Ep. 567 “Timing Is Everything” – The Best Way to Test Hormones, Cortisol & Thyroid for Real Answers with Dr. Carrie Jones | Menopause & Testing

Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives. Today I have the honor of reconnecting with friend and colleague Dr. Carrie Jones, who is a naturopathic physician and hormone expert with over 20 years of clinical experience in women's health and endocrinology. Today we spoke about limitations to traditional testing and how both saliva, urine, and blood can be beneficial for getting an appropriate sense of what's going on with hormones, how timing of labs is critically important, the influence of the Dutch test and specific parameters in which the Dutch looks at estrogen, metabolism, cortisol rhythms, and more. Menopause through the Dutch lens, the impact of liver detoxification and its impact on T3, which is our active form of thyroid hormone. Phase one through phase three and why they're so important, signs and symptoms that our gut microbiome is not optimal. And last but not least, we did rapid fire questions that I picked up that I thought would be the kinds of questions you all wanted to ask Dr. Jones, another truly invaluable humorous and fun conversation with Carrie. How's your Carrie Jones? So good to have you back on the podcast. Is this like our fourth or fifth conversation? I don't know, but I always love talking to you, so I'm happy to be here. Well, the masses have spoken. They were very clear that they wanted to have a conversation around the Dutch and they wanted Dr. Carrie Jones very specifically. So I said, this is one of those things that you have when you're a good friend is the Dutch queen. Let's talk about limitations to blood testing for hormones. Obviously, you are a hormone expert. Let's talk about some of the limitations that you've been able to see working with patients for 20 plus years. And I've done them all. I should start with that. I've done lots and lots of blood tests, lots and lots of saliva tests, lots and lots of urine tests, whether it's, I've done the dried urine, liquid urine, 24 hour urine, I've done them all. And the blood is the gold standard. It's what we're all super familiar with. It's what we all do. We go see our primary care. We say test my hormones and they check them in blood, right? But it only looks at that snapshot in blood in your arm at that moment. And so if you want a progesterone, you get a progesterone. If you want estradiol, you get estradiol. Testosterone is interesting. You probably find this ironically funny as well. But the lower range for free testosterone for women, most laps is 0.0. Sometimes the lab will be 0.2. But I'm like, really, you think women have zero testosterone and that's okay. But I digress. So it's a great snapshot in time. Which the problem is hormones come out in pulses. Hormones are not made in our body like a hose that we just turned on our brain decides depending on feedback and what's happening in the body where we are in our cycle hormones we're taking to pulse out various hormones. So we only make progesterone a few times during the day. Same for estrogen testosterone is a little more consistent low level. And if you're get your blood drawn, then we may or may not hit the pulse when it happens. So you may get low levels, but not actually. And the other thing, of course, is where you are in your cycle, we have to time it accordingly. If you still get your cycle, we need to know so we can decide which hormones are drawing. And then unfortunately, blood doesn't tell us where your hormones are going. Because once it's in the blood, it just means it's in the blood, then it's going to get to your tissue, or not, it's just going to go straight to breakdown detoxification. But once it's in your tissue, then it gets used and then it goes through detoxification. And so we miss out on pieces of the pathway, the timeline, the story with our blood test. So it's helpful initially, but not the full picture. I think that's really helpful for listeners because I think there's a lot of opinions about whether or not it's beneficial to test hormones, either with blood saliva or urine. There are a lot of opinions about when is an optimal time. And maybe it'll be helpful to state when in a woman's cycle, it's optimal to test key hormones, maybe not just progesterone and estradiol, but when you're working with, let's just say younger women. So women that are not yet perimenopausal. What's the ideal time, Rhine, you like to look at specific sex hormones? Here's what's really fascinating too. There's some research to show even thyroid is affected by the menstrual cycle. So we often talk with younger women, not perimenopausal, although early perimenopausal fits in this category. If you have a regular cycle, then we want to test your hormones five to seven days after ovulation. So if you ovulate around day, let's say day 12, then we would count forward five to seven days. So we're looking at day 17, 18, 19. That's when you would go to the lab and get your blood test, or you would do your urine test or your saliva test. And the reason for that is we're trying to catch progesterone at its peak because progesterone only comes out to play in the second half of your cycle after ovulation. If you get a blood test done or any test on day three, on day four, on day five, what happens is you get told, oh gosh, your progesterone is zero or it's very low. And you're like, yeah, I know, it's supposed to be. You don't make progesterone then, not really. It's not, it doesn't come out as a grand finale until the luteal or the second half of the cycle. Now having said that, as a result, because nobody likes to get their blood tested more than once, we tend to do all the hormones at a time. So estradiol, progesterone, DHEA, or DHEA-S, testosterone. But I said thyroid. So thyroid, there's TSH, thyroid stimulating hormone, and it can get caught up an increase for some women around ovulation. So if you are around ovulation, your TSH may go up a point or two, which could make you look hypothyroid, because the higher the TSH goes, it indicates or implies more of a hypothyroid situation. And so I even tell women, hey, when we look at cortisol, thyroid, some of these other hormonally related markers, and recycling, let's try to avoid ovulation, either do it, you know, where I said five to seven days after, or if it's just thyroid, do before, around your period, because it gets caught up in the excitement of ovulation. Now not all women are this dramatic, but I've seen it enough studies, I've seen it enough in real life, where I'm like, oh, I don't need to adjust your thyroid medication, you just got caught up in ovulation, and it bumps up, and then it goes back down to normal, and you're fine. And I don't think this nuance gets talked about enough. And because it's not discussed, and it's not really well understood, instead, healthcare practitioners go, well, don't test. It's pointless to test because your hormones change every day. Unlike they do, but if you understand it, you understand the nuance, that it becomes much easier when I'm ordering a blood test, or any test. I think that's important, because, again, I see so much disparity on opinions about do we test, do we not test? I think it gets far more complicated when we navigate into perimenopause, because we know that we can have 20 to 30% higher estradiol levels, especially if we have a loop cycle. So when you're looking at, let's now look at women in perimenopause, what are some of the key factors that you take into account when you're thinking about the timing of testing, whether or not it's helpful, not helpful? The good thing is we don't have to have a test to determine if somebody's perimenopausal. And I'm sure you get asked this all the time, like, what's the test to tell me? I'm like, are you the right age? And you have symptoms? Guess what? Congratulations, you're perimenopausal. But right, but for most of us who go through perimenopause, in the beginning, we still have regular cycles, you can still have mood issues and insomnia or joint pain or vaginal symptoms. But your cycle is still pretty regular. And even though because it's regular, then I still test. I'm like, look, you're still a 28 day girl or a 26 day girl or a 30 day two day girl. So we'll just do the math and collect all your hormones. The issue becomes once she becomes an irregular girl. When somebody says, well, now I've skipped four months, and then I got two periods in a month, and then, you know, then then I'm back on track again, but then I got two more periods. And on and on and on, then I am less likely to check estradiol and progesterone. Every other hormone is on the table, thyroid, insulin, testosterone, DHA cortisol, etc, etc. But estrogen and progesterone, if I'm doing a one day test, meaning you go get your blood draw, you spit a tube, pee on a stick for urine testing, then I'm less likely to do those hormones. However, a new participant has entered the space, which is the everyday at home testing that was really popularized, of course, with fertility. And now it's going into perimenopause because women who have such your regular cycles are going, I get these symptoms and they go away, and then they come back, and then they go away. And so now people are doing the at home urine testing for the average consumer, not for fertility, but they want to see what their estrogen and progesterone's doing through perimenopause. And I have found that to be personally, and with patients really helpful at giving me some feedback of like, how wild and crazy is it? Or how low is it? Or how high is it? When I'm looking at all this? If you're in perimenopause or menopause and are feeling more fatigued, dizzy, lightheaded, struggling with headaches, or noticing your workouts feel harder than they used to, electrolytes may be part of the missing piece. As estrogen declines, we lose some of the fluid regulating and vascular protective effects that hormones once provided. That means blood pressure regulation can shift, cortisol can run higher, and many women become more sensitive to dehydration, especially if you're strength training, walking more, intermittent fasting, or reducing process foods. That's why I love element. 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I literally have had patients tell me, my GYN said there's no point in testing any of my hormones when I'm in menopause and I'm like, well, intellectually I understand where they're coming from, but I also think it's helpful to have a sense of where things are so that if you're considering hormone replacement therapy, you're like, okay, do we need to be more aggressive or less aggressive about like estradiol as an example? Yes. And I am in the same camp as you. I even prior to my experience with Dutch, I did a lot of testing. I was very well trained in testing, the nuance of testing, but I give testosterone as a prime example. When you're perimenopausal or let's say I've been seeing you as a patient since you were 30, I run your hormones. So now I have your baseline of your hormones at 30. Now you're getting older and now you're 40, right? So and I'm going to continue to test your hormones and maybe your testosterone at 30 was like really robust, really good. Now at 40, I we've dropped a couple of points. So I'm like, okay, let's pay attention to this. And then we get 45, 46, 48, and you're like, carry my libido is terrible. I have no motivation. I don't feel as strong as I was. And your testosterone is bottomed out. But I knew at your peak, you were a very robust person. So if we're going to do testosterone support, some sort of therapy, then I know I have to be more robust with you versus somebody else who's maybe more average or in the middle and at 30. And so if you know this information about yourself, if you knew you always had really healthy, robust levels of estrogen or testosterone or progesterone, then it can really help me or you navigate which where do we start and where will you probably feel better and more like yourself? Yeah, I think that's all so important because I think women feel so gaslit at this stage of life depending on who they're working with, depending on who they're following. There's an individual who I won't identify the gender of this individual or who they are, but loves to be very contrarian to the bulk of what the other people in the perimenopause and menopause space talks about in terms of lab work and hormones and research and just loves being contrarian and I think leads to so much confusion because number one, just because there's not a randomized controlled trial, clinical experience is still really relevant and really important. And if we just bent off of randomized controlled trials for every single thing we consider doing in terms of an intervention, we'd be waiting a long time because women have already been waiting for such a long period of time. Yes, and here here, like 100% and I also find it fascinating why wouldn't you include clinical experience and the contrarian, they, if I'm thinking of the right person, they have a lot of years as well. So surely they have years of experience to fall back on and go, gosh, you know what, I've noticing this as well or I'm seeing this all the time and women of a certain age or with these certain symptoms, let's take that into account. And sadly, a lot of people don't and just the menopausal education across the medical system isn't that great. So they weren't really taught how to test hormones to begin with, it didn't matter what your age was. And I'm sure you've seen this and I'm sure people listening have had this experience, they go and ask, can you test me for everything? I want to get a full hormone workup, test me for everything. And then what do they get? They get CBC, complete blood count, which is red and white blood cells. And the metabolic panel is, you know, glucose and electrolytes and calcium and liver, but still a lot of hormones. Maybe they'll get a TSH for thyroid. And then that's it. And then they get the phone call or the portal message that says everything's normal. And I'm like, well, that's great. But that's not what, that's not even what we wanted. But they weren't taught about hormones. So they don't know. And then as women move into perimenopause, where things are really changing all the time, then it's very overwhelming. They surely don't have that education. And so then they just say, well, we don't test at this age, it's not worth it. Yeah, it's fascinating to me just how much just like, well, as my mother used to say, everyone has opinions. So you will find that people can be well versed in the space and have very differing opinions. And I think for individuals that are listening that feel like there's a lack of clarity, please know that there is a lack of clarity because there are a lot of differing opinions. And this is where I think adjunctive testing can be helpful. Yeah. And I probably used the Dutch more five years ago than I do now. I think it still has validity. And there's usually specific circumstances when I want to look at this. So talk about where kind of standard hormone testing can fall short and where the Dutch can be helpful, especially for women that are in this perimenopause to menopause space. The Dutch is really nice. First of all, it's an acronym, the dried urine test for comprehensive hormones. And it is exactly that. It's you urinate on these pieces of filter paper, couple times throughout the day, let them dry, mail them back to the lab. And the really nice part is that it's a couple times a day in the morning, two hours later around dinner before bed. And if you have insomnia, which a lot of us do, you can do it in the middle of the night. And because it's urine, urine tells us hormones over time because the hormone is made, it's used, it's broken down, it's put in your bladder. And then after a couple hours, you urinate on the piece of paper. And so we get these snapshots of time of average. And like I said, member hormones come out in pulses. And so it's nice to have through the whole day, because they will do a weighted average of every collection. When you do four collections in the day, the Dutch test says, great, I'm going to take these four collections, give you a weighted average. That way, if we missed pulses or caught pulses, we just have it in here. Then if you can't sleep at night, which a lot of women can't, then we get that overnight sample as well. So now I can look at, especially specifically cortisol, to see what's going on. I mentioned earlier the breakdown pathways. So blood will tell us estrogen, for example, estradiol, but not where it goes. And like everything, you have to break it down, go through detoxification, and then eliminate it out of the body. Because urine is a huge route of elimination for hormones, then the Dutch test will pick up on some of these pathways to help you decide where you're going, how are you detoxifying, and how might we optimize it. Some of the pathways we view as maybe better than others, some of the pathways, if they continue, they're more what we call genotoxic or not good for your DNA. We want to preserve our DNA, we don't want to damage our DNA, but these pathways, if they happen, can damage our DNA. Plus on top of it, the Dutch test gives us other markers such as cortisol, melatonin, some nutrient markers, B6, a B12 marker, glutathione. So it's a lot more well rounded as opposed to the blood test. Now, I love a blood test. I use blood testing all the time. But when I need, again, that comprehensive multi-layer pathways, cortisol, melatonin, that I'm reaching for the Dutch test to get that on her. Let's talk about estrogen in particular, because there is a point of that test that I think is very helpful. We talk about detoxification, and yes, we detoxify when we poop, when we breathe, when we sweat, when we urinate. But this is specifically looking at phase one, phase two, detoxification, and really looking at these estrogen metabolites. Because I think this nuance is important. This might be one of my favorite aspects of this test to really hone in on, does someone need more support for phase one or phase two? Are they someone that's a poor methylator, which so many of us are? Are there additional things that we need to support in terms of looking at how they're breaking down their hormones before we even proceed with adding in hormone replacement therapy? Or maybe they're already on it and we want to get a good sense of what their metabolites look like. Yeah. And just as you said, so when it comes to steroid hormones, meaning estradiol, progesterone, testosterone, et cetera, they only go through urine and stool. We can't breathe them out. We can't sweat them out as far as we know. So this is why urine testing is so helpful because we can get an inkling of this information. So you have three estrogens, but two of the estrogens, E1 and E2, will show up on the Dutch test and their detoxification. So they go through phase one, and I always have the same analogy. It's a bathtub. And I prefer a clawfoot bathtub because I'm fancy like that. So that's the water coming into your bathtub. I can't turn off your water, but I can adjust the water. So we have pathways that your estrogen can go down. So, and they're numbered. So we have a two pathway, which is the preferred pathway. We have the four pathway, which if left unchecked can cause the DNA damage. And then we have what's called a 16 pathway, which is more estrogenic. That's phase one. Then you have to go through your drain, the water has to get drained out of your bathtub. That's phase two. Phase two can come in a couple of different options. We have methylation, as you mentioned, and that is shown on the Dutch test. And then we have other asians. And by asians, I mean we have sulfation. We have glutathione conjugation. We have glucuronidation. I would not have named them any of these names, but here's where we're at. And we can get an idea of this on the Dutch test as well. And then after you go through the group of asians, then you get excreted. So you go through urine, or you go through, you know, the stool. And what's really great is that on the Dutch, I can look at this and say, oh, it looks like you're going through the pathway I prefer, which is the two pathway. So your water in your bathtub is the right water. I can see if your drain is open. So I can see your methylation. I can get an idea for sulfation, glucuronidation. And then of course, you know, do you have kidney issues? That will tell me phase three, urination, hydration, things like that. So many asians. So if you're going down the four pathway, which I mentioned is the one that potentially causes DNA damage, what happens is the four pathway itself, if your estrogen forms the molecule, that's called four OH, if it forms four OH, four OH itself is not the problem. Four OH is a problem if it keeps going down the naughty pathway. It forms something called a quinone with a Q. Again, I didn't name these. And the quinone can basically potentially cause a hole in your DNA. A hole in your DNA is not a problem. But if you have a lot of holes, then that can be a problem. It's just like AAA. If you blow a tire, AAA comes and fixes it. You have AAA for your DNA. You've got a DNA hole, your DNA AAA shows up and says, I got you, let me fix you. The problem is, if everybody on the road blows a tire, we don't have that much AAA, and then it gets sloppy. And then we get wheels that are tires that are put on that aren't that great. And then they fall off again. And we have accidents. It's the same in your body. If you have a lot of holes and not that much, many DNA AAAs to come around, then it's going to get sloppy. The risk for cancer goes up, and that's where we can form cancer. We know this in the research on what's called a polyaromatic hydrocarbon, which is essentially an environmental, naughty little environmental toxicant. That polyaromatic hydrocarbon also goes down the same four pathway. And if it becomes a quinone, and if it causes holes in your DNA, we know it increases the risk of cancer. Well, guess what? Estrogen can also go down this pathway. It can form that quinone. It can form holes in the DNA. So estrogen is not the problem at all. It's just if you favor this particular pathway, I don't want holes in your DNA, and I want to make sure you have enough little AAAs to show up and do its job. So I can see this on the Dutch test and go, oh, okay, you're on estrogen, but you also favor this pathway. Estrogen is not the problem. I need to get you off this pathway. Yeah, it's interesting. For full disclosure, the first time I did HRT, this position has never been a guest on the podcast, so I'm just preface this. And so I went the route that he recommended, which was injectable testosterone and estrogen. I don't recommend this for anybody. And I had been able to look at Dutch tests over the past 10 years and always predominantly down that 2OH beneficial pathway. All of a sudden, I pushed almost all of my estrogen down the 4OH along this injectable form. And so I was like, yet another reason that this was not the right option for me personally. And subsequent Dutches demonstrated that I was again back to the 2OH. So sometimes it can be a medication that you're taking. It can be the form of HRT that you're taking. What are some of the other contributors that you saw clinically while working for the Dutch that were pushing women down that non-beneficial pathway? Genetics. So that pathway is what's called a CYP, 1B1 pathway. CYP stands for cytochrome P450, which basically just means it's an enzyme that's part of your phase one detoxification. We're only talking about phase one here. Genetically, if you are boring with a fast 1B1 pathway, you're going to favor that pathway. Doesn't mean you're doomed. Doesn't mean there aren't anything you can do. We can talk about that. The other thing I tend to see is, again, if you are exposed to a lot of air pollutants, toxicants, polyuremajorachydrocarbons, then you're going to naturally upregulate that pathway. The reason is your body is like, you, let's get rid of this. I'm going to upregulate pathways to help you detoxify. Unfortunately, in the route of opening the floodgates to try to detoxify, this pathway also gets upregulated and now we have the increased risk for DNA damage. It's not guaranteed, but it is an increased risk. So if you are in an area with a lot of air pollutants, then I'm more concerned for you, especially if your genetics is also not great. What medications, heavy medications, anything that's taxing to the liver in general, I find over time takes a toll on all the enzymes. So a lot of alcohol use, heavy liver medication use, again, a lot of environmental toxicant use. Your liver uses a lot of nutrients, like a lot of nutrients. It uses basically a multivitamin to do its job. It needs all the B vitamins, it needs magnesium, it needs so many things. So if you're deficient in any of those things, let's say you're anemic, you don't have enough iron, you don't have enough B12, you don't have enough B6, you don't really get in a lot of magnesium, you don't need a lot of protein. So you don't have amino acids. All of these play a role in how your liver does or doesn't detoxify. Now the other kicker is that this detoxification doesn't just happen in the liver. It can happen in your tissue. You actually have phase one ability in your breast tissue. So you can process estrogen and poly aromatic hydrocarbons, these air pollutants, right there in your breast tissue. And so we want to make sure as a whole when the liver does the most of the job, the bulk of the work, but I want to make sure, like as a whole, you have all these nutrients, you're eating quality food, you're absorbing, you're not on proton pump inhibitors and medications that are going to block absorption. You don't have celiac disease and we just don't know it. We want to make sure that you're set up for success when it comes to removing all of this out of your body. I think it's so fascinating how complex the liver can be. 25% of our cardiac output goes to the liver. So I always remind people, obviously my background for a long time was in cardiology and almost always my patients had poor detoxification because they had pump problems, meaning that they didn't get adequate blood flow out of the heart or they had congestive heart failure. They almost always had poor detoxification because so much of the cardiac output is sent to the liver because it's such an important organ. That's really interesting. I'm going to interject something that I just learned yesterday, listening to a podcast with Peter Atia. Oh, in the context of thyroid and the liver, because I think it's so interesting. They were talking about, it was Peter Atia and a thyroid expert, and unfortunately I don't remember his name, but he was, I mean, it was like a two hour long podcast I learned a ton. The big takeaway that I took that was new for me was if you have hypothyroidism, which so many listeners have, I have myself, that even with thyroid replacement, your liver still is hypothyroid. There are receptors there that even with thyroid replacement will still be hypothyroid, which means that it can then lead to your body doesn't clear certain things properly. In the context of this conversation on Peter Atia's podcast, it was you just don't clear LDL particles very well. This thyroid expert was saying, who was an MD, PhD, I think, he was saying in the bigger context, we talk about liver and why the liver is so important, we forget that even the liver can be a little hypothyroid. I was like, I've never known that. I was like, I never knew that till yesterday, Carrie. It's specifically the T3 because even, and I explain this specifically around cortisol detoxification, because yes, even cortisol has to be cleared out of the body, but if you need to break down cortisol, T3 is like the master regulator to get cortisol broken down and not T4, which a lot of people are on T4 medications. They're on levothyroxin or synthroid or something, but it's in a lot of insurance companies, a lot of hospital systems won't or refuse to test free T3. They'll only do TSH. Maybe they'll do T4 or it'll be a reflex, but they surely won't test T3. That's literally what makes the cell go round. That's literally the key that's making a lot of this happen. You can have, which you know, you can have normal T3 TSH levels in your pituitary, up in your brain and back up, like cycled back up, but when out in the periphery, it's different communication. The type of communication, it's these fancy things called diodinases. They're selenium based. Again, another nutrient is very important here, selenium. The diodinase in your pituitary is different than the one out in the rest of your body. Your pituitary is sitting like a queen going, I feel great. I'm good. I have no issue. Meanwhile, your poor liver is like, hello, why diodinase is not working the way it's supposed to, or it's deactivating, and therefore I'm not getting enough T3. Like, what the heck? Absolutely. Super important. It's so interesting. We have these different ways that estrogen is broken down. Inevitably, the questions are, if I'm told that I have poor phase one and don't panic, or I have poor phase two, or I have a combination of both, let's talk about lifestyle things that we can do to support these phases and we'll eventually get to phase three because that's equally important. I was like, actually we should start with phase three. We did even get to the last part of my cloth at bathtub. So after you go through the drain, you have to go through the sewer line because you have to get it away from your house, to your apartment or condo. So phase three, the sewer line is literally the sewer line in your body. It's the kidney urination out, or it is your bile that gets put into your intestines and then you flush it out through your stool. So that's where we start. If you're not having regular bowel movements every day, if you have a lot of digestive issues, even if you remember your digestive tract starts in your mouth, so even if you're having a lot of teeth, gum, tongue issues, every time you swallow that nasty microbiome or infection or issues are going right down into your intestines. So we've got to take care of our mouth. Same goes for the kidneys. Are you hydrated? How's your kidney health? Do you urinate regularly? Are you prone to urinary tract infections? That's phase three. I have to make sure your sewer line is working because if it's clogged or unhealthy or inflamed, then your bathtub is going to overflow and ruin your bathroom and it's the same in your house. Then we go up to phase two because once your sewer line is okay, we want to make sure the drain is open or open wide enough. Phase two is again the asians, methylation, sulfation, glucuronidation. These are when we get into really helpful nutrients such as magnesium. Magnesium is required for the methylation of estrogen, which is really helpful. There's another nutrient some of us, it's called SAM, S-adenosyl methionine. Many of us know it as the supplement known as SAME. SAME is also required. It is the methyl donor to methylation. But all your B vitamins are honestly quite helpful here. Your B2, your B3, your B6, your B12, folate is helpful here, choline is helpful here. So do you eat egg yolks? That you know, choline and choline is hard for women when they get into menopause because estradiol is a big trigger for your body making its own choline. If you don't have estradiol, you will struggle in the choline department. And not only is choline important for the all your cells, it's literally in your cell wall, but it's helpful for estrogen detoxification. With sulfation and glucuronidation, we look at other the micro minerals such as, and nobody ever talks about these, but manganese and molybdemum, which are just fun to say, or trace minerals. And then we have our sulfur donors. So do you eat onions? Do you eat garlic? Do you eat the brassica family? So broccoli, kale, cauliflower. Now there's sort of one nutrient that's really, really helpful. It's called sulforaphane. Again, I didn't name any of these things. Sulforaphane comes from for the, for you foodies, for those of you who like to grow and eat and go that route, it comes from broccoli sprouts. Not a full grown broccoli, although that's very helpful, still eat your broccoli. Broccoli sprouts. So when you chew your broccoli sprouts or chop your broccoli sprouts, it will form something called sulforaphane. Sulforaphane is essentially like a gate opener. It opens a lot of pathways for phase two detoxification. I believe it's something like over 200 pathways get opened up, which is great because that's a drain. So 200 of your bathtub drains get opened up and helps you clear stuff out of your body. And sulforaphane helps both methylation and sulpation and glucuronidation. And so I like sulforaphane because when I don't travel very much that I will grow my own broccoli sprouts. And you don't eat much. It's like a table, like a pinch. It's like a generous pinch. So just eat it, put it in your smoothie, put it on your salad, drop it in a salad and soup, it on your sandwich, like it doesn't require pounds of broccoli sprouts. But you do want to make sure it's organic. That'd be ideal. So that's phase two when we're looking, how can we support that best? And what I like is that it's so nutrient focused. It's really, literally how it makes the world go round. Then we go up to phase one. Now remember, I said you start with phase three. If you are not pooping, if you have kidney issues, we have to start there. Don't jump into, I mean, feel free to eat broccoli sprouts and broccoli and kale and onions and garlic, but we have to start with the two, the phase, excuse me, the gotta poop phase three is key. Then phase two, phase one are the two, the different pathways. We have the two pathway, the four pathway and the 16 pathway. We want to favor that two pathway. So most people are aware of a product called dim dye indole methane. It comes from a product called I3C, indole three carbonyl. That comes from your Brassica family of foods, broccoli, kale, cauliflower, Brussels sprouts again. So when you eat those foods, they make they've indole three carbonyl in them, I3C. I3C will hit your stomach acid. So now you have to have healthy stomach acid. And it breaks it apart and forms something called dim and dim will direct towards the two pathway. That's its goal. Obviously, there are supplements that contain dim and you can just bypass the whole stomach acid thing, but also eat those foods. Now, what's really nice is that if you have high estrogen, higher than maybe your healthcare practitioner would like, dim as a product helps to lower estrogen out of circulation. There was a study published on, I think 2025, actually, at the time of recording, I think it was this year that it came out earlier this summer, showing that it does lower estrogen out of circulation. If you have low estrogen, if you're listening to this and you're menopausal, don't use dim. Don't use indole three carbonyl. That's not for you. Still eat the foods. The foods are not at like really high levels. We're not vilifying food here at all. The supplements are obviously very concentrated. But instead, if you're menopausal, I just move on. I said, then let's go to phase two instead in phase three. Let's do sulfurefane. Let's do broccoli sprouts. Let's do B vitamins. Let's do choline. Let's, you know, look at these other options instead of using dim. Now, it also appears, although it's only in cell studies that we can see this information going back to phase one. If somebody's like, I don't want to use dim, but what else could I use? There's two other ingredients. One is quercetin, which a lot of people use for allergies, but it also seems to decrease or maybe even block the four pathway. And then the other is resveratrol. Resveratrol is obviously talked a lot about in anti-aging. And, but again, it's only in cell studies. We don't have people studies to show this, which is why in a menopausal or low estrogen person, I'm like, let's just move on to phase two and three and support that instead. Yeah. I'm very cautious about using dim. I mean, there have been instances where in a menopausal woman or a woman who's in that late perimenopause phase, I'll say we'll do one bottle. So that's like a month and totally, you know, in that context. But I do think that there's a lot of misinformation about whether it's calcium deglucurate or dim. And I would go back to what Dr. Carey has just said, like really thinking thoughtfully about key nutrients, trace minerals, you know, really looking at diet, like that is going to be far more impactful than just taking a bunch of supplements, which does not suggest that supplements aren't, don't have a place. But it always goes back to lifestyle. Well, I'll even mention creatine because obviously I know you're a huge creatine fan. When I talk about that phase two, the phase two, as I said, uses a lot of magnesium and it uses a lot of CME. So phase two detoxification is a huge process. It's not just estrogen, we have to go through phase two. And basically anything you breathe, eat, drink, swallow, everything has to go through detoxification. Well, it turns out the creation of creatine in your body, because you make it naturally, well, you should, the creation of creatine uses a lot of these resources. It's a heavy user. It's skewed much more towards creatine than any of the other things you methylate in your body. So it turns out it's, if you give creatine to somebody, if you're supplementing, you know, naturally, as a woman, if you're working out or whatever, that it takes the pressure off of stealing away all these resources so that the other pathways can do their job. The creatine people and the choline people, I have two research papers where they, the review articles, where they kind of like argue with each other, because the choline people think choline takes up the majority of the resources, not creatine, but either way, they're like number one and number two. So I'm like, if you're taking creatine, because you listen to Cynthia and you're, you know, making sure you get it every day, know that it is indirectly, absolutely helping your detoxification as well. I love that. And for listeners, creatine plus has both choline and creatine in it. And as I always say, learning new things is certainly a good thing. Now, I think that the estrogen piece is so fascinating with the Dutch. I would say the other thing that I find really valuable is being able to look at cortisol and DHEA over the course of 24 hours. And so let's talk about the cortisol rhythms, what you feel is most helpful when we're looking at saliva and dry urine in terms of, you mentioned with blood, it's like a snapshot. Like what is your cortisol at 8am in the morning? That's what it tells you versus, you know, saliva and dry urine can allow you to see that distribution over the course of an entire day. Because nobody wants to get their blood drawn four or five times a day. That sounds awful. So then saliva came out. Now, so blood tells you total cortisol. And by total, I mean it's your free cortisol, let your cortisol bound up because hormones are like children, they can't really be unattended at any time. So your cortisol is on a little bus or a little Uber and it's being driven through your system. So, but there's a tiny percent that's free. So total cortisol is like what's on a bus or in an Uber and then what's free and available. Then saliva came out and saliva said, well, we can tell you what's free and active because free is really what does the job and binds to receptors and does the thing. So they said we can do free and we can do it multiple times in the day because all you do is spit in a tube or suck on a cotton swab. It's really easy and noninvasive. So then women were like, fantastic. Now I can see my free cortisol all day long, but it still only gave a piece of the puzzle. Then came along dried urine and dried urine said, not only can we look at free cortisol through the day, we can also look at something called metabolized cortisol, which gives us an indication of can you even make cortisol in the first place? Plus it gives us other clues about things such as inflammation, obesity, insulin, thyroid. And then we get the free cortisol layered on top of it. So it's even a bigger cortisol picture when we do the dried urine. Plus, even though you can do it in saliva, you even get the DHEAS and you get melatonin. So then it becomes this really nice, what is my stress system doing? What is my hypothalamic pituitary adrenal system doing? Or basically my circadian rhythm? What's going on here? I think it's so fascinating. I mean, there's always something more to learn. What do you think about individuals that say the Dutch is not helpful in menopause? Do you feel like the Dutch is more helpful in pre-perimenopause, perimenopause, and less helpful in menopause? Do you think there's any truth to that? What are your thoughts? I absolutely ran it a lot in menopausal women because again, I wanted to know their hormones. Testosterone, where is it going? So for example, we talked about estrogen's pathways. Testosterone also goes down a pathway because if one of the testosterone's pathway, we call it the alpha pathway. And actually technically, it's the five alpha pathway. And if the five alpha pathways are upregulated, this is where women get androgenic hair loss, cystic acne on their chin, their jawline down their neck, they get hair growth in places they don't want, they get angry and irritable on top of their already irritation and perimenopause. So it's really nice for me to look at this pathway and go, oh yeah, there it is. I can see why you're having this hair loss or chin hair or whatever it is. This happens in menopause too. Menopausal women completely complain about where's my hair going and why do I have all this chin hair. Then I can see their estrogen. I can see how low their progesterone is. I get all the information about their cortisol and melatonin because guess what? Melatonin on average starts to decline around 50 years old. And so it's nice for me to see, are you one of those people? If you're over 50, has yours already been declining or are you still doing okay? And then like I said, there's that bonus of I get to see some nutrient information. Glutathione, which is a major antioxidant, B6 markers, a B12 marker. I have an indirect, there's a gut marker on there. So I just get more information because menopausal women are generally still not feeling great. If they're in my office or your office, you know, they're there for a reason. If they feel great, they're not coming in. So when they come in and they're like, I'm having all these symptoms and I can't sleep and you know, the weight and the hair and you know, the GI and this, that and the other. And I'm like, Oh, yeah, let's do a Dutch test and we can see what's going on. If you're in your 40s and 50s and feel like your body suddenly stopped responding the way that it used to, you're not imagining it. Bloating, waking, sleep disruptions, food sensitivities and unpredictable energy are incredibly common in perimenopause and menopause. But here's what most people aren't told. 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And when mitochondrial function declines, it can show up as lower energy, slower recovery, reduced muscle strength and feeling less resilient overall. This is a normal part of aging physiology, and it's one of the reasons midlife can feel so different. And that's why I've added mytopur gummies from timeline nutrition into my daily routine. Mytopur is the only clinically proven form of urolithin A, a compound shown in human clinical trials to support mitochondrial renewal. In simple terms, it helps your cells do a better job of making energy. And when your cells have more energy, your body is able to support strength, endurance and recovery as you age. What I appreciate most about mytopur is that it's foundational, not flashy. This isn't a stimulant or a quick fix. It's a daily habit that supports how your body actually works at the cellular level. And the gummies make it easy. They're just two sugar-free gummies per day. They're vegan and cleanly formulated. They're independently tested and certified for quality. And if supporting your energy, muscle health and overall resilience as you move through perimenopause and menopause is important to you, mytopur is worth considering. You want to go to timelinenutrition.com slash Cynthia and use code Cynthia Thurlow for 20% off your order. Again, that's timeline.com slash Cynthia and use code Cynthia Thurlow for 20% off your might appear gummies. Well, and I think, you know, there's a marker on the Dutch about gut putrification. Yeah, Indikin. So let's talk about signs when you're looking like when you have your gestalt, you're talking to the patient, you've run a Dutch. What are the signs for you that point to there's some gut support that's absolutely critical? And maybe the next step is getting stool test. But what are some of the key indicators for you that not all is well in the gut? And this is why I am so excited for your book to come out because it's completely going to focus on the gut and the perimenopausal menopausal woman. But usually she's telling you, she's like, I am bloated. I have constipation or diarrhea. Maybe she is aware or suspects she has something called SIBO small intestinal bacterial overgrowth. A lot of women are very savvy to understanding what that is now. Even heartburn, food sensitivities that she didn't used to have before or food sensitivities she could get away with. And now they're much worse. Those are big ones. Indigestion, yeah, gas. I mean, just any kind of change where women are like, I didn't used to and now this is an issue. So the Dutch test is not a stool test. It's not a poop and a cup for science test. But that Indikin marker is definitely, as you said, it's a great word, putrification. So when women start to say, like everything south is going wrong, and I see that Indikin marker starting to climb or be outright elevated, I'm like, ooh, we probably should do a stool test. Like now the changes in your hormones are happening. I will add, when you're inflamed, your GI tract is inflamed, gas and bloating constipation, the whole thing. I can see issues with estrogen. I can see issues with cortisol. You know, the system works as a symphony. And sometimes the symphony is in tune and sometimes the symphony is not in tune. So if the GI tract is completely off, of course, your hormones and cortisol are probably not going to be that great either. And so I can look back and go, you know, it turns out I bet all this inflammation is impacting the way you do or don't make cortisol. It's making, it's affecting your estrogen and how you get rid of it. But guess what? All your hormones go through the GI tract also, testosterone, progesterone, cortisol. It can all come through the GI tract. So maybe they're not getting eliminated like they should. And so it all just ties together. Yeah, it can be hugely helpful, especially when you're looking at a bigger picture and what could be going on. Can you walk me through a real world example of a symptom that the Dutch for you clinically helped clarify? One that maybe like the blood test for that hormone may not have been particularly helpful with? Yes. So this is, I like to talk about testosterone here because oddly enough, testosterone seems to be a controversial hormone for women. But we have multiple layers of hormones. So we have our main hormones. We've been talking about estradiol, cortisol, progesterone, testosterone. But then we have the different, as it goes down the pathways, it turns into other hormones. Testosterone is not immune. It also turns into other hormones. Some of the other hormones it turns into is very androgenic, meaning it's very potent. It can cause negative symptoms such as hair loss on the head, hair growth on the face or around the nipples, anger, irritation, acne, etc. So multiple times, I have had women have all the symptoms of high androgens and their testosterone is in range. They get a blood test. They're OB is like, I don't know what the problem is, your testosterone looks great. We run a Dutch test and it does look great. But it's the next layer down. That's the issue. So it's like this sneaker, like an onion, like we've peeled back the layer and like, there it is. There's the issue. And I have seen this too, where women will say with progesterone as an example. So progesterone, when it breaks down, it breaks down into a lot of different other hormones. We talk a lot about how progesterone when we swallow it is a pill is very calming. It's soothing, it's relaxing, it helps us sleep. Well, the reason for that is it forms what's called a metabolite, and it's an alpha metabolite. It's called allopregnant alone, A-L-L-O. Now we make other metabolites a progesterone, but that's a main one. And that allo goes to the brain and is calming, it's soothing, relaxing, it helps activate our calming receptor called GABA. But we have another metabolite, a progesterone, and it's a beta, not an alpha, it's a beta. And honestly, in the human body, we make way more beta than we make alpha. So sometimes women are like, my doctor put me on 100 milligrams of prometrium. I thought it was going to be calming, I thought it was going to be soothing, and I don't feel that. I'm not noticing that. What do you think? And interestingly, on the Dutch test, because I can see the alpha and beta, if somebody is a much higher beta person, I know right away that they're going to need more progesterone than somebody else. If somebody is an alpha person, they're not going to need as much progesterone, because their alpha is already high, it's going to calm their brain, and they're going to feel really good. And so even from a dosing perspective, I can look at the Dutch result and go, oh, you're very beta, which means it's not going to be calming. It won't be aggravating, but it just won't give you the desired outcome of calm and relax. You'll probably need 200 milligrams. In fact, you might even be 300 milligrams, 100 is just not going to cut it. And to get just these little nuances of information, I mean, I could just go on and on that I can see on a Dutch test, even thyroid issues. Thyroid issues will show up in the cortisol pattern. So as I said, free T3 from thyroid helps cortisol break down. Well, the breakdown cortisol marker is called metabolized cortisol. And if it's really low, the first thing I think is like, ooh, we need to do a free T3 on a blood work if we haven't done it already. Because eight times out of 10, it's not, it's suboptimal. What percentage of women that you interacted with tended to be more beta dominant for progesterone breakdown versus alpha? I would say, oh gosh, I guess I'm asking, it's not uncommon. It's not uncommon. Oh gosh, no, no, it's not uncommon. And because beta is the more predominant metabolite, so all the at home tests for progesterone, we of course, we have a plethora on the market now, they're predominantly looking at the beta side because it's the most abundant. But some women are very, very, very, very alpha. And so they'll run an at home progesterone test that fertility or perimenopause or whatever. And they're like, man, this is so weird, my progesterone keeps showing up super low. And I'm like, I wonder if you're low or I wonder if you're just not a beta person, you're an alpha person. And that's not going to show up on that test. So even this gets nuanced in how we test hormones through urine. Yeah, I'm wondering like for the PCOS population, who probably already have a luteal phase defect, I'm curious, because if I recall years and years and years ago, when I did those tests, my progesterone was always low. So maybe I am, and I don't recall from my last Dutch test, maybe explain one time. Off run beta. Your biolograms tonight of progesterones, a sustained release progesterone. Okay, I'm going to do some rapid fire questions that I put some thought into that I thought would be interesting. One hormone you think every woman in perimenopause should understand and why? Now in the stay in age estrogen, in the stay in age estrogen, because still to this day, if I post about estrogen, I get the comments of that's a horrible hormone, it causes cancer. I wish I never had estrogen. I want to detox it all out of my body. And there's still so much misunderstanding that the next generations will have a better love for estrogen. But right now, it's a hard one for people to understand. Yeah, so much of the Goldilocks effect. Cortisol, Frend or faux and menopause. Well, it's the Goldilocks effect. So we need cortisol. Cortisol is super important for the body. We would die without it. But obviously too much or too little causes problems. Yeah. Melatonin rhythms, are they real inside or overhyped? Real insight. Melatonin is my most favorite hormone. It's my favorite antioxidant, even more so than glutathione. We make it in every single mitochondria because it is such an important antioxidant. We make it in our brain and our pineal gland for circadian rhythm. Melatonin does really good things for the body. Absolutely. Most underutilized info that healthcare prescribers miss in hormone testing. Timing. They miss timing. You see your OB or your primary care, a GP on Tuesday at two o'clock and that's when you get your hormones tested. There's no thought or care or anything around where you're in your cycle. Do you get a cycle? Are you regular? Do you know if you ovulate? And that is really important. Are you on the pill? Do you have an IUD? All these questions just sort of get overlooked and it's unfortunate. What's a normal, I mean air quotes, normal lab range that often misleads women about their symptoms? Ferritin, which we didn't even talk about. Ferritin is an iron storage marker, but the ferritin range is huge. It's massive. It used to be like 10 to 217. And very recently, the Gastroenterological Association said, oh, you know what? We should probably raise that. Intend seems really low, but labs haven't caught on yet. So a whole lot of people are still at the ferritin of 11 or 12 or 10. They're like, oh, you're normal. They feel terrible because low ferritin means likely often low iron or iron not being utilized. And then they're out of breath and they're pale and they're losing hair and they're so tired and iron helps. It's required for phase one detoxification, all of it. Yeah. So important. So important. Extrigen dominance, meaning what it actually, like I realize I shat that first, but then people use that term. I know some people in the traditional allopathic world hate that. Yeah. And like, it's a relative imbalance. What we're talking about is a relative imbalance of estradiol to progesterone. Why is it important? In our luteal phase, the second half, we make progesterone. We should make like the biggest mountain you've ever seen amount of progesterone and then a bunny hill of estrogen. That's the difference between the two. But if you don't make mountains of progesterone, if you just make a bunny hill, now you have two bunny hills, that's a ratio that's off in favor of estrogen. Or if you don't make any progesterone at all, you don't ovulate, but you still have a lot of estrogen. Again, the ratio is off. So no matter what, the ratio skews towards estrogen in a way towards progesterone. So what we called it is exactly what you said. Estrogen dominance relative to progesterone, usually we're talking about the luteal phase. That's a long mouthful to say. So we shortened it to estrogen dominance. Some people call it progesterone deficiency. It's very real because it's a very real relative ratio between the two in that part of your cycle. Is there anything about the Dutch that you feel like we haven't touched on that you feel is really important for listeners to understand about the validity and the applicability of this test? The great thing is on their website, a lot of their education is free and a lot of all their research is right there and available, but they actually have gone to the effort and the finances to put the Dutch test through peer reviewed research to show the accuracy of it. Now, is a blood test and a Dutch result the exact same thing? No, it's blood to urine, but they correlate really well. So the correlation on average for most people is really pretty fantastic and they have the research to show that. And I appreciate that because there are a lot of labs out there who are not putting in to any type of research. They're just telling you it's legit and good or they're using the Dutch's research to say, see, urine is legit, but they're not testing their own the way they do things in their lab. So I appreciate that they have actually gone to a lot of effort and other companies, other research has used the Dutch as part of their, to verify cycle rhythm or to verify ovulation. Like they'll use Dutch has been used in other research as well. And you can't say that about very many other research companies, a few, but I mean, lab test companies, a few, but not many. So when practitioners push back and say it's not legitimate, there's no research, I'm like, oh, go to their website, they have an entire page dedicated to it. It's been published in many times. Menopause, which we all revere, is a pretty great journal. Absolutely. Well, I can't thank you enough. I can't think of anyone else I would have wanted to interview, to talk about limitations to testing and why timing is so important. If people have been living underneath the rock and don't know you, please let them know how to connect with you outside of this podcast, how to listen to your amazing podcast or learn more about your work. Absolutely. I actually even have an entire write up on estrogen detox because I know that's super confusing for people. So if they go to drcarryjones.com slash estrogen detox, you can learn all about it for free and it'll help summarize everything. I am on Instagram at drcarryjones. And my amazing podcast of which of course I have had Cynthia on. It was one of our most popular in 2025 is Hello Hormones with Dr. Carrey Jones. Oh, thank you again, my friend. Thank you. 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