In this episode of the Smarter Not Harder Podcast, Dr. Christine Maren gives us one-cent solutions to life’s $64,000 questions that include:

• What is the estrobolome and how does it influence women’s health during perimenopause?
• How does gut health affect hormone balance and menopause symptoms?
• Which functional medicine tests are best for assessing gut and hormone health?
• What nutrient and lifestyle strategies support healthy hormones in midlife?
• How can functional medicine help women experiencing perimenopause symptoms?
  

Who is Dr. Christine Maren?

What did Dr. Christine and Dr. Scott discuss?

00:00 Intro: Understanding Perimenopause
01:00 Welcome to the Smarter Not Harder Podcast
01:43 Meet Dr. Christine Maren
03:29 Key Symptoms of Perimenopause
06:59 Gut Health’s Role in Hormones
14:11 Different Perimenopause Types Explained
18:24 How Diet and Stress Impact Hormones
23:19 The Estrobolome: Gut–Estrogen Link
31:11 Birth Control vs. HRT in Perimenopause
36:49 How Doctors Test Hormones in Women
39:15 The Unmasking Effect in Perimenopause
43:18 A Three-Pillar Framework for Treatment
49:47 Vaginal Estrogen and Other Interventions
59:35 Practical Tips for Women’s Health
01:01:32 Closing Thoughts + Symposium Info

Full Transcript:

Dr. Christine Maren: [00:00:00] I say perimenopause is like inverse of puberty. You know, puberty's happening. Hormones are all over the map, but they're like increasing and perimenopause. They're all over the map and decreasing, and sometimes they're just low overall. So, you know, doing testing will help us identify that and will help us identify also like does a woman have really low estrogen or is it all over the map?

And then symptoms are really the most important. And the amount of flow, like how heavier period is, can be a very helpful indicator of what's going on. For women. With the IUD, it can be trickier 'cause we don't really know. Sometimes they're not ovulating. Very often they're not. So I'll check. I'll check their labs like 10 days apart.

You know, symptoms are a huge part of it. Of course, labs are not the primary way to test for perimenopause. There is no definitive test for perimenopause. I think labs are critical and also because, uh, I have coined this term, the unmasking effect in perimenopause. And what that means is perimenopause is a time when any underlying health condition gets unmasked.

Dr. Scott Sherr: [00:01:00] Hello and welcome back to the Smarter Harder Podcast, your Home for 1 cent Solutions, two $64,000 questions. I'm your host again today. My name is Dr. Scott Scher, and it's a pleasure to be back with all of you. So today's podcast was a fun one with Dr. Christine Marin. Christine's actually a neighbor. She lives locally and she's a family medicine doc that has a virtual functional medicine practice that focuses on menopause and perimenopause.

And Christine is actually gonna be speaking at our Health Optimization Medicine and Practice Symposium happening October 17th and 18th here in Boulder, Colorado. Check it out@homehope.org. And so Christine and I had a great conversation. Let me give you a quick bio of her before we get started. So she's a board certified physician and founder of a virtual functional medicine practice here in Colorado, Michigan, and Texas.

Virtually. She was introduced to functional medicine after struggling with pregnancy complications and recurrent miscarriages. Now mother of three. And she's crazy like me getting people every everywhere to [00:02:00] camp. This summer, she devoted her professional life to helping others address the root causes of symptoms to restore health, prevent disease, and get their life back.

She earned her medical degree at the Chicago College of Osteopathic Medicine of Midwestern University, and later moved to San Antonio, Texas to train in one of the nation's premier family medicine programs at Christus Santa Rosa Hospital. She spent some time in Tucson studying with Andrew Weil at the University of Arizona integrative, uh, group over there.

And Dr we is known as the father of integrative medicine. She was later introduced inter fun into into functional medicine to address her own concerns, and she has her own functional medicine practice now virtually working with people in Colorado, Michigan, and Texas. And so I've known Christine for about a year and a half.

We met at an event in Boulder and she's super smart and really, really good when it comes to perimenopause and menopause. And we talked a lot about, you know, a various things, uh, in this podcast, but we started off talking about the gut microbiome and. Perimenopause and menopause, and many people don't really understand the connection here.

So we talked about how estrogen plays a huge role [00:03:00] here, how the estrobolome or estrobolome plays a huge role over here as well. Leaky gut, intestinal person permeability with hormonal changes with the variations in progesterone and eOne. We talked about the lack of bifidobacter, lactobacillus that happens as hormones are changing for women starting in their forties, and how keystone species otherwise like akkermansia can also be modulated and changed.

Uh, hydrogen sulfide or rotten egg smelling gas and how this has effect on the gut as well as insulin resistance. Then we also. Went from there to talk about different types of perimenopausal symptomatology or spectrum. One from a, a variations in estrogen and one from a more of like a low estrogen dominance where you have the latter category and people being more high cortisol and have higher A one Cs.

Interestingly enough, even though they're not insulin resistance. We talked about unmasking. When you have your hormones changed during menopause and perimenopause, you can unmask symptom symptoms and autoimmune conditions. Hashimoto th thyroiditis or other autoimmune conditions as well, gut [00:04:00] dysbiosis and how you manage that.

We also talked about HRV in detail, excuse me. HRT high HRV is, is related to your heart, and HRT is hormone replacement therapy. How she does it, what kind of testing she does, how she testing over time, and the idea of how you can modulate not only hormones, but also her whole framework looking at root causes as to why hormones might be need to be looked at, sort of, of course, but secondarily to looking at heavy metal exposure, toxins, exposure, vitamin, mineral nutrient, cofactor deficiency, and that other, other things like mindset, exercise and things like that.

So this is a, a wide ranging conversation with Dr. Christine Marin. I really enjoyed how she broke everything down. Talked about. The subjective aspect things, the clinical aspect of things, the testing aspect, and how you can really work on this as a clinician and as a patient or as a woman going through perimenopause and menopause, how to kind of navigate some of these things.

So I hope you enjoyed this podcast with Dr. Christine Marin. Don't forget that [00:05:00] we have our Home Hope Symposium coming up October 17th and 18th. You can check it out@homehope.org. Christine will be speaking now without further ado, this podcast with Dr. Christine Marin. Christine, how are you? 

Dr. Christine Maren: I'm doing great.

Dr. Scott Sherr: I know you're only like five minutes away down the street in Louisville today. Right. So 

Dr. Christine Maren: yeah, we only talk virtually though. 

Dr. Scott Sherr: That's how it goes. Right? As clinicians and as busy. Families with lots of children, it's, uh, it's a challenge to get out of our house or to get out of our house other than taking our kids to summer camp.

Right. So 

Dr. Christine Maren: that is exactly right. We'll see each other in the car. 

Dr. Scott Sherr: Yeah. So Christine, it's really good to see you. Um, so for those of you who don't know, so Christine and I, Dr. Christine Marin, thank you for being here. We are neighbors. Um, we actually met at an event. Here in Boulder, relatively recently, about a year ago, I would say.

Right. And, and you, you happen to have the last name. That's the first name of one of my daughters. So I'm saying your name appropriately. I know that you can get it kind of butchered as a result of, you know, various reasons [00:06:00] depending on where you are from the country and what kind of accent you wanna put on.

But Dr. Christine Marin, um, and I know you have a fantastic platform and I wanted to bring you on for a couple different reasons. Uh, first of all to talk about, you know, gut health and menopause is, I think it's a really interesting topic and many women and men of course, and clinicians don't really know about the connection here.

So we're gonna go it into detail and I'm also excited that you're gonna be speaking out our Health Optimization Medicine and Practice Symposium on October 17th and 18th here in Chautauqua at in Boulder, which. Thank goodness is that is one conference that we don't have to travel for. Um, I know that traveling is difficult for the both of us, but we do it often for work and sometimes we, our kids get to come, come, get, come along with us as well.

Right. 

Dr. Christine Maren: Yeah. I'm just glad it's not in Vegas. 

Dr. Scott Sherr: Oh God. Yeah. I'm going to Vegas next week for another conference. Hurts my 

Dr. Christine Maren: soul. 

Dr. Scott Sherr: I know, I know. Um, yeah, we did our last symposium in Vegas right before a four M and in, uh, December. And that was just a bad idea overall. Yeah. So, okay. So [00:07:00] today, Christine, I wanna talk about gut health and menopause.

And so maybe you can frame it for us a little bit before we get into specific questions. Not something that people would typically think about when menopause is happening, right? We know that, you know, that hormones are changing. Tell us a little bit of what's happening in the gut as menopause is starting, as perimenopause is starting, and then how this potentially has like a bi-directional relationship between our hormones and how they may be coming down fast or slow, depending on what's going on in the gut itself.

Dr. Christine Maren: Yeah, so everyone knows that perimenopause and menopause is largely about hormones, and my message is it's a lot more than just hormones. There's huge changes that happen all throughout the body, and one of those primary changes is in the gut microbiome, which, you know, as emerging research shows us, is really important for all sorts of downstream effects from inflammation, autoimmune disease, food [00:08:00] sensitivities, um, you know, you name it.

So. What we now know is that during perimenopause and menopause, a woman's gut microbiome indeed changes along with hormones and the thought is declining estrogen leads to decline in intestinal diversity. Hmm. And that really affects a lot of things, including permeability that we'll talk about. Uh, but we see that a woman's gut microbiome plateaus around age 40, and there are sex differences in a gut microbiome.

So the male and the female gut microbiome look very different. A female gut microbiome has a lot more diversity until she reaches menopause 

Dr. Scott Sherr: compared to men. So compared to me, it's much more diverse until the age 

Dr. Christine Maren: of 40. Exactly. Okay. Yeah. And then it starts to decline from 40 on. Mm-hmm. Largely because of hormonal changes.

And as that happens, you know, when a woman reaches menopause, her gut microbiome is much like a male gut microbiome, and that has a huge effect on the way that she metabolizes hormones. So there's this very interesting bi-directional effect where [00:09:00] hormones are affecting the composition of the gut microbiome, and in turn, the composition of the gut microbiome is affecting the way that we balance and metabolize hormones.

Dr. Scott Sherr: Hmm. Is it just estrogen that we're, that we're considering here? Or are there, are there any other major hormonal, uh, implications here like progesterone or even testosterone, which might have an implication on the, on the male side too? 

Dr. Christine Maren: Yeah, they definitely play a role. Um, I'm not aware of any really great research on testosterone, uh, with regard to females.

I think there is some limited but with males, but I don't know it as well. Um, there is, you know, progesterone we know plays a role, I think a really. Great way to look at this is just in pregnancy. You know, we see when women are pregnant, they have really high amounts of progesterone and estrogen, and we know that women also have slowed gut motility related to the high progesterone.

Of course, progesterone kind relaxes everything. Yes. And so it definitely plays a role in the gut. I think it doesn't play as large of a role as estradiol, or at least the research doesn't show that. Hmm. Um, but yes, I'm sure they all [00:10:00] play a role. And I'm sure testosterone plays a role. We just don't quite understand it yet.

Dr. Scott Sherr: Understood. And so from a diversity perspective, what's, what's happening here as far as the microbiota species themselves? Do we have a sense of what changes or what are the major changes overall and how maybe estrogen has a role here? 

Dr. Christine Maren: Yeah, bifidobacter, lactobacillus species decrease. Okay. And then we see increases in some of the dysbiotic species.

Um, we also see a decrease in akkermansia. Okay. So with that dysbiosis or loss of diversity, uh, as I explained it to my patients, it's like, you know, you have a parking lot, you've, you know. All these parking spaces are now empty and are filled with the bad players, which could be bad bacteria, but also might be yeast or fungal overgrowth.

Sure. Um, and a really interesting one in perimenopause is that women often, um, get overgrowth of the species that produce hydrogen sulfide. Oh. Which hydrogen sulfide sometimes is, can be toxic to the enterocytes or the, uh, cells of the colon. [00:11:00] Um, so that is, you know, definitely an overgrowth that some women will experience, but I think it can be really all over the map.

Dr. Scott Sherr: Gotcha. Well, let's talk about hydrogen sulfide. What is it famous for? 

Dr. Christine Maren: I mean, hydrogen sulfide, SIBO and rotten egg smelling gas. Yes. 

Dr. Scott Sherr: That's what I think of. I think of, uh, very, very bad smelling gas is the hydrogen sulfide, bad gas, lot's of 

Dr. Christine Maren: bloating. It causes a lot of inflammation, and then it can also disrupt metabolism.

So it's associated with weight gain. 

Dr. Scott Sherr: Is it, is it, so is it associated directly with insulin resistance as a result? 

Dr. Christine Maren: Yeah. 

Dr. Scott Sherr: Interesting. Interesting. Yeah. And so I know with Bifidobacterium, lactobacillus, like those are the two most common species in the gut overall. Correct? 

Dr. Christine Maren: Uh, some of the most, I mean, of if we look at keystone species, right?

Yeah. Um, Akkermansia is a big one. Bifidobacter lactobacillus, I mean, e coli, you're gonna, yeah. 

Dr. Scott Sherr: Gotcha. Yeah. I think of, when I think of bifidobacteria and lactobacillus, I think a lot of, uh, the GABAergic nervous system oftentimes. Mm-hmm. Because I [00:12:00] know that bifido and lactobacillus are very correlated with, um, GABA production in the gut.

Mm-hmm. As far as I understand. And that, how that regulates, um, the vagus nerve and how that regulates brain function related to the GABA itself. Do we think, I mean, there's a lot of things that are happening during menopause, of course, right? Mm-hmm. But is that potential another cause of why maybe.

There's more irritability, there's more, um, there's more sort of glutamate toxicity kinds of symptoms related. Yeah. To the menopausal type. I would 

Dr. Christine Maren: definitely think so. I always think it's kind of like this vicious storm. Yeah. That's one of the reasons. Totally. You know, there's a lot of different reasons declining, estrogen and imbalance in estrogen and progesterone.

Um, histamines also a really interesting one. We see increase in histamine during perimenopause. So you know, progesterone pretty much universally declines in perimenopause and progesterone stabilizes mast cells. Hmm, okay. And mast cells release histamine also, you know, some women experience these really high estrogens spikes in perimenopause and it's high [00:13:00] relative to progesterone, which can destabilize mast cells.

On the flip side, low estradiol can affect the immune system, which can not be favorable for histamine. So anyways, histamine can cause a lot of issues. You know, typical kind of stuff is hives or allergies or you know, allergic rhinitis or something like that. But it can also cause headaches and irritability and anxiety because it's also an excitatory neurotransmitter.

So I think that's a piece of that puzzle too. I see. You know, and then like women aren't sleeping as well. I mean, I think there's just so many different reasons why women might feel more irritable during this time of their life. 

Dr. Scott Sherr: Totally. Right. And progesterone's going down too as well. And progesterone is gonna work on the GABA system at the same time, so.

So histamine intolerance or histamine sort of increases comparatively. This is all related to estrogen dropping, is that correct? Or is there other reasons? 

Dr. Christine Maren: Yeah, it's related to. It is really related more to progesterone dropping and to an imbalance between estrogen and progesterone, which is what people usually refer to as estrogen dominance.

Understood. But if you have [00:14:00] too much estrogen relative to progesterone, it's, it's sort of like you've got both problems. You've got low progesterone. Okay. So progesterone stabilizes mast cells and then you've got high estrogen, which is releasing more histamine. Got it. Okay. Or on the flip side, you might also be, I talk about two types of, of women in perimenopause.

One type is this woman who has low progesterone and these chaotic fluctuations in estrogen. So it'll be like high, low, high, low. And that's what most people talk about in perimenopause. However, there is a type two, and I see this a lot clinically, and she is a high performing female who has low estrogen overall, and she doesn't really ever experience those big peaks.

She just has low estrogen and low progesterone overall, and so that affects the immune system. Low estrodiol, I mean, estradiol is really great for us. Estrogen's a really wonderful, hor wonderful hormone. Mm-hmm. Uh, but when we experience low estrogen, you know, women have a lot of symptoms related to that.

Dr. Scott Sherr: Yeah, so interesting. This, there's two [00:15:00] sort of major types. I'm sure there's probably crossover too, where people might start one way and go another way too. Right? And there's never one or the other in clinical medicine, I like to say. 

Dr. Christine Maren: Yeah, totally. I mean, what really what everybody talks about in perimenopause is that type one where it's this very chaotic estrogen and it's not balanced by progesterone.

What I'm talking about is this type two, because most of the patients I see are high performing women who have really suppressed a lot of their HPA axis. 

Dr. Scott Sherr: Pardon the interruption. This episode is brought to you by Health Optimization Medicine and Practice Association, a nonprofit organization, training practitioners how to optimize health rather than treat disease.

For this episode, check out our Home Hope Symposium happening October 17th and 18th at Chatauqua in Boulder, Colorado. We have two days of speakers. Dr. Christine Marin is one of them. They'll be CME credits. You have Dr. Marin, Dr. Chris Shade, Dr. Elizabeth Y from Boulder Longevity, Thomas DeLauer, Dr. Abbot Hussein.

Yours truly, Dr. Scott Scher, Dr. Ted Oso, and more so check it [00:16:00] out@homehope.org and come join us for the symposium in beautiful Boulder, Colorado in October. And now back to the. 

Dr. Christine Maren: A lot of the women I see are very, you know, they've disconnected a bit from their body and pushed through. They've learned how to like, perform and push really hard.

They might be like, a lot of them used to be athletes or they're still, you know, athletes, but, you know, they're athletes when they're younger or they're CEOs or they're just like, really kick ass moms. But they perform really high and they often disconnect from their bodies and just push, push on.

Culturally, it's, it's reinforced too for women to sort of do that and just perform and not, um, not be really connected in our bodies. 

Dr. Scott Sherr: Right. So just be sort of the, the woman or the people, like everything that you, you can do everything kind of woman, right? Yeah. Like you can, she 

Dr. Christine Maren: does everything for everyone.

She's super reliable, you know, to go to her because she's gonna get the thing done, 

Dr. Scott Sherr: right? 

Dr. Christine Maren: I mean, I speak from experience, so, 

Dr. Scott Sherr: yes. Yeah, I got that sense. And that's a, I I totally understand. Um, what is [00:17:00] the relative proportion of women that are in those categories, do you think? Sort of, you know, population wide, do you have a sense of that?

It sounds like many of your patients fall into the second category, but do you have a sense? Yeah, 

Dr. Christine Maren: yeah. It's hard. It's hard to say, you know? Yeah. I don't, there's really no data on it. Mm-hmm. Um, in my patient population, I would say it's about 50 50. I mean, I still, I definitely see those women who have those high spikes in estrogen.

So the type one woman who I'm talking about with the high chaotic estrogen, yeah. She often has like really heavy periods. She's that woman who enters perimenopause and just is like, you know, it's like a murder scene. And she often gets like an ablation or something like that, but it's because estrogen proliferates the endometrial lining and so, got it.

When we have unopposed estrogen proliferating the endometrial lining, coupled with low progesterone, women tend to have really heavy periods. There's also, you know, moodiness and some inflammation and breast tenderness and stuff like that that goes hand in hand with those symptoms. Right. Women on the low estrogen side tend to just be a little bit more flat.

[00:18:00] Um, their periods are often scant or very light. Mm-hmm. So that's a good way for listeners to just kind of determine like what category they're in. Often with low estrogen, we'll have like dry skin sometimes later in the game there can be vaginal dryness or discomfort with intercourse. Um, low libido for sure.

Dr. Scott Sherr: Yeah. It's interesting how you frame it. So the second group that you mostly see are mostly these sort of high performers that have really kind of just pushed and pushed. What is the, so what's the physiologic reason for it? Like, they're pushing and pushing, they're coming outta their body. Why is their estrogen lower?

Do you have a, do you have a sense of that compared to Yeah, it's 

Dr. Christine Maren: HPA access, it's stress. They often have, um. Other markers that show me they're under a lot of stress or Got it. Sometimes that they're under fueled. That's another thing I look for. So along with low estrogen, sometimes they'll have low leptin, they'll have a high reverse T three.

So it's like, got it. I always say the body, your body loves you. It's, it's trying to compensate, it's trying to reach homeostasis. Yeah. And in an effort to do that, in a woman who's under fueled and performing at a really high level, [00:19:00] she tends, you know, that reverse T three goes up as like this body's mechanism of like, Hey, I'm putting on the brakes for you so you can slow down, slow that metabolism down, so you don't need as much.

And she often will gain weight as a result of that because her metabolism slows down. But these same women are often, yeah, it's this whole mix because the same population of women is often really low carb. So I talk about this a lot in my practice because I want them to actually eat more carbs. So it's really good for their gut microbiome and for their hormones.

Sure. For this specific type of woman to eat more carbs, she often actually has a hemoglobin A1C that's a little like borderline, like maybe 5.6. It's like interesting. For years I was like, what? What's up? Like, yeah. All these patients have, you know, this kind of borderline blood sugar where it's just sort of puzzling and I mean they, they're not overweight.

They might be like five or 10 pounds higher than their ideal body weight, but they're not. Obese by any means. Uh, but they just have this surprisingly elevated blood sugar despite a [00:20:00] very healthy diet. But what I find is they're eating really high fat inadvertently many times. 'cause they're gluten-free and like really, you know, on, on their health kick trying to do their best.

Mm-hmm. But they have limited carbs a lot and they're eating a ton more fat than they thought. And sometimes they're undereating protein, oftentimes they're, you know, prioritizing protein. Kind of depends where they are. But the typical pattern is undereating protein, undereating carbs, overeating fat. 

Dr. Scott Sherr: And you're still, and you're seeing a mild insulin resistance.

Dr. Christine Maren: Yes. Within that? Well, I think it's more driven by stress than insulin resistance. Got it. I think these patients don't truly have insulin resistance. 'cause when they start eating carbs, their blood sugar comes down. Interesting. It's more of a stress response. It's their body. Like, Ooh, I gotta stay in survival mode, you know?

Bring up that blood sugar. It's driven, you know, by high cortisol. Right. For sure. Right. So the 

Dr. Scott Sherr: cortisol level is elevating. Yeah. That's increasing the blood sugar. It's not necessarily, and we know this, we know carbohydrates actually [00:21:00] decrease our cortisol response. Yeah. Right. And so this is, makes a ton of sense.

And this, you know, hits relatively close to home as I think about it. And so, um, it's very interesting that, and so when you start putting them on carbohydrates, they tend to feel better. They tend to have you also notice that they're, oh my gosh, that they're one two dumb. 

Dr. Christine Maren: Tell me. Yeah. You know, in the afternoon, so many women are are, you know, suffering through fatigue and just like slogging through, especially when they're moms, you know, when they come home and they're just like, all you wanna to do is take a nap.

It's really hard to mom when you're super fatigued. Yeah. Anyways, they start eating more carbs and women are like, oh my god, my energy is so much better. I'm like, yes, your energy is better. Like you need more carbs. Now we're talking, you know, good complex carbs with fiber. Sure. You know, I always encourage like, your carbs should have fiber though some of the.

Pretty high performance athletes can do great on simple carbs after a workout actually. 

Dr. Scott Sherr: Yeah. Simple carbs such as like what? What would you say? What would you, A good example, 

Dr. Christine Maren: I mean, you know, like Juice, what's my favorite? Yeah. Yeah. [00:22:00] Juice would be okay. I mean this, honestly, if I'm totally. Transparent about simple carbs.

I have a really hard time with them myself. Um, I have a performance coach and she's like, eat rice cakes. Those, that's your simple carb rice cakes. And I'm like, Ugh. I don't really, I don't know about that. 

Dr. Scott Sherr: They don't taste very good. Yeah, 

Dr. Christine Maren: they don't taste very good. Yeah. I'm usually more of, like, when it comes to carbs, I, yeah, I have a hard time.

I do complex carbs. I personally do like a lot of fruit and oats and potatoes. Um, gotcha. Yeah. So I mean, rice would be a more simple. Carb juice, you know, would be a more simple carb, um, 

Dr. Scott Sherr: right. Yeah. And we also know that carbohydrates before bed tend to help us relax and get that cortisol up. Yeah. Cortisol down, excuse me.

Right. And, and they can help people sleep better. So, um, yeah. Yeah. Super interesting. Yeah, 

Dr. Christine Maren: it's such a nuanced conversation because there are, you know, there are also, I mean, I also have patients in my practice who are truly insulin resistance and they, right. They do tend to be on the more overweight slash obese side.

Uh, you know, and we know insulin resistance is, goes hand in hand with perimenopause and [00:23:00] menopause and declining estrogen. I mean, that's a whole thing. Building muscle, all that's super important. But for many of the, like high performing females who are lifting weights and running or walking or doing whatever and really active, those are the patients who usually need more complex carbs and, and maybe simple carbs, if you could figure out how to do that yourself, I don't know.

Dr. Scott Sherr: Gotcha, gotcha. Okay. Well there's one word that I wanted to ask you about with the gut. That is relatively new for people, even clinicians called Estrobolome. 

Dr. Christine Maren: Yeah. Um, 

Dr. Scott Sherr: and I think we've kind of discussed maybe parts of this already, but if you can just maybe define that word and that, I know we have a lot of these ohms now.

We have the metabolome, we have the epigenome, we have the proteome, and uh mm-hmm. Et cetera, et cetera. What is the Estro? Estro The estrobolome 

Dr. Christine Maren: is my favorite because it is the microbiome's specialized unit for handling estrogen. And I think it is so cool because the stroum secretes beta glucuronidase, which is an enzyme that helps us to regulate estrogen reuptake in our gut.

Mm. Mm-hmm. And so, back in the day, I used to [00:24:00] look at this test, 'cause you can get markers of it on a stool test. Yep. The beta. And if I saw, hey, high beta glucuronidase, you know, I'd use something to kind of counteract that. But now I look at it differently. Hmm. Almost like reverse T three. It's your body trying to maintain homeostasis.

Hmm. And so your body is so smart, the erum is so smart that it can help regulate that estrogen level. And so, you know, if you're going through menopause and you have a really health healthy gut microbiome, it'll help you hang on to a little bit more estrogen. Hmm. Or if you. Need to get rid of estrogen, it'll regulate that way.

But once you've got dysbiosis, that that homeostasis is broken. And so what happens is women who are going through menopause tend to have worsening symptoms if they have dysbiosis because of that broken mechanism. So they lower, even lower estrogen levels, so they have less S3 

Dr. Scott Sherr: uptake, right. As a result of that.

And then 

Dr. Christine Maren: estrogen more, you know, high estrogen states like endometrial cancer, this is one point that I really love, [00:25:00] uh, but your risk for endometrial cancer is related to your gut, Hmm. Through the estrobolome. Interesting. So if you're hanging onto more estrogen and you're not able to excrete it as much, you're gonna be at higher risk for the unopposed endometrial proliferation that happens with estrogen.

And so you always want that balance between estrogen and progesterone. I always say it's very yin yang, and part of that balance gets affected by how you metabolize and balance things through your gut microbiome, specifically your estrobolome. 

Dr. Scott Sherr: Hmm. And so, so basically glucuronidase is an enzyme. Can you talk a little bit about how that works and so that people understand what's happening?

And I know it's like sort of a conjugation like thing where estrogen can either be recycled Yeah. Or can be excreted. Right. And yeah. And what is, I guess, what are some of the things that, let's, let's like zoom out 

Dr. Christine Maren: and we'll look at estrogen metabolism. So yeah. Great. There's, there's three phases of estrogen metabolism.

Phase one happens through our liver, through C'S end. And so we can look at this through a Dutch test. Yeah. And see if people are going down this pathway toward four hydroxy or 4 0 8. That's [00:26:00] the quote bad pathway. We don't really want a lot of that. Okay. That can lead to DNA damage. Okay. There's also a 16 hydroxy pathway that's a little bit like indeterminate.

We don't know for sure. A lot of people think it's related to growth, like fibroids or cysts or the 2 0 2 hydroxy pathway, which is favorable. So you really wanna go down that two hydroxy pathway. That's why we tell people to eat broccoli, like eat cruciferous vegetables. That's really good for phase one metabolism.

Hmm. That is also why we use a supplement called dim. It helps with phase one metabolism. So just to be clear, DIM is a tricky one. I wouldn't go by dim. Right? Like if you're listening, don't just start dim. Sure. You don't wanna use dim. If your estrogen is low, it will make it lower. Interesting. Okay. DIM can be a really great tool if you're on HRT and you want this like little bit of extra.

Encouragement to go down the two hydroxy pathway. So I like to use DIM in my patients who are taking HRT. 

Dr. Scott Sherr: Got it. Yeah. 

Dr. Christine Maren: And also if you have hydrogen sulfide overgrowth, cruciferous vegetables might kill your gut. Okay. So that's where like eating [00:27:00] a ton of broccoli and cauliflower and onions and Lees and garlic, like if that is causing a ton of bloating, a lot of women don't tolerate that because they need to first address their gut health.

So phase one, CYP enzymes, cruciferous vegetables, dim phase two goes through COMT methylation. And so that's where like magnesium can be really helpful. Some B vitamins. Okay. And, you know, depends on what your snips look like, but you know, COMT plays a big role here. Mm-hmm. And then phase three is really in your gut.

And that's when beta glucuronidase comes into play. Got it. And that's where your microbiome and your stroum makes a really big difference. And so if you're making a a lot more beta glucuronidase, you're gonna re-uptake the estrogen in your gut. If beta glucuronidase is low, you're gonna get rid of estrogen in your gut.

Got it. That's, and that's where sometimes we'll use calcium DEG glucarate as a supplement to help with that. So there's like, uh, I take DIM detox, which has calcium, deg, glucarate, and dim in it. But now I'm sort of questioning, do I want calcium, deg, glucarate? I'm not really sure. 

Dr. Scott Sherr: Yeah. As you were saying earlier, because it, it, it [00:28:00] piqued my interest because I do a lot of stool testing as well.

Mm-hmm. And I do see the beta glucuronidase enzyme elevated, and when I do, I'm like, okay, well they're, they're likely, you know, there's an inflammatory process going on, likely dysbiosis, but you also think about the liver as well, and, and sort of, again, the re conjugation, not only of estrogen, but other toxic things as well.

Right. And so typically I would give calcium de glucarate for this, but it sounds like. It's more nuanced, like it's not your first go around depending on the person and, and how they're kinda presenting to you. 

Dr. Christine Maren: Yeah. Now I mean, I, I, I really think of it differently than I did a couple years ago. 'cause I used to just give them calcium dgl rate.

But yes, now I'm really thinking about like, well what's the homeostasis here? A good, okay, so good analogy too is like sex hormone binding globulin. Mm-hmm. When we see sex hormone binding globulin go up, my immediate reaction isn't, let me bring that thing down. It's, why is this high? How is this affecting your hormones?

It's your body trying to maintain homeostasis. So what's the mechanism? I mean, [00:29:00] often, you know, sex hormone binding globulin will be really high and a woman on birth control pills. Mm-hmm. So it's like a whole other, we should talk about birth control pills Sure, sure. In perimenopause, but, um, yeah. Yeah. So a woman, you know, on birth control will have A-S-H-B-G that's really high and it's her body's way of trying to protect her from the high synthetic estrogen she's getting in a birth control pill.

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Sleep can be a big issue related to estrogen changes, progesterone changes as well because progesterone works on the GABA system. So check it out@transcriptions.com and save 10% on your order by using code POD 10 at [00:30:00] checkout. Now back to the show. Got it. Are there any other, I mean, looking at S HBG as a particular marker, are there any other reasons why you see it partic potentially being elevated and not in women that are on birth control?

Are there other sort of instances or for 

Dr. Christine Maren: SHBG? 

Dr. Scott Sherr: Yeah. 

Dr. Christine Maren: Yeah. I mean, pregnancy is one. I mean, course any high estrogen state birth control pills, sometimes. Oral estrogen will do. Oral estradiol will increase that. Yeah, not always. I tend to not see those high, uh, a high SHBG in, um, women who are on HRT. Okay.

Bioidentical, HRT. Mm-hmm. Just more on birth control pills. Um, it's gonna also be high. Hmm. Um, really high performance athletes tend to have a high SHBG. 

Dr. Scott Sherr: I've seen that too. 

Dr. Christine Maren: My husband's a cyclist is as high. Yeah. I've got some other athletes who have a high SHBG. 

Dr. Scott Sherr: Yeah. 

Dr. Christine Maren: Um, is it a vegan vegetarian diet that will increase it too?

Dr. Scott Sherr: Yeah, I'm not sure. I'm not sure we, um, but I, you know, I do know it could be an inflammatory marker as well [00:31:00] in the sense that if the, at least with the, if you're holding on more testosterone, typically Right. As you're binding more. Mm-hmm. That's typically what's happening is that there could be an inflammatory piece, there could be a gut dysbiosis piece.

Um, but I think you, you brought up the, uh, the birth control thing. Maybe we should talk a little bit about that. So, um, I wanted to talk to you about testing and, and corrections and things like that, but before we get there. A lot of women around the perimenopausal timeframe are being prescribed birth control pills.

Um, maybe they have been on them when they were younger and then they've been off for a while, or maybe they've been on the whole time. Some people have been. Um, what is your sense of the role of birth control pills at all during this timeframe? Or is it completely misguided and we should be looking at like an HRT focus instead, or what, what's your sense?

Dr. Christine Maren: Yeah, I definitely look at an HRT focus instead of birth control pills. So, um, birth control pills come with risks and they come with a lot more risks in older women. Right. And every time I get on stage in lecture, somebody comes up to me and says, I was the woman who got the blood clot on birth control pills in my [00:32:00] forties, because that is the answer that perimenopausal get when they.

Perimenopausal women get when they go to the doctor and say, yeah, I think my hormones are off. Like typically they're offered a birth control pill. Now obviously some women do need birth control pill. If you need contraception, I would really advocate for a vasectomy. In an ideal world, if that's not an option, an IUD is a better option.

It's not perfect, but it's definitely better than a birth control pill. Right? So birth control pills have side effects. The worst of which are stroke and blood clots, right? Yeah. They also cause low libido and changes in mood. They shut off our ovaries and when we're trying, when we're going through perimenopause, we're not, we don't wanna shut everything down.

Dr. Scott Sherr: Right? 

Dr. Christine Maren: You want more estradiol. So it seems very unfair to me. Yeah. That women are not offered [00:33:00] HRT. It's scrutinized to this higher level. So I've had women tell me also, I can't take factor or I can't take birth control, or I'm sorry, I can't take HRT because I had factor five lein. So factor five leins associated with, you know, increased clotting risk.

Especially if you're homozygous, but there's so many people, like, I don't know, probably 50% of the population has like a snippet factor. Five lighten. Mm. You know, if their zy is that high, it's really, really common. Yeah. And we never counsel women on factor five lighten when they go on birth control pills ever.

Even if she's 40. Right. I don't know anybody who's testing for factor five Liden. I mean, I am, but I am now also not prescribing birth control pills. So the point is there's just a lot more scrutiny around HRT, which has a lot of benefits long term, right? Like estradiol, transdermally will not increase your risk of blood clots.

It will often improve sleep, improve cognition. The gut health piece is really interesting. Yeah. So birth control pills can also mess with your gut microbiome. 

Dr. Scott Sherr: That was my next question. Yeah. Tell me that. You know, lots of other 

Dr. Christine Maren: stuff too, like [00:34:00] alcohol and. Exercise is great for your gut. Alcohol and antibiotics and birth control pills are bad for your gut.

So, you know, if birth control pills mess with your gut microbiome and increase dysbiosis, HRT actually does the opposite. This is emerging research. We don't have awesome research on it yet, but it's coming out and I will bet on it for sure. But HRT can be really helpful for the gut microbiome. And here's another one that I love is estradiol improves intestinal permeability.

So the tight junctions are better with estradiol, which is so cool. 

Dr. Scott Sherr: And that doesn't happen with synthetic estrogens at all. Right? Okay. Yeah. Yeah. It's like 

Dr. Christine Maren: a synthetic derivative of estrogen. It is not, you know, estradiol. So if a woman goes and gets her hormones tested and she's on birth control pills, there's like no estrogen and no progesterone that comes up.

Of course, right? Yeah. But what does come up is the thing we can't test for, which is the synthetic. Ethanol, estradiol, whatever is in her birth control pill. And so, you know, it just looks like her hormones are flatlined, but she's got a lot of this synthetic estrogen derivative in [00:35:00] her blood that's shutting off her ovaries.

Dr. Scott Sherr: Got it. Wow. And so, and so, I mean, go ahead. I mean, there's a time 

Dr. Christine Maren: and place like for some women who have really bad endometriosis, like there might be a time and place for birth control. I never say never kind of thing. Sure. Um, you know, there is a place for it, but it is not a good treatment for women who are concerned about perimenopausal symptoms and want better sleep, better sex, better performance, better gut microbiome, better energy, better mood.

And 

Dr. Scott Sherr: so, yeah, a lot of DI mean, so the synthetic estrogens themselves then have a propensity to increase your, your gut junction leakiness. So they, but, but if you're taking, but, but the, but like, estrogen itself is protective against them, so when you're going through perimenopause, you actually have an increased risk of leaky gut as well.

Dr. Christine Maren: Yeah, I mean, estrogen disrupts your gum, or I'm sorry. Uh, birth control pills disrupt your gut microbiome. Mm-hmm. Mm-hmm. Which the downstream effect is a more leaky gut or increased intestinal permeability. Got it. Whereas HRT helps your gut microbiome and estradiol works directly on your tight junction, so improves your intestinal permeability [00:36:00] and might balance out those big estrogen peaks, or fix the low estrogen that some women have and progesterone can help with the mast cell instability.

A lot of other things. 

Dr. Scott Sherr: Sure. I mean, this is, I think, a good segue to talk about treatment, right? So, I mean, I think we've, you've kinda laid out the, the argument and I think a very good one that, um, HRT is, is, uh, is something that maybe all women during the penny per menopausal timeframe, maybe all, not everybody maybe, but I want, I wanna kind delineate that a little bit.

So let's talk about HRTA little bit, how you think about it in perimenopause, what kind of testing you feel like is helpful and what kind of testing is not helpful. And, uh, and then maybe talk, I mean, we can also talk about the, the gi part of it, like the testing there that you do Yeah. As part of your workup and how that maybe.

Over time how you, how you look at things. We can, we can break all that down, but we can start with that framework. Yeah. 

Dr. Christine Maren: Yeah. So hormones, so in the perimenopausal woman, I test hormones. A lot of clinicians don't. The Menopause Society doesn't recommend that you do. So just be aware. What I do is not what [00:37:00] typical clinicians do, but I see a lot of value in it.

It's just dependent on when you do it and how many data points you get. So I like to look at day three to five hormones when they're low and see like, what's your estrogen doing at this lowest point? And then do it again in the luteal phase. So after ovulation and see like what's estrogen doing. And then you can, with more data points, like I at least get two markers, but I like to get more.

Got it. Uh, especially when it comes to estrogen, the argument against testing estrogen is that it's all over the map with your cycle, which is true. Right? Right. It's all over the board, but that's why you get more than one data point. That's also why you can do daily testing. So there's some upcoming tests like Dutch test will do a cycle map.

Um, there's also a test. It's called Empower. I literally have it on my desk here. I haven't used it yet, but it also will do, you know, give you that kind of, um, data so you can see, you know, what your levels look like throughout your cycle. So, so do you, there are ways to do that, but, 

Dr. Scott Sherr: so when you're doing it, like with data points throughout the cycle, is it you're doing it daily [00:38:00] throughout the cycle?

Yeah. Like something like the, the Dutch test or this other test? 

Dr. Christine Maren: Yeah, the Dutch cycle map is, uh, you pee on a card basically every day of your cycle and then you can see the path. Uh, you know, that happens. I mean, we know, you know, in the first half of your cycle, estrogen's gonna start to increase and then it increases enough where you get this LH surgeon you ovulate in the second half of your cycle, the corpus lium makes progesterone so it sees increase in progesterone.

And so in a perimenopausal woman, I would say almost like pretty much universally perimenopausal women have this decline in estrogen. And I say perimenopause is like the invoice inverse of puberty. You know, puberty's happening, hormones are all over the map, but they're like increasing in perimenopause.

They're all over the map and decreasing and sometimes they're just low overall. Right? So, you know, doing testing will help us identify that and will help us identify also, like, does a woman have really low estrogen or is it all over the map? And then symptoms are really the most important. And the amount of flow, like how heavier period is, can be a very helpful indicator of what's going on for women.

With the IUD it can be [00:39:00] trickier 'cause we don't really know. Sometimes they're not ovulating very often. They're not ovulating. Yeah. Um, so I'll check, I'll check their labs like 10 days apart. But, you know, symptoms are a huge part of it. Of course, labs are not the primary way to test for perimenopause.

There is no definitive test for perimenopause. But it, I think labs are critical. And also because, uh, I have coined this term the unmasking effect in perimenopause. And what that means is perimenopause is a time when any underlying health condition gets unmasked. And so it's really important to look not just at gut health, but also at thyroid.

Sometimes we see, we see a big increase of autoimmune disease in menopause and you know, part of that's the unmasking effect. Hmm. And so, you know, as we're looking through labs, I like to get really comprehensive labs so we understand is this the picture of a woman who has low leptin and a high reverse T three maybe.

She also has subclinical hypothyroidism. She's got low estrogen, low progesterone, um, you know, and nutrient [00:40:00] deficiencies. We're looking at methylation, magnesium, what's her B12 and folate and all that kind of stuff. And then, or we might see this picture of somebody who's actually got really true insulin resistance.

Her insulin is high. This is not my typical patient, but I still see them for sure. Right, sure. But you know, she has high insulin and you know, maybe she has high cortisol too. I mean, that can happen. We see. Both sides of the coin there. I'm looking not just at estradiol and progesterone in the labs. We'll, at DHEA pregnenolone, progesterone, estradiol, and then testosterone we haven't really even talked about, but a, a woman who has a woman has testosterone.

Yes. And the reference range goes for free. Testosterone literally is like zero to five. It really depends on the lab. But I'm like, why? Why does the reference range go to basically zero? It's like 0.2. That's 

Dr. Scott Sherr: crazy. So it's a zero at the point. But why? 

Dr. Christine Maren: Why, what is, how is that okay, you know, a woman's estrogen?

Like if you were to measure unit per unit, estrogen versus estro, or, I'm sorry, estrodiol versus testosterone. A woman actually has [00:41:00] more testosterone than estrogen. Yes, yes. I know this. Yeah. So, you know, a, a lot of times that's forgotten about, but I'm definitely looking at free and total testosterone, SHBG, you know, the full thyroid panel, thyroid antibodies, all that kind of stuff.

Yeah. So, yeah. Yeah. I think really comprehensive testing is important though on its own. It doesn't really identify perimenopause. And there's some better diagnostic tools that we can use, like, you know, a Dutch cycle map and things like that, that are forthcoming. 

Dr. Scott Sherr: Understood. 

Dr. Christine Maren: So that's testing. What was the next part?

Dr. Scott Sherr: Well, that's the, that's the first one. Let me ask you a couple things about that. Yeah. 'cause that was really comprehensive. Um, the, I think the, the idea of unmasking is really interesting and I wanted to just take a minute to talk about that because I think maybe you can describe what that would look like in, in, in a clinical perspective.

Right. 'cause I think giving some examples for clinicians out there, um, I, I've seen this in my own practice over the years, but maybe some people haven't. So tell me what that looks like in, in some of the patients you've, you, you've seen over the years and what that might Yeah. 

Dr. Christine Maren: Is that like, I mean, so many 40 something women are [00:42:00] having a bit of a health crisis and they're not getting a lot of great answers.

They're getting birth control pills and acid blocking medications. And part of the reason behind that is because as we lose hormones, we lose resilience. Hmm. And any of the underlying health issues we have, we can't ignore them anymore. They just become to a point where you can't not look. They're gonna, you know, cause symptoms.

So a lot of the women I see are struggling with an autoimmune disease. Hmm. Hashimoto's is super common. Sure. Sometimes other things like inflammatory bowel disease or something like that, they are often struggling with hypothyroidism in addition to low hormones associated with perimenopause. So estrogen, progesterone, testosterone.

Mm-hmm. Um, other hormonal kind of symptoms. I mean, it's, it's tricky. Like, you know, there's other things that come up for sure between endometriosis and, you know, things like that. But there is, you know, any kind of underlying issue is coming forward. And then gut health is a huge one. Like we see worsening of IBS symptoms, worsening of IBD [00:43:00] symptoms, bloating, you know, all that.

So the, right, the symptomatology around perimenopause and menopause, I mean, said there's like 50 plus symptoms. Right. The reason for that is because of the unmasking effect. It's because there's all this other stuff going on. And that's where, back to what I said at the very beginning, it's not just hormones.

It's so much bigger than just hormones. Hormones play a really important role, but when I approach in my clinical practice, I have a three pillar framework. So number one is address the root cause, and often that's related to gut health. Mm-hmm. But sometimes it's also like autoimmune disease, inflammation, toxin exposure, mold exposure, heavy metals, whatever it might be.

Sure. Number two is optimize hormones, and so that's optimizing, you know, your sex hormones, your thyroid hormone. Insulin levels. Mm-hmm. Um, cortisol. And number three is building resilience. And so that's where I work with patients to really like dial in good lifestyle habits, like a protein centric, high fiber nutrition, strength training, walk movement, sleeping, you know, which definitely there's like crossover between perimenopause [00:44:00] and hormones and sleep and even root cause issues in sleep.

Yeah. Uh, stress, peace mindset, and then low tox living. 

Dr. Scott Sherr: I love it because I think I, I love that you're, I love the order of that, and I talk about this all the time with, with patients as well. I, I work with a lot of, with a decent amount of guys doing hormone optimization. Right. And what I always talk about with them is that we can't mess, we can't start working on your testosterone, your growth hormone, your thyroid, et cetera, until we work on some of those, you know, quote unquote root causes, like under your underlying foundational biology, your vitamins, your minerals, your nutrients, your toxic load, because that's gonna have a huge effect on your hormones as well as you've already described.

Dr. Christine Maren: Yeah, totally. 

Dr. Scott Sherr: Yeah. Um, one thing I wanted to ask you about with, with HRT and, and looking at labs and you mentioned like getting a baseline or trying to get, you know, with data points over like multiple months. Um, as you are working with somebody and doing HRT, is it something that you're doing from there?

You're rechecking labs over time or is it something that you're just kinda looking symptomatically and how they're feeling depending on what kind of, you know, what kind of data points you saw initially? 

Dr. Christine Maren: Yeah. [00:45:00] No, I'm a lab girl. Um, okay. I like labs. Cool. I, I also am a risk versus benefit girl. Like what, what is the risk of getting some blood work?

I mean, there's really not, let's get some data. I mean right. There's some financial risk, but, uh, we can mitigate that. Sure, sure. Um, yeah, so I like to look at labs and I like to use labs to titrate their dose. So, got it. Just like we do with thyroid. And really, this brings up a good kind of point too, with thyroid.

I mean, if somebody has hypothyroidism, we give them thyroid medication. If somebody is perimenopausal and deficient in estrogen, we can give them estradiol, you know, and, and then you look at labs to balance it. Now you can't use FSH and lh, like you use t TSH for thyroid. Sure, sure. Uh, but we can look at estradiol levels in the blood work and look at progesterone.

We can talk through symptoms, we can understand bleeding and what the flow looks like, what your cycles look like, all that kind of stuff. 

Dr. Scott Sherr: Cool. And so, I mean, maybe just a co like a couple notes on, on controversy here a little bit. Just for those that are listening and many of the people that are listening already have a [00:46:00] pretty good framework of understanding HRT and why it could be helpful, but why is it still so controversial?

Christine, why? Why would, why do you think it's still at that level? I mean, it seems like it might be changing a little bit sometimes. I think it is, and then other times I'm like, no, nothing's changing. So, HRT 

Dr. Christine Maren: and TE or testing or both? 

Dr. Scott Sherr: HRT, I would say both. Ht, I think HRT maybe is the, the bigger of the two.

Right? 

Dr. Christine Maren: I mean, largely it's because the Women's Health Initiative study that was published in 2003 is big media, blitz Time magazine, like all the things causes breast cancer. It doesn't cause breast cancer. It increase, like it can grow. It's proliferative. So estrogen, if you have an underlying breast, cancer could grow it.

So you need to be careful about that. I always get mammography before I start patients on HRT. Okay. Um, I wish we had better option than mammography and there are some coming up, you know. Yeah. There are QT imaging. I'm, I'm really curious about. But you know, that's what's accessible. That's what we've got right now.

Uh, that said. Endometrial cancer or uterine cancer is a risk. And so women need to be really cautious about that. That's why we always use progesterone [00:47:00] with estradiol. However, yeah, as we talked about with beta glucuronidase, like that will depend on your gut microbiome and beta glucuronidase, and you're a estrobolome because you might be somebody who needs more progesterone and less estrogen if you're, you know, hanging onto it.

So, you know that balance is really, uh, critical. I mean, the Women's Health Initiative just was a huge setback in women's health because doctors just stopped prescribing about it or stopped prescribing it and talking about it. I didn't learn anything about it in residency. I mean, I was a family medicine resident.

Did you learn anything about 

Dr. Scott Sherr: no hormone replacement? No, not there was nothing. I mean, I was in, they don't, yeah, no. As an internal medicine doc, there was, there was talk about the women's health initiative and how, you know that HRT, that's actually when, when I was in medical school or residency, that's when they started taking everybody off.

Yeah. HRT, because they thought it increased their risk of the cancers, the strokes, the, the thromboembolism, things like that. But yeah, they were using all the synthetic progess and yeah. So estrogens during that study. [00:48:00] Yeah. 

Dr. Christine Maren: The other big, huge piece is like. If you look, they've, you know, the reanalysis, I think was in 20 13, 20 11.

The reanalysis did not get anywhere near the press that the original, you know, data got. But the reanalysis basically showed like, oh, actually I think the estrogen arm was protective against breast cancer. But nobody's really talking about that. But the, the hormones that were being studied are very different than the hormones we use now.

Yeah. So Preemt, Premarin was, you know, from a pregnant horse's urine, and while honestly, I think it's better than nothing if you need estrogen. Yeah. Estradiol, transdermal, bioidentical estradiol that we use now is very different. And same thing with progesterone. What was studied in the Women's Health Initiative was a synthetic progestin.

Right. What we use now in HRT is a bioidentical, micronized progesterone. Very different risks. There's a French study looking at, um, potentially that progestin was associated with maybe a slight increase in breast [00:49:00] cancer risk. But the reality is we just don't have a lot of really awesome data. We do have some data and, you know, it's a risk benefit decision.

I mean, it's not right for every single person. Um, we should talk about vaginal estrogen side note. 

Dr. Scott Sherr: Sure. Go for it. 

Dr. Christine Maren: Yeah. 

Dr. Scott Sherr: Yeah. 

Dr. Christine Maren: Yeah. But it's just, it's really under, doctors are undereducated on it. There's just not a lot of awareness around it, and that's why they're more comfortable prescribing birth control pills because they're educated on that.

They've used it for years. They're very comfortable prescribing it because they've always done it. But HRT is just different. They're not comfortable prescribing it. They don't really know how. Um mm-hmm. I do think it's changing, but I kind of live in a bubble of like, you know. Sure. 

Dr. Scott Sherr: I get it. Yeah. There's a lot of 

Dr. Christine Maren: hormones in my world.

Dr. Scott Sherr: I understand. Do you wanna talk briefly about vaginal estrogen? Just to, yeah. Vaginal estrogen 

Dr. Christine Maren: is a really great tool. It's one of my favorite things. Um. To prescribe to any menopausal woman. But I think, you know, one thing that doesn't get talked about is as [00:50:00] women go through menopause, they actually experience a change in their anatomy.

So the vulva changes and they can get, um, certain kinds of things that will decrease sexual function over time. So it's a really big deal to maintain your anatomy. Mm-hmm. And also it's a great tool for helping pre prevent UTIs, but also helping the urinary bladder. So I've had patients go on vaginal estrogen and now they're able to sleep through the night 'cause they don't have to wake up to pee.

Mm-hmm. It helps tone the urethra. Mm-hmm. Uh, and it's very low risk. It's like you could actually use it if you had breast cancer. However, women with suspected or confirmed gynecologic cancer should not use vaginal estrogen. But outside of that, it's like a really safe, simple intervention with no money behind it.

So you might not learn about it. Like, 

Dr. Scott Sherr: yeah, I got it. Yeah, no, he's making 

Dr. Christine Maren: commercials. 

Dr. Scott Sherr: Right. So typically you'll have people on like an estradiol patch along with vaginal estrogen together, or is it some people that you'll just do vaginal estrogen on its own? 

Dr. Christine Maren: It depends. If you're not a good [00:51:00] candidate for estradiol, transdermally or systemic, I would argue that the vast majority of women should be using vaginal estrogen at least.

Got it. Uh, so you can use 'em together? I use 'em together all the time. Yeah. Um, so local vaginal estrogen versus systemic estradiol. Yeah. Yeah. Um, yeah. You could use either, you could use them both together. Cool. The pharmacy will sometimes give you some pushback, so. We have to explain to the pharmacy Yes, we meant to do that.

Dr. Scott Sherr: Yeah, I understand. Yeah, 

Dr. Christine Maren: they're very different. 

Dr. Scott Sherr: Yes. Understood. Okay, so let's go a little bit a along the side of like, of gut testing, GI testing, and how you think about probiotics, prebiotics, just what's your framework there? I know this is kind of a big area that you plan, so what kind of testing do you typically do and what, what are your major interventions overall here?

So my, 

Dr. Christine Maren: my favorite three tests would be a SIBO breath test because bacterial overgrowth is very common. Mm-hmm. Um, there is also one that tests for hydrogen sulfide. The trios smartt one. So I like to do that sometimes, depending on the patient. [00:52:00] Uh. I'll do urine organic acid testing a lot. Mm-hmm. I like to look at that first page, especially when it comes to fungal overgrowth.

Mm-hmm. So a lot of times patients are dealing with fungal overgrowth. Mm-hmm. Uh, which is really what people call candida or yeast. Right. And I'll do stool testing as well. So that triad tells me a whole lot about what's going on with the gut microbiome, along with talking to a patient and understanding what her symptoms look like.

Uh, but from there, you know, we can look at is there dysbiosis, is there overgrowth of fungal species? Is there overgrowth of clostridia? Um, you know, is there h pylori? Maybe there's a parasite. I just had a patient last week who has been struggling with digestive issues for, you know, a couple years. Mm-hmm.

And, uh, we identified on stool testing that she had. Clostridium difficile. And so I sent her to Quest. I'm like, go test this at Quest. Let's just make sure indeed she's got c Diff. But you know, in the conventional realm, I think, you know, just nobody was checking for that. 'cause she wasn't [00:53:00] like the typical patient who would have c diff, you know, but, right.

Yeah. I mean there's all these different collection of. You know, whatever gut infection, whatever flavor you have. And you could have several. Sometimes I get patients who I'm like, oh crap. Well, literally, no 

Dr. Scott Sherr: pun intended. Yeah, yeah. 

Dr. Christine Maren: No pun intended. Um, what crap, you know? Yeah. That sucks. But we, we got you.

Like, I'm glad you're here. Let's, let's, let's go. So I use a combination of prescriptions and herbals. Um, I like to, my gut framework is, is like remove and replace. So remove the gut infections. So that might be prescription medications like Xifaxan or antifungals. Mm-hmm. Also likely will be some sort of herb.

Um, you know, remove things like gluten and alcohol, some of the gut irritating foods. Sure. Remove auto processed foods, things like that. Mm-hmm. Uh, I don't generally put people on like a really restrictive diet, but you know, if they have histamine issues, we might limit some. Things like [00:54:00] sauerkraut and alcohol, right.

Something like that related. So just kind of, yeah. Yeah. It just depends. Mm-hmm. Um, you know, remove, I also, you know, talk to my patients a lot about, uh, just the psychology and the emotions behind it all. So remove that, like self criticism or that self-critical voice. I think that's a really important point too.

Hmm. Uh, and remove toxins. 'cause those are gonna disrupt your gut microbiome as well. 

Dr. Scott Sherr: Thinking about those estrogens in the water, so Yeah, 

Dr. Christine Maren: totally. Yeah. Yeah. And like, that's a whole other story, like xenoestrogens in your environment. These are bad estrogens. Estradiol is a good estrogen, so, you know, good and bad.

But, um, most of the, the negatives around estrogen are related to, you know, chemicals and plasticizers that resemble estrogen are endocrine disruptor chemicals. So, um, so you know, when we're talking about gut though, like, you know, remove those big offenders and then replace digestive enzymes. Some women need more digestive enzymes or they need some more digestive support.

Those same women who have like disconnected from their body and have low hormones tend to have low [00:55:00] digestive enzyme function and low stomach acid. 

Dr. Scott Sherr: Makes sense. Yeah, because they're super 

Dr. Christine Maren: stressed. So. Replace enzymes sometimes replace stomach acid, replace hormones. HRT, that's a big one I put in there. Of course.

Yeah. Yeah. So that's sort of the framework I use. And then, you know, re inoculate. I like to use spore formm probiotics. I'll, you know, potentially layer in pre prebiotics later on, but don't use a ton of prebiotics. I just really encourage patients to eat more fiber. 

Dr. Scott Sherr: Yeah, 

Dr. Christine Maren: eat more fiber, you know, whole fruits, things like that.

Dr. Scott Sherr: What's your take on selective versus non-selective prebiotic fiber? There's, there's a couple, a little bit of controversy there. Like in the sense if you have like some of the new, like some of the products out there for some of the companies that you and I like will have these sort of selective prebiotics versus non-selective.

You take like acacia fiber or cilium Husker, something like that. Do you have a, a major. Distinguishing aspect of how you think about it clinically, or not really? 

Dr. Christine Maren: I don't, can you school me on that? 

Dr. Scott Sherr: Well, the idea with the, the pre selective, the selective fibers is that they're supposedly only allowing certain types of bacteria to grow Yeah.

Compared to the, the non-selective ones, [00:56:00] which are letting everything grow kind of deal. So in, in general, I have somebody that has bacterial overgrowth. If I'm gonna put them on anything, it's gonna be more of like a, a, a selective prebiotic fiber. Something like, like we would use from like, you know, make a prebiotic or something like that.

Yeah. From like microbiome labs or something like that, as opposed to putting them on acacia or cilium or something like that. But I think it's, it's still controversial. I don't really think we have a good sense of whether that really matters or not. Yeah. But I, I tend to, I tend to be similar to you in the sense of trying to get it from the food, but also not overdoing it on fiber as well.

Especially if they have bacterial overgrowth and, and fal overgrowth and things like that. 'cause I do worry that you're gonna get this sort of, you know, the, the response that, you know, maybe everything will grow even if we're trying to, you know, remove that kinda thing. Exactly. 

Dr. Christine Maren: Yeah. Yeah. And I mean, the first thing most people do when they have a gut infection or when they have gut symptoms is eat more sauerkraut.

Yep. Take a probiotic. Yep. Uh, what's the other thing they do? I mean, those two things. Yogurt. Yogurt. Yeah. Yeah. Eat a lot of yogurt, right? Yogurt. Yeah. Yeah. And all of those things can. [00:57:00] Actually be the opposite of what you wanna do. Like if you are somebody who has a lot of histamine issues, you're gonna worsen that.

If you're somebody who has bacterial overgrowth, that traditional probiotic is gonna make it worse. So, you know, this is where like if you've tried those things and you're discouraged, that's where working with a clinician can be really helpful. The other, they're like, I took out gluten and I didn't feel any better.

I'm like, great. Unfortunately we have to do a lot more than that. Like we've gotta take all the logs outta the fire. And that's the same thing with hormones and HRT and perimenopause. Like I started or menopause. I started HRT and I don't feel better. I'm like, great. And we to do all this other stuff. We gotta address, like you've unmasked all these other issues.

So we need to address all the under other underlying issues. 

Dr. Scott Sherr: Right? The unmasking is a big part of it, and I think it's a huge, uh, important piece that you mentioned there, which is the framework that you use. It's not just about HRT, it's not just about looking at even the quote unquote root causes. It's all looking at things together and then working with clinicians as we do, knowing that everybody is going [00:58:00] to be different.

And I think this is a gripe that I have, and I know you, you do as well when you see on like online advice about adding in fermented foods or, you know, mm-hmm. Or, or starting this sleep protocol, you know, from somebody that's not a clinician, that doesn't see people and that, you know, gives you advice. It kind drives me crazy.

I'm sure it drives you crazy too, so, yeah. It's only to deal with the patients on the other side of it saying, I need this, I need this. I'm like, no, you don't. So, yeah, 

Dr. Christine Maren: one of the things I see is people who are on very restrictive diets, you know? Ah, yeah. Because they've read a book and that's, honestly, it's like that's the easiest thing to give somebody if you're writing a book and you wanna give like an easy win, you give him a special diet, but like.

If we don't, you know, it's a special diet. There's, it doesn't have to be that complicated. Eat real food and more of it. And if you have gut issues and autoimmune disease, don't eat gluten and, you know, yeah. Don't eat ultra processed foods and Yeah. Like limit alcohol and, you know. Yeah. I mean, I don't think we need to follow, like a, most people don't need to follow, you know, autoimmune paleo or, or some of those [00:59:00] really restrictive diets.

It can cause a lot of stress. 

Dr. Scott Sherr: They can, they can. Again, I mean, there's 

Dr. Christine Maren: a time and place, like this isn't a never say never kind of thing. Of course, yeah. But it just, yeah. 

Dr. Scott Sherr: Yeah. I, I love that. I, I I love that that's, you know, more of your framework overall. And I think a big thing that you kind of gave me today as a, as an, again, a little bit of nugget, there is these two different types of women that are going through perimenopause and, and that the change in hormones like very different.

And especially 'cause I know a lot of the high performing type as well, and like the, the mild insulin, you know, resistance. Mm-hmm. And quotes, the elevated cortisol. So that was really cool. Uh, Christine. But at the end of the podcast, which we're at the end, now, I ask everybody the same question, and you may have.

You've already discussed a lot of things that might apply here, but the question we ask everybody is, what are three ways that we can all live smarter, not harder? And that's the name of the podcast, the Smarter and Harder podcast. 

Dr. Christine Maren: Yeah, 

Dr. Scott Sherr: totally. And so, and this could be in anything you discuss today, um, or it could be in other kinds of things that you think that might be helpful, but what are three simple tips that you think all of us can do to live smarter, not harder?

Dr. Christine Maren: I love this question [01:00:00] because I think about it often in terms of strength training. Like you'll see me in the gym three or four days a week lifting weights and you'll see me resting in between those days and trying to take it easy. So I think when it comes to building muscle, that's really key. As we age, it's key to our, you know, metabolic health.

It's key to feeling strong and more confident. Mm-hmm. I think it helps with emotional health. I think it helps with, um, obviously your structural, you know, framework and, um, joint pain and things like that. But anyways, smarter, not harder. Like lift weights three or four days a week. Okay, cool. Make sure you're getting rest.

Okay, cool. I think the diet piece is another one, like smarter nut harder, eat more protein, eat more fiber. You don't have to be on a super restrictive diet. There's definitely some foods to avoid. Uh, alcohol would be a big one. I think a lot of people I see are, you know, they're gluten-free, they're dairy free, they're sugar free, they're like, yeah, a lot, like whatever.

They're not eating any [01:01:00] grains, but then they drink a lot of alcohol or a decent amount, maybe it's not even a lot, but it's a glass of wine every night. Wine has like zero health benefits, so don't fool yourself. I mean, if you wanna have a drink every once in a while, go for it. But like, that's a smarter, not harder concept right there.

Yeah. 

Dr. Scott Sherr: Um, so if you wanna have like a, like a bonus or maybe you're done, that's cool. Either way we can leave it 

Dr. Christine Maren: there. I'll call you later if I think of something 

Dr. Scott Sherr: that No, that sounds great. I, those are great. Overall, I think the rest part is such an important piece too, that many of the people that are listening, the clinicians and the people that are just go, go, go.

And it's, it's hard for us to all, you know, rest and many of us are type A. So I think it's great that you mentioned that as well. So, um, Christine, thanks so much for spending some time with me today and going through, you know, your expertise, which is super cool. And, um, I'm really excited again that you're gonna be speaking at our symposium.

The Health Optimization Medicine and Practice Symposium October 17th and 18th here in Chatauqua, in Boulder. Um, it's a fantastic place. The the leaves will be changing. We're gonna have two days of speakers. Christine, you're speaking Dr. Elizabeth Y from Boulder Longevity, she'll be there [01:02:00] as well. Um, we're gonna have Thomas DeLauer, who's coming from California.

Good friend, is a great educator. We're gonna have, um, multiple other great speakers as well. Um, you can check it out@homehope.org. And Christine, tell us where we can learn about more, more about you. And I know you are taking patients, you have a virtual practice. Tell us a bit about us, a little bit about all of that.

Dr. Christine Maren: Yeah, so I see patients in Colorado, Michigan, and Texas. My website is dr christine marin.com and I mostly on instagram@drchristinemarin.com. 

Dr. Scott Sherr: Awesome. You rock, Christine, so I hope you have a good day. Going to your concerts, picking up all of your children and all the things we talked about before on the phone.

We'll, not to 

Dr. Christine Maren: forget anyone. 

Dr. Scott Sherr: Yeah, that's, that's always a question with my fourth, but you know, that's, that's, you know, that's the breaks of having the fourth kid that if they eat, if they get to where they need to go, you know, it's a blessing. So 

Dr. Christine Maren: that's, that's why I am who I am, you know, that I was the fourth.

Dr. Scott Sherr: Oh, I didn't realize that. Okay, cool. 

Dr. Christine Maren: Yeah, I was, I was the little one who, who took care of herself. 

Dr. Scott Sherr: I love it. Well, you have a great day and hopefully I'll see you non virtually in person soon. 

Dr. Christine Maren: Sounds good. Thanks. [01:03:00] Thanks. 

Dr. Scott Sherr: Thanks so much for tuning into another episode of the Smarter or Not Harder podcast, where we give you 1 cent solutions to $64,000 questions.

This episode was a fantastic one with Dr. Christine Marin. We talked about perimenopause, the gut, the estrobolome, which was a new word for many of us. How to test, how to correct, how to think about things in a framework, nutrient, gut optimization, hormone optimization, and so much more. If you like this podcast, don't forget to like and subscribe below so you never miss an episode.

And check out our Home Hope symposium. Go to home hope.org and check us out. Come join us October 17th and 18th in Chatauqua in Boulder, Colorado. A beautiful time of year, so many different great and amazing speakers. We hope to see you there. Take care.

Find more from Dr. Christine Maren:

Website: https://drchristinemaren.com/

Instagram: https://www.instagram.com/drchristinemaren

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