PRECONCEPTION

018: Estrogen Dominance, The Thyroid, And Fertility w/ Tara Scott, MD, FACOG, ABAARM, ABOIM, CNMP

018

018: Estrogen Dominance, The Thyroid, And Fertility w/ Tara Scott, MD, FACOG, ABAARM, ABOIM, CNMP

Welcome to the Hey Mami podcast!

Our guest today is Dr. Tara Scott, known for her work in Integrative Gynecology and Hormones. Dr. Scott, known as the Hormone Guru, helps women find the cause of their symptoms and get them on a path to optimal health. She comes with over 25 years of experience and 3 board certifications in OB/GYN, Functional medicine and Integrative medicine. She is also an assistant clinical professor at Northeastern Ohio Medical University.

After suffering from infertility and curing her own endometriosis, she now helps others achieve that same balance. Dr. Scott has helped thousands of patients struggling with hormone issues including endometriosis, breast cancer, weight gain and more.

She is the founder of Hormone Guru Academy, a course to help patients improve their hormone problems themselves, and has been speaking and educating for over 10 years and has taught doctors her approach in 5 continents. She recently gave a  TEDx talk this fall. For her expertise, she has been featured in Women’s Health, Shape, The List, Newsweek, Parents, Authority Magazine, and on numerous podcasts.

Dr. Scott sees patients in Ohio, Florida, and Montana.

Or listen on Apple Podcasts | Spotify | Stitcher | TuneIn | YouTube

In today’s episode we are talking about hormones and how they can affect fertility.

Highlights:

  • Dr. Scott’s story
  • What are hormones, and what do they do?
  • Common symptoms of hormone imbalance
  • Is the length of a period significant?
  • What type of testing does Dr Scott do?
  • Can hormone balance optimize fertility?
  • What happens to a woman’s hormones after giving birth?
  • Thyroid and fertility

Important Links

Find Dr. Scott online

Quotes

“Everybody has hormones, whether you’re a male or a female. Women, obviously we’re a little bit more aware of them because they dictate our menstrual cycle.”

“The huge connection between thyroid and estrogen and thyroid and cortisol is why there’s so many people with suboptimal thyroid function.”

018: Estrogen Dominance, The Thyroid, And Fertility w/ Tara Scott, MD, FACOG, ABAARM, ABOIM, CNMP TRANSCRIPT

Dr. Maren:                          Welcome back to the Hey Mami podcast. In today’s episode we are talking all about hormones. We cover hormone balance for cycling women, estrogen dominance, how hormones impact fertility and pre-conception health, using progesterone in early pregnancy, hormones postpartum, and we’ll also touch on one of my favorite subjects, which is thyroid function.

Dr. Maren:                          Our guest today is Dr. Tara Scott. She’s known for her work in integrative gynecology and hormones. Dr. Scott is known as the hormone guru. She helps women find the cause of their symptoms and get them on a path to optimal health. She comes with over 25 years experience and three board certifications in OB/GYN, functional medicine and integrative medicine. She’s also an assistant clinical professor at the Northeastern Ohio Medical University.

Dr. Maren:                          After suffering from infertility and curing her own endometriosis, she now helps others achieve that same balance. Dr. Scott has helped thousands of patients struggling with hormone issues, including endometriosis, breast cancer, weight gain, and more. She’s the founder of Revitalize Academy, which is an online course to help patients improve their hormone problems themselves, and has been speaking and educating for over 10 years and has taught doctors her approach in over five continents.

Dr. Maren:                          She’s been chosen as a TEDx speaker this coming fall and for her expertise, she’s been featured in publications like Women’s Health, Shape, The List, Newsweek, Parents, Authority Magazine, and on numerous podcasts. She sees patients over telemedicine and in person in Ohio and also Florida and Montana.

Dr. Maren:                          Dr. Scott, we know you’re such a busy woman, and thank you so much for joining us.

Dr. Scott:                             Thanks for having me and thanks for what you guys do to help educate patients, as well.

Dr. Maren:                          Yeah, we love having guests like you on our podcast. In part, because you bring so much expertise. I want you to tell us, you have so many initials behind your name, tell us what all these initials mean.

Dr. Scott:                             Everybody learns on themselves. I started with infertility and then I got really interested in hormones, so first I became a certified menopause practitioner and mastered that. Then I learned about this anti-aging and regenerative fellowship, which concentrates on hormones, so I did that fellowship, I got the board certification. Then what the heck, I got a third one in integrative medicine. I thought that would look good. I’m an overachiever and I always feel like I don’t have enough. I think that came from my dad. So I went ahead and got a board certification in integrative medicine. The more you learn, the more you find out the less you know.

Dr. Maren:                          I know, exactly.

Dr. Carrasco:                      And that’s after probably doing a pretty intense OB/GYN training.

Dr. Maren:                          Yeah, let’s not forget [crosstalk 00:02:39] to mention the MD and the FACOG.

Dr. Scott:                             Yeah, yes, that’s true.

Dr. Maren:                          That’s a lot, right?

Dr. Carrasco:                      Has an intense-

Dr. Scott:                             That’s a hard residency. I think it’s up there, it’s with the hardest ones, yeah.

Dr. Carrasco:                      I think it’s very, yeah.

Dr. Maren:                          It’s super intense. We have full appreciation for that. We mentioned in your bio that you walked your own path of infertility and endometriosis, so I imagine that is part of the reason that you do what you do. But can you tell us more about how you got into this and why you do what you do?

Dr. Scott:                             Absolutely. I was never able to get pregnant without drugs. I think if I knew then what I knew now, I don’t know if I would have had such a hard time. I always had painful periods, I figured I had endometriosis. I wasn’t diagnosed until I went through my fertility workups. The first pregnancy I had to take Clomid, it actually worked right away so that was great. Then it was the second one that I had six failed cycles of Clomid, then they said, “You’re going to have to do a laparoscopy.” That’s when I found out I had endometriosis and also got diagnosed with Hashimoto’s thyroiditis. Got treated for that. Was never really told what that means. Here, take this thyroid medicine.

Dr. Scott:                             Then went on to have five more failed cycles with injections, then had a miscarriage and then had another hyperstimulation and then I did IVF and that’s how I got my twins. So quite a bit of money and time [crosstalk 00:04:08]. Exactly, I remember those days and I had a regular period, so it wasn’t like, “Okay, day 28 I’ll either get a period or not,” it was every cycle I’d feel pregnant and then wait, wait, no period, no period, no period. Then do a pregnancy test and it was negative. It was a roller coaster every month, just devastating.

Dr. Maren:                          Totally, in all ways. Were you in residency at this point? Where were you in your career?

Dr. Scott:                             Yeah, I had waited until I was done with residency to start, and even took my boards and everything.

Dr. Maren:                          Yeah, isn’t that wild? Your patients probably had no idea what you were going through, huh?

Dr. Scott:                             Well, and that was the hard thing too. Because at the time, the practice I was in, we saw all kinds of patients, even the Medicaid patients. And the ones that would come that were pregnant with the third one at 18 and be like, “Uh, I’m pregnant.” Then I was just like, “Gosh, [inaudible 00:04:58] take that baby.” It was hard seeing people come and go and get pregnant again and be annoyed about being pregnant and not want to be whatever. That was hard.

Dr. Maren:                          Yeah, I bet, totally. What a ride. Well, let’s start with the basics. Can you just tell our listeners what are hormones, what do they do?

Dr. Scott:                             Everybody has hormones, whether you’re a male or a female. Women, obviously we’re a little bit more aware of them because they dictate our menstrual cycle. The whole menstrual cycle is aimed at reproduction. You make an egg and the egg grows, that egg produces estradiol. At ovulation the egg is released and then the shell of the egg produces progesterone. Progesterone, pro gestation, it’s whole job is to get the whole body ready for implantation. If there’s no sperm and the egg and the sperm don’t meet, the whole thing starts over again.

Dr. Scott:                             But what people don’t know is yes, they are important for reproduction, but they’re also important for a lot of other things. All of our endocrine organs, including your stress hormone, which is cortisol made in your adrenal gland and your thyroid, they’re all interconnected. So if one’s off, it’s going affect another cycle. We’re taught very siloed right now in medicine. And as a matter of fact, as an OB/GYN, I can say that we really got very little hormone training anyway. It’s always still a surprise for people to say, “Why doesn’t my OB/GYN know about this?” But everything is interconnected and everything has to do with your vitality and your energy and just really your whole functioning.

Dr. Maren:                          Yeah, it’s super interesting. We’ll dive into specifics. I want to start by talking about what women might experience before pregnancy and then we’ll go into fertility and pregnancy and postpartum. Tell us for a woman who’s cycling irregular or regular, but a young woman of reproductive age, what are some of the most common symptoms or patterns that you see for women with hormone imbalance?

Dr. Scott:                             I’m actually seeing women all ages. Teens with issues with their periods, and so I don’t know why it is. Is it because of genetic issues with the way their hormones are processed, or is it our environment? I’m wondering [crosstalk 00:07:14] combination, and our diet.

Dr. Maren:                          Yeah, totally.

Dr. Scott:                             If you look at a girl that’s 13 now, it’s not like a 13 when we were younger. I know you guys are younger than me, but girls are looking older and older, puberty’s coming earlier and earlier. There is that influence of environment and food. Women who are in their 20s and thinking about getting pregnant, I mean, again, you have that health check of your cycle. A normal cycle, we teach is 28 days, but you could be ovulating anywhere from 25, 26 to really 35, 36 days. Some women are lucky enough to be normal on the same amount every cycle, some women aren’t. That doesn’t mean there’s a problem. Signs of problems would be heavy periods and as a woman, you only know what your period is like.

Dr. Scott:                             I had a patient this week that I asked her specifically, “How long do you soak a pad or a tampon? What kind of protection do you use and how long do you change it?” She’s like, “I have never had a doctor ask me that,” and she was in her 40s. I’m like, “I ask every patient that. How many days do you bleed?” It may be normal, but if you’re soaking a pad or a tampon in an hour or even two hours, that’s heavy. That is significant. We know that estrogen is a hormone that increases the lining of the uterus. So the thought is that if you have heavier bleeding, it generally goes along with more estrogen.

Dr. Scott:                             Progesterone is that hormone that is regulating. I say, “Estrogen’s the partier and progesterone’s the designated driver.” Saying, “Hey, you sure you want to have another beer? Why don’t we just calm down?” Progesterone’s trying to regulate estrogen, keep estrogen in check so that lining doesn’t go crazy. Symptoms of heavy periods, the average is five to seven days, but if you’re consistently seven to 10 days, that’s heavy. That’s a lot. [inaudible 00:09:01] two or three a days.

Dr. Scott:                             Cramps are not necessarily abnormal, they’re common, but they still could be if you’re missing school, if you’re missing activities, that is significant. If you’re planning your life around your menstrual cycle, we used to call it social menorrhea, where you can’t leave the house because you’re bleeding so much, that is significant. Again, might be common, but it’s not normal.

Dr. Maren:                          Totally.

Dr. Scott:                             Any abnormality in bleeding would be the first thing you would see in a younger person. The other thing we see a lot are headaches. Again, it may be common for you to have a migraine, and it might be a normal finding, but that doesn’t mean it’s not a sign of a hormone imbalance. Not everyone has a migraine at their cycle. I’ve never had a migraine, even with all my abnormal hormality. I think that is a flag too, even if it comes the day before your period. Even if you got to a neurologist, you have a CT scan of your head and your brain is great and they just say, “It’s a menstrual migraine.” Menstrual migraine is still a sign that your hormones could be imbalanced. Those are-

Dr. Maren:                          Do you think of more of the estrogen dominance picture with migraines? Or what do you typically see?

Dr. Scott:                             We see a couple things. It depends on when you have it. If you have it at ovulation, it’s that drop in estrogen with the release of the egg. Usually that is estrogen dominance. If you have it a couple days before your period, it generally means lower progesterone; still estrogen dominance. But then we have people who on day three or five have a migraine and that’s when your egg should be growing. Sometimes that can be from low estrogen, from it not growing as quick it can. We can talk about testing, but when they have so much estrogen all at first, you don’t make progesterone until you ovulate. So mostly estrogen dominance.

Dr. Scott:                             The other thing I’ve seen in migraine patients is low androgens, specifically low DHEA. A lot. That’s a hormone that’s made in your adrenal gland and it does reflect stress. So when you have stress and face it, especially after 2020, everybody has stress, right?

Dr. Maren:                          Totally.

Dr. Scott:                             Everybody has different ways they manage it or affects it, but your androgens, testosterone and DHEA, can drop with chronic stress.

Dr. Maren:                          Yeah, that’s interesting. Good pearl. Okay, and then couple questions about periods. Patients who have short periods and then patients who have long periods, what are you looking at, what are you thinking of?

Dr. Scott:                             The short periods aren’t always a problem. Even when I had endometriosis untreated, I never really had that long of periods. There’s so much that can go into it. We make estradiol in our ovary, but we make estrone in our muscle and fat. So your weight can affect estrone, you can make estrone even without ovaries. That’s part of the problem that we have today, is so many people have more estrone. There’s three types of estrogen, three types of sisters. Estrone’s the bad one. If she’s in the wrong crowd, she can stimulate the breasts to grow, the uterus to grow, the fat around the hips and the butt. It’s a necessary hormone, but too much out of balance from estrone, estradiol, that can be an issue too.

Dr. Scott:                             A lot of times you can see that type of bleeding. What’s typical, is people get older, in their late 30s, or early 40s, is they’ll have a couple days of bleeding and have one day of no bleeding and then they’ll start again. I hear that all the time. To me, that usually is a sign that there could be hormone fluctuations, specifically low progesterone with that.

Dr. Scott:                             Then again, like I said, a long period and then spotting, you should not spot between your periods at all. At ovulation, even if it’s mid cycle spotting, still a sign of a hormone problem.

Dr. Maren:                          Yeah, awesome. And what about estriol? You said estrone, which is E1, estradiol, which is E2 for our listeners. Then this third estrogen called estriol. Most people don’t even know there’s three types of estrogen. What’s E3?

Dr. Scott:                             Right and there’s also another one. They just discovered estetrol.

Dr. Maren:                          Oh, interesting.

Dr. Scott:                             Right, we don’t have a lot of information about that. But estriol is an [inaudible 00:13:24] metabolite. What that means is when your body breaks down estrone or estradiol, one of the things, the options to break it down into is estriol. Your body doesn’t really make estriol that often unless you’re pregnant. Then the fetal placental component contributes to that type of estrogen.

Dr. Scott:                             Now we test on it and replacing hormones, there is a trend to also give that because it’s a weaker estrogen and it was thought to be helpful to compete with the harmful estrogens in the breasts or the uterus. You can’t measure it in the blood because you make it when you breakdown estrogen. So estrone and estradiol, there’s an arrow in between. They can turn into each other. That enzyme is what we call bidirectional. It’s an irreversible act. Estriol can’t turn into estrone or estradiol.

Dr. Maren:                          I am picturing right now the Dutch test, which I think you use, right? These are diagrams for our listeners that we see when we order this test for hormones that’s called Dutch. It leads me to this next question, how do you test for hormones? What’s the best way to test? Do you like to test saliva, blood, urine?

Dr. Scott:                             I do four types of hormone testing and my opinion is you should be using all four types. Now, I know, believe, me, I have had discussions with the founder of the Dutch test, the founder of ZRT saliva test and we all have our different opinions. I’m actually doing a study with the Dutch test too about the types of testing right now.

Dr. Scott:                             All of them have good utility, so I’ll just tell you how I use it. Now blood testing is what we’re all familiar with and it’s most often covered by insurance. Not always, if you have a high deductible. But for patients, they are familiar with it, we have a phlebotomist in our office. You have to be specific about when you tell the patient to get the blood draw in relation to day one of their period. You can’t get it done anytime, but if I’m going to draw blood, it’s a great place to look at your cholesterol, your sugar, your thyroid. Thyroid is a peptide hormone, it’s a large hormone. Your TSH and your pituitary hormones are larger hormones.

Dr. Scott:                             But when we talk about your estradiol, your estrone, your testosterone, those are steroidogenic hormones, so they’re a different chemical structure, which means they like to be in fat. They like to be attached to red blood cells. So when we do blood testing, we’re drawing blood from your venous system. What that means is the blood has come from the ovary, already gone to the body and now is getting out to be excreted. It’s going through the veins, then it’s going to go to the kidney and out your body.

Dr. Scott:                             We have normal levels from research, when we do fertility testing, we know what it should be before the egg’s released, after the egg’s released. At different times of your cycle, if you’re not cycling, if you’re cycling. We have those ranges. Those ranges are developed for tumors and big things, not imbalances, so they’re large normal ranges. But nevertheless, blood is the best place to start if you’re still having a menstrual cycle. Mostly because it’s convenient, people know about it, we have standards and it’s covered by insurance.

Dr. Scott:                             But all it tells you is right now, what’s in the blood. My bank is next door, if I go get my bank account balance, it tells me what’s in my bank today. But if I have to pay rent tomorrow, it’s going to go down. If somebody pays me on Monday, it’s going to go up. So it’s only for that finite point in time. The issue with estrogen, is that, like I said, estrone is the bad estrogen which preferentially causes stimulation in the breasts and the uterus. Then you have estradiol, which is more powerful, but equally causes growth or not growth in the uterine tissues. It’s good for the bones and the heart. What happens in your body, is estradiol can turn into estrone or testosterone can turn into estrone and we don’t see that in the blood.

Dr. Scott:                             I have a 19 year old daughter, if she left the house Friday night and said, “Mom, I’m going to go study.” She left in sweats, I would think, “My, God. My daughter is so great, she’s studying on a Friday night. She’s such a good kid.” What if she went to her friend’s house, changed into a tank top and a mini skirt, pulled out a fake ID and went clubbing? I would never see that, it happens outside of my house. When we’re looking to see estrone and estradiol and these ratios, that’s happening in the muscle and fat, it’s not happening in the blood. Blood is just your highway, it’s just one room of your body, so you’re not getting the whole picture. If I’m a census taker and you come to my house in the living room and you see my husband and I there, I’ve got kids in college that don’t live with me and they’re not physically there. You’re not going to accurately count how many people are in my family.

Dr. Scott:                             So saliva testing, for me, I think is a good measurement of your what I call tissue load. If your body preferentially makes estrone, you don’t actually look at that. Now, urine testing is great to look at several things. Look at how your body metabolizes things. If I have to make my taxes, my tax accountant doesn’t care what my savings account is, right? He wants to know, what did you spend on payroll, what did you spend on rent, what did you spend? He wants to know my receipts. Urine is like your receipt. Everything’s coming out, it’s been metabolized, you’re breaking down your hormones.

Dr. Scott:                             What I see is a lot of people with hormone pathology is because they don’t breakdown estrogen correctly. That’s estrogen detoxification. Everybody detoxes, we know that’s what the liver is for. There is no disputing that science. I don’t know why people dispute estrogen detox because it’s clearly in the textbooks. But what I see is people aren’t efficiently getting rid of estrogen.

Dr. Scott:                             If you came to me and said, “My, God, I am bankrupt,” my first question is, “Are you not making enough money, or are you spending too much? Which one has caused you to be in debt?” That’s the same thing with estrogen hormone. I like to do Dutch testing and look at that. It’s a great test, also very great to look at your adrenal gland and your cortisol.

Dr. Scott:                             The fourth type of testing, I don’t use quite as often, it’s blood spot testing. You know how if you are diabetic and you want to check your blood sugar? That’s exactly what it is. For some reason, this is actually covered by Medicare.

Dr. Maren:                          Oh, interesting.

Dr. Scott:                             I know. We use that for Medicare patients a lot, blood spot testing. You prick your finger and that is whole blood. That’s capillary blood. In the blood, a lot of hormones are bound, so they’re attached to proteins and they’re carried to where they’re going to be. But in the whole blood, it’s thought that they are free because once they get to the capillaries, the proteins release them.

Dr. Scott:                             So it’s a good thing to look at certain hormone levels and especially based on how you’re taking your hormones. A lot of hormones are either a cream, like in the case of men’s testosterone, it’s a gel. You rub it on. Well, if I’m rubbing it on and I’m looking at the blood after that, it doesn’t increase the blood level. That’s like if you’re a UPS driver and you get fed up and you’re like, “You know what, I have too many packages on my route. You need to cut down my route.” And I said, “Okay, at the end of the day I’ll look in your truck,” and you came and there’s no packages in your truck. You don’t have a lot of packages to deliver. You would say, “I’ve already delivered the packages.”

Dr. Scott:                             Venous blood, the hormone has already been delivered, whatever you’re putting on topically. This is where people don’t agree the best way to measure topical hormones, but you can’t measure it via serum.

Dr. Maren:                          Brilliant, cool. You mentioned one thing which I think is super important, which is metabolites. Estrogen metabolism is a thing, it [inaudible 00:21:21] our liver, our gut and all of that. So this term estrogen dominance is a little bit controversial these days. Can you help us understand why and what should women do who think they’re estrogen dominant?

Dr. Scott:                             I agree that it’s controversial, I don’t know why. I mean, as a traditionally trained OB/GYN, like I said, that’s who are giving us most the pushback because we’re taught it doesn’t matter to check hormones because your hormones are constantly changing. That is true. If you check your estradiol on day three, day 14 or day 21, you’re going to get different levels, right? That’s true, but we also know how to check hormones when you have infertility, I went through that. They checked my hormones all the time. Why is it okay to check hormones when you’re going through infertility and you’re monitoring drugs? They’re giving me fertility medications and monitoring the effect based on my blood levels.

Dr. Scott:                             It’s okay to check them then, it’s okay to check thyroid hormones, it’s okay to check for males who have testosterone replacement. They check hormones before, they check hormones after, they monitor those hormones. Why do men get hormone monitoring, but women can’t? It doesn’t make any sense. What I’ve seen the traditional doctors complain, is that you’re doing it for the money, we’re doing it to get unnecessary office visits. I don’t get any money from blood testing, I don’t get any money from these tests. I don’t know where that came from. I mean, maybe some people are doing it that way, but when you do the testing, labs get the money.

Dr. Scott:                             It is potentially an out of pocket expense for the patient, so maybe that enrages traditional doctors. But most of these patients want answers, they want to know, they want the information and they want to know. Like I said, 99% of women coming in to see me that are still cycling are going to start with blood testing. It’s an acceptable way of checking labs, so I don’t know why estrogen dominance then is. I think because it’s any [crosstalk 00:23:26].

Dr. Maren:                          Because they’re not testing for it. [crosstalk 00:23:27] Because you don’t see the pattern because you’re not looking at the test.

Dr. Scott:                             Yeah, I mean, estrogen dominance, I guess maybe they don’t think there’s any validity to having a normal ratio of estrogen and progesterone, which doesn’t make any sense. Because we know when someone has, for example, polycystic ovarian syndrome, we worry about endometrial hyperplasia, that is a precancerous condition where there’s estrogen, but not enough progesterone. Those conditions exist, they might not be called estrogen dominance.

Dr. Scott:                             Whenever someone comes in with heavy periods over 40, the normal algorithm is to do an endometrial biopsy. What are we looking for? We’re looking for endometrial hyperplasia. That is an estrogen condition. I don’t understand why all these things exist only in certain situations, but not in others. We can all agree that if you have heavy periods over 40 and you have endometrial hyperplasia on your biopsy that you have a lot of estrogen. But then we don’t want to balance it? I’m confused. We have to use the synthetic progesterone to balance. I don’t understand.

Dr. Scott:                             Micronized progesterone, which is an FDA approved bioidentical progesterone, has been around since the late ’90s. It’s FDA approved, it comes in generic, it’s covered by most people’s prescription plans. Again, that’s the other criticism, “Oh, you’re prescribing unnecessary things and the doctors are profiting.” I get no profit from that prescription either and it’s an FDA approved bioidentical hormone. I would say 90% plus of my patients are taking generic progesterone that they can get at CVS. I don’t know where this came from. I’m sure there are people out there that are pocketing money for testing. It’s actually illegal for a doctor to get money from a prescription. Isn’t it called a kickback or something like that? You can’t get-

Dr. Carrasco:                      [inaudible 00:25:19]

Dr. Scott:                             Yeah, you can’t do that. I don’t know where that came from either. I don’t know, I’ve been trying to figure it out myself. I’m in my own little bubble on Facebook and Instagram and as soon as I got on TikTok, I’m seeing all this stuff that people are attacking. Not me personally, but even people who I respect in the field, what they’re doing. I’m just like, “Where is this coming from?” Because like I said, I’ve been teaching, I’ve got the credentials, I’ve been teaching other doctors how to do this for all these years.

Dr. Scott:                             When I teach my course, I’ll sometimes get people, I’ve had endocrinologists attend and they’re scowling at the beginning of day one. Then by the afternoon, they’re like this, then by the end of day two, they come up to me, they’re like, “I can’t believe this. I didn’t know this existed.” Because we’re using evidence, we’re using references, we’re talking about physiology.

Dr. Scott:                             I don’t know, I didn’t even answer your question, I just went on my soapbox [crosstalk 00:26:14].

Dr. Maren:                          No, I love it though. I think that’s a really relevant thing for us to discuss right now, just given what I also have seen on social media. I think there’s some sadness to it because I think women are really confused. Like, “Who do I listen to?”

Dr. Scott:                             Yes, and I get that question a lot, “Who do I see?” And then, “How do I convince my doctor to order this testing?” I always say, “I don’t think there’s anyway you’re going to convince a doctor to do something they’re not trained to do or they don’t believe in.” But you do have the right to ask for a second opinion, or you don’t even have to ask your doctor. You can go get a second opinion. You can keep your gynecologist, get your paps, get your mammograms, your breast exams, get your IUD, get your whatever procedures done, and you can see another doctor for your hormones. You don’t have to go to your gynecologist.

Dr. Scott:                             So many women are told, “It doesn’t matter, it’s all in your head, it’s normal with aging. Yeah, you’re gaining weight because you’re just not exercising enough,” or whatever their complaint is. “Oh, just take these migraine medicines. Okay, now take this one for that side effect, and then take this and then take this.”

Dr. Maren:                          Yes. Holy pharmacy, it turns into a slippery slope.

Dr. Scott:                             Right, and then when I’m attacked on social media by whomever, whatever, I’m just like, “I’ll just keep helping patients and you don’t have to do what I do. Just go do what you do and I’ll just be here and I’ll help the patients.” We’re all supposed to help.

Dr. Maren:                          Right, yeah. [crosstalk 00:27:39] We all have the same goal, right? Yeah, yeah.

Dr. Scott:                             Yeah.

Dr. Maren:                          Yeah, it’s so crazy. Yeah. Well, let’s talk a little bit about fertility and preconception health. How does somebody work on hormone balance to help optimize their fertility maybe before they go down the hole like REI, reproductive infertility pathway?

Dr. Scott:                             Obviously, you have to be ovulating, number one. Number two is you have to be able to have the hormonal balance to sustain a pregnancy. The sperm thing is another thing, it’s not a hormonal issue. Having regular periods or ovulating, now there’s so many consumer tests. I just saw on the market Modern Fertility or there’s other ones that you can check your own fertility hormones. There’s ovulation predictor kits, there’s all this. Women can pretty much do that.

Dr. Scott:                             People who start to have low progesterone, the corpus luteum, which is the shell of the egg after you ovulate, is necessary to sustain the pregnancy until the placenta can take over, which doesn’t happen till about 13 weeks. There is something called recurrent pregnancy loss, which after three miscarriages they might investigate. Anyone who’s had one miscarriage doesn’t want to have two more, right?

Dr. Maren:                          Right.

Dr. Scott:                             The standard of care is to not investigate until you’ve had three. But like I said, I’ve only had one. I wouldn’t want to wait till three. What’s the harm in doing some blood levels or whatever? Again, progesterone also comes in a vaginal gel or vaginal suppository. These are FDA approved hormones. Now, we don’t just prescribe progesterone for maintenance of pregnancy without there being either a history of a loss. It’s not routine to just check levels when someone’s early pregnant and make sure that their progesterone’s okay unless they bleed. I don’t even think people check that anymore. We used to, we just check the [inaudible 00:29:40] now, the HCG. But I remember way back when I used to check progesterone in early pregnancy and then they got away from that as the [inaudible 00:29:48] got better.

Dr. Scott:                             Unfortunately, the way the algorithm is set up, is you have to have several abnormal steps before you’ll get a workup. Women going to someone like a hormone specialist, we don’t prescribe fertility medications, but we check everything out. If you do have a low progesterone, I don’t feel like there’s a risk for you taking progesterone in the luteal phase. I just don’t. There aren’t any studies that show there’s any increased risk of breast cancer or blood clots or anything. It’s like financial aid. Your kids are too young, but you fill out the FASFA form and if you qualify you get it, if you don’t, you don’t.

Dr. Scott:                             That’s the way we approach hormone balance and we don’t give people more than they need. We don’t try to supersede the cycle and give them high doses. We just try to balance and fill in the gaps for what their body doesn’t do.

Dr. Maren:                          What if somebody knows that they have these symptoms of low progesterone or maybe estrogen dominance or whatever it might be, and she gets pregnant and she’s early in pregnancy, but she hasn’t had a history of pregnancy loss, she knows her progesterone levels are low? If you have a patient like that, do you just consider using a vaginal suppository just in case, for progesterone?

Dr. Scott:                             If I have a patient that I’ve been working with, that we’ve already documented a low progesterone and they’re taking it before they conceive, we do continue it. That’s an area that doesn’t happen to me anymore because I don’t do mainstream GYN, so I wouldn’t be seeing a patient unless they’re having a problem with their cycles, we would have checked it. I do have patients that their goal is to conceive and so balancing things, they conceive, then we prescribe, we continue to have them take the progesterone. It’s gone back and forth versus whether you give it to them vaginally. Vaginally is going to be a direct route to the uterus and the fetus. But orally still has shown that it could also be helpful as well. If they have what looks like a low progesterone, I do tell them to continue and we continue to prescribe it in the first trimester.

Dr. Maren:                          Then throughout pregnancy, obviously we have tons of hormones onboard. What happens after we deliver a baby? What happens with our hormones and how do we help women who are struggling postpartum?

Dr. Scott:                             When you’re pregnant, at the beginning of your pregnancy your placenta makes a lot of progesterone. It’s always really interesting when I ask patients, “Did you feel good when you were pregnant, or did you not feel good?” Those patients that say, “I felt great when I was pregnant,” generally it’s they’re not making enough progesterone, but when they’re pregnant they are. Because obviously, once the placenta takes over, it’s going to make more progesterone, and if you’re someone that didn’t do it naturally, you’re not ovulating so you’re not making a lot of estradiol. Like I said, it’s a different type of estrogen, it’s estriol and again, you still have your estrone.

Dr. Scott:                             I mean, it’s been a while since I reviewed my pregnancy physiology, but postpartum, everything drops. With the taking of the placenta out, all that progesterone’s going to drop and if you’re nursing, you’re going to have prolactin. Prolactin inhibits ovulation. Generally, we say if you nurse six times a day or more, but everybody’s different when they’re first period comes back. Your ovaries not working, you got this prolactin that’s hanging out. Oxytocin is going to be made right before labor, during labor, sometimes with nursing after. Those are all geared at nursing and breastfeeding. But generally, estradiol low, progesterone low, so some people are very symptomatic.

Dr. Scott:                             As a matter of fact, a lot of people who have postpartum depression, they’re finding is linked to that drop in hormones. About a year ago, there was a drug that was going to be FDA approved that was essentially a synthetic IV version of progesterone. I’m like, “Why wouldn’t you just give them natural progesterone?” But it was a synthetic analog of progesterone IV for postpartum depression.

Dr. Maren:                          Wow!

Dr. Scott:                             I don’t know if it ever really came to market. I think it was approved, or was in the preapproval stage. I thought, “Well, you’re onto something, but let’s just [crosstalk 00:33:56].

Dr. Maren:                          But it’s already there and it’s a lot less expensive.

Dr. Scott:                             Exactly, exactly.

Dr. Carrasco:                      And it’s been shown to be safe.

Dr. Scott:                             That’s part of the problem, is that once the drug companies come into it and then they want to profit on a product.

Dr. Maren:                          Yeah, there’s a lot of industry and finance and all that behind it. I mean, the other thing I talk a lot about with women postpartum who are struggling, is obviously postpartum depression is a real and very important issue. However, it doesn’t just mean that you need a prescription medication. Often it is because of a hormone imbalance and then thyroid is this huge one that I think gets ignored. I know you mentioned you were diagnosed with Hashimoto’s during your infertility workup, which I think is really a lot of times women who are going through infertility learn that they have suboptimal thyroid function or Hashimoto’s or something like that. Well, women who don’t go through that perhaps miss that diagnosis for a long time.

Dr. Maren:                          Anyway, my big question for you is what do you see in terms of thyroid function through the reproductive years and how common is it?

Dr. Scott:                             I’m really glad you brought up thyroid because I don’t want to forget to talk about it. Thyroid disease is becoming more and more common and it’s because of a couple things. First of all, what we don’t realize is that again, the thyroid does not exist in isolation. If you are one of those people that has high estrogen, estrogen increases the binding protein called sex hormone binding globulin, also thyroid binding globulin. If you think about thyroid, it’s also a hormone, it’s a peptide hormone, it’s not a steroidogenic hormone. But it’s also bound and carried in the blood.

Dr. Scott:                             Think of it this way. Your TSH from your brain is like you’re clocking your hours for your job. The thyroid then makes T4, that’s your paycheck. You can’t walk into CVS and use a paycheck, you’ve got to cash it. Your body then takes the T4 and makes T3 out of it. That is the active thyroid hormone. But what is traditionally acceptable screening for thyroid is just TSH. Sometimes if you’ve got a progressive doctor, they also do a free T4. Most doctors though, will only do a total T4, so for any woman that has estrogen, the total is going to be off because of the binding protein.

Dr. Scott:                             For those people that don’t know what the binding and not, there’s free and there’s bound. The free is the thyroid hormone that can work. If everything works through, musical chairs, the free thyroid hormone can sit in the chair and turn on the game or whatever, let’s just say. If it’s bound, it is put away. Back to the paycheck, whatever’s going put away is like your 401K, you never see that. You have it, you just can’t use. You’ve got a thyroid hormone then, it’s cashed. Part goes to your 401K, that’s the reverse T3 and the bound, and then you’ve got the free T3 that’s going to be what you can actively spend, that’s your cash.

Dr. Scott:                             The problem is there’s so many things that will inhibit the conversion of T4 to T3. If you don’t have enough vitamin D, which half of our country does not, you don’t have enough ferritin or iron, if you have too much or too little cortisol. Which guess what, after 2020 everybody has either too much or too little cortisol. The other thing is high cortisol or stress inhibits the release of TSH from the brain. So if we draw the TSH it could be falsely low and I see that a lot. I see the TSH is low, well, it’s supposed to be inversely proportional from the T4 and T3 and it’s not. But what most commonly happens is people look and it’s all in the normal range, so you’re [inaudible 00:37:42].

Dr. Scott:                             Another thing I see is people do not order the thyroid peroxidase antibodies, which would be the way to diagnose Hashimoto’s. People don’t order them or follow them. So people don’t know if they have an autoimmune thyroid. The huge connection between thyroid and estrogen and thyroid and cortisol is why there’s so many people with suboptimal thyroid function. Recently, within the last year or two maybe, there were a couple articles published that normal thyroid in a positive antibodies had an increased risk of miscarriage.

Dr. Maren:                          Oh, yeah. Totally.

Dr. Scott:                             Then there was this thing that, “Oh, no. We shouldn’t make TSH part of the screening for pregnancy blood work.”

Dr. Maren:                          I know, I’ve gone so back and forth at this. Like, “Why? It’s so cheap. Why aren’t we screening for that?

Dr. Carrasco:                      But isn’t the ACOG recommendation that TSH should be under 2.5 for optimal pregnancy?

Dr. Maren:                          It is, but they don’t screen for it.

Dr. Scott:                             It depends on if you have active thyroid disease. The American Academy of Endocrinology recommends that less than 2.5 is optimal, but then no one’s changed their normal ranges. Labcorp and Quest, I think is still 4.5 [crosstalk 00:38:50] range. And if you look further in the endocrinology guideline, TSH five to 10, don’t treat. Why do you have a normal range if your advice is going to be to not treat when the value is abnormal? I don’t understand that.

Dr. Maren:                          Yeah, it’s wild. I mean, the indications for screening for TSH include having a history of abnormal thyroid antibodies. But nobody ever checks the thyroid antibodies.

Dr. Carrasco:                      Then you wouldn’t know.

Dr. Maren:                          That doesn’t happen.

Dr. Carrasco:                      That’s probably why so many women find out postpartum they have Hashimoto’s because it’s the first time it’s ever been checked.

Dr. Maren:                          Yeah, maybe.

Dr. Scott:                             We’re in the information age with the website and internet and social media. Women are finding these things out on their own and they’re driving the change. I mean, not all doctors are bad. Obviously, we’re doctors, but some people are really genuinely invested in helping people even if they’re not trained. If their patient says, “Can you check this?” they will. Then they don’t know what to do with it and they don’t know how to interpret whether it’s abnormal or not. They’ll look and say, “Oh, it’s in a normal limit.”

Dr. Maren:                          Yes, totally. So even if you do get a full thyroid panel, I always say there’s a lot of different challenges when it comes to thyroid. Number one is actually getting the full thyroid panel drawn. Number two is seeing somebody who knows how to accurately interpret and take action on that full thyroid panel. Because even though maybe your TSH is still in a normal range, if you’re actively trying to conceive, it ought to be less than 2.5. You don’t know that based on your labs because they look like they’re in a normal range. So unless you know, you don’t know.

Dr. Maren:                          Then you’ve got T4 and like you mentioned, checking an SHBG, I should always check sex hormone binding globulin because then you know well, you’re free hormones might be less bio available. It can be somewhat complex, but really not that difficult once you master it and start practicing it.

Dr. Scott:                             But I don’t know why in some areas of medicine, they practice that way. For example, if someone has a stroke they put everyone on a statin, even if their cholesterol’s normal because of some study, this was this anti-inflammatory. You’re not even waiting till the cholesterol’s abnormal and you’re treating. So why are we approaching the thyroid differently when we have this data about miscarriage?

Dr. Maren:                          Yeah, that’s such a good point. I mean, I always say, “It’s risk benefit.” Everything’s about risk, benefit, what’s that ratio look like in medicine? Starting a statin after stroke, what are the risks, what are the benefits? Same thing with thyroid medication. You don’t want to over medicate, but it really sucks to be under medicated. So what’s the risk in getting your TSH around one and getting your free T4 above one? And maybe your free T3 above three, what’s the risk in that, as long as we’re not making somebody truly hyper thyroid?

Dr. Carrasco:                      And if you do a slow titration, I mean, you can easily achieve that.

Dr. Scott:                             Yeah, and I’m sure you guys counsel all your patients, “Listen, I’m going to treat this thyroid and if by chance you have palpitations, you feel anxious, then you don’t need it.” There’s a chance you don’t need it, you’re on the borderline. Most people would be like, “Hey, I want to feel better.” If you feel bad, if you’re one of the small percentages of people that can’t tolerate thyroid hormone, then you’ll go off of it.

Dr. Maren:                          Yeah, totally. Yeah, it’s interesting. Well, thank you so much for your time. I think some of these analogies really have helped me sort things through in my brain and hopefully, our listeners. I’m pretty certain they have learned a lot as well.

Dr. Maren:                          Tell us if people want to learn more and follow you on Instagram or Facebook, or TikTok, how do they do that?

Dr. Scott:                             Are people even on Facebook anymore? I don’t know.

Dr. Maren:                          I don’t know, I try to stay away from that, but some might be.

Dr. Scott:                             I don’t do much on Facebook anymore, but I do have a page; Revitalize Med. We do have a private Facebook group, Revitalize private Facebook group. Sometimes we do challenges in there, but it’s been kind of quiet. On Instagram I’m Revitalize Med and on TikTok I am hormone guru. Every modality is different. You’re going to get smaller, smaller segments of things on TikTok versus Instagram. I also have a YouTube page, just Tara Scott, MD. A lot of longer videos are going to be uploaded there, as well.

Dr. Scott:                             I’ve got a free webinar on my website, Revitalize Med, that just talks about a functional approach to women’s health. Goes through my story and all the things that were wrong, how we approach things. Then I do have an online course, it’s very short, 14 modules, but very short, 10 minutes tops. You could be putting your makeup on and watching one of the things. There’s a lot of also diagrams and documents and quizzes that you can download. That’s also at hormone guru. If you just go to hormone guru, it’ll reroute you to the academy and you can look into that to do that.

Dr. Scott:                             Yeah, all kinds of ways to engage.

Dr. Maren:                          Awesome. And for our listeners, Dr. Scott has been super generous to offer a discount for your online course, which is Revitalize Academy. I think that’s awesome you’re doing it, especially like you said, short snippets, that’s what we can digest. So how can patients access that?

Dr. Scott:                             I’ll have to for the show notes give you the updated because [crosstalk 00:44:09].

Dr. Maren:                          Yeah, we’ll do that.

Dr. Scott:                             We did move the website from Revitalize Academy to Hormone Guru and so I’ll also have to give you the updated coupon code, as well for that.

Dr. Maren:                          Amazing. Check out the show notes, everything will be in there. We just really appreciate you. Thanks for what you do and thanks for being here.

Dr. Carrasco:                      Yes, thank you [crosstalk 00:44:28].

Dr. Scott:                             I know it’s a lot of work for you guys to do this, so I appreciate you doing it as well.

Dr. Carrasco:                      Well, thank you and we hope to have you back and pick your brain some more.

Dr. Maren:                          We could talk for a long time about menopause. I have lots to say about that and also thyroid. I could talk for about two hours [crosstalk 00:44:42] thyroid, but yeah. Awesome. Well, thanks again.

Dr. Scott:                             You’re welcome.

Alejandra Carrasco M.D. and Christine Maren D.O.

Hello! We are Alejandra Carrasco M.D. and Christine Maren D.O. We founded Hey Mami because we felt a lack of support for fellow mamis. As physicians, we see women every day who struggle with fertility, are forgotten about postpartum, and have put their health on hold for years while they raise a family. We’re here to change that.

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