: And the labs will go much higher on somebody that has a pellet. So again, it's, you have to pull back and look at the big picture. And oftentimes somebody's gonna be double or triple out of range with a pilot, and some people are symptomatic and some are not.

They feel a whole lot better. So when it comes to tes- testosterone therapy, I always tell people, always tell them, "I'm gonna tell you all the bad stuff first- Yes. ... because this is what we're gonna look for. Are you having hair loss? Are you having hair growth? Are you getting a lot of acne? Um, are you getting clitoral enlargement?

Is your voice changing?" Like those are the things that we don't want to have happen. Mm-hmm. [00:42:00] So when I work with people on testosterone, I mean, they're checking in with me about every three months. Um, so we're either just doing a follow-up or, um, checking labs and then I'm looking at that big picture for them.

So you can't just go off of, um, what the lab values are because for a menopausal woman, the reference r- range, I think it's like seven to 40. Well, you can come in at seven and you're told that you're normal and this person does not feel normal. Mm-hmm. And then once you get the testosterone levels in, you might see the levels go up to like 100 or even 150 on a blood test if somebody's doing a pellet.

Um, but if the person feels good and they're not having a lot of symptoms, that might actually be okay for them. But then you might have somebody where their levels are at like 60 or 70 and they're getting male pattern baldness and they're having hair loss. And that has a lot to do with how they're metabolizing that testosterone.

And so for them, those levels might be too high. So the same thing, you can't just focus on a [00:43:00] number, you really have to, um, look at the person's symptoms and you have to communicate with the practitioner and the practitioner has to listen because I do think that there can be problems with pellets. Yes, I think people can get, um, overdosed and a lot of that is because the person gets focused on the lab number and so they just give the person more and more and more.

Mm-hmm. Meanwhile, this person is telling you of all these symptoms that they're having. So that's why I spend a lot of time talking with somebody. We make the decision together. Um, okay, you know, it sounds to me like maybe we should go down on your dose. Um, so you have to really listen to the patient and the patient and you have to be in a partnership together.

Dr. Brighten: Mm-hmm. I definitely agree. What is going into your testosterone panel? 

Dr. Pamela Langenderfer: On a blood test, a total testosterone and a free testosterone. So those are the two big things and you can add a DHT on there as well and then sex hormone binding globulins. So those would be some of the big things on blood. Um, when it comes to urine [00:44:00] testing though and you're looking at a Dutch test, that's where you can see what you're doing with those androgens.

So if you're converting them down a more potent pathway, um, that's when people start to have more of the issues with acne and you would see some of the PCOS symptoms happen as well. So I, again, like to do the combo of both, um, but when I'm screening for testosterone, I often look at blood testing because that's more of the standard when you're, uh, looking at that.

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

Dr. Brighten: And what other tests are you tracking when it comes to prescribing testosterone to make sure that they're not having any adverse effects to that? 

Dr. Pamela Langenderfer: Well, testing is mainly with the urine and the blood testing, and then a lot of it is we have them fill out a symptom questionnaire- mm-hmm.

every time that they come in. And so I'm looking at that symptom questionnaire, what some of the symptoms are, because that's where I feel like you're gonna, um, see the most in terms of tracking other [00:45:00] things. I kinda go back to that big picture is if you're not, if your microbiome's not healthy, your gut's not healthy, the liver's not healthy, it will make a difference in how your body is metabolizing that testosterone.

So we try to optimize everything and look at the big picture. 

Dr. Brighten: Why are so many menopause providers missing the thyroid picture? 

Dr. Pamela Langenderfer: I feel like the thyroid is one of the other things. When do you see it go wonky? It's usually, uh, right after someone has a baby and then right when they go into menopause. And so that's a part of just my hormone screening panel is I always check everybody for thyroid issues and do a thorough test, meaning we're checking the TSH, the free T3, the free T4, thyroid antibodies.

Uh, I look at a reverse T3, I look at ferritin levels. So I get a big picture on what's happening there, but the thyroid really is like the canary in the coal mine. Mm-hmm. It's kind of the thing that I feel like goes out of balance first when somebody's really stressed and run down. 

Dr. Brighten: What should women know if they do have [00:46:00] hypothyroidism, they're currently managed on a medication, and then they're starting estrogen therapy?

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

So making sure everything is balanced and that you're doing some type of monitoring of it. 

Dr. Brighten: Mm-hmm. I see so often people are like, "I've been on the same medication for years. They start estrogen therapy and now we have to make an adjustment." Mm-hmm. Because estrogen can change binding proteins, estrogen can change how you utilize your thyroid hormone.

And I think that is also a missing piece in the puzzle when women say, "I start hormone therapy and I actually feel worse." If women listening to this right now did one thing Monday morning to start to optimize their hormones, what would you challenge them to do? 

Dr. Pamela Langenderfer: I think the biggest challenge would [00:47:00] be making sure you're eating protein at each meal and making sure you're getting vegetables at each meal and making sure you have fiber in there as well.

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

Dr. Brighten: Well, this has been a fantastic conversation. Thank you so much for sitting down with me. 

Dr. Pamela Langenderfer: Thank you for having me. It's been great to catch up with you.

Dr. Brighten: Thank you so much for joining the conversation. If you could like, subscribe or leave a review, it helps me so much in getting this information out to everyone who needs it. If you enjoyed this conversation, then I definitely want you to check out this.