BONUS: Breaking Down Perimenopause, Menopause and Women's Health with Marcelle Pick

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. this is bonus monday your most downloaded favorite podcast i love that this community runs the gamut from medical professionals research scientists science writers personal trainers and more these are your favorite most loved podcasts of the last five years i could not be more proud of the diversification of guests that appeal to all of you. Thanks for tuning in. Today, the honor of connecting with a good friend and nurse practitioner, Marcel Pick. She's passionate about transforming the way women experience healthcare through an integrative approach. She has successfully treated thousands of women through her unique approach to wellness. She's a faculty member at the Institute of Functional Medicine and has served is a medical advisor to Healthy Living Magazine, has written countless articles and multiple books, including Is It Me or My Hormones? Today, we dove deep into her background and the impact of the Women's Health Initiative. We spoke about the limitations of a traditional allopathic model as it pertains to hormones, common misconceptions about adrenal health and perimenopause and menopause, the role of adverse childhood events and adrenal health, the impact of lifestyle on our sex hormones, fibroids, endometriosis, PMS, PMDD, contraception for perimenopause, the impact of endocrine disruptors, as well as mold and mycotoxin, ways to think about hormone replacement therapy, as well as ways to address intimacy and low libido. I hope you will love this conversation with Marcel as much as I did. I really love connecting with other nurses and nurse practitioners, and I know you'll find this information to be invaluable. Well, Marcel, it is such an honor to have you on today. I've been so excited for our conversation. So am I. I've wanted to do this for a long time with you. So I'm here. Absolutely. Let listeners know a bit about your background because I really think of you as a pioneer in the women's health nurse practitioner space. And as we were talking about before we started to record, I've generally, genuinely had trouble bringing NPs on as experts. And so I want to kind of change the narrative about how nurse practitioners can offer just incredible level of care. And you've really been able to kind of witness what's happened over the last 20, 25 years, you know, with the women's health initiative, how that impacted bioidentical and even hormonal replacement therapies, the net impact on women and women's care. And now we're coming back around and feeling grateful and perhaps hopeful that the narrative is changing again. Yeah. Yeah. So it's interesting. When I went to graduate school, I went to a combined program with Harvard Men and Boston College, and I was very intentional about that because I knew if I had the creds, no one could say anything to me when I really was starting as a nurse practitioner back when very few nurse practitioners were identified. So in 1985, we actually started Women to Women, and I actually started it two years before. That's why I kept the name. And two of the physicians and a nurse practitioner joined the practice, and we were the first all-women's practice in the country. So we had to get attorneys from Colorado because we had different licenses to make sure that we can kind of be equal partners. It was really quite the affair. And we bought this huge Victorian home. I went into debt numbers. I could hardly even speak at that time, but we all really knew back then that we wanted to make a difference and have women become their own midwives to know about their body so well that they could start having a voice and ask questions. So, you know, I didn't think about it at the time. I was terrified. I was a baby. I was young, just got married and was like, Oh my God, what am I doing? But we did a great job and we really grew very, very quickly. I bet. Well, and I think it's interesting that the kind of traditional prevailing allopathic medical model is that women are these kind of silent conduits to contraception and pregnancy and the postpartum period. And God forbid, we talk about aging women, and perimenopause and menopause. And I think for those of us that have navigated both as clinicians and also as patients ourselves, we just realize there are glaring disparities in the way that kind of conventional Western medicine, the model really looks at wellness and healthcare and preventative care as it pertains specifically to women's health. What was so funny when we started the practice is all of the docs around that were mostly all men practices in my area, there were no all women. They said to us, you're never going to be busy. No one's going to want to go to all women. And the people that put our shelves in, because at the time we had paper charts, they had to keep coming back because we were so busy so fast. So it was really interesting. And then we got actually a national reputation at the time because of who we were and what was going on with Chris Northrup's book and so on. So it was hysterical. And I wanted to kind of jump from the rooftops and go, huh. We were right. You were wrong, but we didn't do that. We just really enjoyed how many people were able to help. Yeah. And that's really what it comes down to. I think it's certainly as a middle-aged woman myself, I definitely look for a type of medical provider. And certainly when it comes to preventative care, GYN care, because the years of me having children are many years behind me, it's really important for me to feel very comfortable with the provider I'm working with. And there's just a degree of camaraderie with other women. They understand we have the same parts. We've been through very similar circumstances in many ways. And so I am not at all surprised that you all had such incredible success. Now, in terms of that trajectory, so you preceded the Women's Health Initiative. You were practicing before then. What was that like as a practitioner to see that the results from the Women's Health Initiative or the WHI, as it's more commonly referred to, the downtrod effect of how that impacted the care that you were delivering and people's comfort talking about hormonal replacement therapy, women asking for hormonal replacement therapy, I would imagine that was really impactful. Oh, absolutely. What was so interesting though, is that years before we were already using bioidentical hormones. So I didn't feel that many of the pieces to the puzzle, when you actually looked at the study itself impacted my patient population. The part was difficult is that people were scared. And every single provider around us was saying, absolutely not. It's dangerous. You shouldn't be doing it. But mind you, we opened at 85. So we had years of experience behind us and we were using what was available at the time. As time went on, I started using more trokees and melts. and now we have patches too. So I was using different combinations, including creams and using compounding pharmacies. There are many more compounding pharmacies now than they were back in the day. It was Women's International Pharmacy. I think it was the only one that people were using. And then we looked at the Women's Health Initiative and the unfortunate part about that is that even to this day, a lot of people are not understanding that many of the women that were in the study were actually 10 years post-menopause. And when you have those receptors that are quiet, and then we rev them back up, there's going to be a very different kind of set of circumstances that come out and adverse results than if you're putting somebody that's got hormones still present to some degree, and you're putting them on hormones. But our culture still has not adapted that concept. And if we look at all the research now, and there is tons of it, because as I teach for the Institute of Functional Medicine, the hormone module, We're always every single year updating our data on what do we know about hormones. And there are so many articles now and published double blind studies showing that what we thought was true of all women in 2001 is not true of menopausal women. So that's refreshing and wonderful to know. However, the general public hasn't pulled that together yet. No. And it's interesting. My mom was here for Christmas and, you know, as you can imagine, she's a retired nurse and she was an executive before she retired. And we had a conversation about who I was interviewing today. And I mentioned, you know, Marcel is a friend and an NP. And I said, you know, she was really a pioneer in women's health. And we've had conversations about hormone replacement therapy. And my mom said, your legacy is to ensure that the tides shift. you said, my sister. So I have five ants in totality. All of them were either put on hormones and taken off or just never were on hormones. And they talk very openly about, you know, the degree of osteoporosis and the vaginal atrophy. And, you know, in some instances, chronic inflammation, oxidative stress. So they're insulin resistant and you can be thin and still be insulin resistant. And just the recognition that they understand that their cognitive status, you know, their neurocognitive status has changed significantly. And they talk openly about this. So I'm not sharing anything that they would be uncomfortable sharing, but it makes me realize why it's even more important that we get good information out there so that women don't fear taking hormones, if that's the right choice for them. And that clinicians don't fear prescribing hormones for appropriate patients. Yeah. And I think that's where the question comes in is, you know, do they have a family history of breast cancer, you know, what are their cardiovascular risk factors? And then you really look at, you know, are they a green light, yellow light, or red light, and that you make a decision together. And every year when I would see patients in my practice, we would be going over the symptoms and I would have them sign a consent. And most of the time people would say, don't you ever take me off these. Don't you ever. And because they, you know, at times I would say, look, let's just take a little break and see how you feel. Then you can make a decision based on what you want to do. And sure enough, most of them came back and said, never again. And that's the hard, hard part for me about all these women that were on higher doses than I ever put people on of bio, you know, not bioidentical hormones, Primpro, and they were taken off cold turkey and they suffered so badly. They really, really did. And we didn't have any ability, you know, to be, they did my practice, but very few people would say, look, let's do something a little different and kind of hold it back down again. Cause when I did blood work on these women, their numbers were sky high. I mean, we're talking sky high because their dosages were way out of sync. So you take those women up hormones. They couldn't think clearly. They were moody. They were irritable. It was horrible for them. So no, I'm definitely going to always be on the rampage of saying, look, they need to have choices. Let's talk about what's really good for them. Yeah. And I think that's really important is this whole patient empowerment. Like you're, you know, thinking back to, you know, the years when myself and all my friends were put on oral contraceptives to help control our menstrual cycles, we were never given fully informed consent. We didn't really understand what low estradiol levels would potentially do to our bones. We didn't fully understand what that could do. at that low of a state of hormones for such a long period of time to control our symptoms. For the same reason, we have to fully inform all of our patients when we're working with them to really understand if you choose not to take hormones, that's okay, but understand that these are the potential side effects that can come from that. Now, when we're looking at kind of a traditional, and both of us are both dual trained, traditional allopathic medicine, what are some of the limitations of the traditional view of perimenopause and menopause from the lens of that traditional kind of trajectory. We're really focusing on symptoms as opposed to root cause management, which really does us a tremendous disservice as women. So one of the things that I love about functional medicine is we're trying to look at the cause of the cause. If somebody is having hot flashes, they're not always going to be for the same reason. And when I see somebody coming into my office and they're having perimenopausal symptoms, I'm on high alert as how do I get this woman back to feeling normal? You know, I don't feel like myself. I feel like somebody else has invaded my body. I've gained all this weight. I can't think clearly. I'm crying all the time. I can't sleep and I'm having sweats. Or the biggest thing I'm seeing now is anxiety. You know, anxiety that's coming from the bottom of their soul. So for me, I need to try to figure out where that's coming from. And, you know, around perimenopause, what I say to women is, look, perimenopause is this amazing journey of self-discovery. Who am I? What am I going to be for the second half of my life? And how do I get there? And it's not with an antidepressant. It's really more self-reflection. A lot of women have a lot of issues that they hadn't thought about for years that have been under the carpet that kind of come to the surface. And it's like, okay, so let's kind of look at that. And what can I do also to look at your adrenal function? What do I need to do to help with sleep? Why are you not sleeping? And the anxiety may be coming from high cortisol production, because in perimenopause, estrogen is an anti-inflammatory. It kind of keeps everything at bay a little bit. And then when you're hitting perimenopause and menopause, it's not there anymore. It's kind of like, oh my God, what happened to me? So it's truly doing what you said is let's kind of really unpack what created the problem and let's treat that instead of treating with an antidepressant. Sure, it'll take the symptoms away for a bit. That's not the root cause of what's going on. If you're a woman in midlife or beyond, you'll probably notice those changes in energy, strength, and recovery just don't feel like they used to. 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But most importantly, I give you practical, realistic strategies you can start using right away without extreme diets or complicated protocols. You'll learn why the same diet that worked in your thirties may not work now, how your gut influences hot flashes, mood, and weight, the truth about fiber, protein, and blood sugar in midlife, and the daily habits that help your body feel safe, stable, and resilient again. If you're tired of blaming yourself for changes that are actually biological, this book will help you understand what's really happening and what to do about it. You can pre-order the menopause gut wherever books are sold. And when you do be sure to check out the special pre-order bonuses I've put together for you. Again, you can go to www. Cynthia Thurlow.com. You'll click on the banner. It'll take you to multiple options for where you can order the menopause gut in presale. Yeah. And it's interesting, even my own perspectives as a perimenopausal woman, I just happened to have my menstrual cycle. My first day, my menstrual cycle when I was seeing annual for my annual exam with my GYN. And she was like, oh my gosh, your, your period is so heavy. And I said, well, I've been telling you that I've been dealing with this. And she's like, okay, well, we'll fix this. We're going to put you on oral contraceptives. If that isn't what you're interested in, we'll give you an IUD, you know, next step up would be an ablation. And you know what, you're done having kids. So let's just do a hysterectomy. And I was like, timeout. I don't want that is, I don't want any of the above, you know, one gave me migraines. There's no way I'm having an IUD. I don't want a surgical procedure if I don't absolutely need it. And so that's kind of the prevailing. I feel like that's my perception. That's the prevailing way of dealing with perimenopause is, oh, these things are going to fix the problem. And they really don't fix the problem. And what I find really interesting is if we talk about some of the physiologic changes that are occurring in our bodies, as we're transitioning into perimenopause, the 10 to 15 years preceding menopause, you know, it can be precipitated by suddenly you're not sleeping well, or you have more anxiety or depression or your cycles get very heavy, but not realizing that it's these hormonal changes that are driving a lot of the symptoms we're experiencing. If we don't address that, that can be problematic. In your book, you talk a lot about some of the labs, you know, kind of the traditional allopathic labs are really, there aren't enough labs done often enough to be able to get a sense for what's going on. So do you have, if you come in with a typical perimenopause case, not sleeping, more anxiety. What are some of the labs, like less common labs per se, maybe from the lens of the functional perspective that you'll be looking at in addition to things like the Dutch to get a sense for what's really going on with this female? Yeah, great question. So as I mentioned in my book, adrenals trump hormones and adrenals trump thyroid. So I'm always going to be doing an evaluation of cortisol production, doing a saliva profile to look at the level when they wake up, 30 minutes later, noon, afternoon, and the evening. And this is my bias. I like another company besides Dutch for that. I think they're a little bit more specific to the symptoms that I see in my patients. And in addition to that, I'm going to be a full panel of thyroid testing because that's when we see most women have thyroid issues. So I'm going to do a TSH, free T3, free T4, total T3, thyroid antibodies, and reverse T3. And the reason that's so important is because when people have an enormous amount of stress, we'll do normally a TSH and oftentimes in a T4, but what they're not looking at is how much active thyroid do they have? How much active T3 do they have? And when they've had a lot of stress for many different reasons, because there's a lot going on in the world right now, we have high amounts of reverse T3. So the body's behaving as though it doesn't have enough thyroid. So I always do that as well. And then I'm going to do the standard test, but I'm also going to look to see what their hormonal levels are, depending upon what they want to do. If they say, Marcel, I don't want to intervene with any hormones, then I might not do that testing. But most are curious, you know, what's going on in my body? And the conventional approach is, your hormones are going up and down all day. It doesn't matter. Well, that's not completely true. And that is if we're specific about when we do hormone testing, like on day seven for estrogen levels, estradiol and estriol, I don't do estrone generally. And then on day about 22 of a cycle, if they're still having cycles, I'm going to be looking at progesterone levels then. DHEAS doesn't matter. You know, FSH, LH, I might do around day three if I'm wondering how, you know, where their numbers are for menopause. So I'm going to be more specific to that patient as to what they're wanting. And then we're going to really start to unravel things. But here's the other thing that's interesting. And that is I'm going to do a gut evaluation because the gut is so important, certainly for serotonin production, two thirds of it, you know, serotonin is produced in the gut. So if they're stressed out, that's going to affect serotonin, which is going to have an impact on brain function and round and round the circle goes. And then also the food that they're eating and how much stress do they have there in their lives on a scale of one to 10. And all of those seem to really have a kind of a symphony in perimenopause. It's kind of this climactic, you know, time in which so much happens and it's really unraveling that. And I've used progesterone for years and years and years and years instead of oral contraceptives. And here's something really interesting. And that is that we know now that the microbiome of the uterus is impacted with regards to heavy menses. We know that certainly the food that we eat can actually impact that inflammatory cascade too, but we know that the vagina and the uterus has a microbiome. So as we shift that microbiome, it also very much contributes to that menstrual shedding and that menstrual bleeding, the heavy periods as well. That's pretty new information and pretty exciting. We can actually predict from the microbiome of the uterus, if somebody is going to have cramps and we can predict, this is going to really sound crazy, from the microbiome of the vagina, if they have freckles or not. They did an enormous study kind of looking at how can we really understand things. Now that can shift obviously, as we change the microbiome as well. Those kinds of interesting stuff that's coming down the pike. Well, and it's interesting because very likely when you and I initially trained, the gut microbiome seemed a way far off, but now we talk about the oral microbiome, the gut, the vagina, the uterus. I mean, it's amazing to understand that there is all these microbial products that go on, you know, viruses, bacteria that are designed to be there, but differentiating that it can lead to more inflammation, less inflammation, more likelihood to skin changes. The freckle thing is fascinating. Isn't that fascinating? I thought it was just like, are you kidding me? someone paid for a study to figure that out, which is fascinating. But when we're talking about heavy menstrual cycle, so obviously not unique per se to perimenopausal women, but women that are prone to fibroids or endometriosis, what are some of the unique ways that you look at these problems? Got a lot of questions about this because kind of the standard kind of medical care is fibroids get, they either get a myomectomy or they'll go in and they'll get oral contraceptives. And endometriosis can be very extensive. It can be mild, it'd be very extensive. And for many of these women, there's also from, it's been my clinical experience, a lot of emotional component to it, which is probably completely related to the fact that they're dealing with some chronic pain issues. Well, it's kind of hard to know the chicken or the egg in that case. What I find is when I was in practice, you know, for many, many years, 37 years, that so many women that had endo were high achievers, you know, even though that's not a standard thing and expected a lot of them cells. When I kind of looked back at their story, they oftentimes had a fair amount of, I don't know if I'd call it trauma. I think that's a heavy word in prior to that adolescent time. And we're starting to understand a little bit more about endo that may be an autoimmune reaction, in which case when you have those endometrial cells that are sloughing back into the abdomen, the body doesn't have the ability to actually phagocytose those cells, which may be part of the immune system. We also know that women that have endo almost always, always have candida. And that gets back to the gut microbiome. I've never seen somebody to date that I had that I treated for endo that didn't have overgrowth of candida. And we also know that there's a high number of those women that have high dioxin levels and the association between endo and a high dioxin is also present. So when you're working with someone or me, I'm going to be looking at all those pieces to the equation so I can really see if I can help them look at what for them is that contributing factor. And I had such an interesting case many years ago, I actually wrote her up. It was a Women's World magazine, you know, interviewed me for her. At the time I saw her, she was 32 and she had seven years of IVFs. She had one child and she was getting ready to have a hysterectomy for endometriosis because she had excruciating pain and she couldn't be with her son. And I said, okay, you know, but you got to cancel a hist by next week. I can't, you know, what can I do? So we, indeed, we did the whole evaluation. We looked at her gut. We looked at adrenals, food sensitivity. She did have yeast and a parasite. We treated all that. And I also had her go to Al-Anon because she had a huge family history of alcoholism. And I said to her, once she came back to see me, because her score of how many symptoms she had so much, much better, and she wasn't having pain anymore. And she was all happy. And she, I said, you really should think about birth control. And she's like, you know, give me a break. I've got a half an ovary on one side and a block tube on the other, because they took one of the tubes out and she goes, no way she got pregnant. So she, she had a baby and that's why we wrote her up in, in the magazine because she did all the pieces and really started to understand the connections. So for me, it wasn't just about, you know, yes, it's emotional, horrible when you have endo, but what created some of that to begin with. And that's where I always go. If you don't deal with your story, your story will deal with you is kind of a metaphor I use a lot. So it was a combination of all that. And, you know, it's not the first time I saw that in my practice, I actually saw it quite often. So it's looking at all the pieces to the puzzle for her, what contributed to that. So the good news is we can do something about it. The bad news is the traditional way of dealing with it doesn't always work, but it doesn't always help the pain or cramps. Yeah. And I'm so grateful that she met you and avoided having a hysterectomy. I mean, that's such a severe surgery to have at such a young age, but I do hear over and over and over again, people will send us messages. They'll say, what are my options? And I'm like, well, we're not your treating doctor or nurse practitioner, but you know, here's some resources, discuss them with your healthcare practitioner. What about for women that have debilitating PMS or PMDD, which is the really severe form of PMS that I think for a lot of practitioners, they think of, oh, this is just what every woman goes through. And the one thing I want to interject was I only had PMS when I was taking oral contraceptives. When I wasn't taking oral contraceptives, I had no PMS. So it's like how many thousands and thousands of women every month think they have debilitating PMS. And it's actually a by-product of the contraceptives that they're taking. It certainly can be. And my experience is that many times because the progesterone that's in the pill is not the same as we produce, which is called progesterone. And many times, if somebody is already progesterone deficient, getting them on the pill makes the progesterone deficiency worse. So the symptoms are pretty intense. So when I had people on birth control pills, I'd always use progesterone cream, days seven through 21 of the pill packet, or if they were using a ring, I would kind of shift it as well in the same format. And my experience is, interestingly enough, I mean, back in the day, in 1983, we only had progesterone suppositories to treat women with, but I was using them back then through a compounding pharmacy with amazing results for PMS and PMDD as well. But there were times that I would put, I would use a higher dosage. I mean, there were times for some people, I had them on 400 milligrams a day and I changed it from day seven. You know, then I increased the dose on 10 and increased the dose on 14. And again, I was monitoring the levels very carefully because, you know, progesterone can actually increase estrogen levels. But the results were night and day. I mean, what everybody would say to me is that black cloud is gone. The veil's gone. I feel back to normal. And for many of those women, they would say, I've got one good week a month. I can't live this way anymore. And, you know, for me, it was devastating for these people. So it was really nice to be able to give them an option back in the day, even though I was kind of herald in the community as, Oh my God, you know, she's really kind of gone out to lunch. The irony is that now as many of the things we recommended back then or in standard of care, I mean, I was using probiotics back then, and now it's standard of care, even most kind of, you know, gastroenterology offices are using it. So it's kind of interesting. If you follow the literature with regards to what they're doing in PhD clinics, that's where you really gather the data. It takes a lot longer for the double blind studies to come out, but they're usually medicine oriented anyway. Yeah. It's really interesting because you were way ahead of the curve and a lot of what you're sharing now makes so much sense. As a woman who had thin phenotype PCOS. It makes complete sense why when I was taking oral contraceptives with a luteal phase defect where my progesterone levels endogenously were too low, why it made the PMS, why it really magnified all of that Now we got a lot of questions about what are your traditional recommendations Again generalization for women in perimenopause who are done having their families but don wanna run the risk of getting pregnant prior to menopause Do you have favorite contraceptive options? What are your favorite ones that you'd like to use? You know, I did a whole presentation on that for IFM. And I think my favorite one is probably the NuvaRing. And then I always add progesterone with that as well, because you do not wanna get pregnant if you don't wanna get pregnant, period. You know, you don't want to put yourself in that position and using something like a NuvaRing and really adding to it then progesterone, but also looking at adrenal function and also at nutrition, you know, making sure that the sugar amount is down and all that kind of stuff. So you can feel your optimum. And, you know, when people have asked me, you know, the pill, you know, it's hormones and I'm thinking, you know what, I'd rather them be on that than get pregnant if they don't want to be. We need to have some ability to be able to have control. And, you know, you still want to be sexually active. if you don't want to have a tubal ligation or your partner have a vasectomy, then my favorite is probably the NuvaRing. You don't have to mess with every night. You put it in, you take it out and using it in combination with oftentimes B vitamins because they can deplete the vitamin stores and then using progesterone with it, progesterone cream with it is probably my favorite. I love that. And it's something that is respectful of the fact that women are looking for dedicated, reliable contraceptives, but also understanding that there's no shame. In fact, I am working with an NP right now who is on oral contraceptives in perimenopause and just said, listen, I can't get pregnant at this stage of the game. Like I'm just, I'm older than I would wanna be if to have another child and I just need somebody to be reliable until I go into menopause. Absolutely. Yeah, you've alluded to multiple times adrenal health and I interviewed Dr. Kyle Gillette earlier this year and he used a term I'd never heard of before but it makes complete sense, adrenal pause. So understanding that our adrenals take a little bit of a hit transitioning into middle age and the importance of understanding what our adrenal glands are doing as our ovaries are producing less progesterone would be helpful for listeners to have that reinforced because this is why we become a little less stress resilient. This is why the lifestyle piece becomes critically important in perimenopause and menopause. So, you know, again, we don't have estrogen to kind of cover things up, if you will. And it's really a great masker. And adrenal function is interesting because before menopause, 15% of our hormones are produced by our adrenal glands. Post-menopause, about 30% are. So they're having additional kind of need for production of more hormones. And if they've already been maxed out because of stress and the urine fight flight a lot. And, you know, it's interesting because when I talk to people a lot is, well, I don't really have a lot of stress. And then the question I ask is, well, how much negative self-talk do you have? Well, you know, of course it's like stress right there. Or, you know, how much stress did you have as a kid? You know, what was your, what I call ACE score, which is adverse childhood event score. And if it's right up there, then you may be having this kind of verbiage going on in your head that is contributing to cortisol being produced every situation. If you're on, you know, an over-pleaser, or if you are someone who always thinks you're wrong, or if you're someone that just doesn't have a good self-esteem, all of which gets magnified in menopause, then that's going to come up as an issue too, which is going to produce more cortisol. And the interesting thing is that cholesterol makes cortisol. So if you're on a cholesterol lowering drug, that can contribute to this whole cascade of events that go on that are not really healthy for you. So in and of itself, if we have too much requirement for cortisol, it will go to cortisol at the expense of estrogen, progesterone, testosterone, and DHEA. There's an enzyme called 1720 lyase that blocks that conversion. And what does that mean? Well, it means that we don't have as much progesterone because that's a thing that goes down first. And then it's estrogen and certainly testosterone as well. And that all contributes then to the body trying so hard to produce those hormones and it can't. and we're then more in fight flight. We have more anxiety, that sense of, you know, adrenaline going up and we can't sleep. And that's because oftentimes cortisol is up at night and we don't, you know, we've got too much cortisol production and we don't have enough melatonin sometimes as well. So it's a cascade of events that go on and I call it adrenal dysfunction. You know, you can call it adrenal pause. I mean, all those names are great. I'm not a great fan of the adrenal fatigue concept and I write that in my book because I think that's what's gotten us in trouble in the conventional world. You know, adrenal fatigue, are you serious? But it is a reality. If you look at the bell-shaped curve, most people don't have Addison's, which is too low. Most people don't have Cushing's, which is too high. They fall within the ends of those curves with very significant symptoms. And there's degrees to adrenal dysfunction as well, depending upon how long it's been going on. And our body is not meant to be in fight flight all the time. You know, thousands of years ago, we're gonna be chased by a tiger. We either got eaten or we went back and kind of life was back to normal, that isn't the case anymore with all the social media stuff, all the news, the computers, our lives, the COVID and pandemic and everything like that. So we really have to find ways ourselves to not decrease the stress per se, but to find that parasympathetic kind of pause, if you will, so that we're not on high alert all the time. And it's so true because if the last nearly three years has shown us anything, it's chronic, debilitating, sympathetic dominance, that fight or flight. If that's chronically activated, your amygdala, which is your lizard brain, will override your prefrontal cortex, which is your thinking brain. And people don't say or do things they would otherwise normally do under normal circumstances. And so it explains why fear-driven kind of mentality can impact people pretty significantly and understanding there are things we can do. That's always the message that I know you and I always want people to understand that in middle age, perimenopause and menopause, you have to do more to invite that parasympathetic, whether it's meditation, connection to nature, getting sunlight in the morning, slowing down, saying no more often. I know that's been a work in progress for me, especially coming off of a book launch, having more downtime, taking a nap, doing those kinds of things really has value beyond, you know, the perception that we want to be busy all the time. I think that rushing woman syndrome that you hear used in the vernacular is really problematic. Oh, no question about it. I mean, I think unfortunately we're also very good at multitasking. So when we're good at it and it becomes behavior and then there's, you know, perimenopause is a lot of kind of questions about things about yourself and you stay busy to maybe not deal with that too. So it gets complicated and it's being willing to kind of sit with the anxiety to some degree also to find out what is this about? What is this telling me? Because our bodies are unbelievably infinitely wise. And if we just learn to listen to some of those pieces, we can also gain such incredible information in addition to the hormones and adrenals and gut microbiome and all those pieces together. It's a network that we really need to look at to be able to help people feel better. Absolutely. And I'm glad that you brought up the ACE score. So adverse childhood events. And the more I'm looking at the research, the more I'm realizing that women or, you know, men and women, if you undergo a lot of childhood trauma, it can set you up for not only significant likelihood of developing autoimmune disorders, but also weight loss resistance. You know, the latest studies that I was looking at was showing the interrelationship of this chronic inflammation, oxidative stress, chronic stress at an early age that can really set you up for quite a bit of health problems moving forward. Yeah. And I guess the thing that I really want to reiterate here is that what's so important to know is just because you had a lot of stress as a kid does not mean you can't get over it, nor does it mean you have to go through all of the stress over and over again. It doesn't have to happen, but it is very important to recognize, you know, that if you grew up in a home in which there was a lot of anger, perhaps nothing ever happened, but there was a huge amount of anger. a lot of those women become perfectionists. That doesn't work very well in the world for us in medicine, thank God, but you know what I mean? And so all of that we carry forward until we start to understand ourselves. And it's not a bad thing, but it is a very, very important piece to kind of recognize. And one of the books, my first book that I wrote is basically on weight loss resistance. Again, I was way before my time and it's our issues are in our tissues. You know, that was the last chapter in my book, looking at what are the emotional pieces that are staying connected to us. And it really behooves us to understand it, to kind of do some self-reflection because I promise you it is directly related to heart disease, to cancer, to early retirement, to disabilities, to heart disease. I mean, it's everything. And also metastatic changes. The most recent research is astounding when it comes to that. And it is oxidative stress and stress. So I just urge people, if it is true, you know, they can go and look at the ACE score themselves and also the resiliency score and see, is it high? Okay. So now that's okay. And I do that. And I have an adrenal program, a six week program. It's the first thing I ask people is what's your ACE score. So we can kind of know where we're headed with this. Cause that's the thing I see keeping people in adrenal issues is that they're not dealing with that trauma. Yeah. And I'm so grateful that you have been laying the groundwork for doing this work. And it's interesting. I just interviewed a good friend of ours, Dr. Joan Rosenberg. And we were talking about, you know, childhood trauma and just things that we grew up in. And she said, if you have the capacity to think, you have the capacity to change. And so I just want to make sure I close that loop and offer up that even if you grew up in a less than harmonious environment as a child, you absolutely positively don't have to let that be your destiny. Now, a lot of questions came in talking about liver health detoxification, which I know for us both, we understand this complex interrelationship of, in particular, estrogen and detoxification in the body. So let's talk about that a little bit touch on liver health detoxification, because I think that people need to understand, and this is where the allopathic and functional models really differentiate. If you're seeing a traditionally trained allopathic medicine provider and you're in menopause or perimenopause, you may just get hormones right out of the block, but you and I are really looking at layers of items in terms of lifestyle and detoxification before we even consider adding in hormonal therapies. So it's interesting. I mean, there's two pieces that I think about with that. And one of them is there's layers of how we detoxify our hormones, estrogen, and there's kind of the good, the bad, and the ugly, as I wrote about my book. But in addition to that, some people are what I call pathological detoxifiers. And that's really helpful then to know their genetic profile. Because if you have, we have the liver that has a phase one and a phase two components. So phase one, we actually make things biologically more active. So they actually be more problematic for us if we will. But then we have a phase two that gets it out really fast. So some people have a very active phase one, very, very quickly, much faster than others and a slow phase two. So that would be the person that goes into Home Depot and goes, oh my God, can't you smell it in here? Or the person that's super reactive to perfumes or the person that just says, I'm so sensitive to smells. They're usually the ones that activate it very quickly and can't get it out of their system. So I'd be more inclined to want to know that as well as their ACE score, as well as, you know, how their body is metabolizing that estrogen. Is it going down the pathway of the good, the bad, and the ugly, because the good news is we can do something about it. We add fish oil, we change their diet, less sugar, more protein in their diet, flaxseed oil. And then we add either I3C, indole-3-carbinol, or we do something called DIM. And this controversy, you know, is DIM better, I3C better? It's like, let's see what works to get that. And the beautiful part is we can change that. 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It's really interesting. We kind of take the concept of detoxification for granted. We poop, we breathe, we sweat, we urinate, and it's far more complicated than that. And the more that I know, the more I'm humbly looking at my body and saying, wow, like we just assume if we poop every day that we're, everything's functioning optimally. And what can happen for some people, you know, you mentioned the good, the bad, and the ugly talking about these metabolites that we look at on the Dutch, but for some people, they don't get this proper detoxification of estrogen. They recirculate it, but because they're having a bowel movement every day, they assume that they're ridding themselves of excess hormonal and hormones. And that may indeed not be the case. Absolutely And that why it so helpful to get these additional tests like the Dutch test or even the stool test Because if you see a stool test and they have a high level of what we call beta we know that those are people that more than likely have got recirculation of the estrogens which can certainly be problematic Without even being on hormones, it can be problematic. Especially if you have increased adipose tissue, then you've got more estrogen stored in the tissue, and that can be even more of an issue. So the beautiful part that we're talking about is that we just need to have our people see people that know how to kind of interpret this for them so that we can really get them on the other side and truly go into their 80s and 90s gracefully and feel and look amazing. Because I really do believe that that's possible, but we have to be a little bit more careful about looking at what's underlying the issues. Absolutely. And a lot of questions came in about how you go about, and again, generalities, because you're not treating anyone that's listening. When we're talking about the systematic way that we look at bioidentical hormone replacement, whether it's starting with progesterone or DHEA, and then moving on the continuum to appropriate types of estrogen, possibly testosterone, I don't know what your feelings are on this. And to tie into that, because you mentioned trochies, you mentioned lozenges, you talked about patches. I'm seeing a lot of people in the functional space that are doing subcutaneous testosterone, obviously pellets are something I know we're in agreement on that we don't love, but there's lots of different ways to administer hormone therapies and some are more embraced than others. So I'm always going to be looking at the person and I'm going to be perhaps starting them on what my favorite thing would be. sometimes they say I need to be covered by insurance. Okay, then I can use a patch easily. Mindoville patch, tiny little thing. And I usually start at 0.0375, maybe 0.05 depending upon the symptoms. And then I'll add a progesterone. And oftentimes I will add a time release capsule. There's controversy around that. And the reason I do that is because I want to make damn sure that I'm protecting the endometrium. That's just my bellyache because I've seen too many people come in with hyperplasia, which is an overgrowth of too much estrogen in the uterus because they weren't on and protected enough with the progesterone. I might put it in a trochey, however. So there are times that I will put a combination of the, I might do triest, estriol, estradiol, and progesterone. There are people that I will also do DHEA, but more likely I'll use drops because they'll do a milligram per drop for that DHEA. Then I work them up to five drops twice a day and it works like magic. And then I will also sometimes put people on testosterone, depends on what their level are, but I always test them then to find out. And those people, I will test at baseline to see where have I shifted them to. And then I'll look at them. Usually I do it twice a year. I'll do a blood for some, and depends on what kind of hormones I put them on. And then I'll do a urine. So I can look at two, four, and 16, those metabolites in the urine once a year. So I usually do twice a year testing. And everybody's different, but I always do adrenal testing too, because if their adrenals are off and they've got more stress, It absolutely affects the efficacy of the hormones they're on. Even if they haven't changed for forever and they have a lot of stress, I'm looking at these things going, what happened? And it's usually, well, you know, someone died or something happened or something like that. So it's just important to be on top of what's going on in people's lives. And it really depends on what they like. You know, I'm not a big fan of creams long-term. This is my personal bias because I think sometimes they stop being as effective and you have to kind of try and find different places. I can get as much success with the other. Some people use vaginal creams and that's another option for people that certainly you have to be careful with that though. The absorption vaginally is like 10 times higher. That makes sense. And it's, it's interesting because as we get questions, we have group programs. We get a lot of questions online as I'm sure you do as well. And there's so much variation in how different people practice that sometimes it's a sticky wicket, meaning it doesn't matter what you say because inevitably, you're not the treating provider. You don't have the option of looking at labs to be able to make determinations about what the best options are for them. I know that pellets can be controversial because for many people, there's wide variability in terms of efficacy, symptoms, et cetera. During your 30 plus year journey as an NP, were pellets ever a part of your practice? They weren't. And the reason for that is that when I would do testing on some of these people, and I would do testing not in a conventional lab, I'd do testing in which we're really looking at what do we know for the differentiation of what those numbers should be for someone who's menopausal and on hormones, the numbers were sky high. And I was thinking, I only need a small amount. We don't have a lot in our bodies to begin with. And it's an orchestra. You know, I need to make sure that everything's together, that the testosterone is balanced, The DHEAS is balanced. The estradiols are balanced and the progesterone is balanced and obviously cortisol production. So my experience has been when I see people on trochies, I mean, obviously people love them because there are people still using them. I haven't seen that myself. And once you've got it in, it's like, you know, if you've got a pellet in, it's going to have to just wear itself out and see what happens. I can get the same results using less, but more balanced is in my opinion. And then doing the functional medicine approach, which is looking at all the other contributing factors to what's their diet like, how much exercise, how much sleep, how happy are they? What was their ACE score? Then we can put that all together. And generally people feel remarkable. I bet. And you've touched on it, but let's expand on this a little bit more. You mentioned things that can contribute. It's a lot of its lifestyle, but I think for many people, they don't recognize that chemicals we're exposed to in our environment or personal care products and our food can have a negative net impact on our hormones. You talked about the symphony. They can make this symphony go from being a beautiful, melodious sound to being a disaster. And so over the last 30 plus years, you're probably seeing greater awareness about estrogen mimicking chemicals and, you know, endocrine disruptors and how these can impact our health. And I speak quite a bit about how some of these can actually impact insulin resistance because and vis-a-vis also related to the inflammatory nature of adipose tissue or fat tissue, which is a highly sophisticated organ. And many people don't understand it's not just fat. It is far more sophisticated than that. What have been some of the things that have been big, allotted a great deal of improvement in your patient population by making some of these changes? I think when you look at health overall from skin rashes to mood, to how often people get sick to immune system, all of that can be greatly changed by looking at what those issues are. Do they have a mold issue? Have they ever been exposed to a lot of mold? How many things do they put on their face? The average newborn has 247 chemicals in its cord blood. The average baby that's being breastfed, and that's, This is old data, 150 different chemicals. Do I suggest you stop breastfeeding? Absolutely not. Of course not. I would never do that. However, we have to understand that there's more childhood cancers than ever before in our history. Why is that? And I think a lot of times we don't think of it. We put something on your skin or we're not paying attention to preservatives or we're not kind of acknowledging that these things have an impact and it's enormous. And when I was first in practice, we were talking about organics. Chris Northrup and I were both macrobiotics at the time and we're very conscientious of kind of the food that we eat. And, you know, as time kind of moved on, we started to realize protein was probably more essential. But we've been talking about all of these pieces for a very long time. And back in the day, we were talking about organics and there was no research, no literature. It doesn't make a difference. And now we have the data to show it makes an enormous difference, because if it's conventionally grown, oftentimes they're using pesticides on it that doesn't create something called hermesis, which is the plant becomes resistant to the bugs on its own. And you are able to actually take that in. We know that the nutrient status of those foods are much higher. Now, do you always have to buy organically? No, you can go on the environmental working group and you can look at what foods would be better, what we call the clean 15 and the dirty 12 because they change every year. But they also have information about what skincare products can you use? What about sunblock? What about all the things that we're using that actually can make us really unhealthy? And we've been exposed to so many. If you can go outside, there was a study done in Maine and they looked to see, there's no problem here. We were so pristine and so on. They looked at the legislators and they looked at hair and blood from 17 year old, 18 year olds, all the way up until their eighties. There was not one person that didn't have at least 15 to 30 exposures. So we know that it is true in us. Okay, so don't get scared by it, but then what can we do to detox our system? How can we support the liver? How can we be more mindful of how much alcohol consuming or toxic relationships that contribute to... So it's all of these things that we've beautifully talked about today that contribute to our ill health and stopping those things. The beautiful part is they did a big study in Europe of 70 year olds and looked to see if they changed their diet and got them on nutrients, did it make any difference in their outcome? Yes. It increased their life expectancy by five years. That's a big deal. So if we change, you know, and we're more mindful of, even when you build a new house, there's a lot of off chemicals that are going off, off gassing, we call that, that can be problematic for a long time. When we built this house that I'm in now, we put wall-to-wall carpeting, you know, in the room that I had my children in and my son developed ulcers on his eyes and we took the carpet out the next day. So it's, you know, some kids are just a little bit more sensitive and it was my stupidity of like, why would I do that? You know, I knew better back then. It was a long time ago, but it is those things that we really, really have reactions to that can contribute to people feeling much healthier if we start to understand it. Oh, it's so important because really looking comprehensively at all of the factors that can impact our health, not just, you know, the low-lying fruit, but understanding all these subtleties can have a huge impact. A couple more questions. I got a lot of questions about libido, which I know that you're going to mention that libido is more than just hormonal fluctuations. There are so many contributors, but if you're dealing with a woman that is perimenopausal or menopausal, and the libido is a by-product of painful sex, dryness, et cetera, what are some of the things you start with other than diagnostic testing? So I love this question because here's the thing. In my practice, I would say about 60% of my patients over 60 were not sexually active anymore. And I would always ask the question, what's up? What's going on? Well, we're both okay with it. So I can pretty much guarantee you hormonally, that's absolutely a piece of the puzzle. But when women have vaginal dryness, who would want to have sex? Thank you very much. When you feel like you have knives and vagina, forget it. No way, not going to happen. So I always talk about a happy vagina. I want women to have a happy, happy, happy vagina. And it's easy to treat because we can use, you know, I use estriol cream and sometimes I'll put DHEA in it. Sometimes I'll just use DHEA vaginal cream and that symptom can go away in a week. That's an absolute ridiculous issue that any woman should have to have. And we know that estriol in particular doesn't go back upstream. And even around here, many of my patients whose oncologists are fine with them being on the estriol. Now, other than that, we have some differences between men and women. And the men oftentimes feel loved when they're having sex. Women need to feel loved to have sex. It's quite different. And conversation and really understanding that for women, you know, foreplay starts in the morning. Hey babe, you want me to take a trash out for you? What else can I do for you today? And, you know, men, it's like, hey honey, you're looking really good right now. And you're thinking, what are you talking about? I've got all these things to do for today. I'm not there. So it's finding that balance between the two and really learning to communicate and understanding that we do think differently. Men and women do really think differently. It's not bad or good. It's many times men compartmentalize. So we need to have conversations and learn how to kind of have that conversation as they do with us and really kind of know those pieces. And also what's their sexual appetite? What's your sexual appetite? If the pie in the sky was there, what would it be like? What would this situation be? If you've got small children, it's kind of like sex. How do you spell that again? So it's like, you know, it's like, it's very different. So different times in our lives. The perimenopause oftentimes for many is this kids are gone, they're in college or they're away and you've got more freedom, but then they have to reconnect and find out who are we now as we've come to this time. And I can't stress enough how important that connection is. In addition to finding out adrenal levels, in addition to finding out hormone levels, But the first thing we do is we make the vagina happy and we use the actual cream because it really helps. No, I think that's really important. I recall many years ago when I was a baby nurse practitioner, and this is at the advent of Viagra. And I had patients in conjunction with their cardiologist that we would start them on Viagra. And I would have angry women banging on my door wanting to know why they had to start having sex with their husbands because they hadn't had to do that service, quote unquote, for 15 or 20 years. And so, you know, making sure that we're aligned with our partners, we're having those conversations. And then, you know, first and foremost, as you said, making sure we have a happy vagina, because if that's not happy, then nothing else is really going to come to fruition. Now, Marcel, I could talk to you for hours. This is just one snippet of conversation. Please let my listeners know how to connect with you. If they'd like to work with you, do one of your programs, purchase your books, find you on social media. How can they do that? So I'm not a social media queen, probably because I'm too old, but I'm kidding. But you do that. Oh, yeah, yeah. But they can go to marcellpick.com. I have probably almost 2000 articles that I've written since literally 2001 about functional medicine. All my books are on Amazon. You can just type my name and you can see the three books that I've written. The Core Balanced Diet. Is it me and my adrenals? Is it me and my hormones? And then they have, I also have a very successful weight loss program. You know, most of my people lose 20 pounds in six weeks with the homeopathic drops that I use. And 70% keep it off long-term. So that's really part of my dream. Next year, I'm also gonna do something called the Afterglow program, which is gonna be a year-long program with me, looking at three months of adrenals, three months of digestion, three months of hormones, and then three months of emotions and ACE score kind of information. So I'm looking forward to starting that next year. I love it. Well, thank you again, my friend. It's been a pleasure. I know it'll be the first of many conversations we'll have. Sounds good to me. if you love this podcast episode please leave a rating and review subscribe and tell a friend