Histamine Well Podcast: Exploring Histamine, Methylation & Holistic Health

32. Hormone Replacement Therapy in Perimenopause: Interview with Rachel Schaefer

• Joanne Kennedy • Episode 32

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Are your hormones out of balance? In this episode of The Histamine Well Podcast, Joanne sits down with Rachel Schaefer, founder of Ginkgo Integrative Medicine, to demystify perimenopause and the role of Hormone Replacement Therapy (HRT) in supporting women’s health.

They explore what actually happens during hormone fluctuations in perimenopause, how to recognize estrogen dominance, and the benefits and risks of estrogen, progesterone, and testosterone therapy. Rachel shares practical insights on how personalized care, detailed hormone testing, and integrative medicine can help women navigate this transitional stage with confidence.

You’ll learn how early intervention with the right HRT protocol can improve energy, mood, sleep, and long-term wellbeing—plus how to avoid common pitfalls with synthetic hormones, patches, and oral estrogen.

Whether you’re just entering perimenopause or already considering HRT, this episode offers a clear, empowering look at how to restore hormonal harmony and thrive through midlife.

Learn more about Rachel’s integrative approach to hormone health and women’s wellbeing:

🧪 Rachel’s Recommended Annual Serum Lab Panel (Age 40+)

Done fasting, ideally once per year. Tracks hormonal shifts & key biomarkers:
CBC w/ diff · Ferritin, TIBC, Iron sat · CMP · GGT · SHBG · DHEA-S · Free & Total Testosterone · Estradiol LC/MS (Cycle Day 2–3) · FSH (Day 2–3) · LH · Progesterone LC/MS (Day 20–21) · Homocysteine · MMA · HSCRP · Insulin · HbA1c · ApoB · Lp(a) · TSH · Free T4 · Free T3 · rT3 · TPO antibodies · ANA · Vitamin D

Additional testing based on the case: DUTCH · Tiny Health GI Pro · Mira · 3x4 Genetics · Total Tox Burden · DEXA · OATS · Mood Sense

💡 At-Home Hormone Tracking — Listener Discount

Rachel checked in with Mira, a home-based hormone urine testing device, to offer a special 20% off discount for listeners of The Histamine Well Podcast.

🔸 Public Discount Code: 2GINGKO20
🔸 Mira Website: www.miracare.com

✨ Want more? Follow on Instagram, Facebook, and YouTube for updates and tips.

📘 New to this journey? Buy The Ultimate Bundle for Managing Histamine Intolerance—your step-by-step guide to manage your histamine intolerance effectively.

🧪 Curious about your methylation status? Try our at-home Methylation Test! In just 15 minutes, discover if you're over-methylating or under-methylating and receive targeted supplement recommendations to help rebalance. Use code HISTAMINEWELL10 for 10% off.

🎓 Practitioner or student? Join the waitlist for the Histamine & Methylation Online Group Coaching Course starting early 2026!

📆 Work with us 1:1! Book a consultation and take your first step to real healing.

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Hi, it's Joanne. Hormone replacement therapy is often talked about as something women consider once menopause is official. But what's far misunderstood is that the real confusion often begins earlier- during perimenopause, when hormones are anything but stable. Perimenopause is a time of rapid hormonal fluctuation, shifting symptoms, and mixed signals from the body. One week you feel relatively fine and the next you're dealing with sleep disruption, mood changes, fatigue, histamine reactions or symptoms that don't neatly fit into any checklist. This unpredictability is exactly why perimenopause can feel so hard to navigate. And why decisions around hormone replacement therapy can feel overwhelming rather than straightforward. In this episode, we are reframing that conversation. Because when HRT is approached with nuance, individualized dosing, and a deep understanding of the biochemistry at play, it can be a powerful tool during perimenopause. Not something to fear, delay, or dismiss. Today's discussion is about clarity, context, and helping women understand what support can look like when hormones are fluctuating. Welcome to the Histamine Well Podcast. Designed for practitioners and patients alike. This is your trusted source for insights on histamine intolerance, methylation, gut health, women's hormones, and much more. I'm Joanne Kennedy, your host, naturopath, author, and educator passionate about breaking down complex science into clear, accessible knowledge. Whether you are a health professional or navigating your personal wellness journey, the Histamine Well Podcast bridges the gap between cutting edge research and practical understanding to empower you with the tools to thrive. Before we get started, I just wanna say thank you so much to all of you who've been tuning in. I've loved hearing from so many of my loyal listeners, and even from my patients about how much this podcast is helping you understand your health and giving you extra knowledge about your condition. It honestly means so much to know these episodes are making a difference. If you can just take a minute to leave a quick review, it helps the show so much. It gives us extra traction so more people can find this information, learn and start healing too. Hi everyone. Welcome back to the Histamine well. Today's episode touches on a really misunderstood topic for women, which is the use of hormonal replacement therapy in perimenopause specifically. Perimenopause is such a dynamic and often confusing transition. Hormones are fluctuating wildly. Symptoms can change week to week. And it's hard to know what's normal and what's actually a sign that your body needs more support. And this is exactly where hormone replacement therapy can play a powerful role. When it's done safely, individually, and with a deep understanding of what's happening biochemically. To help unpack all of this, I'm joined by Rachel Scheiffer. I know Rachel as she just completed my histamine and methylation online group coaching course. And Rachel blew us all away on our live calls with her intricate knowledge of hormones. So I knew I just had to get her on the show. Rachel is the founder of Gingko Integrative Medicine in California with over two decades of clinical experience. She's a highly skilled multidisciplinary practitioner, blending functional medicine, acupuncture, and herbal medicine. Rachel is an expert in women's health across the entire hormonal arc. Her clinic offers state-of-the-art, functional medicine testing, and a truly integrative approach to care. So Rachel, so nice to see you, and thank you so much for your time today. Yeah, my pleasure. It delight in chatting with you Rachel and I geek out on this stuff. We're quite obsessed with it. Rachel's an absolute world of knowledge. I'd love to do a course with her one day. I actually said that to her. For educational For practitioners in particular. Your knowledge is amazing. It's such a fun, and I learned so much being part of your histamine mentorship too. I think that that is such an excellent course for these deep dives biochemically and towards this end of personalizing care. So I think we're very like-minded in terms of caring for the individual and I see the depth with which you approach it. And I learned so much in that mentorship. So it's neat to be able to banter as we can. Oh, that's great. Thanks so much, Rachel. Okay, so.. I wanna start what actually happens hormonally during perimenopause and why does this transition cause such a wide range of symptoms? It's such an important question, and I think part of it is that I think that a delight in the fact that the topic of perimenopause is getting more airtime than ever before historically. And it's certainly is true that perimenopause for each woman is a unique set of pieces unfolding. But one thing I can say is that for women, we often will see that they're two distinct phases of perimenopause. And those can be looked at hormonally. So one of the first things that happens, and typically this is around when women are 40, but for many women it may start a little bit before, is that we know that the first sort of step down in our hormonal reserve occurs when women start to have slightly less ovarian reserve. So the quality of their eggs begins to reduce as is appropriate heading towards the end of our reproductive lifetime. And what happens with that is that our ovulation each month. Ovulation really is a vital sign in women's health. And what happens at ovulation is that depending on the fitness of the egg that we ovulate mid-cycle, there's an aspect of that egg called the corpus lutetium, which is the primary contributor to our production of progesterone for the luteal phase, the second half. And what will happen is that as our egg fitness reduces, women will start to make less and less progesterone over time. And some women will even begin to have anovulatory cycles because that ovulation is really the metrodome of our cycle regularity. And so some women will have their fitness reduced enough that certain months they will not even have ovulation. And so then, we can essentially trust that there's almost no progesterone that is made. So this first phase of perimenopause, and for many women, this will last some years before we see any decline in estrogen, will be related to this deficiency in progesterone. And we think about, and we'll talk more about different ways that we attend to women during that time. Both from a progesterone supplementation standpoint, there are a variety of strategies that way, and also herbal medicine or nutrients that can be relevant there too. So that's that first phase of perimenopause. The second phase of perimenopause, we tend to call it late perimenopause is more related to the decline in estrogen. But estrogen is rather funny as it makes its way out. Sometimes I've heard the analogy and I think it's wonderful that the end of our estrogen reserves often will look a little bit like trying to get the rest out of a ketchup bottle. Our brain will signal through a hormone called FSH to our ovaries to try to prompt this estrogen production. That's why we often will see FSH creeping up as women are starting to have this estrogen decline. And it's a little bit like the brain is trying to push out that last little bit. And one of the things we'll see is that estrogen can first become quite erratic before it declines completely. And so this is part of why HRT and estrogen supplementation for women in perimenopause is also so personal. Because for some women, they're gonna have massive fluctuations of their estrogen levels. High highs and great nadirs. And for us to be attentive to them, we need to be able to get a real pulse objectively on how their hormones are fluctuating. So these two phases, hormonally, are really relevant. And typically for just thinking about it from an HRT lens, most women will be candidates for progesterone supplementation or Vitex, or other herbs and nutrients that support our endogenous production of progesterone supporting that ovulatory mechanism because we talked about how relevant that is. And then in this later phase, we start to think about how we scaffold in an estrogen support as well. But we also wanna make sure that we're personalizing that to these stages where women can have more erratic production of estrogen too. I love how you explained that, Rachel.'cause it really is the first decline in progesterone and that's when women do find a very estrogen dominant during that time. Extremely. And I think that it's true that progesterone is very much the dance partner to estrogen and their proper ratios are so relevant to keeping that estrogen not being so errant or so dominant to your point. But part of it too is that some women have for lack of a better word, derangement in estrogen metabolism. And so for us, identifying, and that's part of what we do in our functional medicine lens, where women in their estrogen metabolism and essentially ultimately detoxification of estrogen. Some women, especially in these stages where they have these high highs of estrogen, will become quite symptomatic. And so, thinking about where her particular breakdown and where she needs support. Is also about scaffolding and understanding of where she might need support in that phase one or phase two, which are both in the liver and then phase three that occurs in the GI. But it's also about understanding the cycle very well because there's certain stages in the cycle, which would be trending to be more estrogen dominant themselves. So we wanna always superimpose our cycle map over the woman's month as well, because ovulation ofcourse, would typically be the heightened moment and we'll often get a clinical tell. I know you see this too, where patients, as they're moving towards ovulation will have this uptick in histamine type signs. Because we understand that estrogen dominance is one of the drivers of histamine symptomology. And so we can preempt that, but that same woman will have likely low estrogen signs when she's during her period or when she's right before her period. And so attending to her and giving her phase strategies for supplementation is extremely important and nuanced. And so that's part of why I react sometimes to these sort of set it and forget it protocols. Either from an HRT standpoint or even from a naturopathic standpoint. Because what we find for our patients in this very dynamic time is they're not well served and having just a non physique strategy when their body is going through these very wild transitions. So if we have a strong cycle understanding, we can really approach her in a physique way. Yeah, I totally agree with you. And one of the basic ways of looking at that is just the supplementation of Calcium D Glucarate every day for a woman who's getting a bit older. I did it to myself. I took it every day. I loved it, and I was feeling great. And then I took it every day and I was coming outta my period, and I felt depressed. I felt so sad. I didn't pick up. I just didn't pick up. And it's like women really shouldn't be taking it at least until like after their bleed. Or even I often even prescribe it just from day 10 or day 14. Just depending on the case the symptoms, the age. So just tell listeners, Rachel, what would be the symptoms of oestrogen dominance that they're looking for? Yeah, there are quite a few. And I think too, this can look unique in each woman. But I would say the predominant things. Estrogen imbalanced is more anabolic. And so we can think about it in those terms that it has an inflammatory load when it's not balanced. So women may feel more breast tenderness, more fluid retention. There's a role that estrogen plays with aldosterone and adrenal hormone related to our fluid regulation. So women will feel like they have more of that. Mood as well. So there can be often when estrogen is in this dominant state and the body and liver is perhaps more challenged in its phases of processing it, there can be almost a little bit like a pent up frustration or a stuckness that women sort of feel. And we will see that too in terms of, we've talked some about mood and methylation and sometimes that can be the fix. We can look into that again objectively. Illuminate for ourselves what her needs may be. Other things with estrogen dominance, heavier periods, longer bleeds, more clotting in the bleed, that's some of that inflammatory load, a prostaglandin load that's demonstrating in her period. We can see some impact to the bowel, just like we're talking about. One of the solutions for this in the phase three, which is GI estrogen metabolism, is calcium D glucarate. And that has to do with an enzyme called beta glucuronidase and wanting it to be in a regulated form. But one of the things we may see is that a woman isn't processing in her GI that estrogen very well with this elevation of these glucuronidation pathway deserving more support. So she may also have GI symptoms. Many women will talk about having almost this like round ovulation. Someone will have sort of a stuck bowel sensation. Like there's a fullness in the pelvis, but there's also either some constipation or incomplete defecation. Some of those things can also be related. And then of course there are pathologies that are very well known as being related to these imbalances of estrogen. For instance, endometriosis. We also can see adenomyosis slightly more common in older women. And so some of these pieces are also really relevant. Yeah, exactly. I just wanted to touch on what Rachel was saying about methylation. What we now really see in our female patients, regardless of the genetics, sNPs, M-T-H-F-R included and high homocysteine levels is that the majority of them are over methylating due to estrogen. And how this works is the COMT enzyme, which detoxifies estrogen through the liver requires methyl groups. And you can have a genetic mutation on COMT whereby it's slow and or just overloaded with estrogen. And therefore that enzyme is not churning through the methyl groups. So the methyl groups aren't being used effectively and they build up. And when they build up, the first thing we notice is that they increase dopamine and adrenaline, which causes irritation and anxiety. Agitation. If anyone's interested in methylation, we are now testing methylation at home in real time. It's a test called Mood Sense. You can get access to it via my website. There's also a discount code on my website. I can't exactly remember what it is, but you can find it on my website, joanne kennedy naturopathy.com. And I really encourage you to test your methylation because if it's high due to high oestrogen, this is really contributing a lot to your mood issues. So thank you for bringing that up, rachel. Rachel and I, we unpacked all of this in the course recently, and clinically, I'm seeing it a game changer for women's mood during this transition. Along with hormone replacement therapy and detoxification strategies, as Rachel was talking about. But it's just a really important piece and we can now test it at home in real time. So it's a lot more simple than it used to be. So Rachel,'cause I really wanna talk a lot about the actual hormone replacement therapy. Let's just stick on this early perimenopause when the progesterone starts to drop.'cause I've got my own little stories about progesterone as everyone does. Who was gonna be a candidate for taking bioidentical progesterone? Yeah. I would say that one of the things that we do before we add HRT for women is we illuminate to ourselves through data. To understand a little bit of where her actual progesterone sits in the part of her cycle in that luteal phase around day 20 or 21. What we want progesterone to be doing, so we can look at it on serum to demonstrate to ourselves. We'd like to see that it's in round 10, and that it's able to hold there. We also can look at a Dutch test and we can look at her progesterone that way. And it gives us even further information because it will show us whether she is more of an alpha or a beta metabolizer, which might give us a bit of a clue as to whether she will respond to certain dosing of progesterone. But I think one of the things that you've hit on and many of our patients have too, is that there are strategies for progesterone supplementation, but this is also extremely personal. Because there are a number of women that will tolerate progesterone supplementation orally. This is the standard of care. I would say OMP. It's an oral micronized progesterone. Most women will start around a hundred milligrams and often will get up to 200 as sort of a terminal dose. That's more relevant when we have estrogen on board as well. But there are definitely a subset of women that will not tolerate progesterone orally. And this is a very interesting area and actually it has prompted us in clinic to attempt to identify in advance some patients that actually would not be great metabolizers. There's some very interesting data, so I'll speak very briefly about the way progesterone is metabolized because I think this is relevant to women that wouldn't tolerate it as well orally. Everything we consume orally goes through first pass metabolism in the liver. And when progesterone is taken in orally, it converts in the liver to a metabolite called allopregnanolone. Allopregnanolone has this very sedating and luxatory effect because it's profoundly GABAnergic. So GABA we know is our inhibitory neurotransmitter that operates like a break on our nervous system. So many women will find through that conversion to allopregnanolone that progesterone supports their sleep. And we can see sometimes a clinical tell of low progesterone will be women describing changing sleep pattern in their luteal phase. Where they sleep well the rest of the cycle, but they have quite a bit of challenge in that end of their luteal. And that is related to the progesterone not holding as it should through the duration. So that woman may be supported by this oral progesterone, but almost 80% of the oral progesterone through this first-pass mechanism will be converted to Allopregnanolone. And because that Allopregnanolone has the strong somnolent effect and is a sedative, there are a group of women that are gonna find that progesterone, even in a compounded 30 milligram minuscule dose, to be too sedating and too spacey producing for them. And one of the things, there's some very interesting, I look forward to the research developing more in this area because I think that understanding even better the nuance of how women will respond and what women will do well with that Allopregnanolone and which won't. But we do find that there's some data suggesting women with histamine issues, women with MCAS, women with Hypermobility syndrome. If we think about those things often go together as a group, as you well know. One of the things we'll see is that those women already have this glutamate GABA imbalance that may be inherent to their neurochemistry. And the last thing they actually need is this profound sort of almost like wet blanket sentiment that allopregnanolone will produce in their physiology. So one of the things we've been moving towards more and more is using more vaginal progesterone in a suppository form. And some patients will ask us, well, can't I just use a progesterone cream? And what I would say about that is that there are some women in early perimenopause who can use a cream and get a bit of support with it. It doesn't have the same neurological impact. It doesn't have this allopregnanolone conversion'cause it didn't go through first pass, but it can be soothing to some women. But it is not uterine protective. And so in a bigger strategy, a comprehensive HRT strategy, we cannot think of a progesterone cream as being a good partner to estrogen because then we're not controlling for the hyperplasia that could occur with estrogen use. So our two choices are essentially oral OMP. Or if a woman finds that too spacey, then we will give her a vaginal suppository. And one of the things I like about that too is we spoke about how some of these women with estrogen dominance will have quite significant pain syndromes like endometriosis or adenomyosis. They have quite a lot of inflammation in their pelvis. So when we give them pure progesterone, which is absorbed vaginally, we're actually giving her more support. In essence, she's getting more progesterone because there's not such a large conversion that's just being converted into allopregnanolone. So we use it more and more, and I know some providers that I really admire, like for instance, Dr. Felice Gersh, who is suggesting that we should move entirely away from oral OMP. And she thinks that it's not a natural physiologic process for women to have this abundance of allopregnanolone. That said, many women like the sedative effect of progesterone orally, because in those women it works for. They sleep great. And progesterone does, as does aloe because of the GABAnergic influence have this value in terms of increasing their capacity to rest and relax. So those are some of the ways we think about progesterone supplementation. Yeah, it's a real thing. It took me a while. I was so exhausted. It took me a while to get my estrogen levels right. And then I was right on the progesterone and I'm like still exhausted. Like a different exhausted. Like zoned out, like brain dead. Like hazy brain. I'm like, oh God, here we go. So I just did my own research. And I'm like, there's studies in France down on vaginal prometrium. And so I started using that and it's great. Absolutely no side effects. You're right, the progesterone use and in terms of considering how we think about vaginal instead. Yeah. People need to understand this. We need to have progesterone in place when we're taking estrogen. Is it our own estrogen or with hormone replacement therapy estrogen only? It depends. The hyper proliferation risk comes essentially from exogenous estrogen that we are taking. However, as we described, women that have these surges of estrogen will also have that anabolic impact. We know that over 50% of women over the age of 40 will develop fibroids. This is a result of estrogen dominance. And so in that same vein, that woman would be supported in reducing the growth factors that come with her own endogenous estrogen. But our real concern when we implement HRT therapy and we're adding exogenous estrogen is making sure that we're not allowing her uterine lining to proliferate in a way that it doesn't have the balance of this progesterone cue. Yeah. Great. Just wanna hone in on with perimenopause we are talking about,'cause there's so much information on menopause. It's just peri, right? So like women are still cycling even if it's irregular. So what can also happen, I found when I took oral micronized bioidentical progesterone back when I was like 45 is big sore boobs and really bloated. It's like I had a patient yesterday, she's like, oh my friends say you gotta take HRT'cause it's so good for bone health, et cetera. I'm like, yes. But it's not without side effects in a lot of women, especially when they're still cycling. Once you're in menopause and everything's flat, it's easy. Relatively. Easy. It's just this wild road rollercoaster. I'm finding clinically, like if a woman is feeling good just on progesterone support with like vitamin D and Iodine and Vitex, B6, zinc, they're good. And they're feeling good at age 45, 46. I'm like, you're good. come back to me when things start to change at like 48. On average. Yeah. And it just starts to change whereby they probably start to need estrogen, which is not something I was, so, I don't know. I didn't think I was so oestrogen dominant or was I,? I'm a really bad naturopath. I'm just so bad at treating myself and testing myself. I'll just be honest. Like I've got all the Dutch hormone tests at home and I don't even do them. That's just, I don't know why. I just think I'll just wing it. I'll just work it out. Anyway, I now look back and think when I was in my, about 47, 48 and my mood started to get weird. I remember just going on these walks. Going, why don't I feel happy? I should be happy. And it's a beautiful day. I just felt flat. Now I look back, it's like that my oestrogen started to tank. and because I'd been so oestrogen dominant before, I was just like, oh God, oestrogen. No, no, no. But it wasn't until I just stopped. I just didn't get a bleed for like eight months. I went to the doctor. It's like, oh my estrogen's low. So I started to take the estrogel and I felt a real lift in mood and energy. Which was great. But what happened with me is it caused me to ovulate and I felt terrible when I ovulated. So this is why it's a wild rollercoaster ride. So I just stopped the estrogen'cause I didn't wanna ovulate'cause I felt so bad. And then, because I really did guys, I felt terrible.'cause now I know how sensitive I'm progesterone. And then I just let my estrogen tank. And I remember I was flying back from Portugal and I'm like, why can't I regulate my body temperature? I'm like, jumper on, jumper off, jumper on. It's like a steady state of air con in that place. Like it's monitored, you know? And I was like, off on, off on. I was like, oh, this is hot cold. And then I got back to Sydney and I just like nose dived and I felt terrible on my oestrogen tanked. So this is why I'm so interested in letting, telling women, like, don't let it drop. And then the interesting thing is I felt, and Rachel, I went to the doctor and I said, I just feel flat, just tired. The doctor says Jo, she says, well, you can take an antidepressant. That's the first thing she said, so just be really wary. And I knew, I'm like, it's my estrogen. Like I know. And then because I was so sort of flat and tired. The estrogen helped the energy, but what happened was get trying to get all the estrogen up, it made me super emotional. I went from flat to super emotional, right? And so I'm like, that was a really hard three weeks. I remember. It was really, really difficult. Yes. So it's like women, ladies, it's like, this is why, like if you're in the United States, like seeing Rachel in her clinic, the, that are doing extremely thorough testing and monitoring you is gold. Like it's gold to have Rachel services there because I tell you what, there's very, very few and far between clinics. In Australia, I'm seeing my friends, they're all around my age. 49, 50 irregular cycles, not menstruating. They go to the doctor and now they just, they give them a pack. Estrogen, progesterone on your way. My good friend, they said, just put one pump of estrogen on. And I was like, how, when did you get your last period? She's like, 10 months ago. This is a girl with high energy. She's exhausted. And I'm like, you need more estrogen. Like I can just tell that. Right. So we are not getting good care. This happened to my sister, my good friends. It's just, it's only'cause I know what I need to push for and I push for it and I make them test. They're often young girls, these doctors and I just, they sit down like, we're gonna take your blood pressure. I'm like, no you are not. You're gonna listen to me. And you're go Exactly. You're gonna give me what I need. They're like, oh, okay. So I wanted to do this episode'cause I want women to know that there is support. It's just, it's individual. Right? And what your best friend's doing is not necessarily, in fact, it won't be what you need to do. Every woman is so varied. Yeah, so, so varied. And I think you hit on something so important here, which is that, you know, I understand in the managed care model where conventional providers have seven minutes with their patients. And they're gonna see them once a year, or one thing we have here too now in the US, which I'm grateful for, but we have telehealth services. Women are calling up saying, to your point, I feel flatlined or I have weight loss resistance, or these various things that they are tying into this idea that it must be my hormones, and likely it is their hormones in some errant configuration. But the problem is that. At least in the us, the way that hormone care is being initiated and followed. There is no testing at onset and there is no follow-up testing. And the premise is that it's all subjective treatment. Even the Menopause Society, great group in the us, but they don't suggest any testing. You'll often hear, patients are told all the time, we can't test your hormones in perimenopause. They're too erratic. And that partially has to do with a lack of cycle understanding of where and how we would do testing to illuminate her unique picture. But it's also important because. Even if a woman receives HRT and say her temperature fluctuations improve, so hot flashes and night sweating, textbook classic low estrogen signs improve. In fact, oftentimes just a whiff of estrogen, to your point of your friend who had the one pump, will treat those pathologies. But if I test her serum, she might still be in the 30's or 40's, and what we know is there is no bone protection for her. Women in this decade are starting to lose bone mass quite rapidly, and that will only increase. We are at so much greater risk. Women by the age of 65, over 50% will have osteoporosis, not even osteopenia. In our clinic, we ask all of our patients over 40 to have a DEXA scan at least once a year. And if they're in some kind of a conversion or perhaps they're taking GLP or other things, we ask for it more frequently because we must think about fragility and sarcopenia. And I need to be protective of those things. So I think that part of the issue is that in a managed care model with no personalization based on her actual data. You know, and I reflect, I can't help but have my clinician hat on. When you tell your story of these stages of feeling like, okay, you needed some and you put some estrogen in, but then you felt sort of this other set of feelings. And I think that probably what that highlights to me clinically is there was care that you deserved in phase one and phase two and phase three in helping your body receive that estrogen therapy to back up. So that is something when we initiate hormone therapy in our clinic, we attempt to illuminate first what her unique patterns will be. So that we've already attended to what may be in the background in her challenges in processing it, and then we can go low and slow and there are excellent test strategies. Also, we can use a Dutch once she has initiated HRT to see how she's processing it. We much like the somatic code or the mood sense test we have at home. Hormone monitors that patients can do. Mira is a test kit. It's a urine analysis that patients can do for themselves at home to illuminate their FSH, their lh, their estradiol, and their progesterone. And what I love about this much. As I love about mood sense is that it gives the patients agency. It puts her back in the driver's seat to be able to see where those imbalances are and we can coach her about those meanings. I always wanna share a mechanism with our patients, but I also want her to feel like, Hey Rachel, I'm not sleeping quite as well. I started the HRT and look, my estrogen's up here, my progesterone's here. And that allows us to tinker with objective data and then we can check our work after we've improved things. Yeah, I love it. And so if we don't have the data, then I just think it, to your point, women are just getting protocol strategies and it takes all the individualism that is so central to her out of the picture. And many women. The other little thing, this is just my soapbox perhaps. But you know, women over endure. We ask women to over endure and they're experts of it. And so I also feel protective. I think so many women are hearing now, oh, HRT. I must do it. And they will do it and not feel well. And they'll still feel complicated to continue doing it. And I think some of that is our responsibility as providers to highlight to her, you know what? You don't have to tolerate not feeling well. We don't want you to over endure. Because I think one of the features, and you speak about this a lot, and I love that it's so central to your toolbox too, is that one thing we notice is that the navigation of perimenopause and menopause is really exaggerated. When a woman lacks a toolbox of recovery tools for her nervous system.. Even the data corroborates that a woman with a low D-H-E-A-S or a woman with a flatlined cortisol trend, that woman is gonna have a much harder time with these sets of symptoms because the adrenal reserve steps in as subsidy to the loss of these reproductive hormones. And so if we aren't also in turn, considering this rushing woman syndrome and how we support her and building a toolbox for her of recovery tools. Then it is actually just slapping a patch on. And progesterone, even in the perfect ratio in a nervous system that is frayed, is actually not the full picture of care. And so that's another piece that I find extremely central. And it's actually one of the reasons I love that I still get to perform acupuncture on almost all my patients. I still do acupuncture on like 85% of my patients because I can care for her. Like she doesn't have to be the great orchestrator as she is in every other area of her life. For one hour. And then I can demonstrate to her like, this is what your nervous system can feel like in its parasympathetic track. And here are some other tools, whether it's breath work or meditation or yoga nidra that can keep building in this parasympathetic cue because I think that is actually central and should be central to this perimenopause conversation. 100% agree. What I noticed in myself and my patients in sort of perimenopause, your nervous system does become more sensitive, but you just push through. You push and you push and you push. And you don't give up the coffee. You just keep pushing. Well, you're tired so you have more coffee and you just push and push and push. But then when you actually hit late perimenopause, menopause, your body says, stop. And you will have to stop. Because you can go into functional freeze. You can go into like a hibernation state of adrenal depletion, nervous system freeze. And it's a real thing. The other thing is women, and I'm all for pro, I'm pro weight bearing, but some women push it a lot. And you can end up in a really bad way in that late perimenopause, menopause where your nervous system is so deplete that you can't function. It's a real thing. People, I don't think women really understand that. That our nervous system completely changes our capacity to deal with what we used to changes. It comes back, doesn't it? Like women in their sixties look at them. It comes back. Oh, they're amazing. Yeah. It comes back, but it's very real. Yes. It's very real. It's very real. Yeah, so I'm really glad you brought that up, because it is a really holistic approach and the nervous system component is super key. You know, very basically estrogen and progesterone impact your neurotransmitters. Serotonin, dopamine, adrenaline, histamines, and neurotransmitter. Gaba and the fluctuations can cause crazy symptoms. But when they all start to tank, you can end up really frazzled and especially if you're pushing your nervous system too much. That's totally true. So game, HRT. I wanna talk about delivery mechanisms. I think this is really important. So I liked the estrogen gel because I could put it on myself. And this is a couple of years ago, when I was in sort of perimenopause. I knew I needed a bit of estrogen. But I did one pump and I said, oh my God, I feel good. Like one pump. And I was like, I feel really good. And then got my energy back and I'm like, whoa, two pumps is gonna be better than one. So I just put more on, and then I got really sore boobs and I overdid it a bit. Yeah. And so I'm like, okay, taper it back. So for a couple of days I didn't take any. And then I just did some half a pump for a bit, and I sort of monitored that for myself. I'm not saying to listeners, that's what you need to do. You need guidance from a practitioner. But I found the good thing about the gel or the cream for estrogen is that you can monitor your own dose, especially in perimenopause when you can go low to high estrogen. Like your estrogen's gonna peak at ovulation if you're still ovulating. And then if you're putting too much estrogen on, you'll know all about it. Yes. You're so right and this is absolutely true. So, you know, standard of care, again, typically now is estrogen patching. And if we use a patch in a woman, we will typically use one that has changed twice a week. So that we can really monitor both for steady state. But as I said, we will use tools for assessment to understand where we are level wise. But to your point, for a woman who may have still cycle regularity and she has that ovulatory surge, some of these other tools like an estrogen cream that we can call into a compounding pharmacy or an estrogen mist like the EVA Mist. These are also tools that can be tapered in these smaller dosing protocols for a woman to get stabilized, but not excess. And I think that one of the things we touch on too is that historically, like the women's health initiative study that came out in 2002, that that was oral estrogen. And actually it was not, it wasn't bioidentical estrogen. And we don't use oral estrogen at all in clinic. I just think it's worth denoting, because just like we talked about with progesterone. Oral estrogen will go through first pass metabolism. So that has clotting risks. And so we wanna be mindful of that. Women's cardiovascular risk shifts quite a bit at menopause from being half of men's before menopause to equaling that. And so we wanna be really mindful of those pieces, but I agree. One of the things that's true too about the patches is that if a woman lives in a very humid area, if she sweats a lot, if she saunas, if she takes Epsom salt bath regularly, the delivery mechanism there is will be altered by virtue of that heat and the humidity. And so again, we have to consider her lifestyle. I definitely have many patients. And again, this is where it's useful with the testing'cause we'll see it. We might be giving what should be a therapeutic dose in a patch, but it isn't absorbing for her. Women are different forms of absorbers too. And so in that case, we might have to consider another format. And so I think that's exactly right too. It's personal, but to your point, I think in perimenopause, some of it can also be a little bit about what is the lowest effective dose to be stabilizing there when we're still mirroring that with her own endogenous estrogen production. Yeah, that's the tricky part. When you've got your own endogenous estrogen and progesterone. Then you getting the dose and delivery right is the tricky part. Also, I was using the estrogen gel at two pumps a day, which was fine on my arms, and then it got to winter cold and it just tanked. My oestrogen is tanked. I was like, oh gosh, I need three pumps, and then I did three pumps. I'm like, after about three days of that month, oh, it's too much. I'm like, oh, okay. I'm gonna start doing it on my inner thigh with a bit more fat. And I got under my douna. And I did it in the morning and I jumped under my duvet. What do you say in America? You wouldn't say douna. Anyway, so I got under the duvet and just for in the morning, just to make sure it was sinking in. And it's pretty simple, that cold heat. You know, it's the delivery and the mechanism. And also like, they say on the packet, don't put clothes on for 20 minutes. They mean that. Yes. Oh, how long should you not have a shower for after a cream or a gel? Do you know? I would agree that I ask for at least a half hour. And to be candid, in the best world, I probably would give an hour. It's hour because of this feature of absorption and how that heat for some women will be modified. I like your point, and I think it's astute to adipose tissue is going to be more absorbent. And so that is why like on an arm where there may not be much of that, often it'll be abdomen or buttocks or thighs, which are gonna be a better area if we're using a cream or a gel. Because that added host tissue will help with that. It's more receptive. Yeah, it is way better. They just say on the packet of the oestrogen gel in Australia to put it on your arm. I think that's where they did the research. It's silly. It's not a good place for delivery. Definitely not. Yeah, that's interesting. Usually, most women will put a patch on her buttocks. And I think that that is a good spot for it if she's comfortable with it if we're doing patching. Yeah. I think that's basically the take home message is that perimenopause fluctuates wildly and we need an individual approach for the HRT. But it can be so helpful for women. Would you agree? Oh, so helpful. And I think even too, to your earlier point, if it is just in part about this relationship with these hormones and our nervous system and our neurotransmitters, women deserve stress resilience. This is a chapter of women's life where they often are at the height of their careers. They may have young children or teenagers, they also may be caring for parents. It is a stage where women deserve to have some of these extra buffers and to take the rug out from under them right at this time without support that is appropriate. And we find that in our patients too. You know, it is a time where many women's lives are very much in a state of triage. So we wanna help to do that work, that deeper work, but do it in a way that's approachable for her too, because it's a time where she can very easily be overwhelmed, which is also a reflection of these hormone fluctuations. One thing I will say too that I think is just worth denoting because I think it's an interesting point, I wanna put a pin in it, is that, you know, the data is showing more and more that early initiation of HRT is likely the most protective strategy. So for bone, for vascular system, for cognition. And so I think it's important for us as a medical establishment to understand better how to truly care for women in perimenopause. Because it's not that women cannot initiate HRT after going through menopause. They certainly can. But we look at that a little bit differently. And one of the reasons that I think that women do so well with HRT when they are started in this perimenopause phase is that the receptor matrix to receive these hormonal cues is in place still. And so this idea, you know, it used to be in the US even up to a couple of years ago, and actually frankly still some obese here today, that will say, okay, wait your 12 months. Till you're without a period, and then perhaps we'll give it to you at that menopause transition, which in our country is defined as 12 months without a period. That is the hardest year in a woman's life. And that is actually the time where the data suggests that we can serve her best, not just in that moment, but actually in perpetuity for her protection. So I think it is something we as providers really wanna get, right? Because I really think it's a time. I say it to my patients all the time, I, if we intervene appropriately at this stage in her life, I really feel we are setting her up in her coming decades to have improved vitality. And so it's a responsibility I feel to her at this time. And I want all providers to feel that. You know, it's so true. And listeners, it is where you need to put some time, money, and effort into this. It's time, money, and effort won't lie. I've got friends that are like,'cause I'm an na they just ask me, oh, Joe, like what do I do about my, do you think I'm in perimenopause? Do you think I'm this and that? Like you need to get into with an integrative doctor. You need to get the test done. They're like, oh, it costs too much. I'm like, oh no, it doesn't. Like really, it's so fundamental, important.'cause they haven't experienced the drops in estrogen yet. They don't get it. Well, guys, I couldn't take the estrogen'cause it made me ovulate and that was worse. So my estrogen was tanked and my receptors were starving for estrogen. So the receptors became desensitized. I'm highly aware of that. And so it took time for my receptors to respond. That's a really important point that Rachel made. And you know, it affects mitochondrial health. So that's energy. It affects your skin. It affects your brain. It affects your thyroid, it affects your cardiovascular system. Your vaginal lubrication. Your breath. Like so many things like your teeth. Everything. So it's really good to keep it high and also, you know, you feel so much better when your estrogen's high. Good. You feel great. Your skin looks good, got good energy, your libido's back. Like, it's really, it's really, really important. I can just tell women clinically that come to me that are just low hormones and that they've gone to the doctor and they've just said, oh no, like, you don't need hormones, no testing. And they're the walking dead. Like they feel terrible. And they have every symptom under the sun, Rachel. I say to them, it's just your hormones. You get your hormones up, these symptoms will go away. Yeah, that's right. Before we go any further, I want to speak directly to the practitioners and students listening. If you're intrigued by histamine and methylation and eager to expand your knowledge in this fascinating area. We offer the Histamine and Methylation online group coaching course. The only program of its kind. It covers everything you need to know about histamine and methylation, providing both the theory and guidance you need to treat these issues effectively in clinical practice. We cover sibo, hormonal imbalances, oxalates, M-T-H-F-R, the four pathways of methylation, including the folate pathway, methionine pathway, tetra hydro biopterin pathway, and the all important transsulfuration pathway and much more. The program is delivered by detailed online webinars and handouts for you to keep. And for eight weeks you'll meet with me for live coaching calls in a private community space with other practitioners from all over the world dealing with histamine and methylation issues in their patients every day. Together we learn so much. To learn more and apply, visit joannekennedynaturopathy.com. So, I really need to ask this question'cause people always want to still have information on that. Is there still fear around HRT, specifically estrogen and breast cancer? Such an important question. And such a point of misconstrued data that has permeated our societal conversation for so many years. And of course part of why our mother's generation was so poorly underserved in this regard. So here's the deal. So number one. Very useful to say the data actually suggests again that early initiation of HRT will reduce lifetime risk of a woman's development of breast cancer. Point blank. Important to say. Number two, most women who develop breast cancer will do so in a hypo estrogenic state. The wild majority of women that develop breast cancer will do so postmenopausally. So another data point we have is that, and I think some of it is semantic, we talk about estrogen positive breast cancers and we hear that and we think, oh, that cancer was caused by estrogen. In fact, no. Those women are even now being considered as potential candidates for HRT. And actually there's some very fascinating research on the use of testosterone in those women, which I find really exciting because it actually can control even when she's very actively in treatment for some of the symptoms that she has supports her bone, brain and so forth. But here's where that myth arose. So the Women's Health Initiative published in 2002 had two arms in which it looked at women taking HRT. And one of those arms had a slight uptick in the prevalence of breast cancer. Important to note, that arm had no uptick in mortality. So while I want no one to develop breast cancer. It is important to note that even those patients, and now we have almost a 30 year scan on that cohort, that we see no greater risk to mortality in either of those groups for breast cancer, number one. Number two, interestingly, the track in the women's health initiative that was slightly more vulnerable to breast cancer development was not the track that was estrogen only. The estrogen only track actually has almost a 30% reduced risk of developing breast cancer. And this is now in quite a long cohort study longitudinally of over 30 years. The group that had a slightly higher risk was the group that was exposed to a synthetic progestin. So one of the things we do understand is that progestins seem to have some of this driving propensity to quee in our metabolism some hormonal derangement. Progestins we know as well are what is the active ingredient in birth control pills. One of the reasons I'm so concerned about the great number of young women that are being put on birth control for skin and otherwise, when we really should just look at her physiology and treat her with care. But progestin was the ingredient, not estrogen. And we can also recall the Women's health Initiative did not use bioidentical hormones. This was horses urine, Premarin based estrogen. And this methyl hydroxy progestin. These are nothing like the types of hormones we use today that are bioidentical to the types of hormones that we make. And there is no data suggesting that bioidentical hormones are causal for breast cancer. Do we look at things like a woman's genetics, her SNPs on things like BRCA or her SNP's on even features that are involved in estrogen metabolism, like how she uses her glutathione and those SNPs, because this oxidative stress quality is something that will be a risk factor. More the oxidative stress than hormones themselves, it's in the processing of those hormones. So the correction is that A, I think broadly as a society and medically we should really rethink our use of progestins and as broadly as there are you. And B, that the data shows in no way that there is a heightened risk of breast cancer. And in fact, in our higher estrogen states, women appear to be quite protected from breast cancer. That's not that there aren't women with unique risks, and we wanna attend to them individually like we would anyone. But the idea that these bioidentical hormones that are being offered would be a precursor to that pathology just doesn't bear out in the data. Thank you for explaining that so thoroughly, Rachel. It's just such an important conversation. I think we're in this space and I will listen to podcasts and read books by a lot of the doctors in this space, Felice and Dr. Mary Claire Haver. And the book Estrogen Matters. We now know it's protective. It's not causing cancer. But that's not widespread knowledge. I thought it was kind of, would be, but it's not. Even amongst doctors, especially amongst patients. So they're always still concerned about it and we now know it's not a risk on its own and it can be protective. That's interesting about the progestins though. I'm not sure in the US but there is a combination patch for HRT, which is bio identical estrogen, and progestin. It's here too. We don't use it. But it does get used. Yeah. So I know in Australia when you go to the doctor now, they're trying, right? They're trying. So you go to the doctor and they've Got a handout. A printout of the menopause society, what they say regarding, where you are in your menopause journey. Perimenopause or post menopause. And how much estrogen gel you should take, how many pumps. How much prometrium or biodentical progesterone you should take. And a patch, if you take a combination estrogen progestin patch.. And that's just handed to you from looking at a piece of paper. That's what they do. So no testing. They don't do a thorough analysis. Progestin also, aside from the fact that we know is potential risk for cancer, it blocks your own progesterone. And therefore it's blocking the production of Allopregnanolone and gaba. So it can make you feel terrible. anxious, depressed, massive moon swings I know some women are on the combined estrogen progestin patch and they feel fine, but a lot of women won't. So you're probably better off getting the estrogen patch. We call it, it's Prometrium. Do you have Prometrium, that brand? And Prometrium. Orally or vaginally. You can take Prometrium vaginally. When I was trying to get my progesterone right because orally it was zonked me out. I'm gonna have to take it the second day or do I have to get a 50 milligram compounded from the pharmacy? So I had to see the integrative doctor for that. It was costing a fortune. The compounding pharmacy it was like 10 times the cost of the Prometrium. And I'm just like, I'm just gonna do it vaginally at a hundred milligrams. And see how it goes. And it was completely fine. Completely fine. Yes, actually. And we'll even tell women they can poke a few holes in the Prometrium just for a little bit better absorption. You can use it just like you would a tampon insertion. And I think that, to your point actually this, I think we should put a pin'cause it's so important. Many women in the US also will see their doctors and have hormone irregularities or heavy bleeds or some of these other pieces that are this presentation of the perimenopause window. And their doctors will put them on birth control. Under the suggestion that birth control is a form of hormone replacement. And to your point, there are many downsides to that. But one very important downside is that then. What oral birth control does with this progestin influence. We already talked about some of the issues of progestin, but it will suppress ovulation. We already talked about how ovulation is our endogenous strategy for making progesterone. So then that woman will have no benefit from the progesterone influence on her nervous system. And so we're not catching her and supporting her with that sort of support. So it's yet another downside. I tell patients all the time I lecture on this too. Birth control is not HRT. It's sold as it is. It's promoted. I remember when I was going through my terrible time and ovulation felt terrible. I just admit it. I felt so bad. I was just like, I wanna go on the pill and just shut this show down, right? Like I did. And I went to the doctor just to see what was available and I knew she'd say, oh, you can go on the pill. It's HRT. And she did. Anyway, I took her for a week and I felt terrible, so I stopped it. I know in Australia, when you go to the doctor, they'll have this handout, the patch that is estrogen progesterone. They'll just call it progesterone. It's progestin. And you can get the estrogen patch just on its own. And then the bioidentical progesterone. I have to ask you about testosterone, Rachel, because that's just another piece. That's something that I was really low in as well. Testosterone. And I had to get an appointment with the integrative doctor. The GP wouldn't prescribe it and go down that path to get it from her, which is worth it. But unfortunately the GPs just don't know how to prescribe it and they really just won't get on board with it. Yeah. Here either. And there's a few pieces there. One thing I will say is that. I think it's really important we test everything and I can always share with you, or I could even just give you a writeup if you wanted to add it to the show notes of what the serum labs we would run off the bat to understand. Yeah, that would be great. So then women can take it to their doctors or just have those in mind. But one thing I would say is that, so we will always look right off the bat, we'll look at sex hormone binding globulin of course.'cause that will inform the way all of these hormones, their signal and how muted or loud that signal is. And that is also true of testosterone. We will look at free testosterone. A lot of docs, if they're running the androgens, they'll only look at total and free of course is the actual signal our body can hear. And so it's essential to get a read on. I think it's very important, and I see this clinically, that we get a woman's progesterone and estrogen stabilized before we add testosterone. Because one of the things that will happen in these stages where her female hormones are in so much flux, specifically estrogen, is a woman may have some excess of androgens that are picking up in between these stages where she's having these ups and downs. So we wanna create more stability to her female hormones first. And part of that is because I'm a big fan of testosterone therapy, we're demonstrated on labs that it should be used. But one of the things is that some women will develop more acne, hair growth she does not want. Voice changes that she doesn't sound like herself. And a few of these can be irreparable in terms of those changes will stay. And so we wanna make sure we have the buffer of her female hormones first. I'm more likely to move right off the bat. Again, demonstrated on lab with stabilizing her DHEA because DHEA is in that same androgen family and it's also an adrenal hormone. So DHEA can work on a seesaw with cortisol. And so it will allow her to have more stress resilience as well. But it will also allow me to touch that androgen family while I understand better getting her reproductive hormones right. And then, in our country, I think similar to yours, there's no FDA approved female testosterone. It's such a shame. And testosterone is still classified in our country. Essentially you need a DEA license in order to prescribe testosterone in our country. Wow. And I think some of it may be related to some of the abuses we've seen on the TRT side and the mills and so forth that have been on the male side. But there's no question that testosterone and the androgen family should be optimized to support libido. But in both of our countries, I believe there is this emphasis that the only reason a woman should be prescribed testosterone is for hypo sexual arousal disorder. I'll just be honest. I didn't have that. I had to sign a form that I had that to get it. And I just said to the doc, she knows me.'cause I'm like, I'm trying to run a business and do courses and I need testosterone. Not because of my, like,'cause I'm just beside myself about my libido. It's because I need to, it's like I need to function. I was just like, this is a, didn't you? I was like, this is a joke. But, so that's interesting. So it's the same here. And she's like, oh, like the side effects are like acne and hair growth. I'm like, well the side effects for progesterone for me are actually like, I can't get outta bed. The side effects for progestin is depression. And like some women on progesterone are like suicidal. Especially on the interuterine device that we won't mention is bad. So the side effects, I was like, wow, A bit of acne, bit of hair growth. I'm like, that's when used at the right dose. That's right. And it costs way more than men's testosterone do, by the way. Because we have to compound it essentially. Unless you want to script it for the astro angelic for the male version, and then it's like a, but it's a 10th of a dose. The female dose would be where you'd start, and it's like trying again, we're back to the ketchup. Like it's trying to get that little dose out of. So I know that there is quite a push in our country right now via thoughtful providers who are attempting to push on changing the labeling so that the FDA can support this being available to women that need it. And I'll just say that not every woman's androgens will do the same precipitous dive that we see in estrogen progesterone, but the only way to know is to collect the data. It's not a guesswork. But when needed testosterone will also support lean muscle mass, confidence, their energy brain. So there are many benefits to it. And so we shouldn't also allow women to just live in a trough there because we have some idea that this is a male hormone. Women throughout all of our reproductive lifetime, of course, are making these androgens as part of part and parcel of our hormonal milieu. It just comes down to an individual approach with testing and what is right for each woman. And sometimes it takes a bit of tweaking. Did with me, but you just stick in there until you get it right. And then I feel great hormonally now, like really good. Really, really good. Yeah ladies, it's just, this is when you need to start. I know that everyone's different, but what age should women start to be like, okay, maybe I should go for an assessment to see if I'm a candidate for HRT or, you know, and you being in naturopath as well. Like, being able to prescribe things like calcium D Glucarate, Vitex, and just support either with herbs, supplements, diet, lifestyle, or actual hormone replacement therapy. Yeah, you know, you are right. I think it is so individual, but as I said earlier, around 40, we will ask our patients to do a DEXA scan. Get some baseline there. And one of the things, you know, my practice for the first decade of my career, I did almost exclusively fertility, pregnancy, and postpartum. And so actually it was an incredible training ground for hormonal understanding. But what's been nice now that I'm 21 years in practice is that my patients have aged with me. You know? And so one of the things is that I have this capture point in being able to watch women after they're done having their babies. Where we're looking and moving into the forties, and we wanna keep an eye on her. And I can already identify, like we talked about, how ovulation is this vital sign. And so when a woman's cycle, either she's noticing more pathology around stages in her cycle. Or a woman is noticing irregularities in timing of her cycle. All of those things would cue me. Let's think about these as cues that our body deserves some deeper assessment. And so we attempt to just educate our patients that that's a time to take a look. And then, you know, we will always grade our care. And it may just simply be, I mean, I read Dutch tests all week. And a lot of times a woman will present and I'll think, oh, we may be there and I'll get her Dutch back. And really what I'm looking at is almost exclusively cortisol and adrenal. And it's so great. It's so useful because I can share with her number one, optimizing this for you is going to make this next decade when we do step into it. Easier for you to navigate. And number two, some of these can be mimics in terms of the symptom picture. And so getting that data, but I love to be able to say, yep, we're not moving yet on progesterone, but we are moving on adrenal support and here's how this works. And so then I also know that I preempted that her move into perimenopause will be better scaffolded. Yeah. So good. There's a new test in Australia called EndoMap, which is similar to Dutch. Which I love. And I've been using it a lot more in patients who are really stressed with hormonal issues. And then it's like their cortisol is either through the roof or really suppressed. Really high or really low. Each test for DHEA will be really low and we can just really see that the stress they're putting themselves under is the driver of their hormonal chaos. I mean, there is inevitably gonna be hormonal chaos even if you are, you know, meditate all day long because it's just part of the change into menopause, but especially in sort of women in their early forties, they start really noticing it. And this is where the lifestyle stuff has to kind of change. And they have to really start looking after themselves. They really do. And we see such a link up with blood sugar dysregulation. I've been so disappointed with this persistent intermittent fasting conversation because there are all these ways in which, this is a time where a woman deserves to be nourished. And she really needs her nourishment. She needs protein, she needs. Stabilization that comes from that rich amino acid profile in her diet. And so women that come in and they're doing fasted exercise and then they're not eating till 11 in the morning and then you can see it on their cortisol curve. And so I think these are other things. Exactly. There's so much that we can do in the bigger lifestyle side of integrating these resilient strategies. And so I want women, you know, we'll put continuous glucose monitors on patients when I'm trying to illuminate to them. And ironically, when patients wear CGMs, it's not uncommon that they'll see that their biggest glucose spikes are a challenging phone call or a challenging meeting at work. That it's actually, of course, that cortisol surge that's creating these fluctuations. And it's a great way of proving to her that she needs a counterpoint to it, especially if one of her goals is weight loss resistance. Because in that scenario, she could be eating perfectly, which of course often requires is some restriction, which is not optimal at all. But it's helping to demonstrate to her that actually stability here is also about stress stability. And then giving her little room to build that toolbox is huge. Yeah, it's great. So when Rachel and I are doing a full hormone workout for a patient, it is it's diet. It's gut health. It's their histamine bucket. It's their methylation. We run tests like endo map and Dutch hormones. We do a full blood panel including all your sex hormones, insulin. And then full thyroid panel.. This is like basic stuff and it's simply not done with allopathy unless you find a really good integrative doctor. It's just simply not done. And also the nervous system assessment. I'm big on the body work. The somatics, to really train the nervous system from a deep level. But we've also got beautiful nervous system support supplements and herbs and things like that. And acupuncture, obviously with Rachel. So this is like a holistic approach to your hormone health. And often we start with that stuff and then you move into HRT as you need it. Because you just can't take it when you're not ready for it.'cause you'll be a bucket of estrogen and too much progesterone. You'll just feel worse. When you feel like a bucket of hormones, you need to detox. You don't need to add more yet. Rachel, thank you so much for your time today. You're an absolute world of knowledge. Thank you, Jo. I'm gonna put Rachel's details, links to her website in the show notes. Do you have social, Rachel? Yeah, we're on Instagram. We're@ginkointegrative. And that's our website as well. We're in Marin County, California, so just outside of San Francisco. Thanks so much Jo. And thanks for being such a tremendous educator and bringing these topics to the bigger conversation. I just value it so much. So I'm grateful. Oh, thanks Rachel. It's been so nice to meet you. You too. So thank you for joining me. I hope you found this episode beneficial. Be sure to subscribe to the histamine well so you don't miss an episode. Leave a review and you can also share this episode with someone who could benefit. If you have any questions you'd like answered or have a topic you'd like me to discuss, please go to my website, joannekennedynaturopathy.com, where you can provide us with that information. Until next time, take care and be well.