Thyroid Problems in Women Skyrocket During Perimenopause + What to Do About It | Dr. Christine Maren

Christine Maren: [00:00:00] At age 40, we're seeing a decline in microbial diversity for women, and that correlates with perimenopause. And we see that menopausal women, their gut microbiome resembles the gut microbiome of a male. Mm-hmm. So when a female has the gut microbiome of a male, there's more inflammation and more immune reactivity that goes on.

Gut microbiome is shaped by your hormones, and at the same time, your hormones are really shaped by your gut microbiome. And all of that downstream effect influences immune system and autoimmune disease, which is gonna impact thyroid function. 

Dr. Brighten: So talk to us about sex hormones, thyroid. What do you wish perimenopause patients knew?

Narrator: Dr. Christine Marin 

Dr. Brighten: is a board certified physician and functional medicine expert 

Narrator: who specializes in uncovering the root causes of hormone, thyroid, gut, and autoimmune issues. 

Dr. Brighten: With her signature three pillar method and advanced training in women's health, 

Narrator: she empowers women through every stage of life from fertility and postpartum to perimenopause and beyond.

Christine Maren: I do not think that birth control [00:01:00] pills are a good treatment for perimenopause, period. Yes, they provide contraception, but there can be some serious risks, especially as women are aging, which includes things like. 

Dr. Brighten: Why do you think it is that thyroid health in perimenopause is getting like no airtime? Oh, social media.

Yeah, 

Christine Maren: major media, literally nowhere. I think it's because most of the people talking about menopause are talking about Welcome to the Dr. Brighten 

Dr. Brighten: Show, where we burn the BS in women's health to the ground. I'm your host, Dr. Jolene Brighten, and if you've ever been dismissed, told your symptoms are normal or just in your head or been told just to deal with it, this show is for you.

And if while listening to this, you decide you like this kind of content, I invite you to head over to dr Brighten.com, where you'll find free guides, twice weekly podcast releases, and a ton of resources to support you on your journey. Let's dive in. We're gonna be diving into gut health specifically as it relates to perimenopause and [00:02:00] menopause, but we've gotta start this conversation with thyroid because for whatever reason.

Thyroid is like this stepchild of hormones currently. Like nobody wants to see it. Nobody wants to talk about it. And everybody who has become very prominent in talking about hormones on the internet just forget that thyroid exists altogether, and yet it's a super big concern for women over 35. So can you talk to us about what women should know over 35 about their thyroid health?

Christine Maren: Yeah. I mean, as you said, don't forget about thyroid menopause medicine. Doesn't always address that. So yeah, women over 35 women in perimenopause definitely experience heightened thyroid symptoms. I always call this the unmasking effect, like any underlying condition gets worse in perimenopause. Mm-hmm.

Like rip off the bandaid. So with thyroid, you know, there's a lot of symptoms that can correlate with perimenopause. It's not always just perimenopause. Um, so it might be fatigue, brain fog, weight gain, I mean. [00:03:00] There's a lot of overlap. There can also be changes in our period. And, um, you know, the, the kind of classic ones is like hair loss and constipation, but I think it also contributes to dysregulation in the gut, which might also lead to sibo.

There's a big correlation there. And of course, there's this autoimmune component. And so if we're looking at Hashimoto's, which is the number one cause of hypothyroidism among women in the United States, it's a big one to consider, especially since we see an increase in autoimmune disease through perimenopause.

So yeah, there's this huge connection for women over 35. Um, so test it. I mean, I think the big thing is getting labs done. Yeah. Getting comprehensive labs and looking not just at TSH, but a more comprehensive thyroid panel. 

Dr. Brighten: I wanna talk about a more comprehensive thyroid panel first for everybody listening.

Sibo, small intestinal bacterial overgrowth. They're good bacteria. We love them. They just get in the wrong place and they cause trouble. Uh, but as you were saying, all this, you said. You know, not everything when you're in perimenopause [00:04:00] is just perimenopause. It reminded me I was, um, traveling through Columbia and I, I didn't realize this was what was going to happen, but we went and stayed at a mutual friend's house and before we knew it, there was a line of people to come see me.

And I was like, what is going on? And they were like, the American doctors here. And I'm like, hold up. Like, I'm not licensed here. Like, but one of the things that came up, his wife was having, um, heart palpitations. She was really, really tired. She was losing her hair and she was saying to me like, my skin's getting so dry.

And her, she's like, I saw the doctor. And he said to me, you are just getting old. This is how it is. You are in the change. And I was like, has he checked your thyroid? And so I, I gave her a list of tests. I'm like, you know, at minimum get a TSH, go check it. She comes back, she's like. I'm hypothyroid. Like I wouldn't have known that if you weren't here.

And I'm like, that is, yeah. Such lazy medicine that we see happen so often to women is you are just getting old. Yeah. So tell us, how would someone differentiate between [00:05:00] perimenopause and hypothyroidism? So everybody listening, there's hyperthyroidism too much thyroid hormone, we'll talk about that in a minute.

But hypothyroidism too little. And that's the most common. So that's why I wanna start there. 

Christine Maren: Yeah. I mean, thyroid is not that hard to test for perimenopause is kind of hard to test for. Right, right. Yeah, I mean that's largely symptomatic, but I think you have to rule out other conditions first while you're looking at perimenopause.

So get a TSH. I mean, in my clinic, I order A-T-S-H-A free T four a free T three. I like to look at reverse T three and thyroid antibodies, like thyroid globulin, thyroid peroxidase, and if somebody has a TSH that's high, that's indicative of hypothyroidism, there's other causes of hypothyroidism that are less common.

Some women have a normal TSH with a low free T four, so I think it's really imperative to look at both. Mm-hmm. And that's not always done in conventional medicine. Like in my family medicine training, we were taught to look at TSH, and if that's abnormal, then you look at a free T four. I would at the bare minimum, look at both TS, H and free T four.

Free T three can give you a lot more [00:06:00] information about how your active thyroid hormone is. Interacting with the cell. Um, but I mean, labs, I mean, they're not expensive. I think if you're, if you're being dismissed and told you're getting older, and this is just something to suffer with, like put your foot down and you have to advocate for yourself and get labs drawn elsewhere, either with a different clinician or even on your own.

But I really believe women have to advocate and get labs drawn. 

Dr. Brighten: Yeah, it's so interesting to me in the United States that there's so much gatekeeping with patients' data that uh, you know, now we have a lot more access, but it used to be like you could only get your labs if you went to a doctor and then you can only get your results when you see the doctor.

Again, other countries are like, that's the patient's data. They own that, and it's their responsibility to take it to their provider. Like we give it to them and I just think. That is part of the problem of why people don't get the care 

Christine Maren: they actually need when there is a problem. I agree with you. It's, it's a hard question for me to [00:07:00] answer.

I think about this, why don't doctors order these tests? Mm-hmm. I mean, what's the problem? But they're, they're taught not to, and part of it is financial. Yeah. Insurance companies save money when we order less tests. Although A TSH is like four bucks. Mm-hmm. It's so cheap and it's so easily available in my mind, I think, okay, risk and benefit.

What's the risk of ordering this lab? Purely financial. And it's very little ri like four bucks, right? Yeah. Why, why not? Why aren't we ordering this? But the big organizations and you know, ACOG and. Whatever A BFM, I mean, they don't always recommend that we order A TSH. Mm-hmm. I mean, it's sort of like infertility medicine when we see women with recurrent pregnancy loss, like maybe we'll order a thyroid hormone then, but when women are trying to conceive, we don't do it either.

Yeah. I think it's a really big misservice to women. 

Dr. Brighten: Yeah. And you know, to that point, I think that, you know, unless you've been in that loop of infertility, you don't know that they'll oftentimes let you have three [00:08:00] babies that you lose. Mm-hmm. And I say babies because when you're trying to get pregnant and you do become pregnant, and you have that loss that is your baby, and you feel that, and medicine is so callous about it, they're like, yeah, once three, yeah.

Then, then we'll work things up. And I just think, you know, every time I meet with a reproductive endocrinologist on this podcast, which I'll link to some of those episodes, they're like, that is a huge mistake that we're making and it's costing women time, but also nobody seems to care about women's mental health.

Like they just don't care if that's the algorithm they're following. I mean, I agree with all of that. Let's go through thyroid. So you said TSH. So for people listening, that's a brain hormone. That's what the brain says to the thyroid. We know that sometimes doctors are going by reference ranges that might be like 10, 15, like and, and they're like, yeah, well you're 14 so you're fine.

What's an ideal TSH that you're looking for? 

Christine Maren: I like TSH between one and two. Mm-hmm. So once TSH climbs above [00:09:00] 2.5, I just, I start to watch it a little bit more closely. Mm-hmm. I don't always treat If TSH is above 2.5 in conventional medicine, your TSH is gonna be like usually above 10 before you get treatment.

It's sort of like a watch and wait for you to suffer though again, risk benefit. There are risks to taking too much thyroid medication for sure. Mm-hmm. But that's too much. If it's well managed and it's not dosed too high and you get your TSH between one and two, that's like the sweet spot for me. 

Dr. Brighten: Yeah.

And you mentioned that sometimes the TSH is normal, but the free T four will be low. Explain to 

Christine Maren: people what that means. So secondary hypothyroidism can happen where your TSH, that brain-based hormone isn't responding to low thyroid hormone. So if you have low thyroid hormone and you're not producing enough, there should be this feedback loop that tells your brain like, Hey, kick on.

And your TSH will increase as a way of like knocking on thyroid store to say, Hey, gimme more hormone. And then you make T more, T four, more T three. But that doesn't always happen. And so [00:10:00] some people will have a low free T four with a normal TSH. Mm-hmm. And then they'll have a low free T three of course too.

If you don't have enough T four, you're not gonna have enough T three. Mm-hmm. Can you explain that? 'cause I don't think, I mean, yeah, I know what you're saying. So, but I don't think everyone does. T four converts to T three. Mm-hmm. And T three's really the active hormone. That's the most important. Like that is what interacts with your receptors.

Yeah. And so that's your active hormone, but you've gotta have enough of the raw material, which is T four. You strip off an iodine and you get T three. And so that conversion, sometimes we talk about women who under convert between T four and T three or have like low free T three syndrome. That low T three can contribute to thyroid symptoms.

Mm-hmm. But it's not always a thyroid problem. This is where it gets a little bit. Weeds. So some women will have a normal T four and a low free T three, and that low free T three tells me, Hey, you're not converting that well between T four and T three. But that's not really the problem with the thyroid.

In that case. It's a problem with [00:11:00] conversion. Mm-hmm. Which is often a problem with like inflammation, high stress, certain nutrient deficiencies, not enough food, like a caloric deficiency. That's one of the huge ones where women are under converting. And it just goes back to in everything, I think, well, how's this keeping us alive?

Because that's the real, I always say, your body loves you. It's trying to protect you. And that is our body's mechanism of trying to keep us safe and protected. But it's really like it's slowing down our metabolism. Yeah. So we have to figure out what's going on there. And often it's also rooted in gut.

Mm-hmm. Yes. Which is why we gotta talk about gut. Yeah. You 

Dr. Brighten: can't talk about the thyroid and not talk about gut. It's like a must. Yeah. Uh, so we'll get there, I promise everyone, but I want to get into the. Free T three and the reverse T three. Not a lot of doctors order reverse T three. Yeah. And sometimes I, you know, if I'm doing a CRP and I won't always like include the reverse T three depending on like, you know, how much the patient's like budgeting for labs.

Because unfortunately in the United States this is a big part of the conversation is [00:12:00] like, how much do you think it costs? And if people are like, well, why is that? If your CRP is up. I already know your reverse T three is up. But let's talk about the, because I do think there's value in the reverse T three.

Um, I hate when I have to pick and choose because insurance is just a pain, you know? 

Christine Maren: Yeah, totally. Yeah. Reverse T three is a great marker. I really like it actually when I am dosing GLP ones for weight loss because it's a good indicator for me if women are getting enough food and a lot of times the trend I see, 'cause their appetite will be suppressed on a GLP one, they'll stop eating and their reverse T three will go up, and that's the sign that your body's like putting on the the brakes.

So reverse T three is the brake free. T three is the gas. So you slow your metabolism down when reverse T three goes up. But again, it's your body trying to protect you. It's slowing your metabolism down saying, Hey, I don't have enough food. Right? Mm-hmm. So that's that sweet spot. Also with inflammation, it can go up and so yeah, reverse T three, I mean, it's there for a reason.

It protects us [00:13:00] in certain instances in our modern day world. It doesn't always let us like lose weight and feel great and have great energy if we're not giving our body what we need. But I do love checking a reverse T three. I tell my patients it's not a deal breaker if I'm assessing thyroid function.

Mm-hmm. But it's a really great piece of data for me. I mean, cash pay price in the United States about like $38. Mm-hmm. Uh, depending on what lab you go through, of course. But you know, so it's not like. It's not like a CT scan. I mean, it's not hundreds of dollars, but um, yeah, it can be a good indicator.

Dr. Brighten: Yeah. I like to call reverse T three, the hibernation hormone. Yeah, totally. 'cause I'm like, when it docks on your receptor, you are a barr in winter. Yeah. You are gaining weight. You are super irritable and cranky. You wanna sleep all the time and you're hiding away from everyone because as reverse T three is going up, there's usually issues with the HP axis as well.

And so our resilience to stress mm-hmm. Begins to disappear. So you're literally just like, I need to be in a cave. 

Christine Maren: Loudy live in a cave. Exactly. That's, I tell my patients, this [00:14:00] is like, you're in hibernation mode. I call it hibernation mode when reverse T three goes really high. Mm-hmm. And then I explain to them, I mean, think of it, if you're in a cave and you can't find food, what do you wanna do?

You wanna slow down your metabolism, conserve all your resources. That's why you drive up reverse T three. It's there to protect you. 

Dr. Brighten: Mm-hmm. 

Christine Maren: It's also a signal to us that like, hey, you're not getting enough food or you're under too much stress, or whatever it might be. 

Dr. Brighten: And it's also something really important for people to understand is that this is a big flare of the system is under too much pressure.

'cause where most conventional medicine is actually familiar with reverse T three is the studies on people who have had traumatic events gone through car accidents. And we know an elevated reverse T three is associated with four outcomes. Yeah. Which is usually you're expired. And I'm trying to walk the line with social media and not getting censored here, but it's not a good sign.

And so I think it's a really important thing too that somebody who goes through a divorce, they have the loss of a [00:15:00] loved one, loss of a pet, um, they've had something really traumatic is, is having that test to be like, where are we at? How is your system responding? Because unfortunately for women, especially in the United States, but it might be true in other countries, I just don't treat other people in other countries.

You usually have to have data in front of you to give you permission to slow down and until something is like black and white objective data showing you, you have to slow down. Usually women are like, I need to suck it up. I need to push through it. I need, you know, because there's just a lot 

Christine Maren: weighing on our shoulders.

Totally. Yeah. I mean, I talk about this all the time. Women push through. We are so tough. We are so resilient and like we can't do this forever. Mm-hmm. We can't overcompensate and overperform forever. Eventually it catches up with us and yeah, to see it on data is helpful. I feel like perimenopause is sort of that like biological time piece that says.

It's time to take care of you now. 

Dr. Brighten: Yeah. Why do you think it is [00:16:00] that thyroid health in perimenopause is getting like no airtime? Oh, on social media? Yeah. Major media, literally nowhere. 

Christine Maren: Yeah. Uh, well, it's a good question. I think it's because most of the people talking about menopause are talking about, you know, menopause medicine.

They're talking about estrogen, progesterone, maybe testosterone, but thyroid is sort of left out and lost in that conversation. You know, it's like an endocrinologist usually treats thyroid. Most endocrinologists don't really treat menopause. Some OBGYNs treat menopause, but not really any. OBGYNs treat thyroid health.

Dr. Brighten: Mm-hmm. 

Christine Maren: Primary care doctors often don't know much about menopause. You know, it's just lost in the conversation. So, I mean, that's where a functional medicine lens and menopause medicine lens, like all combined is really useful because as you know, like thyroid. Estrogen progesterone test, like they all go together.

The other thing that's really interesting we gotta talk about is like how those other sex hormones [00:17:00] influence thyroid because they're all connected. 

Dr. Brighten: Yeah, no, I was actually gonna bring that up because I feel like you absolutely cannot do menopause care and not also be managing thyroid health. And if you don't know how to do thyroid health, like this is not looking good for your patient.

And maybe you can have, um, you know, another team member and you're collaborating together. But the reality is, here's the thing. You don't have the uterus, we're just gonna give you estrogen. Okay. Nevermind. Let's forget the fact that without progesterone, you actually don't utilize your thyroid as well. So, but we can just forget about that, right?

Because you don't have a uterus. We're just thinking about your breasts and your, you, you know, downstairs and anything that covers a bikini and your brain, don't wear your pretty head about that. Like we, you know, you were always a little anxious anyways, right? Like, it's a, it's a big disconnect going on.

Yeah, totally. It's a huge disconnect. Yeah. So talk to us about sex hormones, thyroid. What do you wish perimenopause [00:18:00] patients knew? 

Christine Maren: Yeah. Well get your labs tested and it could also be thyroid. Like, yes, it's perimenopause and there are other things that happen here. Mm-hmm. So in terms of thyroid, uh, what's really important is for women who are on thyroid medication, you always wanna have your labs rechecked after starting or adjusting your dose of thyroid medicine, which seems like an obvious, but believe it or not, it's like not.

Done all the time. I always check anytime I, you know, my patients know this, you're gonna get your labs drawn in six to eight weeks after we adjust your thyroid medication. I do the same thing after starting HRT. So if we're gonna start HRT, whether it's estrogen, progesterone, testosterone, we're gonna recheck your thyroid as well because testosterone might decrease your need for thyroid medication.

Mm-hmm. Whereas estrogen might slightly increase your need. Most of the time I don't see that happening For sure. With birth control pills. Yeah. Like that's a whole other topic about sex hormone binding globulin, and maybe we'll go down that, that rabbit hole, but with transdermal estradiol, it [00:19:00] maybe will affect thyroid hormone.

It's a possibility and maybe will mean that you might need slightly more medication. However, it improves the way that your medication works or improves the way that your thyroid hormone receptor sensitivity, mm-hmm. Works. 

Dr. Brighten: When you're talking about birth control, that also falls into any form of oral estrogen that raises sex hormone binding globulin that's gonna grab your estrogen and your testosterone.

This is why anyone listening if you're like, I didn't have a libido in my like twenties and thirties because you were on birth control. You, you were gobbling up these two primary, they're called sex hormones. They do a lot of things in your body, but estrogen definitely for women and testosterone are so important in sexual health.

So you were talking about the difference between oral estrogen and topical estrogen, and I want to really hone in on this birth control conversation for a minute because so often we see doctors say, just take the birth control [00:20:00] pill for your perimenopause. Why is that so problematic? Especially through the lens, what the changing dynamic of thyroid health?

Christine Maren: Yeah. I have a lot to say about this. Um, and most of it's not good. Yeah. Uh, I do not think that. Birth control pills are a good treatment for perimenopause, period. So yes, they provide contraception, but we have better, safer ways to provide women with contraception. So back to the risk benefit discussion.

Let's just talk about the risks. First of all, with birth control pills, there can be some serious risks, especially as women are aging, which includes things like blood clots. I mean, they're big risks. And while they're not super common, they're common enough that every time I give a talk, somebody comes up to me and says, oh, I was that woman who got a clot in my brain, or whatever it might be like.

It's real. Mm-hmm. Also, it decreases libido, like it increases sex hormone binding globulin, which which binds up hormone. So it's gonna bind up free thyroid hormone. It's gonna bind up free testosterone. So lower libido, lower thyroid [00:21:00] function, it's gonna deplete certain nutrients. It's just, why, why are we using that to treat perimenopause?

We have better options and they're safer. And guess what? They come with benefits too. Yeah, right. When we talk about using bioidentical progesterone like. Why would I give somebody a birth control pill? And it's just like, doctors are doing their best. This is what they're most familiar with. Mm-hmm. This is what doctors have been prescribing for 20 years.

They didn't learn about HRT, none of us did in the two thousands. So, you know, it's just, it's what doctors are familiar with and what doctors know. Uh, but it's, yeah, I think it's a terrible treatment for perimenopause. 

Dr. Brighten: Yeah. So I actually did learn about HRT in medical school in the two thousands. And I had to say that it was so wild to me when I found out that doctors who were not getting trained in perimenopause, menopause, HRT prescribing, like so many of the people now who are leading this big menopause movement, they've only been [00:22:00] prescribing HRT for like three years.

Like, they just figured this out. And I remember, uh, seeing Dr. Uh, Mary Claire Hayford when she said that, and I was like. I, you've been in practice longer than me, but I've been prescribing and managing menopausal women like more longer than you, and like what is happening? And I was so glad to see her bring up that topic and for you to bring it up as well.

Because I think often people are like, my doctor hates me. They don't wanna help me. And what they don't realize is that their education had this. Huge gap in it that made it so that they don't really know how to manage things and they don't understand progestin in birth control is not progesterone.

Yeah, and I had Dr. Sarah Hill in the podcast, I will link to that. We were talking all about, you know, she studies how hormones affect women's brains. That's her research and she's like, the fact that everybody acts like progestin is this great thing is wild because it does [00:23:00] not have any of the benefits that progesterone does.

The best it's giving you is like keeping the uterine lining thin. You know, you're having an IUD like. But really in reality, uh, it's just, it's not the same. And I think that's important for women to know. Let me ask you, 'cause I've asked a few other guests this, what do you think about the fact that our whole life, we've been told that birth control pills are safe?

Don't question it, don't worry about the clots. But when you get to perimenopause menopause and you wanna use HRT, that's dangerous. Oh yeah. 

Christine Maren: You couldn't do that. I know. It's a total double standard. It's ridiculous. It's totally crazy. I mean, birth control pills, we're just familiar with them, right? Like they seem easy, but there is a lot more risks.

Versus benefits. Mm-hmm. For most women, especially as we age, especially when we're in perimenopause and we're just not familiar with HRT, I mean, doctors are just not as familiar. So yes, it's a total double standard. Like why are we putting so much scrutiny [00:24:00] on using HRT and bioidentical hormones that our body knows and knows what to do with, but then we're comfortable using synthetic.

Estrogens and synthetic progestins. 

Dr. Brighten: Well, and the progestins, I mean, uh, every time a research study comes out about the breast cancer risk, those progestins are looking worse. Yeah. And worse. And worse. And when we consider why, why we believe now that we have that risk. It's the use of progestins and not progesterone when you're working with that perimenopause and menopause population.

Yeah, totally. Yeah. So I want to talk to you a bit about what are the warning signs. Let's say you're in your forties, you've entered perimenopause, your doctor's like, yes, we're managing your perimenopause, but maybe there's something thyroid going on. Mm-hmm. What are the warning signs that women should pay attention to?

Christine Maren: Well, if you start HRT and it's not working that well for you, I mean, a, a lot of women start HRT and they're like, oh, I feel like myself again. And a lot of women are like, well, what's [00:25:00] missing? I'm not like all those other women who feel better all of a sudden. Mm-hmm. Because there's a lot of other underlying issues.

It's not just about estrogen, it's not just about progesterone, like soften about thyroid. So I mean, persistent symptoms, anything, right? Like you have persistent brain fog, you have persistent mood symptoms, you have persistent fatigue, weight gain issues, cold intolerance, uh, just kind of feeling sluggish, you know, can be a million different things.

I think thyroid is really non-specific. It might even be anxiety. I mean, especially if we're talking about Hashimoto's, like I mentioned earlier, there is an uptick that we see through. Perimenopause, menopause of women who have autoimmune disease. And as you talk about, I know that, you know all this information, women are, they dunno, you don't tell them they're under, women are underdiagnosed with autoimmune disease.

Mm-hmm. That's a really common problem among women. And part of it, by the way, is because we're pushing, pushing, pushing all the time. Like there's a personality associated with that. So [00:26:00] I work with women every day and I talk to them about like, tell me about your childhood. What was that like? I mean, I don't know, 9.9 outta 10 times.

She is super capable, learned how to take care of herself at a really young age. Um, she's a high achiever now. She knows how to get things done. She's super reliable. She does all the things. Except there's this subtle, like self neglect and it's often really subtle. Uh, and it's, you know, it's nothing to be like, to have shame around.

I mean, women are so used to taking care of everybody around us, and especially our children. Mm-hmm. And so when we go from this transition from, you know, motherhood to like. It's called the Crohn phase, or I call it the queen phase. When we go through that transition, it's really, it's a really big transition, but it goes back to this autoimmune piece because there's this personality, and it's so common among women who have autoimmune disease.

And so autoimmune disease starts to show its face when women have these big transitions like pregnancy and [00:27:00] perimenopause. Mm-hmm. So there's definitely a hormonal aspect to that, and of course a gut aspect too. And so that's why we've gotta test for Hashimoto's. Most women who have hypothyroidism don't know that it's actually caused by an autoimmune disease.

And those are two separate issues. There's the hypothyroid component, which is all about the hormones. Mm-hmm. But there's the autoimmune component, which is driving that. And so often the autoimmune component appears first. That's the first thing. But we're not testing for it, so we don't know. So it's not a hard test.

Again, it's like 30 to 40 bucks. It's a thyroid peroxidase or, and a thyroid globulin antibody. I like to do both. Mm-hmm. And so for women who have autoimmune disease, the signals or those signs that they would have some underlying thyroid issue, it's very complicated. Like they might be anxious and then they're depressed, and then sometimes they have like palpitations or fast heart rate, and then sometimes they feel really fatigued and sluggish.

And so it could be all over the map. But it's just these lingering symptoms. I mean, I think ultimately for women, if something doesn't feel right, keep advocating for yourself. Mm-hmm. Get more [00:28:00] tests done. Don't just accept like, oh, it's aging and I'm destined for failure. Screw that. I'm so over that. Like we're getting old and we're moving into our power.

Forget it. I just have to say 

Dr. Brighten: that we were having breakfast this weekend and your husband was like, well, I figured, oh, I'm 51 and I'm getting old. And I was like, no. Did you just say, I like, I mean, no, I'm gonna still, I'm like, I train like every day 'cause I'm still gonna ride my bike in my eighties and like maybe I'll break a hip 'cause I'm being reckless.

I don't know. But I still am like, no, I just feel like we so early start to adopt that, um, mindset when we don't feel good. But when we get pushed back on from our doctor, I do wanna go back to what you said about Crohn because if somebody's hearing from that the first time, they might be like, what? She just called us Crohn's.

No, no. Uh, so there's maiden mother crone. Those are the phases of our life. And somebody decided, crone was a bad word at one point and started to like weaponize it against women, but it was actually like the wise woman. [00:29:00] Um, I think Queen is like a, you know, I think, um. I don't know what, what is that? Gen Z that's always like, yes, queen.

Um, but when you really step back and think about a queen leads, she leads with wisdom. Like she has, like, you know, this, um, embodiment of navigating the world gracefully because, um, she's honestly got knocked around and fallen in some holes and figured it all out. And I think, um. It's a really beautiful perspective.

What I wanna talk about is what about estrogen and progesterone shifting? Sometimes testosterone as well in perimenopause is increasing the risk for hypothyroidism, specifically autoimmune disease. 

Christine Maren: Yeah. So this is really interesting research. So this topic, we can talk about the MicroGen. This was just introduced, I think 2013 was the first time this really appeared in the research.

So we're talking about sex-based differences in the gut microbiome. So gender-based differences in the gut microbiome, how a woman's [00:30:00] gut microbiome and a male gut microbiome are different by design. And as a woman approaches perimenopause, she loses a lot of the diversity that she had. In her younger years, which changes the gut microbiome in a really important way.

The gut microbiome and hormones are very bidirectional, so gut has a really important influence on hormones and the way we metabolize hormones and like bring 'em in, get 'em out, and hormones have a really important influence on. The gut. Mm-hmm. You know, those gender-based differences in the gut and there's these downstream effects that affect the immune system.

And so that's the huge part. Like gut microbiome plays a huge role in intestinal permeability, which is keeping the. Basically like it keeps your immune system when your gut is really tight and you've got those tight junctions, we're good. And when those tight junctions become leaky, that's what people call leaky gut.

And that's when we're not good. That's when we start to have more inflammation and autoimmune disease and it can become [00:31:00] really problematic. And in this like downward spiral really for women. So it's all rooted, it's rooted in gut microbiome, but gut microbiome is shaped by your hormones. And at the same time, your hormones are really shaped by your gut microbiome.

And all of that downstream effect influences immune system and autoimmune disease, which is gonna impact thyroid function. Mm-hmm. 

Dr. Brighten: One of the symptoms of perimenopause that I think, you know, most people are like, hot flashes are perimenopause, like, but there's all of these other weird symptoms, right?

Because like a burning tongue and, uh, ringing in your ears and itchy ears. Like these things are like, this is weird. Yeah. Right. When you're living it, IBS. Really common new diagnosis of IBS. And that is always, I am, I feel like I, I like wanna run through doctor's offices, like throwing red flags when the GI doc's like it's just IBS red flag.

Like Yeah, totally. Yeah. So I, I'm gonna wanna talk about that, but first, I know that there, while Graves disease is not common, there are people listening who [00:32:00] are certainly going to have Graves' disease. So before we totally shifted into the gut conversation, I feel like while we're talking about autoimmunity, let's talk about Graves' disease because that we can see come up as well.

And it can look like hot flashes, perimenopause. 

Christine Maren: Yeah, totally. I mean, anxiety, fast heart rate. So that would be hyperthyroidism. So TSH would be really low for those people listening. So a low TSH and your thyroid's like working overtime? Mm-hmm. Um, and that might feel like a hot flash. That might feel like you can't sleep at night because you're all revved up.

'cause you are like, you've got a ton of thyroid hormone. Yeah. And usually people have a pretty fast heart rate with that. Mm-hmm. 

Dr. Brighten: And in Hashimoto's, your immune system is attacking the thyroid. Destroying the thyroid. That's why we have to come in with medication to replace it. Uh, non-negotiable. By the way, I'm someone who, by the time my Hashimoto's was caught, it was like, you need medication.

You're not coming back from this. And I like living, I really like being alive. So very grateful to have this medication. Tell [00:33:00] us how that's different from Graves. How does, how does Graves 

Christine Maren: actually work? So when women have Graves disease, that's more of a stimulation. So we're stimulating the TSH receptors and so overproducing.

Thyroid hormone. 

Dr. Brighten: Mm-hmm. Yeah. And I think that's important for people to know because they're gonna be, you know, often they're like, why do we have all this thyroid hormone? And it's because your immune system is actually making, basically making your thyroid work over time. And so these, this symptoms of graves, of this hyperthyroidism is they're the same things that you can experience if you're overmedicated with thyroid hormone now overmedicated with thyroid, ho hormone over a long period of time.

We're talking about cardiovascular risk, we're talking about bone risk. Mm-hmm. But what are the signs short term? So you put a patient on thyroid meds, you're like, we're gonna check you in six to eight weeks, but I know you say, look out for these things. Yeah. In the 

Christine Maren: meantime, anxiety. Can't sleep very well.

Like kind of the insomnia piece feels like you drank 10 cups of coffee. Um, racing heart really [00:34:00] fast heart rate. I mean, you can like just feel your pulse. It's often over 100 and women who have graves sense of dread. Yeah. Yeah. It's a sense of dread. Exactly. Yeah. Yeah. And 

Dr. Brighten: you know, I've heard also patients say like, I'm buzzing totally.

Like I just feel like totally there's like electricity running through me and I'm buzzing. And so if you're filling that amped up filling and you're like, I have hypothyroidism. Well, nobody says you can't have more than one autoimmune disease. But also, you know, that can sometimes be an attack on the thyroid mm-hmm.

Happening with, uh, Hashimoto's. Or it can be that you're overmedicated. And I think that's really important to pay attention to. Especially because historically there was a trend of like women who wanted to lose weight being put on thyroid medication. Maybe we should talk about that. Yeah. 'cause weight gain is a symptom of hypothyroidism.

I mean, I remember. I couldn't like work out 'cause I was like in so much pain recovering and um, and I was putting on weight. So I, I had my son and then six months later I didn't even fit in my third trimester of pregnancy clothes. And I was like, what is going on? I'm like going the [00:35:00] opposite direction.

Like, first I lost a bunch of weight, now I'm gaining a lot of weight. And I think we should talk about this in the context of what is going on, what women should be aware of, and then caution that we don't wanna use thyroid medication for weight 

Christine Maren: management alone. Yeah, I mean, I see both sides of the coin in my clinic.

I see women who are undertreated with thyroid medication and then I definitely see women who are overtreated and I'm not a big fan of that. Uh, it's not good for our bone health. It's not good for our cardiovascular risk, especially as we're aging. It's not good for our mood. I mean, I've had patients who had severe anxiety.

I had a. 30 something patient who had such severe anxiety, she stopped working. Mm-hmm. She was living with her parents and when I first looked at her thyroid labs, all of her, you know, T four and T three were like way off the charts and her TSH was suppressed and it was, that's what we call iatrogenic hyper hyperthyroidism.

Mm-hmm. It's because you're on too much medication. So we started weaning off that medication and she did great. I mean, it wasn't all that complicated, honestly, to get this woman her life [00:36:00] back. Unfortunately. It was a problem of like overmedicating. 

Dr. Brighten: Mm-hmm. 

Christine Maren: So yeah, there's a sweet spot. It's like everything, too much of a good thing is a bad thing.

So I think that's something to be aware of and careful with. Ideal levels of T four and T three, we talked about TSH. Yeah. But I'd love for you to share that with people. So I like a free T four when I'm checking labs. I'm checking. Unless women are pregnant, a free T four and a free T three. So I like free T four above one, usually like 1.1 to 1.4, something like that.

Mm-hmm. And free T three I like in the three. So 3.2 to three point A is usually the sweet spot. Now the tricky thing is when women are on thyroid medication, when to test. A lot of women, especially in the conventional paradigm, are given zero like instructions on when to get your labs drawn in terms of when you are, you know, if you're taking thyroid medication.

So if I have a woman who's taking medications that include a T three, so that might be like some sort of levothyroxine, Synthroid, terin plus the T three would be [00:37:00] Cytomel or li thine. I want her to get her labs drawn four to six hours after taking that medication so that I can see the impact of T three.

And then we can titrate the dose. We might increase it, we might decrease it. It depends. There's also natural desiccated thyroid like armor 

Dr. Brighten: mm-hmm. 

Christine Maren: That has T three in it. And so again, same thing. I wanna see her labs four to six hours after she takes those medications. So I have some idea of the impact.

Whereas if you're taking a T four only medication, most women take that medication first thing in the morning, empty stomach as instructed, and then they go get their fasting labs drawn. And of course their free T four is kind of high, but that's all artificial because that's from the medication. So if you're taking a medication and you really wanna know your free T four, don't take it before your labs are drawn.

Take it after, 

Dr. Brighten: at the time of us speaking. Right now the FDA is going to remove natural desiccated thyroid hormone from the formulary from being available to people. What impact do you think this is going to have and do you think this is a wise [00:38:00] move? 

Christine Maren: I, no, I don't think it's a wise move and. I used to use a lot more natural desiccated thyroid in my practice than I do now.

Dr. Brighten: Mm-hmm. 

Christine Maren: Um, I rely a lot on Levo Thro. Well, the, a name brand version of Levothyroxine and Lihi, you can say it. Yes. 

Dr. Brighten: Because most people are gonna be like, 

Christine Maren: levothyroxine. What's that? Here's you're getting prescribed. So the, the generics levothyroxine. The name brand that I like the best is Tynt or Yes.

Synthroid is also a name brand that Talk about why you like Terin best. Yeah, I like Tynt because there's very few excipients. It's a really clean medication. It's got three medic, or it's got three ingredients, levothyroxine and glycerol and water. Mm-hmm. Um, and it comes in a capsule. It comes in a solution.

The solution's great for people have absorption issues. So TLP ones listen up. Yeah. I mean, it's, it can be more effective for sometimes when women is on a levothyroxine generic. We'll see, like TSH will not be as reliable. It's be, it'll be up and down because her thyroid medication isn't as reliable.

Mm-hmm. Um, [00:39:00] so, you know, and then we can use a synthetic T three. So here's the deal. This is an interesting one with perimenopause. When we used to use Premarin, that's not bioidentical to a woman. It's not really even bioidentical to a horse, but it would be the closest, right? Yeah. Like that's almost bi, like it's more bioidentical to a horse because it's made from a horse's urine.

Mm-hmm. From a pregnant MA's urine. So with armor thyroid, it's the same thing. It's not bioidentical to our thyroid hormone. Mm-hmm. It's bioidentical to a pig. So for most women it has too much T three in it. 

Dr. Brighten: Mm-hmm. It 

Christine Maren: doesn't mean I never use it. I have some patients who feel better on it and I listen to my patients so that when they're like, Hey, you know, I literally, there's like a handful of patients who can tell me I felt better on the arm thyroid and so we'll go back on it, but.

I mean, most of my patients are on synthetic T four and synthetic T three. Mm-hmm. Which is bioidentical by the way. So synthetic doesn't mean it's not bioidentical. Yeah. The important piece is that it's [00:40:00] bioidentical. 

Dr. Brighten: I think that's important that you said that. I really appreciate you bringing that up.

'cause we talked about progestins before, which don't look like or act like progesterone at all, but Synthroid levothyroxine looks like, acts like T four Cytomel. Looks like acts like T four I really, um, T three. T three. Sorry. Thank you. I really like, I was gonna start talking about tirosint, so I was going back to T four.

So Tirosint, I like that you brought it up for people with absorption issues because I see that people on GLP ones, because their gut motility slows, they actually do better. And I will even advise people sometimes, like take it at night so you haven't eaten for four hours like you're getting in bed.

Take it. You don't take it with magnesium. So if you. Yeah, I just want people to know if you take supplements at night, that's not gonna be an option. 'cause you have to have everything away from this. But, um, I really like that one. I see that it, it performs really well and I appreciate you bringing up that armor.

So there's armor, np, thyroid, um, Naturethroid is like off [00:41:00] and on. Is it available? Yeah, I haven't been able to get it for years. Yeah. I used to be WT 

Christine Maren: thyroid, like I haven't seen that for five years or something. 

Dr. Brighten: Yeah. I, I used to be on Naturethroid. I felt phenomenal on that. Mm-hmm. I switched to NP thyroid.

Um, there was a time where I was like, I feel awful. Lo and behold, they have a recall. Um, it happened a second time. Yeah. And I was like, your girl's out? I'm switching. I'm just going with, uh, levothyroxine. And then I just monitor things. If like, do I need Cytomel? I'm pretty good about keeping up my conversion.

Um, but life happens sometimes. So, sometimes I do need some T three, but, uh, I think. Taking away this option is a really bad idea because some people, natural desiccated thyroid hormone Yeah. Is all that helps them. The only thing that makes them feel good. And when the, you know, standard super cheap, right?

$5 prescriptions over the, you know, over at Rite Aid or whatever, are not working. If we can't get natural desiccated thyroid hormone, we're gonna start looking at compounded. Yeah. And compounded is tricky. There are very, [00:42:00] very good compounding pharmacies out there who are very rigorous. Um, you know, if you're a practitioner listening, like you wanna meet with them, you wanna ask them all the questions, but then there's lots out there that are like, you can make a lot of money with like hormones.

So we're just gonna like, you know, mail order, all kinds of hormones that can be prescribed. And so that's where things get tricky. And we know the FDA is like, I wanna shut down compounding pharmacies, but. When you're dealing with a hormonal issue that is due to autoimmunity, it's not so cut and dry. It's not like, you know, when you have somebody that has primary ovarian insufficiency and they've got 21 hydroxylase antibodies, it's not as easy as just doing your run of the mill, uh, you know, estradiol patch and then hitting 'em with progesterone because that immune system's involved and that's running amuck.

So I very much am like, we should not be taking away options, especially because Synthroid makes a lot of money in the United States. And I have [00:43:00] a big question Mark Marty, if you're listening, I have a big question mark of like. Did they have influence in this in some way? Yeah. Because they often are the leading prescription in the United States, which speaks volumes.

Mm-hmm. 

Christine Maren: How much hypothyroidism we have. Totally. Yeah. No, I agree with you. I mean, we need options and I, I use compounding pharmacies for some things. Thyroid medication is not really one of them, and it's because we're dealing in micrograms. It's such a small amount. Yeah. It's really hard to be precise.

For those prescriptions. So I don't really, I don't love compounding T four T three medications. Mm-hmm. I'd rather have the option to prescribe armor 

Dr. Brighten: for some women. Yeah, I agree. And I think, you know, sometimes compounding pharmacies make, you know, they'll be like, we can do it in a liquid. That I'm always like, yeah, just, I just want consistency day in and day out.

Your adrenal glands and your thyroid love consistency. They don't love like all over the place. Yeah, totally. So I wanna ask about how, you [00:44:00] know, actually I was gonna ask about exercise, but I wanna go back 'cause you mentioned GLP one. I've brought it up. Um, I had McCalin as you know, treats a lot of thyroid.

She has a weight loss clinic talking about her utilizing GLP ones in thyroid patients. Is that something that you're doing as well? It is. Yeah. Say more. I, 

Christine Maren: the answer is yes. Um, I, yeah, I do microdose GLP ones in some patients, so especially Tirzepatide, tirzepatide ISS being studied in autoimmune diseases.

Mm-hmm. Like psoriasis, we know there's some anti-inflammatory effects as well as weight loss effects. I think it's something to be cautious with. Mm-hmm. Um, and it's really important that women who are on a GLP one are doing it the right way. 'cause you can lose your muscle mass, which is your metabolic engine.

Gives you a lot of good things. Also protects you from things like autoimmune disease, which is pretty cool. Uh, but yes, you can do a GLP one the right way and you can do a GLP one the wrong [00:45:00] way. And when it's done the right way, I do see that it helps a lot with inflammation and it can help with autoimmune disease.

Dr. Brighten: Let's talk about microdosing, because something that I was just made aware of is that. There are some people saying 2.5 milligrams is microdosing. Oh. And I'm like, wait, what? Yeah. Um, I consider microdosing like when we are at 0.25. Yeah. Like we're at the starting dose and we are not going up to the dose that we need to actually initiate weight loss.

So we know that, um, you know, at that lower dose, that's where we start people, we gradually work them up so that they have less side effects, but that's not gonna be a therapeutic dose for our weight loss for people. So when you say, and the reason why I do 0.25 is because less side effects, but also it's very easy to measure in these.

Um, you know, I know that, um, Nicole, she uses, uh, compounding pharmacy. She does things like very differently. I'm always like. How do we make it so easy on the patient [00:46:00] again, women are doing enough. How do we just make this as easy as possible? When you say microdosing, 

Christine Maren: what are you talking about? Yeah, so it depends if we're talking about tirzepatide or semaglutide, but if we're talking about tempera tirzepatide, um, I usually start at 0.5 milligrams.

Mm-hmm. So like about a fifth of this starting pharmaceutical dose. So in the pharmaceutical world, you know, we start at 2.5, ramp 'em up to five, then 7.5, and so on. Uh, and that happens like within weeks. Uh, in my clinic we start at a fraction of the dose and then just really slowly titrate up. But I tell my patients, you're kind of like, you gotta chase this threshold.

So it's important to keep increasing your dose 'cause you've gotta chase this threshold. And when I say threshold, I'm talking about like benefits. Then risks on the other side of that hill is where the risks come up. So we don't wanna like cross that hill where you don't have an appetite anymore and you stop eating food and then you lose all your muscle mass.

And yes, you lose [00:47:00] weight, but you also lose muscle. Mm-hmm. The goal is fat loss, not muscle loss. And so it's really important. You have to feed the machine, you have to feed your muscle. Ultimately, if you're not eating and you're losing fat and muscle, you're slowing down your metabolism and you're telling your metabolism like, Hey, go into hibernation mode.

I'm screwed. I can't find any food here. Slow down. And that's like the opposite goal. What we're trying to do is feed the machine and rev the machine and get it moving. And so you gotta feed yourself. And so if you go past that hump and you are to the point where you're not eating anymore, you're gonna lose.

Wait, but you're gonna lose muscle too. Mm-hmm. And so the right way, the way that we do it is we, we increase just really slowly. And if you get up against that, that like hill where you feel like, oh, I'm nauseous and I don't wanna eat, you gotta back back down. Mm-hmm. And then probably in like another couple weeks or maybe months, you'll be able to go back up to that dose because you're gonna be less sensitive to it the longer you're on it.

Dr. Brighten: Mm-hmm. 

Christine Maren: But you do have to keep increasing it or it's gonna lose efficacy. 

Dr. Brighten: And when I was saying, uh, [00:48:00] 0.25, I should clarify that that was semaglutide. Um, so yeah, as you said that, I was like, oh wait, I didn't say what I was specifically speaking about. You said there's a right way and a wrong way to do it.

So part of that right way is let's go slow and let's not lose our appetite. So we keep eating. What other mistakes are people making when they use 

Christine Maren: GLP 

Dr. Brighten: ones? 

Christine Maren: I mean, not lifting weights is a big one. One of the priorities. We always tell patients, it's like, you got to eat enough, you have to eat enough protein, you have to need, eat enough fiber as well.

Mm-hmm. But pro prioritize protein and fiber, prioritize weight training. 'cause you've gotta build muscle. The goal is that you build muscle, loose fat. And so we'll have women use like a, an in body scan or do like a body composition scan 

Dr. Brighten: mm-hmm. 

Christine Maren: Prior so that we understand like, where's your baseline? And then during treatment so that we can see actual numbers.

Are you losing fat and gaining muscle? Are you losing muscle? If you're losing muscle, like we gotta dial back, there's something going wrong there. 

Dr. Brighten: Yeah. And how much strength training are you [00:49:00] recommending in a week for patients to maintain their muscle mass? 

Christine Maren: I mean, the reality is whatever you do is some is better than nothing.

Mm-hmm. In an ideal world. I would love to see somebody in the gym for an hour, three to four days a week. That's what I do personally. I mean, I do, I lift weights four days a week for a laced an hour. 

Dr. Brighten: Mm-hmm. And when it comes to protein intake, when people are losing their appetite, how do you help them overcome that?

Right. Because you, you're talking about dialing back, but it is something that your, your appetite is gonna come down. Like you, you are going to want to eat less. Uh, you shouldn't lose your appetite altogether is what you're saying, but people are gonna be like, it's easier to eat carbs. Right? That's less filling than eating a steak.

Christine Maren: Yeah. I think really if women are having appetite loss, you gotta dial back. It shouldn't be appetite loss, it should be food noise, so they're not craving sweets. There's less food noise, but you're still eating three meals a day, getting 30 grams of protein [00:50:00] at least, especially at breakfast, but three times a day and carbs.

This is where the carb conversation can be really interesting. They are, uh, GLP ones are insulin sensitizers, so they should, uh, nutrition's nuanced as, you know, everyone's gonna be different. But what I see in most of my female patients, these high performing, high achieving women, they're not eating enough carbs.

Mm-hmm. They're eating a ton of fat. And so when you're on a GLP one, most of these women, especially I'm talking health conscious women, you know, often following like a paleo style diet. Hey, been there, done that. Like I was her, when I started looking at my macros, I was eating so much fat, it was all good fat.

Mm-hmm. Almonds, all the stuff, all the, you know, healthy fats, avocados, um, but I had to dial back on the fats. And when you're on a GLP one, it's important to dial back the fats a little bit and increase complex carbs that have fiber. So things like oats, whole fruits, those are great. Of course, like we're not adv, I'm not advocating for sugar and, you know, juice or whatever.

But [00:51:00] complex carbs with fiber and protein can be really helpful in this phase of life. Especially if you've got a GLP one on board and you're more sensitive, now you've, you've turned up your insulin sensitivity, you're gonna be able to tolerate this more. Mm-hmm. And of course, if they come in the right, like if they're packaged really well, like a resistant starch, that's gonna be better tolerated for blood sugar as well.

Dr. Brighten: And how do you feel 

Christine Maren: about 

Dr. Brighten: liquid proteins? So, mm-hmm. Collagen, uh, doing protein powder 

Christine Maren: smoothies. Yeah. I personally do use a protein powder because I have a hard time getting enough protein in on my days that I work out. Mm-hmm. Um, so I do, uh, like three scoops after my workout. I get 30 grams of protein in that I don't count collagen toward my protein macros.

I still use it 'cause it's good for hair, skin, nails, gut, you know, all the things. So I still use it, I stick it in there, but it doesn't count toward my protein goals for the day. But on days when I work out, I add a 30 gram protein shake [00:52:00] after my workout. Now you have to be really careful about what you're choosing.

And I mean, there's the flavor issue and the tolerability issue. Whey protein, if you tolerate it and you can get a really good quality one, go for it. I cannot do a whey protein personally. Mm-hmm. So everybody's gonna be a little bit different. And if you wanna just get it from real food, like obviously that's the best choice.

I just gotta work, right? Yeah. Like, I gotta like come up with a decent solution. So, um. Really high quality pharmaceutical grade stuff that's been third party tested. I personally use, like, I like Metagenics mm-hmm. As a protein powder. I really like, so 

Dr. Brighten: then everyone you wanna look for the GMP manufacturing?

Yeah. 'cause that is gonna be the pharmaceutical standard of Manu manufacturing. Um, I was just laughing as you were like, I don't count my collagen. I'm like, neither do I and I drink like 40 to 60 grams of collagen every day. That's a lot. Yeah. But I always, I'm like always adding it to my tea. Yeah. Like, I'm always adding it to beverages.

But yeah, as you were saying that, I was like, yeah, I don't, no. Wait. Uh, we gotta explain why, [00:53:00] why does collagen not Yeah. Count? What's your, you know, especially post-workout. Yeah. Yeah. It matters greatly. 

Christine Maren: Yeah. So collagen is not a complete protein. It doesn't have leucine, leucine, iss really important for building muscle.

Dr. Brighten: Mm-hmm. Yeah. I think that's important for people to understand. But again, yeah. I, I, um, I'm not worried about my 40 grams of collagen a day because, um, I'm in my forties. Which I like to make jokes about how my body's like. Yeah. You know that collagen building thing we used to do. Yeah, we're done. Yeah, we're done.

Christine Maren: Yeah. You gotta keep your hair like the forties is also this time when women really have a lot of hair loss. Mm-hmm. So, I mean it can help. It's not gonna solve hair loss, but like, 

Dr. Brighten: let's go there with hair loss though. Yeah. 'cause you said it and women are gonna be all over it. Hair loss can be hypothyroidism, but what else?

For sure. 

Christine Maren: Yeah. So thyroid is like a deal breaker for hair loss. Mm-hmm. But female pattern hair loss is really common in perimenopause and often it's, uh, a relative increase in androgens. So. This is where I love the functional medicine lens [00:54:00] because we know how five alpha reductase works. Mm-hmm. Because we've always been testing this on a Dutch test.

Yeah. So you can see we've been testing this forever. Like you can see how a testosterone breaks down in the body by looking at this enzyme five alpha reductase. And when you turn up the dial on five alpha reductase, it'll make more androgenic metabolites. And so women who happen to have a higher five alpha reductase activity are more likely to lose hair if they take testosterone.

So that can be a big problem during hormone replacement therapy, of course. And or like if you're taking a supplement like DHEA for some women. Mm-hmm. Uh. And we have a relative increase in androgens to estrogens, which is really common with female pattern hair loss. And that's when women start to lose hair a lot.

Like the scalp starts to widen. So it's that kind of hair loss. Yeah. Not like patchy hair loss. 'cause there's other causes of hair loss, like autoimmune issues and all that. So, um, so yes, five alpha reductase is a big deal. Things that can downregulate or turn the dial down on five alpha reductase. I love this one 'cause it's estradiol.

So [00:55:00] estradiol can turn down that dial, but it also offsets the, that's like a quote of a quote, estradiol turns down the dial. Yes. I'm like, I love that. I'm gonna make that into a rep. Um, estradiol can turn off, like can turn down that dial for five L for duct taste and it helps with that. Kind of ratio between estrogen and androgens.

Um, zinc saw palmetto, those are some other favorites that can turn that dial down. And things that can turn that dial up or make it worse, it's of course testosterone or DHEA, which I love. DHEA, I just don't love a lot of DHE. Mm-hmm. And I don't love it for everybody. 

Dr. Brighten: Well, and it's crazy 'cause it's over the counter too.

Um, and, and that's something I don't know, I always, uh, go back and forth on things because in a lot of countries a lot of things are over the counter and people are doing just fine. But in the United States, I don't know what the deal is with DHEA, but like women will be like, I got this DHA on Amazon, I'm taking 50 milligrams and now my hair's falling out.

And I'm like, yeah, of course it is. Like that's, that's far too much, like [00:56:00] far too much going on. So I always caution di with using DHEA, even if it's topical. Yeah. It's really common. And, um, women will jump into that for fertility treatments. Mm-hmm. Because they hurt it on a forum. Yet we know that if you've got too much testosterone, you're pushing too much of that, that can be problematic for a quality.

So it's not, it's one of those hormones that I'm like, it seems benign on paper, but in reality it, it can be really problematic. 

Christine Maren: Yeah. I mean it's again, it's like too much of a good thing. It's a bad thing. Mm-hmm. And we're all so individual and so, I mean, I can do like 10 25 milligrams of DHEA 25 milligrams and I'll get a pimple.

I have, uh, some fertility patients who come to me on 25 milligrams three times a day. Yeah. And I'm like, whoa. But they tolerate it fine. Uh, and then other people who have taken that much and had hair loss, unfortunately. Mm-hmm. So, yeah, I mean, I would just caution, yeah, if you're gonna do DHEA, go low, go slow, start it on its own and watch for hair loss and come off of it if that's what happens.

Mm-hmm. [00:57:00] 

Dr. Brighten: We were talking about exercise before we took the little hair loss tangent. Women with hypothyroidism, they don't have energy. They feel really sluggish. They have a hard time recovering from exercise, and so their idea is. Just do nothing because I feel so awful. Yeah. But I think having you explain like what's a good entryway, because you're not gonna jump to weightlifting four times a week, you know?

Totally. Um, we of course gotta correct the thyroid, but what are some of the entry exercises that women can be doing if they have hypothyroidism? 

Christine Maren: So walking is the first one. I mean, moving your body is really important. And to be clear, if anybody's telling you not to exercise, don't listen to 'em. You gotta exercise.

Mm-hmm. You just, it's gonna depend on thyroid function and also your mitochondrial function. If you have really poor recovery, so you listen to your body for sure, and you gotta work your way up toward more movement. It's gonna be like, maybe the most helpful thing you could ever do is exercise. Mm-hmm. So exercise also influences thyroid hormone receptor sensitivity.

It makes [00:58:00] all your hormones work better. Stand it can be really hard to get started, especially if you're dealing with an autoimmune condition or hypothyroidism. That's first of all, like. Treat it don't like. I don't want anybody to be dealing with untreated hypothyroidism. Yeah. Treat it like there's no reason to suffer and you gotta work your way up.

So start with walking. If you're walking and you're doing okay, like increase it. Maybe if you've got 10 minutes in, you then go to 15 the next week, then to 20, maybe you added weighted vest at a certain point, and then you can start doing just lightweights, right? You can do five, 10 minutes a day. Like there are some apps out there and some different programs that'll give you like a seven to 10 minute weightlifting workout that you do every day.

So I have a patient like this. Mm-hmm. I'm sure she's listening. I love her a lot. So she started working out really slowly. She started walking, then she started, um. Wearing weighted vest. She's gonna the gym with her husband and she's just listening to her body, like she's taking it low and slow. Do what you can.

Mm-hmm. The goal is not to [00:59:00] like put yourself in bed for five days if that's what's happening, you gotta dial back. But again, it's this other thing where you've gotta like chase that threshold. Yeah. 'cause your threshold's gonna change as you build up more endurance. Right. So like, you're still, it's like you don't wanna go over the hill to the point where you're like, oh crap.

Now I'm in bed for five days and I feel like I have the flu and all my muscles hurt and I feel terrible. Like, if that's happening, you're going too hard, but you still gotta do something and you gotta like start climbing the hill. Mm-hmm. So, yeah, I mean it's just, it's, everybody's got a different threshold.

Um, energy should be better when you work out. Not worse. Yeah. 

Dr. Brighten: Well, I appreciate you saying too that use your recovery as a gauge as well, because you know, often that's something that I'll say, if you're struggling with adrenal and you're struggling with thyroid issues and or either or, you, if you are a sore five days later, you did too much.

Mm-hmm. You're not bad. That's just data. Like, and yay for like in a month when you're gonna be like, oh, actually I wasn't, I, I'm not sore for five [01:00:00] days anymore. But we have to individualize this. There's so much on the internet that is super prescriptive. Strangers that, that blows my mind. I mean, especially even in the, um, cycle sinking world with like how you have to program everything like perfect to your cycle.

And I'm like, that's not true for a lot of women. Yeah. Like there's a lot of women, I mean, as someone with endometriosis, uh, and also has a neurodivergent brain. When I'm coming up on my period and I'm on my period, if I want it not to suck and not to be painful and I don't wanna be depressed, like I have to go heavy, I have to lift heavy.

That's what works for me. And that I bring that up because I think people are getting disempowered by all this information. We have access to that they're forgetting that their body and how they feel and their own intuition is their best gauge. 

Christine Maren: Yeah, totally. I mean. Listen to her. Like listen to your body.

Tune in. Mm-hmm. This goes back to women pushing through. Right? Women push through. We [01:01:00] tend to disconnect from our body. There is a coping mechanism that happens there. We disconnect, we dissociate, and it's just this like mild thing that we get used to because we're like multitasking like a queen, right?

We're doing everything except for really connecting with our bodies. And so I think what's important is like really get in there, connect with your body. Focus on like being in body, be in your body, get in touch with her. What does she need? How does she feel? Take your clues, like that's your best data, is how do you feel?

Absolutely. But most women are not connected with. Their bodies. Mm-hmm. 

Dr. Brighten: Yeah. I, I love that you say that. And you know, for people listening, I think, you know, sometimes when we start talking about like, just go for a walk, there's people with like pots, there's people mm-hmm. With hypermobility issues, I always am like, if you have something special with exercise, occupational therapy or physical therapy, that's gonna be your best butt.

But even when you sit at a desk or you're somebody who is stationary, [01:02:00] you can be doing arm exercises, like you can be doing yoga stretches. Like, and I think it's just important to also understand that like there is a way for everyone to find exercise, to find movement, even when individuals like, you know, they need to have somebody moving their body for them, but still getting that movement in place.

What I wanna ask you is what exercise mistakes do women with hypothyroidism often make that. Completely backfire on their energy and metabolism. I 

Christine Maren: mean, doing massive cardio, running marathons. I also have a patient who's doing that right now. She's training for a marathon in her forties. She's got perimenopause, thyroid issues.

She's hit a big wall. Yeah. It's just too much. You know, there's so, there's only so much our bodies can handle. I'm not saying women should not run or challenge themselves or be like, be ath, I'm an athlete. Like, be an athlete. Do the thing. [01:03:00] And you gotta understand like what your body is capable of and how much resilience you have.

So if there's underlying health issues that compromise your resilience, it's probably not, you know, doing a marathon is probably not the right thing. 

Dr. Brighten: Mm-hmm. 

Christine Maren: Um, it might be eventually, like maybe you work your way up to that, but if you're getting, um, symptoms and you're like hitting a wall, like that's a.

A good time to maybe change your goals for the year and focus on your health. So anyways, I think the biggest one is probably neglecting the strength training piece and overdoing. The cardio piece. Mm-hmm. Some cardio is important. Right. It's, IM, it's good for our health. Like I, for my patients who have a lot of resilience, we'll do like sprint interval kind of training.

Yeah. Or HIIT training. Like great. Like we can add it in and if you have a lot of stress in your life and you're trying to like work and take care of aging parents and take care of your kids and, you know, manage your household and do all the things, like, it might be too much for a lot of women. 

Dr. Brighten: Totally.

[01:04:00] I think that's really important to, uh, to just emphasize that if your exercise becomes a chronic stressor in a negative way, that's gonna have a negative impact on your hormones. And I, I had to say in my twenties, I always thought like one day I wanna run, run a marathon, and then I volunteered a few years at the Portland Marathon medic booth, so I'm at the finish line and the people who finish marathons.

I did not want to be those people. Yeah. There's some amazing people, but I mean, I remember the guy with the best time ran straight into the tent and was like, please get me an IV and collapsed. And I was like, so you had good time, but is that worth it, sir? I mean, for him, he was like, yes I am. I'm like the best marathoner in the world.

Yay. And I was like, oh my gosh, this is like so hard on the body. Yeah. And so I don't think like that means marathons are out, but I do have think that you should always, Eva, it's just the same with like cold plunging, right? Mm-hmm. And all of these things that are stressors and they're great stressors.

[01:05:00] Fasting great stressors. Yeah. In the right context, but in the wrong context. You've just sabotaged your energy, your metabolism. Uh, I can't even tell you how many female. Body builders, also marathon runners who started gaining weight, couldn't control it, and it's their, their body was basically fighting back of like, no, no not doing this anymore.

Like, and sometimes that feels like your body's betraying you, but it really is a wisdom of like, you, we need you to survive. Like we're in this together. Yeah. I do wanna switch gears to gut health now. So everybody promise we were gonna go there. You had mentioned how hormone health. Influences the gut microbiome.

Can you say more about, especially hormone optimization in perimenopause menopause, how is that affecting the gut microbiome? 

Christine Maren: Yeah, it's so, it's such a really fascinating area of research that is emerging in the last decade, really, five years even. Mm-hmm. So the gut microbiome is influenced by hormones in a really big [01:06:00] way.

Guess what? Estradiol influences intestinal permeability. So those tight junctions we talked about earlier are positively influenced by estradiol. Guess what? Negatively interest in influences the gut microbiome, birth control pills. Mm-hmm. You know, so there's another, like, why? Why are we doing this? So.

Estradiol can influence the intestinal permeability in an important way. It also shapes the composition of the gut microbiome. Um, some emerging research suggests that HRT positively influences the gut microbiome composition, which is a big deal for lots of different reasons. Mm-hmm. Uh, the gut microbiome also will influence things like histamine.

So when we have all these different, you know. Crazy symptoms that appear in perimenopause, like itchy ears and itchy skin, like there's a reason for it. We can go look at the gut microbiome because estradiol is gonna impact the way that histamine works our in our body. And of course, progesterone's playing a really big role in stabilizing mass.

Cells which release histamine. So there's a huge [01:07:00] component there. We also see, uh, women who go through perimenopause tend to have more hydrogen sulfide. So that's one of the types of SIBO or small intestine bacterial overgrowth and hydrogen sulfide can be really toxic to the cells in our colon. 

Dr. Brighten: Mm-hmm.

Christine Maren: Um, so those are kind of three big ways that, that estrogen and progesterone in particular play a role. 

Dr. Brighten: Sorry, I just laughed. 'cause you're like, hydrogen sulfide is really toxic, uh, to our coal and I was like, and to our partners and, and to everybody 

Christine Maren: else in the household. 

Dr. Brighten: Everyone else though smells like rotten eggs.

There's studies that are like women because of women's diverse microbiome composition. We tend to have stinkier gas. Um, but that is definitely one that when you smell like rotten eggs, like yes. It's not just so I'm this, you can tell I have boys, my children are boys because I'm like, fart joke immediately.

Uhhuh. Yeah. I've got one too. Girl. I've got one too. So. I think this is a, a really important point that we, you and I were talking about. You had said something to me like, oh, I saw that like, you like [01:08:00] oats. And I'm like, yes. And we were talking about how male influencers are out there telling women no one should eat oats.

Our conversation was, I had said to you, but I have a diverse microbiome. And you don't buddy. You do not. So I have to have as much diversity as possible to keep up with that. For women who have been influenced to be afraid of grains and carbohydrates, what do you wanna tell 'em about their gut microbiome?

'cause this is crucial going into menopause. 

Christine Maren: Yeah, I mean, diversity in the foods you eat is critical to maintaining diversity in your gut. Specifically fibers, and we're gonna get fibers mostly from carbohydrates. I mean, whole fruits, okay? Like we're talking whole fruits, not fruit juice. We're talking whole oats, not oat milk.

So there's good carbs and bad carbs, just like there's good fats and bad cat fats, right? Like stick with the good complex carbs that have fiber. Those are really important for your gut microbiome. Get diversity, try new foods, like eat probiotic rich foods. Of course this might backfire and you know, if you have histamine issues, but like [01:09:00] it's complicated, but you wanna eat.

Diversity. Mm-hmm. Right? You want to support the diversity of your gut microbiome. And as your hormones are declining in perimenopause, that's especially important, plus that hormonal impact on your gut microbiome plays a big role. And so if you are a candidate for estrogen, that might help your gut. I can't, like, I have one other patient who has inflammatory bowel disease.

She flared during perimenopause. Mm-hmm. Like, she was really, she's like a nutritionist. She's super dialed in what she eats and her lifestyle, low tox, living, all the things. And when she went through perimenopause, she just flared. And so the things that made her feel a lot better was HRT, like, was a game changer for her actually.

And then we added in a post biotic supplement, which was like the bow on top. Mm-hmm. And you know, now she can, she has a lot more tolerance for foods and she's not flaring. So yeah, all of that stuff plays a big role. Um. Yeah. 

Dr. Brighten: And as we're talking about, you know, um, [01:10:00] inflammatory bowel disease, Crohn's disease is actually, I want everyone to know this 'cause I think it's so important.

Women who take oral contraceptive pills, the birth control pill, the pill, they're high risk for developing Crohn's disease. So new onset. So we know hormonal shifts can trigger autoimmune disease. Birth control pill is implicated in that it also can decrease microbial diversity and lead to leaky gut as you send.

And we see women who do have Crohn's disease, so they already have it. When they take the pill, they have more frequency of surgical intervention. So I just wanna bring this up because if this is you and you're on perimenopause, the pill is not for you. And you can tell your doctors take a trip to PubMed because there's enough research there to justify why they can do better with an estradiol patch and an oral micronized progesterone, or even a vaginal progesterone.

But. With the microbial diversity, what happens when we lose estrogen? Because this I think is uh, uh, uh, you may say what I read in a paper, but this I think was so [01:11:00] shocking to me when I read it. 

Christine Maren: So yeah, at age 40, we're seeing a decline in microbial diversity for women, and that correlates with perimenopause, of course.

And we see that menopausal women, their gut microbiome resembles the gut microbiome of a male. Mm-hmm. So as we hit menopause, our gut microbiome changes a lot and. What, what, like it's, that's more inflammatory for a woman actually. 'cause there's other papers now looking too, like what happens when you, when a female has the gut microbiome of a male, there's more inflammation and more immune, uh, reactivity that goes on.

Dr. Brighten: Yeah, no, that's exactly when I read that, it was like, it's like a man. I was like, Don, don, don. Like that. We definitely wanna avoid that. We have the hypothesis of why we have so much microbial diversity is because we just state the future of the human race and we pass on that microbial diversity as well.

And it has a big influence on their immune health. And when we lose, as you were saying, that microbial diversity, we don't see autoimmune disease get [01:12:00] better. So people are often like, well men don't get autoimmune disease as much, so maybe that's a good thing. It's a bad thing. And so what can we do to 

Christine Maren: prevent that?

I mean, HRT is one. Specifically, there's a lot of difference, right? Mm-hmm. Like a different ways that we support our gut microbiome or take the negatives off our gut microbiome, like avoiding toxins are in our environment that can affect our gut microbiome. Pesticides affect our gut microbiome. Um, antibiotic use.

This is another, like we see this uptick in antibiotic use in women in perimenopause or menopause because they get more UTIs. Mm-hmm. The same women who were taking birth control pills and got UTIs when they were taking birth control pills, they can also get UTIs when they go through perimenopause. It's just, um, GSM, genital urinary syndrome of menopause, or I say it's genital urinary syndrome of birth control pills.

Um, it's the same mechanism when we have low estrogen. Um, so we tend to see, you know, more antibiotic use around just like. The increase in UTIs? 

Dr. Brighten: Well, I was gonna say, I, I just wanted to dovetail on the antibiotic use that [01:13:00] I very much think that there's gonna be research in the future that shows us that the prescribing of antibiotics over topical vaginal estradiol has led to the antibiotic resistance that we see for uti.

I specific organisms because of this fear around estrogen. Because we know if we give topical estradiol, apply it to the vulva, that is not only going to influence the microbiome in a positive way, but also it's gonna help with your urinary tract system and the pelvic floor as well. And so it's doing all of these beautiful things.

And so it's something that, um. Dr. Amy Killen, she was, uh, I will, uh, link to her episode, but she was saying how when she was an ER doctor, if like, if she could go back, she would've given every woman mm-hmm. Vaginal estradiol over those antibiotics because we've got huge antibiotic resistance going on. And a lot of times people are like, it's just a UTI friend, a UTI becomes pyelonephritis.

We need our kidneys. You [01:14:00] got two of them, but it's not worth gambling with even a single one. They're super, super important. So you've talked about microbial diversity built by varying what you eat in your diet. You said, um, estradiol but not birth control. So I am sure there's women right now being like, but wait, if I wanted to affect my gut, don't I have to take oral estrogen?

Christine Maren: No, the answer is no. In fact, I'd prefer that you take transdermal estradiol. Mm-hmm. The oral estrogen goes through first pass metabolism in the liver and breaks down to different, um, components that are, uh, there's, there's some controversy out there with exactly what I mean. Some people do believe that it can help more with heart health, though, it increases your risk of blood clot.

I tend to steer clear for most oral estrogens. Mm-hmm. Especially birth control pill. But that's. They're different, right? Like that's a oral, synthetic estrogen. You can still do an oral synthetic bioidentical estradiol, which is not the worst thing in the world, I mean, at [01:15:00] all. Like, I still fine. Great. But we have transdermal estrogen, and I personally, that's what I use in my practice.

Mm-hmm. 

Dr. Brighten: Yeah. And what we see is, is that you don't have to actually, if, if the estrogen is going systemic, you don't have to take it orally for it to affect the gut. And I think that when we think that way, it's like kind of the, the way medicine has taught us to think, right? Your gut is separate from your vagina.

Mm-hmm. Except your gut is the reservoir for lactobacilli that inhabit your vagina. But we, we think about like these are completely separate entities. The brain is completely separate from the gut. Right. And we've now learned like that is absolutely not true. We've been talking about thyroid and we've been talking about, um, Hashimoto's.

When we lose that microbial diversity, what Inca impact can that have on thyroid health? 

Christine Maren: Well, if we're talking about Hashimoto specifically, it plays a really important role with the autoimmune disease piece. When you have less microbial diversity, you're more at risk of dysbiosis. I mean, that basically is dysbiosis where you have overgrowth of bad [01:16:00] bacteria.

You can also have overgrowth of things like yeast and candida. Mm-hmm. Potentially like parasites or h pylori or other kinds of infections that increase your intestinal permeability, which is directly linked to other autoimmune component Hashimoto's. There is also this interplay of thyroid conversion, so when you go from T four to T three, your gut bacteria plays a really important role in that, in that conversion, and so having less diversity is going to impact that.

Having more gut infections is gonna impact that and potentially increase things like reverse T three, so you have less free T three. 

Dr. Brighten: And this would be a very good argument for everyone listening to bring to your doctor of why levothyroxine is not enough. 'cause there's a lot of doctors out there that are like, mm-hmm.

There's just, you just need to levothyroxine. Why would you need anything else? But also that you need to be checking more than just a TSH because as we get older mm-hmm. As we get older. Nothing works as well and I hate that, but that is the reality. And that includes the conversion of T four to T three.

Do you find [01:17:00] that women who enter their menopausal years are doing better with some T three added in? 

Christine Maren: Not necessarily. Mm-hmm. I think it really depends. Uh, I test all my women, you know, all my patients. I test their T three and some need it, some don't. I mean, there are definitely some who don't, and I would say my younger patients are less likely to need it.

But it depends. I mean, I have some patients who are in menopause who don't need T three, and I have patients who have worked with me long enough where it's like, eh, we don't need T three anymore. Mm-hmm. You know, that kind of thing can change. As we change the gut microbiome, it's gonna influence that. It also is gonna influence things like nutrient absorption, which plays a really important role with thyroid function.

I mean, like you need iron and zinc and selenium and B vitamins and all of these iodine. You need all these nutrients for your thyroid to work well. 

Dr. Brighten: I feel like Iodine's always the one that like only gets attention and you're like, you listed everything and then you're like, oh, and iodine I'm, and they're, I'm like, I feel like that that same way that I'm always like, I need to tell you about all these others.

'cause I know you already are thinking iodine. There are women who are definitely listening right now and they're like, [01:18:00] okay, game over for me too late. Like, I am already 10 years post menopause. My gut microbiome just gone. Like, what can I do? 

Christine Maren: Yeah. No way. I mean, I would say don't ever give up on yourself please.

Like, really? Game's never over. Um. Yeah, if you're post-menopausal 10 years after menopause, I mean, you can still start HRTI don't, there's controversy around that, right? Mm-hmm. Like the later you are, the less benefits you have. So it is better for you to start earlier. But if you know Women's Health Initiative 10 years ago, you didn't have this information and you're 65, 75, whatever, like it's, it's not necessarily too late for you.

Mm-hmm. 

Dr. Brighten: Uh, 

Christine Maren: to start HRT specifically, if that's right for you. Probiotics, prebiotics. Postbiotics. So prebiotics are certain types of fiber to feed the gut microbiome. Um, I am a really big fan of resistant starch, so like cooked and cold potatoes, overnight oats are like my go-to every morning. Um, [01:19:00] prebiotic foods and eating a diet rich in plant-based fibers is important to support the gut microbiome.

And then there's probiotics. So you can take probiotic supplements. I personally take probiotic supplements I give them for a lot of my patients, but the quality really varies and that's one of those supplements that I'm very picky about. Like there's some supplements like vitamin C, you could be less picky about probiotics.

I'm pretty picky about, so I'm, I like Spore Formm probiotics. Um, and it depends on the patients. Like a lot of patients don't do great with like lactobacillus and bifidobacter, which are more traditional stuff that you'd find at your supermarket. And if you are one of the women who has sibo, which is really common by the way, the small intestine bacterial overgrowth that we've mentioned, and you take those probiotics, they usually make women feel worse.

And so it's picking the right probiotic for. And Postbiotics, postbiotics are really this new kind of emerging area of research I've been using. Uh, it's a supplement. It's over the counter actually. You have to have a [01:20:00] physician's like link to get it. Mm-hmm. But it can be really helpful for some of our patients.

Like just like I say, it's like putting the bow on top when you use that. Like the postbiotics can be really helpful. Yeah. But I think also like if you're having issues with your gut microbiome, remove and replace, like remove the infection. That's the big deal. What I see most people do is they remove foods.

Mm-hmm. And then they're on these really restrictive diets and their autoimmune paleo and their diversity's even lower because they're, and they're scared of food and their stress is even higher 'cause they can't eat anything and they can't like, go out to dinner with their spouse or partner or friends or whatever.

So, um, yes, there are certain foods to remove. Alcohol's a really important one to get rid of or at least limit a lot. Yeah. 

Dr. Brighten: If you wanna get rid of hot flashes. Dropping 

Christine Maren: alcohol is like the first thing you can do. Alcohol is not doing us any favors. Yeah. Let's just be really clear about that. If you wanna have a drink, have a drink, but don't do it under the impression that is doing any good stuff for your health.

Dr. Brighten: That's actually a good point. I appreciate you saying that because the same people who are [01:21:00] influenced by the Women's Health Initiative, it's like the same gen. Oh yeah. We're influenced by the get your resveratrol. We love resveratrol. Resveratrol is I amazing. I have a supplement with resveratrol 'cause it's so good for women, but it's, it ain't happening in wine.

You're not getting what you need in wine. No. And in fact, like the polyphenols part of their benefit is what they give your microbiome, which is some serious love and alcohol's like completely the opposite. 

Christine Maren: Yeah. Like stay off the alcohol, drink some green tea and eat a pomegranate. Yes. Um, I mean, and again, like if you wanna have a drink, have a drink, but don't do it because you think it's benefiting your health.

Mm-hmm. Or good for your heart. Like, that's crap. Mm-hmm. So anyways, where is I going with this? So if you are. Whatever age. I think the important piece is to realize like, yes, there are some things to remove, but the important thing to remove that is getting ignored all the time is the infection. There's usually some underlying gut infection in people who have digestive issues and food sensitivities and autoimmune disease and and the most common one I see is [01:22:00] sibo, bacterial overgrowth, but there's also sifo, so fungal overgrowth or other sorts of overgrowth of yeast like candida.

There can be other types of fungus overgrowth, like sometimes I see women who have really high aspergillus levels, especially if they lived in a moldy house. Like that can be a big, huge one. Mold's the worst. Mold's the worst. H pylori, like there's other sorts of gut infections and infections impact your intestinal permeability in a big way.

So yes, you have to rebuild your gut microbiome, but first, don't forget to remove the infection. Mm-hmm. And then replace the enzymes. Sometimes replacing digestive enzymes is really important. And especially for women who are 65, 75, there's a really common, um, issue among older people and it's exocrine pancreatic insufficiency when women don't make a enough elastase from the pancreas.

So one of the main risk factors for that is just age. So as we get older, we make less pancreatic enzyme and so sometimes it's really helpful to replace that. Sometimes it's really helpful to replace stomach acid. So we can use betain HCL. That's [01:23:00] another one where it's like me, you might wanna do it with a practitioner.

Just be cautious. Start logo slow, listen to what happens. Mm-hmm. Um. There's a lot of different, you know, digestive enzymes we can add in for women who, like gallbladder function is a huge one. 

Dr. Brighten: Yeah. How 

Christine Maren: many people don't have well-functioning gallbladders or have had their gallbladder removed? That's when I tend to add OX B or other nutrients to support gallbladder function.

Bitter kind of, you know, compounds can support gallbladder function and this is back to that carbohydrate fat conversation. I've had a lot of women who have had better digestive function when they. I'm not going low fat here. Just let me be clear. Like I'm not low fat. I'm not in low low fat train. But removing some of the high fat foods, high fat can actually increase intestinal permeability, and it's really hard on the gallbladder.

Your gallbladder has to work extra hard to squirt out bile every time you eat like a really high fat meal. And so pulling back on some fat, adding in complex carbs and fiber, of course, prioritizing your lean proteins, all that's super [01:24:00] important. But remove the infection. Remove some of those like big offending foods like I don't even said it.

I think I said gluten, but gluten for a lot of people who have digestive issues and alcohol are kind of the big ones. Refined sugar, maybe some dairy. Certain people. Soy sometimes, right? Some of the big stuff. But, um, I don't love really restrictive diets. And then replace digestive enzymes and then later on you can really focus on like, okay, now can we bring in some more like probiotic foods?

Maybe you'll better tolerate things that are high histamine, like sauerkraut and kimchi after you've really fixed that balance and maybe addressed the hormones and brought in some more progesterone. Mm-hmm. The thing is, it really is like this very complicated puzzle and I'm, you know, I just, I tend to just like see all these like connections.

I've always had a hard time. I can't focus on gut health because the hormones are important. I can't just talk about hormones 'cause the gut health is important. And then you gotta bring in the thyroid piece so it really all goes together. It's a big puzzle. 

Dr. Brighten: Yeah. And to your point about restricted diets, you know, um, I'm actually, so I'm [01:25:00] friends with Mickey Truscott, who really, uh, I think she might be the only autoimmune paleo author, um, of making cookbooks.

And so I know her personally in real life and people will always say like, oh, she wants you to like lead this really restricted diet. I'm like, no, she had to do autoimmune paleo. It was really overwhelming to her. So she made all these cookbooks and she's coming out with another one, which I think is really great because it addresses how people took it too far.

Mm-hmm. And that's, I think exactly what happens, especially in perimenopause. Anytime you intestinal permeability, hyperpermeability happening, that happens in perimenopause. People just start taking out foods. They need a guide. They need someone to work with that. I also see a lot of online influencers who are like, this is the a IP way of life.

And like, you have to eat like this for life, or here's low FODMAPs for life and low histamine for life. And I'm like, I, I would never do this. For life for myself, because I love to eat and I come from a culture where eating is community. Mm-hmm. Like that is how [01:26:00] you stay in community, which is more honestly, community is probably better for our health than necessarily some of these foods that we're eating.

Yeah. And so while these, I want everyone to listening, you might be on this diet and it might have a time and a place, but it should not be forever. Like the ideal is your gut should be, it is designed, but it should be able to eat a big, robust variety of foods. And if you can't do that, there's something else going on.

Mm-hmm. You brought up giving bile acid. We know that, um, bile acids toxic to those organisms that should be in the large intestine, but they get their way into the small intestine. Mm-hmm. And so if you're somebody with gallbladder disease, which we know you're in your forties, right? Fair skin. Yeah. You're still fertile like that estrogen.

So there's this whole, uh, people are like, what are you talking about? Um, there's a whole acronym. Well, is it an acronym? I don't think that's what it is exactly, but there's, I'm like, we all remember it. But the three 

Christine Maren: F's, we don't know what it's called, but, well, there's a fourth 

Dr. Brighten: F, right. But it's not politically correct to [01:27:00] say like fat, but that is the one that as clinicians, we memorize these things because if you are overweight, if you are still cycling, you are in your forties.

And it tends to be women who are white are at risk for gallbladder disease and automatically, I mean, doctors are always so happy to like. Get rid of your gallbladder. I call it like your designer purse of your liver. Like, it's like your accessory, your liver loves it. Like would you throw out like your, uh, you know, designer purse?

I don't know a designer purse name right now, but would you throw that away? No, you wouldn't just throw that away. But when you were talking about SIBO and sifo, that's what was coming up for me is that so often people don't check for that. Why is it so common that we are. Seeing these microbes ending up in the small intestine and calling that their home?

Christine Maren: Ooh. Well, I think that's the big question. I mean, there's a lot of different reasons. Mm-hmm. I think stress is one reason. So I practice meditation. One of the goals of meditation is called coherence. Coherence is organization of the heart and mind and the [01:28:00] brain. So we're doing studies now to look at coherence of the heart and mind, and then coherence of the, of the stomach.

Mm-hmm. So it affects your peristalsis, stress and survival mode affects your digestion. Right. So it's, we know this 'cause we talk about the parasympathetic and the sympathetic nervous systems. These are branches of our autonomic nervous system. Sympathetic dominance is fight or flight. Parasympathetic is rest and digest.

If we're in parasympathetic all the time, great, but we're not. That's just not our culture. So many women live in this sympathetic dominant state. So many people, men and women, live in this sympathetic dominant state. We're not. Putting a lot of energy into our digestion, first of all, but also just that coherence.

So coherence refers to organization when it's disorganized, we tend to get, be more at risk for SIBO and other gut infections, but especially sibo. Sibo iss the one I'm really interested in because I see it all the time. It's so common, and for a long time I thought, well, maybe it's just a downstream effect of other issues.

But now I think it's just so common [01:29:00] because of our lifestyle and because we live in such a stressed out stress and survival mode, right? Mm-hmm. So I think that's, that's a piece of it with sibo also, if you've had your gallbladder removed and you're not squirting out bile, every time you eat, you're not killing some of those organisms.

Also, if you have low stomach acid, which goes hand in hand with being stressed out, actually, so low stomach acid is gonna make you more at risk for infections. You want. To have stomach acid for a reason. God gave us stomach acid for a reason. So there's a lot of piece people out there on acid blocking medications.

Those can increase your risk of sibo, of bacterial overgrowth because it doesn't kill off some of those organisms in your gut. People have infections in their mouth, especially like root canals. Yeah. That can seed your gut, and so you're swallowing that, you know, spit all the time. When you have a root canal in your mouth, you're gonna have usually dysbiosis in your mouth, and that's a two-way street.

I mean, it's a highway between your gut and your mouth. I mean, thyroid has a huge impact on your risk for SIBO because we know thyroid impacts motility. Mm-hmm. [01:30:00] Often we think people with hypothyroidism have constipation and that can sometimes be true, but I see. The greater truth is that people with hypothyroidism have problems with organized peristalsis and are at higher risk for things like sibo.

Mm-hmm. Because they're just like, their gut motility isn't working as it is. I mean, basically, you know, we should eat three meals a day. The migrating motor complex and the small intestine should come sweep the streets of the intestine and clear it out. And that's just not happening for a lot of people.

And you know, part of it's because we're eating six meals a day, maybe, you know? Yeah. So that's, you know, what I work with on, with my patients is like, let's try to aim toward, you know, three meals a day. You don't need to starve if you're hungry, eat, but like. W work toward three big meals a day where you're eating enough at the meal and then you've got enough rest between your next meal, like four to five hours at least.

Mm-hmm. And your gut has time to rest and, and sweep the streets of the intestine. 

Dr. Brighten: Yeah. And another big one we [01:31:00] see 

Christine Maren: is food poisoning. Oh, for sure. Yeah. Thanks for mentioning that. Yeah. Yeah. So, yeah, uh, that's a whole thing. So migrating motor complex can take a huge hit from food poisoning. Um, I think there.

Definitely some autoimmune component going on with sibo. So we can do this test called IBS Smart Measure anti CULLIN antibodies and anti CDTB antibodies. And I mean, we're looking at antibodies here. Of course there's some autoimmune component, right? And sometimes I use lozo naltrexone in patients 'cause it supports gut motility and I'm like, mm-hmm.

That's why, right? There's gotta be some autoimmune component. I don't have the research to support that, but I've got the clinical experience to support that. Like, I know low-dose and naltrexone is gonna be useful in those patients who have antibodies and have post, it's called post-infectious sibo.

Mm-hmm. Um, so yeah, that's a huge one, which I wish I had Xifaxan right now. 

Dr. Brighten: Yeah. Uh, so l so that's, uh, wait for people listening, that's, uh, probably the best treatment for sibo. I will say that there [01:32:00] are herbals that do work and I have used them clinically, but um, when someone's really struggling with sibo Yeah.

I'm like, let's just get it gone. And it's not an antibiotic, it's antiseptic. So it's not knocking down your microbiome in the same way that like penicillin would be. Yeah. Um, but you mentioned low-dose Naloxone or LDN. Are you using this in Hashimoto's patients? Oh 

Christine Maren: yeah, totally. I use it all the time. You know, I try to like pick some things where I'm like, we're gonna hit.

Two birds with one stone and so, mm-hmm. With low dose naltrexone, it can help upregulate treg cells, T regulatory cells in the immune system, so it supports the immune system and decreases inflammation. And it might also improve things like gut motility. And I have patients who have like. You know, pain, they have joint pain and things like that.

And I've had patients get off Celebrex or Motrin because their pain is gone. Yeah. So it can help with pain, it can also help with appetite for some people who struggle with that. Mm-hmm. 

Dr. Brighten: Yeah. I think, uh, and for people listening, because you're gonna [01:33:00] go Google this and then you're gonna be like, wait, this is a drug for drug addicts.

Mm-hmm. Like when we're using low dose naltrexone, it's. You know, one to sometimes 4.5 milligrams. It really depends. Um, it's at that low dose that you get the benefits for the immune system. What's the one thing people should know about starting it though? Well, 

Christine Maren: it can cause some really vivid dreams.

Really 

Dr. Brighten: vivid dreams. 

Christine Maren: So some people who are really sensitive, I'll titrate up the dose. Mm-hmm. Uh, I used to always do this, so I start with like 1.5 and then go to three, and then 4.5. I actually prefer, now in most patients who can tell me, they'll know usually if they're really sensitive or not. But I prefer to start with the full dose because patients can tell me overnight.

They'll be like, yes, it helped. I have another patient who had an. An autoimmune condition in her eye. And she was like, the next day I woke up and my eye felt less blurry. I could see better. I ha, you know, so I wanna know if it's working or not. That's an important piece of feedback for patients. And [01:34:00] so I would say 30, 40% of patients can tell me, like, yeah, it really helped.

Dr. Brighten: Yeah. I started at three milligrams because I was like, I want this to work fast. I, oh, you didn't do well. Oh no. It was the worst, like nightmares. Super vivid. It was like bad things happening to my children, which is like, oh yeah, the worst. Yeah. I did not sleep like that whole night, and I was like, well, now we know.

Yeah. Yeah. I have a, yeah, I should have known better. Honestly, I'm like always so sensitive to medications that I'm like, I probably should have known better. Um, but yeah, whenever people will tell me like, oh, I tried it, but it was so I couldn't sleep and so I just stopped. I'm like, yeah. Okay. So your doctor needed to actually titrate you off.

Yeah. Um, up and I'm like, and that was like years of me having patients like that and then me being like, no, I think I'll probably be fine. And I was not, in fact, fine. 

Christine Maren: Yeah. Yeah. I mean, it's one of those warnings always. Like number one, are you sensitive or are you, do you tend to tolerate stuff? I personally like I'm not that sensitive.

Mm-hmm. So I am fine on 4.5. It's never been an [01:35:00] issue with me, but yeah. Yeah. There's definitely a handful of patients who need to go really low, really slow. Mm-hmm. Yeah. 

Dr. Brighten: Yes. Well, I wanna thank you so much for this conversation. I feel like we covered so much. Um, and there's so many great nuggets and pearls to help people imparting.

Is there anything you'd like to share with women who are in the perimenopause transition right 

Christine Maren: now? I think the big one is don't give up on yourself. None of it is just getting older. Like this is where you're just beginning. And I hope women feel maybe even inspired that you don't have to settle on fatigue and weight gain.

Screw that. No way. Mm-hmm. You can be the best, most beautiful, strongest, most wise version of yourself after 40, 50, whatever it is, 60. Um, harness all the wisdom you've had, take care of yourself. Maybe it's time to prioritize yourself. Uh, I think that's the biggest transition of mindset, maybe where women are [01:36:00] going through this mindset change and starting to really, hopefully understand that they are deserving of love and care in the same ways as they've been taking care of everybody else.

Dr. Brighten: That's so well said. Well, thank you so much. 

Christine Maren: My pleasure. Thanks for having me. Yeah. 

 

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