The Optimal Way to Treat Hormone Imbalance

Dr. Jacqueline Tolentino, of Parsley Health. specializes in hormone optimization. Having hormones balanced is extremely critical because when they're not in balance, we deal with a lot of frustrating and often debilitating symptoms and conditions. 

We get to the bottom of how a woman, if she's suffering from specific symptoms, or has a condition that's been diagnosed, but it's really difficult to treat, how does she approach a clinician to be successfully treated, whether it's the symptoms, the condition, or both.


Georgie Kovacs  

Women tend to do research based on symptoms unless they're already diagnosed with a condition. So I have found even when I'm engaging with the consumer, if I say, for example, “Tell me your greatest concern around your hormones,” silence.  However, if I ask, “What's your greatest complaint,” and I post an Instagram poll, where you can only do an A or B….”Is it your low libido or lack of sleep?” People will respond because they get that. It's familiar. 

What I thought we should do is focus on the symptomatology that happens and maybe talking about what that means from a hormone perspective and then potential solutions and considerations.

Dr Jaclyn Tolentino  03:58

Frankly, the way that I would approach it is if this was a woman or a man who was coming in with these symptoms is, “How do I explain it?” Say for example, it was fatigue, right? So there's just so many different possibilities there. And sure, there's absolutely some low hanging fruit from the surface that really could be contributing to somebody's fatigue. But then at the same time, on the other end of the spectrum, there's just a lot that really should be fleshed out. And if somebody says I have fatigue, I have so many questions for them as a practitioner.

  • When do you get it? 

  • Is it worse in the morning? 

  • Is it worse after eating? 

  • Is it all day every day? 

  • Is it just during your menstrual cycle?

  • Is it directly after you're working out? 

  • Is it only certain meals that create it? 

Starting to get intuitive about when people are experiencing symptoms, and how often they get them and what may also be associated.  We teach that a lot. We really teach them to understand their bodies better so that they can also report some of these things to me and have more clarity and help them figure out exactly what's going on.

Georgie Kovacs  05:02

What I'm noticing is even like on Facebook, it's, “What do you do for getting to sleep? What medication do you take?”  People are just giving their list. It's fascinating because I've been in this space long enough, and I've interviewed almost three dozen experts so far, just for the podcast. And here's what I will say. It's great from the perspective of before, there was nothing, no discussion about any of this, there wasn't an avenue like social media. But my concern is that, in this quick fix world we live in with social media, I think it leads to everything being a quick fix. 

So someone comes in to visit you, what is your process, besides the questions that you ask, of really diagnosing? Maybe we can even do a case study here. If a woman comes in with a given symptom, what are the things you did, what were the things you uncovered, and how did she react to that?  What was able to change in her life? I think women seeing this come to life might help paint the picture for what's truly possible outside of that quick fix.

Dr Jaclyn Tolentino  06:19

Oftentimes, the quick fixes may be short lived, right? One may say, “Oh, this girl was taking it, let me try it.” The next thing you know, it’s, “Okay, this doesn't work for me.” And so sometimes those lists can actually sabotage what you're really trying to uncover. 

So crash course.  If somebody was to be seen, virtually and say the issue, like you mentioned earlier with sleep, I think it's important to really dial back and think how long sleep has been an issue. So it's not just the question surrounding how that person is experiencing it on a day to day basis.

  • Are they waking up feeling refreshed? 

  • Do they wake up feeling tired?

  • Is asleep really trickled down into the rest of their day? 

Holistically, when we're looking at the human being, I'm also asking questions about work and work life balance; looking at micronutrient levels, hormonal function, and signs of excessive inflammation. 

This is typically in that first visit to know that initial consult, really dialing all the way back:

  • Have you always had sleep issues? 

  • Was it just after starting a certain medication? And how long have you been on that medication? 

  • Has the sleep issues been like oh, ever since I was a teen or ever since college, and really pinpointing if there were specific turning points in somebody's life, where that really started to contribute to a lot of the sleep issues? 

And oftentimes, people don't really think about why do I have such bad sleep? Like what could be contributing to it? And when they read some of the checkoff list or some of the things that other people are doing, you really have to take a step back and really think about yourself like, 

  • Am I staying up late? 

  • Am I working, and not shutting off that boundary between work and rest? 

  • What time am I eating dinner compared to what time am I actually sleeping? 

  • What's running through my head at the time that I'm trying to fall asleep? 

  • Do I really feel like I've put a lot of things on the back burner or am I  wired and like bright eyed, bushy tailed that 11 PM because I just watched a drama show like This is Us, and I'm really torn up about what happened in that last episode. 

Georgie Kovacs  08:32

I haven't watched it in a while. But yes, I can see that happening.

Dr Jaclyn Tolentino  08:38

Some people will choose to read, and then I also take into consideration, “What are you reading?” That really can propel some more thoughts rather than trying to calm your body down before you go to bed. 

There's a book on trauma that I'm reading currently, it's called The Body Keeps the Score, recommended by a colleague. I really wanted to understand what the effects are over time and how that manifests. What I've learned about reading a book about trauma is that it's traumatic to read a book about trauma. So is that really the best thing that I should be reading before bed? Because then it has my brain thinking about the physiology of some of the things that these people are going through.  

So there's just so many nuances, and over time, it could be layers and layers of things. It could be that the sleep issue had really been going on since college. But then a lot of the day-to-day habits haven't really been instilled. In order for somebody to really have consistent, good quality sleep that's restorative, maybe there is something physiologically that's contributing there. 

And so part of uncovering it with just the basic labs is sometimes... we dig into specialty testing. Sometimes if I feel like I need to order diagnostics, I do, like sleep studies and so forth. Understanding it holistically versus just okay, you're having trouble sleeping here, let me give you this med, you really have to really take a look at the big picture to see exactly what's going on versus, “let me just give you this medication and see if that works.” That's just band aid. It's lots and lots of band-aids. Over the course of time, people think that that quick fix of getting used to taking the band-aids is the solution. Then they ask, “How do I get off of this medication? It has a slew of side effects, and I'm experiencing all of those, even though now I'm sleeping, but now I have 10 other problems?”

Georgie Kovacs  10:33

Let's talk about another symptom I see a lot is - anxiety is a big one, obviously, with COVID, and low sex drive. I'm curious what you're seeing as themes or is it, again, back to “it depends.” 

I'd love for you to walk through when someone comes in with anxiety and maybe the low sex drive, which could be related. What you're seeing? 

Dr Jaclyn Tolentino  11:12

Anxiety is a tricky one because every one of these symptoms is multifactorial, and so the causes are never just one cause. Usually, it's a combination of things or a layering of things. 

Sometimes anxiety could just be from situational. And given this day and age with COVID, and what we're concerned about how we're internalizing some of these things, it really could be because of COVID. And the situation we're in with quarantine. I mean, who wouldn't be anxious at a time like this? It's also how our body is able to control some of the anxiety that we're experiencing, and whether or not we feel like we're able to continue our day to day and control some of that.  

Honestly, Georgie I get a ton of patients that are experiencing anxiety that had not before. So they're not used to feeling these new sensations in their body because, prior to COVID, the anxiety was easily controllable.  If there was a situation, they were able to handle it.  Now, it's more like anxiety all of the time. It's almost like a blanket level of feeling nervous and anxious, just because of the situation that we're in, so all the more reason to really examine and really talk through with individuals about where it's coming from and exactly why they're experiencing it. 

Are there certain triggers that are really adding fuel to the fire and making this worse? If we're anxious about things that we're hearing in the news, or what's happening politically, or what's happening with COVID, then adding fuel to the fire by opening up your phone and reading about it before you go to bed. Not a good idea. 

I do see a lot of the anxiety and also the decreased sex drive because anxiety can also manifest hormonally and create a lot of problems with the hormones. We think of anxiety also being heavily tied to the cortisol and the adrenaline response that happens through the adrenal glands. So if somebody is super stressed out and anxious all of the time, that will manifest in the body.  We feel it all the time. Humans feel it with a gut brain connection, cranial nerve from the brain that signals and innervates the diaphragm and the digestive tract. Sometimes that anxiety is manifesting in an upset stomach, nervous bellies, acid reflux, bloating, and so forth. 

Sometimes it may be the hormonal connection.  Say it has to do with the way that the cortisol is elevated a lot more than it should be. We're not having this resilience in the way that our body can respond to anxious or stressful situations. The next thing you know, it's affecting their thyroid, and that may also affect the way that their sex hormones are working, not quite working regularly. 

It's so strange, but when it comes to decreased libido, you would think that it's like heavily tied to testosterone. Right? So women that have high levels of testosterone, maybe they have like increased libido, or way more libido, than women that have low levels of testosterone, for example. I don't always see that in the lab work. You'll have women that have rock bottom, low levels of testosterone, their body is not producing enough, whether that's through the ovaries or through the adrenal glands (we get a little bit of testosterone from there), and also helping to build up lean muscle mass and focusing on muscle strengthening, and they'll have really low levels of testosterone. But guess what? Their libido is on fire, through the roof. That's not an issue. Not at all. That's strange, because we've always associated high testosterone with high libido and low testosterone with low libido. 

There's that tie also between anxiety and decreased libido, or some of these other factors are at play. But then it could be situational. It could be intimacy.  It could be a relationship. All of those things also need to be discussed. 

So that just goes to show you that it's not always just based off of the labs.  You're also thinking about relationships, social intimacy, all of these other components that may also be contributing to some of those symptoms.  Lab work, I find it to be, again, one tool in the toolbox. Just like medications are one tool, but I really like fleshing out the details. 

There's a craft to it. Are you asking the right questions? Are the patients intuitive enough to really give you some of the answers and understand holistically what's happening? 

Dr Jaclyn Tolentino  16:03

For women with hormonal conditions?  That's a big one. 

  • Were you having hormonal symptoms prior to getting on your birth control? 

  • Prior to getting off the birth control? 

  • What has a pattern been throughout your life? 

  • Does your mom have certain conditions that may also have a genetic related like genetic predisposition to that may be part of your issue? 

  • How long were you on birth control what other things could be contributing to poor hormonal regulation or function? 

Maybe we're eating junk, not eating well, not sleeping well, really fatigued throughout the day, micronutrients are super depleted. The poor eating also created a lot of gut problems, and now you're having symptoms here. 

It becomes super complex, which is why it's never just one answer.  This takes time for people to understand and also for us to educate them so that they really know the depths of how complex it is and how you really have to focus on it holistically.

Georgie Kovacs  17:11

I've had two journeys, when it comes to chronic conditions - with fertility, and now my son with potty training.  He's five and still not potty trained, and I'm racking my brain over how to solve this. He's been to specialists and to different hospitals. I live in New York City. You’d think it's the best at  trying to solve it, but it has been an absolute nightmare. During my fertility journey, I almost feel like if I'm not the expert already trained in this specific thing, I struggle with evaluating how to know who a good clinician is. 

What guidance would you give women as they're assessing their clinician and their care? Even if the right questions are asked, they may still not get the proper recommendations.

Dr Jaclyn Tolentino  18:43

I run into that a lot because patients are seeing multiple doctors and specialists to get some of their preventive testing done. I think you have to find a doctor who's open minded and willing to listen, because oftentimes, by the time they come to see me, they've seen many doctors, and they never felt like anyone was listening to them. They've consistently reiterated that they're having some of these symptoms, and the doctor says, “That it’s nothing to worry about. I don't think that that's contributing to your issue.” 

But oftentimes too, you have to think about the doctor's training and whether or not they're open-minded. We are learning so much about the human body every single day. And so there is so much more learning to be done. Rather than, “Oh, I went to medical school, I did all my training, then I did it all in residency, and there isn't more than I need to learn.” I've never felt that way about medicine. I've always felt like we should do our best to advocate and keep up with the times and learn about these new modalities and learn about things that we may not have known before. 

So sometimes, it could be that doctors can be narrow minded. Maybe they just have no knowledge about it, and that can be scary because, as a clinician, and seeing patients, for your doctor to say, “Look, I really don't know about that.” It’s hard to say that you don't know and you're the medical professional, but all the more reason for doctors to be as open minded as possible and work together. 

At the end of the day, we're all trying to do the same thing. We're trying to make this person well, and not just well in the short term, but in order for them to be well for the rest of their life. I'm sure a lot of doctors think this way, that if it's something that I'm not sure of, I usually will say, “Look, I'm really not experienced with that, but I'm going to look it up, and I'm going to do my research my due diligence and get back to you.” 

One thing I love about the practice that I'm in is that if it's something that I don't know, or I'm not experienced with, I have a beehive of like more than 30 functional integrative doctors who are board certified and have all gone through their own journey as to the reason why they've chosen to work for Parsley and practice this kind of medicine - an integrative model.  So in my eyes, our doctors have this added lens. It's never like we've never gone back to the grassroots of family practice and me knowing how to diagnose and treat conditions with medications if needed. It's really about how you can expand and open your mind to see that there's other possibilities for ways to support and treat people that are really looking to heal. 

And it's not a short term fix. It's really like over the scope of time that really some of these things evolve. And as I'm sure you know, in your own healing journey, as is mine, it was never a quick fix. Even though in my head, I thought that was the answer. 

Once I got sick, and really took a step back, I realized that there were so many things involved. And it wasn't just that I needed one medication, or I just needed one supplement.  It was the foundation of my body that just needed so much work. That included mental health, stress relief, work life balance.  Under the lens of those, that blanket of baseline labs, it also included: