In acknowledgement of Menopause Month, Dr. Carissa, author of The Menopause Switch, is a Functional Medicine practitioner and an expert in bio-identical hormone replacement therapy and weight loss. She runs a busy clinic in Tampa Bay, Florida, and has helped thousands of patients reach their wellness goals.
Georgie Kovacs 02:11
Finally, I'm seeing people talking about menopause. And it's really nice to see that you've developed content and focus on this area for women. Tell us a bit about yourself and how you got into focusing on menopause.
Dr Carissa 02:26
I'm a nurse practitioner, I also have a clinic in the Tampa Bay, Florida area that has a kind of a functional medicine approach towards menopause. I've been really interested in hormones for a while. It sparked my interest just based on some personal issues that I was going through. So that pushed me towards this and some female related issues that run in my family. Both my mother and my grandmother had a hysterectomy in their 20s. I did notice that I had some of the same issues that they had before they had their hysterectomy, such as fibroids, fibrocystic, breasts, things like that. So I wanted to educate myself on that and see what I could do. To try to prevent problems from becoming too big. I did start doing bioidentical hormone replacement therapy at the clinic that I worked at which I now manage one of the locations. And I just find it really rewarding. There's so many women that are desperate for help to feel better. And a lot of them want a more natural approach.
So that's where the book comes in. It's kind of easy for me just to hand out, meet with them and kind of review some things and then I just can. I can hand them the book so that they can do more research on their own at home too.
I also have a research background, I worked at the University of South Florida on some large clinical trials involving Mindfulness Based Stress Reduction (MBSR) and some breast cancer survivors. So we're looking at MBSR and what the effects are on the body as far as cortisol stress hormone and some other things. So that is a big part of my practice is I do promote MBSR and other stress management techniques, because I find that they're very helpful for women to help deal with any hormonal imbalances that they have.
Georgie Kovacs 04:45
What would you say are some common myths that you hear about menopause when women come to you?
Dr Carissa 05:00
One that you'll never feel great again, because you definitely can. Once you hit menopause life is not over. Even if you are dealing with some of these issues, some of them are fixable, and you can get back to a place where you're having a good quality of life again. So that I think that's definitely one of the myths is a lot of people feel like, , it's over. But it's not.
Georgie Kovacs 05:23
You mentioned bioidentical hormones. Can you talk to us about what they are?
Dr Carissa 05:29
People are starting to hear more and more about bioidentical hormone replacement therapy, but they don't really know what the difference is between synthetic hormones hormones that are found in birth control, for example, things that most conventional medicine doctors will prescribe. These are not similar to your body's own hormones. So bioidentical is exactly what it sounds like. They're biologically identical to your own hormones in your body, on a molecular level. They have the same shape synthetic hormones, different shape molecule bioidentical hormones, the same shape is as your own so your body tends to recognize them as your own hormones. So people tend to have less side effects. And also, there's a lot of research still going on about the safety of bioidentical hormones. I believe they are, there is some more research that needs to be performed.
In my own clinical practice here, I do find that women feel a lot better on bioidentical hormones versus synthetic. Hormone replacement therapy is just an umbrella term. It could cover any kind of hormone that you're replacing in the body. It could be your thyroid hormone, it could be someone who's menopausal or postmenopausal who needs more estrogen, progesterone, testosterone, those are other hormones as well that fall under the bioidentical hormone, umbrella.
Cortisol, some people actually do go on a low dose cortisol, if they have adrenal fatigue, some women need one, some need more than one, it just kind of depends on their medical history.
For most women that I treat at the office, who are no longer having periods anymore, who are very low and estrogen and progesterone and testosterone, most feel better when they get all three actually, some are surprised when I say testosterone because you you hear about it, you're like “that's for men,” but it's not for men only. It's actually a really important hormone for women as well. It's produced in her ovaries, just like estrogen and progesterone are, and it's an important hormone for energy and libido. So I definitely recommend that women kind of look into that as well, and not be afraid of it. Just because someone's getting a little bit of testosterone doesn't mean you're going to turn into like this big beast.
Georgie Kovacs 08:07
A lot of women may and I'll I'll just speak for myself. I assumed that it's mostly estrogen, but it sounds like there's a lot of hormones when it comes to menopause. So obviously, these hormones are relevant throughout life, but so many people focus on the estrogen piece of menopause.
So since you mentioned testosterone, I wanted to dive into one of the questions from our Facebook group, because I think this is really relevant. One shared that she's going through menopause for the last several years and has lost all interest in sex and can't even orgasm if she is having sex. And so a question is, “Is this normal?” And what can she do?
I appreciate this question, because it's, it's so vulnerable, but I will bet you that every woman is turning up the volume right now because they probably have the same question, but we're afraid to ask or didn't know that. They could ask. So we are all ears. Dr. Charissa!
Dr Carissa 09:05
Yes, libido is important. I mean, it's an enjoyable part of life. It doesn't need to end when you're going through menopause. But it is true that a lot of women do lose some of their libido or they don't enjoy intercourse as much as they did before or have a hard time achieving orgasm.
There's some different factors that come into play, but low hormones are one of them. And testosterone is an important hormone for libido. When you still have a menstrual cycle than when you ovulate, in the middle of your cycle, that's when your testosterone level bumps up. So your ovaries pump out some more testosterone to put you in the mood to make a baby because there's an egg, and they're ready to be fertilized. So there's a biological reason why this happens. You have to be in the mood. So your ovaries pump out more testosterone to do that.
Testosterone is also important for maintaining muscle, as women go through menopause as well, there's some muscle loss that women experience and that contributes to weight gain, because their metabolism slows down because of that. So I'm a big fan of testosterone.
Georgie Kovacs 10:27
You mentioned there could be other factors. So what besides testosterone could potentially be playing a role?
Dr Carissa 10:37
Some women find intercourse to be less enjoyable because it's sometimes painful or uncomfortable or because they start experiencing vaginal dryness. So that creates a lot of friction, and also the tissue down there also becomes a little thin, as well. So it's also easily damaged. So that's another reason why women kind of lose interest a little bit because it's just not enjoyable. It just doesn't feel as good as it did before.
But there are things that you can do. And definitely, one is balancing out your hormones. There's also some vaginal creams that women can use as well to kind of restore the moisture. Of course, there's always relationship issues, .
Georgie Kovacs 11:30
The creams - are you speaking specifically about lube?
Dr Carissa 11:37
Lube would be something that you just use in the moment. There are some vaginal creams that you could use regularly, not during intercourse, to restore balance, restore moisture, and from a bioidentical hormone replacement standpoint, there are some vaginal creams that have some estrogen in them as well. So sometimes I'll prescribe that with a little bit of estriol. Estriol is one of your estrogens. There's a lot of different types of estrogens in your body. But estriol is really great for restoring lubrication. So typically women will insert what looks like a little pearl twice a week, just kind of maintain moisture.
Georgie Kovacs 12:27
One of the things that's become quite clear is just because it's marketed on the shelf, which I don't know if you can get these on the shelf, they may have to be prescription, but it doesn't always mean it's necessarily the best thing. For example, do some of these come with toxins that we should be aware of? Are all of them safe?
Dr Carissa 12:52
It is something I'm glad that you brought that up, because I actually mentioned that in the book about things that you should avoid. When we eat organic food, we should probably use organic things.
If you're looking for a lubricant, for example, because I was talking about bioidenticals with estrogen, well, that would be that would be a prescription - something compounded at the pharmacy. But if you're looking for lubricants, then check the labels. And there's a list of ingredients that you should look out for which I do list in my book. But some are also found in other products that you want to avoid, like parabens, for example. Chlorhexidineg is another one and artificial flavors and fragrances, things like that.
So you mentioned that menopause is not an estrogen deficiency disease, because levels of estrogen only dropped by 40 to 60%. And I hesitate to use the word only because that's still a lot. But I'd love for you to talk a little bit more about that.
Dr Carissa 14:06
It's not just from estrogen. And the reason why I mentioned that is because of the other hormones that come into play. Progesterone is another big one that needs to balance out estrogen in the body. That's why a lot of women who go on bioidentical hormone replacement therapy are getting estrogen. If they still have their uterus, then they have to take progesterone to protect their uterus because these two hormones balance each other out. So not only are you losing your estrogen levels as you go through menopause, but you're using progesterone too and it's a very important hormone because it has a very light calming effect in the body. I call it the cuddly hormone.
If you are prescribed it, and you take it by mouth, it actually works as a sleep medication too. It actually has a calming effect in the body. And sometimes women who are low estrogen and low progesterone and low testosterone, some women do great with just progesterone. Sometimes that's enough to relieve their hot flashes and help them feel better. Sometimes they don't even need estrogen. So that's something to definitely keep in mind.
Georgie Kovacs 15:37
Okay. And you mentioned a calming effect and helps you sleep better. So what happens to a woman's sleep pattern, and it may not happen in all cases, but I do hear women waking up in the middle of the night or not being able to sleep. Tell us more about sleep and what women can consider.
Dr Carissa 15:54
I would say the number one reason why menopausal women are having problems sleeping is because of night sweats. So a hot flash happens a night sweat is a hot flash at night, basically. So it wakes them up and they're feeling drenched and sweaty, and then sometimes it's hard to fall back asleep. So there's that issue. And then also, as your hormones shift, things become imbalanced, then it creates anxiety often makes you feel a little bit anxious. So women have a hard time falling back asleep at night, because they start thinking about things that they have to do and start worrying a little bit as well. And then, of course, is hormone shift as well, it does affect your brainwave activity, your sleep waves, as well. So you sometimes don't go into as deep of a sleep as you normally would. So it's easier to wake up.
Georgie Kovacs 16:48
Would you say then that perhaps the Mindfulness Based Stress Reduction would be helpful, and maybe you can tell us a little bit more about that and what women can do. Your book explains it beautifully. But just to kind of give people a nice summary that they can take away and then read more details about.
Dr Carissa 17:06
If you don't manage stress properly, and it continues for a long time, chronic stress, it can interfere with your hormones and create other issues, affecting other hormones in the body, like your thyroid gland, for example, or your progesterone and estrogen balance as well.
Georgie Kovacs 17:26
So tell us about menopause and weight gain and what women can do about it.
Dr Carissa 17:33
There's a lot of different factors that come into play. Very complex. That's why so many people struggle with it. One of the reasons why a lot of women start gaining weight around the time of menopause is because as your estrogen levels decline, then often women become insulin resistant. So insulin is your blood sugar hormone. Blood sugar levels can definitely contribute to weight gain.
Also, like I mentioned earlier, loss of muscle mass, so less testosterone, less muscle, women tend to lose muscle as they go through menopause. That will lower your metabolism because muscle cells require so much energy to keep functioning. If you have less muscle, then you need less calories. So that's another one.
Also a lot of women around the time of menopause also develop a thyroid issue. That will also slow your metabolism down.
As you get older, your calorie needs change. And I I think it's kind of hard to understand because you've been eating a certain way for so long. So if you need less calories and you're still eating like you were in your 20s then you're going to gain weight, unfortunately.
Georgie Kovacs 19:13
I didn't know about the thyroid being possibly impacted with menopause. So is it like a specific condition like a Hashimoto’s?
Dr Carissa 19:30
Most women who are diagnosed with a thyroid issue such as hypothyroidism - when your thyroid is underactive - is usually around the time of menopause. Hashimoto’s is huge. There's so many people with Hashimoto’s. For those who aren't aware, Hashimoto’s is an autoimmune type of thyroid disease. So that's when your body basically attacks itself, so it starts breaking down those thyroid cells and then eventually, your thyroid isn't producing enough hormone. So you have to go on medication.
Georgie Kovacs 20:18
With weight gain, there are a couple of tips that you provided, and I thought it would be helpful to highlight them. One is the sugar free revolution.
Dr Carissa 20:32
Artificial sweeteners - I just wish they didn't exist. The problem with artificial sweeteners is the way that your body digests them. Your body will actually see them as sugar even though they're not. So your blood sugar levels may not spike, but there's also bacteria and your intestinal tract in your gut, called the microbiome. That will see artificial sweeteners as sugar basically. So there's a lot of research going on right now on how your body reacts to these chemicals.
I wish they did away with them.
Georgie Kovacs 21:10
So Stevia is okay then for those who like Stevia?
Dr Carissa 21:15
There are some really over-processed Stevia products out there. So just keep that in mind. But the more natural, the less processed, the better.
Georgie Kovacs 21:27
Okay. Well, that's helped. See, again, it's all about the marketing there are there are times when I am a label reader. There are times when I'm running around, and I forget to read the label. And then I'm like, “Marketers, you got me!”
Dr Carissa 21:41
No, they make it look really like earthy, a little green leaf here.
Georgie Kovacs 21:51
Tell us about brain fog.
Dr Carissa 21:57
That can happen during any phase of a woman's life. There are a lot of premenopausal women who have brain fog, who, for example, their bodies are producing too much estrogen and not enough progesterone. It's called estrogen excess, basically, estrogen dominance, which I mentioned in the book as well. That happens whenever there's any kind of hormonal imbalance and that's why I mentioned the premenopause phase as well.
In perimenopause, your hormones are gone on a rollercoaster ride, sometimes women will get brain fog as well. And then of course postmenopausal to one bioidentical hormone that can be really helpful with brain fog is actually just testosterone.
Some things that you can do besides testosterone to improve that is increasing the blood flow through the body. So exercise definitely helps get more oxygen to those brain cells that need it.
Georgie Kovacs 23:23
When it comes to menopause, do you also have to do diagnostic testing? And if so, what would you recommend? Tell us more about the role of diagnostics and helping the women sort through these symptoms.
Dr Carissa 24:34
Before treating anyone with bio identical hormones. I always test first because symptoms overlap. I do pretty good workup before I put them on anything to see if there's other issues going on. Also women who are perimenopausal who are going on this hormonal roller coaster. Sometimes, they have a lot of estrogen going on. And sometimes they don't have enough you kind of need to see where they are, before giving them something.
I always say test, don't guess. So testing is definitely important. I do hear of other providers who don't do bloodwork, and they just base it off of the symptoms. But I've had patients who come from them with issues where their estrogen levels are really, really high and it's causing some issues with their uterine lining, especially. So definitely get tested.
I do most of my testing using blood. There are some saliva tests out there as well that you can do from home from like ZRT Labs as one of the labs that you can actually just buy the kit from. I do prefer using blood using blood over saliva.
There's also urine testing as well like the Dutch test, if you go to their website, they have the kits as well.
But it also depends on what I'm just checking. For example, if someone does have very low testosterone, and they're premenopausal, they're still getting their periods regularly most of the time, then I'll suspect that maybe there's also an issue going on with their adrenal glands, because your adrenal glands not only make testosterone, but they also make DHEA and another hormones as well.
So I'll test for adrenal fatigue using a saliva test. Because that's the best way to check your cortisol levels throughout the course of a day, instead of just at one time point, when you have a needle in your arm, which is obviously in a spike, your cortisol level, nobody likes getting their blood drawn, right? So it just depends on what we're testing. But I usually do a full workup before putting anyone on anything.
Georgie Kovacs 27:02
I appreciate your explanation. There are companies out there that are also doing this with progesterone, where, from the fertility world, it's “test on day 21.”
I asked these questions, because I want women to know, like, providers are all different. They have different training and different beliefs. And there's not a lot of data in women’s health. And so it's important to be aware of what to ask for.
I went to a provider, and I asked for more than TSH and it was an argument. And I felt like I was this mean, bullying patient asking for what I knew I needed. I appreciate your reinforcement and some of the nuances around what type of test. You mentioned the saliva test for cortisol, right? e
Dr Carissa 28:00
Yes, because it'll check your cortisol levels throughout the course of the day, and it kind of gives me a curve effect. There's a difference in the curve, then I can kind of tell what's going on that way.
Georgie Kovacs 28:13
There are a lot of wonderful companies who are developing these at-home tests. Tell us your thoughts around where the blood work versus the urine versus saliva tests come into play, and how you use that to help determine the best treatments for women. And I think we all agree bloodwork is best.
Dr Carissa 28:39
I'm definitely not against saliva or urine tests at all. In fact, I do have a lot of patients who, exactly, especially right now, people don't want to go out. They don't want to go get their blood drawn, then I'll actually recommend they just do the kit at home, and then I'll get the results from that. So yeah, I'm not definitely not against saliva and urine testing. Blood, I think blood testing is kind of the gold standard. But those other kits were great. They are something that you can actually purchase online and do yourself. But if you want it interpreted through a medical provider, then you'd have to find somebody to do that for you. I don't recommend WebMD-ing anything. That's never a good idea. But some of the labs will give you a general idea of what's going on so that you can take that and go find a provider who's willing to work with you. If you suspect something's off, they can definitely use that.
Georgie Kovacs 29:49
And then a couple more questions from the Facebook group. I know that you don't have the full medical history. So from the perspective of “This happened. What should someone do and consider?” Let's just put that out there that you're not gonna be able to diagnose. One had shared that she was bleeding for over 20 days and wondered if that is normal. I think we would all agree, especially by the look on your face, thatthat's not normal. But any any thoughts on what might be going on what this person should do to try to get answers?
Dr Carissa 30:26
It's definitely not normal. I have to see how old they are and their medical history, but I can tell you some reasons why a woman should definitely go get that checked. That's not normal. So there could be some kind of underlying issue in their endometrium, maybe some fibroids, so little cyst in there that will cause bleeding. Also, when endometriosis as well, when you have that normal tissues, in that same area will cause bleeding as well. If she's on hormone replacement therapy, and there's an imbalance between estrogen and progesterone that could cause some bleeding as well, either spotting or a full-on period too. And then I hate to say but like uterine cancer would be another one. So definitely go see a OB GYN for that..
I always tell everyone every possible outcome. But I have to say that's, that's rare. The most common that I see are fibroids.
Georgie Kovacs 31:45
Joint pain. So is this something that is potentially something that happens when you are going through perimenopause or menopause? Or is this something that could be probably separate, and they would just need to go to a clinician to better understand it.
Dr Carissa 32:04
So it could be something that they had before, like arthritis. But if they're going through menopause, and their hormone levels are dropping, then it can make it worse, because their body becomes inflamed. So when you have a drop in estrogen, for example, then you have developed some inflammation in the body. So that can definitely affect the joints and make it more painful. So yeah, maybe get that checked out, maybe get your hormones checked down. And if those are good, then he could definitely take some things to relieve the inflammation to make you feel better.
Georgie Kovacs 32:44
Okay, thank you. So I will bring up one thought that I didn't cover because I didn't want to get back to the food since we had dropped that topic. One interesting point you brought up about organic foods is that it's expensive, and how can people afford them. One of the points you brought up is that it's really a long term investment, because if you're not eating organic, the impact of what it can have on your life is huge. Maybe you can tell us about that.
Dr Carissa 33:19
Absolutely - it is an investment in your health. There's a lot of additives in our food, and the way our fruits and vegetables are grown and our meat is raised. There are plenty of things like toxic chemicals that come into our food. And this is kind of controversial, because through testing, they say, “Well, it's just a small amount.” But the thing is, small amounts pile up in the body. Your body can store things. So it is important to buy organic.
I do hear people who are concerned about the cost. And sometimes I'll just recommend that if they can't afford to buy everything organic, focus on the big ones. So the big ones are definitely if you're an egg person, organic eggs are very important. poultry as well, your meat products, there are some things that you can kind of get away with things that you don't eat as much like for spices, for example, you're not using a lot of that. So if you can't afford to buy everything organic, that's something that you kind of typically forego.
There are also other things in our environment too, such as skincare products and things that we clean our houses with that our bodies are coming in contact with things that are affecting our hormones. Xenoestrogens is the word for some of them. That will kind of mimic the effects of estrogen in the body and kind of trick our bodies into thinking that they're producing maybe too much when they're not
Georgie Kovacs 35:00
Wow, that's really important to note. I've really transitioned to eating a much healthier lifestyle. And as you were talking, I realized, I don't really eat a lot of snacks in the middle of the day. I'm not as hungry. I think when you really have it balanced, it may seem like a lot of money up front. But I think between the lowered health care costs down the road, because you're staying healthy, but also, there's not as much of the junk food and snacking. So perhaps you're buying less food, because now you're eating right, so your body feels fulfilled. I mean, maybe it's not exactly the same amount of dollars. So in the moment, it might feel like a really expensive grocery bill. But I would imagine if you really looked at all the costs, right?
Dr Carissa 35:49
The snacks are the most expensive part, all the processed foods, even the organic ones are pricey.
Georgie Kovacs 36:10
Well, thank you again for using all the wisdom that you have to help educate our listeners and for writing your book. I think again, it's a great read with simple but extremely helpful tips. At the very least, it will prepare women to be able to have those good conversations with their clinician to help relieve the symptoms for a very important life stage that we all go through. What would you like to say as far as your greatest hope for women's health?
Dr Carissa 36:43
Becoming more aware of their options and learning how to talk to their medical providers about alternatives or more of an integrative approach as well. Try to find the root cause of things rather than just putting a bandaid on it. That's what I hope for our listeners.
Georgie Kovacs 37:07
Thank you, Dr. Carissa. It's been a true pleasure. And I know that our listeners will get a lot out of this. And thank you again to the listeners for posing your questions, because this is what really helps make sure that we cover the topics that are of most interest to you.
Dr Carissa 37:22
Thank you for having me. It's been a pleasure.